Inspection·May 20, 2021

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and cleaned the wound one more time in a circular motion with Dakins solution. Doffed the gloves, washed hands and donned gloves. Staff member A, cut another piece of calcium alginate and placed it over the wound, without inserting into the wound where potential tunneling was observed. Staff member A, then cleaned the small bleeding wound below the pressure wound with normal saline, doffed gloves, washed her hands and donned gloves to apply hydrogel to the area and dressed the two wounds with one 6 x 6 bordered gauze dressing. The ADON was assisting and stated the wound did appear to have tunneling and would need to be measured and observed by the physician. Observation of the left buttock pressure dressing on 5/20/21 at 9:06 a.m., revealed a 4 x 4 bordered dressing with the calcium alginate observed folded in a square under the dressing, ( wound is oval shaped). The dressing, brief and pull sheet was observed with moderate yellow drainage. The peri area of the wound was observed excoriated with some scabbing and was purplish red in color. Staff member A, doffed gloves, washed hands and donned gloves then cleaned the pressure wound one time with Dakins solution in a circular motion. Doffed gloves, washed hands and donned gloves to cut the calcium alginate in a rectangular shape, the wound was more oval shaped, and laid the calcium alginate on top of the wound. The ADON was assisting with positioning and suggested Staff member A cut the calcium alginate to the size of the wound and tuck it in to the wound where potential tunneling was observed. Staff member A then applied the rectangular shaped calcium alginate on top of the wound and used a 4 x 4 bordered dressing and placed the sticky area directly on top of the excoriated skin. The calcium alginate was observed outside the gauze under the dressing. Staff member A stated she was finished with the dressing except changing the resident's brief and sheets. When asked if the dressing was appropriate to the size of the wound and excoriated skin, the ADON, said the dressing should be larger so the tape was not sitting on the excoriated skin and suggested Staff member A, left the room to go get a larger dressing to avoid the excoriated skin. The ADON stated the peri area should have skin prep applied to keep the skin from breaking down and stated the calcium alginate should be placed in the wound and packed under the skin if there is tunneling to aid in healing. Staff member A, left the room and obtained the supplies to redress the left buttock wound. Upon return, washed her hands, donned gloves then cleaned the wound one time with Dakins soaked gauze, doffed the gloves, washed hands and donned gloves then applied the rectangular calcium alginate over the wound and dressed the wound. The resident's bed was set on static mode. The nurse and ADON could not say if that was the correct setting for the resident. The ADON walked out into the hall after the dressing change on 5/20/21 at 9:15 a.m. and observed the orders for the dressings and confirmed the orders did not contain skin prep to the peri area and stated the second wound on the right hip was trauma, related to the tape from the dressing. The ADON confirmed the wound appeared to have tunneling and should be packed with calcium alginate and the nurse should have cleaned the wound three times not one time. The ADON confirmed the wound should be packed if tunneling was present and confirmed the calcium alginate should be placed in the wound not set on top of the wound with the edges outside the wound. During an interview with the DON on 5/20/21 at 9:40 a.m., she confirmed she did not know how to work the resident's air mattress and stated the company came out to set the mattress and took care of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 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 105117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Heritage Health & Rehabilitation Center 718 Lakeview Ave S Saint Petersburg, FL 33705 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the mattress. The DON stated the facility did not monitor the mattress or settings and would not know if the settings were wrong. The DON provided an email of what the correct setting should be for Resident #8's mattress on 5/20/21 at 1:05 p.m. which stated the final therapy setting should be AP-redistribution for the Air force 1000 bed that was delivered on 4/29/21. Observation of the resident's bed with the DON on 5/20/21 at 1:02 p.m. revealed the setting on the bed at static low air loss. The DON confirmed that was the incorrect setting. Photographic evidence obtained. Review of the outpatient wound care center progress notes, dated 5/5/21, revealed the resident's left ischial tuberosity measured length 4.2 cm x width 3.9 cm with a depth of 1.5 cm, wound tunnel location 6, wound tunnel size 4.4 cm, undermining location 12-6, undermining size 1.8 cm. Wound description -drainage/exudate, wound drainage- serosanguineous, wound drainage - moderate. Review of the right ischial tuberosity on 5/5/21 measured length 3.9 cm x 2.8 cm with a depth of 1.5 cm, wound tunnel location 12, wound tunnel size 2.0 cm, drainage/exudate, open. Drainage- serosanguineous, small amount of drainage. Review of the facility skin grid for pressure ulcers, dated 5/4/21, revealed length 4.3cm x 5.5 cm width, depth of 0.2 cm. no tunneling or undermining documented. Review of the facility skin grid for pressure ulcers dated 5/4/21, for the right hip revealed a length of 4.0 cm x 2.5 cm with a depth of 0.2 cm. No undermining or tunneling noted. Review of the outpatient wound care center progress notes, date 4/21/21, revealed left ischial tuberosity measured length 3.5 cm x 3.5 cm with a depth of 1.0 cm. Tunnel location at 6, tunnel size of 1 cm. Review of the right ischial tuberosity on 4/21/21 measured length 4.0 cm x 3.0 cm with a depth of 1.0 cm, undermining at 12, measure 1.5 cm. Impression and plan: Both of his ischial tuberosity wounds are worse. I am afraid