Health inspection·September 9, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm date 8/19/22- refused 8/22, 8/28, 8/29, 8/30 and 8/31/22, 9/2, 9/4, 9/5, 9/6 and 9/7/22. Facility failed to notify the physician. -bupropion HCI ER (SR) 150 MG for Depression- refused on 9/2, 9/4, 9/5, 9/6 and 9/7/22. Documentation was not present of notification to the physician. Residents Affected - Few A review of Resident#346 plan of care for Depression indicates as an intervention to administer antidepressant medications as ordered by physician date initiated 8/18/22. Care plan for nutrition with an effective date of 8/18/22 indicates to administer Liquid Protein as ordered. On 9/8/2022 an interview was conducted with Staff H, Licensed Practical Nurse (LPN). He reported the MAR should be coded as a refusal of medication, followed by the medication note and the physician should be notified. On 9/8/2022 at 9:15 a.m. the Director of Nursing (DON) was interviewed. He reported staff must document the refusal and follow up with notification to the physician and document. He was made aware of Resident#346 ongoing refusals for medications and the lack of notification. On 9/09/2022 at 11:27 a.m. a telephone call was made to Resident#346's Physician and a voicemail was left. A return call was received at 12:01 p.m. He confirmed he would need to be notified of medication refusals. At 12:07 p.m. a telephone call was also made to the Nurse Practitioner who reported the facility called her yesterday to have a psychiatry evaluation to determine why the resident was refusing medications. She said the facility notified her of medication refusal in August and September yesterday. A facility policy was requested; however, none was provided by completion of the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 2 of 19 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 09/09/2022 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a report was filed as a formal grievance and acted upon, for one (#37) of 19 sampled residents related to missing clothing. Findings included: During the initial tour conducted on 09/06/22 at 10:41 AM, Resident#37 stated she had no clothes since she arrived. She had notified staff and feels they are not doing anything. Resident#37 reported she had been at the facility since 8/19/22. She stated, No one has gone to get my clothes from my home. With permission from the resident an observation of her closet was made. The closet had one item hanging which was a gray sweater. She stated the sweater did not belong to her. The clothing cabinet drawers were observed empty, she confirmed they have been like that since she arrived to the facility. The resident was observed sitting on the edge of her bed with a white sweatshirt and no bottoms. She confirmed the sweatshirt was brought for her today but did not have any pants on. A record review was conducted for Resident #37 which revealed she had been initially admitted to the facility on [DATE] with a readmission date of 8/19/22 with multiple diagnosis not limited to head injury and lack of coordination. A review of Resident#37 MDS (minimum data set) for cognition dated 8/12/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating cognitively intact. On 09/07/22 at 11:25 AM an interview with Director of Nursing (DON), who confirmed the resident had no clothing, and the facility was aware. The DON reported they have been trying to get clothing for her from her home. The facility was aware of the voiced concern and did not file a concern for the resident until she voiced her concern to the surveyor on 09/06/22. An additional interview with Resident#37 was conducted on 09/08/22 at 10:54 A.M. Resident#37 reported she still did not have any clothing. She said the Laundry did bring her a pink shirt and a pair off leggings, which she was wearing. An observation, with the resident's permission, of her closet revealed one grey sweater, and the drawers were empty. On 09/09/22 at 11:42 A.M. an interview with Social Service Director was conducted. She confirmed she had no prior knowledge of the resident's missing clothing until she was informed by on 9/7/22. She provided a copy of the grievance, completed on 9/7/22 and a letter to the resident's family member requesting clothing, dated 9/7/22. She confirmed she did not attempt to get clothing for the resident prior to 09/07/22 as she was not aware of the issue. A review the facility Grievance policy with a revision date of 2017 indicated residents and their representatives have a right to file a grievance, either orally or in writing, to facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 3 of 19 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 09/09/2022 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an accurate comprehensive assessment for one (#13) of one residents reviewed. Findings Included: Medical record review of Resident #13 minimum data sheet (MDS) dated [DATE] reflected a restraint was used. The restraint was coded as used daily and used in chair or out of bed and coded: Other. On 09/06/2022 at 12:20 p.m. Resident #13 was observed sitting in a high back wheelchair in the dining room eating his lunch. His legs were elevated and resting on foot pedals. No restraints were identified at the time. On 09/07/2022 at 03:37 p.m. an interview was conducted with the Minimum Data Sheet Coordinator (MDSC), who stated the restraint