Inspection·December 3, 2025

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the longest.Review of Resident #8‘s admission record revealed an admission date of 11/08/25. Resident #8 was admitted to the facility with a diagnosis to include: acute kidney failure, urinary tract infection, repeated falls, colostomy, weakness and severe sepsis with septic shock.A review of Resident #8‘s MDS dated [DATE], revealed a BIMS score of 9, meaning moderately impaired. Functional Abilities revealed substantial/maximal assistance toileting hygiene and lower body dressing; toilet transfer and R#8 is always incontinent of urine. A review of Resident #8‘s bladder continence task log, dated 11/08/25-12/03/25, revealed the resident was approached for incontinent product changes one time in an eight-hour shift on the following dates: 11/12/25, 11/17/25, 11/24/25 and 11/25/25. Resident #8 was approached for incontinent product changes once in twelve hours on the following dates: 11/21/25 and 11/27/25 to 11/29/25. Resident #8 was approached for incontinent product changes once in 24 hours on the following date: 12/01/25.A review of Resident #8‘s care plan, dated 11/08/25, revealed the following, the resident has an alteration in elimination AEB: has a colostomy in place and is incontinent of urine, requiring enhanced barrier precautions and assistance of one with toileting hygiene. Resident #8‘s care plan focus revealed the resident will be clean, dry, and odor free daily. Interventions included: check on resident upon arising, before/after meals and at HS for incontinence, and to observe and notify the physician for changes in bowel/bladder function. Resident #8 requires assistance x1 with toileting hygiene. Resident #8‘s care plan revealed no history of resident refusing care.A review of Resident #8‘s progress notes revealed no documentation of the resident having a history of refusing incontinent/hygienic care.On 12/02/25 at 9:59 a.m., an observation and interview of Resident #9 revealed they were lying in bed waiting for incontinent care to be completed. Resident #9 stated they have been waiting almost an hour to be changed, and they are often left in bed waiting to be changed for extended periods of time.Review of Resident #9‘s admission record revealed an admission date of 11/21/25. Resident #9 was admitted to the facility with a diagnosis to include chronic kidney disease, a history of falling, displaced fracture in right foot, and type 2 diabetes.A review of Resident #9‘s MDS dated [DATE], BIMS revealed a score of 14, meaning cognitively intact. R#9's functional Abilities revealed R#9 requiring substantial/maximal Assistance for toileting hygiene and lower body dressing. Bladder and Bowel revealed R#9 is frequently Incontinent for urinary and bowel continence.A review of Resident #9 ‘s bladder continence task log, dated 11/22/25 to 12/02/25, revealed the resident was approached for incontinent product changes one time in an eight-hour shift on the following dates: 11/23/25 to 11/25/25, 11/30/25, and 12/02/25. Resident #9 was approached for incontinent product changes one time in twelve hours on the following dates: 11/28/25 and 11/29/25. Resident #9 was approached for incontinent product changes once in 24 hours on the following date: 12/01/25.A review of Resident #9‘s bowel continence/movements task log dated from 10/1/25 to 10/23/25 revealed the resident was approached for incontinent product changes one time in an eight-hour shift on the following dates: 11/23/25 to 11/25/25, 11/30/25, and 12/02/25. Resident #9 was approached for incontinent product changes one time in twelve hours on the following dates: 11/28/25 and 11/29/25. Resident #9 was approached for incontinent product changes once in 24 hours on the following date: 12/01/25.A review of Resident #9‘s care plan, dated 11/21/25, revealed the resident has an alteration in elimination AEB: is incontinent of bowel and bladder due to impaired mobility, use of diuretic, requires assist with toileting/incontinent, and is at risk for constipation due to decreased mobility. Resident #9‘s care plan focus revealed the resident will be clean, dry, and odor free daily. Interventions included, check on resident upon arising, before/after meals and at HS for incontinence. Resident #9 requires assistance x1 with toileting hygiene. Resident #9‘s care plan revealed no history of the resident refusing care.A review of Resident #9‘s progress notes revealed no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 2 of 4 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 12/03/2025 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documentation of resident #9 having a history of refusing care.Review of Resident #7‘s admission record revealed an admission date of 10/01/25. Resident #7 was admitted to the facility with a diagnosis to include a displaced trimalleolar fracture of right lower leg, wedge compression fracture of third lumbar vertebra, Type 2 diabetes, and heart failure.A review of Resident #7‘s MDS dated [DATE], revealed: BIMS score of 14, meaning cognitively intact; functional abilities as partial/moderate assistance for toileting transfer; bladder and bowel, revealed Resident #7 occasionally incontinent for urinary continence.A review of Resident #7‘s bladder continence task log, dated 10/1/25 to 10/23/25 revealed the resident was approached for incontinent product changes one time in an eight-hour shift on the following dates: 10/2/25 to 10/4/25, 10/6/25 to 10/9/25, 10/11/25 to 10/13/25, and 10/15/25 to 10/22/25.A review of Resident #7‘s bowel continence/movements task log, dated 10/1/25 to 10/23/25, revealed the resident was approached for incontinent product changes one time in an eight-hour shift on the following dates: 10/2/25 to 10/4/25, 10/6/25 to 10/9/25, 10/11/25 to 10/13/25, and 10/15/25 and 10/22/25.A review of Resident #7‘s care plan, dated 10/1/25, revealed the resident requires assistance x1 with toileting hygiene. Resident #7‘s care plan also revealed no history of the resident refusing