Inspection·June 5, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few X, CNA took over the meal assistance halfway through the feeding. Staff X, CNA was observed standing over the resident during the meal assistance. A follow-up interview was conducted with Staff S, Clinical Student. Staff S stated she did not know there was a facility policy or expectation regarding meal assistance. On 06/04/25 at 12:07 p.m., Resident #37 was observed with her meal tray in front of her. The resident was not eating. An interview was conducted with Staff Y, CNA at 12:15 p.m. She stated the resident needed assistance with her meal. Staff Y said, I'm helping other residents. At some point someone will assist her, she needs to be fed. Resident #37 waited 20 minutes to be assisted with her meal. On 06/04/25 at 12:24 p.m. an interview was conducted with the Director of Nursing (DON). He stated the expectation was for staff to knock and announce themselves prior to entering the resident's room. He stated they should not stand over the residents during meal. He stated they should be at eye- level. The DON said dependent residents should not wait with their tray in front of them. He said, the food will get cold. The DON stated the clinical student's role was dependent on where they are in their course study. He said, We have given our policies to the school to review with students. They should follow appropriate health care procedures, yes, hand washing, knocking and not standing over the residents. 2. On 06/02/25 at 11:44 a.m. an observation was made of Staff T, CNA entering Resident #43's room without knocking. She was observed standing and assisting the resident with eating. Staff T offered the resident more food, while the resident was still chewing food. Resident #43 was admitted to the facility on [DATE], with a primary diagnosis of, nondisclosed fracture of lateral malleolus of right fibula, subsequent encounter for closed fracture with routine healing. A care plan for Resident #43 was initiated on 03/15/2025 and revealed Resident #43 has potential for alteration in nutrition needs related to: Dementia. Interventions showed the resident required assistance with meals as needed. On 06/04/2025 at 11:48 a.m. an interview was conducted with Staff T, CNA. She stated the resident's right hand was limited. She stated the resident required assistance with eating. She stated that the resident can eat certain foods on her own. On 06/02/25 at 12:14 P.M., an interview was conducted with Staff T, CNA. She confirmed she did not knock on the door when entering the resident's room and did not announce herself either. Review of the facility's policy titled Promoting/Maintaining Resident Dignity During Mealtimes, dated 10/14/24 showed It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights or each resident. Policy Explanation and Compliance Guidelines showed: 1. All staff members involved in providing feeding assistance to residents promote and maintain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 2 of 20 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 06/05/2025 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 0550 resident dignity during mealtimes. Level of Harm - Minimal harm or potential for actual harm 2. Assist resident with washing hands before and after meal, if applicable. 3. Assist resident with eating per state training and allowance. Residents Affected - Few 4. Focus on the resident while talking to him/her and addressing him/her individually. 5. All staff will be seated, if possible, while feeding a resident. 6. Resident requests will be honored during meals to the extent possible. 7. All catheter bags will be covered during meals if applicable. 8. Ensure the resident receives the proper tray and diet. 9. Assist resident with opening items, cutting necessary food items, etc. 10. Offer substitutes if applicable. 11. Allow adequate time for resident to complete as much as desired of the meal. Do not rush. 12. If resident is in the dining room, assist back to room as needed. If resident is in his /her room, position as resident desires or as directed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 3 of 20 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 06/05/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, staff interviews, and facility policy review, it was determined that the facility failed to ensure five resident room bathrooms out of ten resident room bathrooms toured on the 400 hallway of the facility's Queen's Way resident unit were maintained in a clean, homelike environment. (Photographic evidence obtained.) The findings include: On 06/02/25 at 10:38 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:11am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:15 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:18 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:30 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:32 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/04/25 at10:41am, during an interview with the Maintenance and Housekeeping Manager, He stated, Daily cleaning by housekeeping. They have a list on their cart for a 10-step cleaning. The list is kept on each housekeeping cart He provided a copy of this list for review. The list revealed: Occupied room: 3. High Dust. The Housekeeping and Maintence Manager said high dust would include the bathroom vents. He was asked who cleans the vents above the toilets in the resident's rooms. He stated, They should be checked and dusted daily but monthly they are vacuumed by one of my guys on staff. But housekeeping should be checking those daily and they should let me know if they need to be vacuumed in between the monthly schedule. The Housekeeping and Maintence Manager reviewed the pictures of the bathroom vents from rooms 400, 401, 403, 405, and 407 