Health inspection·December 22, 2021

F 0685 Level of Harm - Minimal harm or potential for actual harm Check hearing aids [every shift] to make sure they are turned up and functional; change batteries as needed. On 12/21/21 at 02:18 PM, a call was placed to the resident's responsible party with no answer and no voicemail was setup. Residents Affected - Few On 12/21/21 on 02:25 PM an interview was conducted with Staff A, Certified Nursing Assistant [CNA]. Staff A had worked at the facility for about 4 years. Staff A stated the facility procedure was to put the hearing aids in for the residents when assisting them in the morning and take them out at night before bed. Staff A was unaware of any residents with hearing aids on the 400 hall where Resident #55 resided. On 12/21/21 at 02:28 PM an interview was conducted with Staff B, Registered Nurse [RN]. Staff B, RN stated facility procedure was to take resident's hearing aids out during a shower and put them back in afterwards. She stated they also take out hearing aids at bedtime and put them back in as soon as the residents get up in the morning. Staff B was unaware of any residents on the 400 hall that required hearing aids. On 12/21/21 at 02:36 PM the Director of Nursing [DON] stated that she thought there was a grievance filed for Resident #55 about missing hearing aids and would follow up on the grievance filed on 10/28/21 by the responsible party about missing hearing aids. On 12/21/21 at 02:40 PM the Social Services Director [SSD] stated Resident #55's family member took about three weeks to get paperwork to her for the hearing aids. According to the SSD, the family member stated Resident #55 had hearing aids when she was admitted . The SSD stated the paperwork for new hearing aids were given to the Administrator to be replaced for Resident #55. She stated the hearing aids have not been ordered yet. On 12/21/21 at 02:42 PM the DON stated she would follow up with the MDS Coordinator about the process for hearing aids. On 12/21/21 at 02:47 PM the MDS Coordinator stated Resident #55 had come into the facility with hearing aids, but she was unaware the hearing aids were missing. The MDS Coordinator agreed the hearing aids should be included in care plans and medical records moving forward. A review of the facility's Hearing Impaired Resident policy (undated) revealed on page one the purpose was to improve communication with the hearing-impaired individual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 2 of 8 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 105891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ybor City Center for Rehabilitation and Healing 1709 Taliaferro Ave Tampa, FL 33602 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure care and services were provided for a dialysis resident, related to ensuring medications were administered prior to dialysis appointments and ensuring post dialysis orders were followed for one (Resident #58) out of six dialysis residents sampled. Residents Affected - Few Findings included: A review of the admission Record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including: encounter for orthopedic aftercare following surgical amputation, end stage renal disease (ESRD), dependence on renal dialysis, Type 1 Diabetes Mellitus with other specified complications, essential primary hypertension, Type 2 Diabetes Mellitus with unspecified diabetic retinopathy without macular edema, Type 1 Diabetes Mellitus with foot ulcer, and acquired absence of other left toe(s). Review of an admission Minimum Data Set (MDS) dated [DATE] for Resident #58 Section C-Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) of 14 indicating intact cognition. Section G-Functional Status, showed that Resident #58 required minimum assistance for activities of daily living (ADL's) for bed mobility, transfers, toilet use, personal hygiene. Resident #58 required supervision for dressing, eating, and bathing. An initial care plan for Resident #58 with a focus initiated on 12/08/21 showed Resident #58 needs hemodialysis related to the diagnosis of ESRD and attends dialysis on Monday, Wednesday, and Friday. A goal indicated that Resident #58 will have no signs or symptoms of complications from dialysis through the next review date. Interventions included to check and change dressing daily at access site, monitor vital signs every shift, monitor document and report to MD (medical doctor) signs or symptoms to access site. Review of Resident #58's physicians active orders dated 12/22/21 showed the following dialysis orders: AV (arteriovenous) Fistula - (left upper extremity) report any absence of radial pulse, limb coldness, blue color, numbness complaints of pain or decreased mobility to MD every shift for renal dialysis. AV shunt Fistula (left - upper arm) check for bruit and thrill every shift. Auscultate for bruit and palpate for thrill. Document (+) if present and (-) if absent. Report absence of either bruit of thrill to MD every shift for renal dialysis. May go to dialysis on (Monday, Wednesday, and Friday) at [Facility Name] pick up time 5:30 a.m., chair time 6:30 a.m. Vital signs post dialysis every day shift every Monday, Wednesday, Friday for renal dialysis. Vital signs pre- dialysis every night shift Monday, Wednesday, Friday for renal dialysis. Monitor left upper arm fistula site for signs and symptoms of