Inspection·January 31, 2020

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some At 12:04 p.m. on 1/28/20, four residents were seated in wheelchairs in the hallway outside of the dining room while the nine residents in the dining room were still eating their meals. At 12:10 p.m. six residents were observed in the hallway out side of the dining room while the nine residents in the dining room were still eating their meals. The six residents included Resident's #49 and #40 who were both seated in wheelchairs right outside of the dining room and Resident's #23 and #27. Resident #40 was observed to be attempting to move himself into the dining room by propelling with his feet. His wheelchair was observed to be locked so he was unsuccessful in his attempt. An unidentified CNA came out of the dining room and was heard to tell Resident #40 that he needed to stay out here for now as it was not time for him to eat. Resident #49 was observed to be shaking her head. A brief interview was conducted with Resident #49 and she stated, they are telling us to come down here and to come in and then we sit here. She expressed that she was frustrated at having to sit outside the dining room and wait while others were eating. Resident #49 had been observed at 12:04 p.m. being wheeled to the dining room in her wheelchair by a staff member and being placed where she was observed when interviewed. Resident #49 was observed to be moved out of the area she was seated in to an area across the hall in order for staff to assist wheelchair residents out of the dining room. An observation was made of Resident #27 seated in the hallway in her chair outside of the dining room. She was observed speaking to the Director of Social Services. She was heard saying to the Director of Social Services that they are upset, they want to come in the dining room and keep being told it is not time yet. The Social Service Director was heard to say, well they can go in there if they want to but made no attempt to inform other staff to bring these two residents into the dining room or assist them, herself, into the dining room. Observation of the second seating for lunch commenced at 12:27 p.m. when the six residents and other residents were observed to be assisted into the dining room for their lunch meal. Resident #22 was observed to be seated at a table with another resident across from her. A placemat, silverware and napkin were observed on the table in front of her. An unknown dietary staff person was observed to approach Resident #22, pick up her placemat, silverware and napkin, and in a loud voice, heard by the surveyor across the room, stated to Resident #22, you don't eat here, your tray is in your room. She left Resident #22 seated at the table with no place setting. Resident #22 propelled herself up to another table which had a place setting. A lunch meal was eventually provided to Resident #22, after much conversation was heard in the dining room between the dietary aide and the CNAs. An interview was conducted with Resident #22 at 12:39 p.m., she stated she wants to eat in the dining room. Eighteen residents were observed in the dining room for the second meal time with the dietary person and three aides present. A female resident was wheeled into the dining room by a staff person and two aides, across the dining room assisting residents to eat, yelled out she already ate and the staff person wheeled the female resident back out of the room. Random observation at 12:37 p.m. on 1/28/20., revealed: Three residents seated at table 5. One resident was observed being served her soup by an aide while the other two residents had no food or soup in front of them. Three residents were observed to be seated at table one with one resident being fed soup by an aide and the other two residents with no food or soup. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 2 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Three residents were observed to be seated at table 9 with one resident being fed soup and the other two residents with no food or soup. At 1:08 p.m. on 1/28/20, Staff I and Staff M were observed to be seated at a table assisting Resident's #101 and #43 to eat lunch. Staff I and Staff M were observed to be talking to each other about where staff, who used to work at the facility, were now working, while assisting the two residents to eat. During the Resident Council meeting, conducted on 1/30/20 at 2:00 p.m., three confidential residents, who have lunch during the 1st lunch serving (11:30 a.m.) in the main dining room, stated that they felt rushed eating lunch while the second seating residents are gathered outside the door of the dining room. They stated this happens every day during lunch. A second dining observation was conducted in the main dining room on 1/30/20, commencing at 11:47 a.m., with the first lunch seating and ending at 12:50 p.m. during the second seating. The following was observed: Nine Residents were observed to be eating their soup and or salad in the main dining room. At 11:50 a.m., a CNA, was observed to wheel Resident #211 into the dining room and left him in the middle of the dining room while she went to the seating chart to determine where he sat for lunch. He was placed at table 2 in front of a place setting. This aide and another staff person stated loudly that he was not the resident whose place setting he was seated at and that he was scheduled to eat during the second dining at 12:30 p.m. The aide then removed him from in front of the place setting and wheeled him out of the dining room. Review of the seating chart for the 12:30 dining revealed that Resident #211 was assigned to sit at table 9. Resident #22 was observed in her wheelchair seated at a table with a place setting in front to her on 1/30/20 at 11:47 a.m. A dietary aide and a CNA were heard saying loudly that, she is second seating and another aide wheeled her away from the table and took her out of the dining room. An unidentified aide was observed in the middle of the dining room while residents were eating lunch, speaking with Staff O, a CNA. Both were speaking in an audible tone that could be easily heard from the entrance to the dining room. They were discussing whether the unidentified aide should be helping during the meal. Staff O informed her no and explained to her how the schedule worked. As the aide was leaving the dining room, she was observed to yell out from the door to Staff O, who was still in the middle of the dining room, oh its breakfast tomorrow and Staff O was observed to yell back Yes. Resident #39 was observed seated at table 4 finishing his salad at 12:19 p.m. on 1/30/20. He then propelled himself out of the dining room and down the hall. An aide came out of the kitchen with his lunch and two staff who were in the middle of the dining room between table 5 and 6 were heard to yell out, he went to dialysis while other residents were seated in the dining room eating lunch. The Administrator in Training was observed to be assisting Resident #101 with a beverage. She was observed to call out to other staff in the dining room who were assisting residents Is she a sippy cup? to which the other staff who were assisting other residents verbally called out yes. Staff O was observed during the second dining in the main dining room, on 1/30/20 at approximately 12:50 p.m., wheeling a male resident, #20, into the room. She asked the dietary aide where the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 3 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident sat and the dietary aide responded that she would have to get the table set up first. Staff O left Resident #20 in the middle of the dining room and walked away. The dietary aide set up the table and moved him to the table, after he had sat in his wheelchair in the middle of dining room for five minutes. 3. Four of eight confidential residents in the Resident Council Meeting, on 1/30/20 at 2: 00 p.m. stated the did not feel that staff treated them with dignity and respect and felt that when they expressed concerns to the nurses and aides that nobody was listening. 4. An interview was conducted with the DON and the Administrator regarding the dignity concerns identified during dining. on Both the Administrator and the DON stated that 1st and 2nd dining was not set up to be for independent diners at one and assisted diners at the other. The Administrator stated that the intent of the two dining times was to get more residents out of their rooms and into the dining rooms by allowing the residents to choose which lunch time to go to. The Administrator stated its not supposed to be that way. Regarding the dignity, concerns they both stated that they will fix it. 5. An observation was conducted on 1/28/20 at 11:47 a.m. on the 400 hallway during the lunch meal. Staff I, CNA was observed entering room [ROOM NUMBER] without knocking. Then Staff I, CNA returned to the meal cart, removed a tray, and brought it into room [ROOM NUMBER] again, without knocking or announcing herself. Another observation was conducted on 1/28/20 at 12:05 p.m. during the lunch meal on the 500 hallway. Staff H, CNA removed a tray from the meal cart. Staff H, CNA entered room [ROOM NUMBER]. Staff H, CNA did not knock on the door or announce herself before entering the room. Then Staff H, CNA removed another tray from the cart and entered room [ROOM NUMBER] without knocking or announcing herself. Staff H, CNA exited the room. Staff H, returned to the meal cart. Staff H, CNA, removed a tray from the meal cart. Staff H, CNA took the tray into room [ROOM NUMBER]. Then Staff H, CNA, removed another tray from the meal cart, and returned to room [ROOM NUMBER]. Staff H, CNA did not knock or announce herself before entering the room. 6. Review of the policy, Resident Rights, revised December 2016, reflected the following: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and State laws guarantee certain basic rights to all residents in this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 4 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0561 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on observation and interview, it was determined that the facility did not ensure that one (#22) of fifty two residents reviewed was provided the right to make choices regarding her dining experience. Residents Affected - Few Findings include: On 1/28/20 between 12:23 p.m. and 12:27 p.m., Resident #22 was observed to be seated at a table with another resident across from her. A placemat, silverware and napkin were observed on the table in front of her. An unknown dietary staff person was observed to approach Resident #22, pick up her placemat, silverware and napkin, and, in a loud voice heard by the surveyor across the room, stated to Resident #22, you don't eat here, your tray is in your room. She left Resident #22 seated at the table with no place setting. Resident #22 propelled herself up to another table which had a place setting. A lunch meal was eventually provided to Resident #22. Resident #22 was observed to independently eat her lunch meal. An interview was conducted with Resident #22 at 12:39 p.m. She stated she wants to eat in the dining room. On 1/30/20, at 11:47 a.m., Resident #22 was observed in her wheelchair seated at a table with a place setting in front to her. A dietary aide and a CNA where heard saying that she is second seating and another aide wheeled her away from the table and took her out of the dining room. On 1/30/20 at 12:25 p.m. Resident #22 was located in her room in her wheelchair, with her lunch tray on the overbed table in front of her. She was observed to be eating her lunch meal independently. She stated, I eat where I want to. An interview with the Administrator and the DON was conducted on 1/31/20 at approximately 4:30 p.m. The Administrator and DON stated that Resident #22 should be able to eat in the dining room if she wants to. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 5 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 resident record review and staff interview, it was determined that the facility did not ensure that the plan of care was followed related to Diabetes Mellitus, Type II, for one of five residents reviewed for unnecessary medications (#5). Findings Include: Review of the admission Record for Resident # 5 revealed that he was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus without Complications. Review of Physician orders on the Order Summary Report revealed an order, dated 12/17/19, for Humulin R U-500 Kwik-Pen Solution Pen-Injector 500 Unit/ML: Inject 90 unit subcutaneously with meals related to Type II Diabetes Mellitus without complications . Resident # 5 also had a physician's order, dated 11/13/19 for Novolog Solution 100 Unit/ML ( Insulin Aspart): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200. Review of a care plan with a focus of Is at risk for complication related to diagnosis of Diabetes Mellitus Type II (initiated 7/26/2017) revealed: Goal : Will remain free of s/sx (signs and symptoms) of hypo or hyperglycemic episode thru the next review date. Interventions: Administer oral medications and/or insulin per physician orders. Obtain blood sugar levels/ lab as ordered; report results to physician as needed. Review of Resident # 5's Medication Administration Record ( MAR) for December 2019 revealed the Novolog Solution 100 Unit/ML (Insulin Aspart): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200 was documented as administered when blood sugars (BS) were documented as under 200 on 20 of 93 occasions: 0630 am 12/1 BS 168, 12/2 BS 166, 12/6 BS 165, 12/11 BS 191, 12/12 BS 110, 12/13 BS 162, 12/14 BS 150, 12/16 BS 197, 12/18 BS 165, 12/22 BS 194, 12/25 BS 170, 12/28 BS 176, 12/30 BS 90, 12/31 BS 180 11:30 am 12/15 BS 132, 12/22 BS 107, 12/28 BS 135 16:30 pm (4:30 pm) 12/7 BS 108, 12/22 BS 124, 12/28 BS 158 Review of Resident # 5's MAR for January 2020 revealed the Novolog Solution 100 Unit/ML (Insulin Aspart): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200 was documented as administered when blood sugars were documents as under 200 on 8 of 91 occasions: 06:30 a.m. 1/1 BS 109, 1/5 BS 165, 1/6 BS 152, 1/11 BS 81, 1/12/ BS 188, 1/15 BS 110, 1/16 BS 171, 1/21 BS 134. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 6 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 An interview was conducted with the Director of Nursing, on 1/31/2020 at 11: 20 a.m. He reviewed the Medication Administration Records and confirmed that the Novolog insulin was being administered when it was supposed to be held for blood sugars under 200. He stated it looked like the nurses were not paying attention and clicking along too fast. A phone interview was conducted with the Consultant Pharmacist, on 1/31/20 at 4:15 p.m. He stated he does look at the blood sugars and insulin when he does his reviews. He stated he did not like this type of order as it put more stuff on for the nurses to do. He stated it is definitely an issue. He was unable at the time of the phone interview to access his records to see if he had previously identified this issue for Resident # 5. Event ID: Facility ID: 105884 If continuation sheet Page 7 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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** 2.On 01/28/20 at 10:01 a.m. Resident #108 was lying in bed and smiled with verbal stimuli. Her right hand was on top of the blanket that presented with a hematoma (localized bleeding outside of blood vessels, due to either disease or trauma including injury). Just lateral to the hematoma a crescent shape skin tear was noted with dried blood residual. The resident was asked if she knew what happened to the hand. She was unable to verbalize what had occurred. Residents Affected - Few On 1/29/2020 at 11:10 a.m. Resident #108 was sitting in her wheelchair as a staff member was transporting her in the hallway. Resident #108 right hand was resting on her lap as it appeared the same as it had the day prior. On 01/29/2019 at 5:54 p.m. Resident #108 resident was observed in her bedroom with Certified Nursing Assistant N (CNAN) who was sitting next to her. Resident #108 was turned to her right in her wheelchair as the CNA was sitting to her right. CNAN at that time picked up the spoon off the plate that contained food. As the CNA attempted to assist the resident, the resident raised her left hand and swung her hand out blocking the spoon from going to her mouth. CNA N was asked if she knew what had happened to the resident's right hand. The CNA looked at the resident hand and said it looks like a skin tear. She said I don't care for Resident #108 that often indicating it had been a while and she didn't know what had happened. Medical record review was conducted for Resident #108 that revealed on the admission Record information form that she was in her early nineties and been residing at the facility for over a year. The diagnosis stated facial weakness following unspecified cerebrovascular disease and dementia without behavioral disturbance. The assessment section of the record included a weekly skin check/nurse form was reviewed that was dated on 1/27/2020. The box was checked 'no' indicating the resident doesn't have any new skin impairments that have not been previously noted. The resident's care plan was reviewed with a focus for a potential of skin impairment/ pressure ulcers related to impaired mobility, incontinence of bowel and bladder, fragile skin that was dated on 6/19/2018 with a goal date of 3/23/2020. Interventions included to observe skin for an s/sx (signs and/or symptoms) of breakdown during cares and notify physician of any s/sx of skin breakdown/pressure ulcer if noted. The nursing process notes were reviewed that were found without an entry related to the skin tear to Resident #108's right hand. On 01/30/20 at 10:33 a.m. an interview was conducted with CNA B as she was in Resident #108's bedroom. Resident #108 smiled when approached and was cooperative with the CNA as she combed her hair and placed a scarf around her neck. The CNA was asked about the resident's right hand. She stated I worked on Saturday and that wasn't there. I was off on Sunday and when I came in on Monday, I seen it right away it was torn. She stated I told the nurse right way. So, she could cover it up or put something on it. I wanted to know what happened. She was asked if she had found out what had happened. She said no one has told me anything. At 10:56 a.m. an interview was conducted with the Resident #108's Unit Manager (UM) about the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 8 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 - Few process of skin checks. She said that there is a form that is performed weekly we call the skin sweep. And if there are concerns in between the weekly skin sweep it would be documented at that time. She was asked if there was one for Resident #108. The UM at that time reviewed the electronic medical record and stated, I didn't find one. She confirmed at that time it is her expectation that if a skin tear was found the MD(physician) is notified to obtain a treatment. The UM said additionally, an incident report would be started along with an investigation. The UM confirmed that there was no report or notification to the MD. A skin tear is a traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer). Skin tears are acute wounds, which have a high probability of becoming complex chronic wounds, if not properly managed. https://www.woundsource.com/patientcondition/skin-tears Based on observations, record review, interviews, and policy review the facility failed to provide care and treatment in accordance with professional standards of practice for two(#34, #108) of 53 residents reviewed in regards to 1) not ensuring physician's orders were obtained for care and services for a urinary catheter, a nephrostomy tube, and a midline IV(intravenous) line and 2) failing to identify and obtain orders to treat a skin tear. Findings included: Resident #34 was readmitted to the facility on [DATE] with a diagnosis of neuromuscular dysfunction of the bladder and sepsis, according to the face sheet in the admission record. A review of the MDS (Minimum Data Set) assessment dated [DATE], Section H, bladder and bowel, indicated Resident #34 had an indwelling catheter. Upon review of the current physician's orders in the electronic medical record, no orders were found for catheter care. Review of the treatment administration record (TAR) for the month of January showed catheter care orders were not obtained. On 1/29/20 at 9:53 a.m.an observation and interview were conducted with Resident #34. Resident #34 said she has a UTI (urinary tract infection) that started in December. She also said she is getting IV antibiotics for the UTI. The surveyor observed that Resident #34 had a left upper arm midline IV line, and a leg bag of which the contents were unable to be observed. A review of nurse's notes in the medical record revealed that upon admission on [DATE], a urostomy and Foley catheter were noted. The nurse's note dated 1/27/20 reflected a new order to initiate contact isolation, insert midline, start Amakacin 10mg/kg daily x 7 days, pharmacy to dose, ID (Infectious Disease Physician) to consult and CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) on 1/30/20. IV team called for midline insertion. Further review of the nurse's notes showed a note entered on 1/29/20, which indicated Foley in place draining clear, amber urine, Precautions continue. IV site is CDI (clean, dry, intact) and flushes well. The 1/30/20 nurse's note showed Resident continues on IV antibiotic for ESBL ( extended spectrum beta-lactamase) in urine. Foley is in place and patent. Contact precautions continue. IV site is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 9 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 clean and dry. Flushes without difficulty. Level of Harm - Minimal harm or potential for actual harm No other notes discuss catheter care, nephrostomy tube, or midline care. Residents Affected - Few On 1/31/20 at 12:05 p.m. an observation was conducted with Staff L, CNA (Certified Nurses Assistant) during catheter care. Staff L, CNA entered Resident #34's room after knocking. Staff L, CNA explained the procedure to Resident #34. Staff L, CNA put on PPE (personal protective equipment) to include a gown and gloves. Staff L, CNA prepared a wash basin with water, which Staff L, CNA placed on the bedside table where there was