Inspection·October 14, 2021

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DON stated that nursing was responsible for following through on physicians' orders and should have applied the medication on the resident for itching. Based on observation, interview, and record review the facility failed to provide care and treatment in accordance with professional standards of practice, the plan of care, and physician orders for four (#91,#28, #79, #43) of 41 sampled residents related to removal of surgical staples as ordered for Resident #91, weekly weights as ordered for Resident #28, administration of ordered medication for a non-pressure related skin condition for Resident #79, and lack of modification to the medication schedule to accommodate for scheduled dialysis for Resident #43. Findings included: 1. Review of the admission Record for Resident #91 revealed an initial admission date in 2016, a most recent hospital stay of 9/28/21 to 10/5/21, a most recent re-admission date of 10/5/21, and a diagnosis to include unspecified fracture of Left femur and subsequent encounter for closed fracture with routine healing dated 9/23/21. A review of a physician progress note, dated 10/6/21 at 1:00 p.m., identified that Resident #91 was readmitted for continuation of care following a Left hip fracture that required surgical repair on 9/19/21 and staples in place. Further review of the resident's record indicated that the Primary Care Physician had written an order on 10/8/21 at 10:13 a.m., that instructed staff to discontinue left hip staples every day shift for 1 day. The October 2021 Treatment Administration Record (TAR) indicated that Resident #91's left hip staples were discontinued on Sunday, 10/10/21 during the day shift. A review of progress notes written by nurses identified the following: - 10/9/21 at 9:13 p.m., .Skin is warm/dry. No surgical wound noted. No open wounds noted . - 10/10/21 at 9:13 p.m., .Skin is warm/dry. No surgical wound noted. No open wounds noted . - 10/11/21 at 9:13 p.m., .Skin is warm/dry. No surgical wound noted. No open wounds noted . Review of Resident #91's care plan identified that on 10/11/21 a focus was initiated indicating that the resident was noted to have skin impairment as follows: surgical wound: left hip. The interventions related to this focus included, perform wound treatments as ordered. The October TAR identified that nursing staff had applied Eucerin cream topically to Resident #91's body twice daily for dry skin as scheduled at 9:00 a.m. on 10/7 - 10/13/21 and at 9:00 p.m. on 10/6 - 10/13/21 and had Monitor 4 staples to the left hip for signs of infection/redness every shift beginning on the evening shift of 10/6 and continued three times daily through the day shift on 10/14/21. During an interview with Resident #91 on 10/14/21 at 11:15 a.m., the resident identified that he had injured himself back in September when he tried to transfer himself from the bed and fell. The resident stated, I knew I had done something to my hip. The resident stated he currently had four surgical staples that the staff assessed. On 10/14/21 at 11:17 a.m., Staff Member H, Licensed Practical Nurse (LPN), was asked about Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 2 of 16 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 10/14/2021 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 #91's surgical staples. Staff H stated, staples, let me check. She reviewed the physician orders and stated she did not have anything. An observation was conducted with Staff H of Resident #91's left hip. The observation identified four intact surgical staples to the resident's left hip. The staff member confirmed the presence of 4 surgical staples to the resident's left hip. On 10/14/21 at 11:32 a.m., Staff H stated that she spoke with the Director of Nursing (DON) and that the scheduler was trying to schedule Resident #91 to return to the orthopedist (Ortho) but had been notified that the resident did not have to go back to their office, and the facility could remove the staples. The staff member reported that the DON was going to schedule Resident #91's staple removal for Sunday (10/17/21). On 10/14/21 at 12:53 p.m., the DON reported that Resident #91 had two (2) falls related to transferring independently and had to have a left hip replacement. She stated the facility did not have any order to remove the staples and that the facility concierge had informed her yesterday that she had attempted to get an appointment with the Ortho and that the staples could come out on Sunday. She stated she would expect staff to monitor the incision site, document the status of the staples, and describe how the wound looked. She reviewed the October TAR indicating staples had been discontinued. The DON stated she wanted to check to see if the resident's stapled were still in. At 1:05 p.m. on 10/14/21 the DON observed and confirmed that the resident did have 4 surgical staples in the left hip. She stated her expectation was if the staples had been documented