Inspection·December 7, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The resident's PASRR revealed it was completed, on 9/21/23, prior to the resident's admission at an acute care facility. 7. Review of Resident #65's admission Record showed the resident was admitted on [DATE] revealed the primary/admitting diagnosis of unspecified Alzheimer's disease and included diagnoses of severe dementia in other diseases classified elsewhere with other behavioral disturbance, unspecified mood (affective) disorder, and unspecified single episode major depressive disorder. A review of Resident #65's PASRR showed the resident did not have a mental illness diagnosis or a primary diagnosis of related neurocognitive disorder (including Alzheimer's disease). The resident's PASRR was completed at an acute care facility on 12/20/21. 8. On 12/5/2023 at 10: 30 a.m., Resident #56 was observed laying down in bed fully dressed, and well-groomed with his call light within his reach. Resident was presented with no signs of distress. Review of a Resident Information Record dated 12/6/2023 showed Resident #56 was originally admitted to the facility on [DATE] with diagnoses to include but not limited to bipolar disorder, unspecified, altered mental status, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, unspecified, Review of Resident #56 's Preadmission Screening and Resident Review (PASRR) dated 09/11/2023 revealed no PASRR Level II was required. Review of the admission Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Review of the medical record revealed the resident was not assessed for PASRR Level II. An interview was conducted with Staff J , the Social Worker on 12/6/2023 at 2:18 p.m. He said he started working at the facility in October and just received access to complete the PASRRs yesterday. The process when someone was admitted to the facility was the clinical team reviewed the resident's admission paperwork in the morning meeting to ensure they had a PASRR. During the meeting, the clinical team reviewed the admitting resident's diagnoses and if the resident had a diagnosis of bipolar disorder, the team would make sure the resident had a level II PASRR completed. It was an Interdisciplinary Team (IDT) team responsibility to review the PASRR during morning meeting to ensure they were accurate. Review of the facility policy titled, admission Criteria revised date December 2016 showed Policy Statement, Our facility will admit only those residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation 1. The objectives of our admission criteria policy are to: c. assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 2 of 26 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 12/07/2023 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 0644 7. Level of Harm - Minimal harm or potential for actual harm Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program (PASRR) to the extent practicable. Residents Affected - Some 8. Potential residents with mental disorders orders or intellectual disabilities will be admitted if the State mental health agency has determined (through the µreadmission screening program) that the individual has a physical or mental condition that requires the level of services provided by the facility. Based on record review, interview, and review of the facility's policy, the facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASRR) Level I for eight (Residents #50, #2, #69, #3, #22, #54, #65, and #56) of eight residents admitted with mental health and/or cognitive diagnoses sampled for PASRR. Findings include: 1. Review of the clinical record revealed Resident #50 was admitted to the facility on [DATE], with a primary diagnosis of multiple fractures according to the admission face sheet. Further review of the admission face sheet revealed subsequent diagnoses that included unspecified dementia and generalized anxiety disorder. Review of a PASRR Level I form dated 10/13/2023 revealed Section 1A marked 'anxiety disorder' and Section II checked 'no.' Continued review revealed Section 5. (primary diagnosis of dementia or neurocognitive disorder) checked 'no', and Section 6. (secondary diagnosis of dementia or neurocognitive disorder) checked 'yes.' Section IV, (no diagnoses or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation not required) was checked. Instructions on the PASRR form showed 'A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a serious mental illness, intellectual disability, or both .' The clinical record did not reveal any additional PASRR (Level I nor Level II) assessments. 2. Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE], with a primary diagnosis of intravertebral disc degeneration according to the admission face sheet. Further review of the admission face sheet revealed subsequent diagnoses that included unspecified psychosis, paranoid personality, anxiety disorder and unspecified dementia. Review of a PASRR Level I form dated 07/24/2023 revealed Section 1A marked 'anxiety disorder' and Section II checked 'no.' Continued review revealed Section 5. (primary diagnosis of dementia or neurocognitive disorder) checked 'yes', and Section 6. (secondary diagnosis of dementia or neurocognitive disorder) checked 'no.' Section IV, (no diagnoses or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation not required) was checked. Instructions on the PASRR form showed 'A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a serious mental illness, intellectual disability, or both .' The clinical record did not reveal any additional PASRR (Level I nor Level II) assessments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 3 of 26 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 12/07/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 3. Review of the clinical record revealed Resident #69 was admitted to the facility on [DATE], with a primary diagnosis of Parkinson's disease according to the admission face sheet. Further review of the admission face sheet revealed subsequent diagnoses that included major depressive disorder and vascular dementia. Review of a PASRR Level I form dated 03/01/2023 revealed Section 1A marked 'depressive disorder' and Section II checked 'no.' Continued review revealed Section 5. (primary diagnosis of dementia or neurocognitive disorder) checked 'no', and Section 6. (secondary diagnosis of dementia or neurocognitive disorder) checked 'no.' Section IV, (no diagnoses or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation not required) was checked. Instructions on the PASRR form showed 'A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a serious mental illness, intellectual disability, or both .' The clinical record did not reveal any additional PASRR (Level I nor Level II) assessments. Event ID: Facility ID: 105436 If continuation sheet Page 4 of 26 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 12/07/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 2. Review of the clinical record for Resident #313 revealed admission to the facility on [DATE] with diagnoses that included cellulitis according to the face sheet. Review of the Physician's Order Summary showed: -Bactrim DS Tablet 800-160 milligrams (an antibiotic) - give 2 tablet by mouth two times a day for cellulitis for 7 days, started 11/30/2023. Review of the current Care Plan for Resident #313 did not reveal a focus, goals or interventions related to the administration of antibiotics or monitoring for effects and/or side-effects. 3. Review of the clinical record for Resident #2 revealed admission to the facility on [DATE] with diagnoses that included chronic kidney disease, breast cancer and heart failure according to the face sheet. Review of the Physician's Order Summary showed: -DNR (do not resuscitate) dated 10/05/2023 Review of the current Care Plan for Resident #2 did not reveal a focus, goals or interventions related to the resident's advanced directive wishes or the DNR physician's order. 