Health inspection·March 28, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few thinks the family may have it now since she moved into this room for her Droplet isolation. Staff D said she will call the family to see if they have this device. Staff D stated the resident has a speech therapy consult to work with her speech per resident's family request, stating her voice is getting worse but stated she can understand her. A review of the admission face sheet for Resident #19 has an admission date of 11/02/2023 with a primary diagnosis of multiple sclerosis (MS). Secondary diagnoses include but are not limited to the following: paraplegia, unspecified atrial fibrillation, contracture of muscle multiple sites, cognitive communication deficit, major depressive disorder, generalized muscle weakness. A review of the current physician orders included but are not limited to: Consult speech therapy dated 3/27/24 three times a week for two weeks. A review of Resident #19's care plan dated 11/20/2023 identified focus area of selfcare deficit; requires total care for all ADL [activities of daily living] needs: Dx [diagnoses] MS, paraplegia, impaired balance/speech; upper and lower extremity contractures. Goal for focus area will have all ADL needs anticipated and met by staff daily through next review. Interventions for focus included but not limited to: Oral care every shift and prn, place voice amplifier on charger at night, and reposition in bed and chair frequently. On 3/27/24 at 11:27 a.m., an interview was conducted with the Director of Nursing (DON) and the Maintenance Director regarding communication and call light assistance for Resident #19. The DON stated the resident had an amplifier at one point and stated the resident's family may have it. The DON stated the amplifier would help staff understand Resident #19 because it would raise the volume of her voice. The DON stated a communication board may be of some benefit and will check with therapy. The Maintenance Director stated currently there are limited options for different call lights in the facility. The only option is a pneumatic pressure bulb but there are only so many in the facility. On 3/28/24 at 10:35 a.m. an observation was made of Resident #19's room. The resident was out of the facility for a doctor's appointment. The same manual desk bell was seen on the bedside table. On 3/28/24 at 1:45 p.m. an interview was conducted with the Rehab Director regarding Resident #19 and her means of communication to staff for assistance. The Rehab Director there are no alternatives for call light but to have frequent checks offered as a suggestion. Review of the admission packet offered to all residents upon entrance into the facility state the following regarding resident rights: (a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 2 of 18 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 03/28/2024 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 0558 resident. Level of Harm - Minimal harm or potential for actual harm (2) Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. Event ID: Facility ID: 105891 If continuation sheet Page 3 of 18 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 03/28/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure a code status was provided upon admission for one resident ( # 228 ) out of 10 residents sampled. Finding Include: Review of the electronic and paper medical record revealed Resident #228 did not have an advanced directive related to the resident code status for six days after being admitted to the facility. Review of Resident # 228 admission Record dated 03/27/2024 showed the resident was admitted on [DATE] with diagnoses to included but not limited to Acute Kidney Failure, unspecified, hyperosmolality and hypernatremia, major depressive disorder, recurrent, moderate. During an interview on 03/27/2024 at 10:00 AM., with Resident # 228's responsible party. He said that he received a phone call yesterday from someone at the facility to ask him if he wanted his mother to be a full code or a do not resuscitate (DNR). He said he told the person at the facility that he wants his mother to be an DNR because she is [AGE] years old, and she could not handle someone pressing on her chest. During an interview on 03/27/2024 at 10:10 AM., with the Social Service Director (SSD), she said she created a care plan and put the resident as a DNR, but the care plan was not finalized. She reached out to the resident's son yesterday to confirm if he wanted his mother to be a full code or a DNR and he said he wanted his mom to be an DNR. She said the process is whether the resident is admitted to the facility with a DNR paper or not she confirms with the resident or their responsible party to confirm if their code status. Resident # 228 was admitted over the weekend, and she said she doesn't work on the weekend. During an interview on 03/27/2024 at 10: 15 AM., with the Director of Nursing, (DON), she said when a resident is admitted to the facility from the hospital, they come in with a 3008 form that shows whether the resident is a full code or a do not resuscitate). If the resident is a DNR they make a copy of the yellow paper and put it in the DNR