Inspection·February 10, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8/8: 232, 90 Days (lbs.): 234.6, 180 Days: (lbs.) 3/7: 232. Chewing/Swallowing comments: NPO (nothing by mouth) with enteral feeding for all nutrition & hydration needs. Skin Integrity: no pressure sores noted. The Nutrition Summary: Per documentation: NPO enteral feeding for all nutrition and hydration needs. Diabetic formula ordered to assist with glucose control, remains on diabetic meds (medications). Currently with a BMI (Body Mass Index) of 25.1 which indicates overweight status, not of concern due to advanced age. Weight is down with a 1.4% loss in 1 month, 15.7 % loss in 3 months, and a 16.6% loss in 6 months. No issues tolerating enteral feed noted. States he is getting 2 cartons of enteral feeding four times a day (4x/day) but still feels hungry. Denies nausea, vomiting or diarrhea (N/V/D). Receptive to changing to continuous feeding as he prefers to stay in bed. Nutrition Interventions: Noted moderate protein calorie malnutrition as evidenced by mild loss of fat (loss of orbital fat pads, prominent eyebrow bone) and moderate muscled loss (protruding clavicle, bilateral temporal wasting). The RD (Registered Dietician) assessment did not identify a possible cause that could have contributed to a significant weight loss. There was no reference to lab values or medication changes that could have reflected an infection the resident's body was fighting. Prior enteral feeding physician orders, dated 06/17/2021, read as: Four times a day Enteral Feed: Glucerna 1.2 calorie (cal) 8 oz (ounce) ARC Bolus Peg Tube. Administer 474 milliliter (ml) bolus (2 cartons) 4 times a day per 24 hours during waking hours. Total Volume to infuse 1896 ml/24 hour (hr.) for a total of 2280 cal per day. The order was discontinued on 12/05/2022. Findings revealed Resident #17 had received this order of enteral feeding for 18 months without a significant weight change noted. On 12/05/2022 new physician orders for the enteral feeding read as: Glucerna 1.2 at 100ml/hr. x 20 hr for 2000 ml formula daily. A Nutrition Risk Evaluation, Monthly note written by the Registered Dietitian (RD), dated 02/06/2023, read: Weight Status: Current weight 02/06/2023 at 202.4 No significant (sig) weight change in 1 month but 13.5% loss in 3 months and 12.8 % loss in 6 months. On 02/08/2023 at 1:30 p.m. an interview was conducted with the facility's Registered Dietitian (RD) who confirmed her progress note had said Resident #17 was getting his enteral feeding as ordered at two cartons 4 times a day. She said she looked back at his records and denied he had any nausea, vomiting or diarrhea that would have attributed to a significant weight change. The RD stated, He is receiving 2400 calories, verse the 2280 calories before. She confirmed Resident #17 was not on a weight loss diet nor did he desire to lose weight. She said the resident told her he wanted his weight back up. The RD said she notified the Director of Nursing (DON) of the resident's weight loss during their nutrition meeting. When asked if the physician was notified of the weight loss in December 2022 she stated, I did not call the doctor, the DON calls him. The RD went on to say Resident #17 was receiving an additional 120 calories per day by a continuous 20 hour infusion. She stated, For some reason his absorption rate had changed with the bolus. The RD was asked whether an investigation had been conducted to determine why the 38.6-pound weight loss in 26 days. The RD reported the facility had the weight scales checked and labs were performed. The RD added they had checked the resident's thyroid 4 level and found it was elevated. She added the increase in the thyroid 4 level could have contributed to a weight loss. The RD confirmed she did not check the enteral feeding supply to determine if the supplies were being administered as ordered. Review of laboratory results, dated 12/30/2022, for a Thyroid panel T4 Total result 12.56 indicated it was high with a normal reference range of 6.09 to 12.23. The T3 Uptake indicated it was high at 48.7 with a normal reference range of 32.0 to 48.4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 2 of 21 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 02/10/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Laboratory results on 01/12/2023 for a TSH-3rd Generation TSH showed a result of 1.779 which indicated it was within normal limits. Review of the medical record did not reveal the physician was notified of the change in condition related to the significant weight loss. Residents Affected - Few A review of the physician progress notes for Resident #17 revealed a follow up note, dated 12/06/2022. The note did not contain any documentation related to the resident's significant weight loss. A physician progress note, dated 12/13/2022, did not contain any documentation related to the resident's significant weight loss. A physician progress note, dated 12/20/2022, from the Advanced Registered Nurse Practitioner, did not contain any documentation related to the resident's significant weight loss. A physician progress note, dated 12/21/2022, revealed the section titled, History of Present Illness, documented the patient (Resident #17) was being seen today for evaluation and treatment of memory loss. Pt. (patient) was examined at the facility. Memory immediate, recent, and remote is poor, so is attention. Further review of medical record from 11/11/2022 to 12/05/2022 did not reveal a mental, physical, nor medication health change that would have attributed to a significant 38.6-pound weight loss in 26 days. On 02/08/2023 at 1:40 p.m. an interview was conducted with the Director of Nursing (DON) who confirmed they investigated the weight loss for Resident #17. On 02/08/2023 at 2:00 p.m., the DON, was asked about the resident's 38.6 lb. weight loss in 26 days, and if the physician had been notified. The DON stated, I thought the Assistant Director of Nursing (ADON) put a note in. On 02/08/2023 at 2:46 p.m. an interview was conducted with the Nursing Home Administrator (NHA), who reported there had been no investigation related to Resident #17's significant weight loss. The RD, who was present, said after they changed his tube feeding to a continuous infusion, he started to gain weight back, so they did not feel a gastrointestinal (GI) consult was needed. At the time, the NHA confirmed it should have been reported as an adverse event. On 02/08/2023 at 3:41 p.m. a copy of the facility policy was provided on notification of a change in condition. The NHA stated, We did not do an investigation related to his weight loss. We changed his order and saw a positive response. Which resulted in a weight gain. So, it did not trigger an investigation because the change in the order caused him to regain weight. She additionally stated, [Resident #17] knew how much he was supposed