Inspection·August 2, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The review of the medication list from the acute care facility, dated 7/26/23, for Resident #286 showed the resident was ordered Escitalopram 10 milligram (mg) daily (an antidepressant) and Quetiapine 25 mg every night (an antipsychotic). The acute care facility's History and Physical form showed the resident had been admitted on [DATE] and had a past medical history significant for dementia with behavior disturbance. The facility's active Order Summary Report as of 8/2/23 showed Resident #286 had the following physician orders: - Escitalopram Oxalate 10 mg - Give 1 tablet by mouth one time a day for depression, ordered 7/26/23. - Quetiapine Fumarate 25 mg - Give 1 tablet by mouth at bedtime for agitation/anxiety, ordered 7/26/23. A review of Resident #286's Minimum Data Set (MDS) showed a Brief Interview of Mental Status (BIMS) of 3, which indicated severe cognitive impairment. The MDS did not include any active diagnoses of psychiatric/mood disorders. The Medication section of the comprehensive assessment showed the resident had received four days of an antipsychotic and three days of an antidepressant. The Regional Nurse Consultant (RNC) stated on 8/2/23 at 2:35 p.m., [Resident #286's] PASARR should reflect (mental illness) diagnoses. 3. The admission Record for Resident #288 showed the resident was admitted on [DATE] and 7/30/23. The record included diagnoses not limited to unspecified recurrent major depressive disorder. A review of Resident #288's PASARR, completed by an acute care facility on 7/24/23, did not indicate the resident had a mental illness or suspected mental illness based on documented history. 4. A review of Resident # 42's admission Record showed she was admitted to the facility on [DATE], with diagnoses to include but not limited to dysphagia following cerebral infarction, aphasia following other cerebrovascular disease, bipolar disorder, unspecified, major depressive disorder, recurrent, unspecified. A review of Resident # 42's PASARR, dated 6/25/2023, revealed Section I: PASARR Screen DecisionMaking, Section A. MI (mental illness) or Suspected MI, did not list Resident #42's mental illnesses. A review of the admission MDS, dated [DATE], Section I- Active Diagnoses showed a Psychiatric/Mood Disorder of depression and bipolar disorder. On 08/01/2023 at 12:00 p.m., an interview was conducted with the Regional Clinical Director. She confirmed Resident # 42's PASARR was inaccurate and should have been revised to accurately reflect her mental disorders. A review of the facility policy titled, admission Criteria, revised December 2016, showed, Our facility will admit only those residents whose medical and nursing care needs can be met. 7. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 2 of 19 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 08/02/2023 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 0644 (PASARR) to the extent practicable. Level of Harm - Minimal harm or potential for actual harm 8. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined ( through the preadmission screening program ) that the individual has a physical or mental condition the requires that level of services provided by the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 3 of 19 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 08/02/2023 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and record review, the facility failed to 1. provide treatment and services to maintain or improve functional abilities for activities of daily living for one resident (#112) of two residents sampled and 2. failed to assist with meals and offer alternatives for one resident (#74) of seven residents sampled who required assistance with meals. Residents Affected - Few Findings included: 1. A review of Resident #112's admission Record revealed she was readmitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included morbid (severe) obesity, cellulitis of left lower limb, type 2 diabetes mellitus, and sciatica of the left limb. An observation and interview were conducted on 7/30/23 at 11:50 a.m. with Resident #112. She was observed lying in bed watching television. She stated her only concern was that when she first came to the facility in January, she was ordered therapy, but she had bilateral sciatic problems with her legs with unbearable pain and she could not participate in therapy. She stated, When you don't participate then they stop giving you therapy. I have a wound on my left leg and that is finally getting better now, and my sciatic nerve pain stopped, and the physicians wrote in their notes that I needed therapy, so I got occupational therapy [OT], but I never got PT [physical therapy]. I need physical therapy to get my arms stronger and build up my muscles so I can transfer myself in and out of my wheelchair, so I can go home. I have asked people if I can borrow the exercise bands or something to strengthen my arms, but no one will let me use them or give me therapy. I don't have to take up their time I can just do it in my bed if they would provide me with the equipment. I just want to go home. A review of Resident #112's Quarterly MDS, dated [DATE], Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. An interview was conducted with the facility's Rehabilitation Director on 8/01/23 at 4:13 p.m. She stated, We saw and screened her [Resident #112] on 6/20/23, no changes in ADLs [activities of daily living] and no change in mobility, no changes in eating or swallowing, no changes in pain, range of motion, sitting