Inspection·May 7, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few has an order to take medications with meals, it is not acceptable for nurses to provide medications during dining service, while residents are dining with others. The DON later confirmed Resident #50 does not have any type of medications that have to be provided at and during meals. The DON did not have any specific policy/procedure related to medication pass during meal service. Review of resident #50's medical record revealed resident #50 was admitted to the facility 12/3/2019 and readmitted on [DATE]. Review of the admission diagnoses sheet revealed diagnoses to include dementia. Review of the current Minimum Data Set (MDS) Quarterly dated 3/10/2021, revealed, Cognition/Brief Interview Mental Status score 3 of 15, which indicates very low cognitive function. Review of the current Physician's Order Sheet (POS) dated for the month of 5/2021 revealed no medications or treatments to be given/administered at meal service or during meals. Further, review of the current care plans with next review date 6/15/2021 also did not indicate any interventions to pass and give medications at or during meals. Resident #50 was unable to say if she was ok with receiving and taking medications during meal service, while in the dining room with others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 2 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and medical record review, the facility failed to ensure eight (#50, #66, #7, #22, #39, #109, #8, and #35) of thirteen sampled residents who were ordered and to receive drinking adaptive equipment, were provided with that equipment during four of four days observed (5/4/2021, 5/5/2021, 5/6/2021, and 5/7/2021), for six meal service observations. According to the residents' care plans, they should have received 2 handled cups or built up eating utensils with each meal. Findings included: On 5/4/2021 at 9:50 a.m. it was determined through tour of the kitchen and interview with the Certified Dietary Manager (CDM), that the facility's dish washing machine was broken and the facility was using paper and plastic ware and would continue with that during all foreseeable meal services. 1) On 5/4/2021 at 12:15 p.m. resident #50 was observed seated in a high back wheelchair, positioned at a table in the 600 unit dining/activity room. She was served her meal on plastic and paper utensils and dishware. Further observations revealed she was served liquid in a white Styrofoam cup. She did not drink from it. Staff occasionally asked her if she wanted to drink her juice. Review of the meal ticket revealed resident #50 should have received a 2 handled cup with nosey lid. She did not receive this drinking adaptive equipment. On 5/5/2021 at 7:38 a.m. the resident was observed in the 600 unit dining/activity room. She was seated in a high back wheelchair and positioned at a table with one other resident seated across from her. Resident #50 was observed dressed for the day and well groomed. Resident #50 had a small plastic cup with colored liquid in it. She could not reach it should she want to get it on her own. There were no handles on this plastic cup. At 8:20 a.m. the resident was served her meal and the meal tray was placed in front of her by Certified Nursing Assistant (CNA) employee G. The meal was served on paper and plastic containers and consisted of: Eggs, French Toast, Sausage Gravy, Styrofoam cup of orange juice. The cup had no handles or nosey lid. During the meal service, employee G picked up a plastic fork and knife and began to cut up the resident's food into bite sized pieces. While cutting up the food, the Aide stood up and at the right side of the resident. She cut up food for four minutes from 8:22 a.m. to 8:26 a.m. Review of the meal ticket placed next to the resident's meal, revealed: Utilize Two handled cup with Nosey lid. The resident was not served any type of handled cup for breakfast meal. This was confirmed by employee G. At 8:28 a.m. resident #50 picked up the cup with her hands shaking. She brought the Styrofoam cup to her mouth and tried to drink the orange juice. She was observed to spill orange juice on her shirt collar area. Employee G walked by and assisted the cup back to the table. At 8:34 a.m. the 600 (Florida Bay) Unit Manager sat down next to resident #50 and assisted her with her meal. She at times brought the Styrofoam cup to the resident's mouth and the resident took sips from it. It was determined that the resident could not take sips of liquid form the Styrofoam cup on her own without spilling it on her. The Unit Manager sat with her for about three minutes and then left to assist another resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 3 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/6/2021 at 8:20 a.m. resident #50 was observed assisted out from her room and positioned at a table in the 600 unit dining/activity room. She was brought out to the dining room so she could eat her breakfast meal. At 8:33 a.m. resident #50 received her breakfast tray, which served on paper and plastic. She received two liquid drinks in white colored Styrofoam cups. Neither had nosey lids or handles. After an aide, employee F set up the meal for the resident, she walked away and