as removed that they would have been removed. Continued review of Resident #91's October TAR identified that the facility had received a physician order at 3:04 p.m. on 10/14/21, OK to remove left hip staples, STAT. 2. A review of the admission Record revealed Resident #28 was admitted on [DATE] and had diagnoses to include acute on chronic diastolic (congestive) heart failure and unspecified chronic obstructive pulmonary disease. A review of Resident #28's active physician orders revealed an order to obtain Weekly Weights in the morning for Congestive Heart Failure (CHF) monitoring. This order was obtained on 6/29/21 and did not have an end date. The review of the order details indicated that the order type was Standard Other. A review of Resident #28's care plan, initiated on 9/25/19 indicated that the resident had the potential for complications related to an alteration in cardiac function due to diagnoses of hypertension (HTN), congestive heart failure (CHF), Atrial Fibrillation, Coronary Artery Disease (CAD), and hyperlipidemia, also has diagnosis of medical non-compliance with a history of polysubstance abuse. The interventions related to this issue included .Provide diet as ordered. Observed for compliance with diet. Weights as scheduled Vital signs as ordered and as needed . Continued review of the care plan identified that the resident required a therapeutic diet due to CHF, Diabetes Mellitus, and HTN diagnoses and that the resident refuses monthly weights. The interventions instructed staff to obtain weights as ordered and as needed and to notify the physician of significant weight changes if noted. Review of the electronic Weight Summary, reviewed on 10/12/21 at 2:36 p.m., indicated that the following weights were obtained: - 4/9/21: 281.0 pounds (lbs) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 3 of 16 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 10/14/2021 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 - 6/7/21: 278.5 lbs. Level of Harm - Minimal harm or potential for actual harm - 8/9/21: 286.0 lbs. - 8/11/21: 286.0 lbs. Residents Affected - Few - 9/6/21: 283.0 lbs. - 10/6/21: 284.0 lbs. The review of the weights that were obtained for Resident #28 did not indicate any weights were obtained from 6/29 (the day the order was written) until 8/9/21, five weeks after the order was written. The review identified that weekly weights had not been obtained per the Primary Care Physicians' order. A review of the October Treatment Administration Record (TAR), printed on 10/14/21 at 3:52 p.m., indicated the following: - weekly weight one time only for CHF for 1 day, order date 10/14/21. Documentation indicated that a weight was obtained on 10/14 at 10:29 a.m. - Weekly weights every day shift every Thursday (Thu) for CHF monitoring, order date 10/14/21 at 10:11 a.m. The TAR indicated that staff were to obtain a weekly weight on 10/21 and 10/28/21. - Weekly weights every day shift for CHF monitoring, order date 10/13/21 at 6:20 p.m. and discontinued on 10/14/21 at 10:11 a.m. The October 2021 Medication Administration Record (MAR) identified that Resident #28 received the diuretic medications Furosemide 40 milligrams twice daily and Spironolactone 25 milligrams twice daily for CHF. The review of the October 2021 MAR and TAR did not include the order, dated 6/29/21, for the resident's Weekly weights. The Kardex for the resident's care did not include the order for weekly weights. A progress note, dated 6/26/21, indicated that the Advanced Registered Nurse Practitioner (ARNP) was notified of edema in legs. The note identified that the resident refused to elevate legs. Resident #28 was observed and interviewed, on 10/11/21 at 12:22 p.m., while he was sitting in a wheelchair in his room. Multiple observations from 10/11 to 10/14/21 identified that the resident was observed sitting in the wheelchair. During an interview with the Director of Nursing, on 10/13/21 at 3:45 p.m., she stated that a lot of residents had triggered for weight loss. The DON reported that she and the Dietary Manager were reviewing the monthly weights, and she was also reviewing the weekly weights. She reviewed Resident #28's order for weekly weights and did not know if the resident was on the weekly weight list. The facility policy, Charting and Documentation, revised July 2017, identified that All services provided to the resident, progress toward the care plan goals, or any changes in the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 4 of 16 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 (X3) DATE SURVEY COMPLETED A. Building 10/14/2021 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 medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy indicated that Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. and that Documentation of procedures and treatments will include care-specific details, including: Whether the resident refused the procedure/treatment. 