Health inspection·December 10, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 12/09/21 at 12:32 p.m., the Director of Nursing [DON] and Staff A, License Practical Nurse [LPN] confirmed Resident #346 had a catheter with no privacy bag. Staff A denied it being the resident's preference to not have one. Staff A immediately went to supply room to get privacy bag. The DON stated this is something that should have been easily preventable. A review of the facility's Catheter Care, including Drainage Bag Care/Maintenance policy stated, 11. For purpose of privacy and dignity, when the resident is out of bed, drainage bags should be in privacy bag. Event ID: Facility ID: 105881 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 105881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511 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, record reviews, and interviews the facility failed to identify skin conditions by not ensuring weekly skin assessments were completed for one resident (#41) out of thirty-eight sampled residents. Residents Affected - Some Findings included: Resident #41 was observed and interviewed at 11:46 a.m. on 12/7/21. The resident was observed sitting in a wheelchair next to the bed with an over-the-bed table in front of the chair. The resident reported an ongoing rash and staff were applying Nystatin powder. In an interview at 2:11 p.m. on 12/8/21 Resident #41 stated the rash had concrete scabs and was getting Nystatin powder. The admission Record revealed Resident #41 was admitted on [DATE] and had diagnoses not limited to hypertensive heart disease with heart failure, and morbid (severe) obesity due to excess calories. The quarterly Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview of Mental Status score of 15 out of 15 for the resident revealing an intact cognition. The MDS in Section M Skin Conditions indicated that Resident #41 did not have any pressure ulcers or other ulcers, wounds, and skin problems. A review of Resident #41's clinical record on 12/8/21 did not reveal an order for Nystatin powder. The clinical record revealed the last weekly skin assessment for the resident was completed on 8/19/21. The weekly skin assessment, dated 8/12/21, identified non-bleachable erythema pressure ulcer to the right toe and redness to left and right gluteal folds. The assessment, on 8/12/21 (Thursday), indicated the resident's skin was not impaired. The weekly skin assessment, dated 8/19/21, indicated non-bleachable erythema pressure ulcer to the right toe and redness to left and right gluteal folds. The weekly skin assessment, on 8/19/21 (Thursday), identified that the resident's skin was not impaired. The clinical record did not include 15 weekly skin assessments from 8/27/21 to 12/3/21. The active physician orders dated as of 12/10/21 for Resident #41 identified the resident did have an order instructing staff to conduct a weekly skin sweep every night shift every Friday for skin assessment, revised on 7/28 and to start on 7/30/21. A review of the order for the resident's weekly skin sweep indicated the order type was other orders (no documentation required). On 12/8/21 at 2:59 p.m., Staff D, Licensed Practical Nurse (LPN), identified herself as the floor nurse for Resident #41. The staff member stated that skin assessments are daily or weekly depending on the physician order. She stated she looked at all of her residents' skin daily and the assessments could be found in the computer under the Evaluation tab. The LPN identified Resident #41 used a powder or cream and after reviewing the resident's orders she stated the resident used skin prep and zinc to the buttocks. Staff D stated the resident did have an order for a weekly skin sweep and it would come up on the Medication or Treatment Administration Records (MAR or TAR). The staff member confirmed Resident 41's last weekly skin sweep was conducted on 8/19/21. Staff G, Risk Manager, stated at this time she knew Resident #41 had a skin assessment a couple weeks ago because the resident had complained about being red all over. Staff E, Unit Manager (UM), reviewed at this time the resident's physician orders and confirmed the order had been transcribed into the computer as other orders (no documentation required), which was wrong and the order would not show up on the MAR or TAR as it was transcribed as an informational order. The UM reviewed the Certified Nursing Assistant (CNA) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105881 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 105881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shower sheets and was unable to locate one for the resident's shower on 12/8/21. The UM informed Staff D, LPN that since she had been in the shower with the resident, she could have filled out one of the shower sheets. Staff D informed the UM the resident had complained of a rash, but the staff member had observed it as dry skin. An observation was conducted of Resident #41's skin, on 12/8/21 at 4:50 p.m. with Staff E, UM. The resident was lying in bed, wearing bilateral offloading boots, and very specific in the way she was positioned. The UM was assisted in positioning the resident by Staff H, MDS Coordinator. The following areas were identified by the UM: - non-reddened raised areas to Left shoulder and arm. - reddened area under right breast. - macerated left groin, approximately 4 x 2 centimeter (cm). - 4 areas on left buttock - 3 reddened areas with peeling skin around edges and one open area approximately 1 x 1 cm. - reddened, dry and peeling skin on right gluteal fold. The resident exclaimed the area to the right gluteal fold was tender to touch. The progress notes for Resident #41 indicated that Staff E, UM had documented, effective on 12/8/21 at 4:14 p.m., a skin sweep was done and some skin issues were noted: right breast reddened, left groin macerated, left buttock with several areas that dry and skin peeling, inner left buttock with small open area, left shoulder with rash, and right gluteal fold with area that dry, tender to touch, and skin peeling. The note indicated the physician was