Health inspection·May 27, 2021

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 5/26/21 the light was on at 10:12 a.m., multiple staff were observed passing by in the hallway without answering, the light was answered at 10:19 a.m.; on 05/26/21 the light was on at 2:00 p.m., there was housekeeper on the hall, at 2:06 p.m. and 2:08 p.m. staff walked by the door without answering, at 2:11 p.m. the resident's private caregiver was observed donning PPE outside the door, at 2:12 p.m. the DON was observed standing in the hallway talking to the caregiver, at 2:15 the private caregiver entered the room, the light remained on, at 2:18 p.m. a CNA was observed entering the room. During the call light observation beginning at 10:12 a.m. on 05/26/21, Staff B, Licensed Practical Nurse (LPN) and Staff C, Minimum Data Set (MDS) Coordinator were observed donning Personal Protective Equipment (PPE) outside of the room and Staff B entered the room at 10:19 a.m. (seven minutes had passed). Staff B said that the door could not be opened without first donning all required PPE according to facility policy. She was observed entering the room without the required eye protection and said that was because it's an emergency .the resident is on the floor. An interview was conducted with Staff B and Staff C on 05/26/21 at 12:47 p.m. Staff B reported that she had known that Resident #188 was on the floor before arriving to the room because the receptionist had told her. Staff B said that the receptionist had received a call from the resident's daughter informing her that the resident had fallen in her room while on the phone with her. Staff C said, I didn't know what happened, but I saw [Staff B] take off and so I thought, I'm a nurse, I might as well go .you know how it is. Staff B reported that when she entered the resident's room, she found her on her buttocks on the floor, the resident told her she was reaching for her television remote and denied pain or injury. Staff B completed a head-to-toe assessment with no findings of injury or concern. Staff C reported that the resident was confused and forgetful and said the resident did not tell us why the call light was on .I don't know if she even knew it was on. Both confirmed that at the time of Res. #188's fall her private sitter was not there; she was alone in the room. Staff B reported that she followed facility post-fall protocol including initiating neuro checks and notifying the resident's physician and family. Staff C reported that the resident had not fallen in the facility before, had been assessed upon admission to be at risk for falls, and interventions established at admission included low bed with side mats, staff to peek in every so often, and staff to check and change every two hours. Staff C said, If BIMS less than 9 I try to put them on a check and change. Staff C reported that the resident's family wanted the private caregiver with her at the facility because she had her at home, and said, as far as I know she's paid to be here by the family. Staff C confirmed that the private caregiver was only allowed to sit, not allowed to provide any hands-on care to resident in the facility. Call lights were still required to be answered by facility staff. An interview was conducted with the DON and Staff C on 05/26/21 at 2:15 p.m. They confirmed that the private sitter was something the family wanted in place, her schedule was Monday to Thursday generally between hours of 10:00 a.m. to 4:00 p.m., did not come Friday-Sunday, and functioned only as a sitter where in facility, paid by family, and had not been requested by the facility. The DON reported that there was no facility policy that the resident's door could not be opened to check on her without staff fully donning PPE and that there was no policy that mandated the door had to remain closed. The DON reported that there was no specific time standard for answering call lights, that the expectation was timely, and that she would consider answering a light within 6-8 minutes as reasonable. The DON confirmed that a wait of 15 minutes was a long time. The DON confirmed there was no facility policy regarding expectations for answering call lights and that no specific training was provided to facility staff on expectations. The DON followed up at 5/26/21 at 4:30 p.m. to report that she had initiated education with the staff on call light response based on the previous conversation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 2 of 7 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 106015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Andrew Post-Acute Rehabilitation Center 16702 North Dale Mabry Hwy Tampa, FL 33618 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 0689 Level of Harm - Minimal harm or potential for actual harm regarding Res. #188. An interview was conducted with the DON on 05/27/21 at 9:53 a.m. She revealed that post-fall interventions put in place for Resident #188 included 15-minute checks by nurse or CNA during times that private sitter was not there. 2. Residents Affected - Few Resident #28's hall was observed on 05/26/21 at 11:52 a.m.; no staff were observed on the hall. At 11:57 a.m. another resident across the hall from Res. #28's room called out that she needed to use the bathroom. At 12:28 p.m. Resident #28 was observed attempting to get out of bed, Staff A, CNA, was observed walking away down the hallway and was informed. By the time Staff A arrived at the room the resident had rolled out of bed and was on the mat on the floor next to the bed. Staff A assisted her into a side-lying position and called for a nurse. At 12:31 the facility Assistant Director of Nursing (ADON) arrived, and at 12:32 the resident's nurse arrived and began assessing the resident. Staff A was interviewed on 05/26/21 at 12:39 p.m. She said, she (Resident #188) does this all the time .has happened two or three times since she's been here when I've been working .she's very confused, doesn't use call light. Staff A confirmed that when she entered