Inspection·June 25, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During initial observation and an interview with Resident #305 on 6/22/2021 at 09:55 a.m., he was seen to have a left-hand contracture. The resident stated, I had a stroke, I wear a splint, and they have not put it on me yet for some reason this morning. An observation was conducted on 06/22/2021 at 10:25 a.m. of Resident #305. During the observation, the resident was observed to not be wearing the left-hand brace. Resident # 305 was asked if they came in to apply the splint and he stated No, they do it usually first thing in the morning. An observation was conducted of Resident #305 self-propelling outside the main dining room on 06/23/2021 at 08:56 a.m. The resident was observed to not have the brace on his left-hand contracture. Resident #305 stated they have not put it on yet. During an observation conducted of Resident #305 on 6/23/2021 at 10:52 a.m., the resident was observed to be sitting in his room in a wheelchair and did not have the left-hand splint on. Resident #305's left hand was hanging down by the wheelchair and the splint was observed to be on the mechanical wheelchair. (Photographic Evidence Obtained.) An observation was conducted on 06/23/2021 at 02:59 p.m. of Resident #305 not wearing the left-hand brace. The resident stated, No I saw her around, but she did not come in, it's still on my chair over there. On 06/24/2021 at 02:27 p.m. a subsequent observation was made on Resident #305 in the main dining room. The resident was observed to not have the splint on his left-hand contracture. On 06/25/2021 at 08:35 a.m. Resident #305 was observed not wearing the splint. The resident revealed that staff had not put it on him, and that he had not refused having the device applied to his left-hand contracture. Record review of active physician orders dated 5/10/2021 for Resident #305 read Splint by shift Left hand RNP [restorative nursing program] follows for placement and ROM [range of motion], may remove for skin checks. Facility Profile review for Resident #305 indicated he was admitted on [DATE] with multiple diagnoses that included Hemiplegia following Cerebral Infarction affecting Left Non dominate side, and muscle weakness. Further record review of Resident #305's care-plan with Goal date of 7/29/2021 revealed under active interventions RNP for Left Hand splint remove for skin checks and hygiene. A continued record review of quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident #305's Brief Interview for Mental Status (BIMS) score was 12, (on a 0-15 scoring scale) indicating moderate cognitive impairment. During an interview conducted with both the DON and Staff F, Restorative Aide, on 6/25/2021 at 9:06 a.m., Staff F Indicated what her job duties were related to Resident #305's left hand contracture. She stated we do range of motion with his left hand; we wash and dry and lotion his hand and put the splint on. Staff F was asked about Resident #305, she stated I have not made it down there this week, and it is my responsibility to put it on, and sometimes the direct care put it on too. The DON, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 2 of 7 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 105654 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westchester Gardens Health & Rehabilitation 3301 N McMullen Booth Rd Clearwater, FL 33761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who was listening to the interview, then asked Staff F to immediately put the splint device on Resident #305. On 06/25/21 at 09:32 a.m. an interview was conducted with the Director of Rehabilitation. During the interview, she indicated she went down to ask Resident #305 if he can move his hand up, when it falls, and to assess the resident. She further revealed that she told the resident to let someone know when it falls or is in a bad position or his hand is hanging off the wheelchair because he cannot move it. A review of the facility policy titled Comprehensive Care-Plans, with review date of 10/28/2020, C.1, Pages 01- 03 reads as follows: POLICY: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Based on observations, record review and staff interview the facility failed to ensure care plan interventions were properly implemented for two (#65 and #305) of six residents sampled for care planning Findings included: 1. A review of the facility's fall log revealed that Resident #65 had documented falls on 6/7/21, 6/10/21, and 6/15/21. A review of Resident #65's clinical progress notes for the identified events on the facility's fall log revealed: -6/8/21 at 12:35 AM: Patient found on floor in kneeling position at bedside. Patient alert and confused. Unable to answer questions appropriately. Limited [Range of Motion (ROM)] to lower extremities. Patient PERRLA [pupils equal and reactive to light], strong hand grasps bilaterally, no complaints of H/A [headache], nausea or vomiting. Skin intact with slight redness to bilateral knees. Family and [Primary Care Physician (PCP)] notified by supervisor. Assisted patient back into bed via hoyer lift with assist of 2. Will monitor for any changes. Post fall evaluation reviewed with no issues. -6/10/21 @ 11:35 PM: [Nurse] heard someone calling for help, [nurse] asked the aide to check on [room], and the aide found the resident on the floor lying on the left hip. The resident was unable to explain how she fell. The resident was able to do a full ROM without complaint. [Nurse] called and talked to [PCP]'s on-call provider, [On-call provider], with orders to obtain and x-ray of hips and put resident on neuro checks, will continue to monitor. Will put the resident on 15 min [minute] check, and