Inspection·May 30, 2024

F 0580 point. The DON stated the nurse who wrote the note was unavailable. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 02:09 PM an interview with Resident #105's attending physician was conducted. He stated he could not remember if he was notified of the resident's change in condition. He said, If a resident had a change in condition, someone should contact their physician and family. If he was on Hospice, Hospice should have been notified to ensure he was comfortable. The attending physician stated the facility should follow their own policies on documentation. Residents Affected - Few A review of a facility policy titled, Acute Condition Changes-Clinical Protocol, Revised [DATE], showed the following: 5. The nursing staff will contact the physician based on the urgency of the situation. For emergencies they will call or page the physician and request a prompt response. 6. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. (a.). The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. 7. The nurse and physician we'll discuss and evaluate the situation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 2 of 23 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 05/30/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interviews and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II upon a new qualifying mental health diagnosis for one resident (#63) of 8 residents sampled for PASRR's. Findings included: A review of the admission record for Resident #63 revealed an original admission date of 12/30/21 with diagnoses including major depressive disorder, anxiety disorder, Traumatic Brain Injury (TBI), and epilepsy. A review of Resident #63's Level I PASRR, dated 12/15/21, showed only a diagnoses of substance abuse and epilepsy were checked. A review of Resident #63's medical record revealed a new diagnosis of schizoaffective disorder, on 05/22/22, and no documentation a PASRR Level II was completed. A review of Resident #63's medical record revealed a new diagnosis of paranoid schizophrenia, on 05/17/24, and no documentation a PASRR Level II was completed. During an interview on 05/30/24 at 04:22 PM, the Social Services Director, (SSD) consultant stated the PASRR was not correct. She stated if the residents had a new diagnosis of schizophrenia or dementia on the record, they should have resubmitted another PASRR screening. She stated anytime a new diagnosis comes up, or if nurses were reviewing orders and notify a concerning diagnosis, the PASRR should be reviewed and if they needed a Level II assessment, it should be submitted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 3 of 23 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 05/30/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the admission record for Resident #47 showed an admission date of 04/16/24 with diagnoses to include major depressive disorder, mood disorder, unspecified psychosis, and seizure disorder. Residents Affected - Some Review of a Level I PASRR for Resident #47, dated 04/16/24, revealed a blank PASRR with no qualifying diagnosis checked. 3. Review of the admission record showed Resident #79 was admitted on [DATE] with diagnoses including major depressive disorder and anxiety disorder., and on 3/22/24 diagnoses of paranoid schizophrenia and dementia were added. Review of Resident #79's Preadmission Screening and Resident Review (PASRR) Level I Screen, dated 2/14/24, showed anxiety disorder and depressive disorder. An updated PASRR Level I Screen was not completed when a new diagnoses was added on 3/22/24. An interview was conducted on 5/30/24 at 4:22 p.m. with the facility's Social Services Consultant. She reviewed Resident #79's PASRR and confirmed it should have been resubmitted. She said all new admission PASRR's are reviewed at the Monday through Friday morning meetings and errors should be corrected. She said if a resident goes out to the hospital and receives a new diagnosis, the hospital should do a new PASRR before the resident returns, but if a new diagnosis is received in-house, the provider should let social services know so a new screening can be completed. The Social Services Consultant said social services should also be reviewing the psychiatric providers notes. 4. Review of the admission Record, dated 5/30/2024, for Resident #90 revealed the resident was admitted on [DATE] and readmitted on [DATE]. The resident diagnoses included brief psychotic disorder (4/10/2024), persistent mood disorder (4/4/2024), anxiety disorder (4/4/2024), mood disorder (12/1/2023), and dementia (10/11/2023). Review of the Minimum Data Set (MDS), dated [DATE], for Resident #90 revealed in Section C - cognitive patters, a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Review of Resident #90 Pre-admission Screening and Resident Review (PASRR) , dated 9/6/2023, revealed the following: a. Under Section I B - Finding is based on (check all that apply) only documented history is checked. b. Under Section II question 6 - Does the individual have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is a serious mental illness or intellectual disability? Yes, is the response c. Under Section II question 7 -Does the individual have a validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease)? The response is yes and other is checked specified to history and physical. d. Under Section IV PASRR Screen Completion: Individual may be admitted to an nursing facility. No (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 4 of 23 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 05/30/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation not required. 5. Review of the admission Record, dated 5/30/2024, for Resident #87 revealed the resident was admitted on [DATE] and readmitted on [DATE]. Resident diagnoses included schizoaffective disorder, bipolar type (6/6/2023). Review of the Minimum Data Set (MDS), dated [DATE], for Resident #87 showed in Section C - cognitive patterns, a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. Review of Resident #87 Pre-admission Screening and Resident Review (PASRR), dated 5/25/2023, revealed in Section I: PASRR Screen Decision-Making no diagnosis of schizoaffective disorder or bipolar disorder was checked. A review of the facility policy titled, Pre-admission Screening and Resident Review, dated April 2020, revealed the following: Policy Statement: Our facility complies with Pre-admission Screening and Resident Review screens for all new and re-admissions. Policy Interpretation and Implementation. 1. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. 2. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident are outlined in the evaluation. 3. The preadmission screening program requirements do not apply to residents who, after being admitted to the facility, were transferred to a hospital. Based on interviews and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I assessments were completed accurately for five residents (#94, #47, #79, #90, and #87) of forty-four residents sampled. Findings included: 1. Review of Resident #94's admission Record revealed an original admission date of 2/4/24, and a re-admission date of 5/8/24. Resident #94's admission Record revealed diagnoses to include major depressive disorder, recurrent, mild with an onset date of 4/2/24, generalized anxiety disorder with an onset date of 4/2/24, and major depressive disorder, recurrent, moderate with an onset date of 2/4/24. Review of Resident #94's PASRR Level 1, dated 2/13/24, revealed no qualifying mental health diagnosis. A review of the active Clinical Physician Orders, as of 5/30/2024, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 5 of 23 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 05/30/2024 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 0645 Duloxetine HCI 30 MG two times a day related to major depressive disorder, recurrent, mild. Start date 5/14/24. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 6 of 23 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 05/30/2024 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility 1) failed to ensure medications were available for two residents (#101 and #19) out of four residents sampled, 2) failed to assess a skin condition for one resident (#8) out of one resident sampled, and 3) failed to ensure neurological checks were completed for two residents (#105 and #79) out of four residents sampled. Residents Affected - Some Findings included: 1. An observation and interview was conducted on 05/28/24 at 2:30 p.m. with Resident #101. He stated he used to be on antiretroviral medications and would like to be on them again. He stated he did not have a way to get his medications. He stated he wanted to stay on the medications. He stated he was taking them prior to a hospital stay but had not taken them since admission to this facility. A review of the admission record showed Resident #101 was admitted to the facility on [DATE] with a diagnosis of [immune deficiency syndrome]. A review of Resident #101's admission Minimum Data Set (MDS), revealed in Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 12, indicating intact cognition. A review of the May 2024 physician orders for Resident #101 showed the resident had no orders for [immune deficiency syndrome] medications. A review of a hospital document titled, Discharge Instructions, dated 04/12/24, showed Resident #101 was discharged from [Name of Hospital] with follow-up instructions as: Go to [name of clinic] - Specialty care center in 1 week. Resume [immune deficiency syndrome] therapy. You can show up on Monday - Friday without an appointment between 8AM and 3PM. The instructions included the address and phone number of the location. A review of a history and physical progress note from [name of Hospital], dated 04/01/24, showed .Patient reports he takes antivirals for his [immune deficiency syndrome] but does not remember the name and has not been to the health department recently. Assessment and plan: He was also found to have CD4 count of 45 for which ID (Infectious Disease) recommended Bactrim and follow-up with the health department. 2. Review of the admission record for Resident #19 revealed a re-admission date of 03/19/22 with a diagnosis of [immune deficiency syndrome]. During an observation and interview on 05/29/24 at 2:45 p.m., Resident #19 was in his room. The resident did not make eye contact during the interview. The resident kept his head down. He stated he was aware of his [immune deficiency syndrome] status and had previously spoken to another physician about his diagnosis. He stated he was not currently taking medications for this diagnosis. He stated he had not been on them for a while and had not had labs to determine his viral load. The resident stated he did not want to take his medications and did not want to interview any further. Review of Resident #19's quarterly MDS, dated [DATE], revealed in Section C-Cognitive and Patterns a Brief Interview for Mental Status (BIMS) score of 12, indicating intact cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 7 of 23 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 05/30/2024 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 Review of Resident #19's care plan, dated 04/29/24, showed: Level of Harm - Minimal harm or potential for actual harm Resident was at risk for decline in mental or physical condition related to diagnosis of [immune deficiency syndrome] and the disease process. Resident is undetectable, currently not on any anti-viral medications. Interventions included observing new onset of signs/symptoms of disease progression and for complications related to disease progression and to update physician if noted. Residents Affected - Some An interview was conducted with the Social Services Director (SSD) on 5/29/24 at 3:21 p.m. She stated she did not refer residents for outside services because nursing would do so. She stated if a new admission came and they had a diagnosis such as [immune deficiency syndrome], they review in their clinical meeting. She said, Some type of assessment would follow, usually an initial assessment with nursing. We ask them where they came from, we ask to see if they have psychosocial needs that need to be addressed. We as an IDT (Interdisciplinary team) identify if they need access for medications with particular diagnosis. The SSD stated nursing staff would tell her if the resident required psychotherapy, and she would get the resident help. She stated at this time there were no residents who required outside referral for [immune deficiency syndrome] care. She said, No, I don't know there are residents without medications. Nursing would tell me if someone needed a referral. They have not told me. An interview was conducted on 05/29/24 at 3:44 p.m. with the facility's Psychiatric ARNP (Advanced Registered Nurse Practitioner). She stated she had not discussed Resident 19's [immune deficiency syndrome] diagnosis with him. She said, I have seen him for psych reason, depression, I believe. I did not know if he needed medications. I would not discuss these kinds of diagnoses with them, I think it would be inappropriate. The ARNP stated unless a resident