Inspection·July 30, 2021

F 0656 Review of the current care plans with the next review date of 10/19/2021 revealed the following: Level of Harm - Minimal harm or potential for actual harm - Risk for an alteration in nutrition and/or hydration related diagnosis. Osteomyelitis, depression, anxiety, discitis, back pain with interventions in place to include meds (medications) as ordered. Residents Affected - Few - Potential for or has an alteration in comfort r/t (related to) generalized discomfort, dx. (diagnosis) of Osteomyelitis, recent fracture, chronic back pain, resident is able to communicate pain to staff, with interventions in place to include admin of meds for discomfort as ordered. Further review of the entire care plan did not reveal Resident #192 had a problem area with goals and interventions with relation to IV antibiotic use for the current infection, nor did it indicate the resident received antibiotics via IV therapy. On 7/29/2021 at 1:45 p.m. the Care Plan Coordinator was interviewed related to Resident #192's care plans. The Care Plan Coordinator confirmed the resident was a newer admission as of 7/12/2021 and that he was currently receiving antibiotics via Intravenous (IV) route, related to an infection. He confirmed that the resident was admitted from the hospital with the infection. The Care Plan Coordinator then looked through the resident's current care plans and confirmed there was no care plan problem area with goals and interventions related to an infection and being treated with antibiotics. The Care Plan Coordinator revealed that the care plan team would have information based on the admission of the resident, and when nursing had a change of condition, they would either develop or revise care plans based on that. He also indicated that it is the responsibility of the Care Plan Team to review orders, and if they see anything that needs to be care planned, then they would update the entire care plan. The Care Plan Coordinator confirmed the antibiotic use and use via IV route should have been developed upon admission and initiated with a baseline care plan and then carried over to the comprehensive care plan. He said this did not happen and would update the care plan after the interview. 2. On 07/27/21 at 10:52 a.m. Resident #94 was observed asleep in bed. The resident's floor mats were visible on either side of the bed. The bed was not in the low position. On 07/28/21 at 8:20 a.m. Resident #94 was observed in bed. Resident #94's floor mat was on the left side of the bed, and the second floor mat was propped against the wall. The bed was not in the [NAME] position. On 07/28/21 at 10:25 a.m. Resident #94 was observed in bed and only one floor mat was on the floor on the left side of the bed, and the other floor mat was propped up against the wall in the room. The bed was not in the low position. On 07/28/21 at 1:26 p.m. Resident #94 was observed resting in bed and one floor mat was located on the left side of the bed, and the second floor mat was propped up against the wall. The bed was not in the low position. On 07/28/21 at 2:30 p.m. Resident #94 was observed in bed in the low position and a floor mat on the left side of the bed, and the other floor mat was propped up against the wall. Review of Resident #94's admission Record revealed that Resident #94 was admitted on [DATE] with diagnoses to include muscle weakness, unsteadiness on feet, cognitive communication deficit, syncope and collapse and history of falling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 2 of 12 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 105072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lexington Healthcare and Rehabilitation Center 6300 46th Ave N Saint Petersburg, FL 33709 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of Resident #94's most recent MDS, dated [DATE], revealed in Section C for Cognitive Patterns a BIMS score of 05 out of 15 which indicated severe cognitive impairment. Section J Health Conditions revealed the resident had a history of falls prior to admission, and one fall following admission. A review of the Physician Orders for July 2021 revealed the following: Residents Affected - Few - Floor mat(s) when resident in bed- both sides of bed every shift for Fall prevention with a start date of 6/24/21. Review of Resident #94's care plan dated 6/25/21 revealed a Focus as: - (Resident #94) is at risk for falls and/or fall injury r/t, weakness, impaired balance, unsteady gait, uses w/c (wheelchair) as primary mode of locomotion, has h/o (history of) falls, poor safety awareness. Interventions included: Floor mats at bedside, Keep bed in low position, Floor mats in place when resident in bed and Report falls to physician. On 07/28/21 at 2:45 p.m. during an interview with the Director of Nursing (DON) the DON stated the expectation for fall prevention is that the staff follow the MD (medical doctor) orders, and all fall precautions are followed. When the