4. A review of the admission Record for Resident #43 revealed that the resident was admitted into the facility on [DATE] with diagnoses that included renal dialysis and end stage renal disease. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #43 had a Brief Interview for Mental Status (BIMS) score of 99 indicating that the resident was unable to complete the interview. A review of the Order Summary Report revealed the following active active physician orders as of 10/13/21: Dialysis Monday, Wednesday, and Friday at 5:00 a.m. Nepro 1 can- one time a day for nutritional support Prostat Sugar Free- one time a day for nutritional support 30 ml Aspirin Tablet 325 MG- Give 1 tablet by mouth (po) one time a day for generalized pain Atorvastatin Calcium Tablet 80 MG- Give 1 tablet po at bedtime for hyperlipidemia Calcium Carbonate Tablet- Give 750 mg po three times a day for gastroesophageal reflux disease (GERD) Carvedilol Tablet 6.25 MG- Give 1 tablet po two times a day for hypertension Cholecalciferol Tablet 5000 unit- Give 1 tablet po one time a day for supplement FerrouSul Tablet- Give 325 mg po two times a day for anemia Hydralazine HCL Tablet 50 MG- Give 1 tablet po three times a day for hypertension Losartan Potassium Tablet 50 MG- Give 1 tablet po two times a day for hypertension Pantoprazole Sodium Tablet Delayed Release 40 MG- Give 1 tablet po one time a day for GERD Sevelamer Carbonate Packet 0.8 GM- Give 2 packets po with meals for hypocalcemia mix with 8oz thickened fluid of choice There was no order related to holding the medications or giving the medications at an alternative time on scheduled dialysis days. Review of the Medication Administration Record (MAR) for August, September, and October 2021 reflected the following physician ordered medications and supplements were not administered on scheduled dialysis days: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 5 of 16 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 10/14/2021 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 Aspirin Adult Tablet (0900) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. Atorvastatin Calcium Tablet (0900) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, and 10/11. Residents Affected - Few Pantoprazole Sodium Tablet Delayed Release (0900) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. Carvedilol Tablet (0900 and 1700) - 08/20, 08/25, 08/27, and 08/30, 09/01, 09/03, 09/06, 09/08, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. Ferrous Sulfate Tablet (0900 and 1700) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. Losartan Potassium Tablet (0900 and 1700) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. Calcium Carbonate Tablet (0900, 1400, 2100) - 08/20, 08/23, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/24, 09/27, 10/08, 10/11, and 10/13. Hydralazine HCL Tablet (0900, 1400, and 2100) - 08/18, 08/20, 08/23, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/24, 09/27, 10/08, 10/11, and 10/13. Renvela Packet (Sevelamer Carbonate) (0800, 1200, and 1700) - 08/30, 09/01, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/06, 10/08, 10/11, and 10/13. Sevelamer HCL Tablet for phosphate control 800 MG - (0800, 1200, and 1700) - 08/18, 08/20, 08/25, and 08/27. Trazodone HCL Tablet 50 MG for depression (2100) - 09/08, 09/10, 09/13, 09/15, 09/24, and 09/27. Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG related to vascular dementia with behavioral disturbances - 09/17, 09/20, 09/22, 09/24, and 09/27. Cholecalciferol Tablet 5000 unit for supplement (0900) - 10/08, 10/11, and 10/13. Nepro 1 can was not administered on 10/11 and 10/13. The boxes for each medication was blank, had an X, the number three, the number five, the number nine, or the number ten. Per the Chart Codes, there was no code for X, the number three indicated away from facility without meds, the number five indicated to hold/see nurse notes, the number nine indicated other, and the number ten indicated out for dialysis. A review of the nurses' notes indicated the notes only indicated that the resident was out for dialysis. A review of the care plan for dialysis included the following intervention: adjust medication schedule as required to accommodate for dialysis treatments. On 10/14/21 at 8:40 a.m., Staff A/Licensed Practical Nurse (LPN) stated she had suggested to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 6 of 16 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 10/14/2021 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 management that the medications be given on the night shift. She stated that she believed that the dialysis center was able to give blood pressure medications. Staff A stated that when Resident #43 goes out for dialysis, they must make a note for the medication that she was in dialysis. By the time she comes in for her shift, Resident #43 was already gone to dialysis because she leaves at 5:00 a.m. Staff A stated that she can't hold the medicine until she comes back. Residents Affected - Few On 10/14/21 at 9:00 a.m., Staff B/LPN Unit Manager stated that to her knowledge, the dialysis center