resident began to eat on her own but very slowly. At 8:40 a.m. resident #50 was observed dropping food onto her upper shirt while using a spoon. She then grabbed her cup with shaking hands and tried to take a sip. She spilled some orange juice out on her shirt. Review of the meal ticket revealed: To use two handled cup with nosey lid On 5/6/2021 at 12:35 p.m. resident #50 was observed in the 600 dining/activity room and was seated in her high back wheelchair and at a table with her lunch meal in front of her. She was served her meal on paper and plastic and received two Styrofoam cups with liquid. None of the cups had handles or nosey lid. She was observed a times trying to bring the cup to her mouth and spilled liquid onto her shirt. She did not receive a 2 handled cup with nosey lid. On 5/7/2021 at 8:22 a.m. employee G served and set up resident #50 with her meal, while in the 600 unit dining/activity room. The meal was served on paper and plastic with divided Styrofoam container. Further, resident #50 was served two cups of liquid, one orange juice and one water, which were both in Styrofoam cups. Neither had handles on them. Also, cups did not have any type of cut out device. Interview with the aide employee G provided the meal ticket for review. The meal ticket indicated resident was to receive a 2 handled nosey cup with a cut out during all meals. She confirmed that she had not seen the adaptive drinking equipment and that there were several others on this unit that required eating or drinking adaptive equipment. She confirmed that the entire facility has been using paper and plastic the past few days and she just realized that residents do not get the adaptive eating and drinking equipment. Further observations from 8:25 a.m. through to 8:32 a.m. revealed that the resident did pick up the Styrofoam cup of liquid and brought to her mouth. She was observed to spill liquid on her shirt when doing so. An aide removed the Styrofoam cup from the resident's reach at 8:35 a.m. Staff never returned during this meal service with another drink for the resident. At 8:30 a.m. an interview with an aide employee K, who set up all the meal trays for the residents this a.m. in the 600 unit, revealed she was aware the dish machine was not working for the past few days and that the facility was and is using paper and plastic only for meal services. She was asked if residents utilized adaptive eating equipment, what do they do to ensure they are using it. She was not sure at this time because the facility was on paper and plastic eating ware. Then the dietary aide employee L, who was at the steam table and serving plates, revealed, I know that we are using paper and plastic, but I need to make sure the adaptive equipment comes from the kitchen. She was asked if the kitchen had a three compartment sink to wash dishes and she confirmed that they do. She also confirmed that adaptive eating/drinking equipment could be washed in the three compartment sink. She was not sure why for the past few days there was no adaptive eating/drinking equipment for residents to use when the dish washing machine was broken. Review of resident #50's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed the resident had a responsible party in place. Review of the dx. sheet revealed diagnoses to include Dementia, Adult Failure to Thrive, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 4 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0656 depression. Level of Harm - Minimal harm or potential for actual harm Review of the current Minimum Data Set (MDS) Quarterly assessment dated [DATE], revealed, (Cognition/Brief Interview Mental Status/ BIMS score 3 of 15, which indicated very low cognition and not interviewable); (Activities of Daily Living/ADL - Supervision and Set up only for Eating Residents Affected - Few Review of the Nutrition Screening and Data Collection for Skilled Nursing Facilities assessment dated [DATE] revealed in Feeding ability, resident is set up with assist/adaptive equipment. Review of the current Physician's Order Sheet (POS) dated for the month of 5/2021 revealed the resident was ordered for the following: 2 Handled cup with nose cut-out attachment and plate guard for all meals as tolerated (order date 6/8/2020). Review of the current care plans with next review date 6/15/2021 revealed: *ADL self care performance deficit related to CVA, Dementia, Impaired balance with interventions in place to include: EATING - Adaptive equipment as ordered. *Nutrition problems or potential nutrition problem related to low BMI, variable PO intake, Diet restrictions, comfort measures with interventions to include but not limited to: Adaptive equipment as ordered. On 5/7/2021 at 10:30 a.m. the Director of Nursing provided the following information, OptimaSolutions Adaptive Device Master dated 5/7/2021 with names of residents who require and utilize eating adaptive equipment, and what type of equipment they are to utilize. The report included the following residents: 1. Resident #66 - use of 2 Handled Sippy Cup (admitted on [DATE]) 2. Resident #7 - use of Bent Handled Fork, Bent Handled Spoon, Two Handled Cup (admitted on [DATE]) 3. Resident #22 - use of Nosey Cup (admitted on [DATE]) 4. Resident #50 - use of Plate Guard, Two Handled Cup w/Nosey Lid (admitted on [DATE]) 5. Resident #39 - use of Rocker Knife (admitted on [DATE]) 6. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 5 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0656 Resident #109 - use of Transparent Two Handle Mug With Concave Lid (admitted on [DATE]) Level of Harm - Minimal harm or potential for actual harm 7. Resident #8 - use of Weighted Cup, Weighted Utensils (admitted on [DATE]) Residents Affected - Few 8. Resident #35 - Weighted Utensils (admitted on [DATE]) Interview with Occupational Therapist employee M on 5/7/2021 revealed that when a resident is assessed and therapy recommends with physician's orders with regards to adaptive eating/drinking equipment, it is the expectation that the resident utilizes the equipment for each meal. She further confirmed that there should not be any meal services missed with regards to use of adaptive eating equipment. Employee M confirmed that she found out this a.m. that all residents to include #66, #7, #22, #50, #39, #109, #8, and #35 had not received their adaptive drinking equipment since 5/4/2021. On 5/7/2021 at 9:45 a.m. an interview with the Kitchen Dietary Manager confirmed that residents who required use of adaptive drinking equipment, did not receive that adaptive equipment since 5/4/2021, the same date as when the dish washing machine broke. The Dietary Manager revealed that they should have provided them out on the floor and there would be no reason that they could not be washed after each use by using the three compartment sink. She revealed, it just got away from me and I didn't think about the adaptive eating/drinking equipment., and I was just concerned getting paper and plastic out to the floor. It was verified through the current care plan review and current physician's order sheet dated for month 5/2021, residents #66, #7, #22, #50, #39, #109, #8, and #35 did not receive adaptive drinking equipment or built up eating utensils as per dietary/activities of daily living interventions for four days, (5/4/2021, 5/5/2021. 5/6/2021, and 5/7/2021). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 6 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one Resident #27 received showers according to the shower schedule. Resident #27 did not receive any showers for the last 30 days of 5 sampled residents. Residents Affected - Few Findings Included: During an interview with Resident #27 on 5/4/21 at 10:50 a.m. he stated his last shower was about two to three weeks ago and his last bed bath was almost two weeks ago. He stated his skin gets very flaky and dry if he does not get washed and shaved daily or every other day. Resident #27 stated his face was last shaved at least a week ago and he stated that he is itchy on his head, face and chest from not getting washed. He stated that he has asked for a shower but his shower days are on Tuesday and Thursday from 3 to 11 shift and they don't even ask him to shower or get a bed bath. During a interview on 5/05/21 at 12:15 p.m. Resident #27 stated that he will demand a shower if he doesn't get one by tomorrow since he has only had a few baths in the last month. The resident stated again he is supposed to get a shower on the 3 to 11 shift but that does not happen often. The resident stated he has flaky skin and really needs to have his face shaved. During an interview with Staff member X, RN unit manager on 5/5/21 at 12:17 p.m. She asked the resident when he received a shower last and he stated it was at least a couple weeks or so ago. During an interview with Resident #27 on 5/5/21 at 5:04 p.m. He stated he is very happy that he finally got a shower. He was observed without white flaky skin on his chest, face and head. He stated that he was even told if he wanted another one tomorrow (Thursday) he could get one. The resident was so happy and stated he felt so clean and no longer itchy. Resident #27 stated his head feels so much better too. During an interview with Resident #27 on 5/7/21 at 9:40 a.m. he stated he did get a shower last around 9 p.m. and wanted to be shaved but it was late so he will ask today since he has not been shaved yet and has family coming on Saturday. Review of the activities of daily living documentation for the last 30 days of showers revealed from 4/7/21 to 5/4/21, Resident #27 did not receive a shower and received 7 bed baths. One shower was completed on 5/5/21. Review of the Minimum Data Set (MDS) for Brief interview for mental status (BIMS) revealed the resident with a score of 15, cognitively intact. Section G0120. Bathing reflected the resident required physical help in part of bathing activity with one person physical assist. Resident #27 was admitted on [DATE] with diagnoses of muscle wasting and atrophy of left and right upper arm, and contracture of muscle right and left hand. Review of the care plan focus area revealed: The resident has a self-care deficit related to activity intolerance, limited mobility, limited range of motion. Interventions include: bathing and showering to provide a sponge bath when a full bath or shower cannot be tolerated. Personal Hygiene: the resident requires assistance by 1 staff with personal hygiene and oral care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 7 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm During an interview on 5/06/21 at 3:03 p.m. with the Director of Nursing (DON), she stated that her expectation would be to have showers twice a week and as needed. Review of the facility policy for Bathing/Shower, effective January 1999, one page reflected: Purpose to promote cleanliness, stimulate circulation, and assist in relation. Residents Affected - Few Review of the facility policy for bathing/bed bath, effective January 1999, one page reflected: Purpose to cleanse the skin, provide circulation, and provide an opportunity for observation and assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 8 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three Residents (#27, #13 and #85) received restorative therapy of five residents sampled. Findings Included: 1) During an interview with Resident #27 on 5/4/21 at 10:50 a.m. he stated he has not had restorative therapy in at least 3 weeks. The resident said staff told him they are short staffed and that's why he has not had restorative therapy. The resident stated the staff lost parts to his boots he used to wear in bed with the kickstand on them and wore them once or twice. He stated he has not had any one ask or put on his splint that goes on his right hand in weeks. Review of the treatment administration record reflected on 5/4/21 the resident was administered the right wrist/hand splint for 4 to 6 hours 5 days per week or as tolerated During an interview with Resident #27 on 5/5/21 at 5:04 p.m. he stated no one has asked him or applied his hand splint today and has not seen it in several weeks. Resident #27 stated he wears the soft boots to protect his heels but they are not the boots with the kickstands he used to wear before the staff lost the pieces. Review of the treatment administration record reflected on 5/5/21, the resident was administered the right wrist/hand splint for 4 to 6 hours for 5 days per week or as tolerated. Review of the treatment administration record from 4/20/21 to 5/5/21 reflected Resident #27 having the right wrist/hand splint applied every day as checked off by the nurses. Review of the Restorative Nursing program referral/plan revealed therapy referral for restorative nursing program 3 to 5 times per week with the splint 5 times a week. Referred for Range of motion and splints/braces. Problem/assessment: at risk for increased contracture in Bilateral upper extremities and at risk of functional decline. Interventions: right wrist/hand splint 4 to 6 hours as tolerated 5 times a week. Active range of motion for bilateral upper extremity joints, 10 reps for 2 sets. Passive range of motion for bilateral upper extremity joints with sustain stretching at the end range, 10 reps for 1 set as tolerated. Goal to reduce risk for progression of joint contracture. Signed by the restorative aide and Restorative nurse on 4/9/21. Review of the Restorative nursing flow sheet for May was blank and April did not show the right wrist hand splint applied after 4/12/21. Active range of motion and passive range of motion completed 8 times after 4/9/21. The Resident was admitted on [DATE] with diagnoses of muscle wasting, atrophy of left and right upper arm, muscle weakness, hemiplegia, and contracture of muscle on the right and left hand. Review of physicians orders revealed: Apply bilateral podus boots 4 hours daily or as tolerated, use knee wedge to right knee area every night and as tolerated dated 3/5/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 9 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0688 Level of Harm - Minimal harm or potential for actual harm Apply right wrist/hand splint for 4 to 6 hours, 5 days per week or as tolerated, every day shift and as needed dated 4/19/21. Bilateral heel protectors when in bed as tolerated, may remove for skin checks and hygiene, every shift to protect dated 8/17/20. Residents Affected - Some Restorative nursing program for a minimum of 3 days per week as tolerated. Bilateral upper extremity active range of motion (AROM) for 2 sets of 10 reps or as tolerated. Bilateral upper extremity passive range of motion (PROM) with sustain stretching at end range for 1 set of 10 reps or as tolerated, dated 4/19/21. Review of the Minimum data set (MDS) dated [DATE] revealed the resident had a brief interview of mental status (BIMS) score of 15, cognitively intact. Review of the care plan revealed the resident had a self-care deficit related to limited mobility, limited range of motion. Interventions included: apply bilateral podus boots as ordered/tolerated. Apply knee wedge to right knee area as tolerated every evening. Bilateral hand/wrist splints as ordered and as tolerated, revised on 4/20/21. Bilateral heel protectors while in bed. Restorative nursing as ordered revised on 5/5/21. During an interview on 5/07/21 at 12:54 p.m. with Staff member W, CNA restorative, she stated she has not done restorative care this week. She confirmed she has been getting monthly resident weights and working as a CNA on the units every day that she has worked. She stated she worked as a restorative aide about 3 full days last week. Resident #27 receives upper and lower extremity range of motion. Staff member W, CNA confirmed the last time she worked with him was last Friday. Staff member