matts to floor and bed in lowest position. Post fall evaluation reviewed with no issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 3 of 7 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 105654 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westchester Gardens Health & Rehabilitation 3301 N McMullen Booth Rd Clearwater, FL 33761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -6/15/21 @ 10:45 PM: Patient was seen kneeling on the floor mat beside her bed. Bed at lowest position. Nonskid socks on. Call bell within reach but was not activated [by resident]. Alert and oriented x1 with baseline confusion. Patient is incoherent when asked what she was doing before she fell. [Vital signs] within normal limits ([Blood Pressure (BP)]: 140/80mmHg [milligrams mercury], HR [heartrate]: 70[beats per minute (bpm)], RR [respiratory rate]: 15pm, Temp [temperature] 97.0, O2sat [oxygen saturation] 96% in room air). Pupils reactive to light (2mm [millimeters] brisk round). No bruising/open wound noted +ROM/mobility on all 4 extremities with no complaints of pain/discomfort. Positioned safely back to bed. Neuro checks initiated. Assisted with ADLs. Safety precautions reinforced. Daughter informed. PCP notified with no new orders given. Will continue to monitor. On 6/24/21 at 9:00 AM, Resident #65 was observed asleep in bed. The resident's floor mat was visible between the bed and wall but not on both sides of bed. There was a second floor mat leaning against the window's wall. On 6/24/21 at 12:40 PM, resident's second floor mat remained on its side leaned against the wall on top of the other floor mat against the window's wall; the resident was in bed. A review of the resident's face sheet revealed that Resident #65 was admitted on [DATE] with diagnoses that included unspecified dementia, hypertensive chronic kidney disease, protein-calorie malnutrition, syncope and collapse, anxiety, osteoporosis, and sequelae of other cerebrovascular. The resident was a DNR (do not resuscitate). A review of the resident's most recent Minimum Data Sheet (MDS) dated [DATE] revealed: Sections C (Cognitive Patterns), Brief Interview for Mental Status (BIMS) of 04 out of 15, indicating severe cognitive impairment; E (Behavior), the resident had not displayed any behavior symptoms; G (Functional Status), total dependence for all ADLs (activities of daily living); and Q (Participation in Assessment and Goal Setting), The resident participated in their assessment. The resident wishes to remain in long term care. A review of Resident #65's Care Plan dated 4/30/21 showed a focus of [Resident #65] will be free from fall related injury through next review. Interventions included: assist resident with completing tasks, encourage resident to do as much for self as possible, monitor for increased fatigue and encourage rest periods, set resident up with proper equipment within reach, low bed, bilateral floor mats, and widened bed. On 6/25/21 at 8:37 AM, Resident#65's floor mat was again observed leaned against the window wall, and the resident was in bed. Photographic evidence obtained. On 6/25/21 at 9:07 AM, Staff B, Licensed Practical Nurse (LPN), stated the Certified Nursing Assistants (CNA) tend to move the fall mat so it is not a fall risk for the staff during care and mealtimes. Stated both fall mats were in place when she came in this morning. On 6/25/21 at 9:17 AM, the Director of Nursing (DON) stated the facility's expectation for fall mats was that when the patient is in bed then both mats need to be on the floor. If it did need to be moved to provide care, then it would be expected to be placed back before leaving the resident in bed. After seeing photographic evidence obtained by surveyor, the DON stated, It seems pretty cut and dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 4 of 7 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 105654 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westchester Gardens Health & Rehabilitation 3301 N McMullen Booth Rd Clearwater, FL 33761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-seven medications were observed administered and two errors were identified for one (1) (Resident #103) of three (3) residents observed. These errors constituted a medication error rate of 7.41 percent. Residents Affected - Few Findings included: An observation of 500 Hall medication administration on 06/24/2021 at 11 a.m., resulted in Staff E, Licensed Practical Nurse (LPN), giving Resident #103 two (2) medications for Hypertension (HTN) of Losartan Potassium 100mg (milligrams)and Metoprolol Tartrate 25 mg. Observation of the medication on the Electronic Medical Record (EMAR) computer screen that Staff E, (LPN) was looking at was noted to contain parameters for both medications read Hold if SBP [systolic blood pressure] is less than 110 or HR (pulse) less than 60. An immediate interview was conducted at 11:11 a.m. with Staff E, (LPN) related to administration of the two Blood Pressure (BP) medications and noted parameters seen for each medication's SBP for each one. During the interview Staff E, (LPN) indicated she did not give the medications and stated she threw the medications in the garbage. An observation was conducted of Staff E, (LPN) dumping the medication cart garbage on the top of the 500 Hall medication cart. Staff E (LPN) indicated again that she threw the two medications in the garbage and will find them to show the surveyor. In an interview with the Director of Nursing (DON) on 06/24/2021 at 11:20 a.m. she stated My expectation is that they (nurses) follow parameters for Blood Pressure (BP) medications prior to administering the medication. If the BP indicates the medication should