binders located at each nurse's station. The Social Service Director speaks with the resident or family regarding their code status to confirm if they want to remain a DNR, full code or make any changes to their code status. The Social Services Director completes this process within one or two days after admission. Then the nurse responsible for that resident should make sure that the code status is posted in the electronic medical record (EMR). We obtain a physician order if a resident is a full code or a DNR and put it into the EMR. Resident # 228's nurse who conducted her admission should have made sure that the code status was posted on the dashboard in the EMR, and I see that it was not done. She said her expectations are that the nurse who is responsible for the residents when they are admitted on the weekend should obtain the code status and put it in PCC so it would show on the dashboard in PCC. This was an oversight on their end. They normally review weekend admission during their interdisciplinary meetings (IDT) on Monday; however, the meeting did not occur on the past Monday. Review of the facility policy titled, Admission/ Social Services - Advance Directives, no date, showed the facility will promote the resident's right to refuse treatment and care, the right to refuse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 4 of 18 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 03/28/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to participate in experimental research and the right to formulate an advance directive. The facility will inform and educate the resident about these rights and provide the facility policy regarding these rights. The facility will assist the resident in exercising these rights and will incorporate the resident's choices regarding these rights into treatment, care, and services. 2. As part of the admission process, the resident and or legal representative will be given a copy of the form entitled, Acknowledgment of Advance Directives. The resident/ legal representative will verify that they acknowledge they received the following from the admission Department: This form also provided a checklist that gives verification of the resident's wishes regarding advance directives and the receipt of the Living Will; Durable Power of Attorney for Health Care Authority; Durable Power of Attorney for Financial Authority; Health Care Surrogate; and Florida Do Not Resuscitate Order or the resident's refusal to execute Advance Directives at this time. The Acknowledgement of Advance Directive form will be filed under the Advance Directive tab in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 5 of 18 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 03/28/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide a safe, clean, and homelike environment for four (250, 310, 330, and 350) of eight rooms observed during four (03/25/2024, 03/26/2024, 03/27/2024, and 03/28/2024) of four days. Findings included: On 3/25/24 at 09:35 a.m., during the initial tour, an observation was made of room [ROOM NUMBER]. Loose wires were noted between two residents' beds (photographic evidence obtained). Continuing with the initial tour at 10:00 a.m. on the 300 hallway, room [ROOM NUMBER] had privacy curtains with brown and red spots and black streaks at the bottom of one set of curtains, and a dirty floor (photographic evidence obtained). In room [ROOM NUMBER] loose wires we observed between residents' beds, a dirty and dusty AC (air conditioning) Vent, cluttered furniture without access to light cord for resident and/or staff to reach, and the hot water knob for the sink would not turn off (photographic evidence obtained). The main shower room for the 300 hallways was noted with a foul smell of urine and around the toilet was loose yellow toilet paper debris (photographic evidence obtained). room [ROOM NUMBER] was observed with dirty privacy curtains, a rusty IV (intravenous) pole, a dirty urinal and a dirty floor (photographic evidence obtained). On 3/26/24 at 7:30 a.m., during an observation no changes were noted. The 300 hallways shower room had yellow stained toilet paper on the floor by the toilet. room [ROOM NUMBER] had loose wires between the residents' beds. Further observation of room [ROOM NUMBER] noted the same wires tangled between two residents' beds and cluttered furniture remained impeding access to light switch/cord. room [ROOM NUMBER] and room [ROOM NUMBER] were noted with dirty privacy curtains and a dirty floor. On 3/27/24 at 07:40 a.m. observations were made of room [ROOM NUMBER] with loose wires between two residents' beds. room [ROOM NUMBER] was noted with loose wires between two residents' beds and a dusty/dirty AC vent. room [ROOM NUMBER] was observed with dirty privacy curtains, and a garbage can with no liner and overflowing, used Personal Protective Equipment (PPE). On 3/28/24 at 10:00 a.m., observations were made of rooms 250, 310, 330 and 350; no changes were observed from previous observations. On 3/28/24 at 1:00 p.m., an interview was conducted with the Housekeeping/Linen Manager. The Housekeeping/Linen Manager (HKM) stated rooms are cleaned everyday with an emphasis on high touch