W, CNA confirmed he has hand splints, and that he used to refuse to wear the right hand splint because it hurt so therapy was supposed to make him a new one. Staff member W, CNA said she saw him with it the other day, maybe last week. Staff member W, CNA confirmed she has not documented on restorative care. Staff member W, CNA stated the right hand splint is kept in the drawer, closet or the chair and he will have restorative today. Staff member W, CNA confirmed he is supposed to wear the podus boots(hard boots) every day but since working the floor as an aide he has not had them on since April. On 5/7/21 at 1:15 p.m. Staff member W, CNA asked the resident where his splint was and did not observe the splint in the 4 drawer dresser. She asked the resident again and he said it should be in the drawers. After looking again the CNA found a bag with a splint and stated, Is this It?, I have not seen this one! Resident #27 stated, That's my new splint therapy ordered that no one has put on me. Staff member W, CNA asked if she could go ahead and put the splint on and the resident agreed. During an interview on 5/07/21 at 1:32 p.m. with the Director of Rehabilitation (DOR), he stated Resident #27 was referred to restorative on 4/7/21. The DOR stated he was not tolerating his right hand splint and they made home another one. The DOR said they do not follow the residents placed on restorative and was not aware the resident was not getting restorative therapy as ordered. During an interview with Staff member U, RN on 5/5/21 at 4:45 p.m., she stated the facility has one certified nurse assistant (CNA) that completes restorative care and another restorative aide on medical leave. Staff member U, RN stated the schedule for restorative varies and when she is not working then restorative does not get done. Staff member U, RN stated she recently took on the restorative program and was not aware that it was not getting done. She stated that so far for the month of May she did not have any real time documentation on record for any residents and confirmed that April (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 10 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was not complete either. She said she will start a plan of correction and come up with a plan for the restorative program. Review of the policy for restorative nursing effective 9/2010, two pages, reflected: Restorative Nursing Program flow sheet: 1. The restorative nurse will initiate documentation of each completed restorative nursing referral/ plan by implementing the restorative nursing program flow sheet. 2. The restorative nursing program flow sheet will indicate the resident's name, room number, and restorative plan. 3. The restorative nursing assistant will initial the corresponding box to indicate completion of interventions of the program and will record minutes spent in that activity. Should the resident refuse to participate for any reason, the Restorative nurse or designee should be notified. Refusal will be indicated by placing the letter R in the corresponding box on the flow sheet. 4. The restorative nursing assistant will also complete a narrative restorative nursing program summary each week. The weekly summary will include the resident's level of participation, ability and willingness to continue with program and progress toward goals. 5. The restorative nurse will complete a monthly summary of the resident/patient's level of participation, ability and willingness to participate, progress toward goals and will note whether the current program will be continued, revised or discontinued. 7. The resident/patient's physician will be notified of changes and written orders will be obtained if the program is discontinued. Review of the facility policy for documentation, clinical, revised 4/19, 3 pages, reflected: Purpose: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all interdisciplinary team members. Documentation in the medical record of each resident should provide: 1. A complete account of the resident's care treatment and response to the care. 2. Information for the physician when prescribing medications and managing care and treatments. 3. A description of care and services that can be used for measuring the quality of care provided to the resident. Documentation Guidelines: 1. All entries in the medical record should be accurate, legible, dated, and timed. 2) Resident #13 was admitted to the facility with diagnoses of left knee contracture and right knee contracture, according to the face sheet in the admission record. A review of the MDS assessment dated [DATE] revealed that Resident #13 had a BIMS score of 99, indicating severe cognitive impairment. Further review of the assessment reflected Resident #13 required extensive assistance to total dependence of two persons for ADLs (activities of daily living). Review of the physician's orders in the electronic medical record reflected an order dated 3/7/21 apply bilateral knee splints daily as tolerated every shift. A review of the care plan dated 3/6/21 indicated Resident #13 had an ADL self care performance deficit. Interventions included bilateral knee splints as ordered and as tolerated. Review of the care instructions for CNAs (certified nurse's assistants), Dressing/Splint Care, reflected Bilateral knee splints as ordered and as tolerated. A review of the TAR (treatment administration record) in the medical record for the month of May showed electronic signatures for each shift (7a-3p, 3p-11p, and 11p-7a) indicating the splints had been applied. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 11 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/04/21 at 10:35 AM an observation was conducted. Resident #13 was lying in his bed with the head of the bed lower than than foot. His knees were both contracted and bent to his left side. There were no splinting devices observed and there was no support between his knees. On 5/06/21 at 8:58 AM an observation was conducted. Resident #13 was in his bed sitting in an upright position. His knees were both contracted and bent under him positioned to his left side. A pillow was positioned behind the left leg. There wasn't any support between the knees or any splinting devices on his legs. There was a pair of contracture boots sitting in the wheel chair across from the end of his bed. On 5/07/21 at 10:36 AM an observation was conducted. Resident #13 was in bed with the head of the bed elevated to about forty-five degrees. The bilateral knee contracture boots were sitting on the wheel chair across from the foot of the bed. On 5/07/21 at 10:38 AM an interview was conducted with Staff W, restorative CNA. Staff W, CNA said she is a restorative CNA. She is pulled to the floor a lot so she can't do restorative, so she hasn't been putting Resident #13's splints on. Staff W, CNA said since Monday this week she hasn't done any restorative. She doesn't know if the CNAs put the splints on. She confirmed Resident #13 was not wearing his splints. She said she is going to put them on him now. On 5/07/21 at 11:47 AM an interview was conducted with Staff X, RN (registered nurse) unit manager. Staff X, RN said restorative or therapy puts the splinting devices on. CNAs can put them on if they have been trained to. If they haven't, they can ask for assistance from one of the nurses or other staff who are able to help with them. Staff X, RN unit manager was not aware that Resident #13 wasn't getting the splints. 3) Resident #85 was admitted to the facility with diagnoses of dementia and schizophrenia, according to the face sheet in the admission record. Review of the physician's orders in the electronic medical record reflected an order dated 3/521, apply bilateral hand splints for up to 6 hours daily as tolerated daily as needed and every day shift. A review of the 4/7/21 MDS assessment revealed a BIMS score of 3, indicating severe cognitive impairment. Further review of the assessment showed Resident #85 required extensive assistance to total dependence of two persons for ADLs. Additional review showed Resident #85 had impairment on both sides of her upper extremities. A review of the TAR in the medical record reflected the hand splints were scheduled on the 7a-3p shift, and had been signed during the month of May. Review of the care instructions for CNAs under Dressing/Splint Care revealed Bilateral hand splints as ordered/ or as tolerated by patient. Bilateral hand splints per restorative program. A review of the care plan dated 7/10/18 reflected Resident #85 has impaired physical mobility and/or joint impairment. Interventions included bilateral hand splints per restorative program. Further review showed Resident #85 had a self care deficit with dressing, bathing, and grooming related to impaired mobility and cognitive deficit. Requires staff assistance with ADL care. Decreased ROM (range of motion) to BUE (bilateral upper extremities). An intervention dated 1/7/21 reflected bilateral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 12 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0688 hand splints as ordered or tolerated by patient. Level of Harm - Minimal harm or potential for actual harm On 5/04/21 at 1:54 PM an observation was conducted in Resident #85's room. Resident #85's right wrist was noted to be contracted. The left hand was not observed at the time because it was beneath the covers. A splinting device for a hand was observed in a chair at the foot of the bed. Residents Affected - Some On 5/05/21 at at 12:13 PM an observation was conducted in Resident #85's room. A wrist splint was noted in the chair at the foot of the bed. The right wrist was observed to be contracted. The left wrist was not visible during the observation, due to being beneath the covers. On 5/05/21 at 1:45 PM an interview was conducted with the resident's CNA, Staff FF. Staff FF, CNA said Resident #85 only gets the splint when she is up. On 5/05/21 at 4:52 PM an interview was conducted with Staff U, RN, the resident's nurse. Staff U, RN said if the splint doesn't feel right or it's uncomfortable and they want it off at two hours than it's ok to remove it. They would document if they applied it and if they refused it would be documented. On 5/06/21 at 9:14 AM another observation was conducted in Resident #85's room. Resident #85 was in her bed with her eyes closed. Her right wrist was observed again to be contracted and without any splinting device. The left hand was also not observed since it was under the covers. A wrist splint was observed in a chair at the