Inspection·February 25, 2022

F 0684 on a pain scale with a goal to continue current pain medications. A follow -up was expected in 4 weeks. Level of Harm - Minimal harm or potential for actual harm Review of Resident #15's progress notes dated 01/21/22 to 02/21/22 did not show documentation of attempts to schedule the appointment. Residents Affected - Few An interview was conducted on 02/23/22 at 10:03 a.m. with Resident #15. She stated a nurse had informed her that she would be going to the ER (emergency room) for an assessment of her medical condition. She said the nurses had been aware of the growing hernia and the on-going abdominal pain. During observation and interview on 2/23/22 at 10:30 a.m., with Resident #15, she confirmed she had not been assessed by the physician or nurse practitioner since last year when Staff C, RN, UM brought someone in to look at her. Resident #15 stated she was told the doctor was here three days ago but never came to see her and no one had looked at her growing lump. The resident was provided privacy and she pulled up her gown to expose her right lower abdomen while sitting in her wheelchair. The area of her abdomen appeared distorted, extended, and protruded out while sitting down. The lower portion of the lump was observed with a pink color that the resident confirmed was painful. She stated she got pain medications and let them know it was for her abdomen, but they were all agency nurses, and no one had looked at her. The resident stated that she must use pillows to rest her abdomen on to maintain comfort while lying in bed. On 2/24/22 a review of Resident #15's medical record showed she returned from the hospital on 2/23/2022 at 5:30 p.m. Review of hospital discharge record dated 02/23/22 showed findings on abdominal wall which indicated there were rectus diastases with a ventral hernia along the lower abdomen containing non-obstructed segments of small and large bowel. The hernia sac measured at 12.6 x 7.6 cm (centimeters) transverse and the neck measured 5 x 6 cm. An interview was conducted on 2/24/22 at 4:24 p.m. with Staff C, RN and the Social Services Assistant (SSA). Staff C stated Resident #15 had been sent to the ER to assess abdominal pain related to the hernia. Staff C stated that Staff M, Scheduler, was responsible to schedule appointments. Staff C stated that if a resident needed to see the doctor, they put the information on the communication board. Staff C stated that it was also entered as a physician order so that everyone could follow-up. An attempt to interview Staff M was unsuccessful. The Director of nursing (DON) reported that the employee was out of the building. During an interview with Resident #15 on 2/25/22 at 12:50 p.m., Resident #15 stated that she had been notified that an appointment had been secured in August 2022. Resident #15 expressed frustration with the timing. Resident #15 was noted teary during the interview. She said, why would it take that long? I need medical attention. Review of a change in condition evaluation form for resident #15 dated 02/23/22 showed that signs and symptoms identified abdominal pain that was new or worsening. The evaluation showed a start date of 01/21/22. An interview was conducted with the Director of Nursing (DON) on 2/25/22 at 4:00 p.m. The DON stated that she was aware that Resident #15 had a hernia. The DON stated that she was not aware that it was worsening. The DON stated that if a resident needed to see a doctor, they were to inform the nurse. The DON stated that the nurse communicated with the social services department and Staff M tried to set the appointment. The DON stated that they consider the severity of the medical condition and (continued on next page) 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 02/25/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few how soon the appointment needed to be made. The DON further stated they had a hard time trying to secure an appointment for Resident #15. The DON said that the delay was due to not being able to find a surgeon who took the resident's current insurance. DON stated that documentation related to the attempts being made to schedule the appointment would be documented in the EMR. The DON said that the documentation should show on-going physician assessments and hernia changes noted in the nursing assessments. The DON stated that the facility had issues with documentation and that she would be conducting in-services. Review of a facility policy titled, acute condition changes - clinical protocol, revised March 2018, stated that the physician will help identify individuals with a significant risk for having changes of condition during their stay. In addition, the nurses shall assess and document or report all active diagnosis. Review of a facility policy titled, Transfer or discharge, emergency, revised August 2018, showed (9.) the nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. Under treatment and management (3.) If it is decided after sufficient review, that care or observation cannot reasonably be provided in the facility, the physician will authorize transfer to the appropriate setting. Under monitoring and follow -up, the staff will monitor and document the resident / patient's progress and response to treatment. 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 02/25/2022 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 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** Based on observations, interviews, and record review, the facility did not ensure respiratory equipment was maintained in a sanitary manner, for one (Resident #29) of 14 sampled residents. Residents Affected - Few Findings included: During a facility tour on 02/22/22 at 11:01 a.m., Resident #29's nebulizer mask and oxygen cannula were observed stored inside an open drawer, the nasal cannula was observed on the floor, and the oxygen tubing was noted tangled inside the drawer and partly on the floor. Photographic evidence was obtained. On 02/22/22 at 2:30 p.m. a second observation of the nebulizer mask, oxygen tubing, and cannula was made and were in the same condition as noted earlier in the day. Review of an admission record for Resident #29 showed that she was admitted to the facility on [DATE] with a diagnosis to include chronic obstructive pulmonary disease (COPD) with