be held, then they (nurses) should hold it. An interview was conducted with the Staff G, (LPN) Unit Manager (UM) on 06/24/21 at 12:37 p.m. During the interview Staff G, (UM) stated The nurse went off on me too, and then on the DON, and said that we are all lying. She did not find the pills in the garbage, and we knew she was not going to find the pills in the garbage. During a subsequent interview conducted with Staff G, (UM) at 02:07 p.m., Resident #103 was seen sitting in a wheelchair next to the nurse's station near the staff member. Staff G, (UM) stated I called to report the two medical errors to the Nurse Practitioner, and family. I will be personally monitoring the resident for six (6) hours, and taking his BP during the monitoring process. Record review of active physician orders for the Resident #103 read Metoprolol Tartrate 25 mg tablet (1) Tablet by mouth with for diagnosis of Hypertension (HTN). Hold if SBP less than 110 or HR less than 60. Review of Medication Administration Record revealed that the medication scheduled administration times are at 09:00 a.m. and 9:00 p.m.; Losartan 100mg Tablet one tablet by mouth one time a day scheduled at 09:00 a.m. to be given for diagnosis of HTN with BP parameters to hold for SBP less than 110 or HR less than 60. Review of Resident #103's care plan problem area dated 3/26/2021 revealed Alteration in cardiac status r/t [related to] high blood pressure. The goal indicated cardiac stability will be maintained as evidenced by vital signs within (Resident #103's) baseline through next review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 5 of 7 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 105654 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westchester Gardens Health & Rehabilitation 3301 N McMullen Booth Rd Clearwater, FL 33761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A further record review for Resident #103 indicated he was admitted on [DATE] with multiple diagnoses that included Essential (Primary) Hypertension, Hypertensive Urgency and Arthrosclerosis Heart Disease. A review of quarterly Minimum Data Set (MDS) dated [DATE] identified in Section C, Cognitive Patterns, Resident #9's Brief Interview for Mental Status (BIMS) Score to be 09 (on a 0-15 scoring scale), indicating moderate cognitive impairment. On 06/25/2021 at 11:04 a.m., a telephone interview was conducted with the facility's Consultant Pharmacist. He confirmed, both items were medication errors, because it goes against the doctors' orders. A facility provided policy titled, Medication Administration-SNF, with revision date 10/28/2020 Page 01 of 02 reads under Policy, Medications will be administered to residents as prescribed by the physician or only by persons lawfully authorized to do so in a safe and prudent manner. Procedure: 3. Medications. are administered in accordance with the written orders of the attending physician. 9. The person administering the medication will document on the electronic medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 6 of 7 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 105654 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westchester Gardens Health & Rehabilitation 3301 N McMullen Booth Rd Clearwater, FL 33761 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record review the facility failed to appropriately secure medications in four medication carts (100,200,400 and 500 Halls) of five medication carts sampled. Findings included: On 6/24/2021 at 02:51 p.m., an observation was conducted of the Medication Cart located on 100 Hall, which included in the sixth draw from the top of the medication cart, loose tablets. Staff A, Registered Nurse (RN) confirmed the presence of the one (1) white tablet, two (2) one- half (1/2) pieces of a white tablet and one quarter (1/4) of a white tablet observed to be in the third draw from the top of the medication cart. On 6/24/2021 at 3:03 p.m., an observation of medication cart located on the 400 Hall included four (4) loose tablets. Staff B, Licensed Practical Nurse (LPN), confirmed the presence of unsecured medications of one (1) white round tablet and one yellow tablet seen in the 4th draw from the top of the medication cart. Staff B (LPN) also confirmed the presence of a white tablet located in the fifth draw and a pink unsecured tablet in the 6th draw. On 06/24/21 at 03:23 p.m., an observation of the medication cart located on the 500 Hall included two (2) loose tablets. Staff C (Agency LPN) confirmed the presence of the unsecured medications. On 6/24/2021 at 03:58 p.m., an observation of the medication cart on 200 Hall included two loose tablets in the third (3rd) draw from the top of the medication cart. Staff D (RN)confirmed the presence of the round white and oval white unsecured tablets. On 06/24/2021 at 4:00 p.m., an interview with the Director of Nursing (DON) was conducted. The DON was informed of the observations made, and she stated, There should be no loose or unsecured medications in the carts, it is unacceptable and it's the nurses responsibility to check their medication carts for loose pills. On 06/25/2021 at 11:04 a.m., a telephone interview was conducted with the facility's Consultant Pharmacist. During the telephone interview he stated, unsecured tablets and or loose tablets in the medication carts are improper storage of medications. A review of the facility's policy and procedure titled, Medication Storage (Medication Cart/Narcotics), Reviewed 07/25/2020, Page 01 of Page 02, was reviewed and read under Policy Heading, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure temperature and security. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 7 of 7