taken on 06/02/25 and 06/3/25. He stated, Yes the housekeepers should have let us know about the dust that accumulated. A review of the facility policy titled Homelike Environment (created 11/3/15, reviewed 3/15/25) revealed: Policy: The facility will provide a safe, clean, comfortable, and homelike environment. Policy explanation and compliance guidelines: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 4 of 20 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 06/05/2025 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 0584 2. The facility will maintain a clean environment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 5 of 20 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 06/05/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to provide necessary services to maintain grooming and personal hygiene for one resident (#49) out of four residents sampled for grooming and personal hygiene services. Residents Affected - Few The findings include: On 06/02/25 at 11:16 a.m., Resident #49 was observed in a wheelchair in the 400 hallway. His right-hand fingernails were observed elongated with brown debris under each nail. His left-hand fingernails were observed elongated. On 06/02/25 at 11:39 a.m., Resident #49 was observed in his room. His right-hand fingernails were observed elongated with brown debris under each nail. His left-hand fingernails were observed elongated. Resident #49 was interviewed at the time of the observation, and he said he likes his nails short, and he doesn't think staff clean and trim his fingernails. Photographs of Resident #49's fingernails were obtained with his verbal permission. On 06/03/25 at 9:35 a.m., Resident #49 was observed lying in bed, awake and dressed for the day. His right-hand fingernails were observed elongated with brown debris observed under each fingernail. His left-hand fingernails were observed elongated. On 06/04/25 at 8:57 a.m., Resident #49 was observed with his right-hand fingernails trimmed, not filed, with brown debris under the fingernails. His left-hand nails were observed trim, not filed. (Photograph taken with resident's verbal permission.) A review of the medical record for Resident #49 revealed a Minimum Data Set (MDS) evaluation dated 05/20/25, referred to as his admission evaluation. The evaluation revealed section C for Cognitive Patterns with a Brief Interview for Mental Status (BIMS) score of 15. A score of 13-15 indicates intact cognitive function. Review of Resident #49's MDS evaluation dated 05/20/25 revealed section E for Behaviors showed the resident did not display any behavior. This assessment included an assessment for rejection of care, which also revealed the resident did not display any behaviors of rejection of care. A review of the personalized Care Plan for Resident #49 revealed: Focus: (Created 05/15/25) Self care deficit: requires assist with Activities of Daily Living (ADLs) due to safety management; multifactorial comorbidities; generalized weakness; active infectious process. Goal: Resident will be able to participate in ADLs as able on a daily basis through next review date. Interventions: Allow resident to complete as much of the task as possible. Assist as needed. Explain procedures and process prior to starting. Further care plan review revealed Resident #49 did not have a personalized care plan for behaviors/refusal of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 6 of 20 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 06/05/2025 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 0677 A review of Certified Nurse's Assistant (CNA) tasks documented from 05/14/25 through 06/4/25 revealed: Level of Harm - Minimal harm or potential for actual harm What behaviors were observed? (Choices included: neglecting self-care; refusing care). Each day from 5/14/25 through 6/4/25 for 3 shifts per day was charted as no behaviors observed. Residents Affected - Few During an interview on 06/03/25 at 2:22 p.m. with Employee N, CNA, she said the CNA's provide fingernail care. She said there is no set schedule to provide fingernail care It depends on when it's needed, if I see nails are long, I ask them. She was asked what is involved in performing the fingernail care. She stated, I put my gloves on, use nail clippers, and file. She was asked about cleaning under nails if there is any debris observed. She stated, Yes, I use a brush to clean under the nails. She was asked what is the process if a resident declines or refuses fingernail care. She stated, I talk to the nurse, and the nurse will talk to them. They might still say no; I'll ask the next day. She was asked if a resident declines or refuses fingernail care, does she chart or record the refusal anywhere. She stated, No, I just tell the nurse. She was asked if she was caring for Resident #49 today. She stated yes. She was asked if she could explain the current state of his fingernails. She stated, I did clean and trim them one time, when he first came here. He has refused since then. She was asked if she had let the nurse know the times he had refused fingernail care. She stated yes. During an interview on 06/03/25 at 2:35 p.m. with Employee D, Licensed Practical Nurse (LPN). She was asked who provides fingernail care for the residents. She stated, It depends, typically the aides will offer it to them. If they refuse, then they will let me know and I'll try to change their mind. If not, we report it to the unit manager. She was asked how often fingernail care is provided. She stated, It depends on the patient and their nail growth. There is no schedule, no, it's not with shower days. She was asked what is involved in fingernail care for residents. She stated, I've never had to do fingernail care here. She was asked what is the process if a resident declines fingernail care. She stated, We