Health inspection·December 21, 2023

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident # 8's medical record revealed Resident #8 was admitted to the facility on [DATE], and the most recent admission date of 10/30/2023, with a diagnoses including chronic respiratory failure with hypercapnia, acute respiratory failure with hypoxia, and generalized anxiety disorder. Review of Section C- Cognitive Patterns of the Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of Resident #8's care plan, dated October 30, 2023, revealed no assessment, focus, goal, or interventions for self-administration of medications. A focus area for diagnoses of Chronic Obstructive Pulmonary Disease and respiratory failure revealed a goal as: Resident will display optimal breathing patterns daily through review date of 3/6/2024. Interventions included: oxygen as per physician order, monitor for signs and symptoms of respiratory insufficiency, anxiety, and shortness of breath. Review of Resident #8's physician orders, dated October 30, 2023, revealed no orders to assess Resident #8 for the ability to self-administer medications. The Ventolin - Albuterol HFA Inhaler ordered on October 30, 2023, was two puffs by mouth every four hours as needed while awake for wheezing. No other inhaler orders were noted. Review of Resident #8's November 2023 Medication Administration Record (MAR) revealed the resident did not receive the Ventolin-Albuterol inhaler medication at all during the month. Review of Resident #8 December 2023 MAR revealed the resident received the Ventolin-Albuterol inhaler on 12/1/2023 and 12/3/2023 and it was administered by the staff. A review on 12/20/23 at 2:58 p.m. of policy and procedure Self-Administration of Medications, revised February 2021, revealed the following: Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 2. The interdisciplinary team considers the following factors when determining whether self -administration of medications is safe and appropriate for the resident: a. The medication is appropriate for self-administration b. The resident is able to read and understand the medication label c. The resident can follow directions and tell time to know when to take the medication d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff e. The resident has the physical capacity to open the medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 2 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0554 f. The resident is able to store the medication safely and securely Level of Harm - Minimal harm or potential for actual harm 7. I the resident is able and willing to take responsibility for documenting self-administration of medications, the resident is instructed on how to complete a record indicating the administration of the medication. Residents Affected - Few 12. Nursing staff reviews the self-administered medication record for each nursing shift and transfers pertinent information to the medication administration record kept at the nursing station appropriately noting the doses were self-administered. A review on 12/20/2023 3:20 p.m. of policy and procedure Medication Administration revised April 2019 revealed the following: Policy Statement: Medications are administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions 3. Medications are administered in accordance with prescriber orders, including any required time frame. 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined they have the decision-making capacity to do so safely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 3 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and interviews the facility failed to ensure the environment was clean and free from bio-growth for one Hopper Room (East Hallway on the 1st Floor) of four Hopper Rooms observed in the facility. Findings included: An observation on 12/18/23 at 4:00 p.m., revealed a musty like smell in the air on the first floor East Hallway of the facility. An observation on 12/18/23 at 4:25 p.m., revealed a room designated as the Hopper Room on first floor East Hallway. The musty smell was stronger in this area. The Hopper Room was observed to have bio-growth up the walls of the room and also had a big patch of bio-growth on the ceiling. (Photographic Evidence Obtained). During an interview on 12/18/23 at 4:35 p.m. the Maintenance Director (MD) stated he had issues with bio-growth on East Hallway at the First floor Nurses Station before but it was fixed. The MD stated he was unaware of any bio-growth in the facility right now. The Hopper Room East Hallway on the First Floor door was opened and MD stated, I never look in there and then stated there must be a leak to cause the substance to grow on the walls. The MD was asked to confirm bio-growth was present in the Hopper Room and MD stated he was not an expert and would not confirm anything. The MD was asked if he saw the bio-growth on the walls and ceiling and MD stated, There is something there. The MD stated he would have to have the bio-growth tested and may need to have a third-party company to come in to remove the bio-growth again. During an interview on 12/18/23 at 4:40 p.m., the Administrator stated she had never opened the doors to the Hopper Rooms in the facility and didn't know if the rooms were even used. During an interview on 12/19/23 at 9:50 a.m., Staff A, Certified Nursing Assistant (CNA) stated, I use the Hopper Room to dump all Residents' #1 and #2. Staff A CNA stated the Hopper Room was used regularly for Residents' waste. Staff A CNA was asked if she was aware of any bio-growth in the Hopper Room and Staff A CNA stated, I do not speak English that well, I do not understand. During an interview on 12/20/23 at 5:00 p.m., the Administrator stated the facility had called an outside company to come in and test the bio-growth. The Administrator stated an outside company tested the air quality and swabbed the bio-growth. The Administrator stated the facility was now waiting for the results to determine how to get rid the bio-growth correctly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 4 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to complete a Discharge Minimum Data Set (MDS) Assessment for two residents (#49 and #67) out of two sampled for resident assessments. Residents Affected - Few Findings included: A review of the medical record for Resident #49 revealed the resident was admitted to the facility on [DATE] with a diagnoses including but not limited to, cerebral Infarction affecting left side, Type 2 Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), hypertension, and repeated falls. The admission Record revealed Resident #49 was discharged from the facility on 08/21/2023. A review of the MDS assessments for Resident #49 revealed a completed entry assessment dated [DATE] and a completed admission assessment dated [DATE]. No discharge MDS