Inspection·January 14, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's policy titled, Urinary Catheter Indication and Maintenance (Urethral and Supra-pubic), revealed the catheter tubing and drainage bag should be maintained off the floor with a privacy bag as appropriate. On 01/13/22 at 12:21 p.m., the DON stated the supervisor does rounds daily and makes sure that everything listed on the [Provider Name] Surveillance Rounds document has no issues. The DON stated the supervisor makes note of the issue and immediately does education with the staff, but no documentation was kept when education was provided. A review of the Surveillance Rounds document revealed resident rooms are checked daily for privacy practices to include catheter privacy bags. Event ID: Facility ID: 106006 If continuation sheet Page 2 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baldomero Lopez Memorial Veterans Nursing Home 6919 Parkway Blvd Land O Lakes, FL 34639 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to establish a communication process to ensure hospice services were provided in accordance with the hospice agreement and plan of care for one (#56) of one resident sampled for hospice services out of three facility residents receiving hospice care. Findings included: Review of Resident #56's medical record revealed that current physician orders dated [DATE] to Admit to hospice for full services for end stage dementia. Interview on [DATE] at 8:35 AM with Staff A, Certified Nursing Assistant (CNA), revealed that the resident was on hospice and that hospice comes in about 2 times a week. Interview on [DATE] at 8:38 AM with Staff B, Licensed Practical Nurse (LPN), revealed that the resident was on hospice and that hospice comes in 2 times a week. She was not sure if they had come yet this week, but stated they also call routinely to check on the status of the resident. She reported that if there are any changes with the resident, the hospice nurse was notified. She reported that there was a hospice book kept at the nurses station and provided the book. Interview on [DATE] at 9:09 AM with Staff C, Registered Nurse (RN)/Unit Supervisor, confirmed that hospice comes in at least 2 times a week and that the facility communicates any concerns with the hospice team. Review of the hospice book located at the nurses station revealed a Patient Sign-In and Patient Care Log. This form documented vital signs, weights, arm circumference and date of the resident's last bowel movement. Continued review of the form for Resident #56 revealed that hospice staff last documented on this form over 8 months ago, on [DATE], by Staff E, Hospice RN. Continued review of the hospice book revealed that it contained a document titled Hospice Visit Summary. The last Hospice Visit Summary form noted to be in the book was dated over 10 months ago, on [DATE] and completed by Staff E, Hospice RN. Closer review of the [DATE] Hospice Visit Summary revealed that Staff E had included a hand written note which documented a completed visit on [DATE]. The last clinical note present in the hospice book for Resident #56 was dated [DATE]. Phone interview on [DATE] at 9:42 AM with Staff E, Hospice RN, revealed that she was in the facility to see the resident last week, and she comes to see the resident once within a 14 day period. She reported that although the frequency in the plan of care is 1-3 times a week that was only for when there was a change in status. If no change in status occurs, she comes once within a 14 day period. She reported that she does complete progress notes for each visit, but they are in her computer. She reported that she gets too busy so the paperwork does not get filed, but she does speak to the resident's nurse during each visit. Interview on [DATE] at 10:25 AM with the Director of Nursing (DON) revealed that hospice typically does not leave a note at the time of the visit but will send a note once it is completed. She reported that she will check with medical records for documentation. She was not aware that hospice was not providing their notes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106006 If continuation sheet Page 3 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baldomero Lopez Memorial Veterans Nursing Home 6919 Parkway Blvd Land O Lakes, FL 34639 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on [DATE] at 11:10 AM with Staff F, the Social Worker for Hospice, revealed that she writes a progress note for every visit. She stated that the progress notes were shared with the facility. In addition, she will do a report on the phone with the facility and document that in the clinical notes held by hospice. She reported that nurses notes were kept at the nurses station in a folder. Follow-up interview on [DATE] at 12:09 PM with the DON revealed that Social Services was responsible to complete audits of the hospice books. If there were missing notes, they (Social Services) should reach out to hospice and get the notes. Interview [DATE] on 12:29 PM with Staff G, Social Work Service Program Manager, revealed that the facility has two social workers in the building and that they are both assigned to audit hospice books. She reported that when the hospice books are audited they make sure that there is a recertification, a current care plan, a contact sheet, a contract, and notes. She reported that typically they should be leaving the notes. Staff G reported that audits were done quarterly, and if there were missing items then they request the missing items from hospice. Review of the audit dated [DATE] revealed a note indicating request under Question #7, Visit reports completed when hospice services provided. There was no documentation or supporting documentation that would indicate that the request was made for the missing notes. Review of an audit dated [DATE] revealed a check mark indicating a yes response to Question #7, Visit reports completed when hospice services provided. Review of an audit dated [DATE] revealed Question #7, Visit reports completed when hospice services provided had a hand written note in the box of 4-29. Review of an email from the facility social worker dated [DATE] revealed the first request to get hospice paperwork. Review of the email revealed the last recertification and plan of care on file in the facility for Resident #56 was expired and dated [DATE] and the nurses's last log in date was [DATE]. On [DATE] at 12:09 p.m., the DON provided the notes that were sent over from hospice. Review of the provided notes revealed they were dated from [DATE] to [DATE] and had a print date of [DATE]. The DON reported that she was not sure why the facility audits did not consistently reveal missing notes. Review of the hospice plan of care provided revealed the the patient was being recertified in the hospice program from [DATE] to [DATE]. Treatments included Skilled Nursing (SN) 1-3 times per week for 9 weeks and 4 PRN: [as needed] weekly for change in status. Review of the Hospice Agreement signed and dated February 2021 revealed that in section 4.1 Compilation of Records revealed (a) Preparation. FACILITY and Hospice shall each prepare and maintain complete and detailed clinical records concerning each Hospice Patient receiving services under this agreement in accordance with prudent record keeping procedures, their own policies and procedures, and applicable federal and State of Florida laws and regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106006 If continuation sheet Page 4 of 4