Inspection·January 25, 2024

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to electronically transmit the Discharge- Return Non-Anticipated Minimum Data Set (MDS) to Centers of Medicare and Medicaid (CMS) within 14 days for one (Resident # 103) out of one resident whose Resident Assessments was investigated that was discharged to the community. There were 116 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Record review of the clinical records for Resident #103 revealed the resident was admitted to the facility on [DATE] and was discharged home on [DATE]. Review of the Discharge-Return Non-Anticipated MDS assessment dated [DATE] was completed and transmitted on 01/24/2024. Interview with MDS Coordinator on 01/24/2024 at 12:17 PM. She stated that the assessment was not completed in a timely manner. She stated they did not realize the assessment was not completed until Tuesday January 23 when the system alerted them. She stated the assessment will be completed and transmitted today. Follow up review after the above interview of Discharge Non-Anticipated MDS dated [DATE] was transmitted on 01/24/2024. Review of policy and Procedures non dated for Minimum Data Set Completion and Submission Timeframes revealed Policy Statement: Our facility will conduct and submit resident assessment in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation: 1-The assessment coordinator or designee is responsible for ensuring that resident assessment is submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2-Timeframes for completion and submission of assessment are based on the current requirements published in Resident Assessment Instrument Manual FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 2 of 7 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 01/25/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the provision of a safe environment related to safety floor mats to prevent accidents in the event of a fall for one Resident (#83) out of 27 sampled residents. There were 116 residents residing at the facility at the time of the survey. The findings included: On 01/22/24 at 09:31 AM, during the initial observation Resident # 83 was in bed asleep, no distress noted, one fall mat was observed on the left side of bed and one safety floor mat was against the wall behind the head of the bed, (Photographic evidence available). On 01/23/24 at 09:15 AM Resident observed in bed awake watching television, call light on bed, one floor mat on left side of the bed on the floor, right side floor mat against the wall, behind the head of the bed, (Photographic evidence available). On 01/24/24 at 10:17 AM Resident #83 was observed seated in a wheelchair in the therapy room with therapist, no distress noted. During observation on 1/24/23 at 09:00 AM Resident #83 was not in bed, the bilateral safety floor mats were beside bed. On 01/25/24 at 08:24 AM Resident # 83 was observed in bed eating breakfast, the bilateral safety floor mats were beside the bed. Review of the medical records for Resident #83 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] and 12/29/23. Clinical diagnoses included but not limited to: History of falling, Unspecified intracapsular fracture of left femur, subsequent encounter for closed fracture with routine healing, Unspecified fracture of right acetabulum, subsequent encounter for fracture with routine healing, and Fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing. Review of the Physician's Orders Sheet for January 2024 revealed Resident #83 had orders that included but not limited to: Tramadol HCL oral tablet 50 milligram (mg)-give 50 mg by mouth every 8 hours as needed for mild to severe pain level 4-10. Record review of Resident #83 's Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns documented Brief Interview for Mental Status Score 4, on a 0-15 scale indicating the resident is cognitively impaired. Section E for behavior documented Physical behavioral symptoms directed towards others occurred 1-3 days. Section GG for Functional Abilities documented resident requires partial/moderate assistance for Activities of daily living. Section H for Bowel and Bladder documented Resident is always incontinent of bowel and bladder. Section J for Health Conditions documented resident had a fall with major injury since admission, received scheduled pain medications in the last five days, and experienced no shortness of breath. Section N for Medications documented resident is taking antidepressants and opioids and Section O for Special Treatments and Procedures documented no special treatments received. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 3 of 7 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 01/25/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Review of Resident #83's Care Plans Reference Date 01/02/24 revealed: Resident is at risk for falls and/or fall related injury related to: impaired balance, cognitive deficits, requires staff assist with transfers, is non ambulatory, is impulsive; attempts transfer self independently, uses wheelchair as primary mode of locomotion, has a history of falls, has poor safety awareness, receives psychotropic medications, use of anticoagulants. Residents Affected - Few Resident will minimize the risk of falls with staff intervention through the next review date. Target Date: 04/01/2024. Interventions included- Floor mats to both sides of the bed when in bed, Quarter side-rails up in bed as an enabler, assist to wheel to destinations, Low bed, keep call light within reach, Report falls to physician and responsible party as needed, invite to activities of interest and escort to activity as needed. Review of the physical medicine and rehabilitation follow up note dated 1/12/2024, timestamped 15:32 stated: On 11/6/23 patient had fall and was sent to Emergency Department for further evaluation. Suffered laceration to the right forehead. On 12/26/23 patient was sent to Emergency Department due to fall on 12/23/23 and x-ray confirmed left femur fracture. The patient underwent surgical intervention of left hip arthroplasty. Patient was medically stabilized but not strong enough to return home. Patient admitted to the facility on [DATE] for skilled nursing and rehab. Patient asked to be seen by primary team to optimize therapy, pain control and discharge planning. Patient's plan and progress was discussed with nursing staff and therapy. Interview on 01/24/24 at 08:40 AM, the Director of Nursing (DON) stated: the resident was admitted on 10/2 23, he has had 2 falls in the facility on 11/06/23 and 12/23/23. On 11/06/23 the resident bumped his head and had to get stiches on his forehead, he was in the day room on the subacute side, the resident was in wheelchair watching television, the resident was observed 5 minutes prior by staff, two nurses that were counting their medication cart observed the resident on the floor, he had fallen forward, we placed an order through Therapy for wheelchair adequacy and positioning, completed labs on the resident. The resident was sent out to the hospital for stitches to the right forehead and came back later that night on the same day with four staples to his right forehead. On 12/23/23 the resident was sitting in the common room watching television, the Certified Nursing Assistant (CNAs) and the nurse witnessed the resident getting up out of the chair suddenly, took two steps and fell on his left side, the staff was unable to get to the resident on time to prevent the fall. A complete assessment was done, resident denied pain and was able to move all extremities. On 12/26/23 the resident was in therapy and was grimacing holding his left side, we did an in-house x-ray of the resident's left hip, results showed a hairline fracture of the femur on the left side, the resident was sent to the emergency room for evaluation and was admitted for surgical repair to the left hip. The resident was re-admitted on [DATE], we completed pertinent labs on the resident, kept resident in common areas when out of bed, and completed follow up x-rays. The was shown the photos taken by the surveyor; after seeing photos of multiple days observations of the resident's right floor mat against the wall at the head of the bed while the resident was in bed sleeping. The DON stated that she will get the matter corrected as soon as possible and get training and education started immediately with the nursing staff. Interview on 01/24/24 at 10:45 AM Certified Nursing Assistant (CNA) (Staff B) stated: I have been working here since August 2023, I became a CNA in July 2023, I am fairly new to this profession, I do my rounds several times during my shifts checking on each of my residents, I am usually assigned about 10 residents, this week I am assigned on the unit this resident is on. If the resident has any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 4 of 7 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 01/25/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few special equipment that needs to be placed in a certain way the DON would let us know about the care, regarding the resident's floor mats I have been educated today by the DON that when the resident is in bed, both resident's floor mats must be placed on the sides of the bed for safety. ` Interview on 01/24/24 at 11:07 AM Licensed Practical Nurse (LPN), (Staff C) stated: I do my rounds several times during my shifts, we placed the floor mats behind the bed at breakfast time so we can get the overbed table close to the resident for him to eat his breakfast, we all should be following up to make sure the floor mats get replaced beside the bed after the resident is done eating. The DON did a teachable moment with me about making sure the mats are in place when the resident is in bed. Moving forward, when I do my rounds if the resident is in bed, I will make sure that the floor mats are in place beside the bed. Review of the facility's policy titled Safety and Supervision of Residents revision date March 2023 states: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Individualized, Resident- Centered Approach to Safety 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff. b. Assigning responsibility for carrying out interventions. c. Ensuring that interventions are implemented; and d. Documenting interventions FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 5 of 7 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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews, and record review the facility failed to ensure pharmaceutical procedures were followed during medication administration. As evidenced by during medication administration the Registered Nurse signed off on Resident #2's medication as given before administering the medications for one out of four residents observed, and left the medication cart unlocked in the hallway during medication administration in Resident #2's room. There were 116 residents residing in the facility at the time of the survey. The findings included: On 1/23/24 at 9:35AM, during medication administration observation Registered Nurse (Staff A), prepared all the medications for administration to Resident #2, signed off all the medications as given on the Electronic Medication Administration Record, locked the computer and entered the room to give Resident # 2 the medications. Staff A entered the room, gave Resident #2 the medications and exited the room. On 1/23/24 at 9:43AM, the Surveyor apprised Registered Nurse, Staff A that she was observed signing off on Resident's #2's medications as given before she went into the room to administer the medications. Staff A stated she did check off and saved the medications as given to the resident on the system before she administered the medications to the resident. Staff A further stated that she does the check off based on how she knows the residents, the resident usually does not refuse the medications, that is why she checked off the medications before administering. The surveyor showed the Staff A a picture of her cart with the bingo cards (medication packets) turned face-side down on top of the medication cart and the cart unlocked. The picture was taken when the nurse was in the room administering medications to Resident # 2. Staff A stated: I was supposed to lock my cart when I went to give the resident the medications, and the bingo cards that were on top of the medication cart turned face-side down were empty. The surveyor checked the bingo cards that were face-side down on the top of the cart and confirmed they were empty. Review of the facility's policy titled Administering Medications revision date April 2019 states: Medications are administered in a safe and timely manner, as prescribed. Policy Interpretation and Implementation 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on the top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 6 of 7 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 01/25/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store food under sanitary condition by not ensuring the walk-in refrigerator and the milk box cooler contained thermometers on the inside. This has the potential to affect 108 out of 116 residents who eat orally residing in the facility at the time of the survey. The findings included: Observation of the initial kitchen tour on 1/22/24 at 8:42 AM with the Certified Dietary Manager Dietitian (CDM) revealed the following: 1) Walk-in refrigerator temperature outside was 40 degrees F and for the inside temperature, there was no thermometer noted. The walk-in refrigerator contained dairy products, cheese, pasteurized eggs in the shell, liquid pasteurized eggs, milk, vegetables, fruits, and preparation lunch items and 2) Milk Box temperature inside, there was no thermometer noted. The milk box contained milk cartons. Record review of the facility's Food Storage Policy indicated: Cold Policy and Procedure (revision date October 2019); Policy Statement-It is the center policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the [ ] federal organization Food Code; Action Steps: 2) The Dining Services Director/Cook ensures that all perishable foods will be maintained at temperature of 41 degrees Fahrenheit (F) or below and 4) The Dining Services Director/Cook insures that an accurate thermometer will be kept in each refrigerator and freezer. Interview with the CDM on 1/22/24 at 8:43 AM. She acknowledged that the thermometers were missing in the walk-in refrigerator and the milk box. She stated: There should be a thermometer in here. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 7 of 7