spots. The floors will be mopped but when the opportunity presents itself a strip and wax will be done to the floors. Curtains will be cleaned out along with the deep cleaning of floors and when dirty. The HKM manager stated, We clean our curtains on site. The Housekeeping/Linen Manager was presented with photographic evidence and stated she was aware of dirty curtains in room [ROOM NUMBER] but was not aware of rooms [ROOM NUMBER]. On 3/28/24 at 4:30 p.m., an interview was conducted with the Maintenance Director (MD). The MD said currently, there is no system in place for the Maintenance Director to follow up with maintenance requests made by the residents and/or the staff. The maintenance director, prior to the newly hired Maintenance Director was attempting to initiate a maintenance request log on each floor but the system did not do well because staff were not utilizing on a regular basis. Currently, the staff will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 6 of 18 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 03/28/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm come to the Maintenance Director verbally with maintenance requests but admitted this is too much and he may forget some of the requests. A review of the facility's policy titled: Cleaning and Disinfecting Residents' Rooms, revised August 2013, states the purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. Residents Affected - Some 1. Housekeeping surfaces will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 4. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 7 of 18 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 03/28/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of an admission Record showed Resident # 10 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to included but not limited to Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Schizophrenia, unspecified, major depressive disorder, recurrent, unspecified. Review of a Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 06, which indicated severely impaired. Review of Resident #10's care plan date initiated 10/10/2023 and revised 10/10/2023, revealed a care plan focus showing Resident # 10 has impaired cognitive function/dementia, resident has short/ long term memory impairment and is moderately impaired in decision making. Further review of the care plan intervention showed to administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 10/04/2023 and revised 10/04/2023. Further review of the care plan showed a focus for the use of psychotropic medications related to diagnoses depression and mood disorder. Review of the care plan intervention date initiated 10/4/2023 and revised 10/10/2023 showed to administer psychotropic medications as ordered by physician. Monitor side effects and effectiveness every shift, Q (every) shift. Review of Resident # 10's Preadmission Screening and Resident Review (PASRR) level I assessment dated [DATE] revealed no answered in section II for questions 4, 5, 6 and 7 to indicate resident # 32 has no dementia diagnosis. 4. Review of Resident # 32's admission Record dated 03/28/2024 showed he was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to included but not limited to vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, bipolar disorder, Review of a Minimum Data Set (MDS) dated 1/21 /2024 showed the resident had a Brief Interview Mental Status (BIMS) score of 11, which indicated moderately impaired. Review of Resident # 32's Preadmission Screening and Resident Review (PASRR) level I assessment dated [DATE] revealed no answers in section II for questions 4, 5, 6 and 7 to indicate Resident # 10 has no dementia diagnosis. Review of the medical record showed that the resident was not assessed for PASRR level II. Review of Resident # 32's care plan date initiated 1/23/2024 and revised on 1/23/2024 revealed a care plan focusing showing Resident # 32 has impaired cognitive function/ dementia or impaired thought processes related to Cerebral Vascular Accident (CVA). Review of the care plan intervention initiated 1/23/2024 and revised 1/23/2024 showed to observed Resident # 32 for changes in cognitive status. During an interview on 3/28/2024 at 1:00 p.m. with Staff G, Registered Nurse (RN)/ Minimum Data Set (MDS) Coordinator. Staff G stated the Preadmission Screening and Resident Review (PASRR) are received from the hospital on admission. MDS reviews the PASRR for accuracy and makes corrections if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 8 of 18 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 03/28/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed. She completes an updates the PASARR if a resident has a change in behavior or new diagnosis. In monthly psych meetings, the team is made aware of residents with new psych diagnoses. The team attending psych meetings are Social Services, Director of Nursing, Unit Nurse Manager, and MDS. Review of the facility policy titled, Admission/ Social Services - Pre- admission Screening and Resident Review ( PASRR), no date, showed Overview: The purpose of PASRR is to ensure individuals who are being considered for placement in a Nursing Facility are evaluated for serious mental illness and/ or intellectual disability and are offered the most integrated setting appropriate for their long term care needs ( including determining whether a Nursing Facility is appropriate). 