DON was informed that Resident #94's bed was not in the low position and only one floor mat was placed, the DON stated that both floor mats should be in place when the resident was in bed, and the bed should be in the low position. On 07/29/21 at 7:55 a.m. during an interview with Staff H, Certified Nursing Assistant (CNA), Staff H stated that when a resident was on fall precautions, floor mats will be placed on both sides of the bed when the resident is in the bed, the bed would be kept in the low position and the room door would be open to allow staff to observe the resident. Staff H stated, if I do not know whether a resident is on fall precautions, I will ask the nurse or check the computer to find out. On 07/30/21 at 11:04 a.m. Staff C, Licensed Practical Nurse (LPN) stated that if a resident was at risk for falls, I would keep an eye on them, and make sure that the mats were on the floor when the resident is in bed. Staff C would verbally let the CNAs know that the floor mats need to be down whenever the resident is in bed. A review of the facility policy titled, Care Plans, Comprehensive Person-Centered, last revised December 2016, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under the Policy Interpretation and Implementation section, #2, revealed: The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. #8 of the policy revealed: a. Include measurable objectives and timeframes. b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable, mental, and psychosocial well-being . g. Incorporate identified problem areas. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 3 of 12 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 105072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lexington Healthcare and Rehabilitation Center 6300 46th Ave N Saint Petersburg, FL 33709 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 h. Incorporate risk factors associated with identified problems . Level of Harm - Minimal harm or potential for actual harm m. Aid in preventing or reducing decline in the resident's functional status and /or functional levels. n. Enhance the optimal functioning of the resident by focusing on the rehabilitative program . Residents Affected - Few #10 of the policy revealed: Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. #13 of the policy revealed: Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 4 of 12 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 105072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lexington Healthcare and Rehabilitation Center 6300 46th Ave N Saint Petersburg, FL 33709 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 observation, interview and record review, the facility failed to identify, examine, and assess a change of condition in accordance with the professional standards of practice for one resident (#84) related to discolorations and bruises on the resident's left upper arm out of 51 sampled residents. Residents Affected - Few Findings included: An observation on 07/27/2021 at approximately 9:30 a.m. revealed Resident #84 asleep in her bed. Her left arm was uncovered. A small dark purple bruise, approximately the size of 8 cm (centimeters) x 8 cm, and a larger light purple bruise, approximately the size of 18 cm x 18 cm, were observed on her left upper arm. A review of Resident #84's admission Record revealed that she was admitted to the facility on [DATE]. Her diagnoses included, but not limited to frontal lobe executive function deficit following cerebral infraction, sequelae of other cerebrovascular disease, hemiplegia and hemiparesis following cerebral infraction, affecting right dominant side, and dementia. Record review of the admission Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 06 which indicated severely impaired cognition. Section G Functional Status revealed that Resident #84 requires extensive assistance with bed mobility, eating, toileting. Section J Health Conditions showed one fall without injuries (skin tear, abrasions, lacerations, superficial bruises ). Record review of Resident #84's admission Nursing Comprehensive Evaluation dated 6/16/2021 under the subheading Skin Integrity did not reveal discoloration and bruises to her left upper arm. Record review of the physician progress note, effective date 6/18/2021 under Skin revealed, no rash noted, dry in legs. Under musculoskeletal MSK, documentation revealed, arms and legs no edema, no gross asymmetry, no tenderness. ROM (range of motion) decreased in right arm and leg compared with left. There was no documentation in the physician's progress note that identify discoloration and bruises to Resident #84's left upper arm. A review of the physician orders for July 2021 revealed: Skin sweep weekly on Thursdays 7-3 shift Open and complete the weekly skin assessment every day shift every Thu (Thursday) for Prophylaxis, start date of 6/17/21. Record review of nursing progress notes dated 7/7/2021 throughout 7/27/2021, did not reveal