the room the resident was on all-fours and her head was under the bed frame. She said she didn't know if the resident hit her head. Staff A said, we keep the door open and check on her when we pass .lunch is hectic. At 12:42 the ADON exited the resident's room, confirmed head to toe assessment revealed no injury and said, this has happened before. Record review revealed that Resident #28 was admitted to the facility on [DATE] following a right hip fracture with surgical repair. Other diagnoses included history of falling, seizures, and dementia. The most recent completed MDS dated [DATE] revealed a BIMS score of 2 which meant that the resident had severe cognitive impairment. The MDS revealed that the resident required extensive assist from two persons for transfers and had a history of falls with injury. The care plan revealed a focus area for fall risk that included the following interventions: keep resident near concierge desk for high fall risk, poor safety awareness; right side of bed placed against the wall for safety; scoop mattress to prevent falls. Progress notes revealed the following: 05/16/21: Activities assistant notified nurse of resident found on floor on top of side mats . 05/25/21: Resident attempted to stand up from wheelchair alone x 3 despite offering fluids, food and toileting stated, 'I want to get on the floor.' Close monitoring in progress. 05/26/21: Around 12:30 while in nursing round upon entering to room observed resident lying on floor mat next to bed positioned on right side of body, stated 'I was trying to get up . Review of the facility incident log revealed entries for Resident #28 of alleged fall on 05/16/21 and 05/19/21. An interview was conducted with the DON on 05/27/21 at 9:15 a.m. She confirmed that the resident had been assessed to be at risk for falls upon admission and that the following preventive measures had been put in place at that time: bed against the wall (family request); bed in lowest position; floor mat when in bed, call light in reach, check on her every two hours. The DON said that checking on residents every two hours was a facility standard and was not something that got documented. She confirmed that the fall on 05/26/21 was the resident's third fall since her admission to the facility. The DON reported the first fall was on 05/16/21 at 2:00 p.m., she got out of bed and was found (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 3 of 7 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 106015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Andrew Post-Acute Rehabilitation Center 16702 North Dale Mabry Hwy Tampa, FL 33618 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sitting on the mat .could not say what she was doing .no injury .initiated scoop mattress as customized intervention. She reported that the second fall occurred on 05/19/21 at 2:20 p.m. when the resident again attempted to climb out of the bed and was found on the floor on her right hip. The DON reported that the resident's daughter had not wanted her sent out, so a mobile x-ray was completed of her right hip and revealed no injury. The intervention put in place at that time was to place the resident in front of the concierge desk between care, meals, and therapy sessions so she could be supervised. The DON reported that the following had been put in place following the fall on 05/26/21: staff instructed not to leave Resident #28 alone in her room; 15-minute checks would be started today by nurses and CNAs; next step will probably be one on one in the daytime. The DON confirmed that it was facility responsibility to keep resident safe and that they could provide one on one if needed. Review of facility policy titled, Accidents/Incidents effective 02/29/16 revealed the following within the policy statement, It is the community's policy to provide an environment that is free from hazards over which the community has control. The intent of this policy is that the community identifies each resident at risk for accidents and/or falls, and adequately plans care and implements procedures to prevent accidents . Action steps outlined in the policy included, .In the event an accident or incident occurs the Licensed Nurse: .g. Initiates measure to prevent a re-occurrence, including validating that each resident receives adequate supervision and assistance to prevent accidents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 4 of 7 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 106015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Andrew Post-Acute Rehabilitation Center 16702 North Dale Mabry Hwy Tampa, FL 33618 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one Resident #31 received indwelling catheter care to reduce the potential for infection by storing and reusing used catheter bags observed with urine in a plastic bag hanging from the safety rail in the bathroom for 2 of 4 days of 5 residents with urinary catheters. Findings Included: During an interview with Resident #31 on 5/24/21 at 11:40 a.m. she stated she was new to using an indwelling catheter and gets a leg bag that is removed and placed in the bathroom until the next day whey the same bag is put back on while she is out of bed. The resident was observed wearing a drain bag laying in bed and said she was waiting for a shower to go to therapy. Resident #31 was observed on 5/24/21 at 11:48 a.m. going to the shower room with a leg bag on for her shower. Photographic evidence obtained of catheter bags in the the bathroom. During an interview on 5/24/21 at 3:10 p.m. with Staff member A, CNA she confirmed she changed Resident #31 from the urinary bed bag to the leg bag. Staff member A, CNA confirmed the bed bag is removed from the resident and goes in the trash bag which is tied to safety rail. Staff member A, CNA confirmed the urine bag is emptied when changed out and does not clean out the bag. Staff member A, stated she does clean the tube with alcohol sometimes. During observation and confirmation of the urine bags hanging in the