4. Review of the clinical record for Resident #50 revealed admission to the facility on [DATE] with diagnoses that included multiple fractures according to the face sheet. Review of the Physician's Order Summary showed: -DNR (do not resuscitate), do not hospitalize, comfort measure only dated 11/16/2023 Review of the current Care Plan for Resident #50 revealed: -focus: [resident] has requested DNR indicating CPR [cardiopulmonary resuscitation] measures ARE performed, initiated 10/31/2023 and revised 11/19/2023. -interventions: communicate resident/representative choice to appropriate staff members, initiated 10/31/2023. On 12/06/2023 at 1:26 p.m., an interview was conducted with Staff G, Regional Nurse. During the interview, Staff G reviewed the care plan and confirmed the focus was incorrect, which could result in confusion related to the resident's DNR status and actions required to be performed. 5. Review of Resident #22's admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to unspecified dysphagia, pneumonitis due to inhalation of food and vomit, and encounter for attention to gastrostomy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 5 of 26 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 12/07/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident #22's active Order Summary Report showed the resident was ordered the antihistamine medication, Hydroxyzine 25 milligram (mg) via G-tube at bedtime for anxiety. The order was started on 10/6/23. Review of Resident #22's care plan showed the resident did not have a care plan related to the resident's diagnosis of anxiety or use of medication to treat anxiety. During an interview, on 12/7/23 at 7:44 a.m., the Minimum Data Set (MDS) Coordinator confirmed Resident #22 should have a care plan related to the use of psychotropic (medication). The coordinator reviewed the care plan and confirmed it did not include a focus for the resident's diagnosis of anxiety. The staff member reviewed the resident's MDS assessment, confirming the diagnosis of anxiety was listed, and she had missed it. 6. Review of Resident #27's admission Record showed the resident was admitted on [DATE] with a diagnosis of unspecified single episode of major depressive disorder. The psychiatry note, dated 10/25/23, revealed Resident #27's diagnoses included moderate recurrent major depressive disorder and adjustment disorder with anxiety. The plan showed the resident was to continue Effexor for depression and melatonin for insomnia. A review of Resident #27's Medication Administration Record (MAR) showed the resident received the antidepressant, Effexor 75 milligram (mg) by mouth one time a day every other day, ordered on 10/26/23 and discontinued on 12/6/23. The order for Effexor was increased to be administered daily for the treatment of depression, started on 12/7/23. The review of Resident #27's care plan showed the plan did not include a focus related to the resident's diagnosis of depression or the use of a psychotropic medication to treat the diagnosis. On 12/7/23 at 10:14 a.m., the Minimum Data Set (MDS) Coordinator stated she would like a chance to review the care plan related to (r/t) depression, sometimes they put it in interventions, and she would add it now. The policy - Care Plan, Development Baseline and Comprehensive, revised 5/2023, revealed To ensure a resident has a baseline care plan to meet needs upon admission and to further ensure a comprehensive person-centered care plan is developed and implemented to include measurable objectives and timetables to meet the needs of the resident. The guideline showed The facility will comply with the requirements specified in accordance with state and federal regulations as they pertain to baseline and comprehensive person centered care plans. The policy disclosed the following: 1. The inner disciplinary team in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 5. The care planning process will: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 6 of 26 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 12/07/2023 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 0656 - a. Facilitate resident and slash or representative involvement; Level of Harm - Minimal harm or potential for actual harm - b. Include assessment of the residents strength and needs; and - c. Incorporate the residents personal and cultural preferences in developing the goals of care. Residents Affected - Some 6. The comprehensive person-centered care plan will: - a. Include measurable objectives and time frames; - b. Describe the services that are to be furnished to attain or maintain the residents highest price practicable physical, mental, and psychosocial well-being; - c. Describes services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; - g. Incorporate identified problem areas; - h. Incorporate risk factors associated with identified problems; - k. Reflect treatment goals, timetables, and objectives in measurable outcomes. 7. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 8. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the residents problem areas and their causes, and relevant clinical decision making. 9. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. The procedure revealed the Interdisciplinary Team must review and update the care plan where there is a significant change in the resident's condition, when a desired outcome was not met, when a resident in re-admitted from a hospital stay and at least quarterly in conjunction with the quarterly MDS assessment. Based on observation, interview, and record review, the facility failed to develop and implement care plans for six (Residents #77, #313, #2, #50, #22, and #27) of twenty eight sampled residents. Finding included: 1. On 12/4/2023 at 9:30 a.m., and 3:00 p.m., Resident #77 was observed in a room located at the end of the hallway. Resident was observed both times laying down in his bed with his call light not within his reach at 9:30 a.m., and within his reach at 3:00 p.m., his bed was observed in a low (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 7 of 26 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 12/07/2023 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 0656 position. Resident # 77 was presented with no behaviors, pain, or discomfort. Level of Harm - Minimal harm or potential for actual harm Review of the Resident Information Record dated 12/6/2023 revealed Resident #77 was initially admitted on [DATE] and readmitted on [DATE], with diagnosis to included but not limited to Type 2 Diabetes Mellitus without Complications, major depressive disorder, anxiety disorder, hypertensive heart disease without heart failure. Residents Affected - Some Review of a Minimum Data Set (MDS) dated [DATE], showed in Section-C a Brief Interview for Mental Status (BIMS) score was not recorded. Review of the Fall Risk Evaluation with effective date 12/1/2023, showed box C, for number one was checked which indicated Resident #77 was oriented x 2, had no reported falls, and needed assistance with toileting. Further review showed interventions were footwear needs, put bed in lowest position, talk slowly and clearly, therapy referral, encourage resident to wear glasses, and call light re-orientation. Review of nursing progress note dated 12/1/2023 showed Resident #77 was assisted to the toilet by a nurse and was educated to pull the call light and wait for help. The nurse told a nursing assistant to check on the resident. Resident stated he was not finished. 