was an abdominal binder for his peg tube. She said the binder was to prevent him from pulling the tube out. The MDSC was asked about the peg tube placement as he was observed eating orally. The MDSC stated his peg tube was removed and did not recall the date. Further review of the MDS dated on 07/04/2022 revealed the box was checked indicating resident had a feeding tube while a resident. Medical record review of a physician progress note dated 06/09/2022 Digestive Disease Reason for appointment 1. Peg tube removal. History of Present Illness Gastrostomy Malfunction: Mr. (Resident #13 name) is here for gastrostomy malfunction. The peg tube was no longer needed because patient is eating without difficulty. Treatment notes: Peg tube was removed without difficulties. On 09/07/2022 at 3:57 p.m. during an interview, the MDSC stated I just pulled over the prior assessment and did not review the areas indicating Resident #13 did not have a peg tube or a restraint during the assessment period on 07/04/2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 4 of 19 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 09/09/2022 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Baseline admission Care Plan was completed with the input of Resident#37, and that a summary was provided to the resident for one (#37) of 18 sampled residents. Findings included: A review of the Baseline Care Plan policy for the facility dated 8/25/2022 revealed the following: the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality of care. UNDER THE HEADING Policy Explanation and Compliance Guideline reads: The base line care plan will be developed within 48 hours of a resident's admission. #3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. #4. A written summary of baseline care plan shall be provided to the resident and representative in a language that the resident or the representative can understand. The summery shall include, at a minimum, the following: A.- the initial goals of the resident. B. -a summary of the residents' medications and dietary instructions. C. -services and treatments to be administered by the facility and personnel acting on behalf of the facility. #5-A supervising nurse or MDS coordinator is responsible for providing the written summary of the baseline care to the resident and representative. 6.- The person providing the written summary of the baseline care plan shall: A.- Obtain a signature from the resident/representative to verify that the summary was provided. B.- make a copy of the summary for the medical record. A record review was conducted for Resident #37 which revealed she was initially admitted to the facility on [DATE] with a readmission date of 8/19/22 with multiple diagnosis not limited to head injury and lack of coordination. A review of Resident#37 MDS (minimum data set) for cognition dated 8/12/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating cognitively intact. During an interview with Resident#37 on 9/6/22 at 10:41 a.m. Resident#37 reported she never participated in her plan of care and was not provided with a copy of the treatments and services. A review of the medical record revealed no entries for a baseline plan of care or that a summary was provided to the resident. On 9/9/22 at 9:00 a.m. an interview was conducted with the Director of Nursing (DON). He reported the care plan should be in the electronic medical record. He confirmed the residents' medical record was silent in regard to a baseline plan of care and the resident's participation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 5 of 19 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 09/09/2022 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure 1.) skin condition was accurately assessed and documented for one resident (#27) of three residents reviewed; and 2.) wound care was provided as per Physician's orders for one resident (#10) of three residents reviewed. Residents Affected - Few Findings included: 1. Review of Resident #27's record revealed he was admitted to the facility on [DATE] has diagnosis that includes: Parkinson's disease, cognitive communication deficit, Major depressive disorder, and shortness of breath. Review of the skilled nursing note dated 9/1/22 indicated the resident is oriented to person and has impaired decision making ability. Observations of Resident #27 on 09/06/22 at 11:06 AM revealed the resident lying on his bed with his right tennis shoe on and his left tennis shoe off. The residents left foot was noted to be red with abrasions, and had no socks on. Observations on 09/06/22 at 11:50 AM of Resident #27 revealed him seated in the dining room for his midday meal. The resident was noted to be wearing his tennis shoes with no socks to cushion his feet. Observations on 09/06/22 at 12:38 PM revealed the resident lying on his bed. It was noted at this time the resident had bare feet and black wounds were noted to the toe area on bilateral feet, with his toenails long and not manicured. Skilled nursing note dated 9/6/22 indicated that the resident has no current skin impairments. Skilled nursing note dated 9/5/22 indicated that the resident has no current skin impairments. Skilled nursing note dated 9/4/22 indicated that the resident has no current skin impairments. Skilled nursing note dated 9/3/22 indicated that the resident has no current skin impairments. Skilled nursing