does not give medications. She stated that the medication should be given prior to her leaving or the nurses should ask if the medications can be given later. Staff B confirmed that there was no order from the doctor to hold medications. On 10/14/21 at 1:08 p.m., the Director of Nursing (DON) stated the nurses should be communicating with the dialysis center if the physician did not give orders to hold medications. She stated a lot of times the doctor would say confer with the dialysis center. The DON confirmed that there was no documentation related to holding or rescheduling of the medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 7 of 16 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 10/14/2021 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 record review, the facility failed to provide wound care in accordance with professional standards for two (#54, #21) of three residents sampled for pressure ulcers out of 11 total residents with pressure ulcers related to failure to change Resident #54's dressings daily as ordered for two of four days, failure to provide positioning and offloading for wound healing for Resident #54, and failure to ensure weekly wound measurements were taken for Resident's #54, and #21. Residents Affected - Some Findings Included: 1. Review of Resident #54's admission Record revealed an admission date of 9/3/21 and admitting diagnoses to include type 2 diabetes mellitus, paraplegia, pressure ulcer left hip unstageable, pressure ulcer of right buttock stage 4, pressure ulcer of right heel unstageable, pressure induced deep tissue damage of right heel, pressure ulcer of left heel, unstageable, pressure induced deep tissue damage of left heel, and pressure ulcer of other site stage 4. Review of the physician progress note dated 9/16/21 at 9:24 p.m. detailed the chief complaint as comprehensive skin and wound assessment for new admission to the facility for multiple wounds: right heel, right lateral foot, right medial malleolus (cluster), left heel, left foot sole, left medial foot, right great toe, right buttock and left trochanter. Unstageable wounds included: right heel, right lateral foot, left sole and left trochanter. Deep tissue injuries included left heel and right treat toe. Stage 3 wounds included right medial malleolus. Stage 4 wounds included: left medial foot, right buttock. Plan of care: pressure reduction and turning precautions, including heel protection and pressure reduction to bony prominences. Staff educated on all aspects of care. Factors affecting healing: frequent incontinence which can decrease wound healing. Recommend providing incontinence care as needed, increased moisture at wound site can promote poor prognosis of wound healing. Please keep wound site covered and avoid contamination with feces at all times. Review of physician orders for Resident #54 revealed: Wound care consult dated 9/3/21 Cleanse left medial foot with normal saline, pat dry, and apply Santyl, calcium alginate and foam every day shift for wound care, dated 10/6/21. Cleanse left medial foot with normal saline, pat dry, and apply Santyl, calcium alginate and foam as needed for wound care dated 10/6/21. Left sole of foot: apply betadine and leave open to air every shift for wound care dated 9/22/21. Left heel: apply betadine and leave open to air every shift dated 9/22/21. Right great toe: apply betadine and leave open to air every shift for wound care dated 9/22/21. Right heel: Apply betadine and leave open to air every shift for wound care dated 9/22/21. Right lateral foot: Apply betadine and leave open to air every shift for wound care dated 9/22/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 8 of 16 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 10/14/2021 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Right medial malleolus Cleanse with normal saline, pat dry, Santyl, and foam dressing every day shift for wound care, dated 10/6/21. Apply house barrier cream to buttocks, peri area for protection dated 9/3/21. Cleanse left trochanter with normal saline, pat dry, apply Santyl and cover with foam dressing as needed for wound care dated 10/6/21. Cleanse Right buttock with normal saline, pat dry, apply Santyl, calcium alginate and cover with foam dressing every day shift for wound care dated 10/6/21. Cephalexin tablet 500 mg one time a day every 12 hours for infection dated 9/24/21, ended 10/1/21. Sulfamethoxazole-trimethoprim 800-160 mg one tab every 12 hours for 10 days for wound infection started on 9/30/21. Ceftriaxone sodium solution 1 gram Intravenous every 24 hours for 10 days for multiorganism wound infection dated 9/30/21. On 10/13/21 at 11:00 a.m., Resident #54 stated he had not had his brief changed since around 6 a.m. that morning and he had not had wound care for his feet completed in at least two days. During the interview, a pungent odor was noticed. The resident was lying on his left side. Additional observations of Resident #54 on 10/12/21 at 11:08 a.m., 10/12/21 at 4:00 p.m., 10/13/21 