and positioning. When we do the screening, we see the patient. She [Resident #112] always says she needs therapy. When we assessed her, she has not had a decline or a change and she's not on therapy load. I can't tell you the last time she was in therapy because I don't have access to the old documentation. What I do know is that based on the quarterly assessment the therapist did not feel the resident would benefit from therapy services. There is recreational exercises that Activities does and the resident should know about that. The Rehabilitation Director confirmed it would be appropriate to start therapy services for someone who wanted to strengthen their arms to help assist in transfers. An interview was conducted on 8/01/23 at 4:26 p.m. with Staff Q, Physical Therapist. She said, I did not talk to the resident at the time of my assessment, but I did talk to the CNA [certified nursing assistant] and the nurse to see if there were any changes in mobility and there was no change. I'm pretty sure she has had OT in the last 6 months to a year and I'm pretty sure they gave her home therapy exercises but, there was no change functionally with her. She's not very mobile. She's rarely (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 4 of 19 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 08/02/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few out of bed and I know in the past she was getting dressing changes for a wound. She's not highly motivated to get out of bed. 2. A review of the admission Record showed Resident #74 was admitted on [DATE] and 6/14/23. The record included diagnoses not limited to sepsis due to escherichia coli (e.coli), pressure induced deep tissue damage of left buttock, unstageable pressure ulcer of right hip, and type 2 diabetes mellitus without complications. An observation on 7/30/23 began at 12:19 p.m. as the meal cart arrived on the unit. An unknown staff member removed a meal tray from the cart and placed it on the over-bed table for Resident #74. On 7/30/23 at 12:32 p.m., the covered meal continued to sit on the over-bed table with no staff observed entering the room. On 7/30/23 at 12:39 p.m., Resident #74's meal continued to sit on the table without staff entering the room to assist the resident. On 7/30/23 at 12:40 p.m., a staff member entered the resident's room, immediately left the room and shut the door. In an interview on 7/30/23 at 12:41 p.m., the resident said he did not know lunch was there and someone did assist him with his meals. On 7/30/23 at 1:00 p.m., Staff E, Registered Nurse (RN), entered the room and asked if the resident wanted to eat. Staff E lifted the plate cover and identified that it was meatballs and carrots. The resident stated No. Staff E stated the resident's family member brought him a fast food burger. Staff E removed the meal tray and did not offer the resident an alternative. The meal tray had been sitting on the resident's over-bed table for 21 minutes prior to a staff member entering the room then another 20 minutes before another staff member entered the room and asked the resident if he wanted to eat, leaving without offering an alternative. On 7/31/23 at 8:24 a.m., Staff I, Certified Nursing Assistant (CNA) was observed in Resident #74's room. The resident was informed the meal tray was on the over bed table and was asked if he was hungry, which the resident stated no to being hungry or thirsty. The staff member left the room with the meal tray, no alternative was offered. The Minimum Data Status (MDS), dated [DATE], showed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. The MDS showed the resident required extensive assistance from 1-person for eating. The care plan for Resident #74 showed the resident required assist with Activities of Daily Living (ADL) related to multiple factors and staff were to provide assistive devices as ordered/indicated and to encourage and assist with all ADL tasks as indicated, as tolerated by resident, including . meals, (and) personal /oral hygiene, cetera (etc.). The resident was identified as being at risk for alteration nutrition/hydration related to (r/t) diagnosis (dx) of Diabetes Mellitus (DM), wounds (and) infection. The interventions included but not limited to encourage and assist resident .as tolerated for meals and to explain and reinforce to the resident the importance of maintaining the diet as ordered, encourage the resident to comply, explain consequences of refusal, obesity/malnutrition risk factors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 5 of 19 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 08/02/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The CNA task of eating documentation showed from 7/4 to 8/1/23 Resident #74 was independent with eating after meal set up on 7/4, 7/5, 7/12, 7/13, 7/15, 7/16, 7/17, 721, and 7/29/23. The documentation showed the resident required limited assist from 1-person for meal(s) on 7/5, 7/6, 7/10, 7/12, 7/13, 7/14, 7/16, 7/20, and 7/26/23. The task showed the resident required extensive assist for a meal service from one-person on 7/6, 7/8, 7/9, 7/10, 7/11, 7/12, 7/13, 7/16, 7/17, 7/19, 7/22, 7/25, 7/29, and 7/30/23. The task showed the resident required total dependence from 1-person during meal service on 7/4, 7/5, 7/7, 7/8, 7/9, 7/11, 7/18, 7/20, 7/21, 7/23, 7/24, 7/25, 7/26, 7/27, 7/28, and 7/29/23. The facility provided evidence that menu alternatives of soup of the day, chef salad, yogurt or cottage cheese, seasonal fruit plate, grilled cheese sandwich, tuna or egg salad sandwich, peanut butter & jelly sandwich and deli sandwiches were available and baked sweet potato, hot dog, hamburger, and a baked potato was available if ordered 2 hours prior to the meal. Review of the facility's Activities of Daily Living (ADLs), Supporting policy, revised on March 2018, revealed: Policy Statement Residents will [be] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or condition does not alone justify a decline in a residence ability to perform ADLs. .