Health inspection·October 23, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the failed to maintain a home-like environment for fourteen rooms (# 3, 4, 6, 8, 11, 14, 20, 32,33, 37, 48, 50, 54, 55, 62) out of fifty rooms sampled.Findings included: During a facility tour conducted throughout the facility starting at 10/15/2025 at 9:40 A.M., the following environmental concerns were observed:room [ROOM NUMBER] was observed with missing paint on the walls, and the bed had a reddish-yellowish-brown flaky coating of oxidizations on the metal frame. The same stained coloring was observed on the floors in the room.In room [ROOM NUMBER] the toilet was observed without sealant round the base of the toilet, missing paint from the frame of the bathroom door area, and the beds were with reddish-yellowish-brown flaky coating of oxidizations on the metal frame. One of the beds were noted with a broken side rail. One bedside table was observed with the edging detached from the table. room [ROOM NUMBER], was observed with holes in the wallsroom [ROOM NUMBER] was observed with black marks and missing board from off the wall.room [ROOM NUMBER] was observed with paint chipped off the bathroom door.room [ROOM NUMBER] was observed with unfinished work under the sink in the bathroom, toilet without sealant around the base of the toilet.Room # 37 was observed with missing paint and borders detached from the wall .Room numbers 3, 8, 11,37 48, and 50 were observed with baseboards detached from the walls.room [ROOM NUMBER] observed with missing paint in the bathroom and toilet paper stored on a plunger.room [ROOM NUMBER]'s air mattress cord was observed laying across the floor and going up the wall and plugged in to the Television.On 10/15/2025 at 2:00 p.m. an interview was conducted with the Director of Maintenance (DOM). The DOM said environmental concerns are brought to his attention when the staff puts the information in their work order system. He said he has access to the system on his phone, and he checks the system multiple times a day to see if there are any concerns. He said at this time he only had five open tasks to complete, and none of the issues were the concerns identified in rooms numbers (3, 4, 6, 8, 11,14, 20, 32, 33, 37, 48, 50, 54, 55, and 62). The DOM said this was the first time these concerns were brought to his attention. He said he stated he would also be informed about environmental concerns during morning meetings, but those rooms were never mentioned to him as having any environmental concerns. He said he would like to replace the beds in some of the rooms, but if he could not. He stated he would have to sand the beds down to remove the brownish oxidizations. The DOM said they were working on the holes in the walls using a patch and paint system, but have not gotten to some of the rooms yet. The DOM said they will have to wait until the residents are discharged from the rooms to make the repairs.On 10/15/2025 at 3:48 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA said he was notified of environmental concern during the morning meeting. The NHA stated the department heads make room rounds before the meeting every morning, then report any concerns they find in the meeting. He stated most of the time they make sure they put the concern in their work order system. The NHA said Page 1 of 13 105478 105478 10/23/2025 Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some he also identifies concerns when he make his rounds in the facility. The NHA said nursing aides are o trained to report concerns in the work order system. The NHA said he would expect his staff to report any room lights that are out , electrical cords hanging from light fixtures, holes in the walls, any bed cords plugged in inappropriately, and other environmental concerns in the facility. He said when the staff bring concerns about beds with brown colored oxidization, he orders new ones. The NHA said staff should have brought the concerns to his attention.Review of the facility policy titled, Homelike Environment Revision date 02/2021, revealed policy statement: Resident are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belonging to the extent possible.Policy Interpretation and implementation: 2. The facility staff and management, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a clean, sanitary and orderly environment (Photographic Evidence Obtained) 105478 Page 2 of 13 105478 10/23/2025 Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility failed to investigate an injury of unknown origin, related to bruising on one resident (#3) of three sampled residents.Findings included: Review of the admission Record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses included but not limited to osteoarthritis of knee, disorders of brain, neutropenia, osteoarthritis of both knees, spondylosis without myelopathy or radiculopathy of the lumbar region, epilepsy, disc degeneration of lumbar region with back pain and anemia. Review of the current physician orders showed Aspirin 81 mg (milligrams) at bedtime for DVT (deep vein thrombosis) prophylaxis since 09/24/25Review of the Nursing PRN Skin Check dated 10/17/25 showed resident skin intact. No skin impairments noted at this time, full body check performed by this nurse with husband at bedside.Review of a nursing daily skilled note dated 10/13/25 showed skin was warm/dry. No surgical wound noted. No open wound noted.Review of a nursing daily skilled note dated 10/15/2 at 3:36 p.m. showed skin was