to get and confirmed it was provided. On 02/09/2023 at approximately 9:00 a.m. the facility provided a copy of a physician progress note, dated 12/20/2022. The progress note was not in Resident #17's paper or electronic record the day prior. This additional progress note indicated the resident had been seen by the ANRP and the Primary Physician on 12/20/2022. The progress note provided the morning of 02/09/2023 and dated 12/20/2022 read, under Section #3: Dysphagia as late effect of cerebral aneurysm strictly nothing by mouth (npo) continue PEG tube feeds, changed to continuous which I think is medically necessary to tolerate this volume, improving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 3 of 21 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 02/10/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm weight loss, periodically followed by speech therapy. A [AGE] year-old male patient seen in nursing facility for a follow up He has a PEG, and has been losing weight 233 lbs. 10/10/22 to 196 on 12/5. staff contacted me and I asked for them to discontinue the bolus feeding and do continuous to see if better tolerated higher volume. Since then, he had gained about 3 lbs. as of 12/12, and increased to 199 lbs. on 12/19. The progress note was electronically signed 02/08/2023. Residents Affected - Few On 02/09/2023 at 10:07 a.m. a phone interview was conducted with Resident #17's physician, who confirmed he knew the resident. The Physician said the facility had called him yesterday (02/08/2023) and requested his progress note from 12/20/2022. He confirmed the progress note dated from 12/20/2022 and electronically signed on 02/08/2023. He again confirmed he was late in getting the progress note to the facility. When asked about the 38.6 pound weight loss within a 26 day period he stated, Am suspicious in general a lot of times. Of not trusting in data that was fixed by the numbers, not making sense. He said he had put in an intervention. I think at that time he was feeling overly full, his stomach was upset, he has an esophageal stricture. When asked why the documentation of residuals did not reflect an increase in residuals during that time frame, he did not respond to the question. He confirmed the facility had called him and he was notified of the weight loss. The physician was asked how a resident that is totally dependent on staff to provide all of his nutritional and enteral feeding could have lost 38.6 pounds within a short period of time. The physician went on to say it could have been from COVID. He said a significant weight change could have been attributed to the resident getting COVID during their outbreak in October 2022. Further medical record review reflected Resident #17 had tested positive for COVID on 01/06/2022. Resident #17 was then tested in October 2022, during their outbreak, and on 10/18/2022 he tested negative. Review of a facility policy titled, Notification of Resident/Patient Change in Condition, effective October 2021, revealed: Nurses will notify the resident/resident representative, if there is a crucial/significant change in the resident condition. If the change in the resident's condition is not crucial or significant, the resident's Physician, resident representative or legal representative will be notified at the earliest convenient time during regular business hours. Procedure 1. Notify the Physician resident/resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day . 2. Document the Nurses' Notes, the time notification was made and the names of the persons to whom you spoke. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 4 of 21 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 02/10/2023 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 0583 Keep residents' personal and medical records private and confidential. 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 personal privacy was maintained for one resident (#34) out of 22 residents sampled. Residents Affected - Few Findings included: An interview and observation was conducted at 9:10 a.m. on 02/07/2023 with Resident #34. Resident #34 was observed well-groomed, sitting up in her wheelchair watching TV. During the room observation it was observed that Resident #34's room door was off the hinges and could not close shut to give Resident #34 privacy. Resident #34 said she did not like that her room door was not able to close shut because whenever a CNA (certified nursing assistant) provides her with personal care, she feels like someone can walk in her room and see her getting dressed. Resident #34 said her room door has not been able to shut close for a while, and she has reported her concerns to the CNAs, but nothing had been done about it. Review of the admission Record revealed Resident # 34 was admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease, unspecified, acute pulmonary edema, muscle wasting and atrophy, and acquired absence of right leg above knee. Review of the Minimum Data Set (MDS), dated [DATE], Section C- Cognitive Patterns showed Resident #34's Brief Interview for Mental Status (BIMS) score of a 14, indicating intact cognition. On 02/09/2023 at 9:08 a.m. an interview was conducted with Staff A, CNA. Staff A stated Resident #34's door hasn't been able to shut for months. Staff A said that despite letting someone in Administration know about Resident #34's door, nothing was done. Staff A said when helping Resident #34 with her ADLs (activities of daily living), she places a bedside table in front of the door so that no one can walk in. On 02/09/2023 at 11:46 a.m. an interview was conducted with the Maintenance Director. He confirmed that he was responsible for most of the repairs inside the building. He further confirmed that he did not fix Resident #34's door until Life Safety conducted their inspection and told him that Resident #34's door needed to be repaired. Review of the facility policy titled, Resident admission Agreement, Right [NAME] of Rights, dated 1/2012, showed: (19) - You have the right to personal privacy and confidentiality of your personal and clinical records. Personal privacy includes privacy in accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and residential groups, but this does not require facility to provide a private room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 5 of 21 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 02/10/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review the facility did not ensure a safe, clean, and homelike environment in nine resident rooms (108, 117, 116, 119, 123, 124, 126, 127, and 121) out of 34 rooms and four bathrooms (110, 123, 124 & 125, and 126 & 127) out of 22 bathrooms, one hall (Main) out of three halls, and one patio (dining area) out of two patios observed. Findings included: An observation was made on 2/7/23 at 9:10 a.m. of rooms [ROOM NUMBERS]. Both rooms had closet