or a staff member brought up a concern, she would not have a reason to discuss it with them. She said, I let them choose what they want to discuss. I don't know if or why he [Resident #19] does not want medications. The ARNP stated the facility should provide the appropriate follow-up regarding [immune deficiency syndrome] treatment for their residents. On 05/29/24 at 4:08 p.m., an interview was conducted with the Primary Care Physician (PCP) listed for Residents #101 and #19. He stated he had not seen Resident #101 but was scheduled to see him the following Thursday. He stated he would not be the one to address [immune deficiency syndrome] treatment. He stated [immune deficiency syndrome] residents should be seen by an [immune deficiency syndrome] specialist at an [immune deficiency syndrome] clinic. He stated he did not do the referral, but the facility should refer the residents. The PCP said, If someone comes in with a [immune deficiency syndrome] diagnosis, they should be handled like any other diagnoses such as diabetes or dialysis. On 05/29/24 at 4:30 p.m., an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The ADON stated if a resident was admitted with [immune deficiency syndrome] diagnosis, they run their labs to determine where they are. She said, We make sure they have medications. We start with an assessment to determine their needs. The DON stated the SSD should assess the resident to make sure their psychosocial needs are being met. She said, We review their medications with the provider. If they do not have medications, we contact pharmacy and consult with SSD to see about a referral for specialty medications from the community. The ADON stated she was not aware there were residents who did not have medications. The DON, ADON and this surveyor reviewed the resident records for Resident #101 and #19 and confirmed there were no lab orders or a documented process for referral for [immune deficiency syndrome] care. The review showed there was no care plan for Resident #19's refusal for medications. The record further showed these resident's psychosocial needs related to the [immune deficiency syndrome] diagnosis were not documented as being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 8 of 23 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 05/30/2024 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 addressed. Level of Harm - Minimal harm or potential for actual harm In a follow -up interview conducted on 05/30/24 at 10:28 a.m. The DON and the ADON confirmed this was a missed opportunity. They stated the two residents should have been connected with a specialist for care and services. The DON stated their expectation was to assess the residents upon admission and schedule a consultation for external services. She stated if a resident needed specialty medications, they would make it happen. She confirmed they did not refer Resident #101 to the health department per the hospital discharge instructions. She said, We should have done it. The ADON stated for Resident #19, I spoke with him yesterday [05/29/24] upon learning he was not on [immune deficiency syndrome] medications. He did say he was on medications before, but not since admission in 2022. I don't know why he does not want medications. Psych should assess him for that. She stated either way, he [Resident #19] should have been assessed and care planned accordingly. Residents Affected - Some Review of a facility policy titled, admission Assessment and Follow up: Role of the Nurse, dated September 2012. showed the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments including the MDS. Steps in the procedure showed: 10. Reconcile the list of medications from the medication history, admitting orders and the previous MAR (Medication Administration Record) if available and the discharge summary from the previous institution according to established procedures. 11. Contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain orders that are based on these findings. 13. Contact outside services such as laboratory or diagnostic services as necessary. 3. Review of the admission Record for Resident #105 revealed he was admitted to the facility on [DATE] with diagnoses to include history of falling. A review of the care plan showed a focus initiated on 11/08/23, Resident #105 was at risk for falls and/or fall related injury related to generalized weakness, is impulsive, attempts transfers, has a history of falls, and has poor safety awareness. Review of a document titled, SBAR (Situation, Background, Assessment, and Recommendation) communication Form, dated 02/20/24 showed an evaluation was conducted related to falls. The summary of observations and evaluation showed: The CNA (certified nursing assistant) came and told me that the patient was in the hall and told her that he fell in the bathroom and hit his head. I went to the patients room and found him with a red area on the left side in front of his head. He told me he slipped in the bathroom and bumped his head and was noted with the small scratch and red bump. Called POA and MD and Don. Nurse practitioner was on call, and she ordered head X-ray. Review of a neurological evaluation for Resident #105, dated 02/20/24, showed under instructions: This form should be completed for any unwitnessed fall or other accident/injury with possible head trauma or when indicated by the residence condition. The physician should be notified of any neurological change that requires further evaluation. This evaluation should be completed every 15 minutes x (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 9 of 23 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 05/30/2024 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 4, every 30 minutes x 4, then every 1-hour x 4, then every four hours x 4, then every eight hours x 4. Level of Harm - Minimal harm or potential for actual harm The review showed 7 neurochecks were not completed as required. 14 Residents Affected - Some Q4H Check 2 - missed check. 15 Q4H Check 3 - missed check. 16 Q4H Check 4 - missed check. 17 Q8H Check 1 - missed check. 18 Q8H Check 2 - missed check. 19 Q8H Check 3 - missed check. 20 Q8H- Final Check - missed check. On 05/30/24 at 10:26 a.m., an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). They stated the Neuro checks should have been completed to the final check. The DON stated there should have been post fall assessments to monitor the resident especially after he hit his head. The ADON stated the nurses should have continued with skilled assessments post fall. 5. Review of the admission record showed Resident #79 was admitted on [DATE] with diagnoses including Huntington's Disease. Review of Resident #79's progress notes, dated 2/23/24, explained the resident was observed lying on the floor by the nurses' station on her back. The resident had blood coming from the back of her head. The resident was alert and oriented. 