notified with new orders for Nystatin powder to right breast, left groin, left buttock, left shoulder, right gluteal fold, and the antifungal medication Diflucan daily for 10 days. During an interview, on 12/10/21 at 1:15 p.m., the Director of Nursing (DON) stated all residents were to have weekly skin assessments. The DON stated that under evaluation the root cause reason for Resident #41 not having a weekly skin assessment was that it had not been scheduled. The facility provided, per request, the last three Comprehensive CNA Shower Reviews. The CNA Shower Review dated 11/27/21 indicated the left shoulder was circled. The CNA did not identify what type of issue was observed on the left shoulder, and the review was not signed by the charge nurse. The CNA Shower Review dated 12/4/21 indicated left rashes, was signed by the CNA but not signed by the charge nurse. The CNA Shower Review dated 12/8/21 was signed by Staff D, LPN and indicated skin conditions were observed to the right and left chest area, groin, and buttocks. The skin condition identified was dry skin to Left shoulder upper chest, no other skin issue was described. The review was signed by Staff D on 12/8/21 with a new order (n.o.) obtained and was signed by the CNA on 12/10/21. The policy titled Skin Care and Wound Management - Regular skin inspections and prompt interventions to address changes, effective February 2007 and revised January 4, 2021, identified: The facility will inspect the resident's skin on a regular and ongoing basis to provide documentation and prompt interventions of any changes noted. The procedure indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105881 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 105881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - 1. Skin inspections will be conducted by the licensed nurse using the Skin Sweep evaluation for documentation at the time of admission and weekly. - 2. In addition, the Certified Nursing Assistant assigned to the resident will observe the condition of the resident's skin during daily routine care and will report changes or areas of concern to the nurse assigned to the resident. - 3. Any identified skin impairment will be documented by the nurse at the time of discovery and weekly thereafter until healed using the appropriate Skin Sweep evaluation. All non-pressure related skin impairments as surgical wounds, skin tears, bruises, etc. should be documented on the Weekly Skin Evaluation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105881 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 105881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511 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, policy review, and interview the facility failed to ensure medications were disposed of when expired, failed to ensure medicated eye drops were dated when opened and failed for two medication carts (300 Hall and 100/500 Hall) and failed to ensure one medication cart (300 Hall) was organized and uncluttered of five medication carts. Findings included: During the medication administration observation on [DATE] at 11:22 a.m., conducted with Staff D, Licensed Practical Nurse (LPN), a Novolog insulin Flexpen was removed from the 300-hall medication cart. The Novolog pen indicated it was opened on [DATE] and the label instructed users to discard after 28 days. The staff member counted the days and stated the expiration date of the Novolog pen was [DATE]. The Unit Manager, Staff E, arrived to the cart and Staff D, LPN informed her the insulin expired in 28 days not the 30 days they had thought. Staff E reported they had just gone through the (medication) carts yesterday and this one must have been missed. (Photographic Evidence Obtained) On [DATE] at 12:09 p.m., a review of the contents of the 300-hall medication cart was conducted with Staff D and E. The observation revealed the bottom drawer of the cart was disorganized, contained non-medication items (i.e. stethoscopes and manual blood pressure cuffs) stored in the same section of the drawer as medication blister cards currently in use for residents. (Photographic Evidence Obtained) In a section of the top drawer were multiple bags with an assortment of medicated eye drops: - an unopened bottle of Latanoprost 0.005% solution which was labeled Refrigerate until Opened. The pharmacy label indicated the bottle of Latanoprost was dispensed on [DATE]. - an opened, undated bottle of Latanoprost 0.005% solution labeled, Throw Away Any Drug Left After 6 Weeks. - an opened, undated bottle of Latanoprost 0.005% solution labeled to discard after 42 days. The pharmacy label indicated this bottle was dispensed on [DATE]. - an opened, undated bottle of Latanoprost 0.005% solution. The pharmacy label indicated the bottle was dispensed on [DATE]. - an opened, undated bottle of Latanoprost 0.005% solution. The bag indicated, Throw Away Any Drug Left After 6 weeks. The pharmacy label identified the medication was dispensed on [DATE]. - an opened, undated bottle of Timolol Mal (maleate) 0.5% solution. The pharmacy label indicated it was dispensed on [DATE]. - an opened bottle of Latanoprost 0.005% solution. The label indicated it was dispensed on [DATE] and opened on [DATE]. - an opened, undated bottle of Latanoprost 0.005% solution. The label indicated the medication was dispensed by the pharmacy on [DATE] and to Discard After 42 Days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105881 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 105881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511 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 - an opened, undated bottle of Latanoprost 0.005% solution. The label indicated the medication was dispensed by the pharmacy on [DATE]. - a bottle of Dorzolamide 2% solution, opened on 10/15 (2021). - a bottle of Dorzolamide 2% solution, undated as to when it was opened. The label had spaces available for staff to document the date opened, expiration (exp) date, and initial, this label was blank of any staff documentation. Staff D, LPN and Staff E, UM confirmed the above findings. Staff