warm/dry. No surgical wound noted. No open wound noted.Review of a Change in Condition (CIC) dated 10/15/25 at 11:00 p.m. showed the resident had a fall.Review of the progress note on 10/15/25 at 11:36 p.m. showed, this writer was notified by a staff member that this resident was on the floor. Upon my arrival, she was sitting upright, on the floor, between her bed and the window, trying to fold a blanket. She denied having any pain or hitting her head; however, because of her confusion and inability to describe in detail why she was on the floor, Neuro-checks have been initiated. Resident has full ROM (range of motion). Darker bruises on her upper thighs were present upon inspection, that appeared to be from prior falls.Review of the Nursing Daily Skilled Note dated 10/16/25, 10/17/25, 10/18/25, 10/19/25, 10/20/25, 10/21/25 and 10/22/25 showed the same note, Skin was warm/dry. No surgical wound noted. No open wound noted.Review of the care plan dated 09/29/25 showed Resident #3 was at risk for falls and / or fall related injury related to generalized weakness, limited endurance, impaired balance, unsteady gait, requires staff assist with transfers and ambulation, has a history of falls, has poor safety awareness as of 09/25/25, the resident is noted to have actual skin impairment, see wound notes and /or physician orders as of 09/29/25. Interventions included but not limited to observe skin impairment for signs and symptoms of infection and for significant decline: update physician if noted as of 09/29/25.A second focus in the same care plan showed - Resident has a potential for skin impairment related to impaired mobility, requires staff assist to turn and reposition, incontinence of bowel, incontinence of bladder, history of pressure ulcers, fragile skin, receives medication that may increase risk for bleeding and bruising as of 10/04/25. Interventions included but not limited to perform skin treatments as ordered as of 10/04/25. Observed skin for signs and symptoms of breakdown during care as of 10/04/25. Notify physician of any signs and symptoms of skin breakdown / pressure ulcer if noted as of 10/04/25.During an interview and observation on 10/23/25 at 10:00 a.m. Resident #3 was observed in their room. The therapy aide was with her. The resident did present any bruising on her thighs at the time. The aide stated she did not have any bruises, except she had bruising on her chest after a fall.During an interview and observation on 10/23/25 at 10:22 a.m. Resident #3 was observed in the dining room in her wheelchair. Resident #3 was noted to have 5 small areas of bruising, and tears on her left forearm. She stated it was from a bracelet she had on. Resident #3 stated she had not had any falls recently. During an interview on 10/23/25 at 1:06 p.m. Staff A, Licensed Practical Nurse (LPN) (agency staff) stated she took care of Resident #3 today. She stated Resident #3 was alert with confusion and a high fall risk. Staff A stated the report she received was Resident #3 had no changes. Staff A stated Resident #3 had not had any recent falls. Staff A 105478 Page 3 of 13 105478 10/23/2025 Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident #3 was wheelchair bound. Staff A stated if a resident falls, the following should be done: assess the resident, assess for pain, check vital signs, do neuro checks, and check ROM (range of motion). Staff A stated the findings should be documented in the progress notes and facility form in the electronic chart. Staff A stated the neuro checks were in the electronic chart. She stated Resident #3 was currently not on neuro checks. Staff A stated the residents are supposed to have weekly skin checks that are done on their shower days. During an interview on 10/23/25 at 1:12 p.m. Staff B, Certified Nursing Assistant (CNA) stated Resident #3 was incontinent and required incontinent care, help with dressing, redirecting, coaching, and showers. Staff B stated she wakes Resident #3 up, takes her to the bathroom, brushes her teeth and wash her face. Staff B stated she takes Resident #3 out of the room to go to activities, therapy, bathroom, and the dining room. She stated Resident #3 was not on 1:1, but we keep an eye on her. Staff B, CNA stated Resident #3 has a bruise on her upper left hip the size of a fist. Staff B stated it had gotten smaller, since the first time she saw it. Staff B stated It was dark in color. Staff B stated Resident #3 has had it about 10-14 days. Staff B stated she thought she first saw the bruise on the resident the weekend before. During an interview on 10/23/25 at 1:15 p.m. Staff C, LPN stated if someone falls, they will assess them, do neuro checks, skin check, vital signs, pain assessment, and document on the facility internal form on the electronic chart. Staff C stated they will pick the resident up after the assessment. During an interview on 10/23 at 3:40 p.m. with the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and the Regional Nurse Consultant (RNC), The DON stated Resident #3 was alert with confusion. The DON reviewing the Situation, Background, Assessment, Recommendation (SBAR) dated 09/27/25 stated, the resident slid out of the wheelchair. The DON stated they chart by exception at this facility. The DON stated they performed a skin check on the resident on 09/27/25 and it was okay. The DON and RNC reviewed the falls documentation for 09/27/25, 09/28/25, 09/29/25, 10/01/25, 10/06/25, 10/10/25, and 10/15/25. The DON and RNC reviewed the SBAR and progress note from 