assessment was located in the record. A review of the medical record for Resident #67 revealed the resident was admitted to the facility on [DATE] with a diagnoses including but not limited to, osteomyelitis, Type 2 Diabetes Mellitus, respiratory failure, and major depressive disorder. The admission Record revealed Resident #67 was discharged from the facility on 7/20/2023. A review of the MDS assessments for Resident #67 revealed a completed entry assessment dated [DATE] and a completed admission assessment dated [DATE]. No discharge MDS assessment was located in the record. On 12/20/2023 at 11:19 a.m. an interview was conducted with the MDS Coordinator. The MDS Coordinator stated she was unable to locate the discharge assessments for Residents #49 and #67. She stated Resident #49 had been discharged from the facility on 8/21/2023 and no discharge assessment had been completed for the resident. She stated Resident #67 had been discharged from the facility on 7/20/2023 and no discharge assessment had been completed for the resident. She stated she was responsible for completing the discharge assessments and this had been missed for Resident #49 and Resident #67. She stated she did not know how this occurred. A review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Assessment Summary document, dated October 2019, provided by the facility revealed the following: (Page 2-17) Discharge Assessment-return not anticipated MDS completion date no later than-discharge date + 14 calendar days MDS transmission date no later than-MDS completion date + 14 calendar days FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 5 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to develop a patient-centered care plan for one resident (#30) out of thirty-three sampled residents related to behavioral monitoring with the use of psychotropic medications. Findings included: Review of Resident #30's admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to unspecified nontraumatic subarachnoid hemorrhage, other seizures, most recent episode depressed in partial remission bipolar disorder, bipolar-type schizoaffective disorder, generalized anxiety disorder, metabolic encephalopathy, and alcohol abuse in remission. During an interview, on 12/18/23 at 11:35 a.m., Resident #30 reported abuse occurs All the time, employees are very sadistic and there was bad drug abuse with staff. The resident stated the Nursing Home Administrator (NHA) had been notified of the allegations. The resident did not use the same first name of NHA as the current administrator. The resident reported not getting out of bed, left leg was broken and needed to go to (named) acute hospital, and had been in a major military squirmish Here in Tampa with the Russian military a year ago. An interview was conducted with Staff D, Registered Nurse (RN) on 12/20/23 at 9:57 a.m. The nurse reported Resident #30 got out of bed 2-3 times a week for about 1-2 hours then asks to go back to bed. Staff D said the resident was very confused, sometimes asks for police, and to call a politician because someone is drugging him. The staff member said the resident says it every day and had never reported someone abused him, just drugged him. During an interview on 12/21/23 at 7:24 a.m., the Nursing Home Administrator (NHA) reported Resident #30 had reported to her of being in pain, wanting to go to the local Cancer Center, and staff flipped legs over when doing incontinent care. The NHA stated the resident reported the Second-in-command had a girlfriend who was a terrorist and caused pain. The NHA reported Resident #30 had reported similar complaints in January (2023) and had a history of confabulation. She reviewed the resident's care plan and confirmed the care plan did not include the resident's history of confabulation. She stated the care plan should reflect the history of confabulation. The NHA provided a copy of thirteen of the thirteen page care plan reviewed at the time of interview. During an interview on 12/21/23 at 8:05 a.m., Staff G, Licensed Practical Nurse (LPN), stated Resident #30 was confused, said inappropriate things, and reported staff did things to him. The staff member reported asking the resident why would he say that. Staff G said the resident would ask to go to the hospital and local Cancer Center. The staff member did not remember the last time the resident had said anything as she had just started Working back here. Review of Resident #30's care plan focus' included but not limited to the following: - Resident had a recent decline in self-performance of Activities of Daily Living (ADL) and independent mobility. - Resident is alert and oriented and able to make needs and wants known. (Resident) has some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 6 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 intermittent periods of confusion and forgetfulness. Level of Harm - Minimal harm or potential for actual harm - Resident has a history (Hx) of falls prior to admission and requires reminders to call for assist with transfers and ambulation as well as diagnosis (dx) of seizures. Residents Affected - Few - (Resident) takes daily psychotropic medications. - (Resident) is at nutritional risk due to (d/t) mechanically altered diet and Body Mass Index (BMI) elevated. - (Resident) is at risk for pain. - (Resident) is at risk for skin breakdown related to incontinence and decreased mobility. - (Resident) is at risk for impaired gas exchange related to (r/t) Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #30's December Medication Administration Record (MAR) revealed the resident was administered Lacosamide for seizures, Levetiracetam for seizures, Melatonin for insomnia, Oxcarbazepine for seizures, Quetiapine for schizophrenia, and Valproic Acid for seizures. A review of Resident #30's care plan did not reveal the resident had a history of confabulation and did not include the behaviors exhibited related to the use of psychotropic medications. Review of Resident #30's December Psychoactive Medication Monthly Flow Record for Lacosamide, Quetiapine, Valproic acid, Levetiracetam, and Oxcarbazepine did not reveal the resident had exhibited any behaviors. A review of Resident #30's nurse's notes from 11/1/23 to 12/19/23 revealed on 12/11/23 at 8:30 a.m., the resident was combative and confused and on 12/18/23 at 9:20 a.m., the resident refused oxygen. The notes did not reveal how the resident was combative or if the resident had increased confusion. The psychiatry provider note, dated 12/20/23, revealed the resident had Presence of active symptoms (worsening of previous symptoms or new symptoms). The note showed the resident had expressed dissatisfaction with the treatment received at the facility according to staff. The provider noted the resident was displaying acute symptoms of psychosis, including