Inspection·March 22, 2023

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed: Cognition/Brief Interview Mental Score or BIMS score not scored, but indicated resident had Short Term/Long Term memory problems, and with Severely Impaired Decision Making skills. A review of the nurse progress notes dating back from 6/1/2022 through to current date 3/20/2023 did not indicate any notes that Resident #72's POA was involved with any part of the care planning process. There were no notes that indicated Resident #72's POA was invited to any quarterly care plan conferences. A review of the following Care Plan Conference sheets, revealed: 1. The Care Plan Quarterly Conference sign in sheet dated 6/14/2022, revealed no documentation that the Responsible Party, Family Member attended. The sheet was checked indicating Resident #72 was invited to participate, and declined; and also checked that the Responsible Party was notified by mail of review and POA declined. The conference sheet was signed by five departmental staff members. 2. The Care Plan Quarterly Conference sign in sheet dated 9/20/2022, revealed no documentation that the Responsible Party, Family Member attended. The sheet was checked indicating Resident #72 was invited to participate, and declined. The sheet did not indicate if the Responsible party was notified by mail or phone to attend the conference/meeting. The conference sheet was signed by one departmental staff member, Staff L, Registered Nurse (RN), Registered Nurse Assessment Coordinator (RNAC). 3. The chart did not contain quarterly care plan conference/meeting sheets for months 12/2023, and 3/2023. In an interview with the North Unit Manager, Staff A confirmed the chart and other records did not contain the last two quarterly care plan conference/meeting sign in sheets. On 3/22/23 at 9:45 a.m., in an interview with Staff L, he explained he was responsible for coordinating the care plan meetings. He stated he determined who was the responsible party, resident or loved one. He would verbally invite the resident and maybe give them a letter. If the loved one was the responsible party he sent a letter, calls and/or emails. He stated he documented attempts in the past but not anymore. The care plan meeting might include the resident/family member, Interdisciplinary Team (IDT), sometimes a CNA or a nurse. When we have care plan meetings there was a signature sheet that indicated who participated. Staff L recalled Resident #72 and that she did not usually speak to him and he was able to communicate with her. He indicated she was not responsible for herself and her responsible party would be invited. He did not recall if he invited her or not. He indicated there was no documentation of invite. He reviewed the Care Plan Meeting Signature page from 6/14/22 and 9/21/22 and confirmed only his signature was present on the form. On 3/22/2023 at 3:00 p.m. the Nursing Home Administrator provided the following Policy and Procedure for review. The facility policy for Resident Participation - Assessment/Care Plans dated (revised February 2021) Policy Statement states that the resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The Policy Interpretation and Implementation states: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 2 of 25 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 03/22/2023 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 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. 3. The resident/representative's right to participate in the development and implementation of his or her plan of care includes the right to: a. participate in the planning process; e. participate in establishing his or her goals and expected outcomes of care; f. participate in the type, amount, frequency and duration of care; 4. The care planning process: a. facilitates the inclusion of the resident and/or representative; 5. Facility staff supports and encourages resident/representative participation in the care planning process by: a. ensuring that residents, representatives and families understand the care planning process; c. providing sufficient notice in advance of the meeting; and 9. The social services director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. Notices include: a. the date, time and location of the conference; b. the name of each person contacted and the date he or she was contacted; c. the method of contact (e.g., mail, telephone, email, etc.); d. input from the resident or representative if they are not able to attend; e. refusal of participation, if applicable; and f. the date and signature of the individual making the contact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 3 of 25 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 03/22/2023 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 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide one (Resident #134) of 51 residents with a written notification for a room change. Findings include: On 03/19/2023 at 10:00 am., Resident # 134 was observed lying down in bed under her covers. Resident #134's call light was observed within her reach. A review of the admission Record revealed Resident #134 was admitted to the facility on [DATE] with diagnoses included but not limited to Nontraumatic Intracerebral Hemorrhage, Unspecified, Acute Embolism and Thrombosis of Unspecified Femoral Vein, and Type 2 Diabetes Mellitus without Complications. A review of the admission Minimum Data Set (MDS) dated , 2/22/2023, Section C- Cognitive Patterns, Brief Interview for Mental Status, (BIMS) revealed Resident #134's BIMS score was 15, which indicated intact cognition. A review of the Electronic Medical Record, (EHR) revealed Resident #134 was admitted to [room number] on 3/15/2023, then moved to [room number] on 3/16/2023. A review of the EHR showed Resident #134 was not provided with an advance notice of the room transfer and a reason why the move was recommended. During an interview with Resident #134 on 3/19/2023 at 10:00 a.m., she reported she was moved from her room yesterday into another room without her knowledge or consent. She said the facility did not discuss with her and her daughter the reason why she had to relocate to a different room. Resident #134 expressed a desire to return to her original room. On 03/21/2023 at 3:40 p.m., an interview was conducted with Staff P, the admissions coordinator. She said she was helping the facility because they did not have a social worker. Staff P admitted she was unaware that Resident #134 and/or her representative should have been notified of a room change. Staff P acknowledged she did not know the facility's policy and procedure for room change notification. On 03/ 21/ 2023, at 3:00 p.m., an interview was conducted with the interim Nursing Home Administrator (NHA). The NHA said when a resident was transferred to a different room, the staff should first determine what the issues were that were connected to the reason the resident needed to be moved. After that, during the morning meeting, the interdisciplinary team (IDT), which consisted of the NHA, Director of Nurses, unit managers, and the admission coordinator, would decide which room the resident should be moved into. The NHA said since the facility did not currently have a Social Services representative, the NHA advised that someone from the IDT team should contact the resident and/or their family to inquire about whether they agreed to the room change or not. The NHA stated when a room change occurred, residents or their representative should be informed, and it should be noted in the resident's medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 4 of 25 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 03/22/2023 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 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility admission Room Change Policy, showed where feasible the facility will make room to room transfers when requested by the resident or as may become necessary to meet the resident's medical and nursing care needs. 