Health inspection·December 17, 2025

F 0686 Level of Harm - Actual harm Residents Affected - Few pillows under calves if needed.-Pressure redistributing mattress or specialty bed.-Barrier creams with incontinence care .-Use white incontinence pads in lieu of adult diapers.-Daily moisturizers after bath.-Nutritional support. Review of Resident #1's medical record revealed these assessment plan recommendations were not transcribed for follow -up. On 12/17/2025 at 10:42 a.m., an interview was conducted with the Resident Representative (RR) for Resident #1. The RR stated she had Resident #1 in the facility for respite care for a planned two- weeks stay. The respite care started on 11/18/2025. The RR stated she was gone for one week to then returned to her home and she went to visit Resident #1 on 11/26/2025 and requested the assistance of his nurse who was at the medication cart, to straighten his right leg. The RR stated Resident #1's right foot was positioned under the resident's bottom. The RR stated she observed black spots on both sides of Resident #1's foot. The RR stated on the right side of his foot, the pinky toe and the toe next to it were black and the black discoloration was going down towards the top part of his foot. The RR stated on the inside of his right foot was an opening of his skin. The RR stated she immediately went to her car to obtain supplies for dressing changes and requested the nurse to attend to his wounds with the provided dressings. The RR stated Resident #1 had a breakdown on his foot a year ago during respite care at another facility and the same breakdown occurred then. The RR stated she was able to take the resident home where she was able to treat and resolve the wound herself. The RR stated the resident, under her care, required a pillow to be placed between his legs and under his feet to offset pressure. The RR stated she did not see Resident #1 on an air mattress, pillows for offloading, socks on feet nor a heel boot. The RR stated she immediately knew she wanted Resident #1 removed from the facility. The RR called the preferred hospital, and had emergency medical service (EMS) transfer the Resident #1. The RR stated she was afraid of this situation reoccurring and stated she had taken pictures of Resident #1, just prior to leaving on 11/18/2025. The RR stated having taken pictures of the right foot on 11/26/2025. The RR stated she tried calling the facility multiple times, but the phone would ring and ring without answer. The RR stated when she did speak with Resident #1's nurse she informed her EMS was coming to transfer the resident to the hospital. The RR stated the following morning at 7:20 a.m., she received a call from the DON who apologized and stated she was away on vacation and had not met Resident #1. The RR stated, due to Resident #1's new wounds to his feet, the RR was advised by the medical staff to amputate his leg above the knee, the healthiest point due to his contractures and former total knee replacement. On 12/17/2025 at 10:07 a.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN)/wound care nurse and the Director of Nursing (DON). Staff A, LPN/wound care nurse stated, when she starts her shift, she views the [electronic software medical record] dashboard for newly admitted residents and adds these residents to her current list/log of residents with wounds/treatments to be assessed for any skin concerns. Staff A, LPN/wound care nurse stated after she had completed a head -to-toe assessment of newly admitted residents, if the residents required wound care treatments/management, she would document in the electronic medical records her assessment and treatments as completed in the Treatment Administration Record (TAR) and relay her findings to the admitting physician for a treatment plan as well as notify the resident's representative to inform them of the treatment plan. Staff A, LPN/wound care nurse, stated every Monday, the wound care physician will make official wound care rounds with the residents on the wound care/treatment log. The DON stated, as of December 04,2025, the wound care physician had included new admits onto the list for skin assessments, but this did not include Resident #1 who was admitted on [DATE]. The DON stated the list would have included residents with stage 1 non-blanchable skin concerns. The DON stated Staff A, LPN/wound care nurse was a good about communicating to her about residents requiring heel boots (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 2 of 5 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 12/17/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few or air mattresses. The DON was unaware of Resident #1's condition prior to the family member's visit on 11/26/2025. A record review of Resident #1's Baseline Plan of Care with an initiation date of 11/18/2025 showed the following:At risk for skin breakdown with a goal: Will not develop new or have decline in existing wounds unless clinically avoidable. Interventions checked: Inspect skin daily during care for s/s (signs/symptoms) of breakdown Encourage, remind assist in position change regularly and frequently Moisturize skin with lotion especially bony prominences, but avoid massaging skin Encourage and assist with food and fluid to promote nutrition.The plan of care did not include previously recommended physician orders related to turning and repositioning every 2 hours if patient is unable to turn self and use positioning supports including positioning wedge and heel protectors as needed. On 12/17/2025 at 9:50 a.m., during the initial tour of the facility, an interview was conducted with Staff B, CNA/staffing