Inspection·August 14, 2024

F 0553 - Quarterly and modification on 6/6/24, completed on 6/7/24. Level of Harm - Minimal harm or potential for actual harm The facility provided the following care plan invitations and care plan summaries sent to Resident #6's family member/POA: Residents Affected - Some Invitation for care plan meeting 8/9/23 mailed to the POA on 7/28/23. The Interdisciplinary (IDT) Plan of Care Review Meeting Summary showed one attempt to contact the POA was done by mail on 7/28/23 and the meeting was held without the family member due to no reply. The summary had an area to document 3 attempts at contacting the resident and/or their representative which showed one mailed attempt on 7/28/23 was documented without any further attempts. The care plan meeting on 8/9/23 was held approximately six weeks after the Quarterly MDS assessment on 6/14/23 and approximately six weeks prior to the Quarterly MDS assessment on 9/7/23. The IDT Plan of Care Review Meeting Summary, dated 3/14/24 at 10:15 a.m., did not reveal the type of review associated with the meeting, whether the meeting was held in person or by telephone conference, and did not reveal any attempt was made to contact either the resident and/or representative. The note showed no family present for care plan meeting (2) resident confused unable to participate. Review of the Invitation Letters and Care Plan Summaries provided and uploaded in the clinical record revealed no documentation of either in regard to comprehensive assessments completed in June 2023, September 2023, December 2023, and June 2024. Review of Resident #6's Interdisciplinary Narrative notes did not show any progress notes had been written, and review of the Care Plan notes showed the last one written was on 8/31/21. An interview was conducted with Staff A, MDS Coordinator on 8/13/24 at 12:03 p.m. Staff A stated a care plan meeting was conducted every 92 days, and if residents are confused the POA was called. The contact with representatives was done by telephone. Staff A stated Resident #6 was due for a care plan meeting this month and it was going to be scheduled for 8/22/24 but had to reschedule it for 8/29/24. Staff A confirmed not reaching out to the representative. The staff member stated sometimes the receptionist helps with calling the representatives. Staff A stated the last meeting was on 3/14/24 and the representative would have been called. Staff A reported trying to call the representatives the day of the meeting. Staff A stated the last time Resident #6's representative was involved was 4/23/23. An interview was conducted with the Regional MDS Coordinator on 8/13/24 at 12:17 p.m. The staff member provided a handwritten note of names of representatives contacted for the March 2024 care plan meetings and it showed the representative for Resident #6 had been notified of the meeting. The Regional MDS stated Staff A was going through papers to locate any other notifications or summaries and reported if it was not documented (it wasn't done). The staff member stated the facility had identified an issue with notifications during a mock survey two weeks prior. 2. On 8/14/24 at 12:09 p.m. Resident #17 was observed lying in bed and stated staff assisted with eating and hydration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 2 of 6 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 08/14/2024 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 - Some Review of Resident #17's admission Record revealed the resident was admitted on [DATE] and 9/21/23. The record included diagnoses not limited to Type 2 Diabetes Mellitus with hyperglycemia and oral phase dysphagia. The record showed the resident was self-responsible and had a POA. Review of the resident's census showed the resident was not active from 2/27/23 to 3/9/23 and 9/12/23 to 9/21/23. Review of Resident #17's Quarterly MDS, dated [DATE], showed the resident's BIMS score of 14 out of 15, indicating intact cognition. Review of Resident #17's MDS schedule showed the following comprehensive assessments were completed: - Quarterly on 4/25/23. - Quarterly on 7/20/23. - Quarterly and modification on 10/20/23. - Annual on 1/20/24. - Quarterly on 4/15/24. - Quarterly on 7/15/24. Review of Resident's Care Plan Meeting invitation letters and IDT Plan of Care Review Meeting Summaries revealed the following: Letter of invitation was mailed to the POA of Resident #17 on 6/15/23 for a meeting to be held on 6/21/23 at 11:30 a.m., the letter was mailed six days prior to the meeting. The MDS schedule showed the April MDS targeted on 4/25/23, seven weeks prior to the meeting on 6/15/23 and the meeting was held five weeks prior to the quarterly assessment targeted on 7/20/23. - Letter for meeting on 8/1/24 at 10:45 a.m. did not show who received the letter, when or how it was delivered. The summary showed the resident declined to participate in the meeting which was attended by three staff members, the Unit Manager, Staff A, MDS Coordinator, and an unknown staff member. The facility did not provide either a letter of invitation or a care plan meeting summary related to the resident's MDS dated [DATE]. The review of Resident #17's clinical record did not reveal any care plan documentation had been uploaded from 1/25 to 7/9/24 and the facility did not provide any documentation related to the comprehensive assessment done on 4/15/24. During an interview on 8/14/24 at 1:17 p.m. the Staff A, MDS Coordinator stated Resident #17 did not normally participate (in the