Inspection·July 23, 2021

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 07/23/21 at 7:50 a.m., with the Director of Nursing (DON), revealed that Resident #138 was complaining of discomfort from the collar and the attending physician told him that he could loosen it up and remove it for meals. She reported that there should have been a physician's order for removing the collar during meals. An interview on 07/23/21 at 8:05 a.m., with Staff K, Minimum Data Set (MDS) Coordinator, reported that the care plan was updated on 7/22/21 to reflect taking off the collar for meals. She reviewed the care plan history and reported that up until 7/22/21 Resident #138 was to have his collar on except during showers. 2. Review of the facility policy titled Goals and Objectives, Care Plans with a revised date of April 2009 revealed that: 5. Goals and objectives are reviewed and/or revised: a. When there has been a significant change in the resident's condition; b. When the desired outcome has not been achieved; c. When the resident has been readmitted to the facility from a hospital/rehabilitation stay; and d. At least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105866 If continuation sheet Page 2 of 9 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 105866 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza West 912 American Eagle Blvd Sun City Center, FL 33573 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on record review, and interviews, it was determined that the facility failed to ensure physician orders were followed as written according to professional quality of care standards for nursing for one (Resident #138) of twenty eight sampled residents. Residents Affected - Few Findings include: 1. According to the 2019 Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as: (18) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b)The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. A professional nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. 2. Observations of Resident #138 on 07/20/21 at 11:09 a.m. revealed that the resident was noted to have a neck brace lying on his bed. An interview with the resident at that time revealed that the neck brace was for his neck and that he should have it on. Observations of Resident #138 on 07/22/21 at 1:15 p.m., revealed the resident sitting in his wheelchair with his neck brace on. An interview with the resident at this time revealed that he wore the neck brace whenever he was sitting up. He reported that he did not have it on the other day when he was interviewed because he was eating lunch. He reported that staff took it off when he ate because it got in the way. An interview on 07/22/21 at 1:20 p.m. with Staff I, Registered Nurse (RN), revealed that the resident had Spinal Stenosis, recently had a laminectomy, and needed to wear his cervical collar when sitting up. She reported that nursing would take it off for him when he ate as he felt more comfortable that way. She reported that the attending physician gave the ok to take the cervical collar off when the resident ate. Staff I reported that this communication was not documented anywhere and there was no physician order to indicate the physician's directives. An interview on 07/22/21 at 1:30 p.m. with Staff J, Certified Nursing Assistant, (CNA) (Agency staff), revealed that the resident had the collar on all the time except when he ate, the nurses took it off for him when it was time for meals. Review of the order summary revealed that the resident had an order dated 7/1/21 for Immobilizer [brand name] collar to remain on except while showering until seen by surgeon every shift for placement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105866 If continuation sheet Page 3 of 9 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 105866 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza West 912 American Eagle Blvd Sun City Center, FL 33573 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 0658 Level of Harm - Minimal harm or potential for actual harm An interview on 07/23/21 at 7:50 a.m., with the Director of Nursing (DON), revealed that Resident #138 was complaining of discomfort from the collar and the attending physician told him that he could loosen it up and remove it for meals. She reported that there should have been a physician's order for removing the collar during meals. Residents Affected - Few A policy related to following physician orders was requested of the facility, but not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105866 If continuation sheet Page 4 of 9 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 105866 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza West 912 American Eagle Blvd Sun City Center, FL 33573 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed, and two errors were identified for two (Residents #21 and #10) of nine residents observed. These errors constituted a 6.67% medication error rate. Residents Affected - Few Findings included: 1. On 7/20/21 at 3:59 p.m., an observation of medication administration with Staff Member D, Registered Nurse (RN), was conducted with Resident #21. Staff D was observed administering the following medications: - Tizanidine 2 milligram (mg) tablet The staff member dispensed the tablet, crushed it, placed it in a medication cup, and entered the residents room. She placed the medication cup, a box of vinyl gloves, and a bottle of hand sanitizer on the over-bed table. She dissolved the medication in 7.5 cubic centimeter (cc) of water, shut the feeding pump off, disconnected the nutrition from the percutaneous endoscopic gastrostomy (PEG), and inserted a 60 cc syringe into the ostomy. The staff member poured 30 cc's of water into the syringe and had to manipulate the tube for the water to flush. The dissolved medication was poured into the PEG and the staff member flushed with with another 30 cc's of water. She stated she should have checked for residual before the medication but had checked it earlier (which was not observed during the medication administration). A review of Resident #21's physician orders included an order, dated 3/31/15, that instructed staff to: - Enteral Feed: Check residual every shift related to Dysphagia unspecified Gastrostomy Status and before medication (med) administration. Hold 1 hour if above 100 milliliter (mL) and recheck residual; if still above 100 mL Call MD. The documentation indicated staff had documented residual on day, evening, and night shift and had not documented the residual obtained prior to any medication administration. On 7/22/21 at 6:04 p.m., the Director of Nursing (DON) stated her expectation for medication administration via a PEG was for medication to be crushed, if unable to get liquid form. She reviewed Resident #21's physician orders and confirmed that the resident did have an order to check residual prior to administration of medications. 2. On 7/21/21 at 8:47 a.m., an observation of medication administration with Staff Member G, Licensed Practical Nurse (LPN), was conducted with Resident #10. Staff G was observed administering the following medications: - 2 Vitamin D 25 microgram (mcg) 1000 international unit (iu) tablets oral - Clopidogrel 75 milligram (mg) tablet oral - Vitamin B-12 1000 mcg tablet oral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105866 If continuation sheet Page 5 of 9 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 105866 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza West 912 American Eagle Blvd Sun City Center, FL 33573 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 - Eliquis 5 mg tablet oral Level of Harm - Minimal harm or potential for actual harm - Escitalopram 10 mg tablet oral - Ferrous Sulfate 325 mg tablet oral Residents Affected - Few - 2 Fish Oil 300 mg softgels oral - Furosemide 80 mg tablet oral - Multivitamin with mineral tablet oral - Oyster shell calcium 500 mg tablet oral - Potassium Chloride Extended Release (ER) 20 milliequivalent (meq) tablet oral - Metoprolol Succinate ER 50 mg tablet oral A review of Resident #10's physician orders indicated an order dated 5/27/21 for: - Multiple Vitamin tablet - Give one tablet by mouth one time a day for supplementation. The order did not instruct staff to administer a multivitamin with mineral tablet. On 7/22/21 at 6:12 p.m., the Director of Nursing (DON) reviewed Resident #10's physician orders and confirmed the resident did not have an order for the administration of a multivitamin with mineral. The policy, General Dose Preparation and Medication Administration, effective 12/1/07 and revised 5/1/10 and 1/1/13, indicated that Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident and Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, as needed (prn) medications, application sight) on appropriate forms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105866 If continuation sheet Page 6 of 9 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 105866 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza West 912 American Eagle Blvd Sun City Center, FL 33573 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, policy review, and interviews the facility failed to ensure that a supplement with a shortened shelf life was dated when opened in one (Med Cart 1) out of three Medication Carts sampled, expired medications were disposed of, and inhalation medications were stored appropriately in one (1 South Med Room) of one Medication Preparation room. Findings included: An observation was conducted at 9:12 a.m. on 7/21/21 with Staff Member D, Registered Nurse (RN) of medication cart #1 on the 300-hallway. A half-empty bottle of cherry-flavored [brand name] sugar free liquid protein was located inside the cart. The bottle was undated as to when it was opened. The RN turned the bottle upside down to locate the manufacturer expiration date of August 2021 and stated she did not have anyone taking [the liquid protein] at that time. According to the manufacturer of [brand name] complete liquid protein(https://www.nutricialearningcenter.com/globalassets/pdfs/specialized-adult-nutrition/prostat_pp-card_sep2018.pdf) users were to Record date on bottom of container upon opening. Discard 3 months after opening. An observation was conducted, on 7/21/21 at 10:05 a.m., with Staff Member E, Licensed Practical Nurse (LPN) of the medication prep room on Unit 1 South. The observation of the refrigerator