Inspection·August 13, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 08/11/21 at 2:46 p.m., Staff A, Licensed Practical Nurse (LPN) stated Resident #347 is not on any precautions. Staff A, LPN reviewed Resident #347's online medical chart and confirmed an active order in place for contact precautions due to E. Coli in the urine. Staff A, LPN looked at Resident # 347's door and said . yea there is no sign on the door. Staff A, LPN stated Resident #347 was admitted from the hospital with a urinary tract infection and for contact precautions additional PPE requirements for entering the room would be a gown and gloves An interview on 08/12/21 at 7:04 a.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA) revealed for those residents with orders for contact precautions, additional PPE is required of donning a gown and gloves when entering the room. The resident's room should have signage posted on the door indicating to see nurse with the letter of the type of precaution required. An interview on 08/12/21 at 1:50 p.m. with the Infection Preventionist revealed Resident #347 does not have a urine culture to indicate the type of bacterial urinary tract infection. The resident was admitted with orders for contact precautions due to E. Coli in the urine, however, there is no culture to indicate the bacterium requires the precautions. A follow-up interview on 08/13/21 at 5:02 p.m. with the DON confirmed that those residents with physician orders and care plans indicating a type of precaution should be implemented. A policy review of Interdisciplinary Care Planning, updated 03/2018, revealed under section Comprehensive Care Planning Requirements that . The facility must develop and implement a comprehensive person-centered care plan for each patient that includes measurable objectives and timeframes to meet a patient's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment Once the care plan is developed, the staff must implement the interventions identified in the care plan These may include but is not limited to . administered treatments and medications . performing therapies, and . participating in activities with the patient . Interventions identify specific, individualized elements of care, provided y staff, which will help patients achieve their goals. Interventions are the instructions for delivering patient care and allow for continuity of care by staff. Just like goals, interventions are specific and measurable . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 2 of 13 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 105708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Health and Rehabilitation Center 2851 Tampa Rd Palm Harbor, FL 34684 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 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, and fifteen late medications were verified for three (3) (Resident #51, # 295 and #347) of eight (8) residents observed. These late medications constituted a medication error rate of 55.56 percent. Residents Affected - Few Findings included: On 08/11/2021 at 10:07 a.m., an observation was conducted of Staff A, Licensed Practical Nurse (LPN), on the MED Bridge Wing, administering medications to Resident # 51. Staff A, (LPN) was seen administering the following medications: -Amiodarone HCL Tablet 100 milligrams (MG) orally, -Eliquis Tab 5 MG by mouth orally, every 12 hours -Furosemide Tablet 20 MG orally, one time a day -Potassium Chloride ER Tablet Extended Release 10 milliequivalents (MEQ) orally, three times a day -Spironolactone Tablet 50 MG orally, twice daily -Prednisone Tablet 1 MG orally, one time a day Record review of active Physician Orders and the Medication Administration Record (MAR) for Resident #51, revealed that the medications administered to the resident were given late, and scheduled to be administered at 9:00 a.m. On 08/11/2021 at 10:19 a.m., a continued observation of medication administration with Staff A (LPN), was conducted with Resident #347. Staff A, (LPN) was observed administering the following medications: -Ticagrelor Tablet 90 MG orally every 12 hours. -Cefdinir Capsule 300 MG Capsule orally every 12 hours. -Atorvastatin Calcium Tablet 40 MG orally once a day. -Ferrous Sulfate Tablet 325 MG orally one time a day. -Midodrine HCL 10 MG Tablet orally every 12 hours. An immediate interview was conducted with Staff A, (LPN) who was asked if she or anyone else in the facility called the physician to alert him/her the medications were being administered late and for any orders? She stated, My computer went up and down, and I did not know I was supposed to call the physician if the medications were given late. Record review of active Physician Orders and the Medication Administration Record (MAR) for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 3 of 13 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 105708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Health