10/15/25 regarding a fall and the documentation which showed darker bruises on her upper thighs were present upon inspection, that appeared to be from prior falls. The DON stated she saw Resident #3 on 10/16/25 and the resident did not have any dark bruises. The resident had Petechiae (a small, pinpoint red or purple spot caused by bleeding under the skin surface). The DON said the resident had healing areas, not yellow. The DON stated she was not aware of any bruising. The RNC stated they do weekly skin checks around the shower days. The RNC stated the last skin check was performed on 10/17/25 per the electronic record. The RNC stated the skin check form should show anything new on the skin. The DON and RNC were informed regarding a bruise on the Resident #3s left hip. The DON stated the nursing administration team was unaware of this new area. The DON stated she would have to do an investigation. The DON and ADON left the interview to observe Resident #3's hip. The DON stated, when she returned to the interview, she looked at Resident #3 and the bruising Staff C, CNA, was talking about, and confirmed it was a new area. The DON stated this was new information to the nursing administration team and they would have to do a risk investigation. The DON stated Resident #3 had a dark bruise on her left hip about the side of a baseball. The DON and RNC stated they would have to follow a map and find out how it occurred. The DON confirmed she observed the 5 or 6 areas on Resident #3's left forearm and stated they would have to do an investigation about those also. The DON said, You would normally see it (bruising) reported and it would be investigated, and it would be on a skin sweep. The DON and RNC stated it should have been reported to the nurse who would have reported to the DON. The DON stated the skin sweep expectation was to perform them weekly. The DON confirmed they were not being done.During the interview on 10/23/25 at 5:07 p.m. Staff A, LPN stated she observed the bruise on Resident 105478 Page 4 of 13 105478 10/23/2025 Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #3 today (with the DON and ADON). She stated it looked like an old bruise to her. She stated it was dark, red, black, purple bruised area about the size of a golf ball. She stated she did not measure it. She stated she was not aware of the bruise until the DON came down today to look at it.Review of the facility's policy, Change in a Resident's Condition or Status, revised February 2021, showed: - Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the residence medical /mental condition and / or status.Policy Interpretation and Implementation:1. The nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident b. Discovery of injuries of an unknown source.2. A significant change of condition or a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan;3. Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form.8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.Review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2011 showed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exportation. 8. Identify and investigate all possible incidents of abuse, and neglect, mistreat or misappropriation of resident property. 9e. Investigate and report any allegations within time frames required by federal regulations. 10. Protect residents from any further harm during investigations. 105478 Page 5 of 13 105478 10/23/2025 Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews the facility did not ensure two residents (#1 and #2) out of four residents reviewed had physician orders to ensure the residents received necessary care and services upon admission.Findings included: 1.) An interview was conducted on 10/15/2025 at 10:06 a.m. with the resident representative (RR) for Resident #1. The RR said the resident had been discharged from the facility and was in the hospital for an issue with a foot wound. The RR said she had concerns about the facility not giving Resident #1 insulin when he was initially admitted to the facility. She said the resident finally received insulin, but only half of his normal dose. The RR said she had spoken to the nurse assigned to Resident #1 about her concerns. The RR said the resident also informed the nurse he was supposed to be on insulin his first day in the facility and asked about his insulin multiple times and filed a grievance.Review of admission Records showed Resident #1 was admitted from the hospital on 9/24/25 with diagnoses including type 2 diabetes mellitus (DM) with foot ulcer, type 2 diabetes with other specified complications, diabetes mellitus with diabetic peripheral angiopathy, and peripheral vascular disease.Review of Resident #1's Brief Interview for Mental Status (BIMS), completed 9/25/25, showed a score of 14, indicating he was cognitively intact.Review of Resident #1's hospital Medication Discharge Report, dated 9/24/25, showed:Stop Taking the Following Medications-Insulin Aspart (Novolog Flex pen 100 units (u)/milliliter (ml) injectable solution. Sliding scale. Subcutaneous. Three times a day before meals.-Insulin Glargine (Lantus Solostar pen 100 u/ml subcutaneous injection. 