911 was called and the resident was sent to the hospital. A second progress note, dated 2/23/24 at 3:29 p.m., explained EMS arrived at 3:36 p.m.; the resident was stable and responding. A progress note, dated 2/23/24 at 9:00 p.m., showed the resident returned to the facility from the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 10 of 23 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 05/30/2024 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 - Some Review of Resident #79's evaluations and progress notes did not show any post fall notes or neurological checks after the fall with head injury on 2/23/24. An interview was conducted on 5/30/24 at 6:55 p.m. with the ADON. She reviewed Resident #79's medical record and confirmed there were no neurological checks or post fall notes documented after the resident's fall on 2/23/24. The ADON said no records came back from the hospital with the resident showing a CAT scan was done and the resident had no bleeding or head injury, therefore neurological checks and notes should have been completed for three days post fall. Review of a facility policy titled Neurological Assessment, revised October 2010, showed the following: Purpose The purpose of this procedure is to provide guidelines for a neurological assessment: 1) upon physician order, 2) when following an unwitnessed fall; 3) subsequent to a fall with suspected head injury; or 4) when indicated by resident condition. 4. During an observation made on 05/28/2024 at 10:00 a.m., Resident #8 was observed sitting in her wheelchair in the hallway. She was presented well-groomed with her hair comb and no signs of distress. Further observation revealed Resident # 8 with a bruise on her right hand. During an observation made on 05/29/2024 at 3:00 p.m., Resident #8 was observed lying down in bed resting with her call light within her reach. Review of Resident # 8 admission record showed she was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, paranoid schizophrenia, bipolar disorder. Review of a Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicated Resident #8 was severely cognitively impaired. Review of multiple weekly skin assessments, dated 05/14/2024, 05/21/2024, and 05/28/2024, showed Resident #8's skin description was noted as good, skin color normal for ethnic group, and skin condition normal. Further review of the skin evaluation showed Resident #8 had no new skin impairments, note signed by Staff G, License Practical Nurse, LPN Review of a progress note, created on 5/29/2024 by the Director of Nursing, showed Resident #8 was not assessed for discoloration on her right hand until 5/29/2024. During an interview on 05/28/2024 at 10:20 a.m., with Staff F, a Certified Nursing Assistant, CNA, she stated she was the aide assigned to Resident #8. She said she did not know how Resident #8 got the bruise on her hand because it was not on her hand before. During an interview on 05/28/2024 at 10: 40 a.m., with Staff G, License Practical Nurse, LPN, she stated she was the nurse responsible for Resident #8. She stated she did not know Resident #8 had a bruise on her hand. She stated she would notify the Director of Nurses because she does not know what happened to the resident hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 11 of 23 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 05/30/2024 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 - Some During an interview on 05/29/2024 at 11:00 a.m., with Staff G, License Practical Nurse, LPN. She stated she did not assess the resident's hand and complete a new skin assessment because she told the Director of Nursing about the resident, but she would do a skin assessment when she gets a chance to do it. During an interview on 05/29/2024 at 1:00 p.m., with the Director of Nurses, DON. She stated the nurse that was assigned to Resident #8 reported to her about the bruise on the resident's right hand. She said she and the Assisted Director of Nursing went to assess the resident's hand, but they did not document any of their findings. They concluded that they did not know what happened to her hand. She reviewed the resident's medical record to see if she was on any blood thinner, but after her record review she determined the resident had not taken any anticoagulants or any medication that may have caused her to have discoloration on her skin. The DON stated the expectations were that a skin assessment should have been documented in the resident medical record at the time the assessment was done. Review of the facility policy titled, Skin Assessment Guidelines, undated, showed the following: Purpose: The purpose of this procedure is to provide information regarding identification of skin impairment risk factors and interventions for specific risk factors. Monitoring 1. Evaluate report and document potential changes in the skin Photographic evidence obtained FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 12 of 23 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 05/30/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure appropriate use of antibiotics for one resident (#79) out of six residents reviewed for unnecessary medication. Residents Affected - Few Findings included: Review of Medication Administration Records for Resident #79 revealed she was on antibiotics in January, February, and March of 2024 for a urinary tract infection (UTI). Review of admission records showed Resident #79 was admitted on [DATE] with diagnoses including Huntington's Disease, UTI, and hematuria. Review of Resident #79's Lab Results Report, dated 1/10/24 showed the resident had a UTI with bacteria resistant to Levofloxacin. Review of Resident #79's Physician orders showed the resident was ordered Levofloxacin 500mg for a UTI 5 days starting on 1/12/14. Review of Resident #79's Lab Results Report, dated 2/2/24, showed the Urinalysis had no growth. Review of Resident #79's Physician orders showed the resident was ordered Levofloxacin 500mg for a UTI for 5 days starting on 2/1/24. Review of Resident #79's Lab Results Report, dated 3/2/24, showed the resident had bacteria in her urine, however no culture and sensitivity was completed. Review of Resident #79's Physician orders showed the resident was ordered Levofloxacin 500mg for a UTI for 5 days starting 