any documentation related to bruises and skin discoloration of Resident #84's left upper arm. Record review of Resident #84's care plan initiated on 6/22/21 for the focus area of skin impairment, did not reveal discoloration and or bruises on her left arm upon admission or during her stay in facility. During an interview 07/30/21 at 9:44 a.m. with the Director of Nursing (DON). The DON stated that she was not aware of bruises or discoloration on Resident #84's left upper arm. The DON went to Resident #84's room and confirmed the presence of bruises and discoloration on her left upper arm. The DON confirmed that staff should have reported and documented bruises and discoloration on Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 5 of 12 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 105072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lexington Healthcare and Rehabilitation Center 6300 46th Ave N Saint Petersburg, FL 33709 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 #84's left upper arm. Level of Harm - Minimal harm or potential for actual harm During an interview on 07/30/21 at 9:53 a.m. with Staff J, Licensed Practical Nurse (LPN), Unit Manager, (UM). She stated that, she was not aware of bruises or discoloration on Resident #84's left arm. She stated that weekly skin checks are completed by the charge nurse, and new skin issues that are identified are documented. Residents Affected - Few During an interview on 07/30/21 at 10:52 a.m. with Staff K, LPN. The LPN stated that she did not observe any bruises on resident left arm when she administered medications this morning. She stated that if she noticed bruises or any changes in a resident condition, she would report it to the unit manager. During an interview on 07/30/21 at 10:59 a.m. with Staff L, Certified Nursing Assistant (CNA). Staff L stated that if she observed any bruises or discoloration on residents, she usually reports it to the nurse or unit manager. The CNA stated that she was assigned to Resident #84's care last Saturday (7/24/21), and she cannot recall any bruises on her left arm. A review of the facility policy and procedure titled, Resident Examination and Assessment, Level III revised on 02/2014, under the subheading Purpose read: The purpose of this procedure is to examine and assess the resident for abnormalities in health status, which provides a basis for the care plan. Under the subheading Preparation it read: Review the resident's admission assessment/preliminary care plan to assess for special situations regarding the resident's care. Under the subheading Steps in the Procedure for Skin #8e., it read: Presence of bruises, pressure sores, redness, edema, rashes. A review of the facility policy and procedure titled, Acute Condition Changes - Clinical Protocol, revised March 2018, revealed as part of the Assessment and Recognition #3., Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 6 of 12 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 105072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lexington Healthcare and Rehabilitation Center 6300 46th Ave N Saint Petersburg, FL 33709 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record review the facility failed to maintain drugs and biologicals used in the facility in a safe, secure, and orderly manner in one medication room (200 Wing) of four medication rooms, and failed to properly dispose of a medication patch for one resident (#50) of 35 residents on a pain management program. Findings included: On 07/27/21 at 10:17 a.m. an observation of the bathroom for Resident #50, revealed a Lidocaine patch dated 7/23/21, stuck to the edge of the mirror in the bathroom. When asked about the Lidocaine patch, Resident #50 said that she thought that her CNA (certified nursing assistant) may have removed the patch when she had a shower but was not sure. Review of the July 2021 physician orders for Resident #50 revealed an order for a Lidoderm Patch 5% (Lidocaine) apply to Lt (left) knee topically two times a day for left knee pain pls (please) cut patch in 1/2 longitudinally and place in lt knee 1 inch away from surgical wound on each side, start date 6/1/21. On 07/27/21 at 11:10 a.m. an interview was conducted with Staff B, Registered Nurse (RN). Staff B stated that when a resident has a medication/Lidocaine patch, it is usually 12 hours on and 12 hours off. Only a nurse can place and remove medication patches. A certified nursing assistant (CNA) is not allowed to apply or remove medication patches. Medication patches are folded and disposed of in the gloves, and then thrown in the trash. On 07/27/21 at 11:12 a.m. Staff E, CNA stated that sometimes I will take the patch off when giving the resident a shower and put it back on after the shower or take it off if it is peeling and let the nurse know. On 07/27/21 at 12:55 p.m. Staff D, CNA stated that if it was ok with the nurse; I would take the patch off when giving a shower. On 07/29/21 