and Rehabilitation Center 2851 Tampa Rd Palm Harbor, FL 34684 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 Resident #347, revealed that the medications administered to the resident were given late, and scheduled to be administered at 9:00 a.m. On 08/11/2021 at 10:49 a.m. Staff B, Agency (LPN) was observed administering medications to Resident #295. On the MED Bridge Wing. The following medications were seen administered to the resident: Residents Affected - Few -Amlodipine Besylate Tablet 5 MG orally one time a day. -Duloxetine HCL Capsule Delayed Release Particles 60 MG orally one time a day. -Losartan Potassium Tablet 100 MG orally one time a day. -Metformin HCL Tablet 500 MG orally twice a day. An immediate interview was conducted with Staff B, Agency (LPN) about the medications on her computer screen of the MAR observed to be in red, which denotes a late medication. She stated It's been about time management, I have to stop a lot, there are new admissions, I need to call the Physician prior to giving a medication to them, and then I am agency, and I cannot pull medications from the [name of medication dispensing system] because I have to get another nurse to pull them. I do not have access to it to pull. Staff B, Agency (LPN) indicated she did not have any computer issues that morning that would make medication administration late. Record review of active Physician Orders and the MAR for Resident #347, revealed that the medications administered to the resident were given late, and scheduled to be administered at 9:00 a.m. An interview was conducted on 08/11/2021 at 12:50 p.m., with the Director of Nursing (DON). During the interview she was informed of fifteen medications being administered late to three (3) residents. The DON stated I expect the staff follow policy and give the way the medication is ordered by the physician and written. I would expect that they call the physician to inform them the medication is late. The DON further indicated that she spoke to Staff A, (LPN) who told the DON that she did not have computer issues of going up and down, but rather that her computer was slow. A facility provided policy titled, Medication Administration Times, revision date 08/2018, Page 01 of 02 revealed under Procedure: 2. The Nursing Center may commence medication administration within sixty (60) minutes before the designated times of administration and sixty (60) minutes after the designated times of administration. And under Medication Administration read: Medications are administered in accordance with the following rights of medication administration, right time (including duration of therapy). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 4 of 13 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 105708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Health and Rehabilitation Center 2851 Tampa Rd Palm Harbor, FL 34684 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. Based on observation, interviews, and policy review, the facility failed ensure 1) removal of expired medications from one (Med Bridge Hall) of two medication storage rooms observed; and 2) medications were secured in one (Medication Cart A, East Wing) of five medication carts observed. Findings included: On 8/12/2021 at 3:55 p.m. an observation was made of Medication Cart A located on the East Wing. In the seventh draw from the top of the medication cart was a loose blue capsule. Staff D, (LPN) confirmed the presence of the unsecured medication. On 08/12/2021 at 02:45 p.m., an observation was conducted on Med Bridge Wing's, medication room and medications stored in the refrigerator. During the observation four (4) brown plastic envelopes containing Aplisol 0.1 milliliters (ML) Syringe (PPD), were observed with pharmacy labels that had the resident name, and expiration date located on each one. Observation of two (2) medications found to have expiration date of 08/05/2021 and the other two (2) had expiration dates of 08/04/2021 and 08/08/2021 respectively. Staff C, Registered Nurse (RN) verified the presence of the expired medications Photographic evidence was obtained. On 08/12/2021 at 4:30 p.m., an interview was conducted with the Director of Nursing (DON). She was informed of the observations made, and the DON indicated she knew about the expired medications from Staff C (LPN), and stated, All loose medications must be disposed of in the medication carts, and all medications should be routinely checked by my staff and disposed of as the expiration date approaches. On 08/13/21 at 11:37 a.m. in an interview with the facility Pharmacy Consultant he stated The nurses are aware of the timeframe the medications should be administered. A review of the facility titled, Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles, with Revision Date 08/2018, Pages 01 to 03, included under Applicability: This section sets for the procedures relating to storage and expiration dates of drugs, biologicals, syringes, and needles, further read: 3. The Nursing Center should ensure that drugs and biologicals: Have not been retained longer than recommended by manufacturer or supplier guidelines. 