2. Level I PASRR must be fully and accurately completed and distributed in accordance with Rule 59G-1.040, F. A. C. Upon or prior to admission if the facility finds the level I to be incomplete or inaccurate, a correct Level I PASRR must be completed by hospital staff or appropriate Nursing Facility staff (Physician, Registered Nurse Master Social Worker, or License Clinical Social Worker). 4. When Applicable a request for a PASRR Level II evaluation must be made by the Social Services Director / Designee using the FL PASRR Provider Portal at https://portal.kepro,com/. Based on interview and record review, the facility failed to ensure the accuracy of the Level I Pre-admission Screening and Resident Review (PASSAR) for four (#56, #7, #10 and #32) of eleven residents reviewed. Findings Included: 1. Electronic Medical Record (EMR) review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses that included but not limited to Bipolar Disorder, Alzheimer's, Other Schizophrenia, Major Depressive Disorder, Unspecified Mood Disorder, Anxiety Disorder according to the Face Sheet. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed: -Section C: Brief Interview for Mental Status (BIMS) score 99, indicating resident unable to complete interview. -Section I: Active Diagnosis - Alzheimer's. Anxiety, Depression, Bipolar, Schizophrenia checked. -Section N: Medications administered - Antidepressant and Antianxiety. Review of the Medication Administration Record (MAR) for March 2024 showed: -Lorazepam Tablet 0.5 milligrams (mg) - Give 1 tablet via G-Tube every 8 hours for anxiety disorder -Buspirone HCL oral tablet 7.5mg via G-Tube two times a day for anxiety disorder -Sertraline HCL tablet 50mg via G-Tube one time a day for major depressive disorder. Review of the PASSAR Level I, dated 1/19/2024 revealed: -Section IA, Mental Illness, or suspected Mental Illness checked for Anxiety Disorder, Bipolar (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 9 of 18 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 03/28/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Disorder, Depressive Disorder, Psychotic Disorder, Schizoaffective Disorder and Other written in with Unspecified Mood Disorder. -Section I Services, Marked Currently Receiving Services for Mental Illness, based on documented history and medication Residents Affected - Few -Section II 6 secondary diagnoses of Dementia checked Yes. -Section II 7 marked Yes medical/functional history prior to onset -Section IV marked no diagnosis or suspicion of serious mental illness or intellectual disability indicated. During an interview on 3/28/2024 at 1:00 p.m. Staff G, MDS Coordinator reviewed Resident #56 PASARR dated 1/19/2024. The MDS she stated she should have requested a Level II PASARR be completed for Resident #56. 2. EMR review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses that include but not limited to, dementia, major depressive disorder, anxiety disorder, drug induced dyskinesia, unspecified psychosis according to face sheet. Review of quarterly MDS dated [DATE] revealed: Section C: showed a BIMS score of 99 indicating resident unable to complete interview. Section D: showed resident mood interview should not be conducted and PHQ9 score of 5 indicating mild depression. Section I: Active Diagnosis - Dementia, Depression, Anxiety, and Psychotic disorder checked. Section N: Medication administered - taking antipsychotic, antianxiety, and antidepressant. Review of MAR for March 2024 showed: -Xanax Oral Tablet 0.5mg (Alprazolam) 1 tablet by mouth every 12 hours for anxiety -Risperdal Oral Tablet 0.5mg (Risperidone) 1 tablet by mouth at bedtime for psychotic disorder -Mirtazapine Oral Tablet 7.5 mg (Mirtazapine) 1 tablet by mouth at bedtime for depression Review of the PASSAR Level I, dated 01/19/2024 revealed: -Section IA, Mental Illness, or suspected Mental Illness checked for Anxiety, Depressive Disorder and Psychotic Disorder. -Section I Services, Marked Currently Receiving Services for Mental Illness, based on documented history and medication -Section II 5 primary diagnosis of Dementia checked yes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 10 of 18 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 03/28/2024 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 0644 -Section II 7 marked Yes medical/functional history prior to onset Level of Harm - Minimal harm or potential for actual harm -Section IV marked no diagnosis or suspicion of serious mental illness or intellectual disability indicated. Residents Affected - Few During an interview on 3/28/2024 at 1:00 p.m. Staff G, MDS Coordinator reviewed Resident #7 PASARR dated 1/19/2024. The MDS Coordinator stated she should have requested a Level II PASARR be completed for Resident #7. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 11 of 18 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 03/28/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure one resident (# 24) was provided with Activity of Daily Living, (ADL's) assistance out of 10 residents sampled. Residents Affected - Few Findings Included: During an observation on 3/25/2024 at 3: 30 PM., Resident # 24 was observed laying down in his bed with his hair disheveled and facial hair. Resident # 24 said he would like to be shaved but staff won't assist him. During an observation on 03/26/2024 at 10:00 AM., Resident # 24 was observed laying down in bed and appeared with no signs of distress. Review of Resident #24's admission Record dated 03/27/2024 showed he was initially admitted on [DATE] with diagnoses to included but not limited to hereditary and idiopathic neuropathy, unspecified, unspecified osteoarthritis, unspecified site, chronic kidney disease, stage 3 unspecified. Review of a Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 13, which indicated cognitively intact. Review of Section GG0115 functional limitation in range of motion showed Resident # 24 is impaired on both sides of his upper extremities. Review of Resident # 24 care plan date initiated 02/21/2023 and revised on 11/20/2023 revealed a care plan focus showing Resident # 24 requires total assist with Activity Daily Living, (ADL's) diagnoses Parkinson's right knee pain, knee replacement: unsteady balance. Review of the care plan intervention showed ¼ side rails x 2 for bed mobility and transfer assist as needed. Date initiated 1/22/2024 and revised on 3/12/2024. During an interview on 03/26/2024 at 3:00PM., with Staff I, Certified Nursing Assistant, (CNA), staff I said he has worked at the facility for two months, but he has just started working on 400 halls two weeks ago. He said he assisted Resident # 24 with all his Activity of Daily Living, (ADL's). He did not shave Resident # 24 because he is still learning his job and he was afraid that he would cut the resident. He said he did not tell the nurse, but he would let her know that he needed assistance with shaving the resident. During an interview on 3/26/2024 at 3:30 PM with Staff C, License Practical Nurse, (LPN), Staff C said her expectation is that the aides assist their residents with all their ADL's if that is required. She said Staff I did not tell her that he was having trouble shaving Resident # 24 because she would have assisted him with the resident. Her expectation is that if an aide is having trouble assisting a resident with care, they would tell her so she can step in and provide assistance. During an interview on 3/26/2024 at 3:45 PM., with the Director of Nurses, (DON), the DON said her expectation is that residents are provided with ADL care according to their care plan. She said she would have expected her staff to report any changes they are having with the residents so that they can provide support when needed. A policy related to ADL care was requested; however, none was provided by completion of the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 12 of 18 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 03/28/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview and record review, the facility failed to ensure oxygen services, including the safe handling, humidification, cleaning, storage, and dispensing of oxygen, was provided for one resident (#66) out of thirty-nine residents sampled. Residents Affected - Few Findings include: On 3/25/24 at 1:15 p.m. an observation was made of Resident #66 in his room with his nasal cannula hanging from his side rail next to a urinal, which had thick brown liquid inside. The nasal cannula was unlabeled and connected to a powered-on concentrator [photographic evidence obtained]. On 3/26/24 at 10:45 a.m. an observation was made of Resident #66 in his room with his nasal cannula at the bottom of a garbage can unlabeled and connected to a powered-on concentrator [photographic evidence obtained]. On 3/27/24 at 11:50 a.m. an observation was made of Resident #66 in his room with his nasal cannula on the ground unlabeled and connected to a powered-on concentrator [photographic evidence obtained]. Resident #66 stated he uses oxygen on and off. On 3/28/24 at 10:30 a.m. an observation was made of Resident #66 in his room with his nasal cannula hanging from an IV pole unlabeled and connected to a powered-on concentrator [photographic evidence obtained]. A review of the admission face sheet for Resident #66 has an admission date of 01/24/2024 with a primary diagnosis of urinary tract infection. Secondary diagnoses include but not limited to pulmonary embolism without acute cor pulmonale, dyspnea, chronic obstructive pulmonary disease (COPD), emphysema, weakness, unsteadiness on feet, and cachexia. A review of the physician orders has an order dated 01/24/2024 for Oxygen (O2) at two liters/minute continuous inhalation with no discontinue or end date. An order dated 01/24/2024 for oxygen tubing, cannula/mask change weekly and PRN (as needed). A review of Resident #66 care plan dated 01/24/2024 and a revision date of 02/13/2024 showed a Focus area of the resident having emphysema /COPD and receives O2 via NC (nasal cannula) with a new diagnosis of pulmonary embolism. The interventions include but not limited to check O2 saturations as ordered, O2 via NC as ordered (revised 2/13/2024), and to monitor for difficulty