Health inspection·December 18, 2020

F 0641 Level of Harm - Minimal harm or potential for actual harm The resident's December 2020 physician orders included bilateral 1/4 side rails up while in bed as enabler dated 6/16/2020. The resident was care planned to use padded side rails as ordered because she was at risk for injuries or complications related to a seizure disorder. Residents Affected - Few The quarterly MDS dated [DATE] indicated the resident was assessed to not use bedrails or any other restraints in the bed. In an interview with Staff J, Licensed Practical Nurse (LPN)/MDS nurse on 12/18/2020 at 1:45 p.m., she acknowledged that Resident #48 had an order for side rails, but that it was not on the MDS assessment. She also acknowledged that Resident #4 had a stage 4 wound, and was being seen by wound care, but that there was no wound mentioned in the resident's MDS assessment. She stated it was an oversight, and the assessments needed to reflect the correct resident status. In a policy titled, Resident Assessment Instrument, noted to be revised on September 2010, under Policy Interpretation and Implementation #3 read, The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capability. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 2 of 8 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 105050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shore Acres Care Center and Rehab 4500 Indianapolis St NE Saint Petersburg, FL 33703 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. Based on observation, interview and record review, the facility failed to create and implement personalized care plan interventions for one (Resident #41) of two sampled residents related to an identified safety concern. Resident #41 was identified as an elopement risk due to exit seeking behaviors. The facility failed to ensure the Resident's care plan and facility elopement identifier books were updated to reflect the known behavior. Findings: During an observation on 12/16/20 at 8:40 a.m. Resident #41 was seen walking down the unit hallway with a direct care staff member walking with her. Positioned outside of the Resident's room was a single cloth chair. During an interview on 12/16/20 at 2:01 p.m. Staff F, Certified Nursing Assistant stated Resident #41 requires one-to-one due to wandering behaviors. A review of Resident #41's admission Record revealed an original admission date of 9/25/20 and a re-admission date of 11/16/20 with medical diagnoses of encephalopathy, malignant neoplasm of major salivary gland, bipolar disorder, anxiety disorder, and other abnormalities of gait and mobility. Her comprehensive Minimum Data Set [MDS], dated 10/11/20, Section C: Cognitive Patterns revealed the Resident has a constant behavior without fluctuation of disorganized thinking. Section G: Functional Status revealed the Resident is independent with walking and locomotion on and off the unit. A review of Resident #41's Progress Notes, dated 10/05/20, revealed [Resident #41] has been deemed incapacitated by her doctor. Dated 10-5-20. A progress note dated 10/31/20 revealed Pt [patient] on 1:1 precaution for elopement risk, in lounge area. Pt became pre occupied with buying a printer and push the emergency latch and walked out, assigned staff at 6 ft distance at all times notified of incident and return pt to facility safely. [Doctor Name] notified verbal order to re-enforce monitoring precautions. POA [Power of Attorney] . notified of incident and ok with measures that are being taken. A progress note dated 11/7/20 revealed Pt alert with confusion at times. Pt currently on 1:1 precautions for elopement risk and safety. Pt informed that her eye glasses are ready for pickup. LOA [leave of absence] authorized by management with escort supervision. A progress note dated 11/19/20 revealed Pt appeared to be exit seeking last shift, was monitored closely by this Nurse. A progress note dated 11/20/20 revealed SSD [Social Services Director] has been in constant contact with [Resident #41]'s family regarding safe placement for her, as she refuses to cooperate with staff, refuses medication, and is abusive. She has poor insight into her health problems, and needs a secure facility. A progress note dated 11/21/20 revealed Pt alert and able to make needs known. Pt push exit doors until they open, said she was going to the bank. Pt advised that bank was closed and that it could be handle Monday. Pt proceeded to exit building and began walking away from premises. Pt informed that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 3 of 8 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 105050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shore Acres Care Center and Rehab 4500 Indianapolis St NE Saint Petersburg, FL 33703 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 authorities would be notified to return her to the facility safely . Level of Harm - Minimal harm or potential for actual harm A progress note dated 11/24/20 revealed SSD made arrangements with [Resident #41]'s family, to discharge her to a more secure facility . Residents Affected - Few A review of Resident #41's Nursing Comprehensive Evaluation dated 11/16/20, Section 7: Elopement Evaluation revealed a score of 13. A score of 13 indicates Resident #41 is at risk for elopement. A picture of the Resident should be placed within the elopement book, and a wander guard should be applied. A review of Resident #41's care plan, date initiated 10/08/20, revealed a focus related to a self-care deficit with dressing, grooming, and bathing due to terminal status with an expected decline . A care plan focus, date initiated 11/17/20, revealed there is a risk for injury due to a seizure disorder with included interventions that staff should stay with the resident during observed