20 u once a day.No additional medications for diabetic control were listed on the Medication Discharge Report.Review of Resident #1's Hospital Medication Administration Record (MAR) showed the resident last had Insulin Aspart 14 u on 9/24/25 at 6:01 p.m. and Insulin Glargine 10 u on 9/23/25 at 8:57 p.m.Review of Resident #1's progress notes did not show any documentation the discharge medication list was reviewed and reconciled with a provider upon admission.Review of Resident #1's weights and vitals showed no documentation the resident's blood glucose level was checked at the facility until 9/26/25 at 9:21 p.m., when the level reading was 240 milligram (mg)/deciliter (dL). (Normal range: fasting: 70-140 mg/dL; Post-meal: less than 160 mg/dL)Review of Grievance/Concern Reports showed a grievance filed by Resident #1 on 9/25/25 with concerns including the facility not having his medications at admission.Review of Resident #1's facility orders did not reveal any insulin orders until:-Novolog Flex Pen Subcutaneous Solution Pen-injector 100 u/ml (Insulin Aspart) Inject as per sliding scale: if 150 - 200 = 2 units give glucagon notify MD of BS <60; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units give 10 units and notify MD of BS > 400, subcutaneously before meals and at bedtime for diabetes mellitus (DM) type II for 7 Days. Start date 9/26/25.-Insulin Glargine Subcutaneous Solution. Inject 10 units subcutaneously two times a day for diabetes mellitus. Start date 9/29/25. Review of Resident #1's facility MAR showed Novolog insulin was administered for the first time of 9/26/25 at 4:40 p.m. and the resident had a blood glucose level of 240 mg/dL, two days after admission to the facility. The MAR showed Insulin glargine was administered for the first time on 9/28/25 at 6:00 a.m., four days after admission to the facility.2.) An interview was conducted on 10/15/25 at 6:15 p.m. with the RR for Resident #2. The RR said when Resident #2 arrived at the facility it apparently wasn't clear in the hospital paperwork that the resident was on insulin. The RR said when the admitting nurse reviewed medication with them, they notified the nurse the resident needed insulin. The RR said Resident #2 went a day or so without insulin but didn't have any negative effects.Review of admission Records showed Resident #2 was admitted from the hospital on 9/27/25 with diagnoses including diabetes mellitus type II, chronic obstructive pulmonary disease, and obesity.Review of Resident #2's hospital paperwork did not list Residents Affected - Some 105478 Page 6 of 13 105478 10/23/2025 Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some insulin on the Med Rec Discharge meds however, the Medication Discharge Summary from the hospital showed the resident was on Insulin, regular 70/30 100 u/ml 20 u twice daily before meals and Insulin Lispro 100 u/ml before meals and at bedtime.Review of Resident #2's progress notes did not show any documentation the discharge medication list was reviewed and reconciled with a provider upon admission.Review of Resident #2's orders did not show any orders for insulin put in at the facility upon admission.Review of Resident #2's Weights and Vitals Summary showed the resident's blood glucose level was not checked until 9/29/25 at 1:37 p.m., two days after admission to the facility, with a reading of 296 mg/dL.Review of Resident #2's facility orders and MAR showed an order for Novolin 70/30 flexpen 100 u/ml. Inject 45 u subcutaneously before meals related to type 2 DM, start date 9/29/25. The first dose was signed off as administered on 9/29/25 at 4:30 p.m. and the resident had a blood glucose level of 393 mg/dL. An order for Novolin 70/30 flexpen 100 u/ml. Inject 25 u subcutaneously at bedtime related to type 2 DM, start date 9/29/25. The first dose was signed off as administered on 9/29/25 at 9:00 p.m. The resident's blood glucose level was 397 mg/dL.An interview was conducted on 10/15/25 at 4:40 p.m. with Staff D, Licensed Practical Nurse (LPN). Staff D said when admitting a resident to the facility the resident came with a discharge medication list from the hospital, and the admitting nurse entered those orders into the facility orders. Staff D said the day after admission the supervisors reviewed the new admission and the orders. Staff D said the admitting nurse did not call the doctor or send the orders to the doctor to be reviewed. Staff D said when Resident #1 was admitted she was his assigned nurse but Staff E, Registered Nurse (RN) did his admission. She said she didn't recall seeing anything about Resident #1 being diabetic but did see that it said stop insulin. She said the resident's hospital paperwork was confusing. Staff D said a couple of days after admission she checked Resident #1's blood glucose and it was high so she called the provider and they gave an order for long acting insulin.An interview was conducted on 10/15/25 at 5:00 p.m. with Staff E, RN. He said when there is a new admission the resident came from the hospital with paperwork including their medication reconciliation. He said the admitting nurse entered the orders from the medication reconciliation into he computer. He said the nurse did not call and go over the medications with the provider. Staff E said usually the provider already knew the resident from the hospital anyway. He said the provider reviewed the medications when they came in and saw the resident. He said the providers are usually in the building twice a week. Staff E said if the admitting nurse had any questions, they could call the discharge nurse at the hospital or the provider. He said management also reviewed new admissions the next day. Staff E said if a resident came in on insulin or oral DM medications, they would put in an order for blood glucose checks to be done. Staff E said he did the admission for Resident #1. He said he wasn't concerned that the hospital medication reconciliation said to stop insulin because he had seen the hospital stop it for residents before at discharge. He said Resident #1 told him he was on insulin. Staff E said he had to show him the hospital paperwork where it said to stop taking insulin. He said he told the resident that is what he had to go by.An interview was conducted on 10/15/25 at 5:28 p.m. with the Director of Nursing (DON). She said when there is a new admission the facility would get some paperwork ahead of time, but the resident would also come with their discharge medication list from the hospital. The DON said the admitting nurse got the paperwork, did all the necessary evaluations and consents, go over medications with the resident and/or family, then call the doctor to get verification if medications are ok. The DON reviewed the records of Resident #1 and #2 and confirmed she did not see any documentation the admission medications were reconciled with a provider upon admission. She said she would expect there to be a nurses' note saying the provider was called and medications were reviewed. The DON said she expected the 105478 Page 7 of 13 105478 10/23/2025 Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nurses to call the provider before putting orders into the computer for a resident. The DON said as far as blood glucose checks she said there were batch orders that everyone can have a blood glucose check for signs or symptoms of high or low blood sugar. She said if a resident says they are diabetic the nurse should do blood glucose checks. The DON said for Resident #1 the fact he wasn't getting insulin was brought to the facility's attention when the resident filed a grievance. She said she would have expected the nurse to call the doctor if a resident told them they should have insulin and were not getting it. The DON said regarding Resident #2, just because she is diabetic doesn't mean she would get insulin or need blood glucose checks. She said it was concerning that nurses were not calling the provider to reconcile medications on admission. The DON said the facility did have an admission checklist, but it depended on the nurse if they used it or not.A follow-up interview was conducted with the DON on 10/15/25 at 6:45 p.m. The DON said the day after a resident's admission the resident is reviewed in the morning clinical meeting. She said they ensure everything is in the record and match what came from the hospital. The DON said she was not there when Resident #1 and #2's records would have been reviewed, and the clinical team didn't remember if they reviewed them.An interview was conducted on 10/15/25 at 6:48 p.m. with the Assistant Director of Nursing (ADON). She said when reviewing new admission in the clinical meetings the Unit Manager (UM) reviewed the admission paperwork and the resident's electronic medical record if pulled up on the big screen. She said the UM goes through the paperwork from the hospital and they all make sure the orders were entered correctly. She did not recall if Resident #1 and #2's records were reviewed.An interview was conducted on 10/15/25 at 6:55 p.m. with Staff F, LPN/UM. Staff F said she did admission record reviews and in that process, she made sure batch orders were in place, she checked medications on the discharge paperwork and ensured correct doses were ordered. Staff F said she did not recall Resident #1 or #2's review. She said seeing stop insulin on the hospital discharge paperwork wouldn't necessarily make her question it because some residents are on insulin temporarily in the hospital, but if a resident and/or RR said the resident was on insulin she would call the doctor or expect the nurse to call and get orders for insulin and/or blood glucose checks.Residents #1 and #2 primary care provider could not be reached.Review of the facility admission Checklist included but not limited to: -Add/Verify Attending Physician-Input Diagnosis and review H&P (history and physical)-Review hospital discharge orders-Add/Verify MD (medical doctor) orders from discharge med reconciliation ensure appropriate diagnosis, route, parameters. Ensure each diagnosis is covered in medication regimen if applicable.On 10/15/25 at 7:04 p.m. the DON stated the facility did not have a policy on medication reconciliation or diabetes management or the admission process.Review of a facility policy titled Physician Services, revised February 2021, showed: Policy Statement - The medical care of each resident is supervised by a licensed physician.Policy Interpretation and Implementation showed:1. A physician must recommend in writing that an individual be admitted to the facility. This can be accomplished through:a. hospital transfer summary completed by a physician;b. admission paperwork completed by the resident's physician in the community:c. other written form completed by a physician; ord. a physician 's admission orders for the resident's immediate care.2. Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). 