doors that were not on the tracks. (Photographic Evidence Obtained.) An observation was made on 2/7/23 at 10:23 a.m. in room [ROOM NUMBER]. On the wall under the window there was a broken plastic box with exposed wires on the wall. (Photographic Evidence Obtained.) An observation was made on 2/7/23 at 10:41 a.m. in room [ROOM NUMBER]. On the wall under the window there was broken/cracked plaster/drywall. The window was not sealed up and there were open gaps to the outside. (Photographic Evidence Obtained.) An observation was made on 2/9/23 at 10:44 a.m. in the bathroom of room [ROOM NUMBER]. The sink was loose and uncaulked and the toilet was elevated with a [NAME] and not caulked around the bottom. An observation was made on 2/7/23 at 10:51 a.m. in room [ROOM NUMBER]. There was a broken bedside tray table in the bathroom, broken/cracked plaster on the wall under the window, a cracked plastic wall guard near bed A, and a missing baseboard and cracked tiles on the wall near the TV stand. (Photographic Evidence Obtained.) An observation was made on 2/7/23 at 11:39 a.m. in the bathroom between room [ROOM NUMBER] and 125. There was a wet, stained bath towel hanging from the shower rod and a used, wet washcloth lying on the sink. On 2/9/23 at 12:42 a.m. a wet, stained towel was hanging from the shower rod, a wet towel was spread on the bathroom floor, a wet washcloth remained on the sink, and a wet washcloth was lying on the sink drainpipe. Also, on 2/7/23, in room [ROOM NUMBER] the privacy curtain had a brown substance splattered on it as well as dirt. This curtained remained in place on 2/9/23. (Photographic Evidence Obtained.) An observation was made on 2/7/23 at 11:45 a.m. in the bathroom between room [ROOM NUMBER] and 127. Above the sink in the bathroom paint and plaster had peeled off the wall and above the toilet paint had peeled off and was bubbling up. (Photographic Evidence Obtained.) Also, in room [ROOM NUMBER] a closet door was missing. In room [ROOM NUMBER] the privacy curtain between A and B bed had two large splatters of a brown substance. The soiled privacy curtain remained in place on 2/9/23. (Photographic Evidence Obtained.) An observation was made on 2/7/23 at 1:47 p.m. of the patio off of the dining area, which is unlocked and accessible to residents. One resident was currently sitting on the patio. There was a no smoking sign on the wall, but multiple cigarette butts were observed around the patio, as well as what appeared to be ash marks on the wall where cigarettes are being put out. There were also multiple plastic drink lids and trash piles that had been swept up and not removed. The patio remained in this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 6 of 21 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 02/10/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some condition on 2/8/23 and 2/9/23. Also, on the inside of the door there is an exposed electronic box attached the automatic door. (Photographic Evidence Obtained.) On 2/8/23 and 2/9/23 the blinds in room [ROOM NUMBER] were observed to be bent and broken. On 2/9/23 at 1:04 p.m. a large stain on the ceiling was observed in the hall near room [ROOM NUMBER]. (Photographic Evidence Obtained.) On 2/9/23 at 11:56 a.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Plant Operations. The NHA stated they have a concierge program five days a week. The department heads go into each resident room and look for maintenance needed, oxygen tubing, and other issues. A list was provided of items the staff look for. This list included: broken items, needs painting, room dirty, bathroom mess, furniture issues, and curtain issues. An interview was conducted with Staff B, Certified Nursing Assistant (CNA) on 2/9/23 at 2:15 p.m. Staff B, CNA stated the department heads do room rounds daily. She said if staff find items that need maintenance, they enter it in the (electronic work order) system for the maintenance department. Staff B, CNA stated dirty linen should not be left in a resident room; it should be bagged immediately and taken out. On 2/9/23 at 2:30 p.m. a facility tour was conducted with the NHA and Director of Plant Operations. They were shown all the concerns listed above. The Maintenance Director stated he was unaware of these issues and stated they are not being reported to him. The NHA stated she would have expected these issues to have been found on the concierge rounds. She stated she will be doing re-training on the rounds and what is expected. She also stated she will re-train staff on using the (electronic work order) system. The NHA confirmed these items are concerning. As for the dirty patio off of the dining area, the NHA stated they have a few residents that are non-compliant with smoking. She confirmed the marks on the walls appear to be ashes and didn't know why they haven't been cleaned off. On 2/9/23 at 3:05 p.m. the NHA stated the facility does not have a policy for maintenance or housekeeping. She also stated she would talk with the Director of Plant Operations to see what caused the stain on the ceiling outside of room [ROOM NUMBER]. A follow-up interview was conducted with the NHA on 2/10/23 at 9:12 a.m. She stated in November (2022) they had noticed some things that needed to be repaired. At that time they did a QAPI (Quality Assurance and Program Improvement) on environment and did a facility wide audit. She stated none of the items observed on our facility tour had been captured in that audit. She again confirmed these items had not been captured in concierge rounds. She stated all items are now added to a list to be repaired. A facility policy titled, Concierge Program, dated April 1, 2021, showed: The role of the concierge program is a daily review of the rooms for environmental concerns. The NHA or designee is responsible for oversight of the Concierge Program. Procedure: 1. Visit schedule: Daily 2. Focus: Housekeeping cleanliness, maintenance concerns . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 7 of 21 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 02/10/2023 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 0584 5. Present Concierge Visit Took at the morning meeting to the NHA or designee. Level of Harm - Minimal harm or potential for actual harm A facility provided job description titled, Director of Plant Operation was reviewed. The job description stated the following: Residents Affected - Some The Director of Plant Operations is responsible for the overall maintenance of the facility and provides direction for all related to plant operations. The Director of Plant Operations ensures the facility, equipment and utilities are maintained in good working order and facility grounds are properly maintained in accordance with facility policies and State and Federal regulations. Essential Duties and Responsibilities: -Perform minor repairs and supervise the day-to-day repair, improvement, and preventative maintenance of the facility to ensure that machines continue to run smoothly, building systems operate efficiently, or the physical condition of facility does not deteriorate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 8 of 21 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 02/10/2023 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 medical record review the facility failed to ensure care and services were provided in accordance with professional standards of practice for facility acquired pressure injuries for one resident (#1) by not seeking surgical intervention in a timely manner and for not ensuring orders were in place and followed for wound care for two residents (#30 and #7) of a total of three residents sampled. Residents Affected - Some Findings included: 1. On 02/07/23 at 10:00 a.m. Resident #1 was observed in bed with an air mattress in place. On 02/08/23 at 10:16 a.m. a phone interview was conducted with Resident #1's representative and has been with him for over ten years. When asked about the intensity his wounds she said the physician was talking about a skin graft to the buttock's wounds. She said she was looking forward to the procedure so he (Resident #1) would be able to get out of bed more often, and that she could take him outside during their visits. A record review of the admission Record form revealed Resident #1 has resided at the facility for twenty years. The diagnosis information description listed type 2 diabetes mellitus, pressure ulcer left heel unstageable 2023, pressure ulcer of right heel unstageable 11/15/2022, pressure ulcer of right buttock unstageable 08/01/2022, pressure ulcer left buttock stage 3 08/01/2022, and pressure ulcer of right hip unspecified stage 01/01/2021. Review of the Skin Grid for Pressure Ulcers Initial Identification, dated 09/13/2022, showed: Present on admission: no. Site Left buttock #2 Highest Stage; unstageable (US) Length (in centimeter (cm)) 4.0, Width (in cm) 2.0 Depth: unable to determine (UTD). Measurements dated on 12/20/2022 Highest Stage; unstageable (US) Length (in centimeter (cm)) 3.9, Width (in cm) 2.0 Depth: UTD. Measurements dated on 02/07/2023 Highest Stage; unstageable (US) Length (in centimeter (cm)) 6.3, Width (in cm) 2.5 Depth: UTD Review of the Skin Grid for Pressure Ulcers Initial Identification, dated 10/18/2022, showed: Present on admission: no. Site Left buttock #3 stage: US, Length (in cm) : omitted, Width (in cm) omitted, Depth: omitted Measurements dated on 12/20/2022 Highest Stage; unstageable (US) Length (in centimeter (cm)) 9.5, Width (in cm) 3.0 Depth: unable to determine (UTD). Measurements dated on 01/31/2023 Highest Stage; unstageable (US) Length (in centimeter (cm)) 9.5, Width (in cm) 6.5 Depth: UTD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 9 of 21 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 02/10/2023 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 progress notes, dated on 02/10/2023 at 11:33 a.m. showed: Note Text: Resident seen today for weekly wound assessment. Wounds as follow: right buttock wound base with granulate and slough tissue, increased in length, no change in width size, mod (moderate) amt. (amount) of pink drainage. Right buttock wound base #2 with granulated, slough, and necrotic tissue, mod amt. of pink drainage, increased in length and width. MD agrees with Pig Skin Graft that [name of Representative] suggested. Will have to follow up (f/U) with plastic surgeon. Signed by Staff F, Registered Nurse (RN). On 02/10/2023 at 10:44 a.m. an interview was conducted with the Director of Nursing (DON) who said she thought they were waiting for his insurance approval. She stated she was not sure and would get back to the surveyor. She then indicated at that time another staff member was following up with the approval. On 02/10/2023 at 11:14 a.m. an interview was conducted with Staff F, RN and she said she has known Resident #1 for over thirteen years. She said Resident #1 gets frustrated when asked to lay in on his side. He has limited ability to turn, and his skin is thin, and it easily breaks down. When asked about the resident's ordered skin graft she stated, It will benefit him. The areas would be closed; that way he will have a less chance for infection. She confirmed he was on an antibiotic just in December 2022 as his wounds to the buttock had developed an odor. Staff F said that way he would be able to get out of his bed and room more frequently. She stated I think it will help him more mentally too. Staff F stated, He likes to talk with other peers and enjoys leaving his room. She confirmed since the wounds developed; he was not able to get out of his bed. If he does, its only for a short period of time. Staff F confirmed she was responsible for performing weekly wound rounds with the DON, and stated, We all make rounds together. She said part of the process includes calling the family and updating them on the wounds and progress. Staff F said that she would talk with Resident #1's [Representative] weekly. She said the [Representative] had requested an order for a pig skin graft. She told me she knew someone that had one and it was successful. Staff F, said on 12/23/2022 I called for the authorization for the graft, and that included paperwork that had to be filled out and signed by the [Representative], Advanced Registered Nurse Practitioner, and the primary Physician. Staff F said the paperwork and required signatures were completed on 01/12/2023, and that same day she faxed the paperwork to [State Agency] for prior authorization. She added on 01/18/2023 she resent the information a second time to [State Agency] to make sure it was received. Staff F said that she is still waiting for a call back. She then went on to say she had been on a medical leave of absence and came to the facility today after the DON had called her. She said her last day of work was on 01/25/2023, and confirmed, as of today, she was not sure if there had been a call back from the [State Agency] with an authorization. She has not followed up due to her current leave status. Staff F indicated the DON would have been the one to follow up with the authorization during her medical leave. She said the [State Agency], she had spoken to, informed her that it would take a while for it to be processed. Staff F was unable to recall who she had spoken to, and indicated there was no phone number to call, only a fax number. On 02/10/2023 at 11:38 a.m. an interview was conducted with the Nursing Home Administrator (NHA) and she said she was familiar Resident #1's order for a skin graft. She said she had asked the Business Office Manager (BOM) to try to push it along. She said it was a couple of weeks ago. On 02/10/2022 at 11:45 a.m. the NHA was present during an interview that was conducted with the BOM and when asked about Resident #1's authorization