at 12:45 p.m. an interview was conducted with Staff C, Licensed Practical Nurse (LPN)/Rapid Recovery/200 hall nurse. Staff C stated that only nurses handle medication patches. The nurse will write the date on the patch prior to application of the Lidocaine patch in the morning, and the evening staff will remove and dispose of it twelve hours later. If the resident is to have a shower, I will apply the patch after the resident has had her shower. CNA staff should not remove the Lidocaine patch when showering a resident. On 07/29/21 at 11:25 a.m. an observation of the 200 Wing-Medication Room revealed in the large medication refrigerator, an open multi-dose vial of Humulin stored in a bag that was dated 6/11/2021 on the top shelf of the refrigerator door. Staff A, RN and Staff J, LPN Unit Manager were present at the time of the discovery. On 07/29/21 at 11:50 a.m. during an interview Staff A, RN stated that the refrigerator was used for storage of new and unopened medications. Once a medication was removed from the refrigerator it was stored in the medication cart. Multi-dose vials and insulins were dated with the open date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 7 of 12 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 105072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lexington Healthcare and Rehabilitation Center 6300 46th Ave N Saint Petersburg, FL 33709 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/30/21 at 10:01 a.m. during an interview the Director of Nursing (DON) stated that any medication, including the placement, removal and disposal of medication patches, was the responsibility of the licensed staff. The DON stated that the refrigerators in the medication rooms on the nursing wings were for storage of new and unopened resident medications including insulin. Once an insulin multi-dose vial was opened it was her expectation that the vial was dated with the open date, and the vial could be stored in the medication cart. The vial is only good for 28 days and then needs to be disposed of. A review of the facility policy titled, Storage of Medications, effective date 11/2020, revealed: Policy Heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storage. Discontinued, outdated, or deteriorated drugs or biologicals are to the dispensing pharmacy or destroyed. Review of facility policy titled: Discarding and Destroying Medications, revised April 2019, revealed: Policy Heading: Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. Policy Interpretation and Implementation: 1. Non controlled and Schedule V (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposal of non-hazardous medications. 2. Ointments, creams, and other like substances may be discarded into the trash receptacle in the medication room. A review of the Manufacturer Storage instructions for Humulin R 100u/ml (units per milliliter) revealed: http://pi.lilly.com/us/humulin-r-ifu.pdf How should I store HUMULIN R? All unopened vials: o Store all unopened vials in the refrigerator at 36° (degrees) to 46°F (Fahrenheit) (2° to 8°C [Celsius]). o Do not freeze. Do not use if it has been frozen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 8 of 12 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 105072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lexington Healthcare and Rehabilitation Center 6300 46th Ave N Saint Petersburg, FL 33709 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 o Keep away from heat and out of direct light. Level of Harm - Minimal harm or potential for actual harm o Unopened vials can be used until the expiration date on the carton and label if they have been stored in the refrigerator. Residents Affected - Few o Unopened vials should be thrown away after 31 days if they are stored at room temperature After vials have been opened: o Store opened vials in the refrigerator or at room temperature below 86°F (30°C) for up to 31 days. o Keep away from heat and out of direct light. o Throw away all opened vials after 31 days, even if there is still insulin left in the vial. Review of the pharmacy guidelines titled; Medication Storage Guidance, dated March 2020, revealed: Humalog multidose vial: Unopened store in refrigerator (36-46 degrees Fahrenheit) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 28 days Opened store in refrigerator for 28 days Opened store at room temperature for 28 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 9 of 12 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 105072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lexington Healthcare and Rehabilitation Center 6300 46th Ave N Saint Petersburg, FL 33709 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 Based on observations, interviews, record review and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement an infection control and prevention program to prevent possible transmission of Coronavirus Disease 2019 (COVID-19) as evidenced by their failure to ensure