coordinator/central supply and Staff C, van driver. Staff B and Staff C opened an outside shed filled with bed mattresses, large black garbage bags and various other equipment Staff B stated the black garbage bags contained air mattress overlays for beds. Staff B stated she has not had an issue with a request for an overlay air mattress when requested by the nurses. Staff B stated they have air mattress always overlays available and anyone can go into the shed to obtain one if needed. Staff B was unaware why Resident #1 did not have the pressure relief mattress on his bed.A record review of Resident #1 showed an admit date of 11/18/2025 with a discharge date of 11/26/2025 with the following diagnoses: Idiopathic gout, multiple sites Hemiplegia and hemiparesis following cerebral infarction affecting right dominant site Dysphagia following cerebral infarction Type 2 diabetes mellitus without complications Mild protein calorie malnutrition Tinea unguium Major depressive disorder, recurrent, moderate Alzheimer's disease, unspecified Essential hypertension Atherosclerotic heart disease of native coronary artery without angina pectorisA review of physician orders include but not limited to: House barrier cream to peri areas/buttocks/sacrum q (every) shift for 14 days for prevention, ordered 11/19/2025 Skin prep bilateral heels q shift for 14 days for prevention, ordered 11/19/2025 Vital signs every shift , ordered 11/19/2025. Zinc oxide ointment to groin and sacrum area every shift for wound care, ordered 11/21/2025A record review of the Treatment Administration Record (TAR) for the month of November 2025 showed the following documentation in relation to physician orders: House barrier cream documented as completed starting 11/19 through 11/25-day shift as last entry (three times a day administration opportunities) Skin prep bilateral heels documented as completed starting 11/19/2025 through 11/25-day shift as last entry (three times a day administration opportunities) Zinc oxide ointment documented as completed starting 11/21 through 11/25-day shift as last entry (three times a day administration opportunities)A record review of the Minimum Data Set (admissions) dated November 25,2025 showed: Section GG-Functional Abilities, Section GG0100-Prior Functioning : Everyday Activities showed Self-Care and Functional Cognition as Needed some help, resident needed partial assessment from another person to complete any activities. Section GG-Functional Abilities, Section GG0110-Prior Device Use showed manual wheelchair and mechanical lift Section GG- Functional Abilities, Section GG 0115- Functional Limitation in Range of Motion showed impairment on one side to upper extremity and lower extremity. Section GG- Functional Abilities- Admission, Section GG0170- Mobility showed substantial /maximal assistance for roll left to right, lying to sitting on side of bed, and dependent for chair to bed-to chair transfer Section H- Bladder and Bowel, Section H0300 showed resident as always incontinent for urinary and bowel continence Section I- Active Diagnoses showed other orthopedic conditions, anemia, coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia, Alzheimer's disease, cerebrovascular accident, hemiplegia or hemiparesis, depression, with idiopathic gout, dysphagia tinea unguium added to diagnoses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 3 of 5 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 12/17/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few Peripheral Vascular disease (PVD) was not checked or added as a diagnosis. Section M- Skin Conditions Section M0210- Risk for Pressure Ulcers/Injuries showed resident is at risk for developing pressure ulcers/injuries. Section M- Skin Conditions Section M0210- showed resident does not have one or more unhealed pressure ulcers/injuries Section M-Skin Conditions Section M1030 Number of Venous and Arterial Ulcers showed zero total number of arterial/venous ulcers present. Section M- Skin Conditions M1200- Skin and Ulcer/Injury Treatments showed the following items checked: Pressure reducing device to chair, pressure reducing device to bed, applications of ointments, medications (other than to feet On 12/17/2025 at 12:46 p.m., an interview was conducted with Staff D, LPN. Staff D, LPN stated she had Resident #1 on 11/26/2025 during the 3-11 p.m. shift. Staff D, LPN stated she had Resident #1 the day he was admitted on [DATE] but stated she was off for a full week before she was assigned to him again on 11/26/2025. Staff D, LPN stated she was at her medication cart when the RR approached her and asked for her assistance in repositioning the resident. Staff D, LPN, stated the resident had his right foot under his buttocks. Staff D, LPN stated when she assisted moving the resident's right leg was when they both saw the resident's right foot. Staff D, LPN stated, Resident #1 appeared to have new pressure wounds in which she described them as a combination of dark to light red wounds. Staff D, LPN stated she was shocked and said, [Resident #1's] foot was not like this before he was admitted . Staff D, LPN stated the RR left to go to her car and returned with materials to address the wounds. Staff D, LPN stated, She asked me to clean it up and bandage it. Staff D, LPN stated the RR asked her to make sure his foot did not go under his bottom and to keep a pillow under. Staff D, LPN stated she agreed to her request. Staff D, LPN stated the RR left and she called the DON to notify her of the new wound. Staff D, LPN stated the RR called back about 30 minutes later requesting for Resident #1 to be transferred via EMS to the resident's preferred