infection every shift, every 8 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 3 of 8 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 105891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ybor City Center for Rehabilitation and Healing 1709 Taliaferro Ave Tampa, FL 33602 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 0698 Renal multivitamin / Zinc tablet give one tablet by mouth one time a day for ESRD. Level of Harm - Minimal harm or potential for actual harm Sevelamer Carbonate tablet Give 3200 mg by mouth with meals for ESRD, hemodialysis dependent. Nepro Liquid (nutritional supplements) give 240 milliliters by mouth two times a day for renal supplement Residents Affected - Few An interview was conducted with Resident #58 on 12/20/21 at 02:49 p.m. Resident #58 was observed in his room laying on his bed. Resident #58 stated he goes to dialysis three days a week. Resident #58 stated he was new at the facility. Resident #58 stated I don't want to get anyone in trouble. I don't have any concerns. Review of Resident #58's Medication Administration Record (MAR) dated 12/1/21 to 12/31/21 printed on 12/22/21 at 10:46 a.m. revealed that Resident #58 was not receiving his dialysis medications as ordered. The documentation showed that on Mondays, Wednesdays, and Fridays the 08:30 am medications were documented as not administered, chart code #3, indicating Resident #58 was absent from home. The MAR revealed Renal multivitamin / zinc tablet, give 1 tablet by mouth one time a day for ESRD was not administered on 12/1, 12/6, 12/8, 12/10, 12/13 and 12/15. Nepro Liquid (nutritional supplements) give 240 milliliters by mouth two times a day for renal supplement was not given on 12/1, 12/6, 12/8, 12/10, 12/13 and 12/15. Sevelamer Carbonate tablet give 3200 mg by mouth with meals for ESRD, hemodialysis dependent on 12/1, 12/3, 12/6, 12/8, 12/10, 12/13, 12/15 and 12/19. Review of Resident #58's treatment administration record (TAR) dated 12/1/21 to 12/31/21 printed on 12/22/21 at 10:46 a.m. revealed: Vital signs post dialysis every day shift every Monday, Wednesday, Friday for renal dialysis were not taken as ordered on: 12/6, 12/13, 12/15 and 12/20. AV (arteriovenous) Fistula - (left upper extremity) Report any absence of radial pulse, limb coldness, blue color, numbness complaints of pain or decreased mobility to MD (medical doctor) every shift for renal dialysis showed no documentation on 12/4, 12/10, 12/11 and 12/14. AV shunt Fistula (left - upper arm) check for bruit and thrill every shift. Auscultate for bruit and palpate for thrill. Document (+) if present and (-) if absent. Report absence of either bruit of thrill to MD every shift for renal dialysis showed no documentation on 12/4, 12/10, 12/11, 12/13, 12/20 and 12/21. Monitor left upper arm fistula site for signs and symptoms of infection every shift, every 8 hours showed no documentation on 12/4, 12/6, 12/7, 12/8, 12/9, 12/10, 12/11/13, 12/18, 12/20 and 12/21. Review of Resident #58's Dialysis binder showed a form titled, Dialysis center facility communication form Section C of the form [facility nurse to complete upon return from dialysis] revealed no documentation verifying that Resident #58 was assessed upon return from dialysis on dates 12/3, 12/13, 12/15, 12/17 and 12/19. An interview was conducted with Staff C, LPN (Licensed Practical Nurse) on 12/22/21 at 10:53 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 4 of 8 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 105891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ybor City Center for Rehabilitation and Healing 1709 Taliaferro Ave Tampa, FL 33602 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff C stated that she works with Resident #58 at least three days a week. Staff C stated that Resident #58 goes to dialysis around 5:00 or 5:30 a.m. and returns between 12:00 -12:30 pm. Staff C stated that Resident #58's vitals should be taken before and after dialysis per orders. Staff C stated that it should be documented in his dialysis book and also in the TAR. On 12/22/21 at 10:11 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated she became aware after surveyor spoke with her that Resident #58's post dialysis care was not documented. The DON said, I know, if it is not documented it did not happen. The DON stated she had reviewed the policy of documentation and started the in-service on medication administration omissions. The DON stated she was still investigating why Resident #58 did not get his morning medications. The DON stated the post dialysis vitals must be documented in the book. The DON said, The nurses should be checking the bruit and documenting. The monitoring should be documented. The DON stated the nurses should call the doctor with any concerns. On 12/22/21 at 02:19 PM an interview was conducted with Staff C, LPN. Staff C, LPN stated Resident #58 did not get his morning medications on the dialysis days because he was out of the building. Staff C stated that if Resident #58 is out of the building, I just click out of the building. Staff C stated Resident #58 is at dialysis and not here to take the 8:30 a.m. medications. Staff C said, He misses, all his meds because he leaves around 4 a.m. Staff C stated the medications are not sent with him, and he does not get them when he returns. Staff C confirmed that Resident #58 misses all his morning