that facility staff members, seven of which were observed, were screened for signs and symptoms each day before working and failed to supervise the screening of three visitors prior to entry to the facility with the potential to expose a total of 146 residents for two of two days observed. Residents Affected - Some Findings included: During an interview with the facility Administrator (NHA) on 07/27/21 at 9:10 a.m., he confirmed that there was only one entrance used by employees: the front main lobby entrance. He confirmed facility employees should not be using any other entrance doors in the building prior to being screened for COVID-19. An observation was conducted on 07/28/21 at 6:50 a.m. from the parking lot outside the facility main lobby entrance. There were no vehicles parked in the parking lot, and it was noted that all facility employee vehicles were parked in a lot around the back of the facility on the other side of the building from the main lobby entrance. However, during this observation on 07/28/21, at least three facility staff were observed entering the lobby from a hallway inside the facility. Three of them were observed self-screening with no supervision and continuing their way inside the facility. These three staff members had not entered the facility through the front lobby entrance door. After completing observations from the parking lot, the front lobby door was found unlocked at 6:59 a.m. and upon entry there was nobody present in the lobby. Self-screening using the electronic screening tablets mounted on the wall was completed and at no time were any facility personnel noted in the screening area, and no staff intervened to supervise the process or ask any questions. On 07/28/21 at 8:00 a.m., a survey team member entered the facility through the unlocked front lobby door. No staff was present in the lobby area and self-screening was completed using the electronic screening tablet. No staff was present to supervise the process or ensure proper masking or hand hygiene. On 7/29/21 at 6:50 a.m., the front parking lot was again observed with no vehicles parked in any of the parking spaces. The front lobby area could be observed from the parking lot through the large clear window paned doors. There were various staff inside and four were observed walking from the main hallway inside the building up to the front lobby area where they completed screening near the front door using the electronic screening devices. There were no staff members in the lobby area prior to the staff walking up to the area, and there were no staff left in the area after they left. On 07/29/21 at 6:57 a.m., the unlocked lobby entrance door was entered by a survey team member, no personnel were present in the area, and self-screening was again performed without any supervision using the electronic screening device on the wall. On 07/29/21 at 7:00 a.m., a survey team member entered the facility through the unlocked front lobby door. Again, self-screening was completed using the electronic tablet and nobody was present to supervise or ensure proper masking or hand hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 10 of 12 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 105072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lexington Healthcare and Rehabilitation Center 6300 46th Ave N Saint Petersburg, FL 33709 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 An interview was conducted on 07/29/21 at 10:08 a.m. with the facility Infection Preventionist (IP) and the Regional Director of Clinical Services (RDCS). They confirmed the only entrance that should be used was the front lobby entrance, and the expectation was for staff to enter the facility through that door only and be screened for COVID-19 using the electronic tablet system before beginning their shift. The RDCS said there was a possibility that facility staff were using other doors to enter the building since they had the codes for them. Observations and screening experiences during the survey were shared. The IP reported that the facility procedure was for [Staff N, Staffing Coordinator] to unlock the front lobby door and supervise the screening process from her office across the hall from the lobby before the receptionist arrived. The IP said, She (Staff N) knows all the staff so she can know if they are screening. A request was made to RDCS to pull screening data from the electronic screening system and cross-reference it with direct care staff schedules for 07/27/21 and 07/28/21. On 07/29/21 at 3:06 p.m., the RDCS followed up to say that his audit for 07/28/21 had revealed a problem with the employee screening process. He confirmed that his audit had revealed that facility direct care staff were getting into the building without being screened and said it was sporadic and widespread. He said he would be initiating immediate education and a process improvement plan. The interview continued with the NHA and the facility