3/1/24. Review of Resident #79's progress notes showed no documentation a provider was called regarding changing or discontinuing antibiotics. An interview was conducted on 5/30/24 at 2:13 p.m. with Resident #79's primary care physician. He stated if he had been called by the facility and notified the resident's culture came back as resistant to Levofloxacin he would have changed the antibiotic. He said with Resident #79's urinalysis that had no growth, the facility should have called, and he would have stopped the antibiotic. He said if he wasn't called, he wouldn't know until a week or two later, when he came to the facility and reviewed the results. He said he did not recall being notified about the antibiotic concerns, and if he was notified there should have been a progress note in the resident's record. An interview was conducted on 5/30/24 at 5:43 p.m. with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP). She reviewed Resident #79's lab results and orders from January, February, and March 2024 and said, These issues should have been caught. She said antibiotic orders are monitored through morning clinical meetings and order listings. The ADON said the doctor should have been notified the bacteria was resistant to the antibiotic ordered and when the urinalysis came back with no growth. She said a culture and sensitivity should have been completed with the urinalysis on 3/2/24 to see what antibiotic was appropriate to use. The ADON said she would expect nurses to look (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 13 of 23 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 05/30/2024 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 0757 Level of Harm - Minimal harm or potential for actual harm at the lab results and read them completely, making sure they understand what they are reading. She said these concerns should have been caught by the nurse or during the clinical meeting review and the doctor contacted. Review of a facility policy titled Antibiotic Stewardship, revised December 2026, showed the following: Residents Affected - Few Policy Statement Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Policy Interpretation and Implementation 1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. . 9. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as possible to determine if antibiotic therapy should be started, continued, modified, or discontinued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 14 of 23 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 05/30/2024 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 0790 Provide routine and 24-hour emergency dental care for each resident. 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 one resident (#94) out of one resident sampled was offered timely dental services from an outside source. Residents Affected - Few Findings included: On 5/28/24 at 12:20 p.m. Resident #94 was observed in bed in an upright position, conversing with her roommate Resident #82. Resident #94 expressed she had tooth pain from a broken tooth. Observed Resident #94 touching slightly above her lip and verbally indicated that is where the pain is. She stated she was using over the counter medication provided by a family member. She stated the facility would take the medication away if staff knew about it. During the interview, observed Resident #94 with a swab in her mouth and a small blue bottle labeled [vendor name] on the bedside table in front of her. She stated the swab was dipped in [vendor name] and the medication is to help alleviate the tooth pain. Review of Resident #94's admission Record revealed an original admission date of 2/4/24 and a re-admission date of 5/8/24. Review of Resident #94's current care plan revealed diagnoses to include: chronic pain syndrome, dorsalgia, unspecified, other low back pain, muscle spasm of back, spondylosis without myelopathy or radiculopathy, thoracic region, Type 2 Diabetes Mellitus without complication. Further review of current care plan did not reveal any focus, goals or interventions related to dental care. Review of Resident #94's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, cognitively intact. On 5/29/24 at 12:28 p.m. an interview with Resident #94 revealed she continues to have tooth pain. She stated the tooth pain started months ago. She stated she communicated with facility staff about the tooth pain. Resident #94 stated her tooth broke recently. An observation revealed her touching the right side of her lip and mouth area identifying where she is having pain. She stated she thinks she has an active infection. Resident #94 stated, I've gone through two bottles of [vendor name]. An observation of the bedside table in front of her revealed a clear medicine dispensing cup. An observation revealed a caramel-colored liquid inside the cup, with cotton swabs dipped in the liquid. She stated she had a dental appointment scheduled in December 2023 but could not attend due to being hospitalized . She stated when she was admitted to the facility, she filled out paperwork about services provided which included dental. She stated she filled out the admission paperwork with the Social Service assistant and communicated to her she wanted dental services. She stated, I wasn't put on the list to receive dental services. Resident #94 stated there was no follow-up after talking to the Social Services assistant regarding dental services. She stated she doesn't receive pain medication from the facility for tooth pain. At the time of interview, an observation revealed a lunch meal was brought by the Certified Nursing Assistant (CNA) and Resident #94 started eating. Observed Resident #94 eating shrimp and moving the food to the left side of her mouth. She stated she eats on the left side of her mouth due to the tooth pain. Review of Resident #94's Order Summary Report revealed an order, dated 5/8/24, to include, Ophthalmology/Podiatry/Dental/Psych Services as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 15 of 23 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 05/30/2024 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 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #94's progress notes revealed no evidence of tooth pain, a broken tooth, or mention of dental services. A review of Social Service's progress notes revealed no documentation regarding offering dental services to Resident #94. A further review of Social Service's progress notes revealed no documentation for rationale of why the resident did not have access to dental services. Review of Resident #94's medical record for