chart it, the nurse has to chart it and report it to the manager. It could be a behavior issue. She was asked if she was caring for Resident #49 today. She stated yes. She was asked if any CNAs had let her know that Resident #49 has declined fingernail care. She stated yes. She was asked when that was. She stated, I'm not sure. I did not chart it. She was asked if she let the Unit Manager know. She stated, No, I didn't let the Unit Manager know. On 06/03/25 at 3:46 p.m., an interview with the Director of Nursing (DON) was conducted, he was asked if the facility had a policy specific to fingernail care. He stated no. He was asked what the facility process or expectations are for fingernail care are. He stated, To follow the plan of care, depending on the resident wishes, to keep the fingernails trim, clean and dry, safe length. He was asked who provides fingernail care for the residents. He stated, Multiple disciplines, the nurses, the CNAs and activity staff does nails as an activity for some residents. He was asked how often fingernail care is provided. He stated, As needed. He was asked if there was a schedule. He stated, No. I think standard practice is to trim and clean nails if the care is observed as needed. If I was a CNA and saw they needed the care, I would provide it. A review of the facility's policy titled Activities of Daily Living, created 3/11/15 and reviewed on 10/7/24 revealed: Policy: The facility ensures that the resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Definitions: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 7 of 20 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 06/05/2025 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 0677 ADLs include the resident's ability to: Level of Harm - Minimal harm or potential for actual harm 1. bathe, dress, and groom Procedure: Residents Affected - Few 3. Provide necessary services for residents who are unable to carry out activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 8 of 20 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 06/05/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations interview and record review, the facility failed to ensure continuous oxygen therapy was provided per physician orders, and failed to ensure respiratory equipment was stored appropriately for one resident (#76) of one resident sampled. Residents Affected - Few Findings included: During facility tours conducted on 06/02/25 at 09:43 a.m. and 06/03/25 at 09:24 a.m. Resident #76 was observed in her room lying on her bed. The resident was observed with continuous oxygen (O2) on. The oxygen concentrator revealed her oxygen was set at 3.2 liters. During these observations, Resident #76's nebulizer mask was observed on her bedside table uncovered. (Photographic Evidence Obtained). Review of Resident #76's admission record revealed an admission date of 08/23/24 with diagnoses to include respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). Review of physician orders for Resident #76 revealed the following: O2 at 2L/min (liters per minute) via N/C (nasal cannula) PRN (as needed) for O2 sats (saturation) lesser than 92% DX (diagnosis): Hypoxia - Start date 08/23/2024. Ipratropium Albuterol Solution 0.5-2.5 (3) MG (milligram)/3ML (milliliter) 1 vial inhale orally three times a day for sob (shortness of breath) - Start Date 08/26/2024. Review of the MAR/TAR (Medication Administration Record / Treatment Administration Record) for May and June 2025 showed documentation Resident #76 was receiving oxygen at 2L. Review of a care plan for Resident #76 initiated on 10/14/24 showed the resident had oxygen therapy r/t (related to) hypoxia, COPD. The goal showed the resident will have no s/sx. (signs/symptoms) of poor oxygen absorption through the review date. Interventions included to monitor for s/sx of respiratory distress and report to MD (medical doctor) PRN (as needed): Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color, Promote lung expansion and improve air exchange by positioning with proper body alignment. An interview was conducted on 06/04/25 at 09:31a.m. with Staff Q, Licensed Practical Nurse (LPN). Staff Q, LPN reviewed Resident #76's orders and said the oxygen should be set at two liters. He reviewed the photographic evidence and confirmed the oxygen concentrator was set at 3.2 liters and stated the nurses were responsible for monitoring three times a day. Staff Q, LPN said, It should be two liters per orders. He stated he would adjust the oxygen concentrator. Staff Q, LPN stated for nebulizers the nurse should clean the mask and put it in the bag after use. On 06/04/25 at 09:42 a.m. an interview was conducted with Staff K, LPN/UM (Unit Manager). Staff K, LPN/UM stated no one should be touching the oxygen except the nurses and Respiratory Therapist. He stated the nurses should make sure the order is correct, and if there is need to increase, they should contact the Medical Doctor for orders to increase. He stated Resident #76's oxygen should be administered at two liters per her current physician orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 9 of 20 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 06/05/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with the Director of Nursing (DON) on 06/04/25 at 12:35 p.m. was conduncted. He said the expectation is for the nurses to follow the physician orders. He stated the nurses should be checking the oxygen during administration, at least three times daily for Resident #76. The DON stated the mask should be bagged when not in use. Review of the facility policy titled Oxygen Concentrators, dated 10/14/24 showed the purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Under Policy Explanation and Compliance Guidelines it showed 1. Staff responsible for the use and care of oxygen concentrators receive training on oxygen safety and the functionality of the device 2. Oxygen is administered under orders of the attending physician, except in the case of an emergency. 