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .c. Mobility (transfer and ambulation, including walking); . .e. Dining (meals and snacks) .5. A residence ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: .d. Extensive Assistance- while resident performed part of activity over the last 7 days, staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 6 of 19 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 08/02/2023 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 0676 provided weight-bearing support. Level of Harm - Minimal harm or potential for actual harm .6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Residents Affected - Few 7. The resident's response to interventions will be monitored, evaluated and revised as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 7 of 19 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 08/02/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide sufficient staffing to adequately meet the residents' needs for nine residents (#131, #117, #26, #147, #144, #80, #72, #537, and #128) out of 63 residents sampled. Findings Included: 1. On 7/30/2023 at 9:10 a.m., an interview was conducted with Resident #131's family member. The family member said the 11:00 p.m.-7:00 a.m. shift was constantly understaffed, which had an impact on Resident #131 because he was always wet when she visited him in the morning. She said that she visited him before the morning shift started their assigned shift, so she knew that it was the night shift who left the resident wet. A review of the staffing assignment sheet, dated 7/30/2023, revealed Staff K, Registered Nurse (RN) worked as a nurse and a Certified Nursing Assistant (CNA) on the 11:00 p.m.-7:00 a.m. on the Medbridge unit. A review of the staffing assignment sheet, dated 7/31/2023, revealed Staff L, Licensed Practical Nurse (LPN) and Staff K, RN worked as nurses and CNAs from 11:00 p.m.-7:00 a.m. on the Medbridge unit. On 8/1/2023 at 12:00 p.m., an interview was conducted with Staff N, CNA. Staff N said she had been working at the facility for 15 years. She said sometimes they had enough staff and sometimes they did not. She reported she used to help out on 11:00 p.m.-7:00 a.m. shifts, but she stopped because they had a lot of call offs on that shift and it was too much for one CNA to have to work on the unit by themselves. She said last night they only had one CNA on for the 300 hall (Medbridge Unit) for 38 residents. On 8/1/2023 at 1:00 p.m., an interview was conducted with Staff K, RN. She said she worked as a CNA and a nurse for her shift from 11:00 p.m.-7:00 a.m. last night. She said that she and another nurse (Staff L, Licensed Practical Nurse [LPN]) and a CNA divided up the assignment. They gave the CNA 20 residents and both she and the other nurse had nine residents a piece. She said it was hard, but they made it through the night. Review of the CNA Assignment Sheet for 11(p.m.) to 7:00 (a.m.) for the Medbridge Unit showed Staff L, LPN was assigned rooms 301-321, Staff K, RN was assigned rooms 339-349 and 354-356 and Staff O, CNA was assigned rooms 322 - 338 and 357 - 373. and review of the census showed 36 residents on this unit. On 8/1/2023 at 1:38 p.m., an interview was conducted with Staff L, LPN. Staff L reported she worked as a CNA and a nurse last night and the night before due to staff calling out. She said she and Staff K worked as both nurses and CNAs for the whole night on the Medbridge unit. On 8/1/2023 at 1:45 p.m., an interview was conducted with Staff M, CNA. Staff M reported she was not able to provide dining assistance for her residents because they were always working short staffed at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 8 of 19 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 08/02/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm On 8/1/2023 at 4:00 p.m., an interview was conducted with Staff O, CNA. Staff O confirmed that she worked as a full time CNA on the 11:00 p.m.-7:00 a.m. shift on the Medbridge Unit. She confirmed she was the CNA who worked with both Staff L, LPN and Staff K, RN on the 11:00 p.m.-7:00 a.m. shift when they both worked as nurses and CNAs. She said they were short staffed often but she was able to manage her workload. Residents Affected - Some On 08/02/23 at 9:42 a.m., an interview was conducted with Staff R, Staffing Coordinator. Staff R said she determined staffing in the facility by the census, and not by acuity. Whenever there was a call out and she was not in the building, the charge nurse was responsible to make sure there was coverage for the shift. She said they used agency but just for nurses, however after today, they had signed an agreement for agency CNAs. A review of the Facility Assessment, undated, showed: Requirements, Nursing facility will conduct, document, and annually review a facility-wide assessment, which includes both their resident's population and the resources the facility needs to care for their residents. Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using competency- based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychological well-being. The intent of the facility assessment is for the facility to evaluate its resident's population and identify the resources needed to provide the necessary person- centered care and services the resident requires. Staffing Plan 3.2 Based on our resident population, acuity of residents and the duties of the day-to-day operations - the following staffing plan is in place to meet those needs. The ratio of registered and license practical nurses to aids shall be sufficient to assure professional guidance and supervision in the nursing care of the residents. 3. During an interview on 07/30/23 at 1:11 p.m., Resident #26 stated the facility needed the staff to answer the call lights faster and not make residents wait long periods of time. Resident #26 stated they had to wait 45 minutes to an hour for someone to come answer the call light. 4. During an interview on 07/30/23 at 11:40 a.m., Resident #147 stated a concern with call light response time. Resident #147 stated the other night, I was so thirsty and put the call light on. Resident #147 stated it took staff over an hour to answer the call light just to get a drink of water. 5. During an interview on 07/30/23 at 12:05 p.m., Resident #144's family member stated the other day he looked for staff and could not find anyone. Resident #144's family member stated he did not know if it was the time of day of the visit but, there was a concern about staffing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 9 of 19 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 08/02/2023 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 0725 A review of the facility's Resident Council minutes showed: Level of Harm - Minimal harm or potential for actual harm -07/17/23- Old Business- Followed up with nursing with call lights and showers. - 07/03/23- Residents report slow call light response at times on 11-7 shift. Residents Affected - Some - 06/05/23- Followed up with nursing regarding all lights. During an interview on 08/02/23 at 9:33 a.m., Staff A, Activities Therapist (AT) stated the Activity Director was charge of Resident Council. Staff A stated based on the Resident Council minutes notes she was not able to identify when the first complaint about call light response times started but would check more into the question since the Activity Director was out of the facility. Staff A stated when a concern was addressed at Resident Council , the Activity Director wrote a grievance immediately and took it to the social services department to take care of. During an interview on 08/02/23 at 10:00 a.m., Staff A stated the first call light concern identified in Resident Council was on 05/08/23. Staff A stated there was a grievance written corresponding to the identified concern made in the Resident Council meeting on 05/08/23. On 8/2/23 at 12:30 p.m., the Resident Council President (RCP) stated the issue, mentioned in the Resident Council minutes, was that call lights were not answered efficiently then clarified that it took staff to long to answer. A review of the facility's Grievance Log showed concerns related to call bell response times. The Grievance Log showed as followed: 05/08/23- Concern of call bell timeliness - Call bells not timely 11-7. 05/22/23- Concern of call bell- Call bell on 11-7 last weekend. Dinner was late last weekend too. 07/03/23 - Concern call bell- Report times call bell is slow. A review of the facility's Grievance Form with facility response was reviewed related to call bell response times. The Grievance Forms showed as followed: - Dated 05/08/23 the grievance showed, slow call light response at times on 11-7 shift (East and West). An in-service was provided to staff regarding call lights and answering call lights timely. Since staff education patients report its better. The in-service was conducted to all staff on 05/11/23 titled Customer Service. - Dated 05/22/23 the grievance showed, long call light response wait times on 11-7 shift and on weekends. An in-service was provided about call light response times. The in-service was conducted on 05/22/23 titled Call Light Response. -Dated 07/03/23 the grievance showed, slowed call light response at times. Occasionally it took a longer time to get a CNA to answer call lights promptly. An in-service was provided on call light response times. The in-service was conducted on 07/10/23 titled Call Bell Response. During an interview on 08/02/23 at 3:10 p.m., the Nursing Home Administrator (NHA) stated staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 10 of 19 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 08/02/2023 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 0725 were educated regarding call bell response times after each grievance related to call bell concerns. Level of Harm - Minimal harm or potential for actual harm 6. An interview was conducted on 7/30/23 at 10:30 a.m. with Resident #80's family member. The family member stated, The only thing they [the facility] can improve on is always having someone available that can help because, if the person that is assigned to you is on break; the staff will say oh, I'm not your nurse, or I'm not your CNA [Certified Nursing Assistant] you have to wait till they get back. [Resident #80] can't use the call light but if I put the call light on, they don't answer that. It's worse on the night shift there's never any one around or at the nurse's station. Residents Affected - Some 7. An interview was conducted on 7/30/23 at 12:00 p.m. with Resident #72's family member. She stated, If you push the call light it will take 30-45 minutes for anyone to even answer the call lights and that's not including the time it takes for them to do what you were calling them in to do. 8. An interview was conducted on 7/30/23 at 10:05 a.m. with Resident #537. She stated, I put my call light on the other night, I forgot what I needed, but I put the call light on and it took them 45 minutes to answer it and I asked the girl why and she said she starts at one end of the hall and works her way down. I told her what if I was having a heart attack? I could be dead by the time she got to me. Review of Resident #537's admission MDS, dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 15 out 15 indicating the resident is cognitively intact. 