at 11:00 a.m., and 10/14/21 at 3:24 p.m. revealed the resident was lying on his left side. The resident confirmed on 10/14/21 at 3:24 p.m. that he stays primarily on the left side, and no one turns him every 2 hours or offers to turn him. The resident confirmed his feet were always touching and no one had offered to place anything between his feet, so they did not touch; however, they did place a pillow between his knees. An interview and observation of Resident #54's dressings with Staff B, Unit Manager, on 10/13/21 at 11:15 a.m., confirmed the resident was lying on his left side on an air mattress with his legs contracted. The visible wound dressings were not dated. The dressing on the left foot was observed with copious amounts of thick brown drainage, saturated through to the sheet folded beneath the resident's feet. The right medial side of the foot was without a dressing and observed resting on top of the left medial side of the foot placing pressure on the left foot. Resident #54 said, in the presence of Staff B, the dressings were not changed for at least 2 days. Staff B confirmed the pillow was only separating his knees. Staff B confirmed the wound care nurse practitioner was due to come in on this day but did not. On 10/13/21 at 3:24 p.m., wound care observation was conducted with Staff B and the Assistant Director of Nursing (ADON). They gathered supplies and placed disposable trays on a cleaned bedside table. The ADON held the right leg up to allow Staff B to remove the dressing on the left foot. Staff B completed the dressing removal for the left foot. The sole and lateral side of the left foot were observed with red granulation tissue, heavy drainage, and heavy slough with a strong odor. An unknown aide came in to assist Staff B and the ADON. Staff B cleansed the left foot using normal saline soaked gauze by tapping the wound and drying in the same fashion while the aide held the right foot. The aide let the right foot down which touched the area of the left foot that was cleaned. Staff B cleaned the left foot by tapping one time again and drying in the same fashion while the aide held the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 9 of 16 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 10/14/2021 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some right foot up. Staff B applied Santyl in a thin layer to most of the wound and calcium alginate sheets, that were observed to not cover the wound completely, and then wrapped the left foot with one roll of gauze, leaving the heel and toe exposed to air. The aide lowered the right leg down on the left foot. Staff B measured the left sole wound as 8 cm x 5 cm, left medial foot wound as 8 cm x 4.5 cm. No dressing was observed on the right foot except one small white square on the top of the right foot. Staff B stated she was unsure why this white square was there since the right foot did not get a dressing. Staff B did not clean, assess, or apply a dressing to the medial malleolus of the right foot. The aide then prepared the resident for the coccyx dressing and left trochanter by removing the stool and urine saturated brief. The coccyx and left trochanter were observed uncovered without dressings. Staff B, set up for the dressing change of the coccyx and left trochanter and hand sanitized prior to donning gloves. Staff B soaked gauze and tapped the center of the coccyx wound that was observed with tunneling around 12 o'clock. Staff B measured the wound as 5 cm x 5 cm. Staff B removed gloves, hand sanitized and donned new gloves. Staff B confirmed the Coccyx wound had tunneling and stated, I should measure that. The ADON advised on how to measure the tunneling. Staff B, measured a wound depth of 4.5 cm, tunneling 3.5 cm at 12 o'clock. Staff B applied Santyl to the center of the wound only. Applied calcium alginate at the point of tunneling and the center of the wound then covered the area with a dated foam dressing. The resident was turned toward his right side complaining of pain and tenderness on his left trochanter. Staff B confirmed the coccyx and left trochanter did not have dressings present at the start of the wound care and should always have dressings on. Staff B, donned gloves and cleaned the left trochanter with saline soaked gauze by tapping the center of the wound one time. Staff B dried the wound by tapping after changing gloves. Measurements of the left trochanter were taken, Santyl was applied to the center of the wound, and a large piece of calcium alginate was laid over the left trochanter wound and covered with a dated dressing. A new brief was secured in place. The resident was turned back to the left side on the left trochanter and his legs were separated at the knees, but the feet remained touching. Staff B confirmed the resident needed a pillow between his feet for offloading and removed the pillow at his knees and placed it between his feet. A blanket was then used between his knees. The resident's bilateral heels, right great toe, and right lateral foot had