15 minutes later when the nursing assistant went back to check on the resident, he was found laying face down on the floor in the bathroom. Review of nursing progress note marked late entry effective 11/30/2023 by a License Practical Nurse, LPN showed, Resident #77 had an unwitnessed fall reported. Resident was found sitting on the floor next to his bed. On 12/7/2023 at 8:00 a.m., an interview was conducted with Staff E, Registered Nurse (RN) MDS coordinator. Staff E said Resident #77 had a fall each month. The process was the Interdisciplinary team (IDT) reviewed resident's falls the next day during morning meeting. She stated, We take a look at the resident care plan and what interventions are in place and make updates to the care plan each time a resident has a fall. [Resident #77's] care plan was not updated after the fall he had on 11/30/2023, because they reapplied the same intervention he had in place on 10/26/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 8 of 26 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 12/07/2023 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (Resident #24) of one sampled resident received supervision and assistance with eating during all three meals. Residents Affected - Few Findings included: On 12/4/2023 at 12:20 p.m., Resident #24 was observed seated in a wheelchair, in his room, and with the over the bed table positioned in front of him. The call light was observed placed within his reach, his eyes were open, but he was not interviewable. While observing the resident, Staff F, Certified Nursing Assistant (CNA) brought in Resident #24's lunch meal tray. She set up the tray and then left the room. The resident received adaptive eating equipment to include a scoop plate and double handled plastic sip cup. He received regular silverware. He was on a mechanical soft textured diet. At 12:22 p.m. Staff F left the room immediately after setting up the tray and proceeded to help with passing out trays to other residents on the unit. Continued observations from 12:22 p.m. through to 12:40 p.m. (18 minutes), revealed Resident #24 was in his room by himself and scooping his mechanical ground food items from the scoop plate, while using his right hand and fingers. The high built up part of the scoop plate was facing away from him, so when he scooped the food items with his right hand, he brushed the food items off the non built up portion of his scoop plate, facing him. He scooped the food onto the table, on to his lap, and on to the floor. He did not have the scoop plate positioned correctly for him to be able to scoop up the food items while brushing the food towards him. There were no staff in the room to assist or supervise him during this timeframe. He was able to get some food to his mouth to eat. However, a large portion of the food items were all over him and the floor. During an observation on 12/5/2023 at 8:15 a.m., Staff A,CNA was observed to remove the last breakfast tray from the tray cart and set it up in Resident #24's room. Prior to him going in the room with the tray, Staff A and Staff C, CNA were observed talking with each other and were trying to figure out if Resident #24 and another resident down the hall required Eating assistance. Staff A told Staff C Resident #24 was set up only. Staff C replied back to Staff A, I thought he was assist feed, are you sure? Staff A replied back, I check on him from time to time. Staff A brought the tray into Resident #24's room, set it up, and left the room at 8:17 a.m. On 12/5/2023 at 8:21 a.m., during an observation the resident was seen trying to eat on his own. The resident received a mechanical soft regular diet with thin liquids to include scrambled eggs, sausage meat, a bowl of hot cereal, milk, and juice. The meal ticket verified the same. He received the meal on a scoop plate. He was using his hands and fingers to pick up his ground/mechanical food items from the scoop plate. There were no staff in the room at the time to supervise or assist with eating. Further observations revealed while the resident was in the room by himself eating, he was attempting to grab the silverware to eat, but could not scoop food onto the fork. He dropped the fork on the table and then proceeded to use his hand and fingers. The scoop plate was positioned with the high scoop portion of the plate facing away from him, rather than facing inward and towards him. On 12/5/2023 at 8:35 a.m., Resident #24 was trying to scoop food up from his plate with his fingers. He was observed with a clothing protector on and with what appeared to be mechanical soft diet textured eggs and sausage all over his lap. There was some food dropped on the floor as well. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 9 of 26 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 12/07/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/5/2023 at 8:41 a.m., Resident #24 still had not been assisted by staff. He sat alone in his room and attempted to feed himself. He was observed to get some food in his mouth, but again, he brushed food items onto himself and the floor. On 12/5/2023 at of 8:54 a.m., Resident #24 still had not been assisted by staff. He was still using his fingers to try and scoop up food items. More food items were noted spilled on him and the floor. Resident #24 was served a clear plastic cup of red juice with a lid on it as well as an empty double handled plastic sip cup. Staff did not remove the lid of the plastic juice cup, nor did staff pour the juice in the double handled sip cup for the resident to use. On 12/5/2023 from 8:17 a.m. through to 8:57 a.m. (40 minutes), the resident had not had staff supervision or assistance. On 12/5/2023 at 8:58 a.m., Staff A went into Resident #24's room. He was overheard to ask the resident if he was done with his meal, and the resident shook his head yes. He asked if he wanted any juice, and the resident was overheard to say, no. The resident had not been offered juice during the entire time he was eating as the plastic lid was secured on the cup of juice, and the double handled sip cup was empty. On 12/5/2023 at 9:00 a.m., Staff A revealed Resident #24 had consumed almost 100% of the meal and about 240 cc of liquid. However, it was observed the resident did not drink any of the juice, as it was not offered when he was initially served his tray, and he refused the juice when it was offered at the time the tray was removed. Several food items were on the floor, on the resident's lap, and on the over the bed table. Staff A revealed the resident could eat on his own but he needed mostly supervision. Staff A confirmed that he was not able to supervise the resident as much as he would have liked to this morning because he had to help serve and set up other resident trays, on other hallways. On 12/5/2023 at 12:09 p.m., the kitchen staff brought the lunch meal cart to the 240-248 hallway. Resident #24 received his meal tray from Staff A at 12:13 p.m. Staff A set up the meal for the resident and left the room at 12:15 p.m. Resident #24's meal tray consisted of two double handled sip cups with dark liquids as well as a scoop plate as adaptive eating equipment. On 12/5/2023 at 12:16 p.m., Resident #24 was observed eating and attempting to use the fork but was not getting food to his mouth appropriately, spilling food on to his lap and the floor. Continued observations from 12:15 p.m. through to 12:37 p.m. (22 minutes), revealed Resident #24 was not supervised or assisted with his meal. On 12/6/2023 at 8:20 a.m. kitchen staff brought the breakfast tray cart and parked it on the 240 - 248 hall. Staff began to take trays from the cart immediately. At 8:28 a.m., Staff A brought Resident #24 his meal tray while in his room. Resident #24 already had a plastic double handled cup with red juice in his room prior to being served his meal. Staff A brought in the tray which consisted of what appeared to be mechanical ground textured eggs with cheese and sausage. He also received a bowl of hot cereal and another plastic double handled cup with red juice. The meal items were on a scoop plate. Staff A set up the tray and assisted placing a fork in Resident #24's right hand and cued him to scoop the food. Resident #24 tried to bring the food up to his mouth with the fork, but his right hand was shaking. Staff A stayed in the room for only a couple of minutes and cued the resident with the eating utensil. The high back portion of the scoop plate was positioned outward, not inwards towards the resident. Resident #24 scooped the food toward him so there was no high portion of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 10 of 26 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 12/07/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plate to use. Therefore, food items spilled off the plate and onto the tray table and the resident's lap. He was wearing a clothing protector to catch the food items. Staff A left Resident #24's room at 8:31 a.m. to assist with tray pass for other residents on the hallway. Staff A returned to the room to pick up the meal tray at 9:14 a.m. There was no staff in