acute exacerbation. A quarterly minimum data set (MDS) for Resident #29, dated 12/15/21, showed she had a brief interview for mental status (BIMS) score of 15, which indicated intact cognition. On 02/23/22 at 3:26 p.m., a third observation of the nebulizer mask and oxygen cannula was made. The nebulizer mask was stored in an open drawer, exposed to the elements. The nasal cannula and tubing were noted dangling on the floor. On 02/23/22 at 3:28 p.m., an interview was conducted with Resident #29. She said, my nebulizer is usually in this drawer, pointing to where it was. She said, The staff used to keep in a bag. I have not seen one in a while. She stated she did not know when the mask was last changed. She said, I don't know if it has been cleaned recently. Review of physician orders for Resident #29 printed on 02/25/22 showed orders to: change oxygen / nebulizer tubing weekly and PRN (as needed) for prophylaxis. Albuterol sulfate nebulization solution (2.5 mg / 3 ml) 0.083% milliliter inhale orally via nebulizer at bedtime for shortness of breath. Oxygen via nasal cannula as needed - titrate to maintain 2 saturations greater than 92% every shift for COPD. Review of the treatment administration record (TAR) dated 02/01/22 - 02/28/22, indicated to change oxygen and nebulizer tubing weekly and PRN. A care plan with a goal initiated on 05/31/2019 showed Resident #29 had a potential for complications of respiratory distress related to diagnosis of COPD, asthma, chronic hypoxic respiratory failure, emphysema and OSA (obstructive sleep apnea.) Interventions include nebulizer treatments and oxygen saturations as ordered. (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 02/25/2022 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 0695 Level of Harm - Minimal harm or potential for actual harm On 02/24/22 at 8:46 a.m., Resident #29's nebulizer mask and oxygen cannula were observed not stored appropriately, stashed in a drawer, not covered. On 02/25/22 at 10:20 a.m., an interview was conducted with Staff D, LPN (licensed practical nurse). Staff D stated the nebulizer mask and oxygen cannulas, and tubing should be stored in dated bags. Residents Affected - Few On 02/25/22 at 10: 27 a.m., an interview was conducted with Staff E, LPN. Staff E stated that the day nurses monitor storage of equipment. She stated that the nurse should bag the equipment after nebulization treatments. She stated the night nurses were expected to change the tubing. An interview was conducted on 02/25/22 at 10:39 a.m. with staff C, Unit Manager. Staff C stated that the expectation was to maintain the cannulas and mask in a sanitary manner, clean as needed, and change as ordered. Staff C stated that Resident #29 usually moved things around and she should have a bag for her cannula and mask. Staff C looked around and could not find a bag. Staff C stated that the oxygen tubing was too long and that she would ensure that it was changed to the right size. She stated the cannula and mask would be replaced too. She stated the expectation was for the nebulizer mask and nasal cannulas to be bagged and dated. An interview was conducted on 02/25/22 at 11:27 a.m. with the director of nursing (DON). The DON stated that she would expect the nasal cannula, tubing, and nebulizer mask to be stored individually in a bag and dated. The DON stated that the 11:00 p.m. - 7:00 a.m. nurses were supposed to change the cannulas and tubing. She stated that the nurse administering medication should ensure proper storage after administering medication. She reviewed the photographic evidence and stated, that does not look good. She stated the expectation would be to follow the policy and physician orders. The DON said, I expect the nurses to change and store respiratory equipment as ordered. Review of a facility policy titled, respiratory therapy - prevention of infection revised in 2011, showed under steps and procedure #8. to keep the oxygen cannula and tubing in a plastic bag when not in use. Review of a training checklist titled, Oxygen competency check-off dated 03/2020 showed an expectation to secure oxygen tubing in a plastic bag when not in use. 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 02/25/2022 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and policy reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during three of four days of the survey. Findings included: On 02/22/2022 at 9:20 a.m., the initial kitchen tour was conducted with the Certified Dietary Manager (CDM), Staff A, Dietary Aide and Staff B, Cook. An observation was made of the reach in cooler thermometer, located in the back of the cooler on the third shelf, showing a temperature reading of 48 degrees. The digital thermometer on the top of the right door showed a reading of 52 degrees. Staff A, Dietary Aide stated that she was in and out putting items away for lunch and that was why the temperature was off. Inside the same cooler, a stack of white American cheese slices was observed wrapped in clear plastic without a label or date. An observation was made of food debris in the small creamer containers, and sugar packs found behind the reach in cooler. There were two opened and half used bottles of hot sauce with no date, and a container of spices, parsley flakes opened and not dated. An observation was made of a pan on the cook's counter noted with a white grainy substance. The CDM stated it was food thickener. The pan was undated and not covered. On the bottom shelf of the counter was a pan of several unpeeled yellow onions in an open plastic bag. Three of the onions were noted with green bio-growth substance growing on the surface. An observation was made of the kitchen daily cleaning schedule posted on the side of the reach-in refrigerator with a date of 02/10/2022. The cleaning schedules were noted without signatures to confirm that cleaning had been completed. An observation was made of the fryer with cooked food debris and hardened oil splatters. An interview was conducted with the CDM on 02/22/22 at 9:44 a.m. The CDM stated that she was not sure the last time the fryer was used or cleaned. An observation was made of the juice machine nozzle noted clogged with as syrup looking substance. During a tour of the dry storage room, two large cans of food that had dried food stains and dirt on the lids, were