hospital. Staff D, LPN notified the DON regarding the RR requesting the transfer. Staff D, LPN stated thirty minutes later, EMS service arrived to take Resident #1 to the preferred hospital. A record review of the Change in Condition dated 11/25/2025 showed: a change in condition for: skin color or condition. At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 120/78 11/25/2025 20:12 Position: Lying r/arm - Pulse: P 78 - 11/25/2025 20:12 Pulse Type: Regular - RR: R 20.0 11/24/2025 15:57 - Temp: T 97.2 - 11/25/2025 20:13 Route: Tympanic - Weight: W 180.8 lbs. - 11/22/2025 12:31 Scale: Mechanical Lift - Pulse Oximetry: O2 99 % - 11/25/2025 20:13 Method: Room Air - Blood Glucose: [blank] Nursing observations, evaluation, and recommendations are: resident noted with unstageable wound to right medial foot. approximately 10cmx7cm area noted to medial foot, eschar noted throughout wound bed, with areas of deep red discoloration surrounding. scabbed area to medial malleolus, and medial great toe. Right heel noted with open area approximately 5cm x 5cm, moderate amount of serosanguinous drainage noted to heel wound. Lateral foot noted with area of impairment, discoloration with apparent shearing.Review of a Wound Care consultation note signed by a [wound nurse] showed a progress note dated 11/25/2025 at 8:28 p.m., revealing the following: Resident was discharged via AMA (against Medical Advice) per [RR]'s request. [RR] visited the facility around 6:15 p.m. When accessing [Resident#1's]body she noticed his right foot was under his buttocks when she pulled his foot from underneath him she discovered pressure ulcers on multiple areas of his right foot the she stated to me [sic] were not there at the time of his admission on [DATE], she left some supplies to dress is foot with, so I cleaned & dressed his foot. Around 8 p.m. [RR] called the facility stating that she wanted [Resident #1] to be sent to the [hospital] immediately. I informed her he will be AMA (against medical advice) she stated that was fine paramedic arrived at 9:10 p.m. to have resident transferred to the [hospital] Staff D, LPNA record review titled, Daily Medicare A/Managed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105891 If continuation sheet Page 4 of 5 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 12/17/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Care Nursing Notes SC4 a-V 5 under section K- Skin/Wounds pg.6 showed: 11/22/2025 : No new changes to skin integrity noted. 11/23/2025: No new changes to skin integrity noted 11/24/2025: No new changes to skin integrity noted A record review of the wound therapy nurse's progress note (Skin/Wound note) dated 11/21/2025 showed the following: Resident skin assessed by writer/wound care nurse, no open areas seen at time of assessment, redness to groin and sacrum area seen at time of assessment, resident denies pain at time of assessment, wound care provider notified, new orders given, resident incontinent to bowel and bladder call light left within reach, will continue to monitor. Staff A, LPN/wound nurse. On 12/17/2025 at 2:15 p.m., an interview was conducted with the DON, Assistant Director of Nursing (ADON), and Risk Manager. The DON stated all admits will receive a standard order for skin prep to heels for a minimum of a 14-day period. A review of Resident #1's TAR for November showed documentation related to skin prep to heels as complete per shift by the nursing staff. The DON stated the nursing staff should have made an observation of Resident #1's heels during the application of the skin prep and to notify immediately of any skin concerns. The November 2025 TAR documentation did not show any records of turning and repositioning every two hours, floating heels off bed with pillows and use of wedges and heel protectors as assessed by the facility's MD. A record review of the facility's policy titled, Skin Care & Wound Management-Manage Wound Care, no date initiated or revised, showed the following policy statement: The facility will manage wound care based upon current standards of practice. The policy showed the following procedures but not limited to:1) When skin impairment is identified, the nurse will review and select the appropriate treatment protocol for the wound.6) The Interdisciplinary Team will develop a Care Plan to address identified skin impairment(s) which will include at a minimum, effort to stabilize, reduce or remove risk factors and describe treatment protocol.A record review of the facility's policy titled: Skin Care & Wound Management-Regular skin inspections and prompt interventions to address change, no date initiated or revised, showed the following policy statement: The facility will inspect the resident's skin on a regular and ongoing basis to provide documentation and prompt interventions of any changes noted. The policy showed the following procedures but not limited to:1) Skin inspections will be conducted by the licensed nurse using the Skin Sweep form for documentation at the time of admission and weekly.2) In addition, the Certified Nursing Assistant assigned to the resident will note the condition of the resident's skin during daily routine care and will report changes or areas of concern to the nurses assigned to the resident.3) Any identified skin impairment will be documented by the nurses at the time of discovery and weekly thereafter until healed using the appropriate wound log .If the skin impairment is pressure related, use the wound log. All non-pressure related skin impairments such as surgical wounds, etc. should be documented on the wound log. Event ID: Facility ID: 105891 If continuation sheet Page 5 of 5