Inspection·June 4, 2021

F 0684 Level of Harm - Minimal harm or potential for actual harm her wheelchair unwitnessed and sustained a head laceration and right shoulder pain. Transported to the hospital. Review of the physician progress notes dated 5/21/21 at 2:18 p.m. revealed the resident returned from the hospital after suffering a laceration to the forehead from a ground level fall on 5/16/21. Residents Affected - Few Review of nursing progress notes dated 5/16/21 at 10:41 p.m. revealed the resident returned from the emergency room with head laceration with 6 steri strips, right elbow skin tear and right knee skin tear. During an interview on 6/3/21 at 10:54 a.m. the Director of Nursing (DON) confirmed that anytime a resident comes back from the hospital with steri strips or sutures, a physician order should be placed so the nurse can track the healing and look for infection. The DON confirmed she did not see an order to observe or document on the suture. Review of facility policy titled, Resident Examination and Assessment, revised 2/2014, revealed: The purpose of this procedure is to examine and assess the resident for any abnormalities in heal status, which provides a basis for the care plan. 8: skin a. intactness, e. presence of bruises, pressure sores, redness, edema, rashes. 11. Head and neck: c. evidence of trauma. 2. Notify the physician of any abnormalities such as, but not limited to: e. wounds or rashes on the resident's skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105744 If continuation sheet Page 2 of 8 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 105744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Oaks Health Center 2770 Regency Oaks Blvd Clearwater, FL 33759 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 observation, interview and record review, the facility failed to provide wound care according to professional standards of practice by double gloving, not performing hand hygiene and using the gloved finger to apply the paste in the wound for one resident (#15) of three residents sampled. Residents Affected - Few Findings included: An observation of wound care on 6/3/21 at 2:35 p.m. with Staff D, Registered Nurse (RN) and assisted by Staff C, Patient Care Assistant (PCA) was conducted. Staff D, RN kept her supplies in a plastic bag observed in her right pocket. Staff D, RN washed her hands and placed paper towels on the resident's tray table after she moved the resident's personal belongings. Staff D picked up the barrier, slid it off the table, flipped it over, and put it back down saying, I don't know what these little bugs are, but they are not ants. The PCA stated they were fruit flies and the RN continued to put the supplies on the paper towels. The RN then double gloved and opened the brief, observed stool, and pushed the stool down with the brief. The stool was not in the wound. Staff C, PCA asked the nurse if she should change the resident first and the nurse stated, No, after we are done. Staff D, RN applied the normal saline to the gauze and cleaned the wound once. Doffed the second glove and mixed the normal saline with calcium alginate by swishing the medicine cup around to mix the calcium alginate into a paste. She then used a 4 x 4 gauze with her gloved finger and stuck it down in the medicine cup. Scooped out the paste and attempted to place it on the wound. The paste would not stay on the wound, so the nurse stuck her finger in the paste and pushed it down into the wound bed and removed her gloves without performing hand hygiene she dug through both shirt pockets to find a pen to write on the wound dressing. The nurse finished and Staff C, PCA asked if the nurse would assist with changing the resident since the wound was completed. During an interview with Staff D, RN she stated she tries not to double glove and tries to use her hand sanitizer after cleaning the wound. Staff D, RN stated she does not like to go back and forth, so she double gloved for the wound care. The nurse stated the collagen is porous and it would not stick to the wound from the 4 x 4 and stated that she could not use a tongue depressor and did not bring a cotton tipped applicator or a tongue depressor, so she used her finger. Review of the active physician orders as of 6/1/21 revealed an order to cleanse the sacrum with normal saline. Apply collagen (mix powder with small amount of normal saline) Apply to wound bed as paste. Cover with dry dressing, every 3 days and as needed, dated 5/25/21. Review of the consult wound report dated 5/25/21 revealed the resident's wound was a chronic stage IV pressure ulcer measuring 0.2 cm x 0.2 cm x 0.4 cm. Undermining has been noted at 12:00 and 1:00 with a maximum distance of 0.4 cm. No change in wound progression. Review of the consult wound report dated 5/4/21 revealed the resident's wound was a chronic stage IV pressure ulcer measuring 0.2 cm x 0.2 cm x 0.4 cm. Review of the care plan revealed a resident focus area of impairment to skin initiated 2/27/20. Interventions included to provide treatment per physician order, notify physician upon signs and symptoms of infection or non healing, initiated on 2/27/20. During an interview with the Director of Nursing (DON) on 6/3/21 at 3:07 p.m. she stated she would expect the nurse to have all of her supplies and make sure she washed her hands and applied calcium (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105744 If continuation sheet Page 3 of 8 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 105744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Oaks Health Center 2770 Regency Oaks Blvd Clearwater, FL 33759 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 Residents Affected - Few alginate paste with a cotton tipped applicator or tongue depressor. The DON confirmed if the resident had stool in her brief; she would expect that to be cleaned prior to cleaning the wound. The DON said that she expects the wound to be cleaned with normal saline, no double gloving and hand hygiene between dirty and clean. Review of the policy titled, Handwashing/Hand Hygiene, revised October 2019, revealed: 6. Use an alcohol based hand rub containing at least 62% alcohol; or alternatively soap and water for the following; h) Before moving from a contaminated body site to a clean body site during resident care. i) After contact with a resident's intact skin. m) After removing gloves. Review of the policy titled, Dressings, Dry/Clean, revised 10/19, revealed: Steps in the procedure: 1. Clean bedside stand. Establish a clean field. 