hallucinations, delusions, and accusatory behavior. During an interview on 12/21/23 at 11:17 a.m., Staff J, Social Service Director (SSD) reported doing some of the behavior care plans which triggers on the Minimum Data Set (MDS), and nursing does some of them. The staff member stated Resident #30 does have a history of confabulation, watches a lot of television and he thinks its real and is not consistent with stories. The SSD reviewed the care plan provided in the morning by the NHA and asked why the NHA had given the writer that one. The SSD stated the MDS Director, NHA and herself had revised the care plan this morning to include a focus revealing the resident confabulated stories. On 12/21/23 at 1:56 p.m., the Director of Nursing stated the care plan of Resident #30 should include the behaviors exhibited to validate the necessity of psychotropic medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 7 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility provided a copy of regulation 42 CFR 483.21 - Comprehensive person-centered care planning, up to date as of 12/19/2023, which revealed in section 483.21 (b) (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Event ID: Facility ID: 105725 If continuation sheet Page 8 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to conduct an accurate smoking assessment for one resident (#32) out of three residents sampled for smoking. Residents Affected - Few Finding Included: On 12/18/23 at 11:55 a.m., Resident #32 was observed outside in the designated smoking area smoking a cigarette without supervision. The resident was observed with a band aid and burn marks on his left fingers. The resident said when his cigarette burns, he is not able to feel it because he has neuropathy so that's why he has burn marks on his fingers. Review of admission Record, dated 12/19/2023, showed Resident # 32 was originally admitted on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus, Atherosclerotic heart disease of native coronary artery without Angina Pectoris, and unspecified lack of coordination. Review of a Hospice Comprehensive Assessment, dated 10/24/2023, showed Resident #32 was admitted to hospice on 10/24/2023 with diagnoses to include but not limited to severe peripheral neuropathy, Carpel Tunnel, and unable to use hands well. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Section C, Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Review of a Smoking Safety Evaluation, dated 12/4/2023, signed by the Director of Nursing (DON), showed Resident #32 was an independent smoker who did not need assistance. Review of a Smoking Care plan, dated 3/18/2023, showed Resident #32 was currently a smoker. An intervention, dated 3/18/2023, showed resident may carry their own smoking materials and keep in a locked drawer in room when not in use. During an interview on 12/18/23 at 01:10 PM with Staff G, License Practical Nurse (LPN), she said she has not noticed any burn marks on Resident #32's fingers. She stated the skin assessments were done on Thursday's 7am to 7pm shift. She stated the last skin assessment was done on 11/11/2023 and showed he had no new skin issues. During an interview on 12/18/23 at 01:35 PM with the Director of Nursing (DON), she said resident #32's skin checks were done more frequently than just on Thursdays because he was seen by wound care, and he is on hospice. She stated nursing had missed two skin checks that should have been completed but upon review she noticed that they were not done. She stated his last skin check was complete on 11/11/2023 showing he has no new skin issues. She stated prior to that skin assessment he had another assessment done on 10/14/2023 which showed no new skin impairments. She stated the last smoking evaluation was completed on 12/4/2023 which showed he was an independent smoker without supervision, but he should have been reassessed for a new smoking evaluation to show that he needs to be supervised especially if he has neuropathy and is burning his fingers. She stated she would have expected her staff to report the resident's fingers had burn marks so an appropriate assessment could have been completed on him. She stated the care plan should have been updated also showing he was a supervised smoker. She stated, I did not notify the resident's doctor because his burn marks are not an acute (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 9 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0684 condition, and he was threatening to leave the facility. I just did not know what else to do. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/20/23 at 11:32 a.m., with Staff E, License Practical Nurse(LPN), she stated she saw the black marks on the resident's fingers when he was first downstairs, but she never reported it because she did not think it was a burn she just thought it was dirt on his fingers. Residents Affected - Few Review of the facility's policy, titled, Smoking Policy-Residents, revised July 2017 included, in part, the following: Policy: This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 7. The Staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 10 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews the facility failed to ensure wound care for one resident (#17) was provided care per assessment and orders were clarified with the provider out of one resident sampled for pressure ulcer care. Residents Affected - Few Findings included: During an interview on 12/20/23 at 6:57 a.m., Staff D, Registered Nurse (RN) and Staff K, RN stated Resident #17's buttock wound was healed. Staff K reported changing the dressing on Monday (12/18/23), the night before last, it (dressing) did not need to be changed today, it was healed. Staff K stated nurses continue to apply dressing until the Wound Advanced Practitioner Registered Nurse (APRN) comes to the facility and says the wound is healed. An observation was conducted with the Director of Nursing (DON) on 12/20/23 at 7:11 a.m., of Resident #17 lying in bed. The DON requested to observe the resident's wound located on the right buttock. The DON removed a pink foam dressing with a silver/gray patch from the resident's right buttock. The area under the dressing was an area approximately 1.5 centimeter (cm) x 0.3 cm of pink tissue. The DON did not replace the dressing and stated the area was healed. Immediately following the observation and removal of Resident #17's dressing, the DON reviewed the Wound APRN's note, dated 12/5/23, and confirmed the provider had deemed the area healed, fifteen days prior to the observation. The DON said the expectation for the treatment to be discontinued if it was resolved, or get an order for staff to apply a protective dressing but continuing to apply a silver collagen patch on area may have it breakdown again. On 12/20/23 at 8:09 a.m., the DON wrote order to