note dated 9/2/22 indicated Rash to trunk and thighs, no mention of feet skin impairments. Skilled nursing note dated 9/1/22 indicated Rash to trunk and thighs, no mention of feet skin impairments. Interview on 09/07/22 at 11:36 AM with the Director of Nursing (DON) revealed the resident's skin check dated 9/2/22 revealed the resident had Rash to Trunk, redness to left heel, bruising on dorsal left foot. He reported nurses notes should indicate what is actually present, and that the expectation is for staff to provide foot care. Interview on 09/07/22 at 12:48 PM with the Social Service Director revealed she sets up podiatry services, but did not know if Resident #27 had been seen by the podiatrist. Review of the physician order dated 8/19/22 revealed the following: Weekly Skin evaluation FRIDAY (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 6 of 19 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 09/09/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 7-3 Shift -Complete weekly check in [electronic medical record] evaluations. every day shift every Fri for monitoring **Report all new positive findings to the treatment nurse Immediately** RECORD IN SKIN: HEAD TO TOE ASSMNT Review of the Head to Toe Weekly Skin Checks dated 8/26/22 revealed the following: Resident has existing skin impairment, Resident nails cleaned and trimmed, Existing Bruise Existing rash-Right toe(s) - Pressure: Length = .6cm, Width =, Other (specify): dorsal left foot: Bruising: Width = , Right elbow - Other (specify): scab: Width =, Left elbow - Other (specify): scab: Width =, Right heel - Other (specify): redness: Width =, Left heel - Other (specify): redness: Width =, - Other (specify): BUE TRUNK BACK THIGH: - Rash: Width =, Review of the Head to Toe Weekly Skin Checks dated 9/2/22 revealed the following: Resident has existing skin impairment-Resident nails cleaned and trimmed-Existing Bruise Existing rash-Right toe(s) - Pressure: Length = .6cm, Width =, - Other (specify): dorsal left foot: - Bruising: Width =, Left heel - Other (specify): redness: Width =, - Other (specify): BUE TRUNK BACK THIGH: - Rash: Width =, Resolved Bruise, Skin impairment resolved on Review of the Head to Toe Weekly Skin Checks dated 9/7/22 revealed the following: Resident has existing skin impairment, Resident nails cleaned and trimmed, Existing rash discoloration and eschar-Right toe(s) Other (specify): eschar: Length = .8cm, Width = .6, Depth = 0, - Stage Unstageable, - Other (specify): dorsal left foot: - Other (specify): redness: Width =, Left toe(s) - Other (specify): discoloration: Width =, Right toe(s) - Other (specify): discoloration: Width =, Left toe(s) - Other (specify): discoloration: Width =, Left heel - Other (specify): callus: Width =, - Other (specify): BUE TRUNK BACK THIGH: - Rash: Width =, Interview on 09/07/22 at 03:18 PM with the Regional Director of Risk Management and the DON revealed an Assessment done by a nurse today 9/7/22 should be accurate and reflect both of the residents feet. They confirmed that there was no documentation in the record that would indicate the the physician had been notified of the residents wounds. They reported that assessments should be accurate and reflect the actual condition of the residents skin. Review of the facility policy titled Provision of Physician Ordered Services dated 8/25/22 revealed the following: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. 2. On 09/06/22 at 12:49 p.m. Resident #10 was observed sitting up in bed, smiled when approached and was receptive to an interview. Her lower legs were noted wrapped with a kerlix dressing. On closer observation the dressing did not contain a date that would indicate when the dressing was last changed. The right dressing contained a dark yellow shadow drainage. Resident #10 had a personal care giver in the bedroom with her at the time. The care giver said she has been caring for the resident three days a week for over two years, and confirmed the dressing to her legs did not contain a date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 7 of 19 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 09/09/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Medical record review of the admission Record form revealed Resident #10 had resided at the facility just over a year and was geriatric in age. Diagnosis information listed peripheral vascular disease, peripheral vascular angioplasty status, non-pressure chronic ulcer of skin of other sites with fat layer exposed. Review of the wound Visit Report by the Advanced Practical Registered Nurse (APRN) Certified Wound Specialist dated 09/01/2022 revealed assessment of wound #2 left posterior left lower leg chronic full thickness arterial ulcer orders to Cleanse wound with normal saline Apply collagen- with hydrogel gauze and dry dressing (DD) every day (QD). Wound #3 left medial ankle is a chronic full thickness arterial ulcer orders to: Cleanse with normal saline, apply collagen with hydrogel gauze and DD QD Wound #9 Left lateral ankle -there is no change noted in the wound progression. Orders to Cleanse wound with normal saline apply collagen with hydrogel gauze and DD QD Wound #10 Right posterior Lower Leg orders to: Cleanse wound with normal saline apply collagen with hydrogel gauze and DD QD. Review of Resident #10 treatment administration record (TAR) did not reflect the APRN orders from 