betadine applied and were left open to air. During an interview with Staff B and the ADON, on 10/13/21 at 4:24 p.m. Staff B confirmed she normally just dabs the wound and does not clean from the inside to the outside. Staff B confirmed she did the best she could cleaning the left foot after the right one touched it multiple times. She confirmed the right medial foot wound was unchanged and she had not applied a dressing as ordered. Staff B confirmed the resident should be offloading his feet and turning every few hours. Staff B stated she would check to see why the resident was always on his left side when he needs staff to turn him. Review of the treatment administration record (TAR) for October 2021 revealed the dressings changes were signed by Staff F, Licensed Practical Nurse (LPN) as completed for the last 2 days (10/11 and 10/12). During an interview on 10/14/21 at 1:26 p.m. with Staff F, LPN she confirmed she did not change the dressings on 10/11/21 or 10/12/21. Staff F confirmed she checked the wound care as being completed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 10 of 16 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 10/14/2021 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and stated she usually checked them off as done since she does the dressings last and will let the oncoming nurse know that she did not finish. Staff F, LPN then said she forgot to change the dressings as the resident required several people for the dressing change and she was busy. Review of wound culture 1 dated 9/26/21 and reported on 9/30/21 resulted in gram positive cocci, staphylococcus aureus (isolate1) penicillin resistant staphylococcus aureus (MRSA) isolated, moderate growth, gram negative rods, Proteus mirabilis, providencia stuartii. Review of progress notes dated 10/13/21 at 4:56 p.m. revealed: wound care performed on resident, cleaned and dressed as ordered. Resident pre-medicated prior to procedures. Resident calm and cooperative during care, verbalized comfort levels throughout procedure. Resident complaint of pain and tender to touch on left trochanter, redness, serosanguineous drainage, Doctor notified. Wound care areas include heavy slough, drainage of left foot and sacrum. Previous dressings saturated. Measurements of wounds as follows: Left middle foot (sole) 8 cm x 5 cm. Left lateral foot (medial) 8 cm x 4.5 cm, left heel 1 cm x 1 cm dry, necrotic tissue, Sacrum 5 cm x 5 cm, depth 4.5 cm, tunneling 3.5 cm @ 12 o'clock, right heel 2.3 cm x 2 cm dry, necrotic tissue, right great toe 2 cm x 2.5 cm. On 10/13/21 at 4:37 p.m., a phone interview with the wound care nurse revealed the nurse practitioner assesses the resident's wounds and this should be completed as ordered by the physician. Typically, the order says what to clean the wound with and the expectation would be to clean it from the inside to the outside, throwing the gauze away with each rotation. Review of the physician progress notes dated 9/29/21 at 7:01 p.m. revealed the plan of care as heel protectors or floating heels. Plan of care: turning precautions, heel protection, incontinence care as needed. Increased moisture at wound site can promote poor prognosis of wound healing. Keep wound site covered and avoid contamination with feces at all times. Review of wound evaluation documentation revealed the following for the Medial Left Foot: 10/6/21 stage IV, measurements: Area - 9.8 cm2 (centimeters squared), Length - 3.9 cm (centimeters), Width - 3.4 cm, depth 0.2 cm. No odor. Progress documented as improving. 9/29/21 stage IV, no wound measurements. Continuous pain. Pain management provided prior to wound care. Moderate odor. Wound improving. 9/15/21 stage IV, measurements: Area - 12.8 cm2, Length - 4.5 cm, Width - 4.2 cm. Moderate pain. No odor. Mattress with pump. Wound stable. Review of wound evaluation documentation revealed the following for the sole to the left foot: 10/6/21 unstageable, measurements: Area - 11.66 cm2, Length - 6.61 cm, Width - 2.29 cm, Depth 0.1 cm. 9/29/21 unstageable, measurements: Area - 12.6 cm2, Length - 6.3 cm, Width - 2.9 cm. Pain at site. Patient received pain management prior to wound care. Healing stalled. 9/23/21 unstageable, measurements: 2.5 cm x 7 cm x 0.3 cm. The wound was debrided by the Certified Registered Nurse Practitioner (CRNP) for wound care post measurements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 11 of 16 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 (X3) DATE SURVEY COMPLETED A. Building 10/14/2021 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 9/15/21 unstageable, measurements: Area - 9.4 cm2, Length - 5.0 cm, Width - 2.7 cm. Applying betadine only. Level of Harm - Minimal harm or potential for actual harm Review of wound evaluation documentation revealed the following for the left heel: Residents Affected - Some 10/6/21 DTI, measurements: Area - 0.66 cm2, Length - 1.09 cm, Width - 0.8 cm. 9/29/21 DTI, no measurements documented. Resident continues to be in pain. Pain management provided prior to wound care. 9/15/21 DTI, measurements: Area - 0.6 cm2, Length - 1.1 cm, Width - 0.7 cm. Resident refuses pain management, betadine to left heel. Review of wound evaluation documentation revealed the following for the Right Medial Malleolus: 10/6/21 cluster stage 3, improving. No wound measurements were recorded. 