105478 Page 8 of 13 105478 10/23/2025 Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure referral for urology consultation/evaluation was provided for one resident (#5) of three residents sampled.Findings Included: Review of an admission Record dated 10/23/2025 revealed Resident #5 was admitted to the facility on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus with hyperglycemia, neuromuscular dysfunction of bladder, unspecified, infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter, chronic kidney disease, stage 3A. Review of an order summary dated 10/23/2025 showed:Consult Urology for urinary retention, verbal active order, dated 10/23/2025. Review of a progress note dated 10/08/2025 created by Staff G, Advanced Registered Nurse Practitioner (ARNP) noted to start a voiding trial on Resident #5. If voiding trial fails reinsert indwelling foley and consult urology. Review of a progress note dated 10/13/2025 created by Staff G, ARNP showed Staff G gave verbal orders previously on Friday for voiding trial, but it was not done for unknow reasons. Staff G noted she spoke with nursing and the Director of Nurses (DON) about the plan and requested voiding trial to be done and if voiding trial fails, consult urology. Review of a progress note dated 10/20/2205 created by Staff G, ARNP showed on 10/20/2025, Resident #5 did not pass voiding trial despite electronic record documentation indicating otherwise. Staff G noted Resident #5 had not voided with need for straight cath (catheterization) and greater than 400 mls [milliliters] output with urinalysis with culture and sensitivity obtained and + yeast, see labs and plan. On 10/23/2025 at 2:00 p.m. an interview was conducted with the Director of Nurses, DON. The DON said the ARNP put Resident #5 on a voiding trial because she did not have justification for the use of a foley catheter. The DON stated the ARNP wanted Resident #5 to start a voiding trial. The DON said, When we conducted the trial, the resident failed. The DON said the Nurse Practitioner noted to consult urology if Resident #5 failed the trial, but she did not put an order in the system. The DON said when she reached out to the ARNP she told them to just leave the foley in. The DON said the ARNP could have put the urology consult order in the system if she wanted Resident #5 to be seen by urology. On 10/23/2025 at 3:30 p.m. an interview was conducted with Staff G, ARNP. The ARNP said she wrote in her progress notes to start a voiding trial on Resident #5 because she had a diagnosis on her 3008 for acute retention. She said she told the nurse and the director of nurses twice if the resident failed the voiding trial to consult urology. She said the director of nurses reached out to tell her the resident was not voiding, and they only obtained 2000 milliliters of urine. The ARNP said she told the DON they needed to get a consultation from urology. The ARNP said once she gave the facility a verbal order they should have put the urology consult order in the system. She said she told the Unit Manager and the DON both to consult urology if the resident did not pass the voiding trial. She said the told the Unit Manager on Friday and told the DON again on Monday to consult urology for Resident #5. She said she told them to leave the foley in and consult urology The facility did not have a policy/procedure regarding care consultation and referral. Residents Affected - Few 105478 Page 9 of 13 105478 10/23/2025 Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interviews and records review facility did not ensure residents received necessary prescribed medications upon admission for two residents (#1, #2) out of four residents reviewed. Findings included: 1.) An interview was conducted on 10/15/2025 at 10:06 a.m. with the resident representative (RR) for Resident #1. The RR said the resident had been discharged from the facility and was in the hospital for an issue with a foot wound. The RR said she had concerns about the facility not giving Resident #1 insulin when he was initially admitted to the facility. She said the resident finally received insulin, but only half of his normal dose. The RR said she had spoken to the nurse assigned to Resident #1 about her concerns. The RR said the resident also informed the nurse he was supposed to be on insulin his first day in the facility and asked about his insulin multiple times and filed a grievance.Review of admission Records showed Resident #1 was admitted from the hospital on 9/24/25 with diagnoses including type 2 diabetes mellitus with foot ulcer, type 2 diabetes with other specified complications, diabetes mellitus with diabetic peripheral angiopathy, and peripheral vascular disease.Review of Resident #1's Brief Interview for Mental Status (BIMS), completed 9/25/25, showed a score of 14, indicating he was cognitively intact.Review of Resident #1's hospital Medication Discharge Report, dated 9/24/25, showed, Stop Taking the Following Medications:-Insulin Aspart (Novolog Flex pen 100 units (u)/milliliter (ml) injectable solution. Sliding scale. Subcutaneous. Three times a day before meals.-Insulin Glargine (Lantus Solostar pen 100 u/ml subcutaneous injection. 20 u once a day.No additional medications for diabetic control were listed on the Medication Discharge Report.Review of Resident #1's Hospital Medication Administration Record (MAR) showed the resident last had Insulin Aspart 14 u on 9/24/25 at 6:01 p.m. and Insulin Glargine 10 u on 9/23/25 at 8:57 p.m.Review of Resident #1's progress notes did not show any documentation the discharge medication list was reviewed and reconciled with a provider upon admission.Review of Resident #1's weights and vitals showed no documentation the resident's blood glucose level was checked at the facility until 9/26/25 at 9:21 p.m., when the level reading was 240 milligram (mg)/deciliter (dL). (Normal range: fasting: 70-140 mg/dL; Post-meal: less than 160 mg/dL)Review of Grievance/Concern Reports showed a grievance filed by Resident #1 on 9/25/25 with concerns including the facility not having his medications at admission.Review of Resident #1's facility orders did not reveal any insulin orders as follows:-Novolog Flex Pen Subcutaneous Solution Pen-injector 100 u/ml (Insulin Aspart) Inject as per sliding scale: if 150 - 200 = 2 units give glucagon notify MD of BS <60; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units give 10 units and notify MD of BS > 400, subcutaneously before meals and at bedtime for diabetes mellitus (DM) type II for 7 Days. Start date 9/26/25.