2) Unless medically necessary or for the safety and well-being of the resident(s), a resident will be provided with an advance notice of the room transfer. 3) Such notice will include the reason (s) why the move is recommended FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 5 of 25 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 03/22/2023 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one (Resident #19) of fifty-one sampled residents was assessed upon admission related to activities. Findings included: On 3/19/2023 at 10:30 a.m., an interview with Resident #19, who was lying in bed in her room, revealed staff did not get her up so she could attend the Church activity this morning. She revealed staff, at times, would not get her up to go to activities. She required assistance to get up out from bed and required assistance transferring from the room to the dining room. It was observed at 10:20 a.m., prior to visiting Resident #19 while in her room, the main dining room had a group of residents seated at a large table and with a Church activity already in progress. A review of the posted current month's (3/2023) activities calendar, revealed an activity on Sunday, 3/19/2023 was Church at 10:00 a.m. Photographic evidence obtained. On 3/20/22023 at 8:40 a.m., Resident #19 revealed she was happy for Bingo later in the afternoon and expected to participate. At 2:45 p.m., Resident #19 was observed in her room and seated in a wheelchair between the side of her bed and the door wall. She was asked if she was going to the Bingo activity. She revealed it had already began and staff did not come to get her. She confirmed the Activities Director, Staff E never came by her room today to get her. She revealed she loved to participate in group activities to include Bingo, Church, Arts and Crafts, etc. She said she did not like to sit in her room and watch television all the time and liked to be out from her room. She did not remember if any staff member had actually talked to her about her likes and dislikes with relation to activities and activities participation. A review of the Activities calendar posted on the wall outside the dining room revealed on 3/20/2023 Bingo, at 2:15 p.m. Photographic evidence was taken. A review of Resident #19's electronic medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. A review of the advance directives revealed the resident was her own responsible party and makes her own medical and financial decisions. A review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed: Cognition/Brief Interview for Mental Status (BIMS) score was 6, which indicated severe cognitive impairment; Activities of Daily Living ADL - BED MOBILITY = Extensive Assist with One person, TRANSFER = Extensive Assist with Two person; (Activities - Reading activities = Very Important, Music activities = Very Important, Group activities = Very Important. On 3/21/2023 at 10:00 a.m., an interview with Staff A, North Unit Manager revealed Activities assessments should be in the electronic medical record under the Evaluation tab. However, when the Evaluation tab was reviewed, and expanded with a timeframe from Resident #19's original admission date 3/19/2019, there was no evidence of any Activities assessments. She said she would get with the Activities Director to see if he could locate the initial admission Activities assessment. On 3/21/2023 at 1:30 p.m., the Staff E ,Activities Director was interviewed and revealed that Activities assessments were in the electronic medical record in the Evaluations tab. He was asked to pull (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 6 of 25 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 03/22/2023 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few up Resident #19's original admission activities assessment and the last quarterly activities assessment. He stated, I have tried to look for the original admission activities assessment and cannot look back that far on my computer system. He indicated there was a company change during that time and he would have to speak to the Nursing Home Administrator to try and pull that assessment up from a different computer program/system. The Staff E revealed he did a quarterly activities assessment on the resident just moments ago. He said, I could not find one, nor could I find any past quarterly assessments in the electronic medical record, so I just went ahead and did one today. The Activities Director confirmed he could not produce, nor show that the resident had an original admission activities assessment, nor could he produce, nor show that the facility completed past quarterly activities assessments going back at least two years. He confirmed that he knew Resident #19 well and knew she loved to attend group activities to include Church, Bingo, and Arts and Crafts on a daily basis. He was unaware of why she missed Church activities on Sunday 3/19/2023 and the afternoon Bingo activity on 3/20/2023. In review of the activities assessment, with a completion date 3/21/2023 at 12:57 p.m., revealed the following activities information for resident #19: Activities interests included: Religious Services, Religious Studies, Group Discussions, Education Programs, Current Events, Bingo, Movies, Music, Friends/Family visits, Socials, Parties, Resident Council, Television. The assessment further indicated the resident did not have current preference settings, but actively participates, and uses a wheelchair. The notes section of this assessment revealed: Resident is alert and oriented. Resident's favorite activities are Bingo, Religion and TV and movies, coming to group activities and doing 1:1 activities. Resident's main focus is to return to the community. Resident may receive phone calls from family and friends and also may receive visit from them. Resident may receive leisure material upon request. On 3/22/2023 at 3:00 p.m., an interview with the Regional Nursing Consultant and also with the Nursing Home Administrator (NHA), both confirmed they could not find or pull up Activities assessments for Resident #19 on the current electronic medical records program or from any other medical record computer based programs. The NHA revealed all residents upon their admission were to have assessments completed, to include an initial Activities and quarterly assessments. On 3/22/2023 at 4:00 p.m., the Regional Nursing Consultant provided the Activities Attendance policy and procedure with a revised date of June, 2018. The document revealed under the Policy Statement; The activity department records activities attendance and participation of all residents. The Policy Interpretation and Implementation section of the policy revealed but not limited to: #2 Records are reviewed on a regular basis, and at least quarterly, to determine any changes in resident participation that might indicate a change in condition and lead to reassessment and care plan review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 7 of 25 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 03/22/2023 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A Review of Resident #38's admission record revealed she was a [AGE] year-old female who was re-admitted on [DATE]. Review of Resident #38's medical chart revealed medical diagnoses which included but were not limited to schizoaffective disorder, bipolar type, bipolar disorder, anxiety disorder, and recurrent depressive disorder. Review of Resident #38's Preadmission Screening and Resident Review (PASARR) dated 5/22/18 revealed qualifying medical diagnosis of anxiety disorder, bipolar disorder, and depressive disorder and no PASARR Level II was required. Review of Resident #38's psychiatry physician note dated 3/1/23 revealed .Diagnosis primary psychological DX code: schizoaffective disorder, bipolar type secondary dx code: anxiety