Director of Nursing (DON). All parties confirmed that only the front main lobby entrance was supposed to be used by staff for entering the facility. The NHA said the entrance was supposed to be unlocked when the receptionist was in the area and confirmed the receptionists oversaw ensuring employee screening was completed along with proper hand hygiene and masking. He said the door was locked at 9:00 p.m. by the evening receptionist and [Staff N] unlocked the door in the morning between 6:45 a.m. and 7:00 a.m. He confirmed the expectation was that Staff N was monitoring the screening from her office, which was across the hall from the main lobby area until the lobby receptionist arrived at 8:30 a.m. The NHA said that if a screening question was failed, the tablet alerted and sent an email to him, but otherwise there was nothing in place to ensure that failed screening resulted in non-entry. The RDCS revealed his data audit for direct care staff for 07/28/21: only 31% of direct care staff working over the entire 24 hours were screened for COVID-19 before starting their shift. The NHA said, We have multiple parking lots and staff have codes to other doors, so we'll be changing the codes on the doors .what I've noticed is staff are coming in another door, going to time clock, and then screening. The NHA confirmed that Staff N had been trained on her role as screener in the mornings before receptionist arrival, and that facility receptionists had also been trained on screening responsibilities. The NHA reported the following expectations of the screening task: being present in the area; ensuring screening was completed properly; ensuring hand hygiene was performed using sink outside or hand sanitizer; ensuring mask was applied and worn properly over nose and mouth. An interview was conducted with Staff O, Receptionist on 07/29/21 at 3:51 p.m. He confirmed he worked as the receptionist in the front lobby Monday - Friday 8:30 a.m. - 5:00 p.m. He said he had been trained on how to supervise screening and that he was expected to make sure everyone washed their hands, completed screening questionnaire and temperature using the wall-mounted devices, and wore a mask properly. Staff N, Staffing Coordinator was interviewed on 07/29/21 at 4:04 p.m. She confirmed her shift generally started between 6:30 a.m. and 6:45 a.m. and that she was responsible for unlocking the front lobby entrance door. She said, I leave my door open so that I can verify it's only staff coming to the building and that they screen before they enter any further. Staff N said that the door was locked at night and during that time anyone needing to enter would ring the doorbell and anyone holding a supervisor phone would answer the door and ensure screening. She said, If staff are caught entering (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 11 of 12 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 105072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lexington Healthcare and Rehabilitation Center 6300 46th Ave N Saint Petersburg, FL 33709 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 through another door they are made to leave. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 07/29/21 at 4:28 p.m. with the NHA, DON, and RDCS about the process for screening during the night shift. The NHA said there is a night supervisor who oversaw monitoring the front lobby, answering the phone, and sitting up there unless she was assigned to a cart. He said if the night supervisor couldn't be in the lobby area, then staff were expected to ring the doorbell and facility staff already inside would answer the door and let them in. Residents Affected - Some An interview was conducted on 07/30/21 at 12:45 p.m. with the NHA, DON, and RDCS. The RDCS revealed the data audit he had completed for direct care facility staff for 07/21/21-07/29/21. He revealed a 22% compliance rate for direct care staff screening for the audited date range which meant that only 22% of all direct care staff working with residents had been screened for COVID-19 before beginning their shifts. He said he had focused the audit on direct care staff because they post the most significant risk to transmission. Review of the most recent CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the COVID-19 Pandemic, updated 02/23/21, revealed the recommendation that anyone entering a healthcare facility should be screened for signs and symptoms of COVID-19. The guidance advised, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. The guidance for healthcare facilities included: Limit and monitor points of entry to the facility. Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control. Review of the facility policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised October 2020 revealed, Anyone arriving at the facility (including staff) is screened for fever and symptoms of COVID-19 before entering. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 12 of 12