breathing on exertion, signs and symptoms of acute respirator insufficiency. A review of the Minimum Data Set Section O-Special Treatments, Procedures and Programs showed resident under section for respiratory treatments C1- Oxygen therapy as checked for continuous. A review of Resident #66's medication administration record for the month of March 2024 showed entries made by staff for every shift of O2 2l/min (liters/minute) and tubing was changed every night shift on Tuesday with a date of March 26th as completed. A review of the facility's policy titled: Nursing Oxygen Administration (no date) showed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 13 of 18 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 03/28/2024 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 0695 The purpose of this procedure is to provide guidelines for oxygen administration. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few 11. Adjust the delivery device so it is comfortable to the resident and the proper flow of oxygen is being administered. 12. Observed the resident to be sure oxygen is being tolerated. 13.Check the mask, tank, etcetera to be sure they are in good working order and are securely fastened. . 17. Date tubing and humidifier bottle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 14 of 18 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 03/28/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure Side Rail evaluation were conducted prior to installation for two residents (# 10, 24) out of 10 residents sampled Findings Included: 1 During an observation on 03/25/2024 at 03:26 PM Resident # 10 was observed laying down in bed fully dressed, well groomed, with no signs of distress. Resident # 10 was observed with two different types of ¼ side rails on his bed. During an observation on 03/27/2024 at 10: 00 AM., Resident #10 was observed laying down in bed with 1/4 side rails up on both sides of his bed. Resident # 10 said he did not know why he had side rails on his bed. Residents were observed with no signs of distress. Review of a admission Record showed Resident # 10 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to included but not limited to Type 2 Diabetes Mellitus with Hyperglycemia, Parkinson's disease without dyskinesia, without mention of fluctuation, need for assistance with personal care, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Schizophrenia, unspecified, major depressive disorder, recurrent, unspecified. Review of a Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 06, which indicated severely impaired. Review of an Order Summary Report dated 03/24/2024 showed an active order dated 03/27/2024 for ¼ siderails x2 for bed mobility. Review of the Electronic Health Record (EHR,) evaluation section on 03/26/2024 showed no evidence a side rail assessment was completed to show appropriate alternatives were utilized prior installation of the side rails. Further review of the (EHR) evaluation section showed no assessment was completed to show Resident # 10 was not at risk for entrapment. Review of Resident #10's care plan date initiated 10/10/2023 and revised 10/10/2023, revealed a care plan focusing on the resident at risk for skin breakdown related to (r/t) decreased mobility and incontinence; requires extensive assist with bed mobility and transfers. Further review of the care plan showed an intervention for ¼ side rails up x2 as enablers for bed mobility/ transfer and reposition the resident frequently. Date initiated 03/15/2024 and revised 03/18/2024. 2 During an observation on 3/25/2024 at 3: 30 PM., Resident # 24 was observed laying down in his with both side rails up and his call light in reach. During an observation on 03/26/2024 at 10:00 AM., Resident # 24 was observed laying down in bed with both side rails up on each side of his bed. Resident # 24 was observed with no signs of distress. Review of Resident #24's admission Record dated 03/27/2024 showed he was initially admitted on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 15 of 18 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 03/28/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [DATE] with diagnoses to included but not limited to hereditary and idiopathic neuropathy, unspecified, unspecified osteoarthritis, unspecified site, chronic kidney disease, stage 3 unspecified. Review of a Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 13, which indicated cognitively intact. Review of Section GG0115 functional limitation in range of motion showed Resident # 24 is impaired on both sides of his upper extremities. Review of Resident # 24 care plan date initiated 02/21/2023 and revised on 11/20/2023 revealed a care plan focus showing Resident # 24 requires total assist with Activity Daily Living, (ADL's) diagnoses Parkinson's right knee pain, knee replacement: unsteady balance. Review of the care plan intervention showed ¼ side rails x 2 for bed mobility and transfer assist as needed. Date initiated 1/22/2024 and revised on 3/12/2024. During an interview on 03/26/2024 at 3:00PM., with Staff I, Certified Nursing Assistant, (CNA) staff I said he had worked at the facility for two months, but he has just started working