care.A review of Resident #7‘s progress notes revealed no documentation of the resident having a history of refusing care.An interview was conducted with Staff G, Registered Nurse (RN) on 12/02/25 at 10:20 a.m. Staff G, RN stated if a certified nursing assistant (CNA) comes to her with a resident who is refusing incontinent care, the nurse is to talk to the resident, and each attempt should be documented whether the resident refuses incontinence care or not.An interview was conducted with Staff H, CNA on 2/02/25 at 10:27 a.m. Staff H, CNA stated residents should be checked for incontinence care every two hours, and each attempt should be documented in the resident's chart.An interview was conducted with Staff A, CNA, on 12/02/25 at 1:56 p.m. Staff A, CNA stated residents should be checked for incontinence care every two hours, and each attempt should be documented in the residents' chart.An interview was conducted with Staff F, RN, on 12/02/25 at 2:13 p.m. Staff F, RN stated staff know to document and attempt every two hours, all attempts for incontinence care.An interview was conducted with Staff B, CNA, on 12/02/25 at 2:20 p.m. Staff B, CNA stated she does not document attempts to change an incontinent product if the resident does not need to be changed when checked for incontinence care.An interview was conducted with Staff C, CNA, on 12/02/25 at 2:26 p.m. Staff C, CNA stated not documenting attempts to change an incontinent product if the resident does not need to be changed when checked for incontinent care.An interview was conducted with Staff E, CNA, on 12/02/25 at 2:31 p.m. Staff E, CNA stated incontinence care should be attempted every two hours, and document each attempt whether the incontinence care was completed or not.An interview was conducted with Staff D, RN/Unit Manager (UM), on 12/03/25 at 10:03 a.m. Staff D, RN/UM stated CNAs are to complete first rounds when they clock-in and then see what their residents' needs are, pertaining to their assignment. Residents are to be checked and changed every two hours, as needed, and as the residents' call light comes on. If a resident refuses incontinence care, CNAs are expected to try again after the initial refusal, then should go get the nurse if the resident refused a second time. The nurse and UM would go and check back with the resident to, convince, them to complete incontinence care. Each attempt on incontinence care that is being made by staff should be documented. Between the UM, Assistant Director of Nursing (ADON), and the Director of Nursing (DON), they all check the dashboard system, speak with staff, and check tasks to ensure that care is properly being provided. The UM is responsible for checking the dashboard system at least once an hour, and when the UM is out of office the ADON and DON monitored care checks.An interview was conducted with the ADON on 12/03/25 at 12:17 p.m. The ADON stated every two hours is the standard for providing incontinent care but is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105884 If continuation sheet Page 3 of 4 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 12/03/2025 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete more frequent, whenever a resident needs to be changed. The ADON said CNAs needed to be walking the floor as frequently as possible to ensure needs are being met. The staff are to document each attempt, this way all responsible parties know that care is provided properly. The ADON said all resident interactions are to be documented timely. The ADON stated it is not acceptable to only have two or three incontinent care changes documented in a 24-hour day. The ADON said the expectation is for documentation to be completed and incontinent care provided. The ADON stated the documentation provided for Residents #7, #8, #9, and #10 is not the expectation or standard of documentation for incontinence care.Review of the facility's policy titled Charting and Documentation, dated July 2017, revealed the following: Policy Statement: 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. Policy Interpretation and Interpretation and Implementation. The following information should be documented in the resident medical record: a. objective observations. c. Treatments or services performed . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individuals who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting.Review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, not dated revealed: Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Policy Interpretation and Implementation: 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living do not diminish unless the circumstances of their clinical condition(s) demonstrate diminishing ADLs are unavoidable. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support assistance with: a. hygiene (bathing, dressing, grooming, and oral care); . e. elimination (toileting) .Review of the facility's policy titled Dignity, dated February 2021 revealed: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: . b. promptly responding to a resident's request for toileting assistance.Review of the facility's policy titled Urinary Incontinence-Clinical Protocol dated April 2018 Policy revealed: . Assessment and Recognition . 4. For incontinent individuals, the nursing staff will identify, and document circumstances related to the incontinence; for example, frequency, nocturia, dysuria, or relationship to coughing or sneezing. Treatment/Management . 4. As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continent status. Monitoring, 1. The staff and physician will review the progress of individuals with impaired continence until continence is restored or improved as much as possible, or it is identified that further improvement is unlikely. a. This should include documentation of a resident's responses to attempted interventions such as scheduled toileting, prompted voiding, or medications used to treat incontinence. Event ID: Facility ID: 105884 If continuation sheet Page 4 of 4