the room from 8:31 a.m. through to 9:14 a.m. (43 minutes). On 12/6/2023 at 9:20 a.m., an interview with Staff A revealed he had Resident #24 routinely on his daily assignment and knew of his care needs. Staff A confirmed Resident #24 received adaptive eating equipment to include a scoop plate and a double handled sip cup. He confirmed Resident #24 was not able to speak related to his daily care needs, but could answer some simple yes and no questions. Staff A revealed the resident received one person assistance with most of his Activities of Daily Living, and more specifically supervision with eating. Staff A confirmed supervision meant the resident should be supervised by staff the entire meal service. Staff A said at times, Resident #24 required one person assistance with eating. Staff A could not provide a reason as to why Resident #24 did not receive juice in the double handled sip cup, and juice was left in a regular plastic cup with a lid on it the entire meal service. He also could not give a reason as to why Resident #24 was given a scoop plate with the scoop portion facing away from the resident, rather than facing in. Staff A confirmed Resident #24 scoops inward and towards him, not outwards. Staff A confirmed the food debris on the over the bed table, on the resident's lap, and on the floor. Staff A said, he routinely went in the room to check on Resident #24 every 3-5 minutes to supervise him with eating. He could not account for the forty minutes, twenty-two minutes, and forty-three minutes where Resident #24 was left alone to eat with no staff assistance or supervision. Staff A said he was, at times called to assist with tray pass and set up in different halls on the unit. During an observation on 12/7/2023 at 8:10 a.m., Staff F, CNA took a breakfast meal tray from the tray cart in the hallway and brought it to Resident #24's room. She placed and set up the meal for the resident and then sat down to assist the resident with Eating assistance. Staff F said she would set up the meal and assist the resident with eating this morning. She confirmed she did not have the resident regularly on her assignment and did not know if the resident was supposed to be assist or supervision with eating. She said she was told this morning, 12/7/2023, the resident needed full assist with eating. Though Staff F assisted Resident #24 with eating assistance, he still received the scoop plate and double handled plastic sip cup as adaptive eating equipment. Once Staff F set up the meal, she picked up a fork, loaded it with food items, and brought the fork to the resident's mouth. He accepted the bites of food. At this point, there was no cueing, only staff assistance with eating. Review of Resident #24's medical record show he was admitted to the facility on [DATE]. Review of the advance directives revealed the resident had a Power of Attorney in place to make his medical and financial decisions. Review of the diagnosis sheet revealed diagnoses to include: Parkinson's, Dementia, Anxiety, Insomnia, Depression, Low back Pain. Review of the current Physician's Order Sheet for the month of 12/2023 revealed the following but not limited to orders: (a.) Diet Order: Regular Diet, Mechanical soft with Scoop Plate and two handled cup to be used once a day during dinner meal only. (b.) Consult speech therapy for dysphagia (order date 11/28/2023) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 11 of 26 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 12/07/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (c.) ST Clarification 4 x wk x 90 days for treatment of speech, language, voice, communication, and or auditory process disorder (order date 11/24/2023) Review of the following Minimum Data Set (MDS) assessments revealed: (1.) admission MDS dated [DATE]: (Cognition/Brief Interview Mental Status or BIMS score - 00 of 15, which indicated the resident was not able to be interviewed related to his care and services), (Activities of Daily Living or ADL Eating = Dependent on Staff.) (2.) Significant change MDS dated [DATE]: Cognition - the Brief Interview for Mental Status (BIMS) score was 00 of 15, which indicated the resident had severe cognitive impairment. Activities of Daily Living ADL Eating = Independent. Review of the following Speech Therapy (PT)/ Occupational Therapy (OT) assessments revealed; a. Speech Therapy (ST) Discharge summary dated [DATE], and to include service date from 11/24/2023 12/4/2023 revealed Resident #24 resident was evaluated initially due to the resident refusing treatment and with diagnoses to include Neuroleptic induced Parkinsonism, Dysarthria/Anarthria, and Symptoms and signs concerning food and fluid intake. Section STG #2.0 comments section revealed, Patient will demonstrate absent overt signs and symptoms of dysphagia or aspiration with mechanical soft solids/thin liquids in the current environment with long term goals Within Function Limits (WFL). The assessment summary of skilled section medical history notes revealed the Patient was referred for Speech Therapy Evaluation per quarterly screening, and patient expresses desire to improve his speech intelligibility. Also reported that patient has required food cut up small at home due to being edentulous expect for one upper incisor. The patient progress notes revealed, Progress and Response to Treatment: Patient has been able to self feed independently with the mechanical soft/thin consistency after tray set up by CNA or this SLP. The discharge recommendations revealed; Oral intake what modified diet is recommended for the patient to swallow solids safely? = Soft and Bite sized. Recommendations for Restorative programs was documented as: Not at this time. b. Occupational Therapy (OT) evaluation and plan of treatment for dates 11/25/2023 - 12/24/2023 revealed primary diagnoses to include: Neuroleptic induced Parkinsonism, Dementia, Other symptoms and signs involving the musculoskeletal system. Section STG #5.0 Goal revealed; Patient will improve ability to safely and efficiently perform eating tasks with setup or clean up assistance with use of 2 handled mug and scoop dish to ensure adequate nutrition and hydration with Eating = Supervision or touching assistance. Review of the functional skills assessment - Activities of Daily Living and instrumental ADL revealed; Eating = Supervision or touching assistance. Review of the OT assessment summary revealed; Clinical impression/reason for skilled services: Patient presents with impairments in balance, dexterity, fine motor coordination, gross motor coordination, mobility, strength, follow through, planning, problem solving, self modification and self monitoring resulting in limitations and/or participation restrictions in the areas of General tasks and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 12 of 26 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 12/07/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm demands. OT services to assist safety and independence with ADLs, assess safety with adaptive equipment. An interview was unable to be conducted with the Speech Therapist during the time of the survey from 12/4/2023 - 12/7/2023. Residents Affected - Few On 12/6/2023 at 10:30 a.m., the Care Plan Coordinator and the Director of Nursing both revealed they were not sure why the order stated Resident #24 was to use the scoop plate and double handled sip cup for only one meal a day, and also confirmed that at this point Resident #24 should have at least supervision by staff during each meal service, and during the entire time he eats. They were not sure as to why staff were not in the room with Resident #24 during several meals observed. Review of the current care plans with a next review dated 2/22/2024 revealed the following: 1. Resident #24 has an ADL self care deficit r/t physical limitations, weakness, with interventions in place to include but not limited to: Assistive devices as ordered/indicated, Encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc., Patient needs assistance with meals, On 12/7/2023 at 8:30 a.m., the Nursing Home Administrator provided the Activities of Daily Living (ADL), supporting policy and procedure with a last revised date March, 2018, for review. The policy statement revealed; Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The Policy Interpretation and Implementation section of the policy revealed; 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical conditions(s) demonstrate that diminishing ADLs are unavoidable. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including but not limited to: (d.) Dining (meals and snacks). 3. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions. (b.) Supervision = Oversight, encouragement or cueing provided 3 or more times during the last 7 days. (c.) Limited Assistance = Resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non weight bearing assistance 3 or more times during the last 7 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 13 of 26 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 12/07/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm 4. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 5. The resident's response to interventions will be monitored, evaluated and revised as appropriate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 14 of 26 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 12/07/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the urinary drainage bag was maintained in a sanitary manner and drained every shift according to the plan of care for one (Resident #22) out of 10 residents with urinary catheters. Findings included: Review of Resident #22's admission Record showed the resident was admitted on [DATE] and included the diagnoses not limited to site not specified urinary tract infection, personal history of malignant neoplasm of prostate, and sepsis due to enterococcus. An observation on 12/4/23 at 8:20 a.m. of Resident #22, revealed a full urinary drainage bag sitting on the floor with the tubing lying on the base of the over-bed-table, the tubing contained pale straw-colored urine. The drainage bag was hanging in front of the urinary privacy bag. Staff H, Certified Nursing Assistant (CNA), observed the drainage bag and confirmed it was full and should have been emptied. A review of Resident #22's care plan revealed the resident was at risk for injury/infection related to (r/t) presence of urinary catheter secondary to a diagnosis (dx) of obstructive Uropathy. The focus was initiated on 10/26/23 and revised on 12/7/23. The interventions instructed staff to position catheter bag and tubing so that it promoted dignity and drainage. On 12/6/23 at 3:49 p.m., the Director of Nurses (DON) reviewed the photos of the resident's drainage bag and confirmed the bag had not been drained during the night shift if observed at 8:20 a.m. and catheter bags should, at minimum, be drained every shift. The policy - Catheter Care, revised September 2014, instructed staff to maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. The management portion of the policy showed staff were to empty the drainage bag regularly using a separate, clean collection container for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 15 of 26 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 12/07/2023 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 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 observation, record review, and interview, the facilty failed failed to obtain and document current body weight of two (Residents #22 and #65) out of thirty-six sampled residents. Residents Affected - Some Findings included: A review of Resident #22's admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to diverticulitis of large intestine without perforation or abscess with bleeding, unspecified dysphagia, and encounter for attention to gastrostomy. An observation was made on 12/4/23 at 8:20 a.m., of Resident #22 lying in bed and informed Staff H, Certified Nursing Assistant (CNA) of being on a strict no food diet. On 12/5/23 at 8:19 a.m. the resident was observed lying in bed with liquid nutrition running at 70 milliliter/hour (mL/hr). The Order Summary Report, active as of 12/7/23, included a physician order , dated 10/6/23, instructing staff to obtain Monthly Weight every day shift starting on the 7th and ending on the 8th every month. The enteral nutrition order for the resident showed the resident was to receive [liquid nutrition] 1.5 at 70 mL/hr to start at 2 p.m. until completion of 1400 mL's. A review of Resident #22's Weight and Vital Summary revealed the resident weight on the day of admission [DATE]) was 198 pounds (lbs). The summary showed the resident's weights on 10/7, 10/9, 10/14, 10/30, and 10/31/23 was 200.5 lbs. The summary did not include a weight for the resident in November. The November Medication Administration Record (MAR) for Resident #22 revealed staff had documented 9 on 11/7 and 11/8/23 regarding the obtaining of the weight for the resident. The chart code of the MAR showed 9 equaled other/see nurse notes. The progress notes dated 11/7 and 11/8 did not show the reason Resident #22's monthly weight was not obtained as ordered. The care plan for Resident #22 showed the resident required tube feeding related to (r/t) dysphagia and instructed staff to follow physician orders regarding nutrition order and flushes. A review of Resident #65's admission Record showed the resident was admitted on [DATE] and included the diagnoses of unspecified Alzheimer's disease, unspecified single episode major depressive disorder, and gastro-esophageal reflux disease without esophagitis. An observation was made on 12/4/23 at 8:31 a.m. of the resident lying in bed. The Weight and Vital Summary for Resident #65 revealed the resident's weights as 137.5 lbs on 6/4, 6/18, 6/20, and 6/25, 130.4 lbs on 7/14, 7/15, 7/16, 7/24, 8/1, 8/17, and 8/19/23, 130 lbs on 8/20, 128.6 lbs on 9/2/23, 125.4 lbs on 10/7, 10/12, 10/14, 10/15, 10/22, 11/3, 11/6, 11/10, 11/16, and 11/19/23, 125 lbs on 12/2 and 12/3/23 and 126.2 lbs on 12/6/23. The documented weights were obtained by wheelchair scale. The review of Resident #65's Annual Quality of Care Review, effective 10/26/23, showed the resident had no weight concerns since the last review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 16 of 26 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 12/07/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The review of Resident #65's Nutrition Evaluation, effective 11/26/23, showed the resident's current weight was 125.4 lbs, had a weight loss of greater than or equal to 10% within 180 days. The estimated nutritional needs of the resident was based on the current body weight. The evaluation revealed the resident was Independent regarding feeding assistance. The summary of the evaluation revealed the resident's weight was 125.4 lbs on 11/19 and 10/7/23, with a 10.11% weight loss in 180 days, a Body Mass Index (BMI) of 24.5 which was within a healthy range, and weight was stable in 30 days. The summary instructed to continue to monitor weights. A review of Resident #65's care plan showed the resident was at risk of alteration in nutritional status related to (r/t) Alzheimer's, depression, and history (hx) of meal refusals. The resident goal was no significant weight changes through next review. The interventions for Resident #65 instructed staff to Review weights and notify physician and responsible party of significant weight change and to Weigh per facility protocol, if otherwise indicated by MD. The focus related to the resident's resistiveness and noncompliance with treatment/care showed the resident's refusal to have weight taken, refuses to get out of bed/transfer, refuses meals at times, refusing care at times, combative and yelling out using foul language at times, and yelling out r/t cognitive loss. On 12/6/23 at 11:44 a.m., the Director of Nursing (DON) reported the weight scale was broken so had requested to have (weight) scales fixed or new ones and had reached out to rental companies for scales. She stated the facility had ordered 2 new scales which were received the end of last week and needed to be calibrated. The DON reported the facility's mechanical lift scales had not been calibrated either. She stated staff were documenting previous resident weights because the scales were not working. The DON