disorder. .The patient presents screening tests, structure, interview, criteria from the DSM-5 schizoaffective disorder marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania. She is taking Clonazepam 0.5 mg. Depakote 250 mg. Fluoxetine 20 mg. and Risperidone 2 mg . Review of the admission Minimum Data Set (MDS) dated [DATE], section I, active diagnoses, indicated a psychiatric/mood disorder diagnosis of manic depression (bipolar disease). Review of Resident #38's significant change MDS dated [DATE], section I, active diagnoses, indicated psychiatric/mood disorder diagnosis of anxiety disorder, depression (other than bipolar), bipolar disorder, and schizophrenia. Based on record review and interview, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for three (Residents #90, #47 and #38) of four residents sampled for PASARR Level II Findings included: 1. Review of the electronic medical record (EMR) revealed Resident #90 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) dated [DATE] showed under Section I active diagnoses, the resident had anxiety disorder, depression and Schizophrenia diagnoses indicated. A significant change in mental status MDS for Resident #90 dated 12/29/22 showed under Section I active diagnoses, the resident had anxiety disorder, depression and Schizophrenia diagnoses indicated. Review of Resident #90's PASSAR Level I screen dated 08/25/21 revealed Resident #90 had bipolar disorder, depressive disorder and schizoaffective diagnoses indicated. The diagnosis of Schizophrenia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 8 of 25 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 03/22/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was not indicated. The review showed a level II PASARR evaluation was not completed following a qualifying mental health diagnosis. A Care plan for Resident #90 dated 08/27/21 showed a goal revised on 03/21/23 indicating the resident had the potential for adverse side effects related to the use of psychotropic medications antidepressants for treatment of depression, insomnia, and antipsychotics for treatment of schizophrenia. A goal initiated 02/23/22 and revised on 10/31/22, showed the resident had mild communication deficit related to bipolar disorder and schizoaffective disorder. Review of Resident #90's Resident Information sheet dated 3/21/23 showed an anxiety disorder was added on 12/24/21 while the PASARR was completed on 8/25/21. Review of a psychiatric note for Resident #90 dated 12/22/22 showed the resident was seen for psychiatric evaluation, anxiety, schizoaffective disorder bipolar type. Review of a psychiatric note for Resident #90 dated 01/03/23 showed the resident was seen for psychiatric evaluation, anxiety, schizoaffective disorder bipolar type. Review of a psychiatric note for Resident #90 dated 02/02/23 showed the resident was seen for major depressive disorder, recurrent, severe with psychotic symptoms. Review of a psychiatric note for Resident #90 dated 02/07/23 showed the resident was seen for psychiatric evaluation, anxiety, schizoaffective disorder bipolar type. The record review showed a level II PASARR evaluation was not completed for a Resident #90 with a history and/suspicion of a serious mental illness to include schizophrenia. 2. Review of the electronic medical record (EMR) revealed Resident #47 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] showed under Section I active diagnoses, the resident had depression diagnosis indicated. A quarterly MDS for Resident #47 dated 12/28/22 showed the resident had new diagnoses to include seizure disorder or epilepsy, depression, and schizophrenia. Review of Resident #47's PASSAR Level I screen dated, 02/08/21 revealed no qualifying mental health diagnosis were indicated and that no PASARR Level II was required. A care plan for Resident #47 dated 1/16/23 requested but not provided, showed the Resident had the potential for adverse side effects related to the use of psychotropic medications, antidepressant, antipsychotic for treatment of depression, antipsychotic for treatment of schizophrenia/depression. A care plan for Resident #47 revised 01/24/23, showed the resident has the potential for side effects related to the use of psychotropic medications, antidepressant for treatment of depression. A focus dated 11/26/21 showed Resident #47 is at risk for injury/complications related to seizure disorder. Review of Resident #47's Resident Information sheet dated, 03/21/23 showed a schizophrenia diagnosis was added on 02/19/21 while the PASARR was completed on 02/08/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 9 of 25 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 03/22/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm The review further showed a diagnosis of major depressive disorder was added on 02/10/21, while the PASARR was completed on 02/08/21. The record review showed a level II PASARR evaluation was not completed for a Resident #47 with a history and/suspicion of a serious mental illness to include schizophrenia. Residents Affected - Few On 03/21/23 at 11:45 a.m., an interview was conducted with Staff K, Licensed Practical Nurse (LPN), Unit Manager (UM). She stated if a resident had new psychiatric diagnosis, the MDS coordinator would input the diagnosis in the record, once the doctor confirmed it. She stated treatment and medications were added accordingly. She stated the MDS coordinators initiated the care plan and interventions. She stated she did not know who would have had to submit a level II PASARR for newly acquired diagnosis. On 03/21/23 at 1:14 p.m., an interview was conducted with Staff M, Registered Nurse (RN), MDS and Staff N, MDS Consultant. They stated they did not do PASARRs. Staff N stated the SSD did the PASARRs. Staff M stated she would expect a level II PASARR to be submitted if a resident had acquired a new psychiatric diagnosis. Staff M stated the previous Director of Nursing (DON) had put the new schizophrenia diagnoses on these residents records. Staff M stated, I don't know why. The care plan should also reflect the new diagnosis and interventions. On 03/21/23 at 1:19 p.m., an interview was conducted with the Regional Nurse Consultant (RNC). She stated the previous DON had added the new diagnoses. The RNC said, A new level II should have been submitted. Any time there is a significant change, and a new mental diagnosis is indicated, the PASARR should be updated. I do not know why she did not. On 03/21/23 at 3:20 p.m., an interview was conducted with the RNC. She stated the concerns were that their Social Services Director (SSD) position was open. She stated it was clear the PASARRs were not done. The RNC stated she had sent the new DON the link to get access to submit the PASARRs going forward. She stated the process was for the admission department to review PASARRs prior to admission, make sure they had a level I PASARR and submit a level II as indicated. The RNC stated the SSD should have submitted the PASARRs for review upon acquiring a new qualifying mental health diagnosis. She stated their expectation was to review the PASARR upon admission, review any changes in diagnosis and submit a level II recommendation as needed. On 03/21/23 at 11:58 a.m. The RNC stated they did not have a PASARR policy. She stated they should be reviewing changes on-an ongoing basis, and the SSD should initiate new PASARRs as new diagnoses are indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 10 of 25 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 03/22/2023 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 Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure care plan interventions were implemented for three (Residents #19, #98, and #114) of fifty-one sampled residents. Findings included: 1. A review of the current medical record revealed Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed Resident #19 was her own responsible party. Review