in the medication room identified a medication bottle which contained a vial of [brand name] insulin prescribed to Resident #51. The medication review for Resident #51 indicated that the resident's [brand name] insulin order was discontinued on 7/20/21. The label indicated that the insulin had expired on 7/10 (2021). A bag of an assortment of inhalation medications was discovered in a drawer next to shelving units containing over-the-counter medications. The enclosed shelving unit restricted the staff's ability to open the drawer all the way. The bag contained inhalation medications prescribed to different residents, which included Resident #40. Resident #40 was admitted to the 1 South unit on 6/8/21 and moved to 3 North on 7/15/21. The Unit Manager arrived to the medication room and stated that the residents that the inhalation medication belonged to had been sent to the hospital and some had come back to the facility. She stated that the nebulizer medications should not have been stored in a drawer and should have been either destroyed or moved with the resident to another unit. The Unit Manager identified that the room had a separate bin for medications to be returned and they could not return the opened medications. On 7/23/21 at 1:41 p.m., a review of the medication storage issues were discussed with the Director of Nursing (DON). She stated that staff know better than that regarding the storage of multiple residents inhalation medication together in a bag in a drawer of the medication room. The DON stated staff should have gotten rid of it regarding the bottle of [liquid protein] and the vial of [insulin]. The Consultant Pharmacist stated, on 7/23/21 at 2:23 p.m., that if a medication had a shortened shelf life the bottle should be dated when opened and regarding the storage of inhalation medications in the drawer she stated, maybe that's where they had room (to store the medication). The policy, Storage and Expiration of Medications, Biologicals, Syringes, and Needles effective 12/1/07 and revised 5/1/10 and 1/1/13, identified that facility should ensure that medications and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105866 If continuation sheet Page 7 of 9 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 105866 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza West 912 American Eagle Blvd Sun City Center, FL 33573 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 biologicals: Level of Harm - Minimal harm or potential for actual harm - have not been retained longer than recommended by manufacturer or supplier guidelines; Residents Affected - Few - that the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened; - facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105866 If continuation sheet Page 8 of 9 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 105866 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza West 912 American Eagle Blvd Sun City Center, FL 33573 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility did not maintain the kitchen in a safe and sanitary manner related to failing to ensure that the range hood was free from dust and grease. Residents Affected - Some Findings include: Observations during the initial tour of the facility's kitchen on 7/20/21 at 10:55 a.m., revealed that the kitchen housed a range hood which was located over the kitchen stove, fryer and steam oven. Closer observation of the range hood revealed dust particles on the light covers. Closer observation of the range hood revealed that grease build-up was noted on the inner sides and inner edges of the range hood. (Photographic Evidence Obtained) During the initial tour, Staff H, Certified Dietary Manager (CDM) revealed that the vendor for the range hood came in and serviced/cleaned it quarterly. The company was last in the facility in April and was due to come back this month. He reported that in between the vendor's visits, the kitchen staff wipe down the range hood after every shift. Observations on 7/22/21 at 10:30 a.m. during the comprehensive tour of the kitchen, revealed that the range hood still had dust particles on the light covers, and the grease build-up was still on the inner sides and and inner edges of the range hood. Review of the vendor's last Job Service Report dated 4/26/21, indicated that the system was cleaned. Review of the facility's Log book Documentation revealed that the last monthly inspection of the range hood was completed on 6/9/21. This checklist did not include an inspection of grease build up on the range hood surface or dust build up on any area under the hood. An interview on 7/22/21 at 11:27 a.m. with the full campus Maintenance Director, revealed that the maintenance department received work orders from the kitchen if repairs were needed. He reported that quarterly cleaning was completed by a vendor and that the next visit was scheduled for this Sunday. He reported that in between the vendor's visits the kitchen staff would complete the cleaning of the range hood. Review of the facility policy titled Sanitization with the revised date of October 2008 revealed the following: 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105866 If continuation sheet Page 9 of 9