stated she had discovered the scales were broken in November after starting at the facility on 10/24/23. On 12/6/23 at 12:18 p.m. the Registered Dietitian (RD) reported starting with the facility in October and approximately 2-3 weeks ago she was notified of the issue with the scales. She reported she had raised the question regarding weights to the DON 2 or 3 weeks ago. The RD reported looking at weights, looking at baseline weight, looking at oral intake or if weight is stable, and when doing an assessment if intake has decreased and weight was stable would do a re-weigh. She reported the facility was having the new scales calibrated and calibrated quarterly. The RD reported not noticing an issue (with weights) until doing quarterly assessments that there was a trend in weights not changing. On 12/7/23 at 12:05 p.m., Staff I, Certified Nursing Assistant (CNA), reported all aides were supposed to obtain (resident) weights and did not realize how long the scales were broken. The staff member confirmed documenting the previous weight for the residents was trying make sure my charting was done, my things were green. The staff member reported no one at the facility had told her to document previously obtained weights. Review of the Standard and Guidelines - Weight Assessment, revised 8/20/23, revealed The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents as indicated. The guideline revealed To determine a baseline and an ongoing record of the resident's body weight as an indicator of their nutritional status in medical condition while taking into consideration resident's preferences on obtaining weights and therapeutic diets. The Weight Assessment revealed With the resident's permission the nursing staff will measure the resident's weight within 72 hours of admission, weekly for three weeks, and monthly thereafter or as determined by the physician or per the residences preference. Weight variance changes that are undesired or unplanned since the last weight assessment will be retaken as soon as practical for confirmation. If the weight (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 17 of 26 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 12/07/2023 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 0692 is verified, nursing will communicate with the dietician and or the physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 18 of 26 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 12/07/2023 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (Resident #26) of one sampled resident, who was diagnosed and assessed with Post Traumatic Stress Disorder (PTSD), received care and services in accordance with professional standards of practice to minimize triggers and/or re-traumatization. Residents Affected - Few Findings included: On 12/6/2023 at 9:45 a.m., Resident #26's assigned 7:00 a.m.-3:00 p.m. shift Certified Nursing Assistant (CNA), Staff B was interviewed. She revealed she did not have Resident #26 routinely but knew of her care needs and had had her previously as a routine assignment. Staff B revealed Resident #26 presented sometimes with some depression episodes but was not aware of any other type of behaviors to look out for, nor had been given any direction to report any type of behaviors to nurse staff. Staff B revealed nobody had ever told her that Resident #26 had PTSD, nor had anyone explained to her the reason for PTSD and how to look out for behaviors related to any type of trauma. She also confirmed she had not been educated and/or inserviced related to the resident's PTSD behavior monitoring. Staff B confirmed the Care Plan, [brand name of a informational filing system] did not speak to behaviors or interventions related to PTSD. On 12/6/2023 at 9:55 a.m., Resident #26's assigned 7:00 a.m.-3:00 p.m. Staff D, Licensed Practical Nurse revealed she knew the resident and her care needs. Staff D revealed Resident #26 was mostly pleasant, talkative and allowed for care performed for her. Staff D revealed she rarely if any ever refused care and services, nor had she had any complaints related to other residents, staff, or with her care. Staff D revealed sometimes the resident presented with some depressive episodes and she had teared up at times talking about her family. But other than that, she stayed in her room and watched television, or used her electronic phone device. Staff D confirmed Resident #26 had not presented with any other type of behaviors, at least none that she had been aware of. Staff D was not aware Resident #26 had an admitting diagnosis of PTSD since 6/15/2023. Staff D confirmed that she would not know what type of behaviors to look out for and report related to that diagnosis and did not know the reason she had PTSD. Staff D confirmed the resident had been seen by psychology services, but did not know of the specific reason for being seen by that service. Staff D revealed Resident #26 received antipsychotic medications and she was to be monitored for behaviors related to the use of that type of medication. However, she confirmed that behavior coding would be related to the use of psychotropic medications, and not for a diagnosis of PTSD. Further interview with Staff D revealed she, nor had any other of her direct care staff been trained and inserviced related to PTSD behaviors for Resident #26. She confirmed she did not know what the PTSD was related to and was not clear on what type of PTSD behaviors Resident #26 may present as a result from that diagnosis. She confirmed there was a Care Plan that noted trauma and PTSD, but there was nothing specific to reflect the types of trauma Resident #26 had incurred in the past. Staff D also confirmed Resident #26 had been assessed and checked with an active diagnosis of PTSD on the current quarterly and admission Minimum Data Set (MDS) assessment. Staff D confirmed, she nor her aides, would not be able to appropriately observe, report, or document behaviors of PTSD, related to Resident #26. On 12/6/2023 at 10:20 a.m., an interview with the Social Service Director revealed he was aware of the resident and aware of her care needs. He confirmed the resident had an admitting diagnosis of PTSD but did not know the reason for it. He stated the resident had spoken about missing money from family members pre admission, but did not know of any other reason that would relate to PTSD. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 19 of 26 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 12/07/2023 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 0699 Level of Harm - Minimal harm or potential for actual harm Social Service Director also confirmed he would not know what to look for behavior wise that would attribute to PTSD. He said he would need to follow up with the resident and psychology department to find out what behaviors to look out for. He also confirmed Resident #26 had been diagnosed with PTSD prior to admission, and had also been care planned for PTSD, but with no specific interventions, or specific behaviors. Residents Affected - Few On 12/4/2023 at 10:00 a.m., an interview was conducted with Resident #26 in her room. She was dressed for the day and well groomed. The resident provided a very long history of her life without any mention of past trauma. She said she served in the military, but had nothing but very good things to speak of. She did not speak of any traumatic experiences while she served in the military. Resident #26 had a room mate at the time of the survey and she revealed she was happy with her room mate and had no issues with her. She also said she had no current issues with any of the staff who worked in the building. Resident #26 was visited several more times during the survey from 12/4/2023 through to 12/7/2023. During the times she was observed and interviewed, she did not present with any behaviors, pain or discomfort. On 12/7/2023 at 10:00 a.m. the resident was visited and she was asked about her care and services to include visits from physicians and/or psychologists. She noted that she had been visited by both her physician as well as some visits from a psychologist. She revealed the visits were positive and had nothing negative to speak of other than she had some concerns with her family and also felt residents at the facility would not talk to her that much. Resident #26 was asked if when she was visited from psychiatric services, did they speak to her or did she speak to them related to any type of past trauma. She could not remember if she had spoken about anything or not. She did not have anything to offer related to any past trauma while being interviewed. She revealed she had anxiety and was currently being treated for it and felt the treatment was working well. On 12/4/2023 the Director of Nursing (DON) provided the facility's Resident Matrix assessment for review and it revealed Resident #26 had been marked/checked for Post Traumatic Stress Disorder (PTSD). Review of the electronic medical record revealed Resident #26 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed Resident #26 was her own responsible party and did not have any family or friends who visited. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Encephalopathy, Depression, , Anxiety, Insomnia, and Post Traumatic Stress Disorder (PTSD). Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 10/17/2023, revealed: (Cognition/Brief Interview Mental Score or BIMS score = Was not scored but further revealed Short term/Long term memory was ok, and was independent with decision making skills); (Mood = Checked yes with 7-11 days of feeling or appearing down, depressed, or hopeless, Checked yes with 2-6 days of feeling tired or having little energy, Checked yes with 1 day with trouble with things such as reading a newspaper or watching TV); (Behaviors = none checked as exhibited); (Active Diagnoses = Checked yes for Post Traumatic Stress Disorder (PTSD). Review of the Social Services History and initial assessment dated [DATE] (upon admission), revealed: Section 5 Trauma Screening = Checked No/Not Applicable for all questions; which indicated there was no Trauma. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 20 of 26 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 12/07/2023 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The notes section revealed; Patient states she is sad, psych services were offered and declined. This writer told the patient to alert social services if she wishes to have psych services in the future. Review of the Social Services History and Initial assessment dated [DATE] revealed; Section 5 Trauma Screening; = Checked No/Not Applicable for all questions; which indicated there was no Trauma. There were no additional notes in this assessment. Review of the nurse progress notes since admission 6/15/2023 through to current date 12/6/2023 revealed; 1. Review of 7/15/2023 at 15:25 (3:15 p.m.)note revealed; Pt. with increased weeping and crying states has some anxiety due to personal situations currently, one on one support provided and had effective outcome to calm patient's nerve. 2. Review of 7/16/2023 at 14:47 (2:47 p.m.) note revealed; Pt alert and oriented, can verbalize needs well. Pt verbalized to [doctor] that money was stolen from her prior to this admission, she knows who the person is and would like the police notified. Writer called Sheriff's department, a deputy will be in touch. 3. Review of 10/17/2023 23:00 (11:00 p.m.) note revealed; Pt. seen today for follow-up Psychiatric evaluation and medication management. Pt. is alert and oriented x 2 and verbalizes frustrations. She reports increased depression and anxiety which is worse because she does not have any family or friends. She reports that other residents do not engage in any conversations with her and she is having some minor issues with her room mate. She is open to talking to a psychologist regarding her past trauma. She denies any suicidal ideation or homicidal ideations. Meds reviewed and changes made. 4. Review of 10/24/2023 23:00 (11:00 p.m.) note revealed; Psych note, Pt. seen today to evaluate med effectiveness with recent dose increase. She was seen crying and noted to be very anxious and worried about not being able to contact a very good friend. She reports she does not have any friends and feels very lonely. 5. 11/1/2023 (1:00 p.m.) psych note - Pt. seen today for follow up and med review. She continues to endorse feeling depressed but reports some improvement in anxiety. Psych support ongoing. An interview could not be conducted with Resident #26's psychologist. Review of the current care plans with next review date of 1/18/2024 revealed the following but not limited problem areas: b. Resident #26 has experienced a traumatic event which has impacted their emotional health As Evidence By (AEB) PTSD, with interventions to include: Refer to Psych services as need, Alert Physician of any significant changes in behavior, Encourage and assist resident with activities of choice, Encourage and assist the resident to have contact with family and friends if able, Encourage expression of feelings/concerns/thoughts, Provide non threatening environment as indicated, Respect resident's space and privacy. The care plan did not specify what type of behaviors the resident would need to be monitored for, nor did it mention what type of behaviors needed to be reported to the Physician with regards to past trauma. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 21 of 26 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 12/07/2023 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/6/2023 at 10:20 a.m., during an interview with the Staff E, Care Plan Coordinator she confirmed the resident was admitted with a PTSD diagnosis. She said the resident had been marked on the Minimum Data Set (MDS) as having PTSD and care planned with a problem area regarding PTSD. She was not sure of the reason Resident #26 had PTSD and it did not reflect in the care plan or admission notes. Staff E was able to pull up and show a psychologist note dated 10/17/2023. It revealed documentation including Resident #26's maternal grandmother had committed suicide. The Care Plan Coordinator was not able to say this was part of the PTSD. Staff E confirmed all staff to include the Interdisciplinary Care plan Team and the direct care staff who care for Resident #26 need to be aware of what specific trauma she had in order to monitor, report, and care plan to ensure the resident's needs were met related to PTSD. She confirmed the PTSD care plan did not specify any type of trauma behaviors to look out for. On 12/6/2023 at 1:00 p.m., an interview with the Director of Nursing, the Social Service Director, and Staff E, all confirmed Resident #26 had been assessed upon her admission to have PTSD and was care planned for it. The above interviewed staff further confirmed that the care plan did not reflect types of trauma behaviors the resident would need to be monitored for related to PTSD. They also confirmed Resident had been seen by psych services but they do not know the reason for past trauma or PTSD. Staff E did reveal one of the psychologist notes documented the resident's Grandmother had committed suicide, but they were not for certain this was part of the diagnosis of PTSD. She revealed she would need to have another psychologist visit and to assess the reasons for past trauma in order for them (care plan team) to identify the specific problem area, as well as provide the appropriate specific interventions related to that type of trauma. On 12/7/2023 at 8:30 a.m. the Nursing Home Administrator provided the Trauma Informed Care policy and procedure with a revised date of March, 2019, for review. The purpose of the policy revealed it is to guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. The preparation section of this policy revealed; 1. Staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting. 2. Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. The general guidelines of this policy revealed to include but not limited to: 3. Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. Review of the steps in procedure section of this policy revealed; Organizational Strategies to include: (1) Develop an organizational culture that supports trauma-informed care. (2) Use trauma-informed principals in strategic planning. (3) Use trauma-informed care and part of the QAPI plan, so that needs and problem areas are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 22 of 26 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 12/07/2023 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 0699 identified and addressed. Level of Harm - Minimal harm or potential for actual harm (4) Implement universal screening of residents for trauma. Resident-Care Strategies to include: Residents Affected - Few (1.) As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. (2.) Utilize staff members who have established a rapport with the resident to assess him or her for previous trauma. (3.) Involve psychiatry/psychology services as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 23 of 26 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 12/07/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure a Medication Regimen Review was completed for one month of three months reviewed for three (Residents #27, #77, and #56) of five sampled residents and failed to ensure a recommendation was adequately and accurately implemented for one (Resident #27) out of five residents sampled for unnecessary medications. Findings included: An observation and interview was conducted on 12/4/23 at 2:00 p.m., with Resident #27 as the resident lay in bed. On 12/7/23 at 8:30 a.m. the resident was observed sitting up in bed feeding self breakfast. Review of Resident #27's admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to hemiplegia unspecified affecting left non-dominant side, subsequent encounter unspecified fall, and encounter for other orthopedic aftercare. A review of Resident #27's Medication Regimen reviews for the requested month of September, October, and November 2023 revealed the resident was not reviewed by the Consultant Pharmacist in October 2023. The Consultant Pharmacist's 11/28/23 recommendation asked nursing to consider adding Remove patch 12 hours after applying in regards to Resident #27's Lidocaine External 4% (topical) patch. The Order Summary Report, active as of 12/7/23, revealed an order for Resident #27: Lidocaine External Patch 4% (Lidocaine) - Apply to affected area topically every night shift for mild pain. REMOVE PATCH 12 HOURS AFTER APPLYING. This order was started on 12/6/23. A review of Resident #27's December Treatment Administration Record (TAR) included an order, started on 8/1/23 and discontinued 12/6/23, for Nigh (night) shift to Apply Lidocaine 4% external patch to affected area topically every night shift for mild pain. Review of Resident #27's December TAR included an order, Lidocaine external patch 4% (Lidocaine) Apply to affected area topically every night shift for mild pain. Remove patch 12 hours after applying. This order was scheduled to be applied during Nigh (night) shift. The TAR does not designate the location of the affected area that the Lidocaine should be applied nor it does not schedule the patch to be applied so it can be removed 12 hours after applying. The TAR does not reveal documentation that the patch was removed. A review of Resident #27's care plan revealed the resident had pain and/or was at risk for pain related to (r/t) fracture (fx) right (rt) humeral fx, left distal tibia/fibula (tib/fib), at risk for further decline in function secondary to unmanaged or under managed pain issues. On 12/7/23 at 10:50 a.m., the Director of Nursing reviewed the order for Resident #27's Lidocaine patch and stated the order should specifically identify the area to apply the patch and not affected area also the Lidocaine patch should be on the Medication Administration Record (MAR) not the TAR, and the order should have specific times to apply and remove the patch. The DON confirmed the order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 24 of 26 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 12/07/2023 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 0756 was located on the TAR and did not include on and off times. Level of Harm - Minimal harm or potential for actual harm The policy - Medication Utilization and Prescribing, revised 10/2022, revealed the standard was To ensure medications are prescribed and utilized according to State and Federal guidelines. The guideline showed The facility will comply with the requirements specified in accordance with State and Federal regulations as they pertain to Medications Utilization and Prescribing. Review of the Assessment and Recognition revealed When a medication is prescribed for any reason, the physician and staff will identify the indications (condition or problem for which it is being given, or what the medication is supposed to do or prevent), considering the resident's age, medical and psychiatric conditions, risk, health status, and existing medication regimen. The consultant pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications, including medication regimens that are not supported based on clinical signs or symptoms. Residents Affected - Some On 12/4/2023 at 9:30 a.m., and 3:00 p.m., Resident # 77 was observed both times laying down in his bed with his call light within reach, and his bed observed in a low position. Resident # 77 was not presented with no behaviors, pain, or discomfort. The resident room was presented with a clean, well-lit and home-like environment. Review of admission Resident Information Record dated 12/6/2023 revealed Resident # 77 was initially admitted on [DATE] and readmitted on [DATE], with diagnosis to included but not limited Type 2 Diabetes Mellitus without Complications, Muscle Weakness (Generalized) , Major Depressive Disorder, Single Episode, Unspecified, Anxiety Disorder, Unspecified, Obesity, Unspecified, Hypertensive Heart Disease without Heart Failure. Review of a Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score not recorded. Review of the Consultant Pharmacist Medication Regimen Review dated 11/28/2023 by the consultant pharmacist and found no irregularities on 11/28/2023 for Resident # 77. Further review showed residents did not have any Medication Regimen Reviews conducted for the month of October. On 12/5/2023 at 10: 30 a.m., Resident # 56 was observed laying down in bed fully dressed, and well-groomed with his call light within his reach. Residents were presented with no signs of distress. Review of a Resident Information Record dated 12/6/2023 showed Resident # 56 was originally admitted to the facility on [DATE] with diagnoses to include but not limited to bipolar disorder, unspecified, altered mental status, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, unspecified. Review of the admission Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Review of the Consultant Pharmacist Medication Regimen Review, dated 11/28/2023 by the consultant pharmacist and found no irregularities on 11/28/2023 for Resident # 56, Further review showed resident did not have any Medication Regimen Reviews conducted for the month of October. On 12/52023 at 3:30 p.m., an interview was conducted with Staff G, the Regional Nurse Consultant. She said the facility did not have a pharmacist for the month of October due the facility not paying their pharmacy bill so residents at the facility did not have any Medication Regimens Review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 25 of 26 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 12/07/2023 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 0756 completed in October, but they were seen the months prior and in November. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, 5.0 Consultant Pharmacist Provider Requirements no date, showed Policy Regular and reliable consultant pharmacist services are provided based on a contractual agreement with a consultant pharmacy company. The consultant pharmacist will establish a system whereby the consultant pharmacist observations and recommendations regarding customers' drug therapy are communicated to those with authority and /or d routine drugs) of each customer at least monthly, incorporating federally mandated standards of care in addition to other applicable professional standards, and documenting the review and findings in the customer's medical record. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 26 of 26