of the current Minimum Data Set (MDS) Annual assessment dated [DATE], revealed: Cognition/Brief Interview for Mental Status: Score = 6 which indicated severe cognitive impairment ; Activities of Daily Living ADL - BED MOBILITY = Extensive Assistance with One person, TRANSFER = Extensive Assistance with Two person; Further review of the MDS and Diagnoses sheet did not indicate any extremity Range of Motion (ROM) deficits. A review of the current Physician's Order Sheet (POS) for the month 3/2023, revealed the following orders: (a) Apply Left ankle Splint as tolerated due to reduced ROM. Monitor Skin and splint integrity when applying and removing every day and evening shift with an original order date 1/6/2023. (b) Mechanical lift [NAME] steady lift when assisting out from bed, with an original order date 7/22/2022. (c) Wheelchair Positioning support Right lateral support when up in wheelchair, with an original order date 4/22/2021. A review of the 1/2023, 2/2023, and 3/2023 Medication Administration Record (MAR), and the Treatment Administration Record (TAR) both revealed no documentation related to daily application use, or monitoring of either a left ankle splint or a right lateral wheelchair support device. On 3/19/2023 at 11:15 a.m., an observation and interview was conducted with Resident #19. The resident was seated in her wheelchair and positioned between the side of her bed and the door wall. She had her over the bed table placed in front of her. The resident was noted dressed for the day and well groomed. She revealed she was not happy about missing a Church activity because staff did not get her up out of bed in time today. She was not wearing any splints or braces on either of her lower extremities. At 11:20 a.m., a staff member was observed to go into Resident #19's room and asked if she was ready to go to the dining room for lunch. The resident accepted and the staff member assisted her to the dining room. Prior to leaving the room, staff did not offer, nor place any splints or braces on the resident's lower extremities. Further observations revealed Resident #19's wheelchair did not have any type of additional positioning support devices. There was no evidence in the room of either splints/braces or wheelchair positioning support devices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 11 of 25 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 03/22/2023 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 On 3/19/2023 at 11:45 a.m., in an interview with Staff F and Staff G, Certified Nursing Assistants (CNAs), both were asked if Resident #19 wore any type of lower extremity splints and they both said they did not think so. Staff F looked in Resident #19's room and could not find either a foot splint/brace, or any type of wheelchair positioning pad/device. Staff F and G both confirmed they had not seen her with either of those devices recently. Residents Affected - Few On 3/20/2023 at 8:20 a.m., and 11:13 a.m., Resident #19 was observed in her room and seated in her wheelchair, dressed for the day and well groomed. She revealed she could not participate with her Activities of Daily Living (ADLs) on her own and had to have staff assist her with Dressing, Transfers, Toileting, Personal Hygiene. Further observations revealed Resident #19 was not wearing any splints on her lower extremities and there was no additional positioning support devices in her wheelchair. She was unaware of either and commented, I don't know if I have a splint for my foot. Resident #19 said, I usually have an extra pad on my wheelchair behind my back, but I don't know where it is. Resident #19 was observed again at 1:30 p.m. and 2:30 p.m. in her room and seated in her wheelchair with no lower extremities splint/brace on, nor any type of extra wheelchair positioning device. Resident #19 confirmed and said she did not know where they were and staff did not offer her the use of either. On 3/21/2023 at 9:10 a.m., Resident #19's was observed in her room, seated in her wheelchair, and dressed for the day. She was positioned in her wheelchair between her bed and the door wall. Further observations did not reveal any type of splint/brace on either of her lower extremities. Resident #19 confirmed she had no splint or brace and had not had one to use in the past. She also denied any type of support devices on her wheelchair behind her back at this time. She said she did not know if she had one before and did not know what it would be used for. On 3/21/2023 at 10:20 a.m., the North Unit Manager, Staff A was interviewed and revealed Resident #19 was supposed to wear a splint on her left ankle when up and out of bed to prevent further contractures. She revealed Resident #19 required assistance from staff to get up and out of bed and transfer to a chair. She also required assistance from staff with transfers from her room to other places to include the activities/dining room. Staff A revealed, after reviewing the resident's current orders for the month of 3/2023, the resident required and was ordered to have a left ankle splint applied daily and as tolerated. She revealed it was the responsibility of the CNAs to offer and apply the splint, daily. The Unit Manager was not sure why the resident was not wearing the left ankle splint the past three days (3/19/2023, 3/20/2023, and 3/21/2023). She revealed this order was also under the care plan and the CNA Kardex. Staff A said there might be times when the resident might have refused to wear it, but she did not have any documented evidence of the resident refusing to wear the splint. Staff A said if there was documentation of the resident refusing, this would have been noted in the Care Plan meetings and they would have developed a Behavior care plan that indicated the resident refused. Staff A confirmed there were no Behavior care plans that reflected the resident ever refused to wear the left ankle splint. On 3/21/2023 at at 11:45 a.m. and 12:55 p.m., Resident #19 was observed seated in her wheelchair either at a group activity in the main dining room, or seated in her wheelchair in the unit lounge area. She was observed with a left ankle splint on and with a pad in between her back and the wheelchair back. Resident #19 was asked about her left ankle splint and she pointed at it and said, this makes me feel better. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 12 of 25 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 03/22/2023 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 Residents Affected - Few Review of the current care plans with next review date 3/29/2023 revealed the following but not limited problem areas with goals and interventions: (a) Has potential for complications related to range of motion limitations of: Left Lower Extremity, Left Upper Extremity with interventions to include but not limited to: Apply/remove splint/brace for joint protection as ordered, Encourage resident to participate in activity programs related to exercise, Observe for signs and symptoms of decreased in ROM ability, refer to therapy for further screening as need. (c) Self care ADL deficit related to impaired mobility, weakness, dementia with interventions to include: Assist with splint/device per order and as tolerated, Monitor splint/device for cleanliness and that it is in good repair. (f) Has potential for or has an alteration in comfort related to weakness, neuropathy, and with interventions to include but not limited to: Observe for proper body alignment when in bed/chair; assist with repositioning as need. 2. On 3/19/2023 at 12:10 p.m. Resident #98 was observed seated in the main dining room and eating her meal. She waved over this writer as she wanted to talk about what she was served. Her meal tray/plate was observed with what appeared to be two slices of thick turkey, brown gravy on the turkey, mashed potatoes with what appeared to be brown gravy on it, and bread stuffing with what appeared to be