for a skin graft she stated, No, I have not been talking with the insurance company. On 02/10/23 at 12:44 p.m. a call was placed to Resident #1's Physician and he confirmed he knew (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 10 of 21 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 02/10/2023 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 Resident #1 and asked is this about the graft? He said we have been dealing with it for over three weeks now, and we're waiting for approval from the insurance. Then we need to find someone to take the insurance. The Physician confirmed he needs the graft sooner than later, and the graft at the stage of his wounds would be beneficial for him. The Physician stated, This is only option he has left. He said he was not that old and then confirmed it was a psychosocial issue more than anything. The Physician was informed it took the facility twenty-three days to complete and fax paperwork to the [State Agency] for prior authorization, and since 1/18/2023 no one had followed up with the [State Agency] for the prior authorization. The Physician, at that time, stated, That is a problem .It's a nightmare even finding someone to perform the procedure. The Physician then reiterated no one will see him unless insurance is approved. On 02/10/23 at 2:46 p.m. an observation of the pressure injuries was conducted with Staff C, RN. She indicated the dressing was changed daily but due to the drainage it at times will need to be replaced. Resident #1 was alert and receptive to the observation once he was repositioned to his left side the dressing was noted not covering the injury. Staff C, RN said she would need to replace the secondary dressing. Staff C, RN removed the dressing that revealed a left wound with an open area the size of a golf ball, the depth of the area could not be visualized without a flashlight, the edges on the left side of the open area from 12 o'clock to 6 were rolled under/migrated down. The right side of the open area; a second open area was noted as attached to the golf sized area. The open area revealed, from 12 o'clock to 5 o'clock, a bright red beefy colored tissue, the area extended toward the right buttock and appeared over two inches in width and three inches in length, with macerated edges. Just below the open areas on the right buttock, three separate distinctive purple colored areas were present on the intact skin, and the areas ranged from a quarter to a fifty cent piece in size. The right buttock contained an open area that presented three inches wide and over four inches in length, the edges were macerated. On 02/20/2023 at 5:10 p.m. the DON denied the facility used outside wound care services. The DON indicated the last time Resident #1 had received professional wound care services was in May 2021. 2. An observation was made on 2/8/2023 at 9:59 a.m. of Resident #30. Resident #30 was lying in bed with pressure relieving boots on both feet. He was also noted to have a gauze dressing on both feet. A review of active physician orders for February 2023 did not reveal any orders for wound care for the left or right foot. A review of the admission Record indicated Resident #30 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including legal blindness, type II diabetes mellitus, and pruritus. A review of discontinued physician orders revealed an order to apply skin prep to blister left heel every shift until resolved. The order date was 1/17/23 and with a discontinued date of 1/19/23. There were no previous orders for the right heel/foot. A review of the Skin Grid for Pressure Ulcers form indicated wound care was completed on Resident #30's left and right heels on 1/31/23 and 2/7/23. There were two wounds on the left heel which were noted to have increased in size between 1/31/23 and 2/7/23. On 1/31/23 left heel wound #1 was 2.9 cm (centimeters) in length and 4.5 cm in width with a small amount of drainage. On 2/7/23 left heel wound #1 was 6.5 cm in length and 5.5 cm in width with a moderate amount of drainage. On 1/31/23 left heel wound #2 was 1.5 cm in length and 1.0 cm in width and on 2/7/23 left heel wound #2 was 1.8 cm in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 11 of 21 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 02/10/2023 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 length and 1.5 cm in width. Level of Harm - Minimal harm or potential for actual harm A review of progress notes did not show any notes indicating a provider was notified of the worsening wounds at any point. Residents Affected - Some On 2/9/23 wound care orders were entered. The orders were as follows: -Cleanse area to left heel with normal saline, pat dry. Apply med honey to wound bed, then apply calcium alginate and cover with ABD pad and wrap with gauze wrap for wound healing daily and PRN (as needed). -Cleanse right heel with normal saline, pat dry. Apply skin prep, wrap with gauze wrap and sterile gauze for protection daily and PRN. An interview was conducted with Staff C, Registered Nurse (RN) on 2/10/2023 at 11:24 a.m. Staff C, RN stated when the wound care nurse is out, the nurse assigned to the resident does wound care. She stated she did wound care for Resident #30 the last two days. An interview was conducted with the Director of Nursing (DON) on 2/10/2023 at 3:29 p.m. The DON checked Resident #30's orders and confirmed there were not any wound care orders in place prior to 2/9/23. She said according to the Skin Grid for Pressure Ulcers, wound care was completed on 1/31 and 2/7/23 with no order in place. The DON reviewed the wound measurements and confirmed the wound had increased in size. She stated she was unable to find any notes indicating a provider had been notified. She confirmed there should have been orders in place and a provider should have been notified. A follow-up interview was conducted with Staff C, RN on 2/10/23 at 3:40 p.m. Staff C, RN stated the unit manager (Staff D) told the nurses to do the wound care for Resident #30. She stated she had looked in the medical record for the order and didn't see it. She said she was just doing what she was told and didn't know why the order wasn't there. Staff C, RN stated the resident originally had a large blister on his heel that popped over a week ago. She said the nurses started doing daily skin prep, dressing and wrap. When asked if the provider had been notified she stated the unit manager (Staff D) would have been the one to call the provider. An interview was conducted with Staff D, RN/Unit Manager (UM) on 2/10/23 at 3:45 p.m. Regarding Resident #30's heel wounds, she stated staff were just wrapping it and keeping it dry. Staff D, RN/UM stated she does not recall telling anyone to do daily care besides keeping it wrapped. She stated the doctor should have been notified, but she doesn't know if he was. She reviewed the resident's wound notes and confirmed wound care was completed on 1/31/23 and 2/7/23 and there were no orders in place. Staff D, RN/UM stated she forgot to put in the alginate order for 2/7/23. She said she didn't know why the order wasn't put in for the 1/31/23 treatment. 