9. An interview was conducted on 7/30/23 at 11:25 a.m. with Resident #128, she stated, The only concern I have is I think they have had too many cutbacks. The girls [CNAs] here used to have nine patients, now they each have 11. They are very nice, and I don't let them miss any of my care because I will go out into the hall and just yell until I get what I want. They are very nice, but they just wiz in and out of the rooms because they just don't have the time to spend with anyone like they used to. Review of Resident #128's Quarterly MDS, dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 15 out of 15 indicating the resident is cognitively intact. 2. The admission Record for Resident #117 identified admission dates of 1/20/22 and 5/31/2023. The record included diagnoses not limited to unspecified anxiety disorder, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 8/1/23 at 9:41 a.m., during an observation of medication administration, Resident #117 informed Staff S, LPN, of not getting a shower last night and that staff had told the resident they didn't have time. On 8/2/23 at 9:29 a.m., during an interview with Resident #117 she stated the staff were not very nice when giving a shower, they were rushed, and had an attitude. The resident stated when she did not receive a shower the staff would tell her they were too busy. A review of the Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. A review of the shower day schedule showed Resident #117 was to receive a shower during the 3:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 11 of 19 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 08/02/2023 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 0725 p.m.-11:00 p.m. shift on Monday and Thursday. Level of Harm - Minimal harm or potential for actual harm A review of the Certified Nursing Assistant (CNA) documentation showed on Monday on 7/3/23 at 2:59 p.m., Resident #117 received a sponge bath, on 7/31/23 at 10:30 a.m., in addition at 9:14 p.m. the documentation indicated the resident had refused. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 12 of 19 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 08/02/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of Resident #40's admission Record showed diagnoses of ataxic gait, unspecified dementia, anemia, essential hypertension, history of falling, sarcopenia, weakness, atherosclerotic heart disease, and other symptoms and signs of concerning food and fluid intake. Review of the active physician orders as of 8/2/23 showed a physician order, dated 01/31/23, showed, Escitalopram Oxalate Tablet 5 mg- Give 5 mg by mouth one time a day for depression give with 10 mg to equal dose of 15 mg. A second physician order, dated 01/31/23 showed, Escitalopram Oxalate Tablet 10 mg- Give 10 mg by mouth one time a day for depression give with 5 mg to equal dose of 15 mg. A third physician order, dated 11/02/22 showed, Buspirone HCI Oral Tablet 5 mg- Give 5 mg by mouth two times a day for anxiety. The Medication Administration Record (MAR) was reviewed for June 2023 and July 2023 and showed Escitalopram Oxalate Tablet 5 mg, Escitalopram Oxalate Tablet 10 mg, and the Buspirone HCI Oral Tablet 5 mg were given per the physician orders. The Quarterly Minimum Data Set (MDS), dated [DATE], showed a diagnosis of dementia but no diagnoses of anxiety or depression in Section I-Active Diagnoses of the MDS. The Quarterly Minimum Data Set (MDS), dated [DATE], showed the medications of antianxiety and antidepressants were administered all seven days during the seven day MDS day look back period. A review of Resident #40's care plan showed a focus diagnosis of dementia, initiated on 1/24/22, with appropriate goals and interventions. The care plan showed a second focus on adverse risks related to the use of antidepressant medications, initiated on 1/24/22, with appropriate goals and interventions. The diagnoses of anxiety and depression as the administration of antianxiety medications were not found on Resident #40's care plan. During an interview on 08/02/23 at 2:25 p.m., the Regional Nurse Consultant (RNC) stated the expectation of the facility was to have a resident diagnosis that corresponded with the medication ordered by the physician. Additional review of the facility policy titled, Medication Utilization and Prescribing-Clinical Protocol, issued 10/14 and revised on 10/2022, showed, Assessment and Recognition 1. When a medication is prescribed for any reason, the physician and staff will identify the indications (conditions or problem for which it is being given, or what the medication is supposed to do or prevent), considering the resident's age, medical and psychiatric conditions, risks, health status and existing medication regimen. Based on observation, interview, and record review, the facility failed to ensure an as needed psychotropic medication was limited to 14 days