09/01/2022. It reflected orders that were dated on 08/10/2022 to cleanse left lateral ankle with normal saline (NS) soaked gauze, pat dry, and apply collagen to wound beds, cover with abdominal (ABD) pads and dry dressing (DD)/Kerlex tape; every night shift every 3 day(s) for arterial ulcers start date 08/10/2022. Cleanse Left Medial Ankle with NS-soaked gauze, pat dry, and apply collagen to wound beds, cover with ABD pads and DD/Kerlex tape; every night shift every 3 day(s) for arterial ulcers start date 08/10/2022. Cleanse left posterior lower leg with NS-soaked gauze, pat dry, and apply collagen to wound beds, cover with ABD pads and DD/Kerlex tape; every night shift every 3 day(s) for arterial ulcers start date 08/10/2022. Cleanse Right Posterior Lower Leg ankle with normal saline (NS) soaked gauze, pat dry, and apply collagen to wound beds, cover with ABD pads and DD/Kerlex tape; every night shift every 3 day(s) for arterial ulcers start date 08/10/2022. On 09/07/2022 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON); he confirmed the Wound APRN comes to the facility weekly. He stated last week (09/01/2022) Staff Member H Licensed Practical Nurse had made rounds with her at the time. On 09/07/22 02:59 p.m. an interview was conducted with Staff Member H and indicated he had performed rounds with the Wound APRN. He said during the rounding the APRN will discuss changes that are needed to the treatments. He said prior to APRN leaving the facility for the day she always prints out her reports that can include changes to treatments. He was asked if he reads the reports he stated yes and confirmed that he will make the changes in the TAR. Staff H stated I didn't go with the APRN on 09/01/2022. The DON went with her that week On 09/08/2022 at 09:15 a.m. an interview was conducted with the Wound APRN and confirmed she sees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 8 of 19 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 09/09/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #10 every week. She confirmed she had changed the resident wound orders last week from every three days to daily. She said it was due to the amount of drainage the wounds were producing. And due to the delay in wound progression. The APRN confirmed at that time it is her expectation her orders are followed. Review of policy Wound Treatment Management dated 8/25/22 Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physicians orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type if dressing, and frequency of dressing changes. Event ID: Facility ID: 106015 If continuation sheet Page 9 of 19 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 09/09/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #27's record revealed that he was admitted to the facility on [DATE] has diagnosis that includes: Parkinson's disease, cognitive communication deficit, Major depressive disorder, and shortness of breath. The review of the skilled nursing note dated 9/1/22 indicated that the resident is oriented to person and has impaired decision making ability. Residents Affected - Some Observations of the resident on 09/06/22 at 11:06 AM revealed that a oxygen concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Observations of the resident on 09/06/22 at 11:50 AM revealed that a oxygen (O2) concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Observations of the resident on 09/06/22 at 12:38 PM revealed that a oxygen concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Observations of the resident on 9/7/22 at 8:41 AM revealed the resident lying on his bed, with the O2 concentrator not running and the tubing bagged, The resident was noted with no O2 on. observations of the labeled tubing still indicated a date of 8/24/22. Observations of the resident on 09/07/22 at 10:31 AM revealed that a oxygen concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Observations of the resident on 09/07/22 at 11:28 AM revealed that a oxygen concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Review of the residents current physician orders revealed an order dated 8/19/22 which indicated the following: O2 at 2liter/min via nasal cannula continuous for sob/comfort-every shift related to SHORTNESS OF BREATH Review of the September treatment administration record (TAR) revealed that the resident was administered O2 on all 3 shifts for 9/6/22 Review of the residents care plan dated 8/22/22 revealed the following: The resident has oxygen therapy r/t Ineffective gas exchange, with interventions that included Give medications as ordered by physician. Monitor/document side effects and effectiveness. If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal. Review of the skilled nursing noted for the month of September revealed the following: Skilled nursing note dated 9/6/22 indicates N/A for respiratory. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 10 of 19 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 09/09/2022 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 0695 Skilled nursing note dated 9/5/22 indicates N/A for respiratory. Level of Harm - Minimal harm or potential for actual harm Skilled nursing note dated 9/4/22 indicates N/A for respiratory. Skilled nursing note dated 9/3/22 indicates N/A for respiratory. Residents Affected - Some Skilled nursing note dated 9/2/22 indicates N/A for respiratory. Skilled nursing note dated 9/1/22 indicates N/A for respiratory. Interview on 09/07/22 at 11:29 AM with Staff D, Licensed Practical Nurse (LPN) revealed that there is no documentation in the TAR yet for her residents because she has not yet started her treatments. Interview on 09/07/22 at 11:36 AM with the DON, confirmed that he did not see an order for changing O2 tubing but in the absence of an order the tubing should be changed weekly. the DON confirmed that current tubing for Resident #27 is more than a week old per the existing labeled tape. (Photographic evidence obtained) The DON confirmed that based on the physician order the resident should be getting O2 continuously which means at all time. He reported that the expectation is to follow the doctors orders for O2 use. Review of the facility policy titled Oxygen Administration dated 8/25/22 revealed the following: b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Review of the facility policy titled Provision of Physician Ordered Services dated 8/25/22 revealed the following: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided according to professional standards of practice for three (#19, 28, 146) out of four residents sampled. Findings Included: 1. On 09/06/22 at 12:33 p.m. Resident #19 was observed sitting in her wheelchair in her bedroom, and smiled when approached. Resident #19 stated I can't leave my room as she pointed to her nose that contained oxygen tubing. The tubing was attached to concentrator, which was turned on and registered at 2 liters. The tubing reflected the date 08/24/2022. Additionally on the bedside table a small volume nebulizer machine was observed with the tubing and mask dated 08/24/2020. The nebulizer aerosol mask was lying on top of a gait belt and not stored in a clean manner (photographic evidence obtained). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 11 of 19 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 09/09/2022 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 0695 Level of Harm - Minimal harm or potential for actual harm On 09/07/22 at 11: 00 a.m. Resident #19 was observed sitting up in her wheelchair with nasal cannula in place and attached to the concentrator running at 2 liters. On 09/08/2022 at 2:34 p.m. resident #19 lying in bed sleeping with oxygen running at 2 liters per nasal cannula. Residents Affected - Some Medical record review revealed Resident #19 Physician orders for small volume nebulizer 3 ml Ipratropium-Albuterol solution 0.5-2.5 mg (3) MG (milligram)/3ML (milliliter) via neb (nebulizer) every (Q)12 hours (H) dated 8/15/2022 for pneumonia (PNA) supplementary, and Oxygen at 2L (liters) via nasal cannula to maintain a sat (saturation) above 90 as needed related to chronic obstructive pulmonary disease start date 08/14/2022. Review of the medication administration record did not reflect the use of the oxygen on 09/06/2022, 09/07/2022 nor on 09/09/2022. Further review of the Vitals Summary reflected the use of oxygen on 09/02/2022, 09/03/2022, 09/04/2022, 09/05/2022, 09/07/2022 and 09/08/2022. Review of the treatment administration record did not contain orders to change oxygen tubing nor nebulizer equipment weekly. On 09/08/2022 at 4:00 p.m. an interview was conducted with the Director of Nursing, who confirmed if an as needed order (PRN) is being used it should be documented. 2. On 09/06/22 at 12:41 p.m. Resident #28 bedroom revealed a small volume nebulizer machine with oxygen tubing attached that was dated 08/24/2020. The tubing was attached to an aerosol mask that was not stored in a clean nor sanitary manner. Medical record review contained physician orders for Albuterol Sulfate Nebulization Solution 1.25 MG/3ML 1 applicator inhale orally one time a day for COVID/Pneumonia (PNA) start Date 07/12/2022. Review of the treatment administration record (TAR) read to change nebulizer mask and tubing every week by respiratory therapist (RT) every day shift every Tue for Infection control Start date 10/13/2020. The TAR revealed documentation on 09/06/2022 that the nebulizer mask and tubing were changed yet photographic evidence does not depict. 3. On 09/06/22 at 12:19 p.m. random observation revealed Resident # 146 oxygen tubing stored on the floor. Upon closer observation the tubing did not contain a date. On 09/08/2022 at 4:00 p.m. an interview was conducted with the Director of Nursing, who confirmed oxygen tubing should not be stored on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 12 of 19 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 09/09/2022 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure communication and coordination with an external service were conducted on days of treatment for one (#32) out of three residents who receive hemodialysis. Residents Affected - Few Findings Included: On 09/06/22 at 10:05 a.m. Resident #32 call light was on she stated, I going to dialysis pretty soon and I'm waiting for the nurse to apply cream to my site. The resident said she was at the facility for short term therapy services and was hoping to return home some. Medical record review for Resident #32 revealed admission to the facility a month prior. Diagnosis information read dependence on renal dialysis, acquired absence of kidney, and end stage renal disease. On 09/07/22 at 11:30 a.m. an interview was conducted with Staff Member N, Licensed Practical Nurse, who said the normal process when