assessment documents revealed no evidence related to dental services. Review of Resident #94's medical record revealed an evaluation titled, Social Service admission Evaluation, dated 2/9/24 completed by the Social Service Director. The Social Service admission Evaluation revealed no evidence regarding dental services. Review of Resident #94's MDS Section L - Oral/Dental Status, dated 5/12/24, revealed no response for mouth or facial pain, discomfort, or difficulty with chewing. On 5/29/24 at 3:25 p.m. an interview with the Social Service Director revealed the contracted dental service is with [vendor name]. She stated residents can be referred to dental from nursing or through the residents' request. The Social Service Director stated a referral and permission slip is sent to dental services. She stated the dentist and hygienist come once a month. She stated Social Service's monitors the dental list. The Social Service Director stated the hygienist will send a list to the facility of who was seen by the doctor and/or hygienist. She stated the list of residents seen by the hygienist and doctor can be obtained from Social Service's. She stated dental services through [vendor name] are for residents with Medicaid. A review of [vendor name's] list of scheduled cleanings, dated February to May 2024, showed no evidence of Resident #94 on the list. A review of facility visits from [vendor name] dated 2/19/24, 3/20/24, and 4/24/24, revealed the resident was not treated by the dentist or hygienist. An interview on 5/29/24 at 4:51 p.m. with the Social Service Assistant revealed Resident #94 communicated with her on 5/28/24. She stated the resident is Medicaid pending. She stated [vendor name] sometimes provides Pro bono services. The Social Service Assistant stated Resident #94 had not mentioned to her, prior to 5/28/24, that she wanted dental services. She stated she communicated via email with [vendor name's] appointment scheduler and received an email response on 5/29/24 at 3:00 p.m. that Resident #94 has a dental appointment scheduled on 6/4/24. She stated she has not let the resident know yet. The Social Service Assistant stated she did not have a conversation with Resident #94 upon admission about dental services. She stated the resident may have had a conversation with the Social Services Director that she didn't qualify for dental services through [vendor name], which is why she was not on the dental list. An interview on 5/30/24 at 12:45 p.m. with Staff B, UM/LPN confirmed Resident #94 told her about her tooth pain and wanting to see a dentist. Staff B, UM/LPN stated she cannot recall when the resident told her. She stated she, Carried it on, to Social Service's. Staff B stated Resident #94 may not have been seen by dental previously due to being an, insurance thing. She stated certain times a month dental services will come to the facility. She stated if Resident #94 could not be seen by dental services through the facility, then she should have been referred to outside services. Staff B confirmed the resident does take pain medication. She stated the pain medication is mostly for lumbar back pain. Review of a facility policy titled, Availability of Services, Dental, revealed the following in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 16 of 23 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 05/30/2024 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 0790 Level of Harm - Minimal harm or potential for actual harm Policy Statement: Oral healthcare and dental services will be provided to each resident. The policy further revealed, in the policy interpretation and implementation, the following: .3. Social services will be responsible for making necessary dental appointments. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 17 of 23 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 05/30/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure medical records were complete for two residents (#104 and #106) out of three residents reviewed for leaving the facility against medical advice (AMA). Findings included: 1. An interview was conducted on 5/29/24 at 11:35 a.m. with a family member of Resident #104. She said Resident #104 signed out of the facility AMA and she was not notified. She said when she spoke with the Nursing Home Administrator (NHA) she was told they did not have any healthcare proxy on file. The family member stated Resident #104 had a history of mental illness and dementia and she doesn't feel like the facility assessed the resident's mental health. The family member said after the resident's admission, they emailed the facility the healthcare proxy as well as some medical history documents. Review of admission Records for Resident #104 showed she was admitted on [DATE] with diagnoses including Hemiplegia affecting left dominant side, dizziness and giddiness, ataxia, cerebral infarction, and ataxia. No mental health diagnoses were mentioned upon admission. Review of Resident #104's medical record did not show any documentation of medical history or healthcare proxy in the electronic record or paper record. The facility confirmed they had no additional records for the resident. Review of emails provided by Resident #104's family showed on 5/8/24 a family member emailed a healthcare proxy and contact information for both resident's children to the Social Services Director (SSD). The SSD confirmed receipt of the email on 5/8/24 and asked for a PDF format of the proxy. On May 9, 2024, at 10:16 a.m. the family member emailed the requested PDF format of the healthcare proxy along with some medical history records. The email also stated I talked with my mother yesterday evening and the conversation did not go well. She was stating that she was leaving the facility and asked me for money so she could leave. I don't know how her behavior was after talking with her but that's why I asked for her to be on the elopement list there. Please have an assessment done on her for elopement risk. Also, please call me and/or my brother with any updates about my mother. On May 9, 2024 at 12:41 p.m. the SSD confirmed receipt of the email. Review of the healthcare proxy showed it was signed/dated 11/27/2021 and signed by two nurse witnesses in New York. In the emailed medical history there was a document, Certificate of Examining Physician, dated 8/29/23, showing [AGE] year old female traveling from city to city due to paranoia and delusional beliefs. Psychosis is interfering with patient's ability to care for herself. Pt needs in pt. stabilization. A second Certificate of Examining Physician, dated 