6. Put on clean gloves. Loosen tape and removed soiled dressing. 8. Wash and dry hands thoroughly. 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. 17. Apply ordered dressing and secure with tape or bordered dressing per order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105744 If continuation sheet Page 4 of 8 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 105744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Oaks Health Center 2770 Regency Oaks Blvd Clearwater, FL 33759 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate and effective supervision for one resident (#32) with a pattern of falls to prevent continued falls of three residents sampled. Resident #32 sustained four falls (5/5/21, 5/16/21, 5/21/21 and 5/22/21) in a 17- day period from 5/5/21 to 5/22/21. Findings included: Resident #32 was observed sitting watching TV in the day room on 6/2/21 at 2:30 p.m. The right side of her forehead was noted with scabs and a blue suture. Resident #32 was observed sitting in the hallway on 6/3/21 at 9:45 a.m. and her hair was combed back, and the right side of her forehead was observed with a small amount of scabs and a blue suture. A review of the admission Record revealed that Resident #32 was admitted on [DATE], and diagnosed with dementia without behavioral disturbance, history of falling, fracture of lumbosacral spine and pelvis, and fracture of left femur and difficulty in walking. A review of the medical record for Resident #32 showed the following documentation for the four falls: * Review of the comprehensive nursing notes dated 5/22/21 at 10:30 p.m. revealed the resident fell from a wheelchair on 5/22/21 at 7:20 p.m. no injuries noted, forehead wound dressing changed per orders. Review of Resident #32's change in condition evaluation on 5/22/21 at 8:42 p.m. revealed the resident was at the nurse's station and fell from the wheelchair. No injuries noted. * Review of the nursing progress notes dated 5/22/21 at 3:33 a.m. revealed the resident returned back from the hospital with two steri strips to right forehead laceration. Review of the nursing progress notes dated 5/21/21 at 10:42 p.m. revealed the resident fell from her wheelchair unwitnessed and sustained a head laceration and right shoulder pain. Transported to the hospital. Review of Resident #32's change in condition evaluation on 5/21/21 at 10:14 p.m. the resident had an unwitnessed fall at the nurse's station and sustained a head laceration and right shoulder pain. The resident was transferred to the hospital for evaluation. * Review of the physician progress notes dated 5/21/21 at 2:18 p.m. revealed the resident suffered a ground-level fall on 5/16/21, she suffered a laceration to her forehead, imaging probable nondisplaced right sacral [NAME] and posterior iliac bone fracture. At baseline, patient is wheelchair dependent for mobility, primary nurse repos that her pain is currently controlled on as needed Tramadol. Patient seen and evaluated sitting in wheelchair, she is pleasant and cooperative who presents with no acute complaints. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105744 If continuation sheet Page 5 of 8 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 105744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Oaks Health Center 2770 Regency Oaks Blvd Clearwater, FL 33759 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of nursing progress notes dated 5/16/21 at 10:41 p.m. revealed the resident returned from the emergency room with head laceration with 6 steri strips, right elbow skin tear and right knee skin tear. Nondisplaced pelvic fracture. Review of CT of Pelvis without contrast report dated 5/16/21 at 20:44 (8:44 p.m.) revealed Impression: probable nondisplaced right sacral Ala and posterior iliac bone fracture correlate with clinical findings. Review of physician orders revealed on 5/16/21 to send Resident #32 to the hospital for a fall with head injury, right arm and hip pain. Review of Resident #32's change in condition evaluation on 5/16/21 at 6:25 p.m. the resident was observed at the nurses station and fell hard to the ground. Resident sent to the hospital with diagnoses of nondisplaced fracture to the right sacral ala and posterior iliac bone, and head laceration. * Review of Resident #32's change in condition evaluation on 5/5/21 at 12:35 a.m. revealed the resident was observed laying on the floor on her left side at bed side. Grimacing and moaning upon assessments. Medicated for pain, cool compress applied to left hip and immediate x-ray ordered. No injuries observed at the time. During an interview with Staff A, RN on 6/3/21 at 4:25 p.m. she stated Resident #32 had another fall from her wheelchair the day after she fell and went to the hospital. Resident #32 came back with steri strips on her forehead. Staff A, RN confirmed the resident was a high fall risk and must be watched closely. An observation of Staff B, Activity Assistant taking Resident #32 back to her room on 6/3/21 at 4:30 p.m. revealed the resident was sitting in her wheelchair to the right of her bed and did not have her call light in reach. The call light was observed on the wall on the left side of the bed. An interview on 6/3/21 at 4:55 p.m. with Staff B, confirmed the resident was taken to her room but did not place the call light in reach. Review of the care plan revealed the resident focus area of potential for falls due to decreased standing balance and tolerance, decreased mobility secondary to weakness of extremities following hospitalizations, fall history and decreased awareness due to cognitive loss secondary to dementia, initiated