observed propping the door open. Further observation revealed three white storage bins on wheels containing a product with no label or dates. One of the three containers had food spillage on the bottom along with a white foam cup. There were no scoops in the bins. Additional observations during the tour revealed in the cook's prep sink, portions of raw chicken sitting in an 8-inch full size steam table pan. The chicken was piled above the water line of the pan and water was running from the faucet over one end of the pan. Staff B, [NAME] confirmed the water had been running for five minutes and stated the chicken was still frozen and needed to get it ready as it is on the menu for fried chicken today. Underneath the cook's prep sink was loose floor tiles and a puddle of water over the loose tiles. An interview was conducted with the CDM. She stated that work orders had been submitted but nothing had been resolved. (continued on next page) 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 02/25/2022 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 An observation was made of a cook's prep table located in the middle of the kitchen with a puddle of water around the dish washing floor area. The observation revealed that there were no yellow signs warning of slippery / wet floors. An observation was made of staff walking around the puddle without anyone cleaning it. In an interview with the CDM on 02/22/22 at 10:08 a.m., she stated that work orders had been submitted but nothing had been resolved. Residents Affected - Some In the main kitchen area, an observation was made of a 4- tier open wire rack storing various clean stainless-steel pans used to cook with and store food. The rack was placed between the employee's hand washing sink and the dirty side of the 3-bay sink area. At the time of walk-through there were no splash guards on the rack to prevent possible contamination or splatters of chemicals and food. During the ongoing kitchen tour, five-gallon chemicals were observed underneath the dish washing area noted with dirt, dust, and food debris. The floors were soiled with hardened food remnants which extended to against the walls. An observation was made of the air vent located above the dish machine and clean dish area and was noted with dirt and dust. The vent was noted not allowing for proper ventilation and concerns with dirt and dust blowing over clean dishes. An interview was conduced with the CDM on 02/22/22 at 10:08 a.m. The CDM stated that she would have staff clean it right away. The CDM said, I don't know how we missed that. It should be cleaned due to contamination. On 02/24/2022 at 11:15 a.m., a second tour of the kitchen was conducted. During the tray line and food temperature checks, Staff A was asked to check the temperature of the sour cream. The reading was noted at 51 degrees. A test of the milk cartons that were about to be served showed a temperature reading of 48 degrees. Staff A and the CDM removed the items from the tray line and stated that they would not serve them like that. The CDM said, that temperature reading is not right. Review of the facility's temperature form with a date of 02/20/22 to 02/26/22 revealed a statement of, Record of food temperatures Prior to service, and AGAIN after half of the meals have been served. Review of the document showed that second temperatures were not recorded for any days of the week for any of the meals served per their own policy. On 02/25/22 at 1:30 p.m., an interview was conducted with the CDM, regarding the sanitation, safety and dietary concerns identified during the survey. The CDM confirmed that food items should be labeled and stored in sanitary conditions per regulation and policy. She stated the cleaning tasks should be completed daily. The CDM further stated that she would follow up with reported maintenance concerns. She said she would in-service her team on proper thawing and cooling methods. Review of the of facility policy titled, Food Storage-Dry Goods-Policy 18, revised October 2019, showed that it is their policy to insure all dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code. (5) Ensures that all packaged and canned food items shall be kept clean, dry, and properly sealed. Review of a facility policy titled, Food Storage-Cold- Policy 19, revised October 2019, showed an expectation to insure all Time /Temperature Control for Safety (CS) frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code Under (2.) Ensures that all perishable foods will be maintained at temperatures of 41 degrees or below except during necessary periods of preparation and service. Ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross (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 02/25/2022 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 contamination Level of Harm - Minimal harm or potential for actual harm Review of a facility policy titled, Storage of Chemicals- Policy 20, dated October 2019, showed an expectation to ensure all chemicals will be properly stored for safety and to prevent cross contamination with food. Under (1.) Ensures that all chemicals are stored in a separate/secured area. Residents Affected - Some Review of a facility policy titled, Safety- Policy 26, dated October 2019, showed an expectation to ensure that kitchen equipment is properly maintained, and that staff follow safe operating practices. All equipment and physical plant maintenance issues are promptly reported and according to center protocol. (1.) Ensures that the environment will be maintained in good repair with appropriate light and ventilation. (2.) Ensures that all equipment is in proper working condition and equipped with safety guards as appropriate. Review of a facility policy titled, equipment- Policy 27, dated October 2019 showed that all food service equipment is clean, sanitary and in proper working order. (1.) Ensures that all equipment is routinely cleaned and maintained in accordance with manufacturer directions and training materials (2) Ensures that all staff members are properly trained in the cleaning and maintenance of all equipment (4.) Ensures that all non-food contact equipment is clean (5.) Ensures request for maintenance or repair to the administrator and/or Maintenance Director as needed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 8 of 8