for one resident (#125) out of six residents reviewed for unnecessary medication. The facility also failed to ensure three residents (#128, #40, and #286) out of six residents reviewed for psychotropic medications had documented corresponding diagnoses for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 13 of 19 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 08/02/2023 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 0758 ordered medications. Level of Harm - Minimal harm or potential for actual harm Findings included: Residents Affected - Few 1. Review of Resident #125's admission Record revealed she was readmitted to the facility on [DATE] from hospice. Resident #125's medical diagnoses included but were not limited to senile degeneration of the brain and dementia without behaviors or mood disturbances and anxiety disorder. An observation of Resident #125 was conducted on 7/30/23 at 11:29 a.m. The resident was observed to be clean, lying in bed, with her eyes closed. During an observation conducted on 7/31/23 at 3:50 p.m., Resident #125 was observed to be lying in bed, her eyes were closed, and music was playing in her room. Review of Resident #125's physician orders active as of 8/2/23 revealed an order for Ativan oral tablet 0.5mg to be given every 4 hours as needed for anxiety and agitation which started on 6/21/23 without an end date. Review of Resident #125's admission Minimum Data Set (MDS), Section I - Active Diagnoses, dated 5/6/23, revealed Resident #125 did not have any Psychiatric/Mood Disorders including the resident did not have anxiety disorder. Review of Resident #125's June and July 2023 Medication Administration Record (MAR) revealed the resident received her as needed Ativan 4 times from 6/21/23 to 7/31/23. One of the four Ativan administrations was administered on 7/15/23 at 2:45 p.m. which was 24 days after the medication was ordered. Review of Resident #125's pharmacy recommendation reviews for June 2023 revealed no recommendations. An interview was conducted with the facility's Regional Nurse Consultant on 8/01/23 at 3:29 p.m. She confirmed she reviewed Resident #125's Ativan order and confirmed it was ordered for longer than 14 days and the pharmacist just sent her an email for the July (2023) review and the resident did not have any recommendations. 2. Review of Resident #128's admission Record revealed she was re-admitted to the facility on [DATE]. The resident's medical diagnoses included heart failure, encephalopathy, cognitive communication deficit, cellulitis of left lower limb, morbid obesity (severe) obesity due to excess calorie, sepsis, type 2 diabetes mellitus with diabetic polyneuropathy. Her medical diagnoses did not include depression. Review of Resident #128's physician orders active as of 8/2/23 showed an order which started on 6/11/22 for Duloxetine HCL capsule Delayed Release Particles 60mg (milligrams), give 1 capsule by mouth one time a day for depression. Review of Resident #128's July 2023 MAR showed the resident received her ordered Duloxetine for depression. Review of Resident #128's Quarterly MDS, Section I-Active Diagnoses, dated 4/18/2023, showed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 14 of 19 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 08/02/2023 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 0758 resident did not have any Psychiatric/Mood Disorders including the resident did not have depression. Level of Harm - Minimal harm or potential for actual harm Review of Resident #128's Pharmacist reviews for the month of June 2023 did not show recommendations related to Resident #128 having ordered medications for diagnoses that were not documented. Residents Affected - Few A phone interview was conducted with the facility's Consulting Pharmacist on 8/02/23 at 2:40 p.m. He stated, Residents are reviewed once a month and then if anyone needs a review in between we will do that too. We do look at medications and make sure there are corresponding diagnoses and as needed psychotropics should be limited to 14 days. 3. Review of Resident #286's admission Record showed the resident was admitted on [DATE]. The resident's medical diagnoses included syncope and collapse, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The MDS assessment, dated 7/29/23, showed Resident #286 had a Brief Interview of Mental Status score of 3 out of 15, which indicated severe cognition impairment. The MDS showed the resident had an active diagnosis of Non-Alzheimer's Dementia and did not include any psychiatric/mood disorder diagnoses and received 4 days of antipsychotic and 3 days of antidepressant medications. The active Order Summary Report as of 8/2/23 for Resident #286 showed the resident was receiving the following psychotropic medications: - Escitalopram Oxalate 10 milligram (mg) - Give 1 tablet by mouth one time a day for depression; - Quetiapine Fumarate 25 mg - Give 1 tablet by mouth at bedtime for agitation/anxiety. The acute facility's History and Physical report, which showed a date of admission of 7/23/23, indicated Resident #286 had a diagnosis significant for dementia with behavior disturbance. The Physician/Practitioner progress note, dated 7/31/23 at 12:53 p.m., included diagnoses for Resident #286 of vascular dementia (vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety) and showed to continue supportive care. During the observation of medication observation with Staff D, Registered Nurse (RN), for Resident #286, on 7/31/23 at 8:04 a.m., the resident was observed lying in bed, pulling up the blankets that covered