9. The Nursing Center should ensure that the drugs and biologicals for each resident are stored in their originally received containers. 15. The Nursing Center should destroy or return all discontinued outdated/expired, return or deteriorated drugs or biologicals in accordance with Pharmacy return/destruction guidelines. 16. Nursing Center personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 5 of 13 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 105708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Health and Rehabilitation Center 2851 Tampa Rd Palm Harbor, FL 34684 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, interviews, and record review the facility failed to ensure coordination among departments which resulted in the failure of the facility's food and nutrition services system for accommodation of food choices and preferences for two (Residents #141 and #70) out of six sampled residents. Findings included: 1. Resident #141 was observed during the lunch meal on 08/10/21 at 12:10 p.m. Observation of his lunch tray revealed a plate with an entrée selection, a cup of coffee, a cup of iced tea, a serving of pudding, and a chocolate flavor frozen nutritional treat. The only meal ticket present with the tray revealed the following information: no allergies; nutritional treat supplement; beverages iced tea and water; diet soft & bite-sized (SB6). There was no other information printed on the ticket. Resident #141 said he did not like chocolate and had told the facility, but they said they only had chocolate flavor (for the supplement). He said lunches were generally too heavy and not great but that he had to eat it because he had lost weight. He said he could not identify the food items on his plate and did not know if it was what he had ordered. He said the process for meal selection was he was given a printed menu by facility staff and circled the items he wanted. Photographic evidence obtained. Review of the medical record for Resident #141 revealed he was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive. The Minimum Data Set, dated [DATE] revealed the resident required supervision for eating and had weight loss of 5% or more in the last month. There was no completed Brief Interview for Mental Status (BIMS), or other assessment related to cognition recorded in the MDS, however a social services progress note dated 07/28/21 revealed: Patient is alert and oriented w/ (with) some forgetfulness/confusion. Physician orders revealed enhanced diet soft and bite-sized texture and nutritional treat supplement three times a day for nutrition with meals. The nutrition assessment dated [DATE] revealed the resident was underweight, had involuntary weight loss, and .Recent weight loss proven of 8# (8 pounds)/5.6% since initial admit date .Patient was not responding to questions during visit. An interview was conducted with Staff Q, Dietetic Technician Registered, Certified Dietary Manager (CDM) on 08/12/21 at 2:52 p.m. She confirmed she performed nutrition assessments for residents upon admission to the facility and said, sometimes I get a lot of information and sometimes I don't .almost always my assessment involves food preferences. Regarding food preferences for Resident #141, Staff Q consulted notes in the Electronic Health Record (EHR) and said, he was not responding to questions is what I have in my note. She said she was not aware that he did not like chocolate. She said anyone could communicate resident food preferences to the kitchen and said her process was, I write recommendation sheets which is communicated to the kitchen .I don't know the process for other disciplines. Regarding the chocolate nutritional treat supplement for Resident #141 she said that if the kitchen was sending chocolate, they were probably not aware that the resident did not like chocolate. She said, I don't know what flavors are stocked available weekly. Review of Resident #141's medical record on 08/13/21 revealed an entry dated 08/13/21 7:52 a.m. made by Staff Q: Met with Patient after report that he does not care for chocolate flavors .asked Patient about report of dislike of chocolate and he agreed. Dietary notified of update . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 6 of 13 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 105708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Health and Rehabilitation Center 2851 Tampa Rd Palm Harbor, FL 34684 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #141 was observed during the lunch meal on 08/12/21 at 12:18 p.m. Staff O, Certified Nursing Assistant (CNA) was in the room providing delivery and setup of the meal tray. The tray contained a plate with entrée selection, a covered Styrofoam cup, a dessert item on a plate, and a chocolate flavor nutritional treat supplement. The resident could not identify the items on his tray. Staff O could not identify the items on the tray. The meal ticket on the tray did not list any of the food items and did not list any preferences regarding the nutritional supplement flavor. Staff O said she had noticed the meal tickets had been blank this week and she did not know why. She said normally the tray would come with the printed menu selections that the resident had circled so that the resident could identify their meal items. Staff O said she did not know what had changed. Photographic evidence obtained. An interview was conducted with the facility Dietary Services Director (DSD) on 08/13/21 at 1:27 p.m. He reported the facility had a process in place for select menus for residents to choose their food items and preferences for each meal. He said the kitchen printed a week of menus for each resident, the menus were delivered to each unit nurse's station and the nurse in charge was responsible to ensure the menus were delivered to the residents. He said the residents were to circle their choices and/or alternate preferences. He said after the residents completed their selections, the menus were either delivered to the kitchen by the nursing staff or, I will go and retrieve them from a wall sleeve at each nurse's station. The DSD said that the menus with circled selections made by the residents were transformed to the meal ticket that goes out on the tray .that menu that was circled becomes the ticket and goes back out with the tray. Observations made during survey were revealed and he said, without trying to point any fingers I think sometimes they (residents) may not get the menu or sometimes the menus might not be in their designated spot for us to pick up .the process should be that if I deliver them (menus) to the station then it's in the hands of the person in charge .if we don't get the tickets back then we can't follow what they chose .I think the problem is pretty clear. Regarding dietary staff role in assessing for resident preferences he said, my CDM assesses for resident preferences on admission, as needed, and quarterly. Regarding flavors of frozen nutritional treat supplements, he said, if the preferences are known we will of course honor that. A follow-up interview was conducted with the DSD on 08/13/21 at 2:05 p.m. He confirmed that Resident #141 should have received a select menu and had not received them that week and said, no clear answer as to why he didn't have them with his tray this week .probably because it didn't come back to us .we did not get them in the kitchen. He said, I don't have a checklist to see whose has come back and whose has not, that would be my responsibility, I rely on the staff to do their jobs, it's an imperfect thing. He revealed printed select menu tickets that should have been issued to Resident #141 on 08/13/21 and provided with his trays and confirmed they had not been provided to the resident. The tickets were for 08/13/21 and revealed the special instruction, no chocolate nutrition treats for all meals which did not match the ticket that was observed with Resident #141's tray during the lunch observation on 08/13/21. Review of concern forms filed on behalf of the resident council for June 2021 and July 2021 revealed concerns had been reported about meal preference selections. The concern form dated 06/01/21 revealed the concern, Resident not getting what they circled on menu had been assigned to the DSD for follow up on 06/02/21 and resolution was documented as ongoing meetings with residents would continue and additional follow up was needed. The concern form dated 07/07/21 revealed the concern, Don't always receive what was circled on menu had been assigned to the DSD for follow up on 07/16/21, concern was documented as resolved with the following note: attention to tray cards will continue to improve .spoke w/ (with) members of resident council. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 7 of 13 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 105708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Health and Rehabilitation Center 2851 Tampa Rd Palm Harbor, FL 34684 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility policy titled Selective Menus dated 11/2020 revealed, Selective menus offer patients the opportunity to make choices in food selection and may improve intake of meals and customer satisfaction. The guidelines included: .Daily selective menus are distributed to patients who will participate in the selective menu program .A list of participating patients may be printed by sorting the patient view in Dietary eKardex by the selective menu column header. This list can be used to check off that a completed select menu has been returned to the kitchen .Completed menus may be dropped off at the kitchen office or a drop off box may be set up at each nursing station for the ease of collection .At the time of meal service, the competed selective menu tray tickets are combined with the non-select menu tray tickets and placed in serving order . 