that he is not getting proper offloading at his institution. Instructions were given regarding offloading and dressing changes. See again in one week. Review of the facility skin grid for pressure ulcers for the left buttock revealed on 4/20/21, length 2.3 cm x 2.5 cm, depth is unable to determine, moderate drainage, no tunneling or undermining noted. Review of the facility skin grid for pressure ulcers for the right hip revealed on 4/20/21, length 2.9 cm x 2.5 cm, depth is 0.2 cm, no tunneling or undermining noted. Review of the outpatient wound care center progress, notes date 3/31/21, revealed left ischial tuberosity measured length 2.6 cm x 2.5 cm with a depth of 0.6 cm. Tunnel location at 12 and 6, tunnel size of 3.6 cm. Review of the right ischial tuberosity on 3/31/21, measured length 1.9 cm x 1.0 cm with a depth of 0.5 cm, undermining at 9 and 3, measure 1.0 cm. See again in one week. Review of the facility skin grid for pressure ulcers for the left buttock revealed on 3/30/21, length 3.5 cm x 2.0 cm, depth is 0.2 cm, no tunneling or undermining noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 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 105117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Heritage Health & Rehabilitation Center 718 Lakeview Ave S Saint Petersburg, FL 33705 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility skin grid for pressure ulcers for the right hip revealed on 3/30/21, length 2.0 cm x 1.0 cm, depth is 0.2 cm, no tunneling or undermining noted. Review of the outpatient wound care center progress notes, dated 3/17/21, revealed a narrative note: Informed patient's caretaker who comes to the appointment needs to make every single weekly appointment because his wound is getting worse. Doctor states the wound looks like it is not being offloaded enough. Educated caretaker on offloading the area and making sure patient is being turned and offloaded properly. Review of the outpatient wound care center progress notes, dated 3/17/21, revealed the left ischial tuberosity measured length 2.8 cm x 2.3 cm with a depth of 0.8 cm. Review of the outpatient wound care center progress notes, dated 3/17/21, revealed the right ischial tuberosity measured length 2.6 cm x 0.9 cm with a depth of 0.3 cm. Review of the impression and plan: The resident has stage IV pressure wounds to bilateral ischiums. Unfortunately these are not improving and offloading is inadequate. Orders are given for more aggressive offloading. Review of the facility skin grid for pressure ulcers for the left buttock revealed on 3/16/21, a length of 3.2 cm x 2.2 cm with a depth of 0.2 cm. Review of the facility skin grid for pressure ulcers for the right hip revealed on 3/16/21, a length 2.4 cm x 1.5 cm with a depth of 0.2 cm. Review of the physician progress notes from 5/10/21 revealed the wounds are to continue with Dakins solution packing, change every day. Review of the physician progress notes from 5/3/21 revealed to continue Dakins solution packing change every day. Offloading is being done with frequent turns. Treatment: if he has continued deterioration would consider doing a wound culture after discussion with DON and would consider systemic antibiotics at that time. Review of the physician orders, dated 4/28/21, read: clean right hip wound with Dakins solution. cover wound bed with calcium alginate and apply dry dressing everyday for wound healing. Review of the physician order, dated 4/28/21, read: clean left buttock with Dakins solution. Cover wound every day shift with calcium alginate and cover with dry dressing for wound healing. Review of the physician order, dated 5/19/21, read: right hip #2. Cleanse area with normal saline, pat dry, apply hydrogel, and cover with dry dressing. Review of skin grid - other skin problems revealed on 5/19/21, a right hip #2 wound measured length 1 cm x width 2.5 cm x depth of 0.1 cm, abrasion/trauma related. Review of the care plan, revised on 5/20/21, revealed the resident had an actual wound related to immobility, non compliance with plan of care. Pressure areas to right hip and left buttocks. Goal to promote wound healing through review date, revised on 5/19/21. Minimize wound infection from developing through the review date, initiated on 5/19/21. Interventions include schedule and transport to wound specialist as needed initiated on 5/19/21. Encourage/assist with frequent repositioning initiated on 5/19/21. Support surface to bed: air mattress to bed. Check placement and function every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 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 105117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Heritage Health & Rehabilitation Center 718 Lakeview Ave S Saint Petersburg, FL 33705 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shift, initiated on 9/9/20, and revised on 5/19/21. Treatment as ordered (Refer to orders for current order). Premedicated as indicated, initiated on 9/9/20. Monitor wound weekly of location, highest stage, and or visual stage. Measure length, width, and depth, color of drainage, color of wound bed, presence of odor, tunneling or undermining, review for improvements, report declines to doctor, dated 9/9/20. During an interview with the Director of Nursing (DON) on 5/19/21 at 4:20 p.m., she stated the facility had transportation issues and could not get the resident to wound care, but, did not have any documentation related to why or if a follow up appointment was made. During an interview with the DON on 5/20/21 at 8:22 a.m., she confirmed she did not have any documentation to show the resident went to wound care as ordered on 4/7/21 and 4/14/21. The DON confirmed she would expect the resident to go to outpatient wound care as ordered and if he did not for any reason, she would want to see notes and follow up. During an interview with the Nurse practitioner (ARNP) on 5/20/21 at 9:45 a.m., she confirmed she had not observed the resident's wound but if the wound had tunneling and undermining she confirmed the wound should be packed and the calcium alginate