from the waist down. The resident informed the staff member to get rid of the five inches of water, lifting up the blankets indicating it (the water) was under there. The behavior monitoring for Resident #286 identified on 7/31/23 during the day shift Resident #286 did not have any episodes of behaviors. The Medication Administration Record (MAR) instructed staff to document behaviors, effectiveness, and non-pharmaceutical interventions. The care plan for Resident #286 indicated the following: - a focus was initiated, on 7/31/23, an identified the resident had a history of exhibiting the following behaviors agitated (and) anxious. The interventions instructed staff to Administer medications as ordered. Monitor/document for side effects and effectiveness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 15 of 19 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 08/02/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm - a focus was initiated, on 7/31/23, an identified the resident was at risk for falls related to impaired mobility, use of psychotropic medications. - The resident uses antipsychotic medications related to (r/t) behavior management and instructed staff to administer antipsychotic medications as ordered by physician. Residents Affected - Few - The resident uses antidepressant medication r/t depression and instructed staff to administer antidepressant medication as ordered by the physician. Staff J, Certified Nursing Assistant (CNA) stated on 8/1/23 at 4:48 p.m., that Resident #286 had no extra confusion noted, had never mentioned sitting in water, and that the resident was constantly dropping the water on the floor and when that happened staff changed the bed. During an interview that started on 8/1/23 at 5:00 p.m., Staff F, Registered Nurse/Unit Manager (RN/UM) reported understanding if a psychiatric consult was requested a Nurse Practitioner would come in. Staff F reported not noticing anything new with Resident #286's confusion. Staff F stated if the resident voiced lying in water that would be a behavior and should be noted on the behavior log. Staff F reviewed the medical diagnoses of the resident and stated the resident had dementia without behavioral disturbances then reviewed the hospital history and physical and identified it indicated the resident had a diagnosis of dementia with behaviors. Staff F reported the resident did not have a psych (psychiatric) consult. On 8/1/23 at 11:22 a.m., the Regional Director of Clinical Services (RDCS) stated the behavior monitoring should be included on the Medication Administration Record (MAR). The policy titled, Medication Utilization and Prescribing - Clinical Protocol, issued 10/14 and revised 10/22, showed the standard was To ensure medications are prescribed and utilized according to State and Federal guidelines. The assessment and recognition showed, When a medication is prescribed for any reason, the physician and staff will identify the indications (condition or problem for which it is being given, or what the medication is supposed to do or prevent), considering the resident's age, medical, and psychiatric conditions, risks, health status, and existing medication regimen. The assessment showed, Symptoms should be characterized in sufficient detail (onset, duration, frequency, intensity, location, etc.) to help identify whether a problem exists or whether a symptom is just a variation of normal. As part of the overall review, the physician and staff will evaluate the rational for existing medications that lack a clear indication or are being used intermittently on a PRN (as needed) basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 16 of 19 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 08/02/2023 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 observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and four errors were identified for two residents (#186 and #95) of six residents observed. These errors constituted a 11.43% medication error rate. Residents Affected - Few Findings included: 1. On 7/31/2023 at 8:30 a.m., an observation of medication administration with Staff B, Registered Nurse (RN), was conducted with Resident #186. Staff B dispensed medications scheduled at 9:00 a.m. which included but not limited to the following medications: - Oyster Shell Calcium 500 mg (milligrams) - 3 tablets. During the observation Staff B searched the medication cart, dispensing three Oyster Shell Calcium tablets identifying the tablets contained calcium carbonate. Staff B reported they had contacted the pharmacy this morning about the resident's Sodium Bicarbonate and was told they were out of it, and the physician was notified already. Staff B documented, med not available at this moment, pharmacy notified and MD notified this am, waiting for MD call back for update order. The July 2023 Medication Administration Record (MAR) showed Resident #186 was to receive at 9:00 a.m. on 7/31/23 the following medications: - Calcium Carbonate Oral wafer 500 (200 Ca) mg - Give 3 tablet by mouth every 8 hours for supplement during the observation, which Staff B had documented as given. - Sodium Bicarbonate 650 mg oral tablet (Sodium Bicarbonate (Antacid)) - Give 3 tablet by mouth two times a day for supplement. On 7/31/23 at 10:53 a.m., a review of progress notes and assessments for Resident #186 did not show the physician or pharmacy had been contacted prior to the medication administration observation with Staff B. The Electronic Medication Administration Record (eMAR) notes, dated 07/27 at 5:20 p.m., 07/28 at 8:02 a.m., and 