foot of the bed. On 5/06/21 at 9:29 AM an interview was conducted with Staff T, RN unit manager. Staff T, RN said there are residents with multi podus boots, hand splints, and one with a shoulder brace. They are all scheduled under restorative. She said she wasn't sure about Resident #85's hand splint. The order is categorized as restorative. There are some residents that put their own on. Resident #85's order indicates bilateral hand splints for up to six hours as tolerated daily, every day shift. She was up a couple days ago when she was out here and she had them on. She is up when she is alert. That is not always. Her mentation fluctuates. Sometimes she is just very sleepy and other times she will be alert and talking to you. The CNAs put the splints on. They are in the kardex (care instructions for CNAs). The nurse signs it on the TAR. They both see the order. She opened the TAR and showed it had been documented for the month of May. On 5/07/21 at 11:14 AM an interview was conducted with Staff V, CNA, the resident's CNA. Staff V, CNA said Resident #85 required total care. She is not really alert. Sometimes she says things, but she is not all the way alert. She wears a hand splint. We use the hand splint only when she is up. We put splints on, and restorative does too. Review of the policy, Restorative Nursing - Contracture Prevention and Management - Splint/Brace Assistance, dated September 2010, reflected the following: Purpose The contracture prevention and management program is designed to assist the resident by promoting normal joint alignment and positioning, preventing or reducing contractures and facilitating daily living skills and mobility. Clinical conditions that may place a resident at risk for decreased range of motion (ROM) are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 13 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some immobilization, weakness or deformities arising out of neurological deficits (strokes, multiple sclerosis, cerebral palsy, and polio), pain, spasms, and immobility associated with arthritis or late stage Alzheimer's disease. In addition, a reduction in range of motion may occur because of injury or surgical procedures, weakness or paralysis. Procedure: 4. Should skilled therapy not be indicated or skilled goals have been met with the likelihood of continued improvement, the OT (occupational therapist) or PT (physical therapist) will assist in the development of a restorative splinting/brace program. 5. Verify that the resident is able and willing to participate and obtain a physician order. 6. Record the program in the resident's comprehensive plan of care. 7. The program should be carried out as ordered by the resident's physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 14 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview and facility record review, the facility failed to ensure kitchen equipment was operating to meet manufacturer specifications regarding one of one mechanical dish washing machine on one of four days observed (5/4/2021). It was determined the facility had a High Temperature dish machine and the wash and rinse temperatures were below the minimum requirements. Findings included: On 5/4/2021 at 9:15 a.m. a tour of the kitchen was conducted with the Certified Dietary Manager (CDM). In the dish machine room the CDM and employee A revealed that they operated a High temperature Dish Cleaning Machine. During the time of the observation, employee A was operating the machine and there were several crates of clean dishes that had run through. Interview with employee A revealed that the Wash temperature should reach at least 165 degrees F., and the Rinse temperature should reach at least 180 degrees F. This was confirmed by the CDM. Observations of the temperature read out gauges located on the machine, revealed print that read, Wash High Temp - 150 degrees F., and Rinse High temp - 180 degrees F. At 9:18 a.m. the CDM asked employee A to run the machine to demonstrate the wash and rinse temperatures. Employee A placed a crate of dishes in the washing compartment, closed the door/lid and the machine turned on and began to wash. Reading the gauges on the machine, the wash temp reached 147 degrees F. and did not go higher. After the wash cycle, the machine then made a heavy click and hot water is then filled in to start the rinse cycle. Once the rinse cycle began the gauges were observed and the rinse gauge reached only 175 degrees F. and did not go higher. This surveyor asked employee A if they have to prime the machine every day and in between meal services to ensure the water was heated appropriately. Employee A and the CDM both confirmed that they do and that they had already did that this a.m. She said the machine was fine because she had already run several crates of dishes. The surveyor at 9:24 a.m. asked for another opportunity to observe the machine during its wash/rinse process. Employee A then ran another crate of dishes in the machine. After the door was closed, the machine began its wash cycle. The wash cycle only reached 148 degrees F. and did not go any higher. Once the wash cycle was completed and the rinse cycle clicked over, the rinse temperature only reached 178 degrees F. and did not go any higher. This was