a towel with supplies. Staff L, CNA used a soapy wash cloth to clean from the catheter insertion site downward. Staff L, CNA changed washcloths after each downward motion, wiping the catheter tubing from top to bottom. Staff L, CNA dried the areas with a dry wash cloth. The surveyor asked if she could look at the nephrostomy tube site. Resident #34 said it was okay. Staff L, CNA turned Resident #34 to her right side. The nephrostomy tube site was free from signs or symptoms of infection; no inflammation, redness, or drainage was observed. However, the dressing was wrapped around the tube beneath the site. There was also no odor present. Further review of physician's orders revealed there was also not an order for the midline IV site care and maintenance, or nephrostomy tube care. An interview was conducted with Staff K, LPN on 1/30/20 at 6:03 p.m. Staff K, LPN (Licensed Practical Nurse) confirmed Resident #34 had a midline in her left arm. Staff K, LPN also confirmed Resident #34 does have a catheter. The surveyor asked who provided care to the catheters and midline. Staff K, LPN said IV care would be herself. Staff K, LPN said it's documented on the resident's MAR (Medication Administration Record), and she documents it on the skilled notes. She said both herself and the CNAs document catheter care. It's documented on the TAR and ADL (Activity of Daily Living) sheets. Normally I assist her at night when we turn and reposition her. We do the Foley care. Staff K, LPN said there should be orders for the midline and catheters. Staff K, LPN reviewed the orders in the electronic record and confirmed there weren't any orders for the catheters or midline. Staff K, LPN also said they're not on the TAR either. Staff K, LPN said the midline gets flushes, and it requires dressing changes once a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 10 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 medical record review the facility failed to ensure that a pressure injury for one (#103) out of four residents with a pressure injury were provided treatment without an active Physician order. Residents Affected - Few Findings Included: On 1/30/2020 at 12:15 p.m. Resident #103 was observed lying in her bed and was receptive to an interview. She appeared comfortable and said she had received a pain medication. She indicated and was in agreement to the observation of her treatment to her pressure injury. LPN F walked over to the treatment cart that was positioned with the drawers facing inside the bedroom doorway entrance. She donned a clean pair of gloves and went to the left side of the resident bed. After the table was cleaned LPN F returned to the treatment cart and removed one package of calcium alginate pad 2 x 2-inch size, one 6 x 6 sterile adhesive bordered dressing, three normal saline ampules, five individual packaged gauze dressings, and two packages of skin preps. LPN F removed the dressing from the resident sacral area. The dressing was saturated in appearance with pale yellow and pink drainage. The dressing along with the nurse gloves were disposed of inside of the red bag. After she washed and dried her hands, she donned clean gloves while she approached the bedside. The wound bed still contained an old dressing that fell out with little manipulation. The nurse left the bedside and returned after hand hygiene was performed. The skin surrounding the wound bed was pink in color, the edges presented as epibole (refers to rolled or curled-under) and pale white in color. The wound appeared the size of small avocado with the bed beefy red in color. Undermining appeared between 11 and 1 o'clock. No active drainage nor odor were noted. LPN F removed a clean gauze dressing and saturated it with normal saline as she cleaned the surrounding skin to the left lateral area of the peri-wound. Disposed the gauze dressing and her gloves and washed and dried her hands. LPN F removed a second clean gauze dressing and saturated it with normal saline and cleaned the peri-wound on the right side. She disposed of the gauze and her gloves and washed and dried her hands. The LPN then removed a third clean gauze dressing and saturated it with normal saline and lightly patted the wound bed. And disposed the gauze dressing and her gloves and washed and dried her hands. LPN F returned to the bedside and applied the skin prep to the peri wound. She removed her gloves and washed and dried her hands. LPN F returned to the bedside and picked up the cup that contained crushed Flagyl and applied it directly to the calcium alginate pad. The pad was then placed flat to the wound bed as the edges of the pad laid on the peri-wound and not lightly packed to the undermining areas. Then the secondary dressing was applied. The Medical record was reviewed that revealed a wound care assessment was performed by the resident's wound care provider(Physician Assistant) on 1/29/2020. The assessment read sacral ulcer is chronic and nonhealing. Measurements 3 x 2.1 x 0.8 centimeters (cm) and undermining 1.5 cm at 11 o'clock. Plan: remove old dressing avoiding trauma to the wound bed and peri-wound skin cleanse wound and peri-wound with non-cytotoxio wound cleanser prior to each dressing change. Apply 500 mg of Flagyl to wound bed, skin prep to peri wound skin gently pack ulcer with calcium alginate and cover with dry dressing daily and as needed dislodgement/ soiled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 11 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 Physician orders were reviewed that did not contain an active treatment order for the observed treatment. Level of Harm - Minimal harm or potential for actual harm On 01/30/20 at 2:47 p.m. an interview was conducted with the DON, he confirmed that the treatment had been discontinued by the Physician Assistant on the 1/29, it was not reordered and there was no current order for wound care. Residents Affected - Few The facility provided a copy of their policy titled Wound Care that contained a revision date of October 2010. Purpose: the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 12 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. 2. On 01/29/20 at 2:16 p.m. Resident# 29 was observed lying in bed with the with feeding tube attached to the machine. The head of the bed was elevated but the resident's head was flat resting in the middle of the bed on her right side. She appeared comfortable with her eyes closed. Medical record review conducted for Resident #29 revealed the admission Record information sheet that showed her diagnosis of encounter for attention to gastrostomy and revealed she was in her late eighties. Physician orders dated on 3/21/2019 included nothing by mouth diet and enteral feed order two times a day jevity 1.5 at 65 ml per hour from 10:00 a.m. to 2:00 p.m. (10-2p) dated on 11/27/2019. Additional orders stated Head of Bed (HOB) elevated at least 45 degrees every shift dated on 5/31/2019. On 01/30/20 at 10:05 a.m. Resident #29 was observed with the tubing feeding machine running at 65 cc per hour. The head of the bed was positioned between a 10-15-degree angle. Resident #29's head was positioned toward the middle of the bed with her body in the fetal position. Her eyes opened for a moment with verbal stimuli. At 10:18 a.m. the Director of Nursing entered Resident #29's bedroom. He was asked about the resident positioning as the tube feeding machine was running. He indicated that the head of the bed was not high enough and that she needed to be repositioned at that time. At 10:20 a.m. Licensed Practical Nurse A (LPNA) said that she had given Resident #29 her medications at 8:00 this morning and her head of bed was up at that time. LPN A stated, if the tube came disconnected then it did. LPN A was asked about the resident positioning as the tube feeding machine was running. LPN A stated, she always repositions herself like that and walked out of the bedroom. The facility provided a copy of their policy titled Enteral Feedings - Safety Precautions that contained a revision date on May 2014. Purpose: To ensure the safe administration of enteral nutrition. Preparation: 1. All personnel responsible for preparing, storing and administrating enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. 2. The facility will remain current in and follow accepted best practices in enteral nutrition. Preventing aspiration: 3. Always elevate the head of the bed (HOB) at least 30 degrees- 45 degrees during tube feeding and at least 1 hour after. Monitor the tube-fed resident for signs and symptoms of respiratory distress during feedings and medication administration. Based on observations, interviews and medical record review, and policy review the facility failed to ensure that care was provided according to standards of practice for two (#277 & 29) out of ten residents with enteral tubing feedings who were not positioned appropriately to prevent possible aspiration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 13 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0693 Findings included: Level of Harm - Minimal harm or potential for actual harm 1. Resident #277 was admitted to the facility with a diagnosis of attention to gastrostomy, according to the facesheet in the admission record. Residents Affected - Few On 1/28/20 at 4:53 p.m. an observation was conducted. Resident #277 was in his bed lying on his right side in a fetal position. The head of the bed was elevated less than 30 degrees. Resident #277 was huddled in the middle of the bed, with his body flat. A tube feeding was connected to Resident #277, running with Jevity 1.5 at 60 ml per hour. On 1/31/20 at 8:14 a.m. another observation was conducted. Resident #277 was in his bed with his eyes open. The head of the bed was down all the way. The tube feed was running at 60 ml per hour, and the tubing was connected to Resident#277. On 1/31/20 at 8:17 a.m. an interview was conducted with Staff D, RN unit manager. Staff D, RN unit manager confirmed Resident #277 was in the bed with the tube feed running and the head of the bed lowered all the way. She said the head of the bed needed to be raised. She put on a pair of gloves and raised the head of the bed. Staff E, CNA came into the room during the observation, and assisted with positioning Resident #277. Resident #277 was in a fetal position on his right side, the pillows for support were in the chair next to the bed. Upon review of the physician's orders in the electronic medical record, the following order was discovered: 1/22/20 HOB (head of bed) elevated at least 30 degrees every shift. Further review of the electronic medical record revealed a baseline care plan dated 1/23/20, and showed an intervention under Nutrition and Enteral Feed, Elevate HOB as ordered. The goal was resident will tolerate tube feeding without complications. The CNA(Certified Nurses Assistant) Kardex (care instructions) dated 1/22/20 review showed under General Information, Keep head of bed elevated. Reposition frequently due to tendency to turn self sideways in bed. The treatment administration record in the electronic medical record was also reviewed. The order dated 1/22/20 HOB elevated at least 30 Degrees every shift, was signed by the nurses caring for Resident #277. On 1/31/20 at 6:02 