E, UM stated that eye drops should be dated when opened. The package insert for the Latanoprost (Xalatan) Ophthalmic solution, located at https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020597s044lbl.pdf, indicated, Once a bottle is opened for use, it may be stored at room temperature up to 25C (celsius) (77 F) for 6 weeks. According to the manufacturer information, located at https://patient.info/medicine/dorzolamide-eye-drops-for-glaucoma-eydelto-trusopt-vizidor, Bottles of eye drops only keep for four weeks once the bottle has been opened, so do not use the drops if the bottle has been open for longer than this. This will help to prevent the risk of eye infections. On [DATE] at 12:11 p.m., an observation was conducted with Staff A, LPN of the medication cart for the 100 and 500 hall. A vial of insulin was opened on [DATE]. The bottle containing the vial instructed users to discard after 28 days. A review of the calendar indicated 28 days from [DATE] was [DATE]. A policy titled, 5.0 Medication Storage, without an effective date, indicated, Medications will be stored in a manner that maintains the integrity of the product an ensures the safety of the residents and is in accordance with Florida (FL) Department of Health guidelines. The procedure identified: - Medications will be stored in an orderly, organized manner in a clean area. - Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105881 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 105881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to ensure one resident (#37) received physician ordered laboratory services related to obtaining a urinalysis out of thirty-eight sampled residents. Findings included: The admission Record revealed Resident #37 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified malignant neoplasm of brain and malignant neoplasm of thyroid gland. An observation at 11:23 a.m. on 12/7/21 of Resident #37 indicated the resident sitting in a wheelchair in the resident's room. On 12/8/21 at 8:53 a.m. Resident #37 was observed sitting in a wheelchair with a meal tray on the over-bed-table. The review of the clinical record identified a progress note, dated 12/6/21, that indicated nursing staff had received an order from the physician for a urinalysis (UA) with a culture/sensitivity (CS) related to cloudy, foul-smelling urine. A progress note, dated 12/7/21 indicated two attempts were made to collect a urinalysis as ordered, [Resident #37] did not cooperate, and the information would be passed to the next shift for follow-up. A review of the December 2021 Medication Administration Record (MAR) identified that a UA and CS was ordered to be obtained on 12/6/21 for one time only for 1 day. The MAR indicated a nurse had signed that on 12/6/21 the order had been administered. An interview was conducted at 3:51 p.m. on 12/9/21 with Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM stated the UA for the resident was originally ordered two days ago and that she was going to call the physician and ask for an order to straight cath Resident #37 to obtain a urine sample. On 12/9/21 at 3:58 p.m., Staff D, LPN, stated she had not gotten in report that Resident #37 needed a urine sample for testing. The UM reviewed the resident's MAR and confirmed the UA C/S was signed off on 12/6/21 at 4:55 p.m. by a staff member. Staff D confirmed it was her initials that had signed off on the UA on 12/6/21. The UM stated her expectation was that if a lab was not obtained it be reported to her, and the next shift nurse, and the physician should be notified. Staff D stated she had given the order to the 600-hall night shift to obtain the urine from the resident. A review of the laboratory requisitions for 12/6/21 and 12/7/21 was conducted with the UM and confirmed there was no requisition on those dates for Resident #37. The UM spoke with the laboratory vendor, on 12/9/21 at 4:13 p.m., and confirmed that a urine sample for the resident was not sent to the lab. She stated all lab requisitions were printed on the other side, pointing toward the unit on the other side of the building. The UM stated she had printed an order listing report, and confirmed the lab was not on the requisition forms. The UM stated she did not know why the order was missed, she had noticed it today, and was going to call the physician. At the time of the interview, the UM called the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105881 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 105881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511 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 0773 physician and informed him the urinalysis for Resident #37 had not been done. Level of Harm - Minimal harm or potential for actual harm During an interview, on 12/10/21 at 1:04 p.m. the Director of Nursing (DON) stated all labs go to the 600-hall. He stated the physician probably was the one who told staff the UA was not done as he was very particular. The DON stated that it was his interpretation when the order was signed off (on the MAR) it indicated the UA was attempted. The DON stated that it was dropped and followed up on. Residents Affected - Few A policy titled, Laboratory Tests/Diagnostic, effective December 2016, indicated, The facilty will track ordered labs and diagnostic procedures and promptly notify the resident's physician or nurse practitioner or physician's assistant of results of resident labs results and diagnostic procedure findings. The resident and/or resident representative will also be made aware of lab and diagnostic procedure results. The procedure indicated the nurse receiving the order is responsible for completing the lab requisition or verifying the diagnostic procedure appointment has been made as part of noting the order. The ordered lab is logged in on the lab log sheet found in front of each date in the binder. Designated nurse will review lab log sheets daily to verify protocol is followed. The designated nurse will follow up on any discrepancies noted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105881 If continuation sheet Page 9 of 9