a resident has a dialysis appointment the nurse is to perform the pre-dialysis assessment. After the resident returns a post dialysis assessment is completed, and the dialysis center communication form is completed and reviewed for any changes or new orders. On 09/07/2022 at 11:55 a.m. the Regional Director of Risk Management was asked where the communication forms were located for Resident #32 outside dialysis services. She stated, we have a difficult time getting communication forms from dialysis center. Review of Resident #32 Pre/Post Dialysis forms and the Dialysis Communication Form form from 08/04/2022 to 09/06/2022 revealed the following omissions of either pre-dialysis, post-dialysis or the outside Dialysis Communication Form on 08/04, 08/06, 08/13, 08/18, 08/20, 08/23, 08/25, 08/27/2022, 08/30, 09/01, 09/03, and 09/06/2022, indicating a lack of communication between the two entities. Review of Care Plan with a focus on Renal failure with dialysis. The goal: Resident will be free of complications at dialysis access site thru next review. The Interventions included: review Dialysis communication form(s). Review of policy tilted Hemodialysis dated 08//20/2022 Policy This facility will provide the necessary care and treatment, consistent with professional standards of practice. Purpose: Ongoing communication and collaboration with the dialysis facility regarding dialysis care ands services. Definitions: End stage Renal Disease - the stage of renal impairment that appears irreversible and permeant and requires a regular course of dialysis or kidney transplantation to maintain life. Dialysis- A process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane. The two types that are currently common are hemodialysis (HD) and peritoneal dialysis (PD). Review of the Nursing Facility Dialysis Agreement that did not contain a date C. Communication Nursing facility shall reasonably cooperate with center. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 13 of 19 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 09/09/2022 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure a paid caregiver for one (Resident#30) of 18 sampled residents had specific competencies and skill sets necessary to care for the Resident#30 care needs. Findings included: During an observation of Resident#30 on 9/6/22 at 2:49 p.m. a private paid caregiver (Staff C) was observed providing care. An immediate interview with private sitter who was providing perineal care to Resident#30 was conducted. She reported she has been his private paid caregiver for the last three years. She was asked if she is here everyday and reported that she is here from 7:30 a.m. to 3:30 p.m. Monday through Friday. She said Resident#30 has an additional private caregiver here on the weekends until Sunday afternoon when his wife arrives. During the interview she was asked if the resident was incontinent, as she was observed putting on a brief to the resident. She confirmed that she places a brief on the resident while he is in bed and demonstrated the brief. She also confirmed that Resident#30 has a catheter and she empties the catheter bag. The medical record review for Resident #30 revealed he was admitted to the facility on [DATE] with a readmission date of 8/23/22 with multiple diagnosis but not limited to pulmonary embolism, cerebral infarction, dysphagia, muscle wasting and atrophy, pressure ulcer and urinary tract infection. Resident#30 had an indwelling catheter, and was not interviewable due to poor cognition. A review of Resident#30 plan of care dated 7/12/2022 for skin impairment indicates: The resident has potential/actual impairment to skin integrity r/t (related to) fragile skin. Left posterior hip, sacrum, open area to penis, bilateral heel boggy. Intervention: Date initiated 8/24/22-Do not use briefs while in bed. Use a bed pad under resident while in bed/chair unless resident having loose stools. On 09/08/22 at 1:40 PM an interview with Certified Nursing Assistant (CNA) staff member (A) reported she only provides care to the resident after the sitter leaves. Today CNA staff member (B) assisted the resident with a bath. CNA (A) stated she has been at the facility for 2 weeks, and this was her first time working with Resident #30. On 09/08/22 1:19 P.M. an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was conducted. The DON confirmed there was no education provided to her and they would start education as soon as possible. He was asked if she had any credentials, and said he was unsure. During the interview the NHA reported she was unaware that Resident#30 had a caregiver in his room. A continued review of the medical record revealed only one note documenting the paid caregiver's presence, dated 8/23/2022. A facility policy on private caregivers/sitters was requested; the DON reported the facility did not have a policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 14 of 19 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 09/09/2022 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 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-one medication administration opportunities were observed, and seven errors were identified for five (#8, 6, 24, 30 and 9) of six residents observed. These errors constituted a 22.58% medication error rate Residents Affected - Some Findings Included: 1. On 09/08/2022 at 9:15 a.m. medication observed task was conducted alongside Staff Member D, Licensed Practical Nurse (LPN) as she prepared medications for Resident #8. She confirmed the medications that were prepared was all that was due at that time except the Medrol dose pack. She said it was not available to be given. She stated when the order was put in the medication administration record it was not transcribed accurately. Staff L confirmed the order was dated on 09/07/2022 and the order still needed to be clarified before it could be administered. 