4. (a.) The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc.). (l.) Keep delivery devices covered in plastic bag when not in use. Review of the facility policy titled, Nebulizer Treatments, dated 10/14/24 showed the policy expectation is to provide residents with appropriate nebulizer treatments administered in a safe, effective manner in accordance with physician orders and current clinical standards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 10 of 20 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 06/05/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 (#59) of three sampled residents who require wound care were provided with pain management services and staff accurately assessed for the presence of pain. Residents Affected - Few Findings included: On 6/2/25 at approximately 10:48 AM, Resident #59 was observed in his room and Staff I, Licensed Practical Nurse (LPN) was observed to be preparing supplies for wound care treatments. Staff I, LPN requested a Certified Nursing Assistant (CNA) to assist her with turning the resident onto his right side. The CNA held the resident on his right side and Staff I, LPN proceeded to remove a sacral dressing and a dressing to the left ischial (buttock) area. Resident #59 was observed to attempt and reach back behind him with his left hand toward the CNA and the CNA was observed to hold the resident's hand down. Staff I, LPN proceeded to use a gauze pad soaked with normal saline to clean the resident's wounds. Resident #59 began to make noises indicating he was uncomfortable and attempted to move away from Staff I, LPN. Staff I, LPN continued with the cleaning and the resident was heard saying ow in a loud voice. The CNA was observed to attempt to hold the resident on his right side as the resident attempted to take his left hand and try to reach backwards toward his buttock area. Staff I, LPN was asked if Resident #59 had received any premedication for pain prior to the wound care treatment and she indicated that she did not know whether the resident was pre-medicated or not but would check. Staff I, LPN reviewed the resident's medication orders and indicated Resident #59 received Tylenol earlier in the morning. Staff I, LPN then met with the Assistant Director of Nursing (ADON), and he indicated he would contact the resident's physician to see if pain medications were indicated during wound care. A review of Resident #59's medical record revealed he is a [AGE] year-old male with a recent hospitalization for a respiratory infection and returned to the facility on 4/26/25. The admission Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment. The wound care weekly assessment dated [DATE] from the Advanced Practice Registered Nurse (APRN) revealed the resident had a history of sepsis, renal failure, adult failure to thrive, dysphagia, congestive heart failure, senile dementia, muscle weakness, and acute respiratory failure with hypoxia (low oxygen levels). The APRN documented the resident had several wounds and described the left posterior thigh wound as a chronic shear with a status of not healed measuring 2.4cm (centimeter) length x 1.2cm width x 0.3cm depth with moderate amount of serous drainage (type of wound drainage). The APRN documented the resident's sacral wound as an acute shear not healed measuring 4.2cm length x 2.2cm width x 0.2 cm depth and moderate amount of serous draining. The clinical record revealed current physician orders for wound care for the left ischial open skin chronic shear wound were to clean with normal saline, pat dry, apply Santyl (wound care medication to promote healing), calcium alginate (material to promote wound healing) and cover with a foam dressing daily. The current physician orders for the sacral wound were to clean with normal saline, pat dry, apply calcium alginate, Santyl, and cover with a large optifoam dressing daily. A review of the daily nursing vital signs flow record from 3/5/25 through 6/3/25 revealed the resident was coded as 0 as not experiencing any pain, however the CNA task record from 5/22/25 through 6/4/25 revealed the resident had experienced pain 9 times during the 14-day period. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 11 of 20 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 06/05/2025 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/3/25 at approximately 7:50 AM Staff K, LPN was observed preparing medications for Resident #59 and Staff K, LPN explained that he would be giving Resident #59 Tramadol 50 milligrams (medication to treat moderate to severe pain) prior to the wound care treatment this morning. At 8:10 AM Resident #59's physician was observed checking on him. The physician was interviewed at that time, and he confirmed his expectation is staff ensure the resident is comfortable during wound care. At 8:41 AM Staff L, Registered Nurse (RN) was observed performing wound care treatments for Resident #59. Staff L, RN asked Staff K, LPN, to assist, and he turned the resident. Staff L, RN was observed to ask Resident #59 if he was having any pain and he replied no. The RN proceeded with the wound care and the resident appeared more comfortable, did not try to pull away from the RN, and did not make a verbal expression of discomfort. On 6/4/25 at approximately 8:30 AM an interview was conducted with the wound care APRN. She indicated she was conducting her weekly rounds and had provided wound care treatment for Resident #59 earlier. She indicated the resident appeared comfortable when she had seen him. The APRN said pain is avoidable and residents should be premedicated to avoid that as much as possible. She indicated she