9/29/21 stage 3, measurements: 2.2 cm x 2.1 cm x 1.3 cm x 0.2 cm in depth. 9/23/21 stage 3, measurements: 4 cm x 3.2 cm x 0.2 cm. 9/15/21 stage 3, no wound measurements recorded. Review of wound evaluation documentation revealed the following for the right heel: 10/6/21 unstageable, measurements: Area - 2.69 cm2, Length - 2.37 cm, width - 1.51 cm. 9/29/21 unstageable, measurements: 3.5 cm x 2.7 cm x 1.7 cm. 9/23/21 unstageable, measurements: 3 cm x 2 cm x 0. 9/15/21 unstageable, measurements: 6.6 cm x 3.3 cm x 2.8 cm. Review of wound evaluation documentation revealed the following for the lateral right foot: 10/6/21 unstageable, measurements: Area - 2.78 cm2, Length - 2.11 cm, width - 1.94 cm. 9/29/21 unstageable, measurements: 3.2 cm x 2.2 cm x 2. 0 cm. 9/23/21 unstageable, measurements: 3.5 cm x 2.5 cm x 0. 9/15/21 unstageable, measurements: 4.3 x 3.0 x 2.0 cm. Review of wound evaluation documentation revealed the following for the right buttock: 10/6/21 stage 4, no wound measurements recorded, and moderate drainage. 9/29/21 stage 4, measurements: Area - 7.5 cm2, Length - 4.9 cm, Width - 2.9 cm, Depth 1.2 cm, undermining- 3.0 cm. Moderate odor. Wound infection noted - currently on IV antibiotics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 12 of 16 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 10/14/2021 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 9/23/21 stage 4, measurements: 5.5 cm x 4.5 cm x 4 cm, 6 to 3 o'clock. Level of Harm - Minimal harm or potential for actual harm 9/15/21 stage 4, measurements: Area- 3.6 cm2, length- 2.8 cm, width- 2.1 cm. Review of wound evaluation documentation revealed the following for the left trochanter: Residents Affected - Some 10/6/21 unstageable, no measurements documented. 9/29/21 unstageable, measurements: Area - 3.7 cm2, length- 2.6 cm, width- 1.9 cm. 9/23/21 unstageable, measurements: 2 cm x 2 cm x 0. 9/15/21 unstageable, measurements: Area - 2.6 cm2, Length- 2.2 cm, Width- 1.6 cm. During an interview with the Director of Nursing (DON) on 10/14/21 at 12:32 p.m. she confirmed the resident should have seen a physician related to wounds after admission and the wounds should be measured weekly. The DON confirmed the nurses document after the treatment is completed and should make sure that their documentation is accurate. The DON confirmed Staff F, did not change the dressings on 10/12/21 and only asked about 10/12/21. Review of the treatment administration record (TAR) for 10/11/21 and 10/12/21 showed the treatments were documented as completed by Staff F for wounds on Left medial foot, left trochanter, right buttock, right medial alveolus, betadine to left heel, betadine to left sole of foot, betadine to right great toe, betadine to right heel, betadine to right lateral foot. During an interview with Staff B on 10/14/21 at 12:55 p.m. she confirmed Resident #54 did not see a wound care physician or nurse practitioner from 9/3/21 to 9/15/21 and the wounds were not measured until the wound care nurse practitioner came in to see him. Staff B confirmed the aides should be offloading the resident and turning the resident every 2 hours and did not realize they placed the resident back on his left side where he was positioned prior to wound care. Staff B confirmed the resident was on an air mattress but was not sure who sets them up or what the correct setting should be. During a phone interview on 10/14/21 at 9:44 a.m. with the wound care Nurse Practitioner she stated she completes wound rounds weekly on Wednesday around 7:30 a.m. and Mondays were typically the days she sees new patients. She stated she conducts rounds with Staff B and the DON, completes the wound measurements with Staff B, gives verbal recommendations, and verifies later the orders were correct from the physician. The Nurse Practitioner stated she was a consultant and makes recommendations. The Nurse Practitioner stated she will make referrals to infectious disease and dermatology. She stated the wound measurements were captured with the camera which does not keep the picture but measures the wound. She confirmed the staff complete the dressing changes and should complete them as ordered. The Nurse Practitioner confirmed that staff should not be seeing thick brown odorous dressings on Resident #54 and if they did, she should be contacted and had not been as of this time. She stated she would expect the staff to call her. The Nurse Practitioner confirmed the resident's feet should be offloaded and not touching together. She confirmed the resident should be moved every couple hours to assist with healing and offloading of the left trochanter and should not be left on the side of the wound. They should be offloading every day. The