confirmed by both employee A and the CDM. Employee A and the CDM were asked how they monitor the wash and rinse temperatures for each meal service. Employee A pointed to the Dish Machine Temperature Log, which was hanging on the wall. She confirmed that before each wash service to include Breakfast, Lunch and Dinner, they log wash and rinse temperatures. She and the CDM both confirmed there were no documented temperatures for this a.m. on 5/4/2021 and no documented temperatures logged for all three meal services for the day before, on 5/3/2021. Neither employee A and the CDM could show if the machine was working appropriately since the dinner meal service on 5/3/2021. Photographic evidence was taken of both the temperature log and the dish machine temperature gauges. At 12:22 p.m. the CDM revealed that the facility maintenance department was responsible for maintaining the machine and ensuring the temperatures are as per machine specifications. She also revealed that the maintenance man came in this a.m. to check on the machine, tried to make adjustments and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 15 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many could not get the required 150 degrees F. for wash and 180 degrees F. for rinse. She did say however, that moving on they will be using paper until a machine repair company can come out and repair it. She further confirmed that she does not know if the machine was not working properly this a.m. before the observations, and there were no indications of log temperatures from the day before on 5/3/2021. Interview with the Maintenance Director confirmed that the Dish Machine was not running according to machine specifications and would have to have a repair company come out and look at it and repair it. Review of the facility's Dish Machine Temperature Log dated for two months reviewed to include 5/2021 and 4/2021, revealed: Minimum Wash temperatures should reach at least 150 degrees F. Also revealed Minimum Final Rinse temperatures should reach at least 180 degrees F. Review of the 4/2021 month log for all three meal services revealed 4/1/2021 through 4/16/2021 had appropriate wash and rinse temperatures documented. However, dates 4/17/2021 through to 4/27/2021 revealed out of service, paper in use. It was verified from the Certified Dietary Manager that the machine received some maintenance that was not temperature related and had to wait for a part to be installed before using, and therefore the machine was out of service for eleven days. She further confirmed they used paper and plastic during those days. However, further review of the 4/2021 Dish Machine temperature log revealed there were no documented temperatures during all three meal services on 4/28/2021 and 4/29/2021. This was confirmed by the CDM. There were appropriate temperatures for both wash and rinse documented for the last day, 4/30/2021. Review of the 5/2021 month log for all three meal services revealed 5/1/2021 - 5/2/2012 had appropriate wash and rinse temperatures documented. However, there were no documented temperatures for all meal services on 5/3/2021. The CDM confirmed that staff must not have documented on that date, which was just one day ago, and one day prior to observing machine not meeting required wash and rinse temps. The CDM and dietary aide (employee A) did not know if the machine was not running appropriately the day before as there was no documented evidence. Both confirmed that the machine is not at optimum wash and rinse temps for today 5/4/2021. On 5/6/2021 the Nursing Home Administrator provided the facility's Mechanical Cleaning and Sanitizing of Utensils policy and procedure with date 2016, for review. The policy states: The facility will follow the cleaning and sanitizing requirements of the Florida Food Code for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. Under the procedure section of the policy #1, revealed: Use only an approved dish machine that is properly installed and maintained. Operate the dish machine as instructed in the manufacturer's directions. Schedule and complete regular maintenance inspections. #8 of the procedure section revealed: If a machine that uses hot water for sanitizing is in use, follow these guidelines; (b) Water must be maintained at not less than the temperatures stated below, depending on the type of machine; ii. Single tank, sanitary rack, single temperature machine: Wash temperature 165 degrees F., and Final rinse temperature 165 degrees F.; (c) Temperatures must be monitored and recorded during each wash/rinse cycle. A sample Dish Machine Temperature and Sanitizing Log follows this policy. On 5/7/2021 the Nursing Home Administrator provided the (Brand name) SERIES Installation, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 16 of 17 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 0812 Operation, and Service Manual for its in house Dish Cleaning Machine and dated 6/6/2015. Level of Harm - Minimal harm or potential for actual harm Page #2 of the manual and under the Specifications section revealed the following: (Brand name) HH NB/(Brand name) HH S: Wash Temperature (minimum) 150 degrees F.; and Rinse Temperature (minimum) 180 degrees F. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 17 of 17