a brown gravy all over it. The brown gravy was on all three main food items. Photographic evidence was taken. On 3/19/2023 at 12:10 p.m., during an interview with the resident, she revealed she hates gravy and had asked time and time again for staff not to put gravy on any of her food. The resident picked up her meal ticket and pointed at the notes section, which revealed: No Gravy, No Cabbage, No Broccoli, No Cauliflower, No beans, No canned fruit. Resident #98 revealed she and many other residents continued to receive items they had documented as to not receive and they had continually asked dietary staff, nursing staff, and management to not provide items they did not like. She said , it falls on deaf ears, and it has never gotten any better. She revealed she, along with other residents, continually mention this concern at monthly resident council meeting minutes as well with no resolution. Resident #98 said she received food items that were too spicy and had spoken to dietary aides, the dietary manager, the serving staff and at one point the social service person, when they had one. She revealed that nothing ever got fixed. She presented approximately fifty of her past daily meal tickets for all three meals. Each one of the meal tickets were noted in handwriting no spicy food. She circled the meal tickets where she marked no spicy food on the days when her meals were too spicy. Of the fifty meal tickets reviewed, approximately twenty-five were observed with no spicy food circled, indicating she received spicy food. A review of the electronic medical record revealed Resident #98 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Advance Directives revealed Resident #98 was her own responsible party to make her medical and financial decisions. A review of the current Physician's Order Sheet for the month 3/2023, revealed a diet order for: Regular Diet, Regular Texture, and Thin liquids. A review of the annual Minimum Data Set (MDS) assessment, dated 3/16/2023 revealed: Cognition/Brief Interview Mental Status score =15 which indicated intact cognition; Activities of Daily Living ADL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 13 of 25 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 03/22/2023 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 - EATING = Independent. Level of Harm - Minimal harm or potential for actual harm Review of the current care plans with next review date 6/14/2023 revealed the following areas: Residents Affected - Few - Risk for an alteration in nutrition and/or hydration related to: Morbid obesity, mechanically altered diet, trying to lose weight for upcoming surgery, Dietary staff speaks to resident regularly; and with interventions to include but not limited to: Provide diet as ordered, Offer and provide alternate as need, Honor food preferences. 3. On 3/21/2022 at 12:45 p.m. an interview with Resident #98 revealed that her lunch was ok today but her roommate [Resident #144] received things that she should not have received today. At that time, Resident #114 was observed and interviewed in her room. She was seated on the side of her bed. She had her over the bed table placed in front of her with her meal tray still on it and with the lid covering the plate. She also had a bag of outsourced food that was sent to the facility through personal ordering. She was upset because she received her first meal tray this afternoon and she received fish as the primary course. She revealed that she was very allergic to fish and fish products. Her first tray was already taken away and replaced with a second tray which had a breaded pork chop. The resident pointed at her meal ticket to show what she originally received and the meal ticket indicted she was served fish. The meal ticket further indicated under the allergies section; Allergies: All fish/fish sauce ingredients, All shellfish ingredients, All shrimp ingredients, All crab ingredients. Photographic evidence was taken. A review of the electronic medical record revealed Resident #114 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Advance Directives revealed Resident #114 was her own medical and financial decision maker. A review of the current Physician's Order Sheet dated for 3/2023 revealed Resident #114 had the following Diet order: NAS (No added salt)/CCHO (Controlled Carbohydrate), Regular texture, and Thin liquid. Review of the current MDS quarterly assessment, dated 12/20/2022, revealed: Cognition/BIMS score 15 of 15, which indicated intact cognition; ADL - EATING = Independent. Review of the current care plans with next review date of 3/23/2023 revealed the following: - Risk for an alteration in nutrition and/or hydration related to: receives therapeutic diet, receives mechanically altered diet, BMI indicates obesity; with interventions to include but not limited to: Provide diet as ordered, offer and provide alternate as need. On 3/21/2023 at 2:45 p.m. in an interview with the Staff C, Dietary Aide she said, I take responsibility for [Resident #114] receiving fish on her tray this afternoon. She said she did not know how it happened and knew that Resident #114 was allergic to fish and fish related items. On 3/22/2023 at 4:00 p.m., the Nursing Home Administrator (NHA) revealed she was made aware a resident was served on 3/21/2023, a food item that she was allergic to. She confirmed there should be several fail safe systems in order for residents to receive their ordered meal with proper diet, choices, and to ensure they did not receive items that they were allergic to. The NHA said the kitchen staff should have caught that during tray line, and the nursing floor staff should have caught it when removing the tray from the meal cart, prior to the resident receiving the meal. The NHA said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 14 of 25 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 03/22/2023 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 Residents Affected - Few Registered Dietitian should have evaluated and documented this allergy in his assessments, but confirmed that it was not. On 3/22/2023 at 2:00 p.m. the Nursing Home Administrator provided the Care Plans, Comprehensive Person-Centered policy and procedure with revised date of December, 2016 for review. The Policy Statement indicated; 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. The Policy Interpretation and Implementation section of the policy revealed: #1 The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. #3 The IDT includes: (e.) The resident and the resident's legal representative (to the extent practicable). #4 Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: (a) Participate in the planning process (b) Identify individuals or roles to be included (e.) Participate in establishing the expected goals and outcomes of care (g) Receive the services and/or items included in the plan of care #5 The resident will be informed of his or her rights to participate in his or her treatment. #7 The care planning process will: (a) Facilitate resident and/or representative involvement FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 15 of 25 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 03/22/2023 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (Resident #19) of fifty-one sampled residents, was offered and provided assistance to activities of her choice during two of four days observed (3/19/2023, and 3/20/2023). Residents Affected - Few Findings included: On 3/19/2023 at 10:30 a.m., an interview with Resident #19, who was lying in bed in her room, revealed staff did not get her up so she could attend the Church activity this morning. She revealed staff, at times, would not get her up to go to activities. She required assistance to get up out from bed and required assistance transferring from the room to the dining room. It was observed at 10:20 a.m., prior to visiting Resident #19 while in her room, the main dining room had a