bathroom Staff member A, CNA confirmed on 5/24/21 at 3:16 p.m two leg bags and one drain bag containing dark yellow brown urine in each bag. Staff member A, CNA also stated one leg bag did not have the cap attached to the bag. During an interview on 5/24/21 at 3:17 p.m with Staff member B, LPN, she stated it was facility protocol to remove the urine bags and place them in a plastic bag in the bathroom as long as the bags were emptied and checked for tears or spills prior to use. Observation of two leg bags with urine hanging in the bathroom on 5/25/21 at 10:21 a.m. Photographic evidence obtained. During an interview on 5/25/21 at 10:45 a.m. the Assistant Director of Nursing (ADON) stated the facility does reuse the catheter bags but does not have a policy on reuse of the catheter bag or how to clean and store the bag. She stated the facility uses nurses discretion and the physician order that stated to change the bags weekly. The ADON confirmed three used catheter drainage bags with urine were in two plastic bags. One leg bag, dated 5/19/21 and two leg bags, dated 5/12/21. The ADON confirmed the bed bag that was on the resident was dated 5/20/21. The ADON stated the aides should be rinsing out the catheter bags prior to placing them in the plastic bag and they should be used for one week. The ADON disposed of the three bags and said she would start an inservice. During an interview with the Director of Nursing (DON) on 5/25/21 at 12:15 p.m. she was asked to provide the instructions for use on the drain bag and bed bag. The ADON brought in a document typed by the DON on 5/25/21 at 12:20 p.m. signed by the DON titled: Instructions for usage of Foley catheter bags: it is the practice of [NAME] Gardens of [NAME] certified nursing assistants can rinse the Foley catheter leg bag or the large drainage bag with soap and water and store in plastic bag labeled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 5 of 7 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 106015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Andrew Post-Acute Rehabilitation Center 16702 North Dale Mabry Hwy Tampa, FL 33618 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 0690 Level of Harm - Minimal harm or potential for actual harm with the resident room number and date in the bathroom for up to seven days, unless bag is leaking, then bag will be discarded and notification to the nurse will be made. Signed by the DON Resident #31 was admitted on [DATE], diagnoses included neuromuscular dysfunction of bladder, urinary tract infection. Residents Affected - Some Review of the medical certification for medicaid long-term care services and patient transfer form (3008) revealed the resident had urinary retention due to Vancomycin-resistant enterococcus (VRE) urinary tract infection (UTI). Review of the physician orders revealed: Change catheter drainage bag every Wednesday 11 to 7 shift every night shift every Wednesday dated 5/1/21. Review of care plan revealed a focus area of indwelling catheter. Goal to show no signs or symptoms of urinary infection through review date, initiated on 5/1/21. Interventions to change catheter as ordered by physician, initiated on 5/1/21. During an interview with the Advanced Registered Nurse Practitioner (ARNP) on 5/26/21 at 1:13 p.m. she stated she was told the staff emptied the urine bags before hanging them in the bathroom in a plastic bag and she would expect the bags to be emptied and rinsed prior to reusing them. During an interview on 5/26/21 at 12:45 p.m. the DON stated the facility had a template order to change the leg and drain bag once a week. The DON stated her expectation would be to rinse leg or drain bag with water and soap. The DON confirmed she never contacted the company or looked on the company website to find a cleaning protocol to verify the bags could be reused. The DON stated the facility does not have a policy on how to clean or store the urine bags. The DON confirmed the facility has 5 residents that use the catheter bags and stated the staff were instructed to dispose of all drainage bags earlier today. A phone call to the catheter bag manufacturer on 5/25/21 at 1:48 p.m. revealed the leg and drain bag can be reused as long as they are cleaned according to the instructions for use. The manufacturer emailed the instructions for use indicating Cleaning your drain and leg bag: mix cleaning solution: either 2 parts of vinegar and 3 parts water or 1 tablespoon of chlorine bleach and 1/2 cup of water. Step 1. Empty the bag of urine, and then close the drainage spout. 2. Place tubing under the faucet, putting warm water into the bag. 3. Swish it around for 10 seconds, and then empty it through the drainage spout. Close the spout. 4. Pour cleaning solution into the bag. Put the protective cap on the connector. 5. Swish solution around for 30 seconds, and then let it sit in the bag for 20 minutes. Empty through the drainage spout. 6. Keep spout open and pointed down. Hang the bag to dry until switching bags again. 7. Remember to close the spout when attaching it to the catheter. Review of the the facility Foley catheter care skills checklist, dated 2017, 9 pages, revealed: 12. Fill the bag with cleaning agent. 2 parts vinegar and 3 parts water or 1 part bleach to 10 parts water. 13. Swish the cleaning agent around to get hard to reach areas. 14. Allow the cleaning agent to remain in the bag 20 to 30 minutes. 15. Drain the cleaning agent by opening the drainage spout/clamp. 16. Rinse the bag with tap water. 17. Hang the bag to drain and dry. 18. Remove your gloves and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 6 of 7 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 106015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Andrew Post-Acute Rehabilitation Center 16702 North Dale Mabry Hwy Tampa, FL 33618 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 0690 wash your hands. 19. Clean bags daily and use new bags at least every 30 days. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 7 of 7