Nurse Practitioner stated she would expect the nurse to clean the wound using a little pressure to get it clean and would expect it to be cleaned from the inside out in a clockwise motion, not tapped or dabbed. The Nurse Practitioner confirmed the wounds should be covered at all times as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 13 of 16 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 10/14/2021 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 Level of Harm - Minimal harm or potential for actual harm 2) During an interview with Resident #21 on 10/11/21 at 11:44 a.m. the resident stated he had no issues with his wound care. Review of Resident #21's skin and wound evaluation dated 10/6/21 revealed the stage 4 coccyx wound measured 2.0 cm x 2.9 cm x 0.5 cm. with moderate drainage and no odor. Wound improving. Residents Affected - Some Review of Resident #21's skin and wound evaluation dated 9/29/21 revealed no measurements were taken for the stage 4 coccyx wound with moderate drainage and faint odor. Wound improving. Review of Resident #21's skin and wound evaluation dated 9/22/21 revealed the stage 4 coccyx wound measured 2.5 cm x 2.0 cm x 2.0 cm, moderate drainage. Wound stable. Review of physician orders revealed a 9/22/21 order to cleanse coccyx with normal saline, pat dry, apply collagen to wound base, calcium alginate with silver and foam dressing. During an interview with the Nurse Practitioner on 10/14/21 at 9:58 a.m. she stated she debrided the wound last week due to increased slough in the wound. Review of facility policy wound care, revised October 2010, 2 pages revealed: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Review of facility policy charting and documentation, revised July 2017, revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. 2. c. treatments or services performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 14 of 16 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 10/14/2021 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure physician orders were received for monitoring and care of an intravenous (IV) site for one (#54) of one resident sampled for intravenous (IV) care out of two facility residents receiving IV therapy. Residents Affected - Few Findings included: Review of Resident #54's admission Record revealed an admission date of 9/3/21 and admitting diagnoses to include multiple pressure ulcers and two pressure induced deep tissue damaged areas. Review of wound culture 1 dated 9/26/21 and reported on 9/30/21 revealed gram positive cocci, staphylococcus aureus (isolate1) penicillin resistant staphylococcus aureus (MRSA) isolated, moderate growth, gram negative rods, Proteus mirabilis, providencia stuartii. Review of physician orders revealed the following orders dated 9/30/21: Ok to insert midline for IV antibiotic therapy x 10 days may use lidocaine 1% for insertion and Ceftriaxone sodium solution 1 gram Intravenous every 24 hours for 10 days for multiorganism wound infection. No additional orders were present related to the IV. On 10/12/21 at 4:00 p.m., Resident #54 was observed with an IV on the left upper arm dated 10/12/21. On 10/13/21 at 11:00 am., Resident #54 was observed with an IV to the left upper arm intact. On 10/13/21 at 3:24 p.m., Resident #54's wound care for pressure areas was observed with Staff B, Unit Manager and the Assistant Director of Nursing (ADON). After completion of the wound care on 10/13/21 at 4:24 p.m., Staff B confirmed the resident had a wound infection, finished antibiotics recently, and had orders for his IV in the left upper arm. On 10/13/21 at 4:26 p.m., the ADON checked Resident #54's orders and confirmed the resident did not have orders associated with the care and monitoring of the IV. The ADON stated that these orders should have been put in when the physician originally ordered the IV for the wound infection. Following the interview with the ADON, the following orders were added for Resident #54 on 10/13/21: Change midline IV dressing 24 hours post insertion, then weekly and as needed every 24 hours as needed for IV site care. Use securement device with each dressing change. Flush IV port with 10 ml normal saline (NS) one time a day every 7 days for IV maintenance. Number of lumens: single Observe site for signs and symptoms of infiltration, infection and extravasation every shift and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 15 of 16 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 10/14/2021 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 0694 Level of Harm - Minimal harm or potential for actual harm Review of facility policy for administration set/tubing changes, Revised April 2016 revealed: The purpose of this procedure is to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV equipment. Assessment: inspect intravenous catheter for any signs/symptoms of IV related complications at scheduled intervals. Documentation: 6. The condition of the IV site. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 16 of 16