3. A review of the admission Record indicated Resident #7 was admitted to the facility on [DATE]. Residents #7's current diagnoses include cerebral palsy, paraplegia, mild protein calorie malnutrition, pressure ulcer left heal stage 3 and pressure ulcer left buttock unstageable. Both of these pressure wounds were acquired during her stay in the facility. A review of the wound care notes on 2/9/23 indicated the last wound care note in the medical record was on 1/24/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 12 of 21 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 02/10/2023 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 A review of the physician orders revealed the following: Level of Harm - Minimal harm or potential for actual harm 1-Cleanse coccyx wound with normal saline, pat dry, apply skin prep to peri wound. Apply Santyl to wound base and cover with dry dressing daily and PRN. Dated 9/6/22. Residents Affected - Some 2-Cleanse right buttock wound with normal saline, pat dry, and apply skin prep to peri wound. Apply wound gel to base and cover with dry dressing daily and PRN. Dated 11.8.22. 3-Left lateral foot wound #2. Cleanse with normal saline, pat dry and apply Santyl to base then cover with a dry dressing daily and PRN. Dated 10/18/22. 4-Left lateral foot wound. Cleanse wound with normal saline, pat dry and apply skin prep to base then cover with a dry dressing daily and PRN. Dated 11/2/22. A review of the January and February 2023 electronic Treatment Administration Records (eTAR) revealed the following: From February 1st through the 9th order numbers 1, 2, 3, and 4 were completed 8 out of 9 times. From January 1st through the 31st order numbers 1,2,3, and 4 were completed 30 out of 31 times. A review of care plans revealed a care plan for: Actual Wound: [Resident #7] has an actual wound to, and right buttocks, UST left great toe, left lateral foot. The care plan was updated on 2/6/23. Interventions included: -Treatment as ordered. -Monitor wound weekly of location, highest stage and/or visual state. Measure length, width, depth, color of drainage, color of wound bed, presence of odor, tunneling or undermining. Review for improvements, report declines to MD. A review of Resident #7's Skin Grid for Pressure Ulcers was conducted with the following findings: Left lateral foot #1 On 11/8/22 the left lateral foot wound #1 was noted to have an odor, with no odor the previous weeks noted. On 1/17/22 the wound was 0.7 cm in length and 1.0 cm in length. On 1/24 the wound was 2.0 cm in length and 2.5 cm in length. On 1/31/23 the wound was 2.9 cm in length and 2.5 cm in width. On 2/7/23 the wound was 3.0 cm in length and 2.5 cm in width. Coccyx Wound On 1/31/23 the wound was 4.0 cm in length and 0.7 cm in width. On 2/7/23 the wound was 4.5 cm in length and 0.7 cm in width. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 13 of 21 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 02/10/2023 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 Right Hip Wound Level of Harm - Minimal harm or potential for actual harm Wound care and measurements were completed on 1/31 and 2/7/23. A review of physician orders and progress notes revealed the following: Residents Affected - Some A note on 11/8/22 indicated the wound had no signs of infection. The odor was not mentioned in the note. A note on 1/24/23 indicated a new right hip abrasion with pink tissue, no drainage, coccyx wound base with red tissue, small amount of pink drainage, increased in wound sizes, left later food wound base #1 with granulated tissue, small amount of pink drainage, increased in sizes, no signs of infection. MD was notified. There were no further progress notes to indicate the MD had been notified of the continued increase in wound sizes after 1/24/23. There was no wound care order in place for the hip wound that was treated on 1/31 and 2/7/23. An interview was conducted with the DON on 2/10/23 at 4:48 p.m. The DON reviewed Resident #7's medical record and confirmed there are no more recent wound care notes than 1/24/23. She stated there should be notes in the record and the doctor should have been notified of the increased wound sizes. As for the odor noted on the Skin Grid for Pressure Ulcers on 11/8/22, she stated the progress note should have mentioned the odor and she wasn't sure why it didn't. She did say they round for wound care as a group and one person does the Skin Grid and another does the progress notes. A facility policy titled, Wound Prevention and Treatment Overview, dated October 2021, was reviewed. The policy stated the following: The facility also recognizes that the most vigilant nursing care may not prevent the development &/or worsening of ulcers in high-risk categories. In those cases, efforts will be directed at the following: -Managing risk factors. -Providing therapeutic interventions. -Providing treatment. A resident with ulcers will receive continued preventive interventions & necessary treatment and services to promote healing & prevent infection. Wound characteristics will be documented by measuring length, width & depth in centimeters. Additional documentation shall also include: -Color of drainage. -Wound bed color. -Odor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 14 of 21 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 02/10/2023 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 -Amount of drainage. Level of Harm - Minimal harm or potential for actual harm -Wound bed tissue type -Tunneling/undermining with depth if applicable. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 15 of 21 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 02/10/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on observation, interview, and medical record review, the facility failed to ensure medications were administered without irregularities and followed as ordered for one resident (#1) out of five residents sampled as evidenced by failing to follow blood pressure parameters. Findings included: On 02/07/2023 at 10:00 a.m. Resident #1 was observed lying in bed and receptive to an interview, his speech was difficult at time to understand and he appeared thin and frail. Review of the admission Record indicated Resident #1 resided at the facility for twenty years. The diagnoses included atherosclerotic heart disease of native coronary without angina pectoris, hypertension, chronic kidney disease stage 3, and hypotension. Review of the February 2023 physician orders revealed an order for: Midodrine HCL oral tablet give 10 mg (milligrams) by mouth three times a day related to HYPOTENSION, UNSPECIFIED, give if BP (blood pressure) is Less than 