on 11/10/17. Interventions included maintain scoop mattress on bed dated 5/24/21. Monitor for attempts to stand and transfer without assistance, initiated on 1/29/16, Monitor for proper positioning in wheelchair, reposition as needed initiated on 8/11/19. Occupational therapy to evaluate and treat for wheelchair positioning dated 5/25/21. Return to bed after dinner, therapy will assess for wheelchair positioning, initiated on 5/24/21. Review information on past falls and attempt to determine cause of falls initiated on 8/27/18. Therapy will screen. Frequent position changes while in wheelchair, alleviate and distract upon agitation while at the nurse's station, initiated on 5/17/21. During an interview with the Director of Nursing (DON) on 6/03/21 at 10:54 a.m. she stated the resident started falling on 5/5/21 and had not had a fall for five months prior to the 5/5/21. The DON confirmed the fall was not investigated to see when she was last toileted or what she was trying to do at the time of the fall. She stated they only investigate the fall and get witness statements if the resident has injuries. The intervention put in place was to keep the bed at a safe transfer height. The DON stated she was able to transfer at that time. The DON stated the fall on 5/16/21 occurred (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105744 If continuation sheet Page 6 of 8 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 105744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Oaks Health Center 2770 Regency Oaks Blvd Clearwater, FL 33759 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some at the nurses' station and a nurse was present. The resident was irritated and tried to move herself away from other residents when she stood and fell. The DON confirmed the resident was sent to the hospital and diagnosed as a probable fracture of pelvis with history of fractures and no new fractures. The interventions were therapy to screen for wheelchair positioning and distract resident upon irritation. The DON stated on 6/3/21 at 11:08 a.m. the fall on 5/21/21 occurred at 10:40 p.m. and was an unwitnessed fall at the nurses' station. The resident sustained a head laceration and transferred to the hospital then returned with two steri strips to the forehead and no other injuries. The DON confirmed the facility did not investigate the unwitnessed fall. The DON stated the interventions were to screen for therapy caseload and occupational did pick her up for wheelchair positioning. They also added return to bed after dinner. During an interview with the resident's physician on 6/4/21 at 11:47 a.m. he stated the resident sustain a probable nondisplaced fracture and that the resident has advanced osteoporosis. The physician confirmed the treatment is weight bearing as tolerated and would treat the pain with medication. No surgery or other treatment was needed. The DON stated on 6/4/21 at 11:10 a.m. that they are having meetings every morning to discuss the falls and have no control over her falls. Review of facility policy titled, Falls and Fall Risk, Managing, revised 3/2018, revealed: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, based on assessment of the nature of category of falling, until falling is reduced or stopped, or until the reason for the continuation of falling is identified as unavoidable. Monitoring Subsequent falls and fall risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. Review of facility policy titled, Accidents and Incidents - Investigating and Reporting, revised on 7/17 revealed: All accidents or incidents involving residents, on our premises shall be investigated and reported to the Administrator. 1. The nurse supervisor charge nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. c. The circumstances surrounding the accident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105744 If continuation sheet Page 7 of 8 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 105744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Oaks Health Center 2770 Regency Oaks Blvd Clearwater, FL 33759 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review and staff interviews the facility failed to keep kitchen equipment related to one burner (back right side, burner #4) of an eight-burner stove functioning in a safe, and operating condition. Residents Affected - Few Findings included: During the initial survey of the kitchen on 6/1/2021 at 9:57 a.m., it was observed that the back right side burner #4, on an eight-burner gas stove's pilot light wound not ignite. The Certified Dietary Manager (CDM) turned the gas burner on, and it was observed that a strong gas odor was present. The CDM then tried to light the burner with a pocket lighter and it failed to light. A comprehensive inspection of the kitchen was conducted on 6/3/2021 at 11:07 a.m. During the observation, the pilot light would not light for burner #4, and the CDM confirmed the presence of a strong gas odor. The CDM stated, I told maintenance about the burner yesterday. He further revealed that he reported it not functioning to the facility Maintenance Director six months prior. An interview on 6/04/21 at 10:23 a.m. with the Maintenance Supervisor was conducted. The Maintenance Supervisor stated that he was just made me aware of the burner, and the service company will be out Monday (6/7/21) to take care of it. He stated there was no log, but generally we do a digital work order but he (CDM) never told me about it. A subsequent interview was conducted with the CDM on 6/4/2021 at 10:40 a.m. During the interview, the CDM indicated that since the burner (#4) has been out for a while, an appointment will be made to check the gas lines, due to a strong gas odor coming from the burner when turned on. The CDM also stated, The burner has been out for months, we do not use it. A facility provided policy titled, Maintenance Service, revision date December 2009, Page 01 of 02 under Policy Interpretation and Implementation, read: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105744 If continuation sheet Page 8 of 8