also used lidocaine topical spray to help with any discomfort during wound treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 12 of 20 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 06/05/2025 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations interviews and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for three residents (#37 #86, and #76) of 36 sampled residents. Findings included: 1. During a facility tour on 06/02/25 at 10:01 a.m. an observation was made of Resident #37 sitting in her wheelchair with her bedside table positioned in front of her. An observation was made of a white capsule medication on the bedside table. Another observation was made of an unidentified white powder in a medication measuring cup placed on top of the resident's dresser next to four bottles of a beverage. The resident could not answer questions related to the capsule medication or the unidentified powder. On 06/03/25 at 09:25 a.m. an observation was made of an unknown white powder in a plastic medicine cup on Resident #37's dresser next to bottles of beverages, similar to what as previously observed. Review of Resident #37's admission Record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, Dementia and peripheral vascular disease. On 06/02/25 at 11:06 a.m. an interview with the Director of Nursing (DON) was conducted. He said the capsule medication found on Resident #37's bedside table was a probiotic. He stated the nurses should supervise the residents during medication administration. Review of physician orders for Resident #37 confirmed the order for Probiotic Capsule 250 MG (Saccharomyces boulardii), Give two capsule by mouth two times a day for probiotic/ family to provide. Review of a care plan for Resident #37 initiated 05/18/22 revealed the resident did not have a self-administration medication care plan. On 06/03/25 at 12:48 p.m. an interview was conducted with Staff B, Certified Nursing Assistant (CNA). Staff B, CNA stated the white unidentified powder was an antifungal treatment powder. Staff B, CNA stated she applied it to the resident as needed. Staff B, CNA stated all the medications are supposed to be locked up. She stated the antifungal was in a medicine cup because she had to get some from Resident #76's drawer a couple days ago, because Resident #37's bottle was empty. Staff B, CNA said the antifungal should have been secured. Staff B. CNA looked in both residents' drawers and pulled out bottles of antifungal powder. 2. During an interview on 06/03/25 at 12:48 p.m., Staff B, CNA stated Resident #76 was receiving an antifungal powder. Staff B, CNA walked into the resident's room and pulled an antifungal powder stored in the resident's drawer. Staff B, CNA stated she applied it to the resident's groin areas and under her breasts. Staff B, CNA did not know if there was a physician order for the antifungal powder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 13 of 20 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 06/05/2025 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 Review of the admission Record for Resident #76 revealed an admission date of 08/23/24 with a primary diagnosis of unspecified fracture of right acetabulum. Review of physician orders for Resident #76 showed the resident did not have orders for the antifungal powder. Residents Affected - Few An interview was conducted on 06/03/25 at 01:01 p.m. with Staff K, LPN. Staff K, LPN stated all resident's medications to include antifungal powders /creams should be secured and administered by nurses. Staff K, LPN stated the CNAs should keep the antifungal powder in its original container and secured in the treatment cart. He stated the residents should have physician orders for powders and creams. 3. On 06/02/25 at 10:17 a.m. an observation was made or Resident #86 sleeping. A round, yellow-colored medication was observed on the floor next to his bed. An immediate interview was conducted with Staff D, Licensed Practical Nurse (LPN) assigned to the resident. Staff D, LPN stated this resident did not take any yellow - colored tablets. Staff D, LPN looked at the medication and noted it had an imprint of number 36. Staff D, LPN further stated the medication did not belong to Resident #86's roommate. She stated she would notify the Director of Nursing (DON). A follow-up interview was conducted on 06/02/25 at 10:50 a.m. with the DON. The DON stated the medication was a blood pressure medication. He said, It probably belongs to a staff member. No resident at this facility is taking it. On 06/03/25 at 01:10 p.m. an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated medications of all kinds should be secured. An interview was conducted on 06/03/25 at 03:44 p.m. with the DON. The DON stated all biologicals, and all medications should be secured. The DON confirmed Resident #37 and #76 did not have orders for antifungal powder. He stated the residents should have active orders and the medications should be secured. Review of the facility policy titled Medication Storage (Medication Cart/Narcotics) dated 07/22/24 showed 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. The General Guidelines showed: A. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. B. Only authorized personnel will have access to the keys to locked compartments. C. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 14 of 20 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 06/05/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an accurate medical record for medication and transmission-based precautions for one resident (#451) of 36 sampled residents on five of five days reviewed involving five nurses on three different shifts. Findings included: Review of Resident #451's medical record revealed Resident #451 was admitted to the facility on [DATE] for short-term rehabilitation. On 5/29/25 the resident was placed on empiric contact transmission-based precautions for a rash identified on the resident's skin. The resident received treatment on 5/31/25 for Ivermectin three milligrams, give three tablets by mouth one time only for one day. Review of the progress note documentation for 06/02/25 at 3:29 PM indicated the contact precautions were removed after the nurse practitioner examined the resident and treated her for folliculitis and ordered doxycycline antibiotic for seven days. Documentation by nurses for the ALERT antibiotic/infection note revealed the following: On 6/01/25 at 1:22 AM Staff Y, licensed practical nurse (LPN) inaccurately documented the current treatment was Ivermectin that was already given on 5/31/25. On 6/02/25 at 9:39 PM and 6/03/25 at 3:17 AM Staff X, Registered Nurse (RN) inaccurately documented the current treatment was Ivermectin that was already given on 5/31/25 and inaccurately documented the resident was on contact transmission-based precautions that were discontinued at 3:29 PM on 6/02/25. Doxycycline was not documented in the antibiotic note. On 6/03/25 at 10:03 PM Staff W, RN inaccurately documented the current treatment was Ivermectin that was already given on 5/31/25 and inaccurately documented the resident was on contact transmission-based precautions that were discontinued the previous day at 3:29 PM. Doxycycline was not documented in the antibiotic note. On 6/04/25 at 1:16 AM Staff Y, LPN inaccurately documented the current treatment was Ivermectin that was already given on 5/31/25 and inaccurately documented the resident was on contact transmission-based precautions that were discontinued two days earlier. Doxycycline was not documented in the antibiotic note. On 6/04/25 at 2:50 PM Staff Z, RN inaccurately documented the current treatment was Ivermectin that was already given on 5/31/25 and inaccurately documented the resident was on contact transmission-based precautions that were discontinued two days earlier. Doxycycline was not documented in the antibiotic note. On 6/04/25 at 8:43 PM Staff X, RN inaccurately documented the current treatment was Ivermectin that was already given on 5/31/25 and inaccurately documented the resident was on contact transmission-based precautions that were discontinued two days earlier. Doxycycline was not documented in the antibiotic note. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 15 of 20 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 06/05/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview with the infection preventionist on 6/05/25 at 10:00 AM, he stated the night shift nurse must have copied the note inaccurately from the previous shift. An interview with Staff Z, RN on 6/05/25 at 11:35 AM was conducted. She stated the electronic medical record system must have defaulted to the previous treatment. She said she did not notice it or make the correction to the accurate antibiotic/treatment and that the resident was no longer on contact transmission-based precautions. On 6/05/25 at 11:45 AM the Director of Nursing (DON) was asked about the facility expectations for accurate documentation and he said his expectation is for the nurses to document accurately for each resident and avoid copying previous documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 16 of 20 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 06/05/2025 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 0880 Provide and implement an infection prevention and control program. 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 proper hand hygiene during meal service in four halls (200, 300, 400 and 500 hall of six halls observed, and for nine residents (#3, #60, #452, #448, #96, #76, #1, #58 and #43) of 36 residents sampled. 2) The facility failed to implement their infection prevention and control plan by failing to provide evidence of process surveillance of staff practices directly related to resident care. 3) The facility failed to properly use enhanced barrier precautions (EBP) for one resident (#19) of two residents observed for EBP with indwelling medical devices. 4) The facility failed to properly disinfect a multi-use blood glucometer for two staff members observed during medication administration (Staff members O, Licensed Practical Nurse (LPN) and P, Registered Nurse (RN)) of five staff observed. The current census was 113 residents. Residents Affected - Some Findings included: 1. During a dining observation on the 500 wing on 6/02/25 at 11:32 AM, two staff members assisted Resident #3 to sit on the edge of the bed to eat lunch. Hand hygiene was not offered to the resident prior to eating. On 6/02/25 at 11:40 AM Resident #60 and Resident #452 were observed in their rooms eating lunch as they were seated in their wheelchairs. Both residents stated staff did not offer hand hygiene to them prior to their meal. On 6/02/25 at 11:45 AM family members were visiting Resident #448 and Resident #96. Both residents were seated in wheelchairs. The family members stated when the residents were in the hospital, staff offered a hand wipe to clean their hands before meals. They stated since they have been in this facility, hand hygiene was not offered prior to meals. On 6/02/25 at 12:18 PM Resident #76 was eating lunch in her room while seated in a wheelchair. She stated staff did not offer hand hygiene before they brought her meal. During an interview with the Infection Preventionist (IP) and the Director of Nursing (DON) on 6/04/25 at 11:30 AM, they stated the current IP is also the Unit Manager and Assistant Director of Nursing. He has been in the IP position since December of 2024. The DON stated he was the IP prior to November and has been training the ADON for the IP role. They were asked about offering or assisting with hand hygiene to residents before meals. They were not aware that residents who dine in their rooms and need assistance with hand hygiene were not offered or assisted with hand hygiene. The IP and the DON were asked to provide any process surveillance for hand hygiene for staff. The IP indicated he did not think he had any documentation of any process surveillance, but he would look for it. On 6/05/25 at 11:00 AM, the IP stated he did not have documentation of hand hygiene surveillance. When asked about any policy for staff fingernails, he stated they take a liberal stance on fingernails, and he acknowledged several direct care staff have long artificial fingernails that extend past the fingertips. 