group of residents seated at a large table and with a Church activity already in progress. A review of the posted month's (3/2023) activities calendar, revealed the activities on Sunday, 3/19/2023 were Church at 10:00 a.m. and Bingo at 2:15 p.m. Photographic evidence obtained. On 3/20/22023 at 8:40 a.m., Resident #19 revealed she was happy for Bingo later in the afternoon and expected to participate. At 2:45 p.m., Resident #19 was observed in her room and seated in a wheelchair between the side of her bed and the door wall. She was asked if she was going to the Bingo activity. She revealed it had already begun and staff did not come to get her. She stated, nobody helped me, and I wanted to go. She revealed she loved to participate in group activities to include Bingo, Church, Arts and Crafts, etc. She said she did not like to watch television all the time and hates staying in her room all day. She said there were times when staff did help her to activities and she missed them. She revealed this happened on the weekends more than weekdays, but not too often. She did not remember if any staff member had actually talked to her about her likes and dislikes with relation to activities and activities participation. A review of Resident #19's electronic medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. A review of the advance directives revealed the resident was her own responsible party and made her own medical and financial decisions. A review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed: Cognition/Brief Interview for Mental Status (BIMS) score was 6, which indicated severe cognitive impairment; Activities of Daily Living ADL - BED MOBILITY = Extensive Assist with One person, TRANSFER = Extensive Assist with Two person; (Activities - Reading activities = Very Important, Music activities = Very Important, Group activities = Very Important. On 3/21/2023 at 10:00 a.m., an interview with the North Unit Manager, Staff A confirmed Resident #19 liked to attend many group activities. Staff A was not aware that on Sunday 3/19/2023, the resident was not assisted to the Church activity or the Bingo activity. Staff A said the activities staff and nursing floor staff were to work together in an effort to offer each resident daily activities. On 3/21/2023 at 1:30 p.m., the Staff E, Activities Director was interviewed and revealed that Activities assessments were in the electronic medical record in the Evaluations tab. He was asked to pull up Resident #19's original admission activities assessment and the last quarterly activities assessment. He stated, I have tried to look for the original admission activities assessment and cannot look back that far on my computer system. He indicated there was a company change during that time and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 16 of 25 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 03/22/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few he would have to speak to the Nursing Home Administrator to try and pull that assessment up from a different computer program/system. The Staff E revealed he did a quarterly activities assessment on the resident just moments ago. He said, I could not find one, nor could I find any past quarterly assessments in the electronic medical record, so I just went ahead and did one today. The Activities Director confirmed he could not produce, nor show that the resident had an original admission activities assessment, nor could he produce, nor show that the facility completed past quarterly activities assessments going back at least two years. He confirmed that he knew Resident #19 well and knew she loved to attend group activities to include Church, Bingo, and Arts and Crafts on a daily basis. He was unaware of why she missed Church activities on Sunday 3/19/2023 and the afternoon Bingo activity on 3/20/2023. In review of the activities assessment, with a completion date 3/21/2023 at 12:57 p.m., revealed the following activities information for resident #19: Activities interests included: Religious Services, Religious Studies, Group Discussions, Education Programs, Current Events, Bingo, Movies, Music, Friends/Family visits, Socials, Parties, Resident Council, Television. The assessment further indicated the resident did not have current preference settings, but actively participates, and uses a wheelchair. The notes section of this assessment revealed: Resident is alert and oriented. Resident's favorite activities are Bingo, Religion and TV and movies, coming to group activities and doing 1:1 activities. Resident's main focus is to return to the community. Resident may receive phone calls from family and friends and also may receive visit from them. Resident may receive leisure material upon request. On 3/22/2023 at 3:00 p.m., an interview with the Regional Nursing Consultant and also with the Nursing Home Administrator (NHA), both confirmed they could not find or pull up Activities assessments for Resident #19 on the current electronic medical records program or from any other medical record computer based programs. The NHA revealed all residents upon their admission were to have assessments completed, to include an initial Activities and quarterly assessments. On 3/22/2023 at 4:00 p.m., the Regional Nursing Consultant provided the Activities Attendance policy and procedure with a revised date of June, 2018. The document revealed under the Policy Statement; The activity department records activities attendance and participation of all residents. The Policy Interpretation and Implementation section of the policy revealed but not limited to: #2 Records are reviewed on a regular basis, and at least quarterly, to determine any changes in resident participation that might indicate a change in condition and lead to reassessment and care plan review. The Regional Nurse Consultant also provided the Activity Programs policy and procedure with a last revision date of June, 2018 for review. The Policy Statement revealed: Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well being of each resident. Review of the Policy and Interpretation and Implementation section of the policy revealed but not limited to: #1 The activities program is provided to support the well being of residents and to encourage both independence and community interaction. #3 The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 17 of 25 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 03/22/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #4 Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. #6 Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. #7 Out activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident. #9 All activities are documented in the resident's medical record. #11 Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually. #12 Individualized and group activities are provided that: (b) are offered at hours convenient to the residents, including evenings, holidays, and weekends; (c.) Reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents. #13 Residents are encouraged, but not required, to participate in scheduled activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 18 of 25 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 03/22/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor for behaviors and side effects for psychotropic medications for one (Resident #9) of five residents reviewed for unnecessary medications. The facility also failed to limit as needed antianxiety medication for one (Resident #9) of five residents reviewed for unnecessary medications. Findings included: Resident #9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was a hospice resident and her medical diagnoses included but were not limited to recurrent depressive disorders and anxiety disorder. Review of Resident #9's physician orders revealed an order with a start date of 12/31/22 and no end date for Trazadone 100 mg 1 tablet by mouth one time a