seizure activity to provide safety. A review of Resident #41's care plan revealed no interventions related to her elopement risk status, or exit seeking behaviors. During an interview on 12/17/20 at 9:00 a.m. Staff G, CNA stated Resident #41 was on one to one because she tries to escape the building. During an interview on 12/17/20 at 9:08 a.m. Resident #41 stated she had numerous outside facility appointments due to her cancer and the doctors . Are attempting to get to the route of the problem. An observation of Resident #41 revealed no elopement bracelet in place on any exposed body part. Resident #41 stated Staff G was her nanny for the day. She stated I don't need a nanny. I used to be on Seroquel [a medication used to treat schizophrenia, bipolar disorder, and sudden episodes of mania] but it made me a zombie, so I stopped taking it. During an interview on 12/17/20 at 9:18 a.m. Staff A, Licensed Practical Nurse (LPN) stated Resident #41 had cognitive and psychosocial problems with some behaviors of attempting to leave the building. Resident #41 would call taxis or other car services to leave the building so facility staff were constantly redirecting her. Staff A said, I'm not sure if she has always had those behaviors but at least since I have been here, which is about 2 months. On 12/17/20 at 9:30 a.m., an observation of nursing station 1 and nursing station 2 elopement identification books revealed no picture of Resident #41. The identification books did not have any of Resident #41's information in the event of an elopement. During an interview on 12/17/20 at 9:36 a.m. Staff H, LPN stated Resident #41 had behaviors of being verbally abusive to people she did not like. Staff H had known Resident #41 for about three months. Resident #41 had behaviors of walking around and so staff had to redirect her back to her room. Staff H stated the procedure for if a resident was an elopement risk was the nursing staff would attempt to get a physician order to place an elopement bracelet. During an interview on 12/17/20 at 10:19 a.m. the Director of Nursing (DON) stated the facility rarely accepts residents that are elopement risks. She stated the elopement books were used for anyone at risk for elopement, That is how they are identified. She stated the facility had morning meetings (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 4 of 8 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 105050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shore Acres Care Center and Rehab 4500 Indianapolis St NE Saint Petersburg, FL 33703 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 where residents that were identified as elopement risks were discussed and a care plan was created. The MDS Coordinator would trigger a care plan and create interventions. She stated Resident #41 would be considered an elopement risk. The MDS Coordinator was called into the interview on 12/17/20 at 10:19 a.m. by the DON to discuss Resident #41's care plan. The MDS Coordinator said, [Resident #41] does attempt to elope but I would not consider her to be an elopement risk. The DON stated that when Resident #41 first entered the building, she had a high cognitive functioning rating. However, due Resident #41's brain cancer her mental state has been deteriorating so she was put on one to one for safety reasons. Both the DON and the MDS Coordinator reviewed Resident #41's medical chart and confirmed she was identified as an elopement risk on 11/16/20, they confirmed that Resident #41 did not have an individualized elopement care plan in place. The DON confirmed on 12/17/20 at 10:25 a.m. through observation that none of the elopement books throughout the facility had Resident #41's information. A policy review of Wandering and Elopement, revised March 2019, revealed The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents . If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A policy review of Care Plans, Comprehensive Person-Centered, revised December 2016, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 5 of 8 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 105050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shore Acres Care Center and Rehab 4500 Indianapolis St NE Saint Petersburg, FL 33703 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 ensure one medication cart was locked, and failed to follow their policy to secure medications appropriately in three of four medication carts. Findings: On 12/15/2020 at 09:51 a.m. an observation of the Persons Under Investigation Hall (PUI) was conducted. The medication cart was observed to be open and not locked. Random staff were seen to quickly pass the unsecured medication cart. One maintenance staff member was observed running an industrial floor cleaning machine right next to the unsecured medication cart. Staff B, Licensed Practical Nurse (LPN) was seen exiting a nearby room and was interviewed. Staff B (LPN) confirmed the medication cart was not locked. On 12/17/20 11:45 AM an observation of medication cart located on the Low Hall Station #1 was conducted. Observed were two small white tablets, one large round white tablet and 1/4 white tablet loose in the second drawer from the top of the cart. On the right side of the drawer next to the Narcotic box observed were one green capsule, one round white tablet and one round beige tablet. Staff A, (LPN) confirmed the presence of the 6 and 1/4 loose medications in the drawers. (Photographic Evidence Obtained.) On 12/17/2020 at 1:35 p.m. an observation was conducted of medication cart Station #1 on High Hall. Observed were one white and beige capsule, one oblong white tablet, one round white tablet, one dark yellow tablet and 1/2 of a yellow round tablet loose in the second drawer from the top of the medication cart, located