3. On 6/2/25 at approximately 9:30 AM, Resident #19 was observed seated in a wheelchair in his room and noted to have a urinary catheter drainage bag hanging from his wheelchair frame. The resident's room was noted to have a magnetic sign which read Enhanced Barrier Precautions and instructed staff to use gowns and gloves when providing direct care. Staff M, Certified Nursing Assistant (CNA) was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 17 of 20 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 06/05/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some observed at this time to enter the resident's room and touch the resident's urinary catheter tubing and bag several times to find a location to hang the bag. The CNA did not have gloves or a gown on. An interview was conducted with Staff M, CNA at this time, and she confirmed she should have put on a gown and gloves before handling the urinary catheter tubing and bag. 4. On 06/03/25 at 4:21 PM, an observation was made of Staff O, Licensed Practical Nurse (LPN) as she was preparing to administer evening medications to the patient in room [ROOM NUMBER]. She was standing at the cart outside the resident's room having just checked the residents' blood sugar. She was holding the glucometer (portable device used to measure the amount of glucose (sugar) in a person's blood) in her gloved hand. She stated that she had just checked the resident's blood sugar. At this time, she opened the top drawer of the medication cart and placed the glucometer into the cart. At no point was she observed to disinfect the glucometer prior to placing it into the cart. At this time, she was asked if she cleaned the glucometer and she said, I guess I should have She then retrieved the glucometer from the drawer and wiped with bleach wipes and immediately placed it back into the cart. On 06/03/25 at 4:44 PM, Staff P, Registered Nurse (RN), was observed checking the blood sugar of the patient in room [ROOM NUMBER]. After checking the patient's blood sugar, she returned to the medication cart she placed the glucometer into the top drawer. At this time, she was asked if she had disinfected the glucometer prior to placing it into the cart and she stated, I must have missed it but I should have done it. She then cleaned the glucometer with a small alcohol wipe stating, We can use alcohol wipes or the cleaning wipes if they are available. On 06/04/25 at 8:48 AM, during an observation of medication administration an interview was conducted with Staff Q, LPN. He reported that staff clean glucometers after use using big bleach wipes but if they are not available staff can use an alcohol wipe. He clarified that he was referring to a small alcohol wipe used to clean fingers when checking blood sugar. On 6/04/25 at 4:01 PM, an interview was conducted with the Infection Control (IC) nurse and the Director of Nursing (DON), during which they were asked how staff should clean a glucometer after checking a resident's blood sugar. The IC nurse stated that staff are expected to wipe the glucometer with a bleach wipe, if the bleach wipe container has a blue top the dwell time (the period a disinfectant must remain on a surface to effectively kill germs, bacteria and viruses) is 3 minutes or if it has a purple top the dwell time is 1 minute. He reported that this information is written on top of the bleach wipe containers, so staff do not have to look it up. The DON stated that it is Never appropriate to clean with an alcohol wipe to disinfect a glucometer after use. He also stated that it is never appropriate to return a glucometer to a cart without disinfecting it. Review of a corporate facility policy titled Promoting/Maintaining Resident Dignity During Mealtimes, dated 10/14/24 showed It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights or each resident. The Policy Explanation and Compliance Guidelines showed: (2.) Assist resident with washing hands before and after meal, if applicable. Review of the facility policy Glucometer Disinfection, created on 10/3/22 and reviewed 10/14/24 revealed Glucometers should be disinfected with a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective against HIV (Human immunodeficiency viruses), Hep C (Hepatitis C virus) and Hep B virus (Hepatitis B virus). Glucometers should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 18 of 20 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 06/05/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Review of the manufacturers' recommendations for cleaning the glucometer used by facility staff revealed Cleaning and Disinfecting Procedures for the Meter (The glucometer brand name) should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the (glucometer brand name): The list includes a list of 4 disinfectant cleaners that contain bleach. Step 5 for Materials needed states To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Other EPA registered wipes may be used for disinfecting the (glucometer brand name) however, these wipes have not been validated and could affect the performance of the meter. Allow the surface of the meter to remain