p.m. an interview was conducted with the DON (director of nursing). He said my expectation is that my unit managers round and make sure the bed is up. I also make rounds. The NHA (nursing home administrator) was also present during the interview. He said the policy is that the bed has to be up when the tube feeding is running. The usual practice is to put the bed up after care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 14 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the facility did not ensure acceptable practices were implemented during care of a tracheostomy for one resident (#267) of one resident observed for tracheostomy care and services. Residents Affected - Few Findings included: Resident #267 was admitted to the facility on [DATE] with a diagnosis of respiratory failure, according to the face sheet in the admission record. A review of the physician's orders in the electronic medical record revealed the following information: 1/21/20 change inner cannula daily and prn (as needed) (size 4 DIC) as needed for tracheostomy 1/21/20 cleanse stoma daily with NS (normal saline) and and apply T-dressing if needed every shift Review of the TAR (Treatment Administration Record) dated 1/22/20 revealed the inner cannula change was not signed on the 1/22 or 1/ 23. On 1/30/20 at 2:20 p.m. an interview was conducted with the DON (Director of Nurses). He said yes, it should be signed every day. On 1/31/20 at 12:21 p.m. an observation was conducted during tracheostomy care with Staff A, LPN. Staff A, LPN put on ppe (personal protective equipment). Then Staff A, LPN knocked on the door and announced herself before entering Resident #267's bedroom. Staff A, LPN explained the treatment. Then Staff A, LPN removed the vent collar from the tracheostomy site so she could access the tracheostomy. Next, Staff A, LPN put a pulse oximeter on Resident #267's right index finger. The oxygen saturation read 83%. Staff A, LPN removed the gloves and disposed of them. Then Staff A, LPN washed her hands and put on a clean pair of gloves. Staff A, LPN gathered the supplies needed for the treatment from the table where they were located, and brought them to the bed side table, where she placed them on paper towels. Then Staff A, LPN removed the inner cannula from the tracheostomy and disposed of it in the trash can at the bedside. Staff A, LPN also removed the gloves she was wearing and placed them in the trash can. Then Staff A, LPN put on a pair of sterile gloves. Staff A, LPN did not perform hand hygiene after removing the cannula and gloves. Next Staff A, LPN removed the new cannula from the tray and inserted it into the the stoma. The stoma was red and clean, without drainage, secretions, or inflammation. Staff A, LPN did not clean the stoma. Staff A, LPN disposed of the sterile gloves. Then Staff A, LPN washed her hands in the bathroom sink and put on new sterile gloves. Staff A, LPN poured cleaning solution into a sterile bag in a box. Then Staff A, LPN used a gauze 4x4 to clean the outside of the trach collar around the stoma. Staff A, LPN used another gauze 4x4 to pat dry. Next Staff A, LPN placed a new gauze drain dressing beneath the tracheostomy site. Finally, Staff A, LPN disposed of the supplies in the trash can at the bedside. Then Staff A, LPN removed her gloves, and disposed of them in the trash can. Next Staff A, LPN went to the bathroom where she washed her hands in the sink. Staff A, LPN did not return the vent collar to the tracheostomy site. She left it sitting on Resident #267's left neck side, away from the tracheostomy site. Staff A, LPN put on new gloves and placed the call light near the resident. Then Staff A, LPN moved the tubing from the vent so it wasn't pulling. Staff A, LPN still did not return the vent collar to the the tracheostomy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 15 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stoma. Staff A, LPN had removed her gloves and was preparing to exit the room. The surveyor asked if the what the nurse thought about the oxygen saturation. Staff A, LPN said the oxygen saturation went up to 90. She said Resident #267's baseline is 90-94. The surveyor then asked if she was going to put the resident's oxygen back. Staff A, LPN said it wasn't there when she came in. Then Staff A, LPN returned to the bedside and placed the vent collar over the tracheostomy. Staff A, LPN put on another pair of gloves, and returned the pulse oximeter to Resident #267's right middle finger. It read 94%. After removing the pulse oximeter Staff A, LPN removed her gloves and gown. Then Staff A, LPN sanitized her hands. When Staff A, LPN exited the room she washed her hands in the soiled utility room. On 1/31/20 at 5:39 p.m. an interview was conducted with the DON. He agreed the nurse needs to remove the gloves and do hand hygiene prior to donning sterile gloves. A review of the policy Tracheostomy Care, revised August 2013, reflected the following information: Purpose The purpose of this procedure is to guide tracheostomy care in the cleaning of reusable tracheostomy cannulas. General guidelines 1. Aseptic technique must be used: a. During cleaning and sterilization of reusable tracheostomy tubes. b. During all dressing changes until the tracheostomy wound has granulated (healed) ; and c. During tracheostomy tube changes, either reusable or disposable. 2. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures. 5. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomys, and at least every eight hours for residents with unhealed tracheostomys. Procedure Guidelines Preparation and Assessment 1. Check physician order. Clean the removable inner cannula 8. Put on sterile gloves. 9. Secure the outer neck plate with non-dominant gloved hand. 10. Unlock the inner cannula with gloved dominant hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 16 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0695 11. Gently remove the inner cannula, rotating counterclockwise while lifting away from the resident. Level of Harm - Minimal harm or potential for actual harm 14. Remove and discard gloves into appropriate receptacle. 15. Wash hands and put on fresh gloves. Residents Affected - Few 16. Replace the cannula carefully and lock in place. Sight and Stoma Care 1. Apply clean gloves. 2. Clean the stoma with two peroxide soaked gauze pads (using a single sweep for each side). 3. Rinse the stoma with Saline soaked gauze pads (using a single sweep for each side). 4. Wipe with dry gauze (using a single sweep for each side). 5. Disinfect the stoma with anti-septic soaked gauze pads (using a single sweep for each side). Allow to air dry or wipe with clean, dry gauze. 7. Apply a fenestrated gauze pad around the insertion site. 8. Replace supplemental oxygen mask over tracheostomy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 17 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on resident interview, observation, record review and staff interview, it was determined that the facility did not ensure that consistent pain management was provided for one of fifty three residents reviewed ( # 165). Residents Affected - Few Findings Included: An interview was conducted with Resident # 165, on 1/28/20 at 3:03 p.m. Resident # 165 stated he was in pain from a fractured knee and recent abdominal surgery. He stated the facility does not have his pain medications at times or it gets discontinued for a day or two then starts again. He stated he is in a lot of pain when he does not get his pain medication. Review of the record for Resident # 165 revealed that he was admitted to the facility for rehabilitation on 1/9/20. Diagnoses included Displaced comminuted fracture of left patella, Acute embolism and thrombosis of left popliteal vein. His diagnoses in physician notes also indicated recent Right Iliofemoral and profunda femoris endarterectomy with angioplast and Left iliofemoral endarterectomy and angioplast and aorto-bifemoral bypass. Review of care plans for Resident # 165 revealed a care plan initiated 1/27/20 for Has an alteration in comfort related to multiple surgical wounds, recent fracture of left patella, decreased mobility, chronic left extremity pain and muscular atrophy. Is able to communicate pain to staff. Has routine pain medication regimen. Goal : Will voice an acceptable level of comfort thru next review Interventions: Administer medication for discomfort as ordered, observe for effectiveness and for SEs(side effects), Activities as tolerated, Assess pain level as needed, Report changes in comfort level to physician as ordered. ' Review of physician orders for January 2020 revealed 1/9/20 Acetaminophen 325 mg as needed for mild pain level 1 to 3, not to exceed 3 gm/300/ mg in 24 hours 1/9/20 Percocet tablet 5-325 mg ( Oxycodone- Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Acute Pain . Order was discontinued 1/10/20 1/9/20 Evaluate resident for pain by using the the appropriate scale: 0 - no pain, 1-3 - mild pain, 4-6 Moderate pain, 7-10 Severe pain, as needed for pain 1/9/20 Evaluate resident for pain by using the the appropriate scale: 0 - no pain, 1-3 - mild pain, 4-6 Moderate pain, 7-10 Severe pain, every shift 1/10/20 Percocet Tablet 5-325 Mg ( Oxycodone - Acetaminophen ) Give 1 tablet by mouth every 4 hours as needed for Acute Pain for 3 days. Order was discontinued 1/13/20 1/13/20 Oxycodone - Acetaminophen Tablet 5-325 mg Give 1 tablet by mouth every 4 hours as needed for pain . This order was discontinued on the day it was ordered 1/13/20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 18 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0697 1/15/20 Oxycodone - Acetaminophen 5-325 mg Give 1 tablet every 6 hours for pain Discontinued 1/27/20 Level of Harm - Minimal harm or potential for actual harm 1/20/20 Consult for pain management per patient request 1/27/20 Oxycodone - Acetaminophen 5-325 mg Give 1 tablet by mouth every 6 hours as needed for pain Residents Affected - Few 1/28/20 Gabapentin Capsule 100 mg by mouth three times a day for nerve pain Review of the January 2020 Medication Administration Record, revealed that the routine order for Oxycodone - Acetaminophen tablet 5-325 Give 1 tablet by mouth every 6 hours for pain was documented as not given and pain level was not assessed on 1/16/20 at midnight, 0600 a.m. and 12:00 pm; 1/20/20 0600 am, 1200 pm and 1800 pm; 1/26/20 0600 am , 1200 pm and 1800 pm, and 1/27/20 midnight and 0600 am Review of nursing progress notes for these dates indicated on 1/16/20 at 0016 am that the resident needed a new prescription and at 12:49 waiting for script. Documentation of the Controlled substance log form the emergency drug kit revealed that it was administered at 6:00 p.m. from the emergency drug kit For 1/20/20 nursing progress notes indicated the medication was not given as ordered at 6:00 a.m. as the resident needs a new script, not given at 1200 p.m. as script fax to pharmacy, awaiting delivery. At 1820 the nursing progress note indicated resident refused, stating his pain is not bad at this time and will take med later. For 1/26/20 nursing progress notes indicated that the medication was on order, and awaiting pharmacy For 1/27/20 nursing progress notes for ordered times of midnight and 0600 am indicated on order and then a refusal of the medication at 12:00 noon. A subsequent interview was conducted with Resident #165, on 1/29/20 at 5: 30 p.m. He stated that there is still an issue with his pain medications and he is not getting them as he is supposed to. On 1/28/20 , Resident # 165 was seen by a Physiatrist. Review of the Physiatrist progress note revealed Rehabilitation Medicine was asked to consult on the patient for recommendations on rehabilitation, pain, and therapy management, HPI: Present to (local hospital ) on 12/28/19 with complaints of left knee pain after a mechanical fall. He has a history of severe peripheral vascular disease. He had an angiogram which showed completely thrombosed infrarenal abdominal aorta, bilateral common and external iliac arteries, abrupt occlusion at the proximal left popliteal artery compatible with acute emboli. He had x rays which showed a left knee comminuted fracture of the patella and underwent right iliofemoral and profunda femoris endarterectomy with angioplasty, left iliofemoral endarterectomy and angioplasty and aorto- bifemoral bypass. I was asked to evaluate the patient for poorly controlled pain. He currently has orders for Percocet 5 mg every 6 hours as needed, but apparently was on a standing dose every 6 hours prior to day. Nursing staff reports that this change was ordered because they ran out of the medication and had to make it a PRN order in the computer for this reason. He reports acute pain in his abdomen and in the left knee, he stated that he fell several weeks ago and has had pain in the knee ever since then. The pain is sharp and worse with any movement. He reports decent pain control with the Percocet. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 19 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0697 Level of Harm - Minimal harm or potential for actual harm also has abdominal pain around his surgical site. This too is controlled with Percocet. He also repots chronic shooting pains in the feet and lower extremities. This has been present for several years. He reports numbness on the inner part of both legs from his thighs down to his feet. This is more of a shooting pain, moderate in intensity and seems to be worse in the evenings. He stated that he has been on the Percocet for some time, but has not really tried any other medications for pain. Residents Affected - Few Review of depositaries note indicated that he has adequate control with Percocet and a trial of Gabapentin would be initiated. Gabapentin was ordered 1/28/20 An interview was conducted with the Director of Nursing on 1/31/20 at 2:25 p.m., regarding the Oxycodone - Acetaminophen 5- 325 not being available at times and the Physiatrist note regarding the pain medication being changed from routine to as needed per the nurses stating they kept running out of it. The DON stated he is not sure what occurred with the pain medication as it is available in the emergency drug kit. An interview was conducted with Resident # 165, on 1/31/20 at 2: 30 p.m. He stated he did receive his pain medication today and he is trying to make sure he asks for it every 6 hours to keep the pain down. He stated he knows he is on a new medication for the pain but it is not helping yet. He states his pain is not controlled yet. He stated he is also trying to coordinate his pain medication before therapy as he is in pain in therapy and after therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 20 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 observation, interview, record review, policy review, and manufacturer's instructions the facility did not ensure that the medication error rate was below 5% for three (#5, #33, and #100) of six sampled residents who were administered medications. This resulted in five errors from twenty-five medication administration opportunities, for a medication error rate of 20%. Residents Affected - Few Findings included: 1. Resident #5 was admitted to the facility with a diagnosis of essential hypertension, according to the face sheet in the medical record. On 1/30/20 at 7:54 a.m. an observation was conducted with Staff F, LPN. Staff F, LPN prepared Resident #5's medications. Staff F, LPN said she could not find Resident #5's Allegra-D. Staff F, LPN poured a capful of Miralax into a plastic cup. Then Staff F, LPN poured water into a 30 ml medication cup. She poured the 30 ml of water into the Miralax powder. The surveyor read the instructions on the Miralax which indicated to mix it in 6-8 ounces of water. Staff F, LPN knocked on Resident #5's door after preparing all of his medications. Staff F, LPN assessed his pain. Then Staff F, LPN gave Resident #5 his pills whole with water. Next Staff F, LPN gave him his lactulose and then Miralax mixture of 30 ml. Staff F, LPN shook the inhaler and handed it to Resident #5. Staff F, LPN instructed Resident #5 to blow out and take 2 puffs. Resident #5 took 2 puffs, consecutively, as instructed by the nurse. Staff F, LPN instructed him to rinse his mouth. Resident #5 said he didn't want to rinse his mouth. Staff F, LPN took the inhaler and exited the room. Then Staff F, LPN performed hand hygiene. On 1/30/20 at 4:07 p.m. an interview was conducted with Staff F, LPN. She said the Allegra was in the stock, and she got it and gave it to Resident #5. The surveyor asked to see the medication. It was Allegra 60 mg and not Allegra-D 60-120 mg. Staff F, LPN reviewed the order and confirmed it was not correct. The following physician's orders were found in Resident #5's medical record: 1/31/19 Allegra -D extended release 12 hour 60-120 mg give 1 tablet by mouth one time a day for allergies 6/26/19 Miralax powder give 17 gram by mouth one time a day every Tue, Thu, Sat, Sun for constipation 10/16/19 Symbicort aerosol 160-4.5 mcg/act 1 inhalation inhale orally two times a day for asthma Review of the policy, Administering Medications through a Metered Dose Inhaler, revised October 2010, revealed the follwoing information: Purpose The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications. General guidelines (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 21 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 Follow the medication administration guidelines in the policy entitled Administering Medications. Level of Harm - Minimal harm or potential for actual harm Steps in the Procedure Residents Affected - Few 15. Repeat inhalation, if ordered. Allow at least one minute between inhalation of the same medication and at least two minutes between inhalations of different medications. The following was found at www.symbicorttouchpoints.com: Quick Guide 3. Breathe out fully, then place the mouthpiece cover into your mouth and close your lips around it. Make sure that the inhaler is upright and the opening of the mouthpiece is pointing towards the back of your throat. Inhale deeply and slowly while pressing down firmly on the top of the counter on the inhaler. 4. Continue to breathe in and hold your breath for about 10 seconds, or for as long as comfortable. Before you breathe out, release your finger from the top of the counter. Keep the inhaler upright and remove from your mouth. For your second puff, shake the the Symbicort inhaler again for 5 seconds and repeat steps 3 and 4. Review of the policy, Administering Medications, revised December 2012, revealed the following information: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 7. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 2. Resident #100 was admitted to the facility with a diagnosis of type 2 diabetes mellitus, according to the face sheet in the admission record. On 1/30/20 at 8:47 a.m. with Staff A, LPN. Staff A, poured Resident #100's medications. Then Staff A, LPN knocked on the door and entered the room. Next, Staff A, LPN washed her hands in the bathroom sink. Then Staff A, LPN put on a pair of gloves. Staff A, LPN placed the supplies and medications on paper towels on bed side table. She gave Resident #100 his medications whole with water. Then Staff A, LPN opened the needle for the insulin pen. Staff A, LPN attached the needle to the pen. Then Staff A, LPN dialed the Novolog insulin pen to 10 units. Staff A, LPN did not prime the needle with 2 units of insulin prior to dialing it to 10 units. Next, Staff A, LPN used an alcohol prep to clean Resident #100's left lower abdomen. She placed the insulin pen against the area she had cleaned, and pressed the top to inject the medication. Then Staff A, LPN removed her gloves and placed them in the trash can near the bedside, along with the other supplies she had used. She went into the bathroom and disposed of the insulin needle in the Sharp's container. Then Staff A, LPN washed her hands in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 22 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 the bathroom sink. Staff A, LPN returned to the medication cart where she cleaned the insulin pen with a germicidal wipe. Level of Harm - Minimal harm or potential for actual harm A review of Resident #100's physician's orders in the electronic medial record revealed the following: Residents Affected - Few 1/29/20 Novolog flexpen 10 units subcutaneously with meals 3. Resident #33 was admitted to the facility with a diagnosis of type 2 diabetes mellitus according to the face sheet in the admission record. On 1/30/20 at 11:40 a.m. an observation was conducted with Staff A, LPN during insulin administration. Staff A, LPN removed a glucometer, test strips, lancet, alcohol prep pad, Novolog flexpen, and a needle from the medication cart and placed the supplies on a foam plate. Then Staff A, LPN knocked on Resident #33's door. Staff A, LPN went to the bathroom and washed her hands in the sink. Next, Staff A, LPN put on a pair of gloves. After turning on the glucometer, Staff A, LPN placed a test strip in it. Then Staff A, LPN used an alcohol prep to clean Resident #33's left middle finger. Staff A, LPN poked the finger tip with the lancet and applied a droplet of blood to the test strip. The glucometer read a blood glucose of 99. Next Staff A, LPN attached the needle to the Novolog flexpen. Staff A, LPN removed the gloves and washed her hands in the bathroom sink. Then Staff A, LPN returned to the medication cart for another alcohol prep. When Staff A, LPN returned to the room, she washed her hands in the sink again. Then Staff A, LPN put on another pair of gloves. Staff A, dialed the insulin pen to 4 units. Staff A, LPN did not prime the insulin pen. Then Staff A, LPN cleaned Resident #33's right upper abdominal area with the alcohol prep pad. Staff A, LPN pressed the insulin pen against the area she had cleaned, and pressed the button to release the insulin. Next, Staff A. LPN disposed of the needle and lancet in the sharps container in the bathroom, and the supplies in the trash can. The Staff A, LPN removed the gloves and placed the in the trash can as well. Then Staff A, LPN washed her hands in the bathroom sink. Staff A, LPN exited the room and looked for a germicidal wipe in the medication cart. When she couldn't find one, she asked a staff member to bring her some. Then Staff A, LPN removed a germicidal wipe from the container, and cleaned the glucometer with it. She placed the glucometer in a drawer in the