on the right side of the drawer next to the Narcotic box. Staff B (LPN) confirmed the presence of loose medications in the drawer. On 12/17/2020 at 12:20 p.m. an observation of the Medication cart #2 on High Hall was conducted. Observed were one loose pink tablet located in the second drawer, on the right side of the draw next to the Narcotic box. Staff C (LPN) confirmed the presence of the loose medication. On 12/17/20 at 04:04 p.m. an interview with the Nursing Home Administrator (NHA) was conducted. During the interview she was informed of the observation made on 12/15/2020 of the unlocked medication cart. She stated That is not proper, and they are supposed to close their carts when they walk away from them. A review of the facility's policy and procedure titled, Storage of Medications, effective April 2007 included under Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Under Policy Interpretation and Implementation read: 1. Drugs and biologicals shall be stored in the packaging containers or other dispensing systems in which they are received. 2. The nursing staff shall be responsible for maintaining medication storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 6 of 8 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 105050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shore Acres Care Center and Rehab 4500 Indianapolis St NE Saint Petersburg, FL 33703 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, policy review, and the facility failed to ensure 1) dishware and food equipment designated for resident usage was stored as clean, and 2) potentially hazardous cooked food was cooled to 41 degrees Fahrenheit within an appropriate timeframe to prevent foodborne illness. Findings included: 1. During the kitchen comprehensive tour on 12/18/20 at 8:55 a.m. a food processor was observed on the countertop next to the stove. Staff I, [NAME] stated she used the food processor at 6:00 a.m. in the morning and that the area where the food processor was stored in would be considered clean. The food processor blade from lifted from the equipment base and examined. Food debris was observed on the inside of the blade rotator. Water was observed on the inside of the food processor base. The [NAME] stated she placed the food processor into the sink earlier, but she was still in the process of cleaning the equipment. The [NAME] removed the food processor from the location and placed it into the 3-compartment sink. Observation of dishware stored on the clean storage rack next to the dishwasher revealed old food debris on the inside of three cups. The Certified Dietary Manager (CDM) stated cups stored on the rack were considered clean. The cups were examined by the CDM and passed to a kitchen aide standing by the dishwasher. the CDM examined additional five cups, which were determined to be unclean. The CDM removed the entire clean cup storage tray and placed it by the dishwasher for re-cleaning. 2. During an observation on 12/18/20 at 9:25 a.m., a large, deep pan was seen double wrapped in saranwrap in the outside walk-in cooler. The CDM stated the food item was soup, which was made the day before that .would be served to residents' today. She stated the soup was made in-house, cooked, and stored in the walk-in cooler to be cooled down. An internal temperature of the food item was measured by the CDM using a metal stem probe thermometer. The CDM cleaned the thermometer using an alcohol wipe, lifted the saranwrap, and inserted the thermometer into the soup. The thermometer measured the food item at 50 degrees Fahrenheit. The CDM stated the food item was not cooled properly and would need to be discarded. She stated food that is not cooled properly and served to residents could result in making the residents sick. During an interview on 12/18/20 at 9:30 a.m., the [NAME] stated she did not make the soup that was stored in the walk-in cooler. The process for cooling down a food item is to leave the food item on the stove top for four hours, transfer the product to a new container, cover the item, and store it into the walk-in cooler. The CDM stated that there is no cooling log that is kept logging the temperatures of food items that are being cooled down. Therefore, the original time the food was cooked and cooled was unable to be determined. A policy review of Equipment, no date, revealed It is the center policy that all food service equipment is clean, sanitary, and in proper working order . The Dining Services Director will ensure that all equipment is routinely cleaned and maintained in accordance to manufacture directions and training materials . The Dining Services Director ensures that all food contact equipment is cleaned and sanitized after every use . the Dining Services Director ensures that all non-food contact equipment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 7 of 8 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 105050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shore Acres Care Center and Rehab 4500 Indianapolis St NE Saint Petersburg, FL 33703 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 is clean. Level of Harm - Minimal harm or potential for actual harm According to the United States Food and Drug Administration (FDA) Food Code, 2017, page 94, revealed .Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57°C (135°F) to 21°C (70°F); and (2) Within a total of 6 hours from 57°C (135°F) to 5°C (41°F) or less . Cooling shall be accomplished in accordance with the time and temperature criteria . by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment . Loosely covered, or uncovered if protected from overhead contamination during the cooling period to facilitate heat transfer from the surface of the food . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 8 of 8