2. On 09/08/2022 at 9:41 a.m. Staff D prepared the following medications for Resident #6 Ibuprofen tablet 200 mg (milligrams) three tablets, carbidopa-levodopa 25 -100 mg, apixaban 5 mg, glipizide 5 mg two tablets, metformin HCL tablet 500 mg, nuplazid capsule 34 mg, oxybutynin chloride tablet 5 mg, lorazepam tablet 0.5 mg, and one multivitamin tablet. Resident #8 was observed sitting up in his bed with the over bedside table positioned in front of him. The table contained a toothbrush, toothpaste, water, and a basin. The resident was receptive with the observation and accepted his medications. Medication reconciliation revealed Physician orders for glipizide tablet 5 mg give 2 tablets by mouth in the morning related to TYPE 2 Diabetes Mellitus before breakfast dated 08/30/2022, and multivitamin with minerals tablet give 1 tablet by mouth one time a day dated 08/05/2022. 3. On 09/08/2022 at 10:08 a.m. an observation was conducted with Staff Member I, Registered Nurse (RN) as she prepared the following medications for Resident #24. Zinc tablet 50 mg, vitamin D tablet 25 mcg (micrograms), aspirin tablet 325 mg, vitamin C tablet 500 mg, cranberry 425 mg one tablet, methenamine Hippurate tablet 1 gr (gram), tamsulosin HCL capsule 0.4 mg, amlodipine 10 mg, and valsartan 40 mg. Medication reconciliation revealed zinc tablet 25 mg give 1 tablet by mouth one time a day dated 07/30/2022, and cranberry tablet 400 mg give 2 tablet by mouth one time a day for vitamin supplement dated 07/20/2022. 4. On 09/08/2022 at 11:53 p.m. Staff Member I was observed as she prepared insulin for Resident #30 at his bedside. The flex pen read Novolog 70/30 flex pen Staff I turned the dose selector to 2 units; the pen was held down and pressed the injector button. The pen was then turned the dose selector to 4 units and administered the insulin into his right upper extremity. 5. On 09/08/2022 at 12:05 p.m. Staff member D, was observed as she prepared Humalog an insulin pen for Resident #7 the pen dose selector was dialed to 2 units. The pen was held sideways as she pressed the injector pen. When asked she stated it's not perfectly straight as she selected 16 units. The insulin was administered into Resident #7 left upper abdomen. On 09/08/2022 at 1:00 p.m. an interview was conducted with the Director of Nursing (DON); he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 15 of 19 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 09/09/2022 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 0759 confirmed medication should be administered as ordered. Level of Harm - Minimal harm or potential for actual harm Review of policy titled Medication Administration dated 8/25/2022 Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do in this stated, as ordered by the Physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name medication name, form, dose, route, and time. Examples guidelines for Medication Administration (unless otherwise ordered by physician), this list is not all-inclusive. Medications requiring administration on an empty stomach: Glipizide. Residents Affected - Some Accessed on 09/09/2022 at: https://pi.lilly.com/ca/basaglar-ca-ifu-kp.pdf Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 5: To prime your Pen, turn the Dose Knob to select 2 units. Step 6: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 7: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat the priming steps, but not more than 4 times. If you still do not see insulin, change the Needle and repeat the priming steps. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 16 of 19 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 09/09/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and policy review, the facility failed to maintain drugs and biologicals in a safe and secure manner in one (A) out of two medication carts. Findings Included: On 09/06/22 at 09:03 a.m. upon entrance to the facility lobby multiple residents were observed sitting in their wheelchairs. Staff and family members were also observed walking through the area to enter adjoining units. An unlocked medication cart was observed positioned next to one of the residents. Upon closer observation a soufflé cup sat on top of the cart that contained multiple different colored capsules and tablets. The cart top also contained a blister card facing the lobby entrance revealing a resident name. There were no licensed staff members in the immediate vicinity (photographic evidence obtained). Approximately three minutes later the Nursing Home Administrator (NHA) was observed walking down the hallway toward the facility lobby. Upon approaching, the NHA reached past the surveyor and locked the medication cart. She then reached forward with her right hand to the cart were the souffle cup sat with multiple pills. The NHA indicated at that time she did not know which nurse was responsible for the