7/29/23 at 5:36 p.m. showed waiting for delivery, 7/30 at 10:45 a.m. not aval (available), and 7/30/23 at 5:49 p.m. called pharmacy will deliver. On 7/31/23 at 5:15 p.m., a list of over-the-counter (OTC) medications was reviewed with Staff R, Staffing Coordinator/Central Supply. Staff R stated she would have to check with the wound care nurse that they knew more about it (available OTC medications). Staff R stated on 7/31/23 at 5:40 p.m. the highlighted items on the OTC list could be ordered. The list identified Sodium Bicarbonate tablets were highlighted and listed as (pharmacy) Do NOT Send. During an interview on 7/31/23 at 5:42 p.m. the Regional Nurse Consultant (RNC) stated the facility would contact the pharmacy for OTCs; would just need authorization from the Director of Nursing (DON) or Nursing Home Administrator (NHA) (for pharmacy) to bill the facility; could also order from supplier. Staff R stated medications only take a couple of days to receive from the supplier. The RNC stated the facility could also go to the nearby pharmacy and buy it if a resident had it ordered and we did not have it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 17 of 19 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 08/02/2023 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 Residents Affected - Few On 8/2/23 at 11:27 a.m., Staff F, Registered Nurse/Unit Manager (RN/UM), stated Oyster Shell Calcium was not the same as Calcium Carbonate and identified it as a name brand Antacid. Staff F stated they could go get some (medication) and should have let her know of the missing medications (regarding Sodium Bicarbonate). On 8/2/23 at 11:29 a.m., Staff H, Wound Care/Registered Nurse (RN) stated not all house stock (OTC) were available. Staff H reported the facility calls the pharmacy if they do not have house stock and requests a form for the DON to sign, then the pharmacy sends it. 2. On 7/31/2023 at 5:17 p.m., an observation of medication administration with Staff C, Registered Nurse (RN), was conducted with Resident #95. Staff C dispensed medications which included: - Ferrous Sulfate 325 milligram (mg) tablet - Multi-Vitamin with minerals tablet - Vitamin D3 25 microgram (mcg) tablet - Calcium + D3 600 mg/10 mcg tablet - Memantine 10 mg tablet - Novolog FlexPen 4 units. Staff C confirmed dispensing 5 tablets. During the dispensing Staff C searched the medication cart and could not find the following medication scheduled to be administered with the above medications: ICaps Oral Capsule (Multiple Vitamins with minerals) - Give 1 capsule by mouth in the afternoon for supplement. Staff C confirmed ICaps tablet was not administered and documented the medication was not available. A review of Resident #95's Medication Administration Record (MAR) identified the resident had a physician order to administer Caltrate +D Plus minerals 600/800 mg-unit. According to the website, https://www.caltrate.com/calcium-supplement-products/600d3-plus-minerals/, Caltrate 600+D3 Plus Minerals contained 600 mg of Calcium and 800 International Unit (IU) of Vitamin D3. Medscape.com indicated that 10 mcg (that was administered) = 400 IU. On 8/2/23 at 11:29 a.m., Staff F, Registered Nurse/Unit Manager (RN/UM) reported ICaps was a (brand name) eye vitamin and mineral supplement. Staff H, Wound Care/RN, reviewed Resident #95's medications and stated the resident had duplicate medications that needed to be reviewed but did not identify the resident did not receive the 800 international units of Vitamin D as ordered. The policy titled, Medication Shortages/Unavailable Medications, undated, showed When medications are not received or are unavailable for the customers, the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. The procedure portion of the policy documented the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 18 of 19 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 08/02/2023 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 Residents Affected - Few - If a medication shortage is noted at the time of medication administration (Med-Pass), the licensed nurse or certified medication assistant must immediately initiate action to obtain the medication and not wait until the med pass is completed. The policy documented if a medication was noted during normal pharmacy hours a licensed nurse was to notify the pharmacy and speak to the pharmacist to determine the status of the order and if not order, place the order or re-order to be sent with the next scheduled delivery. The facility link may also be utilized to order or re-order. The policy documented if a medication shortage is noted after normal pharmacy hours a licensed nurse obtains the medication from the emergency stock supply and if unavailable, calls the pharmacy and requested to speak the on-call pharmacist. If an emergency delivery is not feasible a licensed nurse contacts the attending physician to obtain orders or directions which may include holding the dose/doses, use of an alternative medication available from the emergency stock supply, and/or change in order (time of administration or medication). Review of document titled, The Medication Dispensing System, undated, showed, All medications will be prepared (blister card, vials, [brand name] box) and administered in a manner consistent with the general requirements outlined in this policy. The procedure identified that prior to Medication Administration staff were to Verify each medication preparation that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105708 If continuation sheet Page 19 of 19