discontinue the treatment. Review of Resident #17's December 2023 Physician Orders revealed orders dated 11/28/23: 1. Right (RT) buttocks cleanse area with (c) normal saline (ns) Apply silver collagen and cover with Kerlite. Change Monday-Wednesday-Friday (M-W-F) on 7 p - 7 a. 2. Gel wheelchair (w/c) cushion 3. Place patient on facility protocol for preventative. Review of the Wound APRN note, dated 12/5/23, revealed the chief complaint was Right buttocks. The history was a wound recently discovered after a change in the patient condition, Wound Status: Resolved. The note showed Discussion with member of healthcare team: Nurse. The visit summary revealed on 11/6/23 the APRN discontinued a dressing to the left (LT) thigh of Resident #17 and revealed a New RT Buttocks wound. Additional summaries revealed the wound was improving on 11/13/23 and on 11/20/23 the plan was to discontinue previous wound care orders and to apply silver collagen and Keralite changing the dressing on M-W-F. The note showed the residents right buttock wound continued to improve on 11/27/23 and was resolved on 12/5/23. Review of Resident #17's Treatment Record revealed the staff continued to change the resident's right buttock wound on 12/6, 12/8, 12/11, 12/13, 12/15, and 12/18, six times after the Wound ARPN resolved the wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 11 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0686 Level of Harm - Minimal harm or potential for actual harm A review of Resident #17's Body Audit Form, dated 12/7/23, instructed staff to Mark any open/reddened areas, bruises, skin tears, rashes, cuts or scars present and describe. The form dated 12/7/23 revealed a dressing was present on the residents coccyx/sacral area with additional discoloration under the dressing. The comment section did not describe the area under the dressing or discoloration. The audit form dated 12/14/23 did not show any skin conditions and commented no new skin issues. Residents Affected - Few Review of the policy - Wound Care, revised October 2010, revealed The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The documentation information should be recorded in the resident's medical record and include Any change in the resident's condition and All of assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. The policy revealed staff were to Report other information in accordance with facility policy and professional standards of practice. During an interview on 12/21/23 at 1:49 p.m., the Director of Nursing (DON) stated the question of the day was why the APRN had written an order. She stated Staff D had showed her an order to discontinue the treatment to the right thigh scratch. The DON stated the better way (to receive orders from vendor) was to give the order the DON. She said the usual way the facility received an order from the Wound APRN was to write the order then hand it to the nurse who takes the order, signs it, and puts in on the order (form). The DON stated her expectation would be for the nurse to question whether to put a dressing on a wound that appeared to be healed. The DON stated she was going to be laser-focused on assessing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 12 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to provide appropriate care and services to one resident (#21) out of one resident sampled for bladder and bowel management related to inaccuracy and incomplete documentation of bowel movements and transfer to an acute care facility with a diagnosis of bowel impaction. Findings included: Review of Resident #21's admission Record revealed the resident was originally admitted on [DATE] and recently re-admitted on [DATE]. The admission Record included diagnoses not limited to unspecified constipation, overactive bladder, and unspecified other psychoactive substance use with psychoactive substance-induced persisting dementia. A review of Resident #21's nurse's notes revealed the Director of Nursing (DON) wrote on 11/7/23 at 9:00 a.m. of the resident's physician giving a verbal order to transfer the resident per family request to an acute care facility for a critical Hemoglobin (Hgb) value of 6.9 (according to https://www.mayoclinic.org/tests-procedures/hemoglobin-test/about/pac-20385075 normal value 11.6 -15 grams per deciliter in females). The note showed the resident left the facility at 10:00 a.m. on 11/7/23 via stretcher. Review of hospital records revealed on 11/7/23 at 10:43 a.m., Resident #21 was assessed by an Emergency Department (ED) provider with critical care procedure orders. The chief complaint showed the resident presented with an abnormal Hgb value without bleeding. The physical exam noted the resident's abdomen was flat and soft with tenderness in the right lower quadrant. Will order computerized tomography (CT) abdomen pelvis with contrast, given patient with hemoglobin of 6.9 will repeat labs here in the emergency department but patient will likely need blood transfusion. Anticipate admission. The final diagnoses showed hypernatremia, altered mental status unspecified altered mental status type, unspecified type Leukocytosis, and right lower quadrant abdominal pain. The note revealed the resident's care was transferred to the admitting team at 3:34 p.m. Review of Resident #21's Abdomen Pelvis CT with contrast examination results revealed Large volume of stool in the rectum with mild thickening of the rectal wall and adjacent fat stranding suggestive of stercoral proctitis. Review of the article, Stercoral Colitis described the condition as a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually fecaloma formation. Fecalomas can lead to focal pressure necrosis and perforation, while colonic distention and increased intraluminal pressure can lead to compromise of the vascular supply and ischemic colitis. ([NAME] C, [NAME] T. Stercoral Colitis. [Updated 2023 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560608/) Review of Resident #21's Pulmonary/Critical Care Medicine Consult note, date of service 11/7/23 at 4:00 p.m., revealed the resident had a known history of high blood pressure, dyslipidemia, bedbound, (and) chronic constipation. The note showed in the ER CT of abdomen pelvis with contrast showed fecal impaction's with no free air or free fluid, sodium was 16, chloride 127, and creatinine 1.9. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 13 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gastrointestinal exam showed the resident had active bowel sounds and was mildly distend, not tender. The resident had very dry skin with poor skin turgor. The assessment showed concerns of Hypernatremia/Dehydration, Hemoconcentration, low Hgb (Hb), constipation, wheelchair bound, and advance age. The note calculated water deficit between 2.7-3.5 liters (L), would correct sodium slowly, not to resume her diuretic, likely real hemoglobin is lower than 7.4 once to be replaced fluids, she may need blood transfusion which is okay with her family, will treat pyuria with antibiotic, and aggressive bowel prep. Review of the facility's nursing note, dated 11/7/23 at 5:00 p.m., showed the resident's family member called at around 3:30 p.m. to inform resident had been admitted to Intensive Care Unit (ICU). A review of Resident #21's admission Record showed the resident was re-admitted on [DATE]. Review of Resident #21's Attending Physician note, dated 11/16/23, showed the resident had a history of advanced dementia and anorexia, had transferred to the hospital for altered mental status, anemia, and electrolyte imbalance, was given intravenous fluids and packed red blood cells, and was in ICU for 10 days prior to transferring back to the facility. Review of Resident #21's October 2023 Certified Nursing Assistant (CNA) Activities of Daily Living (ADL) Flow Sheet, included the following areas for staff to record the resident's intake and elimination. The form instructed staff to document Bowel movements with L = large, M = medium, S = small, and 0 = none, Continence: U/urine, B/bowel, I/Incontinent (Incn), C/continent, and # of times, and Meal Intake: Percentage of Meal Intake. The areas of Bowel Movement showed available areas to document for shifts: 11-7, 7-3, and 3-11. The area for Continence had available areas to document urine and bowel on 11-7, 7-3, and 3-11 shifts. The October CNA ADL Flow Sheet revealed the staff had documented Resident #21's bowel movements (BM) as follows: 9 out of 31 opportunites on the 11-7 shift (no documentation from 11/13 to 11/31), 29 out of 31 opportunities on the 7-3 shift, and 6 out of 31 opportunities on the 3-11 shift with no documentation after 11/8/23. The documentation showed the resident had a large BM on 10/20, a small on 10/21 and 10/22, no documentation of bowel elimination on 10/23, a medium on 10/24, no documentation on 10/25, no bowel movements on 10/26, 10/28 and 10/29, and small BM's on 10/27, 10/30, and 10/31/23. The sheet showed Resident #21 had 3 small BM's for the period of 7 days (10/25 - 10/31/23). The form did not offer staff an area to document the consistency of Resident #21's bowel movement. The October 2023 CNA flow sheet showed a variable meal intake for Resident #21, between 10/18 and 10/23 the residents intake was between 50-100% of the meals with consistent snack acceptance, no documentation of meal intake on 10/24 and 10/25/23, and from 10/26 to 10/31 the resident's meal intake was between 25-75% with 3 snack acceptances. The Meal Intake section had available documentation areas for Breakfast, Lunch, Dinner, and snack. The October 2023 CNA Flow Sheet revealed the resident was Total dependent upon staff for toileting needs and independent for eating and drinking. Review of Resident #21's November 2023 Certified Nursing Assistant (CNA) Accountability Form revealed the resident was dependent upon staff for toileting hygiene and 9 (not applicable per legend) for toilet transfers nine times and dependent upon staff three times out of fifteen charting opportunities between 11/1 and 11/7/23. The form revealed staff were to Please complete the 3 areas with a star daily Thank you. The star areas were Bowel movement which instructed to document with L = large, M = medium, S = small, and 0 = none, Continence: U/urine, B/bowel, I/Incontinent (Incn), C/continent, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 14 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and # of times, and Meal Intake: Percentage of Meal Intake. The areas of Bowel Movement showed available areas to document for shifts: 11-7, 7-3, and 3-11. The area for Continence had available areas to document urine and bowel on 11-7, 7-3, and 3-11 shifts. The form did not offer staff an area to document the consistency of Resident #21's bowel movement. The November 2023 CNA form showed the resident did not have a BM on 11/2, revealing the resident had 3 small BM's from 10/25 to the 3-11 shift on 11/2, a total of 8 days. The resident had a medium BM on 11/2, a small and large BM on 11/3, none on 11/4, a small on 11/5, and no documentation of any until a medium during the 7-3 shift on 11/9 (resident was in hospital on that date). The Meal Intake section of the November 2023 CNA form showed available documentation areas for Breakfast, Lunch, Dinner, and snack. The form showed the resident ate 25% of breakfast on 11/5, 0% for lunch on 11/5, refused dinner and snack on 11/5, no documentation of any oral intake on 11/6, and 0% of breakfast on 11/7/23. The form claimed the resident ate 75% of breakfast and lunch on 11/9 (the resident was in the hospital on that date). Review of Resident #21's October 2023 Medication Administration Record (MAR) showed the resident received 20 milligrams of the diuretic medication, Furosemide (Lasix) daily for hypertension/congestive heart failure, received the opiate analgesic, Hydrocodone/Acetaminophen (Norco) twice daily, and received the stool softener/stimulant laxative, Senna-S twice daily. The MAR showed the resident had orders for the stool softener, Docusate Sodium twice daily as needed for constipation and Milk of Magnesia, (laxative/antacid) one time a day as needed for constipation. The MAR revealed the resident did not receive either as needed medication during the month of October. Review of Resident #21's November 2023 Medication Administration Record (MAR) showed the resident continued to receive 20 milligrams of Furosemide daily and Senna S twice daily. The record did reveal the resident's Hydrocodone/Acetaminophen was discontinued and an order was dated 11/2/23 for 2 liters D5/Normal Saline was to be administered at 60 milliliter (mL)/hour. The MAR revealed the resident did not receive the as needed medications, Docusate Sodium or Milk of Magnesia during the period of 11/1 11/7/23 for constipation. A review of nursing notes, dated 11/1/23 at 3:00 p.m., revealed Resident #21 was more confused. Staff notified the physician and orders for an urinanalysis with culture and sensitivity, comprehensive metabolic panel (CMP), complete blood count (CBC), and to discontinue the resident's Hydrocodone were received. A note on 11/2/23 at 5 p.m. revealed lab results were received with some abnormal values. Review of Resident #21's Situation, Background, Assessment, and Recommendation (SBAR), dated 11/2/23 at 6:00 p.m., showed the situation was Abnormal Labs with pending labs which started on 11/2/23. The condition had exhibited before and previous orders were for staff to encourage oral fluids and Intravenous fluids. The resident evaluation showed no changes were observed with mental status, functional status, behavioral, respiratory, cardiovascular, abdominal, Genitourinary (GU)/urine, skin or neurological. A review of Resident #21's nursing notes showed on 11/2/23 at 10:40 p.m., the physician ordered intravenous fluid Dextrose 5% Normal Saline (D5NS) at 60 mL/hour for 2 liters and to repeat basic metabolic panel, and complete blood count on Monday. Review of 11/1 to 11/7/23 nursing notes did not reveal staff assessed or addressed Resident #21's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 15 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0690 lack of bowel elimination. Level of Harm - Minimal harm or potential for actual harm Review of Resident #21's care plan included the following focuses with associated interventions: Residents Affected - Few - (Resident) has impaired cognitive function and impaired thought processes related to (r/t) dementia. the interventions instructed staff to administer medications as ordered, monitor/document for side effects and effectiveness. - The resident has potential for fluid deficit r/t diuretic use. The interventions instructed staff to administer medications as ordered, monitor/document for side effects and effectiveness. - (Resident) is at risk for skin breakdown due to decreased mobility and incontinent episodes. The intervention instructed staff to monitor nutritional status, serve diet as ordered, and to monitor intake and record. - (Resident) has pain related to (r/t) arthritis. The interventions instructed staff to observe for signs/symptoms of constipation r/t pain medication use. The policy - CNA ADL Flow Sheet, CNA ADL Incidentals Flow Sheet, revised 9/28/16, revealed To assist nursing assistants with accurate documentation of the level of assistance rendered to their residents daily over all shifts. It is the policy of this facility to document care provided to residents by the Certified Nursing Assistant (CNA) through the use of an Activities of Daily Living (ADL) flow sheet. Each shift, the resident's ability to to self perform their ADL's and the level of assistance required from the CNA's will be recorded. This information will provide the facility with a thorough account of the resident's care, functional limits, and provide valuable information needed to develop an appropriate plan of care. This documentation will provide guidance to the physician in prescribing an appropriate plan of treatment, assist nursing in monitoring resident progress towards goals, and be a vital source for accurate (Minimum Data Set) MDS coding resulting in the most appropriate reimbursement. 3. CNA's will record on the appropriate day and shift what they did for the resident as follows: a. In regards to bed mobility, transfers, eating, and toileting, the resident will receive a two-part score. First a letter to document what level of assistance the CNA provided and second a number to document the number of CNA's involved in the assistance the code will reflect the residents most dependent level of need for that shift. (Example E2 would denote extensive assist of two people). c. Patterns of continence will be coded with an I for incontinent, C for continent and the number of times found to be that way on your shift. 6. Both CNA ADL Flow Sheet (NUR 3.3.1) and CNA ADL Incidentals Flow Sheet (NUR 3.3.2) will be periodically audited by a director of nursing [NAME] for timeliness, accuracy, and completeness. These results will be included in the CNA's annual performance evaluation. The clinical protocol - Bowel (Lower Gastrointestinal Tract) Disorders, revised September 2017, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 16 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0690 revealed: Level of Harm - Minimal harm or potential for actual harm 4. The staff and physician will identify risk factors related to bowel dysfunction; for example, severe anxiety disorder, recent antibiotic use, or taking medications that are used to treat, or that may cause or contribute to gastroenteritis intestinal erosion, bleeding, diarrhea, dysmotility, etc. Residents Affected - Few 5. The staff and physician will characterize symptoms related to bowel function for example, location and radiation of abdominal pain, time relationship to meals, presence of cramps or bloating, etc. 7. Correct terminology is important; For example, loose stools do not necessarily constitute diarrhea, stomach is not the same as abdomen, etcetera (etc). Consistent terminology and documentation over time enable comparison of symptoms and evaluation of the effectiveness of specific interventions. The Monitoring and Follow-up section revealed the staff and physician will monitor the individuals response to interventions in overall progress; For example, overall degree of discomfort or distress, frequency, and consistency of bowel movements, and the frequency, severity, and duration of abdominal pain, etc. An interview was conducted with Staff D, Registered Nurse (RN) on 12/19/23 at 3:57 p.m. The staff member said Resident #21 was confused, before going to hospital the resident was independent with eating but when resident returned was dependent for eating. Staff D stated the resident had worsened bilateral lower edema after coming back from hospital. An interview was conducted on 12/19/23 at 4:22 p.m. with Staff N, Certified Nursing Assistant (CNA). The staff member stated the 7-3 and 3-11 shifts chart intake every shift, stated the staff document on how many BM's every shift. The staff member reported when a resident did not have a BM, staff report was to report it to the nurse. An interview was conducted on 12/21/23 at 8:09 a.m. with Staff G, Licensed Practical Nurse (LPN). Staff G reported Resident #21 had been incontinent and was dependent on staff for toileting. The staff member stated if constipated with complaint of pain, bloating, staff were to contact family. Staff G stated if resident did not have a BM in 3 days, most of time there is an as needed (prn) order for Milk of Magnesia, check bowel sounds, and encourage fluids for small BM's then if no large BM's would start BM protocol. An interview was conducted on 12/21/23 at 8:25 a.m. with Staff I, CNA. The staff member reported having seen a lot of small BM's, demonstrated size of small with putting thumb and finger together, and described as a small nugget. The staff member stated when the rectum was stretched the staff member would notify the nurse. Staff I said staff were supposed to chart BM's daily, if resident doesn't have a BM document 0, and S, M, L, and also document texture as the staff member voiced hard or loose. The staff member reviewed the ADL book and claimed staff do not document texture but admitted to telling the nurse if BM was hard or loose. Staff I reported working with Resident #21 one time and the resident was incontinent. During an interview on 12/21/23 at 1:30 p.m., the Director of Nursing (DON) stated We need to educate them, we don't know if they know what is a small, medium, large, I want to help