meetings) and only reaches out to family members if they wanted. The staff member reported even though the resident did not normally participate they would still invite the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 3 of 6 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 08/14/2024 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 - Some 3. On 8/14/24 at 12:14 p.m. Resident #23 was observed lying in bed, with a family member at the bedside. The resident was able to make their needs known. Review of Resident#23's admission Record showed the resident was admitted on [DATE] and again on 2/27/24. The diagnoses included but was not limited to dementia in other disease classified elsewhere mild without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified schizophrenia, Type 2 Diabetes mellitus, and unspecified bipolar disorder. The record revealed the resident was the responsible party and did not show a Power of Attorney (POA) or Healthcare Surrogate (HCS). The census for the resident also showed a period of no billing from 1/26/24 to 1/31/24. Review of Resident #23's MDS assessments revealed a BIMS score on 3/31/24 of 9 out of 15, indicating a moderate cognitive impairment, and on 4/11/24 a BIMS score of 10, continuing to indicate a moderate cognitive impairment. Review of Resident #23's MDS schedule revealed the following comprehensive assessments: - Quarterly on 1/23/24. - Quarterly on 3/31/24 and 4/11/24 - Quarterly on 7/8/24. Review of the facility provided Care Plan summaries on 11/16/23 showed Resident #23 had participated and on 8/6/24 the resident and family member participated along with Hospice and the facility's IDT. Review of Resident #23's uploaded documents showed a baseline signature page on 10/20/23, and Care Plan Meeting Summaries dated 11/20/23 and 8/6/24. The documents provided did not show an invitation or summary related to the Quarterly assessments done on 3/31 and 4/11/24. Review of Resident #23's Care Plan Notes and IDT Narrative notes showed no notes were included in the clinical record. During an interview on 8/14/24 at 1:11 p.m. Staff A, MDS Coordinator stated the last care plan was conducted with Resident #23, [family member], and Hospice. The staff member reported the resident does participate in care plan meetings. Staff A reported not writing a progress note regarding the care plan meetings, he uses the IDT summary, which was uploaded into the resident's electronic records and the staff member uploads the summaries. He stated a summary was done with every (care plan) meeting. Staff A stated he would have to look into why summaries were not uploaded and reported being in the facility during the time of Resident #23's care plan meetings. Review of the facility policy titled, Resident Participation - Assessment/ Care Plans, revised February 2021 revealed, 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 interpretation in implementation of the policy included of the following: 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 . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 4 of 6 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 08/14/2024 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 3. The resident/ representatives right to participate in the development and implementation of his or her plan of care includes the right to: Level of Harm - Minimal harm or potential for actual harm -a. Participate in the planning process; Residents Affected - Some -b. Identify individuals to be included in the planning process; -c. Request meetings; -d. Request revisions to the plan of care; -e. Participate in establishing his or her goals and expected outcomes of care; -f. Participate in the type, amount, frequency and duration of care; -g. Receive the services and/ or items included in the care plan; -h. Be formed, in advance, of changes to the plan of care; -i. Refuse, request changes to and/ or discontinue care or treatment offered or proposed; -j. Be informed, in advance (by physician, practitioner, or professional), of the risk and benefits of the care or treatment proposed; -k. Have access to and review the care plan; and -l. Review & the care plan after any significant changes are made. 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; -b. Holding care plan meetings at times of day when the resident, representative, and family members can attend and are functioning at their best; -c. Providing sufficient notice in advance of the meeting; and -d. Planning for enough time for exchange of information and decision making. 7. A comprehensive care plan is developed within seven (7) days of completing the resident assessment. 8. A seven (7) day advance notice of the care planning conference is provided to the resident and his or her representative. Such notices made by mail and/ or telephone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105072 If continuation sheet Page 5 of 6 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 08/14/2024 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 9. The social service director or designee is responsible for notifying the resident/ representative and for maintaining records of such notices. Notices include: Level of Harm - Minimal harm or potential for actual harm -a. The date, time, and location of the conference; Residents Affected - Some -b. The name of each person contacted in the date he or she was contacted; -c. The method of contact (e.g. Mail, telephone, e-mail, 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 6 of 6