8/29/23, showed The patient is exhibiting signs of paranoia and delusions, believing she is running an investigation for the U.S. Military. She could benefit from inpatient psychiatric care. I concur. An Application for Involuntary admission on Medical Certification, dated 9/1/23, was included in history sent to the facility. An interview was conducted on 5/29/24 at 3:11 p.m. with the SSD. She said she remember Resident #104. She said the resident stated she was oriented and did not want her daughter involved in her care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 18 of 23 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 05/30/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The SSD confirmed she had communicated with the family and was given information about past psychiatric diagnoses for the resident. The SSD said they tried to do a psych evaluation, but the resident wanted to leave. The SSD said Resident #104 did not come from the hospital with any medical history and the records the family sent in were given to the Interim Director of Nursing (DON) at the time for her to review. The SSD said if the resident had a healthcare proxy it would be in her medical record, both electronic and paper records. An interview was conducted on 5/30/24 at 12:14 p.m. with the Social Services (SS) Assistant. She said when documents are sent to social services they are loaded into the documents section of the electronic medical record and a healthcare proxy would be listed under advanced directives. She said the documents should be put in as soon as they touch our hands. An interview was conducted on 5/30/24 at 12:33 p.m. with the NHA. He said he would have expected whoever received the documents from Resident #104's family to have uploaded them to the resident's medical record. 2. Review of the admission Record for Resident #106 showed she was admitted on [DATE] with diagnoses including seizures, Rhabdomyolysis, and anemia. The resident was discharged AMA on 3/9/24. Review of progress notes showed the following: -3/7/2024 6:00 p.m. Narrative Nurses note Writer was told by a staff member that this resident had her hand in her roommate's face. -3/7/2024 6:39 p.m. Narrative Nurses note Writer called in room by CNA due to this resident being aggressive to her roommate. Writer entered room and observed resident standing on the side of her bed yelling, cursing and screaming. She was shaking and threatened to physically strike writer. She would not state what happened and commented that she is extremely upset with both fist balled. Writer immediately placed this resident on one to one. Police were called and are in route. Risk manager notified (advised he will notify DCF and AHCA). Psych notified - no med orders, okay 1:1 and room change as resident was seen yesterday and will refuse psych meds. -3/7/2024 6:45 p.m. Narrative Nurses note Resident refused to provide a statement regarding the situation that occurred with her roommate and stated she will speak with police directly. There are no additional Nurses' notes in the Resident #106's medical record from 3/7/24 at 6:45 p.m. through her leaving the facility AMA on 3/9/24. An interview was conducted on 5/30/24 at 5:45 p.m. with the Assistant Director of Nursing (ADON). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 19 of 23 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 05/30/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She reviewed Resident #106's medical record. She confirmed there was no documentation after the resident-to-resident situation on 3/7/24 as to what happened or why the resident left two days later. The ADON said there should be a note in the record about the resident leaving AMA. She said if a resident is leaving AMA, staff should try to find out why the resident wants to leave or if there is something they may not understand. She said the nurse should call the doctor then see if they can coach or educate the resident about trying to do a proper discharge. She said if the resident is adamant about leaving the nurse should ensure they know the risk for leaving and sign the AMA documentation. She said the nurses should document the entire situation and everything they did during the process. She said she did not know what happened with the resident and why there was no documentation. She said there is no way to know if the doctor was called or family notified. Review of a facility policy titled Discharging a Resident without a Physician's Approval, reviewed October 2022, showed the following: Policy Statement A physician's order is obtained for discharges, unless a resident or representative is discharging himself or herself against medical advice. Policy Interpretation and Implementation 1. Should a resident, or his or her representative (sponsor), request an immediate discharge, the resident's attending physician is promptly notified. 2. An order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record no later than seventy-two (72) hours after the discharge. The facility was no able to provide a policy related to incomplete medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 20 of 23 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 05/30/2024 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 0880 Provide and implement an infection prevention and control program. 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 1) failed to ensure an effective infection control program related to isolation orders for one resident (#95) out of two residents sampled on contact precautions, 2) failed to properly use personal protective equipment (PPE) on two out of four units, and 3) failed to use proper hand hygiene during tray pass on one out of four units. Residents Affected - Some Findings included: 1. An observation was conducted on 5/28/24 at 9:26 a.m. of a housekeeper in room [ROOM NUMBER] with no PPE on. The room had a contact precaution sign posted on the door with no PPE cart at the door. (Photographic evidence obtained). Contact precaution signs were observed to be on room [ROOM NUMBER] and room [ROOM NUMBER], however they were not on the list provided by the facility as being on isolation precautions. An observation of meal service was conducted on 5/28/24 at 12:35 p.m. on the northwest hall. A CNA picked up a tray and delivered it to a resident. She set up the resident's food tray and proceeded to move the resident's personal fan and items on her tray table. The CNA performed no hand hygiene before going to pick up another tray. The CNA delivered that tray and set it up for the resident. She took a bag of trash from that