medications three days a week, (Monday, Wednesday, and Friday). Staff C stated she had not notified Resident #58's physician that he was missing his medications. Staff C stated I'm not sure what I can do when he is not here. A follow-up interview was conducted on 12/22/21 at 02:33 p.m. with the DON. The DON said, when we have a dialysis resident that will not be here during med time, we get a physician order to hold or change the administration times to when the resident is in the building. The DON stated the expectation would be to call the doctor and let him know that Resident #58 was not receiving his medications. The DON stated the doctor had not been notified. The DON stated she also had not been notified that Resident #58 was missing his morning medications on dialysis days. The DON said, No, residents should not go without medications because of a dialysis schedule. On 12/22/21 at 03:02 p.m. an interview was conducted with the facility's Advanced Registered Nurse Practitioner (ARNP). The ARNP stated she sees Resident #58 three to four days a week. The ARNP said, if morning meds are not given, once the patient comes back from dialysis, they should be administered. The ARNP stated she and the doctor had not been notified the resident was going without the medications. The ARNP stated the expectation would be to notify the doctor if a resident did not receive their medications. The ARNP stated the process would be to give an order to administer medications after the resident returned or hold the medications. The ARNP stated there were no current orders to adjust hours or hold medications for Resident #58 because the doctor's office was not notified. Review of Resident #58's progress notes for November/December 2021 showed no documentation related to missed post dialysis care, missed medications or communication with the doctor. Review of the facility's policy titled, Nursing - Care of the Resident Receiving Dialysis, with an effective date of April 2011, showed the facility will provide care to the resident receiving dialysis to maintain patency of the arteriovenous shunt, prevent complications such as infections bleeding and trauma, and identify specific measures to follow if complications occur. The care will be directed by licensed nurses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 5 of 8 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 105891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ybor City Center for Rehabilitation and Healing 1709 Taliaferro Ave Tampa, FL 33602 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 0698 Post dialysis care showed: Level of Harm - Minimal harm or potential for actual harm a. Nurse will evaluate resident's condition upon return from dialysis clinic. Residents Affected - Few b. Document evaluation by completing bottom section of the dialysis form. Sign /date the form. File the completed form in the resident's medical record. c. Follow standard precautions. d. Take vital signs upon return from dialysis and every shift for the first 24 hours. e. Inspect the area around the shunt site dressing for color warmth redness and edema every shift f. Notify MD of any changes. Review of an undated facility policy titled Nursing - Medications, Oral showed, a procedure to verify the physician's order for resident's name, drug name, dose, time, and route of administration. Under reporting and documentation, the policy stated: The following information should be reported to the staff / charge nurse and should be documented in the resident's medication record: 5. If a drug is withheld or if a drug is refused by the resident, circle the time it should have been given on the MAR and document reason it was not given or the reason it was refused in the nurse's notes. An undated position description for a registered nurse (RN) and LPN showed medication administration recording expectations as follows: 2. Medications are charted correctly with dose, route, site, time, and initials of nurse administering. 3. Pulse and Blood pressure are obtained and recorded as appropriate. 4. medications not given are circled, reason noted, and physician notified. 5. Appropriate notes are written for medications not given and actions taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 6 of 8 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 105891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ybor City Center for Rehabilitation and Healing 1709 Taliaferro Ave Tampa, FL 33602 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and medical record review the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and six errors were identified for three (Resident #24, Resident #54, and Resident #31) out of five residents observed. These errors constituted a 24% medication error rate. Residents Affected - Few Findings Included: On 12/21/21 at 9:25 a.m. an observation of medication administration was conducted alongside Staff Member D, Registered Nurse (RND) for Resident #24. He prepared Acetaminophen 325 milligrams (mg) two tablets, Amlodipine 50 mg one tablet, Lotensin HCL 20-25 mg one tablet, Clopidogrel 75 mg one, Potassium 20 milliequivalents ([NAME]) ER on e tablet, Multivitamin with mineral one tablet, Senokot one tablet, and Zinc 50 mg one tablet. He confirmed a total of nine medications as he placed all the medications into a plastic sleeve. He crushed the