2. On 08/10/21 at 10:40 a.m. an interview with Resident #70 revealed she had voiced her dietary preferences to the facility but was not receiving the correct food items. Resident #70 stated she would receive food items on her tray that she had trouble digesting. A record review of Resident #70's admission Record Report revealed medical diagnoses of urinary tract infection, unspecified fractures, and disorder of the muscle. A record review of Resident #70's MDS [Minimum Data Set] 3.0, dated 06/22/21, revealed under Section CCognitive Patterns a brief interview for mental status [BIMS] score of 15; indicating an intact cognition with no behaviors of inattention, disorganized thinking, or altered mental status. Section G- Function Status revealed Resident #70 only required supervision with set-up help only for eating. A record review of Resident #70's CarePlan revealed a focus area of Nutritional status as evidenced by actual/potential weight loss/gain related to specific diet preferences ., created on 6/17/21, with interventions of Food Allergy/Intolerance/Preference: NO PORK, NO BEEF, NO SUGAR, NO SWEET TYPE DESSERTS, NO SAUSAGE/BACON, NO [NAME]/ NO SWEET N' LOW, NO FRIED FOODS . FOLLOW PATIENTS SELECT MENU . Provide diet as ordered . A record review of Resident #70's Nutritional Assessment, dated 6/21/21 revealed on page 6 that . Patient voiced multiple food related concerns, food preferences are in place . Patient reported hx [history] of gastric bypass surgery for weight loss. Patient commended that she avoids certain foods due to gi [gastrointestinal] tolerance . Continue current diet . Honor preferences . A review of Resident #70's meal ticket, dated 08/13/21, revealed under ALLERGIES listed sugar packets or sweet desserts . DISLIKES . gravy . During a meal observation on 08/12/21 at 12:01 p.m. an interview with Resident #70 revealed she was not sure what was on her tray because the meal ticket does not indicate the food items and sometimes, she can not tell what the food item is. At the beginning of the week a selection of meals for the following week is provided and the resident will circle what food item they want. Resident #70 stated she returned her meal selection listing for the week but .apparently they lost the package. An observation of the meal tray revealed a meal ticket placed on the tray without indication of what the food items were. On the meal ticket, Resident #70's allergies and dislikes were listed. An observation of the meal tray revealed a piece of chocolate cake (sweet dessert). Further observation revealed the chicken was covered in a mushroom gravy sauce. Photographic evidence was obtained of the meal tray. During the interview on 08/12/21 at 12:01 p.m. Resident #70 stated she is cognitive enough to not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 8 of 13 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 105708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Health and Rehabilitation Center 2851 Tampa Rd Palm Harbor, FL 34684 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few eat the cake, however, . what if they put something like that on a tray for someone that isn't able [cognitive]. Resident #70 stated that while her meal ticket states sweet treat is an allergy, it is more of her preferences to not have the item because she lost over 100 pounds and she prefers to not have the treat on her tray, so she won't be tempted to eat it. On 08/12/21 at 12:24 p.m. an interview with Staff M, Registered Nurse (RN) revealed resident not on a diet restriction are provided a menu with the food items for the following week. The resident circles what food item they want and then that document is given to the dietary department. Those residents that are on a diet restriction are not really given an option menu. Once the resident makes their choices the document goes to dietary and from there the nursing staff does not have any input. If the resident does not like the food item, then they do have the option to ask for an alternative item. The tray ticket will also indicate dislikes and preferences. If a tray has a food item that states allergy then the tray/food item should not be provided to the resident. If the resident gets an item, they dislike they may still be provided with the tray because they may still want the item, especially if they selected it. On 08/13/21 at 1:27 p.m. with the FSD, it was revealed that a resident's allergies are listed on the meal ticket and as the tray line is started, the staff member that is serving the food will be educated on what the resident should be receiving. The FSD said . If the resident says it is an allergy, then it is an allergy . The CNAs' will also double check the meal tray to make sure there is nothing on the tray that should not be there. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 9 of 13 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 105708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Health and Rehabilitation Center 2851 Tampa Rd Palm Harbor, FL 34684 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, record review, and Centers for Disease Control and Prevention (CDC) recommended infection control guidelines, the facility failed to ensure infection control practices during an active COVID-19 facility outbreak were followed related to 1) donning of personal protective equipment (PPE) prior to entering designated COVID-19 person under investigation (PUI) rooms (307, 312, and 357); and 2) ensuring all direct care staff wore a well-fitted face mask while inside of the facility on two (300 hall and East Wing) of three hallways observed. Residents Affected - Some Findings included: 1. An observation on 08/12/21 at 5:36 a.m. revealed personal protective equipment (PPE) requirement signage posted on the double entrance doors into the 300-unit hallway. The signage stated an N95 & [and] Face Shield Required Prior to entering unit. Photographic evidence obtained of the signage. Upon entering the 300-hallway unit, an observation on 08/12/21 at 5:37 a.m., revealed Staff G, Certified Nursing Assistant (CNA) entering room [ROOM NUMBER]. Signage posted on the room door stated, AIRBORNE DROPLET PRECAUTION with instructions of Upon Entry into Room: -Gown - Face Shield N95 Mask. IN Room: -Cleanse Hands - Apply Gloves for Direct Care - Offer Resident a Mask. BEFORE you EXIT Room: -Remove Gown & Gloves -Cleanse Hands. Photographic evidence was obtained. Staff G CNA wore a surgical mask; the staff member did not don an N95 mask or face shield. Upon entering the room, Staff G closed the door. An observation on 08/12/21 at 6:07 a.m., revealed Staff G, CNA walking down the 300-unit hallway without a face shield or N95 mask donned; Staff G, CNA was wearing a surgical mask. During an immediate interview with Staff G, CNA, she stated while working on the 300-unit an N95 mask and face shield are required. She further said upon entering a designated airborne droplet precaution room, the requirements are to don additional PPE of a gown and gloves. Staff G stated she has an N95 mask that the facility provides, which is stored in the front of the facility in a designated brown bag. Immediately following the interview on 08/12/21 at 6:07 a.m., Staff G, CNA was observed entering room [ROOM NUMBER] again which had the AIRBORNE DROPLET PRECAUTION signage still posted on the door and a PPE caddy placed outside the door with gowns. Staff G, CNA was overheard speaking to the resident stating she would be assisting with draining the catheter bag. Staff G, CNA was observed standing inside room [ROOM NUMBER]'s bathroom. Staff G, CNA did not don an N95 mask, face shield, or gown prior to entering the room. Staff G, CNA closed the room door. 2. An observation on 08/12/21 at 5:37 a.m. revealed Staff E, CNA walking in the 300-unit hallway without a face shield, or face mask of any kind covering her nostrils and mouth. Staff E was observed walking behind the nursing station prior to walking down the hallway and entering room [ROOM NUMBER], which had a call light turned on. An observation of room [ROOM NUMBER] revealed signage posted on the room door as AIRBORNE DROPLET PRECAUTION. Photographic evidence obtained. Staff E, CNA did not don any PPE, including a face shield, N95 mask, or gown, prior to entering room [ROOM NUMBER]. Staff E, CNA exited the room and walked back to the 300-unit nursing station. Staff E, CNA began speaking to Staff J, Licensed Practical Nurse (LPN) regarding how to turn off the doorbell alarm. Staff J, LPN provided Staff E, CNA with instructions on how to turn off the alarm prior to walking back to her medication cart. During this conversation, Staff E, CNA did not have on a face shield or face mask of any kind covering her mouth or nostrils. Staff J, LPN did not instruct Staff E, CNA to don the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 10 of 13 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 105708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Health and Rehabilitation Center 2851 Tampa Rd Palm Harbor, FL 34684 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 appropriate PPE requirements for the 300-unit hallway. Level of Harm - Minimal harm or potential for actual harm During the continued observation on 08/12/21 beginning at 5:37 a.m., after speaking with Staff J, LPN, Staff E, CNA walked down the 300-unit hallway and entered room [ROOM NUMBER]. Staff E, CNA was overheard talking to a resident. Upon looking into the resident's room, Staff E, CNA was observed standing within 6 ft of the resident and was