resident's room, disposed of it, went to the common area to speak to someone then returned to the cart to grab another tray without performing hand hygiene. The CNA was observed delivering two more trays and setting them up for residents before performing hand hygiene. Review of admission Record for Resident #95 showed he was re-admitted to the facility on [DATE] with diagnoses including Methicillin Resistant Staphylococcus aureus (MRSA) and Extended Spectrum Beta Lactamase (ESBL). Review of Resident #95's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated 5/21/24, showed the resident was screened and tested positive for Clostridium difficile (C-diff) on 5/19/24 and was on contact isolation precautions. Review of Resident #95's physician order showed the order for Contact Isolation Precautions for C-diff and MRSA were not put in until 5/28/24, 1 week after the resident was re-admitted . An interview was conducted on 5/30/24 at 5:52 p.m. with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP). She said hand hygiene should always be done by staff in between each room while passing trays to residents. She said when any staff in the facility sees a contact precaution sign on the door, they should know what the sign means. She said if the sign is for contact precautions, PPE should be worn anytime someone goes in the room. When discussing doors that have contact precaution signs that may not have contact precaution orders due to a mix up, she confirmed if the sign is on the door, the PPE should be worn because all staff do not know the resident's orders. The ADON reviewed Resident #95's medical record and confirmed the contact precaution order was not put in until one week after he was admitted . She said it should have been put in immediately upon his arrival. She confirmed they have no way of knowing if the sign was put up and PPE was being used in the week prior to the order being entered in the computer. Review of a facility policy titled Handwashing/Hand Hygiene, revised August 2019, showed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 21 of 23 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 05/30/2024 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 0880 Policy Statement Level of Harm - Minimal harm or potential for actual harm The facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation Residents Affected - Some 2. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents l. After contact with objects in the immediate vicinity of the resident p. Before and after assisting resident with meals Review of a facility policy titled Isolation-Categories of Transmission-Based Precautions, revised September 2022 showed the following: Policy Statement Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection, or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation 1. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for the use of PPE, and/or instructions to see a nurse before entering the room. Contact Precautions 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room . 8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 2. An observation on 5/28/24 at 9:50 a.m. revealed an enhanced barrier precaution sign on the door for room [ROOM NUMBER]. Upon observation, there was no evidence of personal protective equipment (PPE) for room [ROOM NUMBER]. Observations of other rooms in the unit with precaution signs revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 22 of 23 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 05/30/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some PPE supplies hanging on the door to include gloves, masks, and gowns. Further observation of room [ROOM NUMBER] revealed Staff C, Certified Nursing Assistant (CNA) stated out loud she was going into room [ROOM NUMBER] to change the resident. An observation revealed Staff C did not put on PPE when entering the room, as indicated on the precaution sign when staff is providing direct care to residents. An observation on 5/28/24 at 9:51 a.m. of the resident's name outside room [ROOM NUMBER] revealed a pink sticker next to the resident's name. During an interview on 5/28/24 at 9:52 a.m. Staff D, CNA revealed the pink sticker indicates fall risk. She stated the pink sticker does not indicate who the precaution sign is for. Further observation revealed an enhanced barrier precaution sign on the door of room [ROOM NUMBER]. When asked who was on enhanced barrier precautions in rooms [ROOM NUMBERS], Staff D stated, To be honest, I'm not sure. Staff D stated sometimes they are not sure who is on the precaution and why. An observation on 5/29/24 at 12:25 p.m. revealed room [ROOM NUMBER] had a contact precaution sign on the door. An observation on 5/29/24 at 12:57 PM revealed a contact precaution sign was no longer on the door for room [ROOM NUMBER]. An observation on 5/29/24 at 12:58 p.m. with the Assistant Director of Nursing (ADON), Infection Preventionist (IP) revealed she had contact precaution signs in her hand. The ADON/IP stated she just removed the contact signs for room [ROOM NUMBER]. She stated room [ROOM NUMBER] previously had contact precaution signs as recommended by the health department. She stated the resident had Candida Auris (C. Auris). She stated the resident acquired C. Auris from the hospital and that is why he was on enhanced barrier precautions on 5/28/24. She stated the Department of Health (DOH) called her. She stated, The contact from the health department was very persistent that [the resident] needed to be on contact precautions for C. Auris. She stated she spoke to her regional who then communicated with the DOH. She stated because of the regional's and health department's conversation, she was instructed by her regional to take the contact precaution sign down. A further interview with the ADON/IP regarding staff education revealed staff members receive verbal communication about what they need to do for residents who are on enhanced barrier or contact precautions. She stated enhanced barrier precautions is for residents who have wounds, Foley, and/or tube feeding. She stated if there is prolonged contact with the resident who is on enhanced barrier precaution, then the expectation is to wear PPE. An observation of room [ROOM NUMBER]'s bedside table on 5/29/24 at 1:04 p.m. revealed a urinal, containing urine, next to the food from lunch. The meal tray was not observed. The food observed next to the urinal included a bowl, with no lid, containing a soup-like liquid and a wrapped bake good. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105050 If continuation sheet Page 23 of 23