should be placed in the wound not around the wound. She also confirmed the peri wound should be treated with a barrier cream to prevent breakdown. A phone interview was conducted on 5/20/21 at 10:12 a.m., with the physician taking care of Resident #8's wounds. He stated he was in last week and would be in later today. He confirmed he did see the resident's wounds and stated the resident stopped going to the outpatient wound care due to his wounds getting worse. The physician was unaware the resident did not go to his appointments, as ordered, and had not observed wound care to ensure accuracy of the care. The physician confirmed that he started Dakins solution due to odor and to decrease biogrowth in the wound on 5/3/21. The physician stated the wound had redness and had some colonization with early infection and they were able to stop it. The physician stated the resident had about 3 mm of tunneling and would expect the wound to be packed so the wound could heal from the inside out. The physician stated the resident did not have excoriation around the wound and would expect the dressing change to include a saline rinse with Dakins soaked into the packing material to fill the tunneling and would not expect the dressing to sit directly on the excoriated skin. During an interview with Staff member B, Unit Manager on 5/20/21 at 10:56 a.m., she stated she did not round with the physician on 5/10/21 and put orders in the computer from another nurse and could not remember which one. Staff member B confirmed the order was the same as previous, so, she did not change it in the computer and confirmed she was not aware the wound should have been packed. During a phone interview with the wound care center on 5/20/21 at 11:45 a.m., she stated the facility had transportation problems and was notified that transportation had come too early and left the facility before the resident was seen. The manager at the wound care center stated the policy was to get transport to sign they received the information and the facility was called as a back up to assure the orders are completed. If an order was for three times a week it would really be four times as we would also complete wound care here. A phone interview was conducted on 5/20/21 at 12:52 p.m., with the nurse practitioner who saw the resident. She stated the resident had not been coming to his appointments as ordered and was not being offloaded and the wounds would get worse. The nurse practitioner stated the facility transport would leave the resident on a stretcher that was not big enough for him for three to four hours on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 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 105117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Heritage Health & Rehabilitation Center 718 Lakeview Ave S Saint Petersburg, FL 33705 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some occasion. The nurse practitioner stated the resident needed to be turned more and that he should not be on an air mattress set at static. The nurse practitioner confirmed the facility had received the physician orders for each visit and kept calling as they would misplace them and ask for another copy. She confirmed the facility would give the orders to the care giver that was with the resident. During an interview with the DON and Regional Nurse Consultant (RNC) on 5/20/21 at 11:18 a.m., the DON stated she had not seen the physician note from 5/10/21 as she never received the notes until yesterday on 5/19/21 when they were requested. The DON stated she had completed competencies on the nurses that do wound care and would come up with a process between the physician and nurses to ensure orders were followed. The RNC confirmed no one used the standard batch orders for wound care and stated wound care should include skin prep on the peri wound. She would make sure the staff were inserviced with a wound care company to make sure they were assessing and documenting the wound correctly. Review of facility policy for wound prevention and treatment overview revised on 10/2011, two pages, revealed: The facility implements the following interventions to prevent the development of pressure ulcers: Identify residents/patients at risk and the specific factors placing them at risk them implement and individualized plan of care based on the identified factors. Reduce occurrence of pressure over bony prominence's to minimize injury. Protect against the adverse effects of external mechanical forces. Increase the awareness of ulcer prevention through educational programs. The facility has developed prevention and treatment protocols. A resident with ulcers will receive continued preventative interventions and necessary treatment and services to promote healing and prevent infection. Wound characteristics will be documented by measuring length, width and depth in centimeters. Additional documentation shall also include: color of drainage, wound bed color, odor, amount of drainage, wound bed tissue type, and tunneling/undermining with depth if applicable. Procedure: 4) communicate interventions to staff. 5. Review and revise plan of care as needed. 7. Review skin integrity on a weekly basis as a proactive approach enabling facility staff to identify changes in skin integrity/condition. Review of facility policy for physician orders, undated, 4.3.1, three pages revealed: 2. Assure physician's order include the drug or treatment and a correlating medical diagnosis or reason. 5. Clarify unclear written orders by reviewing with the physician and documenting clarification on the Physician telephone order form as an orders clarification. 13. Confirm the accuracy of all orders. Review all orders daily in the clinical meeting to assure accuracy in transcription and errors of omission. 15. Review orders from a physician other than the attending with the attending physician prior to implementation unless the attending physician has given previous written direction to accept the specialist/consultant orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 6 of 6