day for depression. Remeron 15 mg by mouth at bedtime for protein cal (calorie) nutrition which started on 12/30/22 with no end date. Further physician order review revealed an order with a start date of 1/13/23 and no end date for Lorazepam 0.25 ml buccally every 12 hours as needed for anxiety/restless/dyspnea. Review of Resident #9's medical record did not indicate behavior or side effect monitoring for the ordered psychotropic medications. Review of Resident #9's medication administration record (MAR) revealed the Remeron and the Trazodone were given as ordered but the Lorazepam was not limited to 14 days and the resident received the medication 19 times since the medication was ordered on 1/12/23. Further medical record review was conducted for Resident #9 and there was no evidence to support the continuation of Lorazepam longer than 14 days. Review of the Consultant Pharmacist's Medication Regimen Review: Listing of residents Reviewed with No Recommendations dated 2/1/2023-2/28/2023, revealed Resident #9 had no pharmacy recommendations for the month of February. Review of Resident #9's care plan initiated on 1/25/2022, revealed a focus for [Resident #9] has the potential for adverse side effects related to the use of psychotropic medication: antidepressant for tx [treatment] of depression/appetite. Antianxiety for tx anxiety. The goal indicated: Resident will receive the lowest effective dose of psychotropic medication to ensure maximum functional ability through the next review date. And resident will remain free from adverse side effects r/t (related to) use of psychotropic medications through the next review date. Interventions included but are not limited to observe for effectiveness of psychotropic medications. Observed for side effects r/t psychotropic med use; report to physician if noted. Psychotropic review for dose reduction as able. Observe for changes in mood/behavior; report to physician if noted. An interview was conducted on 3/21/23 at 3:40 p.m. with the Regional Nurse Consultant. She reviewed the medical record and confirmed there was no side effect monitoring or behavior monitoring for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 19 of 25 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 03/22/2023 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 0758 residents' psychotropic medications. Level of Harm - Minimal harm or potential for actual harm A phone interview was conducted on 3/22/22 at 6:30 p.m. with the facility's Consultant Pharmacist. He stated, Psychotropic medication should have behavior monitoring and side effects monitoring. Antianxiety medication that are scheduled as needed should have a 14 day stop date, even including hospice residents. All of those things are things I review monthly to ensure they are in place. If there is not a stop date on the order, then I am requesting that they put one on. About 6 months ago they completely threw out the old behavior templates and put in place new templates. And then I came in and made maybe about 20 recommendations to recommend changes to the behavior monitoring to create an order that relates to that specific resident rather than a long laundry list of possible behaviors and side effects. It has been a long difficult process to get that implemented. Residents Affected - Few Review of the facilities Antipsychotic Medication Use policy revised December 2016 revealed Policy Statement Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Policy Interpretation and Implementation 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. .13. Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 15. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. .17. Nursing shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 20 of 25 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 03/22/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two (Residents #98 and #114) of fifty-one sampled residents were provide with food items of choice and preference; and failed to ensure Resident #114 received a meal tray which did not include items she was allergic to, during two of four days observed on 3/19/2023, and 3/21/2023. Findings Included: On 3/19/2023 at 12:10 p.m. Resident #98 was observed seated in the main dining room and eating her meal. She waved over this writer as she wanted to talk about what she was served. Her meal tray/plate was observed with what appeared to be two slices of thick turkey, brown gravy on the turkey, mashed potatoes with what appeared to be brown gravy on it, and bread stuffing with what appeared to be a brown gravy all over it. The brown gravy was on all three main food items. Photographic evidence was taken. On 3/19/2023 at 12:10 p.m., during an interview with the resident, she revealed she hates gravy and had asked time and time again for staff not to put gravy on any of her food. The resident picked up her meal ticket and pointed at the notes section, which revealed: No Gravy, No Cabbage, No Broccoli, No Cauliflower, No beans, No canned fruit. Resident #98 revealed she and many other residents continued to receive items they had documented as to not receive and they had continually asked dietary staff, nursing staff, and management to not provide items they did not like. She said , it falls on deaf ears, and it has never gotten any better. She revealed she, along with other residents, continually mention this concern at monthly resident council meeting minutes as well with no resolution. Resident #98 said she received food items that were too spicy and had spoken to dietary aides, the dietary manager, the serving staff and at one point the social service person, when they had one. She revealed that nothing ever got fixed. She presented approximately fifty of her past daily meal tickets for all three meals. Each one of the meal tickets were noted in handwriting no spicy food. She circled the meal tickets where she marked no spicy food on the days when her meals were too spicy. Of the fifty meal tickets reviewed, approximately twenty-five were observed with no spicy food circled, indicating she received spicy food. A review of the electronic medical record revealed Resident #98 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Advance Directives revealed Resident #98 was her own responsible party to make her medical and financial decisions. A review of the current Physician's Order Sheet for the month 3/2023, revealed a diet order for: Regular Diet, Regular Texture, and Thin liquids. A review of the annual Minimum Data Set (MDS) assessment, dated 3/16/2023 revealed: Cognition/Brief Interview Mental Status score =15 which indicated intact cognition; Activities of Daily Living ADL - EATING = Independent. Review of the current care plans with next review date 6/14/2023 revealed the following areas: - Risk for an alteration in nutrition and/or hydration related to: Morbid obesity, mechanically altered diet, trying to lose weight for upcoming surgery, Dietary staff speaks to resident regularly; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 21 of 25 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 03/22/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and with interventions to include but not limited to: Provide diet as ordered, Offer and provide alternate as need, Honor food preferences. On 3/21/2022 at 12:45 p.m. an interview with Resident #98 revealed that her lunch was ok today but her roommate [Resident #144] received things that she should not have received today. At that time, Resident #114 was observed and interviewed in her room. She was seated on the side of her bed. She had her over the bed table placed in front of her with her meal tray still on it and with the lid covering the plate. She also had a bag of outsourced food that was sent to the facility through personal ordering. She was upset because she received her first meal tray this afternoon and she received fish as the primary course. She revealed that