wet at room temperature for the contract time listed on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. NOTE: Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients. The facility policy and compliance guidelines for the Infection Control Program Overview reviewed 10/22/23 and 1/04/25 indicated surveillance activities with be monitored facility-wide and a combination of process and outcome measures will be utilized. The section for surveillance revealed separate, site-specific measures may be tracked as prioritized from the infection control risk assessment. A review of the Risk Assessment report for Infection Surveillance, Prevention and Control Program completed on 11/13/24 indicated the risk assessment is used to provide information about where an organization should focus its surveillance. Treatment and care practices is one category included in the assessment tool. Hand hygiene, Glucometer cleaning/disinfecting were two areas the facility identified as high priority. On 6/05/25 at 11:20 AM the DON confirmed the facility had not documented any process surveillance, including but not limited to hand hygiene and glucometer cleaning/disinfecting. A review of the Hand Hygiene policy provided by the DON revealed a review date of 10/14/24. The top of the policy indicated it was applicable for Minnesota, Arizona, California, Florida, Montana, Oregon, South Dakota. Printed copies are for reference only. Please refer to electronic copy. On 6/04/25 the Administrator stated they did not have any electronic versions of the policies and procedures that are specific to his facility based on the Facility Assessment. He stated they are corporate policies for all the facilities in the states listed in the policy. The policy indicated: The health care community will take every precaution to prevent spread of infections by using proper hand hygiene techniques at all times. The procedure included: Facility will follow current Centers for Disease Control and Prevention (CDC) recommendations for hand hygiene techniques and recommended hand hygiene protocols. The current CDC Hand Hygiene for Healthcare Workers as of February 27, 2024, key points includes: Protect yourself and your patients from deadly germs by cleaning your hands. All healthcare personnel should understand how to care for and clean their hands. Hand hygiene protects both healthcare personnel and patients. Recommendations included but are not limited to: Know how to wash hands with soap and water, Know how to use alcohol-based hand sanitizer, and maintain fingernail and jewelry safety. (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html) The current CDC Hand Hygiene for Patients in Healthcare Settings as of February 27, 2024 includes: Cleaning your hands can prevent the spread of germs, including those that are resistant to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 19 of 20 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 06/05/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some antibiotics, and protects healthcare personnel and patients. When patients should clean their hands: Before preparing or eating food. Review of the policy and procedure for enhanced barrier precautions (EBP) reviewed 10/14/24 indicated EBP employs targeted gown and glove use during high-contact resident care activities. EBP will be initiated for residents with indwelling medical devices ( .urinary catheters .). Personal protective equipment for EBP is only necessary when performing high-contact care activities. The policy compliance guidelines listed device care or use: urinary catheters as a high-contact care activity. 2. During a dining observation of Halls 200 and 300 on 06/02/25 at 12:04 PM observations were made of staff members delivering trays to residents in their rooms as follows: Staff T, CNA was observed going into rooms 301, 305 and 307 without performing hand hygiene on herself nor the residents. Staff U, CNA was observed going into rooms 202, 209 and 311 without performing hand hygiene on herself nor the residents. Staff A, CNA, was observed going into rooms [ROOM NUMBERS]. Staff A,CNA did not apply hand hygiene and did not offer the residents hand hygiene prior to meal service. Staff T, Certified Nursing Assistant (CNA) and Staff W, CNA were observed going into Rooms 200, 209, 202 and 205 to provide lunch trays to the residents without performing hand hygiene on themselves nor the residents. On 06/02/25 at 12:14 PM an interview was conducted with four CNA's, Staff T, Staff W, Staff B and Staff A. They confirmed they did not offer the residents hand hygiene prior to meal service. Staff B, CNA stated the expectation was for them to perform hand hygiene when going from room to room. The four CNAs did not answer regarding offering the residents hand hygiene. During dining observations on Hall 200 on 06/04/25 at 11:50 a.m. observations were made of staff members Staff A, CNA, Staff X, CNA and Staff T, CNA delivering trays to residents in their rooms. The staff members did not offer the residents hand hygiene prior to meal service. An interview was conducted on 06/04/25 at 11:56 a.m. with Staff A, CNA, Staff X, CNA and Staff T, CNA. They confirmed they did not offer the residents hand hygiene prior to meal service. Staff X, CNA stated she offers the residents hand hygiene when they are done with the meal but not prior. On 06/04/25 at 12:24 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated the staff should apply hand hygiene prior to passing trays or when moving from resident to resident. He stated expected staff to wash hands or use hand sanitizer. He stated they had not thought about hand hygiene for the residents prior to meal. The DON stated it was a good learning opportunity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105654 If continuation sheet Page 20 of 20