touching the resident's bed. Staff E, CNA was not wearing a face shield or mask of any kind while interacting with the resident. Residents Affected - Some During an interview on 08/12/21 at 5:45 a.m., Staff E, CNA said sorry . I am doing a million things right now. Staff E stated she was unsure where she placed her face mask, N95 mask, and face shield. She stated she was currently assigned to 12 residents. She said upon arriving to the facility, the night supervisor provided instructions on what the PPE requirements were while working on the 300-unit. She stated she might have left her face shield and N95 mask in the bathroom. Finally, Staff E, CNA stated she went out to her car earlier and must have left her required PPE in the car. During this interview, Staff I, Registered Nurse (RN) was observed watching the interview while standing by a medication cart. 3. An interview on 08/12/21 at 5:52 a.m. with an assigned 300-hallway nurse, Staff I, Registered Nurse (RN), revealed that while working on the 300-unit a face shield and N95 mask are required due to residents that are actively infected with COVID-19. The requirement is that should a staff member be observed on the unit without a face shield or mask, they must be instructed to don the appropriate PPE. Staff I, RN stated he had not seen Staff E, CNA without PPE. An interview on 08/12/21 at 6:00 a.m. with Staff J, LPN revealed the PPE requirements while working on the 300-unit is to have an N95 mask and a face shield on. If a staff member is entering an airborne droplet precaution room, then they are required to don additional PPE of a gown and gloves. Staff J, LPN stated if a staff member were observed without any PPE on such as a N95 mask, surgical mask, or face shield then she would instruct the staff member to don the items and ask them if they needed assistance in finding an N95 mask and face shield. An interview on 08/12/21 at 7:04 a.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA) revealed there are COVID-19 positive residents in the facility. The PPE requirements for the 300-unit hallway is to always wear an N95 mask and face shield. The employees have personal bags stored in the dining room where they can keep their N95 mask and face shield. Those rooms designated as AIRBORNE DROPLET PRECAUTION are for residents considered to be persons under investigation (PUI) for COVID-19 due to being new admissions who have not been vaccinated for COVID-19. When entering one of these designated rooms, additional PPE of a gown and gloves are required. To ensure staff are wearing their PPE appropriately on the unit, the nurses on the floor are the main line of defense. 4. A record review of COVID-19 PREVENTION Please follow these tips when in our facility, not dated, revealed Maintain Social Distancing . Wear A Mask . A record review of Personal Protective Equipment Usage Guide, dated 06/17/21, revealed under section Mask revealed . N-95 Respirator . WHEN TO USE: Procedure masks or surgical masks are used for center/community staff under universal masking criteria N-95 respirators are used: . When providing care or services within (6) feet of patients with suspected or confirmed COVID-19 in transmission-based precautions including new admissions for quarantine period . Under section Face Shield/Goggles revealed . Full Face Shield . WHEN TO USE: Full-face shields are worn when providing direct care activities where splashes and sprays are anticipated as aerosol generating procedures or prolonged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 11 of 13 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 105708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Health and Rehabilitation Center 2851 Tampa Rd Palm Harbor, FL 34684 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 face-to-face or close contact with a potentially infections patient as with any patient in airborne droplet isolation. Must be used when providing care or services within six (6) feet of patients with suspected or confirmed COVID-19 in transmission-based precautions including new admissions for quarantine period . A policy review of Airborne Precautions, dated 07/2021, revealed Special air handling and ventilation required for airborne precautions is not routinely available in centers. Airborne transmission occurs by dissemination of either small [less than or equal to] 5 micron airborne droplet nuclei remaining suspended in the air for long periods of time or dust particles containing the infectious agent. Microorganisms carried in this manner can be widely dispersed by air currents and may become inhaled within the same room or over a longer distance depending on environmental factors . A policy review of Droplet Precautions, dated 07/2021, revealed Droplet transmission involves droplets generated by the individual during coughing, sneezing, and talking or during the performance of certain procedures, such as