she was very allergic to fish and fish products. Her first tray was already taken away and replaced with a second tray which had a breaded pork chop. The resident pointed at her meal ticket to show what she originally received and the meal ticket indicted she was served fish. The meal ticket further indicated under the allergies section; Allergies: All fish/fish sauce ingredients, All shellfish ingredients, All shrimp ingredients, All crab ingredients. Photographic evidence was taken. A review of the electronic medical record revealed Resident #114 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Advance Directives revealed Resident #114 was her own medical and financial decision maker. A review of the current Physician's Order Sheet dated for 3/2023 revealed Resident #114 had the following Diet order: NAS (No added salt)/CCHO (Controlled Carbohydrate), Regular texture, and Thin liquid. Review of the current MDS quarterly assessment, dated 12/20/2022, revealed: Cognition/BIMS score 15 of 15, which indicated intact cognition; ADL - EATING = Independent. Review of the current care plans with next review date of 3/23/2023 revealed the following: - Risk for an alteration in nutrition and/or hydration related to: receives therapeutic diet, receives mechanically altered diet, BMI indicates obesity; with interventions to include but not limited to: Provide diet as ordered, offer and provide alternate as need. On 3/21/2023 at 2:45 p.m. in an interview with the Staff C, Dietary Aide she said, I take responsibility for [Resident #114] receiving fish on her tray this afternoon. She said she did not know how it happened and knew that Resident #114 was allergic to fish and fish related items. On 3/22/2023 at 4:00 p.m., the Nursing Home Administrator (NHA) revealed she was made aware a resident was served on 3/21/2023, a food item that she was allergic to. She confirmed there should be several fail safe systems in order for residents to receive their ordered meal with proper diet, choices, and to ensure they did not receive items that they were allergic to. The NHA said the kitchen staff should have caught that during tray line, and the nursing floor staff should have caught it when removing the tray from the meal cart, prior to the resident receiving the meal. The NHA said the Registered Dietitian should have evaluated and documented this allergy in his assessments, but confirmed that it was not. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 22 of 25 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 03/22/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and interview, the facility failed to maintain an ongoing infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one month (March) of three months reviewed. The facility also failed to maintain an ongoing surveillance program to prevent reoccurring urinary tract infections for one (Resident #80) of 51 sampled residents. Residents Affected - Few Findings included: 1. A review of the facility's infection prevention and surveillance book revealed tracking and trending of infections for January, 2023 and February, 2023. There was no evidence of an ongoing infection prevention and control program to prevent infections for the month of March. A review of the facility's Nursing Home Key Staffing Form revealed the Assistant Director of Nursing (ADON) was the infection preventionist. An interview was conducted on 3/22/23 at 4:40 p.m., with the Director of Nursing (DON) who had been with the facility for approximately 2 weeks, she stated, I am not certified in infection prevention. The ADON holds the certificate [infection preventionist certificate], but she has not done anything with infection control. The last day of February was the last day the previous DON left. And typically, I like to log my antibiotics as they are ordered rather than at the end of the month and play catch up and look at all the orders for the whole month and log it then. So going forward that is what we will be doing. But, as of right now nothing is done for the month of March related to antibiotic stewardship or tracking and trending infections. At the end of the month, we will finish up March and then in April we will start to track infections throughout the month. During this interview, the ADON stated she had been employed with the facility since November and confirmed she had not had a part in the infection prevention program. She indicated the previous DON handled it. 2. A review of Resident #80's admission Record revealed she was initially admitted on [DATE] from an acute care hospital. Resident #80's medical diagnoses include but were not limited to unspecified dementia without behaviors, muscle weakness, disorders of the skin and subcutaneous tissue, and recurrent depressive disorder. A review of Resident #80's diagnostic laboratory reports revealed a urinalysis was collected on 3/14/23 and resulted as an Escherichia coli (E. coli) urinary tract infection (UTI). Further diagnostic laboratory reports were reviewed and revealed Resident #80 also tested positive for E. coli UTI's on 2/2/23, 12/17/22, and 12/3/22 which she received antibiotics for. A phone interview was conducted on 3/20/23 at 2:56 p.m. with Resident #80's family member. She stated [Resident #80] has dementia, so my concern is that she keeps having repeated UTI's and I tell the administration my concerns and then the administration changes. My mom can't say I have to be changed and I talked to the doctor, and I talked to the aids [CNA] and they are trying to take care of the situation but they [CNA's] are so territorial and get upset. So, my concern is the repeated UTI's . An interview was conducted on 3/22/23 at 4:40 p.m. with the DON and the ADON/Infection Preventionist, they both indicated they were unaware Resident #80 had reoccurring UTI's. The DON stated, When we (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 23 of 25 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 03/22/2023 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 review the month of March we will look at our UTI's. Level of Harm - Minimal harm or potential for actual harm A review of the facility's In-service Training Class Attendance Record revealed the last UTI prevention education was provided to 24 nurses and Certified Nursing Assistants on 1/4/23. The subject was Preventing UTI's in the elderly- see attached. 1. Proper hydration 2. Wipe front to back 3. Check and change every 2 hours. Residents Affected - Few A review of the facility's Infection Prevention and Control Program policy Revised October 2018 revealed Policy Statement An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Interpretation and Implementation 1. The infection prevention and control program is developed to address the facility-specific infection control the needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. .3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 4. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. .7. Surveillance a. Process surveillance(adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of health care acquired infections) are used as measures of the IPCP effectiveness. b. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. .9. Data Analysis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 24 of 25 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 03/22/2023 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 a. Level of Harm - Minimal harm or potential for actual harm Data gathered during surveillance is used to oversee infections and spot trends. . 11. Prevention of Infection Residents Affected - Few a. Important facets of infection prevention include: (1) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures; (4) communicating the importance of standard precautions and cough etiquette to visitors and family members; (5) enhancing screening for possible significant pathogens; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 25 of 25