educate them. The DON reiterated not thinking staff knew what a small (BM) was and reported wanting to change it to actually Tell me about it. The DON reported Resident #21 had been in facility for a long time, was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 17 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete notified of dehydration and the resident received 2 liters of fluid. The resident had a critical hemoglobin of 6.9 and (the lab) was the reason for going to the hospital. The DON stated it takes awhile to get impacted and educated every thing slows down. The DON stated her expectation would be for the aide to notify the nurse when intake decreases from 100 to 25%, the nurse should assess, and notify the physician. The DON stated the aides need education and the nurses should also be asking the aide if a resident had a BM, part of their assessment, their job isn't just passing med. She reported if a resident continued to have small bowel movements it's constipation. The DON reported Resident #21 had been making sounds, not verbalizing, and was eating more prior to discharging. Event ID: Facility ID: 105725 If continuation sheet Page 18 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure 1) medications were stored and labeled properly in two (1 West-East and 2 West) of three medication carts and three of three nursing stations, and 2) medications were inaccessible to residents, visitors, and unauthorized personnel in three of three nursing station/medication rooms and two of three medication carts. Findings included: On 12/19/23 at 8:43 a.m., an observation was conducted at the 2 [NAME] nursing station. The medications at the nursing station were accessible through an unlocked door, the observation revealed nursing staff were engaged elsewhere and the area was unlocked and unattended. On 12/19/23 at 9:02 a.m., an observation of the 2 [NAME] nursing station revealed the following: -In an upper cupboard was a pink basin containing two 50 usp/5 ml (United States Pharmacopeia (usp) per 5 milliliter) prefilled Heparin syringes. -The basin also contained several tablets of denture cleanser and a hairbrush. -One tablet of Amlodipine, individually packaged in a top drawer of the nursing desk. The tablet was unlabeled with a resident name or a pharmacy label. -39 individually packaged tablets, unlabeled with resident names or pharmacy labels in a top drawer of the nursing station. The additional tablets were an assortment of Mirtazapine (antidepressant), Loperamide (anti-diarrhea), and Metoprolol (Beta blocker). Staff E, Licensed Practical Nurse (LPN) and Staff F (LPN/Unit Manager) confirmed the observations. Staff F stated the findings were not appropriate. Staff E stated the nursing station/medication room had not been locked for years. (Photographic evidence was obtained). On 12/19/23 at 9:26 a.m., an observation was conducted with Staff F, LPN of the unlocked, unattended 2 East nursing station/medication room. The observation revealed the following: -6 vials of Albuterol inhalation solution in the unlocked top drawer of the station's desk and another unlocked drawer contained a bottle of [NAME] Ruth's Organic Lymphatic Support. The Unit Manager stated heparin syringes (from 2 West) were ordered to specific residents and should not have been stored where located. Staff F stated, on 12/19/23 at 9:30 a.m., the nurse had informed her that the Albuterol vials were for the nurses' personal use and had taken the bottle of [NAME] Ruth's from a resident. (Photographic evidence was obtained). On 12/19/23 at 10:28 a.m., an observation was conducted with Staff D, Registered Nurse (RN) of the combined 1 West-East medication cart. The observation revealed a box labeled for Latanoprost ophthalmic solution prescribed to a resident. The box contained an opened bottle of Latanoprost and a one -dose vial of Refresh lubricant eye drops. The staff member confirmed the findings. (Photographic evidence obtained). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 19 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 On 12/19/23 at 10:44 a.m., an observation was made of the 1 East nursing station/medication room with Staff D. Staff M, Maintenance was observed sitting unattended in the nursing station sitting at the desk near the door working on unknown wires. The observation revealed the following: -In an unlocked bottom desk drawer was a box labeled 0.9% Sodium Chloride Injection-10 milliliter (mL) in a 10 mL Flush Syringe -The box contained 11 prefilled, individually packaged syringes of Heparin 50 usp/5 mL. (Photographic evidence obtained). A continued observation was conducted with Staff E, LPN of the 2 [NAME] medication cart. The observation revealed the following: -2 undated vials of insulin and one undated Basaglar Kwikpen. -The second to the bottom drawer of the medication cart was separated into 4 compartments: one compartment containing 2 boxes of pain relief topical patches, a box of nasal spray, multiple bottles of oral liquids, and a reusable manual sphygmomanometer (blood pressure cuff), and another compartment held 2 boxes of pain relief topical patches, 2 bottles of liquid oral medications, and a box of Ipratropium Bromide/Albuterol Sulfate inhalation solution. The staff member confirmed the findings and stated the insulin vials and pen should be dated as the bags holding them could be destroyed. On 12/21/23 at 1:11 p.m., an interview was conducted with the Director of Nursing (DON). She stated she absolutely agreed with the findings. The DON stated she was really concerned with the Heparin syringes, thinking the facility did not have any residents receiving intravenous medications, She stated, What if they thought Heparin for Normal Saline (NS). Review of the policy - Storage of Medications, revised November 2020, revealed The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The review included the following: - 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. - 2. Drugs and biologicals are store in the packaging, containers or other dispensing systems in which they are received Only the issuing pharmacy is authorized to transfer medications between containers. - 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 6. Compartments (including but not limited to , drawers, cabinets, rooms, refrigerators, carts, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 20 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 boxes) containing drugs and biologicals are locked when not in use. Unlocked medications carts are not left unattended. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 21 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on record review and interview the facility failed to ensure the Dietary Manager met the mandatory minimum qualifications for the Dietary Manager position. Residents Affected - Many Findings included: Review of the Dietary Manager's qualifications revealed the Dietary Manager (DM) was not [Food Certification Service] qualified and was not certified as a dietary or food service manager. During an interview on 12/20/23 at 11:09 a.m., The Dietary Manager (DM) stated I have been working as the Dietary Supervisor for three months now. The DM stated prior to being DM, I was a cook here since 2016. The DM stated she did not have an associate degree in food service or hospitality, and was not certified in food management but was working on obtaining the [Food Certification Service] certification. The DM stated she had a lot of experience working in dietary. The DM stated she attempted the [Food Certification Service] when she first started the DM job on 09/01/23, but did not pass it the first time and took the exam again a week later and was unable pass it again. The DM stated the online site would not allow her to re-take the test again until beginning of January 2024. The DM stated that her plan was to start studying after the New Year and take the [Food Certification Service] test for her certification after the new year. During an interview on 12/20/23 at 3:00 p.m., the Administrator stated the Dietary Manager should have [Food Certification Service] completed or be certified at the very least. The Administrator stated that since being Administrator at the facility for about five weeks now that she had no idea that the DM was not certified or had the appropriate training. The Administrator stated that starting 01/15/2023 [an outside contracted dietary service] would be coming in to take care of food services. Review of the facility's Dietary Manager Job Description showed, Dining Services Manager in Training Assist in ensuring that established sanitation and safety standards are maintained. Assist in overseeing and participating in the preparation and serving of food. Must be able to perform the essential job functions or dietary aids, cook and dishwasher positions. All other duties assigned. Qualifications: High school diploma or equivalent is required. Specialized training in dining services management and nutrition is desirable. Must successfully complete an approved sanitation and safety course. Knowledge, Skills and Abilities: Certificates- Food Safety Manager or Food handler Certification: Current [Food Certification Service] or State Certification Licenses: Acceptable minimum equivalent experience in place of degree: 2 years. There is no replacement for Federal/State/County required certifications/training. A review of the facility's policy titled, Preventing Foodborne Illness- Food Handling revised date July 2014 showed, 3. All employees who handle, prepare and serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food and serving food to residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 22 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, record reviews, and interviews the facility failed to ensure food was held at a safe and appropriate holding temperatures prior to food tray distribution. The failed practice had the potential to affect 67 of 69 residents in the facility: Findings included: During an interview on 12/19/23 at 11:45 a.m. Staff B, [NAME] stated hot foods should be held above 150 degrees Fahrenheit and cold foods should be held under 41 degrees Fahrenheit. Staff B, [NAME] proceeded to check the temperatures of the food to be served for lunch. An observation on 12/19/23 11:45 p.m., showed Staff B, [NAME] completed a temperature check on all the food being served to residents. The food items/temperatures included: Hamburger- 150 degrees Fahrenheit French Fries- 154 degrees Fahrenheit Puree Broccoli- 140 degrees Fahrenheit Puree Beef- 140 degrees Fahrenheit Puree bread- 140 degrees Fahrenheit Mush- 150 degrees Fahrenheit Brown Gravy- 160 degrees Fahrenheit Broccoli Salad- 78 degrees Fahrenheit Tuna Salad- 60 degrees Fahrenheit During an interview on 12/19/23 at 11:55 a.m. Staff B, [NAME] stated the puree foods needed to be heated back up in the oven to get to at least 150 degrees. Staff B, [NAME] stated for the Broccoli Salad at 78 degrees and the Tuna Salad at 60 degrees he would just stick both food items back in the refrigerator to cool them back down prior to serving to the residents. Staff B [NAME] looked at State Surveyor and stated, So we are good. During an interview on 12/19/23 at 11:57 p.m., the Dietary Manager (DM) stated cold foods should be held under 41 degrees Fahrenheit. The DM stated any cold foods that were above 41 degrees cannot go back into the refrigerator to be cooled again and could not be served. The DM stated, Now what are we supposed to use for substitute food? It is time for tray line. The DM stated Staff B, [NAME] should not have suggested the cold food be put back in the refrigerator to cool back down. During an interview on 12/19/23 at 12:13 p.m., the DM stated the broccoli salad and tuna salad was not served and grilled cheese sandwiches were made in place for the broccoli salad and tuna salad. The DM stated Staff B, [NAME] as he knew better than to put the cold items next to the steam table (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 23 of 24 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 105725 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605 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 0812 and hot foods. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/20/23 at 11:40 a.m., The Dietitian stated she heard about the food temperatures and she would be assisting the DM with re-training the staff. The Dietitian stated putting cold food near the hot food steam table was not appropriate. The Dietitian stated suggesting putting the cold food items, made with a mayonnaise based, and were above the safety zone temperature back in the refrigerator was a problem and not acceptable. The Dietitian stated she would be helping with the training on this incident as this was a problem that needed to be fixed. Residents Affected - Some A review of the facility's policy titled, Preventing Foodborne Illness- Food Handling revised date July 2014 showed, 3. All employees who handle, prepare and serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food and serving food to residents. 6. Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms. A review of the facility's policy titled Cold Food Policy revised date October 2022, showed, 3. All prepared cold food items will be stored in cold holding equipment at a temperature of 41 degrees Fahrenheit or lower. 4. Product will be checked for proper temperature of 41 degrees Fahrenheit or lower by Dietary Manager or [NAME] prior to tray line delivery. 6. Food will be delivered to resident at a temperature of 41 degrees Fahrenheit or lower. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105725 If continuation sheet Page 24 of 24