-Insulin Glargine Subcutaneous Solution. Inject 10 unit subcutaneously two times a day for diabetes mellitus. Start date 9/29/25. Review of Resident #1's facility MAR showed Novolog insulin was administered for the first time of 9/26/25 at 4:40 p.m. and the resident had a blood glucose level of 240 mg/dL, two days after admission to the facility. The MAR showed Insulin glargine was administered for the first time on 9/28/25 at 6:00 a.m., four days after admission to the facility.2.) An interview was conducted on 10/15/25 at 6:15 p.m. with the RR for Resident #2. The RR said when Resident #2 arrived at the facility it apparently wasn't clear in the hospital paperwork that the resident was on insulin. The RR said when the admitting nurse reviewed medication with them, they notified the nurse the resident needed insulin. The RR said Resident #2 went a day or so without insulin but didn't have any negative effects.Review of admission Records showed Resident #2 was admitted from the hospital on 9/27/25 with diagnoses including diabetes mellitus type II, chronic obstructive pulmonary disease, and obesity.Review of Resident #2's hospital paperwork did not list insulin on the Med Rec Discharge meds however, the Medication Residents Affected - Some 105478 Page 10 of 13 105478 10/23/2025 Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Discharge Summary from the hospital showed the resident was on Insulin, regular 70/30 100 u/ml 20 u twice daily before meals and Insulin Lispro 100 u/ml before meals and at bedtime.Review of Resident #2's progress notes did not show any documentation the discharge medication list was reviewed and reconciled with a provider upon admission.Review of Resident #2's orders did not show any orders for insulin put in at the facility upon admission.Review of Resident #2's Weights and Vitals Summary showed the resident's blood glucose level was not checked until 9/29/25 at 1:37 p.m., two days after admission to the facility, with a reading of 296 mg/dL.Review of Resident #2's facility orders and MAR showed an order for Novolin 70/30 flexpen 100 u/ml. Inject 45 u subcutaneously before meals related to type 2 DM, start date 9/29/25. The first dose was signed off as administered on 9/29/25 at 4:30 p.m. and the resident had a blood glucose level of 393 mg/dL. An order for Novolin 70/30 flexpen 100 u/ml. Inject 25 u subcutaneously at bedtime related to type 2 DM, start date 9/29/25. The first dose was signed off as administered on 9/29/25 at 9:00 p.m. The resident's blood glucose level was 397 mg/dL.An interview was conducted on 10/15/25 at 4:40 p.m. with Staff D, Licensed Practical Nurse (LPN). Staff D said when admitting a resident to the facility the resident came with a discharge medication list from the hospital, and the admitting nurse entered those orders into the facility orders. Staff D said the day after admission the supervisors reviewed the new admission and the orders. Staff D said the admitting nurse did not call the doctor or send the orders to the doctor to be reviewed. Staff D said when Resident #1 was admitted she was his assigned nurse but Staff E, Registered Nurse (RN) did his admission. She said she didn't recall seeing anything about Resident #1 being diabetic but did see that it said stop insulin. She said the resident's hospital paperwork was confusing. Staff D said a couple of days after admission she checked Resident #1's blood glucose and it was high so she called the provider and they gave an order for long acting insulin.An interview was conducted on 10/15/25 at 5:00 p.m. with Staff E, RN. He said when there is a new admission the resident came from the hospital with paperwork including their medication reconciliation. He said the admitting nurse entered the orders from the medication reconciliation into the computer. He said the nurse did not call and go over the medications with the provider. Staff E said usually the provider already knew the resident from the hospital anyway. He said the provider reviewed the medications when they came in and saw the resident. He said the providers are usually in the building twice a week. Staff E said if the admitting nurse had any questions, they could call the discharge nurse at the hospital or the provider. He said management also reviewed new admissions the next day. Staff E said if a resident came in on insulin or oral DM medications, they would put in an order for blood glucose checks to be done. Staff E said he did the admission for Resident #1. He said he wasn't concerned that the hospital medication reconciliation said to stop insulin because he had seen the hospital stop it for residents before at discharge. He said Resident #1 told him he was on insulin. Staff E said he had to show him the hospital paperwork where it said to stop taking insulin. He said he told the resident that is what he had to go by.An interview was conducted on 10/15/25 at 5:28 p.m. with the Director of