medications he stated, she likes her pills crushed and given in applesauce. Medication reconciliation conducted for Resident #24 revealed Physician orders for Acetaminophen 325 mg two tablets, Amlodipine 50 mg one tablet, Lotensin HCL 20-25 mg one tablet, Clopidogrel 75 mg one, Potassium 20 [NAME] ER on e tablet, Multivitamin with mineral one tablet, Zinc 50 mg one tablet, Senokot 8.6- 50 mg give two tablets by mouth two times a day, only one Senokot was given. Vitamin D3 capsule 50 micrograms (mcg) give 1 capsule by mouth one time a day this was not given. Recommendations reviewed at https://healthy.kaiserpermanente.org > drug-encyclopedia revealed Potassium Chloride ER 20 mEq tablet, extended release listed as: Do not crush, chew, or suck extended-release capsules or tablets. Doing so can release all of the drug at once, increasing the risk of side effects. Also, do not split extended-release tablets unless they have a score line, and your doctor or pharmacist tells you to do so. On 12/21/2021 at 9:50 a.m. medication observation was conducted with RND for Resident #54. He prepared Anastrozole 1 mg one tablet, Hydralazine Hcl 50 mg one tablet, Levetiracetam 250 mg one tablet, and Lisinopril 20 mg one tablet. RND stated her Amlodipine Besylate is not here. I will call the pharmacy and have them send it over, they are usually here between 12:00 and 1:00 p.m. Reconciliation of Physician ordered medications for Resident #54 scheduled at 9:00 a.m. were reviewed and included Anastrozole 1 mg one tablet, Hydralazine Hcl 50 mg one tablet, Levetiracetam 250 mg one tablet, Lisinopril 20 mg one tablet, and Amlodipine Besylate 10 mg one tablet. Amlodipine Besylate was not given. On 12/21/2021 at 11:30 a.m. an interview was conducted with RND as he confirmed he had crushed the Potassium Chloride ER 20 meq tablet for Resident #54. He removed the bubble card from the medication cart and was directed to a sticker on the card. The sticker read DO NOT CRUSH RND stated I did not see it. It's too big she can't swallow that. He said he would have to ask for it in a different form. RND confirmed the omitted medication for Resident #54 had not arrived yet. He was asked if the facility had a backup or a contingency system in place that contained medications. He did not respond. On 12/21/21 at 12:30 p.m. an interview was conducted with the Director of Nursing (DON) as she confirmed medications cannot always be crushed. The DON said they had a contingency system in place. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 7 of 8 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 105891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ybor City Center for Rehabilitation and Healing 1709 Taliaferro Ave Tampa, FL 33602 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated that she was unsure if the Amlodipine was in the system. She said she would provide a list of their contingency medications. The list of medications was not received prior to the exit of the survey. On 12/22/2021 at 8:50 a.m. an medication observation was conducted with RND for Resident #31 as he prepared Calcium with Vitamin D 600/400 mg one tablet, Colace 100 mg one tablet, Eliquis 5 mg one tablet, Depakote 25 mg one tablet, Metoprolol 50 mg one tablet, Seroquel 50 mg one tablet, Zoloft 25 mg one tablet, Sinemet 25/100 mg, and Flomax 0.4 mg one capsule. RND crushed all of the medications except for the Flomax capsule that he had opened and poured it into a souffle cup with the crushed medications. Reconciliation of Physician ordered medications for Resident #31 revealed Calcium with Vitamin D 600/400 mg one tablet, Colace 100 mg one tablet, Eliquis 5 mg one tablet, Divalproex Sodium tablet Delayed Release (Depakote) 25 mg one tablet, Metoprolol 50 mg one tablet, Seroquel 50 mg one tablet, Zoloft 25 mg one tablet, Sinemet (Carbidopa-Levodopa) 25/100 mg give one tablet by mouth four times a day, and Flomax 0.4 mg one capsule. Recommendations reviewed revealed Depakote ER (dep-a-kOte) (Divalproex Sodium) Extended-Release Tablets to swallow Depakote tablets or Depakote ER tablets whole. Do not crush or chew Depakote tablets or Depakote ER tablets. 2020 AbbVie Inc. North Chicago, IL 60064 US-DPKT-200005 July 2020. https://www.rxabbvie.com/pdf/depakote_medguide.pdf. Sinemet is an oral medicine and has to be taken at least an hour before or two hours after food in empty stomach. The drug has to be swallowed only and not chewed or broken. This is because Sinemet is a slow releasing tablet. https://www.sinemet.org. On 12/22/2021 at 10:00 a.m. an interview was conducted with RND he indicated at that time he was unaware that Sinemet, and delayed release medications were not to be crushed. Review of the facility policy that did not contain a date read POLICY SPECIFIC PROCEDURES FOR ALL MEDICATIONS. All medications will be prepared and administered in a manner consistent with the general requirements outlined in this policy and the requirements outlined in the specific dispensing method policy. 2. Dose preparation: Crushing oral medications REQUIRES a physician order because some medications are not designed to be crushed (e.g., time release capsules, coated tablets, etc.). Crush medications only in accordance with pharmacy guidelines and/or Facility policy. (Refer to DO NOT CRUSH MEDICATION LIST). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 8 of 8