cart. She stated, I will be looking into it. On 09/06/22 at 10:00 a.m. an interview was conducted with Staff Member H, Licensed Practical Nurse, he confirmed he had left his medication cart unlocked, with medications on top of the cart. Review of policy Medication Storage dated 8/25/22 Policy: It is the policy of this facility to ensure all medication housed on our premises will be stored in the pharmacy and or medication rooms according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. all drugs and biological's will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperate controls. c. during a medication pass medication must be under the direct observation of the person administering medications or locked in the medication storage area/cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 17 of 19 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 09/09/2022 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 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 make attempts to ensure hospice services were appropriately coordinated related to effective communication and consistent delivery of services was maintained for one (#27) of two residents sampled for hospice services. Findings included, 1. Review of the agreement between the facility and the hospice vendor dated September 1, 2021 revealed the following: 2.1 Hospice Plan of Care-Hospice will furnish to facility a copy of the most recent Hospice Plan of Care specific to each patient provided Hospice services (including Respite Care Services, Inpatient Services and Purchased Hospice Services) under this agreement. The Hospice Plan of Care shall reflect the participation of Hospice, Facility, and Hospice Patient and Hospice Patient's family to the extent possible, and must specifically identify which provider or party is responsible for performing the respective functions that have been agreed upon and included in the Hospice Plan of Care. 3.1 Facility Plan of Care. Facility will develop a Facility Plan of Care to coordinate with the Hospice Plan of Care for each Hospice Patient. Review of Resident #27's record revealed he was admitted to the facility on [DATE] has diagnosis that includes: Parkinson's disease, cognitive communication deficit, Major depressive disorder, and shortness of breath. The review of the skilled nursing note dated 9/1/22 indicated that the resident is oriented to person and has impaired decision making ability. Review of the resident's record revealed the resident's payer source changed on 8/19/22 to hospice. Continued review of the record revealed no documentation in the record from the hospice vendor Review of the residents care plan dated 8/22/22 indicated that the resident chooses to have death with dignity, advanced directive established. Resident is hospice. Interview on 09/07/22 at 10:52 AM with Staff D Licensed Practical Nurse (LPN) revealed there is no hospice book, and the hospice staff start their documentation in the facility and then finish at their office; they send them to the facility electronically and then they are scanned into the residents record. Interview on 09/07/22 at 11:36 AM with the Director of Nursing (DON), revealed all residents on hospice should have an physician's order for hospice services, and the hospice plan of care (POC), and the hospice notes should be in documents section of the resident record. He reported he could not determine when hospice was last in the building to see Resident #27, and was unable to verbalize what disciplines the resident receives from the hospice vendor, He reported all this information would be in the hospice care plan. He confirmed there was no physician orders for hospice, no hospice plan of care from the hospice vendor and no hospice notes from the hospice vendor. Interview on 09/07/22 at 12:27 PM with the Resident Assessment Coordinator revealed the hospice care plan in place does not mirror the hospice care plan from the hospice vendor as she has never seen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 18 of 19 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 09/09/2022 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a hospice care plan from the hospice vendor. She reported she did not know she was supposed to mirror the hospice vendors care plan to ensure continuity of care. Interview on 09/07/22 at 12:48 PM with the Social Service Director, revealed she was not sure who is supposed to ensure that hospice documentation is in the building. She reported she sets up and runs care plan meetings, but does not do anything related to continuity of care with hospice. Interview on 09/09/22 at 08:54 AM with the Hospice Nurse, Registered Nurse, (RN), revealed the resident started on hospice services on 8/19/22. She reported she shares info with the facility and talks to the nurse. She reported she will normally will call and collaborate with the facility and that the communication is word of mouth with nursing and CNAs (certified nursing assistants). The Hospice nurse reported she provides the written notes and plan of care to the facility and visits this resident weekly, and the aide comes in one time a week as of last week. Continued interview with the Hospice nurse at this time revealed this facility did not get a plan of care for this resident until this week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106015 If continuation sheet Page 19 of 19