Nursing (DON). She said when there is a new admission the facility would get some paperwork ahead of time, but the resident would also come with their discharge medication list from the hospital. The DON said the admitting nurse got the paperwork, did all the necessary evaluations and consents, go over medications with the resident and/or family, then call the doctor to get verification if medications are ok. The DON reviewed the records of Resident #1 and #2 and confirmed she did not see any documentation the admission medications were reconciled with a provider upon admission. She said she would expect there to be a nurses' note saying the provider was called and medications were reviewed. The DON said she expected the nurses to call the provider before putting orders into the 105478 Page 11 of 13 105478 10/23/2025 Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some computer for a resident. The DON said as far as blood glucose checks she said there were batch orders that everyone can have a blood glucose check for signs or symptoms of high or low blood sugar. She said if a resident says they are diabetic the nurse should do blood glucose checks. The DON said for Resident #1 the fact he wasn't getting insulin was brought to the facility's attention when the resident filed a grievance. She said she would have expected the nurse to call the doctor if a resident told them they should have insulin and were not getting it. The DON said regarding Resident #2, just because she is diabetic doesn't mean she would get insulin or need blood glucose checks. She said it was concerning that nurses were not calling the provider to reconcile medications on admission. The DON said the facility did have an admission checklist, but it depended on the nurse if they used it or not.A follow-up interview was conducted with the DON on 10/15/25 at 6:45 p.m. The DON said the day after a resident's admission the resident is reviewed in the morning clinical meeting. She said they ensure everything is in the record and match what came from the hospital. The DON said she was not there when Resident #1 and #2's records would have been reviewed, and the clinical team didn't remember if they reviewed them.An interview was conducted on 10/15/25 at 6:48 p.m. with the Assistant Director of Nursing (ADON). She said when reviewing new admission in the clinical meetings the Unit Manager (UM) reviewed the admission paperwork and the resident's electronic medical record if pulled up on the big screen. She said the UM goes through the paperwork from the hospital and they all make sure the orders were entered correctly. She did not recall if Resident #1 and #2's records were reviewed.An interview was conducted on 10/15/25 at 6:55 p.m. with Staff F, LPN/UM. Staff F said she did admission record reviews and in that process, she made sure batch orders were in place, she checked medications on the discharge paperwork and ensured correct doses were ordered. Staff F said she did not recall Resident #1 or #2's review. She said seeing stop insulin on the hospital discharge paperwork wouldn't necessarily make her question it because some residents are on insulin temporarily in the hospital, but if a resident and/or RR said the resident was on insulin she would call the doctor or expect the nurse to call and get orders for insulin and/or blood glucose checks.Residents #1 and #2 primary care provider could not be reached.Review of the facility admission Checklist included but not limited to: -Add/Verify Attending Physician-Input Diagnosis and review H&P (history and physical)-Review hospital discharge orders-Add/Verify MD (medical doctor) orders from discharge med reconciliation ensure appropriate diagnosis, route, parameters. Ensure each diagnosis is covered in medication regimen if applicable.On 10/15/25 at 7:04 p.m. the DON stated the facility did not have a policy on medication reconciliation or diabetes management or the admission process.Review of a facility job description titled Licensed Practical Nurse/Registered Nurse, revised 1/1/15, showed: Purpose of Your Position - The primary purpose of your position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by CNAs/GNAs and other nursing personnel. To monitor the performance of CNAs/GNAs, nursing and non licensed personnel, provide education and counseling, perform disciplinary action as necessary, and complete performance evaluations. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times.Charting and Documentation Complete and file required recordkeeping forms or charts upon the resident's admission, transfer, and/or discharge. Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies. Receive telephone orders from physicians and record on the Physician's Order Form.Transcribe physician's orders to resident charts, cardex, medication cards, treatment or care plans, as required. 105478 Page 12 of 13 105478 10/23/2025 Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor and/or Unit Manger.Drug Administration Functions Review medication cards for completeness of information,) accuracy in the transcription of the physician's order, and adherence to stop order policies. Notify the attending physician of automatic/stop/orders prior' to the last dosage being administered.Nursing Care Functions Consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary. Review the resident's chart for specific treatments, medication orders, diets, etc., as necessary. Maintain established nursing objectives and standards. 105478 Page 13 of 13