medication cart. Staff A, LPN removed another germicidal wipe and cleaned the flexpen. Then Staff A, LPN placed the flexpen in a plastic bag and returned it to the drawer. On 1/30/20 at 11:54 a.m. in an interview with Staff A, LPN she said she did not know she had to prime the insulin pen. She said she did not know what priming was. A review of the physician's orders in the electronic medical record reflected an order dated 8/20/19 for Novolog flexpen solution 4 units subcutaneously before meals A review of the manufacturer's instructions for Novolog Flexpen reflected the following information: Getting started on Novolg Flexpen A Guide to Using Your Novolog FlexPen Prepare you pen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 23 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 Remove the cap Level of Harm - Minimal harm or potential for actual harm Pull off the pen cap and wipe the rubber stopper with an alcohol swab. Attach a ne needle Residents Affected - Few Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps. Prime your pen Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Select your dose Turn the dose selector to select the number of units you need to inject. Give your injection Insert the needle. Press and hold the dose button. After the dose counter reaches 0, slowly count to 6. On 1/31/20 at 4:04 p.m. an telephone interview was conducted with the Consultant Pharmacist. The surveyor asked if the insulin pen wasn't primed, if that would be a significant medication error. He said I think it would be a med error. I don't think it would qualify as a significant med error since it's only 2 units. The surveyor asked about use of the Symbicort inhaler. The Consultant Pharmacist said, You want to wait a minute between puffs, absolutely. When the surveyor asked about the Allegra error, he said I don't like pseudophed for that population, but the only possible outcome would be a runny nose. If the order called for Allegra D they should give Allegra D. Then the surveyor asked what the outcome would be if the Miralax wasn't mixed in 6-8 ounces (oz) of water. The Consultant Pharmacist said, A small amount of water won't dissolve the miralax, so then you're not getting the full dose. On 1/31/20 at 5:39 p.m. an interview was conducted with the DON. The DON said he was not aware the insulin pens needed to be primed. The surveyor shared the Allegra error with him, and the DON said they called the physician and got the one time order for the Allegra. He said It should be available, yes, of course. When the surveyor shared the concern with the inhaler, the DON said The resident shouldn't be doing his own inhaler. There should be some wait time between. The nurse should have administered the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 24 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and policy review the facility did not ensure residents were free from significant medication errors, for 3 residents (#5, #33 and #100) of 11 residents observed during medication administration or reviewed for unnecessary medications. Residents Affected - Some Findings Included: 1) Review of the record for Resident # 5 revealed that he was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus without Complications. Review of Physician orders on the Order Summary Report revealed an order dated 12/17/19 for Humulin R U-500 Kwik-Pen Solution Pen -Injector 500 Unit/ML: Inject 90 unit subcutaneously with meals related to Type II Diabetes Mellitus without complications . Resident # 5 also had a physician's order, dated 11/13/19 for Novolog Solution 100 Unit/ML (Insulin Aspart): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200. Review of Resident # 5's Medication Administration Record ( MAR) for December 2019 revealed the Novolog Solution 100 Unit/ML (Insulin Aspart): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200 was documented as administered when blood sugars (BS) were documented as under 200 on 20 of 93 occasions: 0630 am 12/1 BS 168, 12/2 BS 166, 12/6 BS 165, 12/11 BS 191, 12/12 BS 110, 12/13 BS 162, 12/14 BS 150, 12/16 BS 197, 12/18 BS 165, 12/22 BS 194, 12/25 BS 170, 12/28 BS 176, 12/30 BS 90, 12/31 BS 180 11:30 am 12/15 BS 132, 12/22 BS 107, 12/28 BS 135 16:30 pm (4:30 pm) 12/7 BS 108, 12/22 BS 124, 12/28 BS 158 Review of Resident # 5's MAR for January 2020 revealed the Novolog Solution 100 Unit/ML (Insulin Aspart): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200 was documented as administered when blood sugars were documents as under 200 on 8 of 91 occasions: 06:30 a.m. 1/1 BS 109, 1/5 BS 165, 1/6 BS 152, 1/11 BS 81, 1/12/ BS 188, 1/15 BS 110, 1/16 BS 171, 1/21 BS 134. An interview was conducted with the Director of Nursing, on 1/31/2020 at 11:20 a.m. He reviewed the Medication Administration Records and confirmed that the Novolog insulin was being administered when it was supposed to be held for blood sugars under 200 . He stated it looked like the nurses were not paying attention and clicking along too fast. A phone interview was conducted with the Consultant Pharmacist, on 1/31/20 at 4:15 pm. He stated he does look at the blood sugars and insulin when he does his reviews. He stated he does not like this type of order as it puts more on for the nurses to do. He stated it is definitely an issue. He was unable at the time of the phone interview to access his records to see if he had previously identified this issue for Resident # 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 25 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2) Resident #100 was admitted to the facility with a diagnosis of type 2 diabetes mellitus, according to the face sheet in the admission record. On 1/30/20 at 8:47 a.m. with Staff A, LPN. Staff A, poured Resident #100's medications. Then Staff A, LPN knocked on the door and entered the room. Next, Staff A, LPN washed her hands in the bathroom sink. Then Staff A, LPN put on a pair of gloves. Staff A, LPN placed the supplies and medications on paper towels on bed side table. She gave Resident #100 his medications whole with water. Then Staff A, LPN opened the needle for the insulin pen. Staff A, LPN attached the needle to the pen. Then Staff A, LPN dialed the Novolog insulin pen to 10 units. Staff A, LPN did not prime the needle with 2 units of insulin prior to dialing it to 10 units. Next, Staff A, LPN used an alcohol prep to clean Resident #100's left lower abdomen. She placed the insulin pen against the area she had cleaned, and pressed the top to inject the medication. Then Staff A, LPN removed her gloves and placed them in the trash can near the bed side, along with the other supplies she had used. She went into the bathroom and disposed of the insulin needle in the Sharp's container. Then Staff A, LPN washed her hands in the bathroom sink. Staff A, LPN returned to the medication cart where she cleaned the insulin pen with a germicidal wipe. A review of Resident #100's physician's orders in the electronic medial record revealed the following: 1/29/20 Novolog flexpen 10 units subcutaneously with meals 3) Resident #33 was admitted to the facility with a diagnosis of type 2 diabetes mellitus according to the face sheet in the admission record. On 1/30/20 at 11:40 a.m. an observation was conducted with Staff A, LPN during insulin administration. Staff A, LPN removed a glucometer, test strips, lancet, alcohol prep pad, Novolog flexpen, and a needle from the medication cart and placed the supplies on a foam plate. Then Staff A, LPN knocked on Resident #33's door. Staff A, LPN went to the bathroom and washed her hands in the sink. Next, Staff A, LPN put on a pair of gloves. After turning on the glucometer, Staff A, LPN placed a test strip in it. Then Staff A, LPN used an alcohol prep to clean Resident #33's left middle finger. Staff A, LPN poked the finger tip with the lancet and applied a droplet of blood to the test strip. The glucometer read a blood glucose of 99. Next Staff A, LPN attached the needle to the Novolog flexpen. Staff A, LPN removed the gloves and washed her hands in the bathroom sink. Then Staff A, LPN returned to the medication cart for another alcohol prep. When Staff A, LPN returned to the room, she washed her hands in the sink again. Then Staff A, LPN put on another pair of gloves. Staff A, dialed the insulin pen to 4 units. Staff A, LPN did not prime the insulin pen. Then Staff A, LPN cleaned Resident #33's right upper abdominal area with the alcohol prep pad. Staff A, LPN pressed the insulin pen against the area she had cleaned, and pressed the button to release the insulin. Next, Staff A. LPN disposed of the needle and lancet in the sharps container in the bathroom, and the supplies in the trash can. The Staff A, LPN removed the gloves and placed the in the trash can as well. Then Staff A, LPN washed her hands in the bathroom sink. Staff A, LPN exited the room and looked for a germicidal wipe in the medication cart. When she couldn't find one, she asked a staff member to bring her some. Then Staff A, LPN removed a germicidal wipe from the container, and cleaned the glucometer with it. She placed the glucometer in a drawer in the medication cart. Staff A, LPN removed another germicidal wipe and cleaned the flexpen. Then Staff A, LPN placed the flexpen in a plastic bag and returned it to the drawer. On 1/30/20 at 11:54 a.m. in an interview with Staff A, LPN she said she did not know she had to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 26 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0760 prime the insulin pen. She said she did not know what priming was. Level of Harm - Minimal harm or potential for actual harm A review of the physician's orders in the electronic medical record reflected an order dated 8/20/19 for Novolog flexpen solution 4 units subcutaneously before meals Residents Affected - Some A review of the manufacturer's instructions for Novolog Flexpen reflected the following information: Getting started on Novolog Flexpen A Guide to Using Your Novolog FlexPen Prepare you pen Remove the cap Pull off the pen cap and wipe the rubber stopper with an alcohol swab. Attach a needle Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps. Prime your pen Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Select your dose Turn the dose selector to select the number of units you need to inject. Give your injection Insert the needle. Press and hold the dose button. After the dose counter reaches 0, slowly count to 6. On 1/31/20 at 4:04 p.m. an telephone interview was conducted with the Consultant Pharmacist. The surveyor asked if the insulin pen wasn't primed, if that would be a significant medication error. He said I think it would be a med error. I don't think it would qualify as a significant med error since it's only 2 units. The surveyor asked about use of the Symbicort inhaler. The Consultant Pharmacist said, You want to wait a minute between puffs, absolutely. When the surveyor asked about the Allegra error, he said I don't like pseudophed for that population, but the only possible outcome would be a runny nose. If the order called for Allegra D they should give Allegra D. Then the surveyor asked what the outcome would be if the Miralax wasn't mixed in 6-8 ounces (oz) of water. The Consultant Pharmacist said, A small amount of water won't dissolve the miralax, so then you're not getting the full dose. On 1/31/20 at 5:39 p.m. an interview was conducted with the DON. The DON said, what do you mean prime it? What's an air shot? He was not aware the insulin pens needed to be primed. The surveyor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 27 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shared the Allegra error with him, and the DON said they called the physician and got the one time order for the Allegra. He said It should be available, yes, of course. When the surveyor shared the concern with the inhaler, the DON said The resident shouldn't be doing his own inhaler. There should be some wait time between. The nurse should have administered the medication. Review of the policy, Administering Medications, revised December 2012, revealed the following information: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 7. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 28 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation and resident record review, it was determined that the facility did not ensure all staff were aware of adaptive equipment required during meals for one of fifty three residents reviewed (#101). Residents Affected - Few Findings Include : On 1/30/20 at approximately 12:40 p.m. Resident # 101 was observed to be seated at a square table in the main dining room. A sippy cup was on the square table across from Resident # 101 near the middle of the table. The Administrator in Training (AIT) was observed to be serving beverages to residents in the dining room. She approached Resident # 101 and asked her what she would like to drink. Resident # 101 was heard to choose cranberry juice. There was no meal ticket or tray slip on the table. She was not observed to determine what consistency and in what form Resident # 101's beverages should be. The AIT was heard to say to Resident # 101 oh you don't have a cup, let me get you a cup. She then walked toward the kitchen area and returned with a regular drinking cup, poured cranberry juice into the cup and placed the cup in front of Resident # 101. The surveyor intervened and indicated, by gesture, the sippy cup on the table. The AIT was then observed to call out to other staff in the dining room who were assisting residents Is she a sippy cup? to which the other staff who were assisting other residents verbally called out yes. She then transferred the cranberry juice from the regular cup to the sippy cup. Review of the record for Resident #101 revealed that she had diagnoses which included Dementia, Altered Mental Status , and Dysphagia. Review of physician orders for Resident # 101 revealed a diet order for Mechanical Soft Texture, Thin Consistency, dated 9/12/19 and an order, dated 11/12/19 for OT(Occupational Therapy) orders for pt(patient) to receive a sippy cup with all meals in order to decrease spillage of liquids. Review of a quarterly MDS(Minimum Data Set) assessment, dated 12/21/19 revealed a score of 3 on the Brief Interview for Mental Status, indicative of severe cognitive impairment, and limited assistance of one person required for eating. Review of the tray slip for Resident # 101, which arrived with her meal tray after beverages were served, revealed that sippy cup was listed on the tray slip. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 29 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews the facility failed to implement their quality assessment and assurance measures for corrective action related to deficient practice identified on the annual survey conducted on 1/31/2020 Annual Survey. Continued non-compliance was identified for 2 (F810, F880) out of 12 deficiencies cited. Residents Affected - Few Findings included: An annual survey was conducted on 1/31/2020 and deficient practice was identified at:

F550, F561, F656, F684, F686, F693, F695, F697, F759, F760, F810, F880. A revisit to the annual survey was conducted on 3/04/2020 - 3/05/2020 and continued deficient practice was identified at: F810 and F880. A review of the facility's plan of correction for the recertification survey, ending 1/31/2020, revealed the following measures identified by the facility Quality Assurance Committee (QAC), would be taken to correct the deficient practice for F810 and F880.

F 810: Resident #29 was given the correct consistency in her assistive device and the Administrator in Training was educated on the use of assistive devices and dignity. Other residents with assistive devices were reviewed for compliance. Guardian Angel program sheets were updated to observe one meal a day and ensure proper voice volume, dignity and assistive devices are being use. The facility Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed on 3/05/2020 at 4:17 p.m., We provided education to 100% of Certified Nurses Aides and licensed staff, all staff were educated on dining with dignity and addressing residents appropriately, volume of voices and use of assistive devices. The facility failed to correct as evidenced by the facility failed to provide appropriate assistive devices for meals for 1 (#29), resident out of 3 residents sampled. For F880, Glucometers were cleaned and identified staff were immediately educated on the facility infection control policy. Education on infection control was initiated for all staff to ensure practices were not repeated or or continued. The Assistant Director of Nurses (ADON), educated all current staff on infection control guidelines. Education following infection control practices and competencies as appropriate will be included in newly hired employee orientation and annual education requirements for staff. Competencies will be completed and post tests conducted to determine understanding. At the conclusion of the revisit on 3/5/20, it was determined that the facility had current deficient practice in infection control in several areas including: Failing to follow professional guidelines for washing hands with soap and water or using hand sanitizer between patient contact; cleaning shared patient equipment after each resident use; ensuring staff used personal protective equipment (PPE) for 2 of 2 isolation rooms and failing to ensure pertinent isolation signage was posted for 2 of 2 isolation rooms; and use of hand sanitizer to meet the CDC (Centers for Disease Control) with 6 confirmed cases of the flu. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 30 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0868 Level of Harm - Minimal harm or potential for actual harm The facility NHA and DON were interviewed on 3/05/2020 at 4:17 p.m., The NHA stated that as of 03/01/2020, 100 of facility staff infection control practices and competencies were performed, as needed. An interview was conducted on 3/05/2020 at 4:30 p.m., with the Nursing Home Administrator and the Director of Nurses. The DON stated, We will continue to educate the staff. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 31 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, policy review, manufacturer's instructions, and CDC (Centers for Disease Control) guidelines the facility did not ensure appropriate infection practices were implemented related to 1) glucometer disinfection for two (#15 and #33) of two residents observed during glucometer use, and 2) the facility did not ensure appropriate personal protective equipment (PPE) was worn during care for one resident (#34), on contact precautions, and appropriate hand washing after exiting a contact isolation room for Resident #267, of two residents on contact isolation, and 3) the facility did not ensure staff wore gloves during eye drop administration for one (#89) of six residents observed during medication administration. Residents Affected - Few Findings included: 1) Resident #15 was admitted to the facility with a diagnosis of type 2 diabetes mellitus, according to the face sheet in the admission record. On 1/28/20 at 5:03 p.m. an observation was conducted with Staff G, LPN during glucometer use. Staff G, LPN explained the procedure to Resident #15 placed the glucometer and bottle of test strips on Resident #15's dresser, and on a pair of gloves. Staff G, LPN turned the glucometer on and placed a test strip in it. Staff G, LPN cleaned Resident #15's right index finger with an alcohol prep. Then she used a lancet to poke Resident#15's right index finger. Staff G, LPN applied a drop of blood from Resident #15's finger onto the test strip in the glucometer. The meter reading was a blood glucose of 111. Staff G, LPN removed her gloves and disposed of the needle and lancet in the Sharps container in the bathroom. Staff G, LPN washed her hands in the bathroom sink. Then Staff G, LPN put the bottle of test strips in her left pocket. Staff G, LPN returned to the bathroom and washed her hands in the sink again. Then Staff G, LPN took the glucometer and headed out of the room. Staff G, LPN placed the glucometer on top of the medication cart. Then Staff G, LPN removed keys from her right pocket. After that, Staff G, LPN removed the test strips from her pocket and placed them on top of the medication cart. After unlocking the medication cart, Staff G, LPN opened the top drawer and placed the glucometer in it. Staff G, LPN closed the drawer. Staff G, LPN began pushing the medication cart down the hallway. She had not performed any hand hygiene after handling the contaminated glucometer. The surveyor asked her if she cleaned the glucometer. Staff G, LPN said she cleaned it before she used it on Resident #15. The surveyor asked if she should clean it after using it. Staff G, LPN indicated she thought she did. She proceeded to push the med cart down the hallway. The surveyor stopped her again and asked if Staff G, LPN was going to clean the glucometer. Staff G, LPN stopped and unlocked the medication cart. Staff G, LPN removed a germicidal wipe from the container in the medication cart. Staff G, LPN wiped the glucometer using her bare hands, for less than 5 seconds. Then Staff G, LPN set the glucometer back in the drawer and disposed of the wipe. Resident #33 was admitted to the facility with a diagnosis of type 2 diabetes mellitus according to the face sheet in the admission record. On 1/30/20 at 11:40 a.m. an observation was conducted with Staff A, LPN during insulin administration. Staff A, LPN paced the supplies on a foam plate, knocked on Resident #33's door, went to the bathroom and washed her hands in the sink. Next, Staff A, LPN put on a pair of gloves. After turning on the glucometer, Staff A, LPN placed a test strip in it. Then Staff A, LPN used an alcohol prep to clean Resident #33's left middle finger. Staff A, LPN poked the finger tip with the lancet and applied a droplet of blood to the test strip. The glucometer read a blood glucose of 99. Next Staff A, LPN attached the needle to the Novolog flexpen. Staff A, LPN removed the gloves and washed her hands in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 32 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the bathroom sink. Then Staff A, LPN returned to the medication cart for another alcohol prep. When Staff A, LPN returned to the room, she washed her hands in the sink again. Then Staff A, LPN put on another pair of gloves. Staff A, dialed the insulin pen to 4 units. Then Staff A, LPN cleaned Resident #33's right upper abdominal area with the alcohol prep pad. Staff A, LPN pressed the insulin pen against the area she had cleaned, and pressed the button to release the insulin. Next, Staff A, LPN disposed of the needle and lancet in the sharps container in the bathroom, and the supplies in the trash can. Then Staff A, LPN removed the gloves and placed them in the trash can as well. Next, Staff A, LPN washed her hands in the bathroom sink. Staff A, LPN exited the room and looked for a germicidal wipe in the medication cart. When she couldn't find one, she asked a staff member to bring her some. Then Staff A, LPN removed a germicidal wipe from the container, and cleaned the glucometer with it. She placed the glucometer in a drawer in the medication cart. Staff A, LPN removed another germicidal wipe and cleaned the flexpen. Then Staff A, LPN placed the flexpen in a plastic bag and returned it to the drawer. Review of the manufacturer's instructions for Assure Platinum Blood Glucose Monitoring System, Page 47, Cleaning and Disinfecting Guidelines, revealed the following information: Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1 Cleaning and disinfecting can be completely by you using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid on the test strip and key code ports of the meter. Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used, use one wipe to clean and a second wipe to disinfect. A review of the policy, Obtaining a Fingerstick Glucose Level, revised October 2011, showed the following: Purpose The purpose of this procedure is to obtain a blood sample to determine the residents blood glucose level. 18. Clean and disinfect reusable equipment between uses according to the manufacturers instructions and current infection control standards of practice. A review of manufacturer's instructions, Microdot Blood Glucose Monitoring System, Protocol to disinfect Microdot Meter, undated, reflected the following information: To disinfect the Microdot Meter: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 33 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Read the Microdot Bleach Wipe (EPA reg. no. 69687- 1- 88459) label and follow directions for use. Microdot Bleach Wipe is for the exterior surfaces of the blood glucose meter and is not for use on the needle or the monitor. 3. Open Microdot Bleach wipe pop-up canister. The wipes are pre-saturated with a sodium hypochlorite (bleach) hospital use solution. 4. Remove a pre-saturated 6 x 6 wipe. 5. Thoroughly wipe the Microdot Meter surface to be disinfected. 6. Then allow the Microdot Meter surface to air dry. Disinfectant tip: In order to maintain five minutes of contact time with the sodium hypochlorite, wrap the MD meter in the wipe and place meter face down. 2) Resident #34 was admitted to the facility with a diagnosis of sepsis, according to the face sheet in the admission record. Upon review of Resident #34's physician's orders in the electronic medical record, the following order was discovered: 1/27/20 Contact isolation every shift for 7 days. Further review of the electronic medical record revealed a lab result for a urine culture, dated 1/23/20. The culture results indicated Resident #34 had ESBL (Escherichia coli, Extended Spectrum Betalactamase), and another isolate was found as well, Pseudomonas aeruginosa. Review of the MDS (Minimum Data Set), Bladder and Bowel, dated 1/14/20, indicated Resident #34 had an indwelling catheter. On 1/30/20 at 6:12 p.m. an observation was conducted. There was an isolation kit located outside of the door to Resident #34's room, with gloves, gowns, and masks in it. There was also a sign indicating to see nurse before entering the room. Staff C, CNA was observed in Resident #34's room wearing only a pair of gloves. Staff C, CNA was assisting Resident #34 with the dinner meal. Staff C, CNA removed the gloves, and went in the bathroom where he washed his hands in the sink. Then Staff C, CNA removed the dinner tray form the bedside table and exited the room. Staff C, CNA put the tray in the dining cart. Then Staff C, CNA went to the soiled utility room and washed his hands. At 6:15 p.m. on 1/30/20 an interview was conducted with Staff C, CNA. He said he has only worked at the facility for a week. This is the first time he has had this assignment. Staff C, CNA said Resident #34 required total care assistance. She had a Foley catheter, and she was on contact isolation. Staff C, CNA said he was told he only needed to wear gloves to feed her. Staff C, CNA said, They did tell me she was on isolation for her urine. Yes, you wear a gown if you're providing care, but I was just feeding her. If I was turning her or emptying the catheter I would wear a gown. Resident #267 was admitted to the facility with a diagnosis of enterocolitis due to C-Diff, according to the face sheet in the admission record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 34 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the physician's orders in the electronic medical record revealed an order dated 1/21/20: Contact isolation precautions. On 1/30/20 at 4:45 p.m. an observation was conducted. Resident #267 was in her bed, clean, groomed, eyes closed, and no odor was present. The surveyor asked Staff J, CNA to remove the blanket from Resident #267's legs to confirm if her heels were being floated as ordered. Staff J, CNA came in the room after putting on PPE. Then Staff J, CNA removed the blanket from Resident #267's feet. Resident #267's legs were propped up with a pillow. Staff J, CNA said she was not caring for Resident #267. Staff J, CNA didn't know what kind of isolation she was on. She said it was contact, but she wasn't sure if it was urine or bowel. When Staff J, CNA exited the room she did not wash her hands or perform hand hygiene. The surveyor instructed her the resident was on isolation for C-diff and she must wash her hands with soap and water. According to Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2008) from the Centers for Disease Control and Prevention, III.B.1. Contact precautions. Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient ' s environment as described in I.B.3.a. The specific agents and circumstance for which Contact Precautions are indicated are found in Appendix A. The application of Contact Precautions for patients infected or colonized with MDROs is described in the 2006 HICPAC/CDC MDRO guideline927. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. A single-patient room is preferred for patients who require Contact Precautions. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient ' s environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, C. difficile, noroviruses and other intestinal tract pathogens; RSV)54, 72, 73, 78, 274, 275, 740 https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html 3) Resident #89 was admitted to the facility with a diagnosis of hypertension, according to the face sheet in the admission record. Review of Resident #89's physician's orders in the medical record revealed an order dated 9/18/18 for artificial tear solution instill 1 drop in each eye three times a day for dry eyes. On 1/30/20 at 8:17 a.m. an observation was conducted during medication administration. Staff F, LPN performed hand hygiene. After removing Resident #89's medication from the medication cart, including a bottle of artificial tears, Staff F, LPN brought some tissues along with Resident #89's medications into his bedroom after knocking on the door. Staff F, LPN opened the bottle of eye drops. Staff F, LPN did not perform hand hygiene or apply any gloves. Staff F, LPN handed Resident #89 a tissue with her bare hands. Then Staff F, LPN pulled down Resident #89's left lower eye lid, and placed a drop of the artificial tears in it. Then Staff F, LPN proceeded to Resident #89's right eye, without performing any hand hygiene, or applying gloves. Staff F, LPN used a bare hand to pull Resident #89's right lower eyelid down, and squeezed a drop of the artificial tears into it with her other hand. Resident #89 used the tissue she had handed him to wipe the excess eye drops away. Staff F, LPN returned the eye drops to the box. Then Staff F, LPN performed hand hygiene, exited the room and returned the eye drops to the medication cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 35 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0880 Review of the policy, Handwashing/Hand Hygiene, revised August 2015, reflected the following information: Level of Harm - Minimal harm or potential for actual harm Policy statement This facility considers hand hygiene the primary means to prevent the spread of infections. Residents Affected - Few Policy interpretation and implementation 1. All personnel shall be trained and regularly in-service on the importance of hand hygiene and preventing the transmission of healthcare associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: b. After contact with a resident with infectious diarrhea including, but not limited to infections caused by Norovirus, salmonella, shigella and C. Difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents. f. Before donning sterile gloves. m. After removing gloves. n. Before and after entering isolation precaution settings. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. On 1/31/20 at 5:39 p.m. an interview was conducted with the DON and NHA. The DON said the glucometers are shared. There are 2 per nursing cart. The NHA said it's company policy. The DON- said if one (of the meters) gets lost then you have to share anyway. They (nurses) have to follow the policy and procedure. After use, a bleach wipe is utilized on a glucometer for 3 minutes. They should wipe it, and I actually wrap it and let it set for a 3 minute duration. The surveyor asked if the nurse needed to wear gloves during eye drop administration. The DON said Yes, they should be wearing gloves to give eye drops. Yes, you don't want cross contamination. She does need to change gloves and perform hand hygiene. The surveyor asked if staff needed to wear PPE (personal protective equipment) for all resident contact if they are on contact precautions. The DON said Yes, staff must wear the PPE at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 36 of 37 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 105884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Excel Care Center 2811 Campus Hill Dr Tampa, FL 33612 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete all times for resident contact. The new policy states that if you're not in close contact you don't have to wear PPE. If it's close contact you need PPE. It depends if it's a closed system. With a catheter, they don't need PPE to feed the resident. The surveyor asked if staff should be handwashing prior to exiting the room when a resident has C-Diff (Clostridium Difficile). The DON said Yes, they definitely need to wash their hands prior to exiting that room. The surveyor asked if the nurse should perform hand hygiene before donning sterile gloves. The DON said, Yes, she needs to remove the gloves and do hand hygiene prior to donning sterile gloves. Event ID: Facility ID: 105884 If continuation sheet Page 37 of 37