90/60, dated 09/15/2022. Review of the January 2023 Medication Administration Record (MAR) showed the Midodrine HCL administrations as: 01/01/2023 at 6:00 a.m. (0600) Blood Pressure (BP) documented at 98/60, at 1:00 p.m. (1300) BP 128/74, and at 5:00 p.m. (1700) BP at 131/88. The documented BP reflected the blood pressure was greater than 90/60 and Midodrine HCL should have been held per the physician ordered parameters. Further review of the January 2023 MAR revealed Midodrine was administered as follows: -01/02/2023 at 1:00 p.m. BP 110/62, and at 5:00 p.m. BP 110/62, -01/03/2023 at 6:00 a.m. BP 104/64, and at 1:00 p.m. BP 110/62, -01/04/2023 at 1:00 p.m. BP 110/68, -01/05/2023 at 6:00 a.m. BP 90/70, and at 1:00 p.m. BP 128/60, -01/06/2023 the 6:00 a.m. dosage and BP was omitted and administered at 1:00 p.m. BP 128/60, -01/07/2023 at 5:00 p.m. BP 98/60, -01/08/2023 at 1:00 p.m. BP 112/68, -01/09/2023 the 6:00 a.m. dosage and BP was omitted and administered at 1:00 p.m. BP 100/60, and at 5:00 p.m. BP 100/60, -01/10/2023 at 1:00 p.m. BP 100/60. -01/11/2023 the 6:00 a.m. dosage was held for BP 90/58 - parameters indicated it should have been given, at 1:00 p.m. it was administered at 1:00 p.m. BP 100/60, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 16 of 21 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 02/10/2023 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 0756 -01/13/2023 at 1:00 p.m. BP 98/68, Level of Harm - Minimal harm or potential for actual harm -01/15/2023 at 1:00 p.m. BP 131/78 and at 5:00 p.m. BP 131/78, -01/17/2023 at 1:00 p.m. BP 95/68, Residents Affected - Some -01/18/2023 at 1:00 p.m. BP 95/67, -01/21/2023 at 1:00 p.m. BP 136/78 and at 5:00 p.m. BP 108/60, -01/23/2023 at 5:00 p.m. BP 107/76, -01/24/2023 at 1:00 p.m. BP 98/66, and -01/26/2023 at 1:00 p.m. BP 90/68. Review of the February 2023 MAR revealed Midodrine was administered as follows: -02/02/2023 at 1:00 p.m. BP 96/62, -02/03/2023 at 1:00 p.m. BP 100/78 and given at 5:00 p.m. BP 110/62, -02/07/2023 revealed Midodrine was held at 1:00 p.m. for BP 73/42 and held at 5:00 p.m. for BP 99/54. The forty-day look back reflected Midodrine was administered 30 times when the BP parameters indicated it was, to be held, 2 omissions of the medications without BP being performed, and Midodrine was held three times when it should have been administered. On 02/09/2023 at 4:07 p.m. an interview was conducted with the Director of Nursing (DON) she confirmed it was her expectation a blood pressure medication that has ordered parameters should be followed as ordered. On 02/10/2023 at 12:44 p.m. a phone interview was conducted with Resident #1's physician who confirmed he knew the resident and had been his physician for a while. He was unaware the ordered Midodrine was not being given as ordered. When informed the parameters were not being followed he stated, They're doing the opposite of what the order states to do. The Physician confirmed it was his expectation that his orders are followed as written and would be following up with the facility. Review of the Medication Record Review (MRR) for recommendations created between 11/1/2022 and 11/14/2022 for Resident #1 read, The resident is receiving Midodrine 10 mg three times a day (tid) hold if systolic blood pressures (SBP) less than 90/60 millimeters of mercury (mm Hg). Please consider discontinuing/decreasing the order for midodrine or change to as needed (prn) status. Nursing will monitor for any recurring symptoms. The facility provided a second MMR for Resident #1 dated 1/11/2023 that documented, This resident is receiving Midodrine 10 mg tid hold if systolic blood pressures (SBP) less than 90/60 millimeters of mercury (mm Hg). Please consider discontinuing/decreasing the order for midodrine or change to prn status. Nursing will monitor for any recurring symptoms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 17 of 21 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 02/10/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 02/10/2023 at 3:44 p.m. a phone interview was conducted with the Pharmacist who confirmed she provides monthly record review services at the facility. She said part of her process was to review the physician orders and make recommendations. When asked about Resident #1's blood pressure medication Midodrine and the parameters she stated, Sometimes certain places don't do parameters. She confirmed she reviews the medication administration record and stated, If I identify a discrepancy, I will address it in the letter. The Pharmacist said she had addressed the Midodrine two separate times to change it or discontinue it. She stated she can recommend a change in the medication, but the Physician will not always follow the recommendation. She stated, I wanted them to change the (Midodrine) order to PRN (as needed). The Pharmacist denied she had documented in her recommendation that the medication was being administered outside of the ordered parameters. The Pharmacist stated, I was aware it was a concern and to adjust the order. The Pharmacist then stated, I don't know when the blood pressure it taken. If it is taken before the medication or not. She indicated that was why she had not notified the DON of the discrepancies. On 02/10/2023 at 4:07 p.m. an interview was conducted with Staff E, Registered Nurse (RN) and she confirmed she provides Resident #1 his blood pressure medication. She stated she always takes the BP herself and does this right before giving the medication. Review of the agreement titled, PHARMACY SERVICES AGREEMENT SCHEDULE 2 Consulting Services and Charges, revealed: 1. Consulting Services: Pharmacy shall provide the consulting services set forth below (the Consulting Services). Where so indicated, a qualitied licensed pharmacist (the Consultant Pharmacist) shall perform such services. 2. Standard Services: (a) On a monthly basis, during the previously scheduled visit to the Customer, a Consultant Pharmacist shall perform a medication regiment review (MRR) for each Resident on active Customer census on the visit date. (b) within 48 hours after conducting the MRR, the Pharmacist or Consultant Pharmacist shall provide the MRR report to Client's Administrator/Executive Director and the Director of Nursing. When irregularities are noted, the MRR report documenting such irregularities will be provided to the Client's Administrator/Executive Director and the Director of Nursing. Review of the policy titled, Medication Monitoring Medication Regimen Review and Reporting, dated 2007, showed under 8.1 MEDICATION REGIMEN REVIEW AND REPORTING the policy as, Medication Regimen Review (MMR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing the adverse consequences and potential risks associates with medication. The MRR includes review of the medication record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the IDT [interdisciplinary