suctioning. Transmission occurs when droplets containing microorganisms generated from the infected person are propelled a short distance through the air and deposited on the susceptible conjunctiva, nasal mucosa, or mouth. Special handling and ventilation are not required . In addition to standard precautions, the following measures are necessary for droplet precautions . Mask . Wear a mask when within six (6) feet of the patient . Apply mask upon entering the patient room and remove mask upon exiting the patient's room and immediately wash hands with antimicrobial agent or use alcohol-based hand sanitizer. Avoid touching from of mask during removal as it is considered contaminated . Goggles . Wear goggles if likelihood of exposure during care . Remove goggles and immediately wash hands with an antimicrobial agent or use alcohol-based hand sanitizer. Avoid touching front of mask during removal as it is considered contaminated. A review of Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated March 29th, 2021, under section Personal Protective Equipment, revealed . Facilities should have policies and procedures addressing . Which PPE is required in which situations (e.g., residents with suspected or confirmed SARS-CoV-2 infection, residents placed in quarantine) .? The fit of the medical device used to cover the wearer's mouth and nose is a critical factor in the level of source control (preventing exposure of others) and level of the wearer's exposure to infectious particles. Respirators offer the highest level of both source control and protection against inhalation of infectious particles in the air. Facemasks that conform to the wearer's face so that more air moves through the material of the facemask rather than through gaps at the edges are more effective for source control than facemasks with gaps and can also reduce the wearer's exposure to particles in the air. Improving how a facemask fits can increase the facemask's effectiveness for decreasing particles emitted from the wearer and to which the wearer is exposed . Further review of the CDC Infection Control for Nursing Homes, updated March 29th, 2021, under sub-section Manage Residents with Suspected or Confirmed SARS-CoV-2 Infection [COVID-19], revealed .Residents with suspected or confirmed SARS-CoV-2 infection do not need to be placed into an airborne infection isolation room (AIIR) but should be cared for HCP using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 12 of 13 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 105708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Health and Rehabilitation Center 2851 Tampa Rd Palm Harbor, FL 34684 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 5. A tour of the facility east wing was conducted on 08/12/2021 at 05:50 a.m. Prior to entering the unit a double door with a signage STOP was posted. The signage read, MUST HAVE N95 Mask and Face shield Prior to Entering Unit. During the tour, an observation was made of Staff F, RN wearing a surgical mask. The mask was not covering her nose and was loose fitting around her ear. In addition, Staff F was not wearing a face shield. Residents Affected - Some An interview was conducted on 08/12/2021 at approximately 05:51 a.m. with Staff F following the observation. Staff F, RN stated that she is aware of the signage posted, but she is not able to breathe effectively when wearing a N95 mask. She stated that she did not inform the facility of not being able to breathe when wearing a N95 mask. Staff F stated that she was not taking care of the resident on airborne precautions and did not think it was necessary to wear a face shield. On 08/12/21 at approximately 05:55 a.m. Staff E, Dietary Aide was observed entering facility lobby, she had no mask on. Staff E then opened the door to the main entrance of the facility to enter. Staff E was not wearing a mask upon attempt to enter the main entrance. In addition, she was not screened for signs and symptoms of COVID-19 upon entering the facility lobby. In an interview with the Staff E at approximately 5:56 a.m. on 08/12/2021. She stated that she has been working at the facility for a month and had never worn a mask upon entering the facility prior to getting to her assigned department. She stated that she usually does self-screening in the lobby area for COVID-19 but confirmed that this morning she did not. Signage was observed posted on the facility entrance related to cough etiquette, and face mask to be worn upon entrance to facility. On 08/12/21 07:17 a.m. an interview with the facility DON and the NHA revealed the expectation is for staff to wear the appropriate PPE in the designated areas. The DON and NHA stated that they expect staff and visitors to wear a mask upon entering the facility, and to be screened in the lobby area for COVID-19, before entering the main facility area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 13 of 13