on 400 halls two weeks ago. He said Resident # 10 and 24 both have had side rails on their beds ever since he has worked on the 400 halls. He said he did not know why either resident had side rails. During an interview on 3/26/2024 at 3:30 PM with Staff C, License Practical Nurse, LPN. Staff C said residents are assessed upon admission for the use of side rails. Residents # 10 and 24 did not have a side rail assessment done because theirs must have been overlooked. We had more than one person completing the side rail assessment at that time. During an interview on 3/26/2024 at 3: 45 PM., with the Director of Nursing (DON). She said they do a screening on admission to see if a resident would benefit from having a side rail. If a resident uses a side rail for bed mobility or they use it when going to a laying down position to a sitting position, then they would be assessed for a side rail. Side rails assessment is completed upon admission, quarterly and if a resident has a change in condition. The nurse who is assigned to the resident would complete a side rail assessment within five to seven days of the resident admission. The DON stated I don't see a side rail assessment completed for Resident # 10 and 24. Both residents should have had a side rail assessment completed and I don't see that it was done. Review of the facility policy titled, Restorative Nursing - Side Rails No dated, showed Policy: The use of side rails by a resident may be considered a restraint or an enabler, depending on the resident's functional status and whether or not the side rail restricts freedom of movement. Prior to the use of side rails, the resident's strengths and needs should be evaluated by the Interdisciplinary Team to determine the reason for the side rail and any alternative devices that may be used to achieve the same goal. The manufacturer's instructions for the use of side rail will be followed. Side rails longer than ¼ the length of the mattress from the head of the bed will not be used. Procedure. 1. Complete the Side Rail Evaluation upon admission, readmission, quarterly, and with a significant change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 16 of 18 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 03/28/2024 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 Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed and 3 errors were identified for two residents (#9 and #32) of five residents observed. These errors constituted a 9.38% medication error rate. Residents Affected - Few Findings Include: On 3/26/24 at 8:50 a.m. an observation of medication administration with Staff C, Licensed Practical Nurse (LPN) was conducted for Resident #9. Staff C, LPN dispensed the following medications: -Clonazepam 0.5 milligrams (mg) one tablet -Plavix 75 mg one tablet -Haldol 5 mg one tablet -Paroxetine 40 mg one tablet -D3 50 mg/2,000 International units (IU) one tablet Staff C, LPN was observed continuing medication administration for Resident # 32 with the following medications: -Aspirin 81 mg chewable one tablet -Losartan 50 mg two tablets -Metoprolol 50 mg one tablet -Doxazosin 4 mg one tablet -Spironolactone 25 mg one tablet -B12 100 micrograms (mcg) one tablet -Incruse 62.5 mcg inhaler 1 puff A review of the physician orders for Resident # 9 showed an order for Vitamin D3 tablet 25 mcg/ 1,000 IU one tablet by mouth daily. During administration on 3/26/24, Resident #9 received Vitamin D3 50 mcq /2,000 IU one tablet. A review of the physician orders for Resident #32 showed an order for Incruse Ellipta aerosol powder breath activated 62.5 mcg/INH with the following instructions: one puff orally one time a day for COPD (chronic obstructive pulmonary disease), rinse mouth with water after use. During administration on 3/26/24 after oral tablets were administered, Resident #32 did his inhaler with the assistance of Staff C, LPN but was not offered the opportunity to rinse his mouth with water as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 17 of 18 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 03/28/2024 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 Further review of physician orders for Resident #32 showed an order for Biofreeze external gel 4% with the following instructions: apply to left knee topically two times a day for pain related to muscle weakness. During administration on 3/26/24, Resident #32 did not receive the Biofreeze external gel as ordered nor at the time designated. On 3/27/24 at 1:45 p.m. an interview was conducted with the Director of Nursing (DON) regarding medication administration. The DON stated medications including over-the-counter medications and topical medications should be administered correctly according to physician orders. A review of the facility's policy entitled: Administering Medication (revised April 2019), showed the following policy statement: Medications are administered in a safe and timely manner and as prescribed. The following policy interpretation and implementation include but not limited to the following: . 4. Medications are administered in accordance with prescriber orders, including any required time frame. . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 18 of 18