team], including the resident, their family, and /or resident representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 18 of 21 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 02/10/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to maintain kitchen equipment in a clean manner by not ensuring three drip trips were free from grease for one of one stove in one of one kitchen. Findings included: On 02/02/2023 at 9:00 a.m. an initial tour of the kitchen was conducted with the Dietary Manager and revealed three unclean drip trays on top of the stove. The three drip trays were observed with grease piled up on the foil liner. On 02/02/2023 at 9:10 a.m., an interview was conducted with the Dietary Manager. The Dietary Manager said the kitchen staff should have checked and changed the drip tray liners at the end of their shift. The Dietary Manager said the drip trays should be deep cleaned weekly and the drip tray foil should be changed out every evening. Review of the facility policy and procedure titled, Cleaning and Sanitation, dated September 2021, showed the facility promotes a clean and sanitary environment for its employees, residents and visitors. The entire Food and equipment, walls. floors, ceilings, equipment, and utensils are clean, sanitized and in good working order. Local, State and Federal regulations are followed to assure a safe and sanitary Nutrition Services Department. 1. Food Service Manager will review the completed Food and Nutrition Services Cleaning Schedule to ensure the kitchen equipment is in operation 3. Inspect kitchen sanitation Daily, Weekly and Monthly using the Kitchen Sanitation Checklist. 7. Follow appropriate procedures for washing and sanitizing kitchen equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 19 of 21 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 02/10/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review the facility failed to collaborate with the hospice agency related to current plans of care for one resident (#8) out of one resident sampled with hospice services. Findings included: An interview was conducted with Resident #8 on 2/7/23 at 11:07 a.m. The resident stated she was on hospice. She stated an aide and nurse come to see her, but she didn't know how often. A review of admission Record indicated Resident #8 was admitted on [DATE] with a re-admission date of 11/3/22. Her diagnoses included malignant neoplasm of overlapping sites of unspecified bronchus and lung and hemiplegia and hemiparesis following cerebral infarction. A review of the active physician orders as of 2/9/23 revealed an order for hospice services for a diagnosis of lung cancer, dated 2/16/22. Resident #8's facility care plan, initiated on 2/16/22 and revised on 2/06/23, showed the following: Terminal Diagnosis. [Resident #8] is diagnosed with a terminal condition and is at risk for loss of dignity during dying process related to the terminal diagnosis of: Lung Cancer. Supportive care only. [Hospice Agency and Team Identifier]. The Interventions included to: Collaborate with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met and collaborate with the Interdisciplinary team to develop a plan of care that promotes the resident's spiritual, emotional, intellectual, physical and social needs. A review of Resident #8's Minimum Data Set (MDS), completed 11/8/22, Section O Special Treatments, Procedures and Programs section, indicated the resident was not receiving hospice care. A review of Resident #8's hard copy medical records revealed a Hospice Face Sheet, but no hospice care plan or current visit notes. An interview was conducted with Staff E, Registered Nurse (RN) on 2/8/23 at 3:20 p.m. Staff E stated hospice notes are kept in the hard chart, there is no separate hospice book. She stated hospice usually comes earlier in the day and she works a later shift. An interview was conducted with the Regional Nurse Consultant on 2/8/23 at 3:40 p.m. She reviewed Resident #8's hard chart. She stated there were notes from October and November, but nothing from December to current. When asked about a hospice care plan she stated the facility care plan had a hospice care plan, but there was not a separate care plan from hospice services. An interview was conducted with the Director of Nursing (DON) on 2/8/23 at 4:26 p.m. She stated she does not coordinate with outside services and stated maybe social services or the MDS Coordinator does. On 2/8/23 at 4:28 p.m. the Social Services Director stated she does not have anything to do with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 20 of 21 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 02/10/2023 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 0849 coordinating with hospice and stated maybe the MDS Coordinator does. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Staff G, RN/MDS Coordinator on 2/8/23 at 4:49 p.m. She stated the only documentation she could find about hospice being invited to a care plan meeting was from February and April of 2022. She stated, Oh wow, when she could not find anything further. She stated she has only been in the position a couple of months. Residents Affected - Few An interview was conducted with the Nursing Home Administrator (NHA) on 2/9/23 at 9:17 a.m. The NHA stated she spoke with the hospice team and they said the resident is not on full hospice. She stated she will need to speak with the person that comes to the facility to see why they are not leaving any notes. She confirmed the notes should be in the facility. An interview was conducted with Staff C, RN on 2/9/23 at 11:20 a.m. Staff C, RN stated the hospice nurse and aide do come to see Resident #8. She stated, I wouldn't say there is coordination of care but they ask us if we need anything. Staff C, RN stated she has never seen a hospice care plan or hospice notes for Resident #8. An interview was conducted with the DON on 2/10/23 at 4:54 p.m. The DON stated she didn't know why hospice notes were not being left at the facility and she confirmed there is no hospice care plan. She stated, To be honest, I have never seen them here. She said she is newer in the facility, but going forward there will be someone to coordinate with hospice. She stated she didn't know hospice wasn't really coordinating with nurses. A facility policy titled, Hospice, dated October 2021, was reviewed. The policy stated the following: Upon request by a patient or physician, the facility will coordinate care services for a licensed Hospice Agency of the patient's choice. Guidelines 2. Communicate, establish, and agree upon a coordinated Interdisciplinary Plan of Care. a. Assure the Plan of Care reflects the hospice philosophy. 4. Assure a registered nurse from hospice is designated to coordinate the implementation of the Plan of Care between the Hospice Agency and the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 21 of 21