Inspection·April 25, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 the day she fell and went to the hospital on 3/23/25. He confirmed he communicated with the Director of Nursing (DON) immediately about the change in condition and also notified the physician who gave orders to discharge the resident to the hospital. On 4/24/25 at 2:29 p.m., a phone interview was conducted with Resident #1's family member, who is her emergency contact (EC). She stated, I was made aware of the fall later. She said Resident #1 called her to tell her she was in the hospital, but the facility did not call her. She said Resident #1 called her on 3/24/25, while she was in the hospital, and told her she had fallen. The EC said the facility normally called her when there was an issue, but this time they did not. She stated, I'm supposed to be her first call when she goes to the hospital or if she has an emergency. She said when she initially talked to Resident #1, she didn't specify which hospital because, She was out of it. The EC stated, I had to call around and find out which hospital. The EC said she called another resident at the facility to find out where Resident #1 was. She confirmed she called the facility and was told Resident #1 was at [Hospital name], but she wasn't there. She found out Resident #1 was at another hospital. On 4/25/25 at 11:39 a.m., an interview was conducted with the Director of Nursing (DON). She said staff are supposed to call the family when there is a change in condition and complete a risk event note, where they are supposed to call the family, and doctor, and document. The DON said risk events are reviewed the next morning at the clinical meeting. They review the event note to see if the family was notified. She stated, They should be documenting in the medical record about that notification. A review of Resident #1's risk event note was conducted with the DON on her computer. She said usually under action is where staff is supposed to document the family notification. She confirmed she did not see notification to the family when Resident #1 went to the hospital. A review of the facility's policy titled Notification of Resident/Patient Change in Condition, effective October 2021, revealed the following under Policy: Nurses will notify the resident/resident representative, if there is a crucial/significant change in the resident condition. The policy revealed under 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 person(s) to whom you spoke. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 2 of 18 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 04/25/2025 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 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#1) of three sampled residents, was provided transfer assistance in accordance with the resident's ability, care plan, facility policy, and/or the mechanical lifts manufacturer's recommendation, resulting in harm to Resident #1. Findings included: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. The electronic medical record included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, subsequent encounter for closed fracture with routine healing (created 3/1/23), and displaced transverse fracture of shaft of left femur subsequent encounter for closed fracture with routine healing (created 3/28/25). Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview of Mental Status (BIMS) score was 15/15, indicating an intact cognition. The resident had Range of Motion (ROM) impairment on one upper extremity and bilateral lower extremities. The resident utilized a wheelchair for mobility, requiring substantial/maximum assistance for bed mobility, and was dependent upon staff for sitting to lying, lying to sitting, and for bed-to-chair transferring. The resident did not ambulate and the sit-to-stand ability was not applicable. The comprehensive assessment revealed the resident had frequent pain requiring scheduled and as needed pain medication. The resident was shown to have had a fall in the last month prior to admission/entry or reentry, no falls in the last 2-6 months, and had a fracture related to a fall in the 6 months prior to admission/entry or reentry. Review of Resident #1's care plan showed the resident had an Activities of Daily Living self-care performance deficit due to a cerebrovascular accident (CVA), weakness, unsteady gait, impaired mobility, decreased strength, recent fracture, and reduced mobility. The included interventions showed the resident was a total mechanical lift to chair of 2 assist with a large sling size (revised on 3/27/25). The history of the original care plan, created 6/7/23, showed the resident was a mechanical lift to chair of 2 without specifying a sling size, on 6/3/24 the resident was a mechanical lift to chair with 2 assist, revised on 2/12/25 to dependent, without mention of type of transfer to be utilized. Review of the facility Incident Log revealed Resident #1 had a fall incident on 3/23/25. A Change in Condition Evaluation, effective 3/23/25 at 7:40 p.m., revealed the resident had a fall and complained of left leg pain. The pain was chronic, intermittent, and needed either an x-ray or ultrasound for evaluation. The physician recommended the resident be sent to hospital for further evaluation and treatment. Review of the Situation, Background, Appearance, and Review and Notify, dated 3/23/25, revealed Resident #1 had a fall with worsening of chronic pain in the front left thigh and front left knee and rated the intensity of pain 7 of 10. The summary of staff observation and evaluation revealed the resident was complaining of left leg pain, pain condition was chronic, it was intermittent, and a need for x-ray or ultrasound for evaluation. The primary care clinician recommended at 7:30 p.m. to send patient to hospital for further evaluation and treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 3 of 18 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 04/25/2025 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 0600 Level of Harm - Actual harm Review of a Progress Note, effective 3/23/25 at 8:18 p.m., revealed Resident #1 complained of left leg pain after sliding from the chair to the floor. The nurse did not find any neurological abnormalities other than pain and after 30 minutes the resident continued to have a 9 out of 10 rating of pain and around 8:15 p.m. the resident was sent to hospital for evaluation. Residents Affected - Few Review of the acute care facility's physician attestation signed on 3/24/25 at 5:51 a.m., date of service on 3/23/25 at 10:23 p.m., revealed a trauma consultation for Resident #1 with a significant past medical history of hypertension, cerebrovascular accident (CVA) with left-sided deficits who presented with left-sided leg pain after falling off of her lift and onto her knees. The note revealed the resident did not walk at baseline and was unable to inform the physician on how long it had been since last walked. The workup in the Emergency Department (ED) included x-rays of the left ankle, femur, knee, and tibia/fibula with hip and pelvis x-rays. The results showed an acute fracture of the mid to distal femoral shaft with intra-articular extension to the knee joint with a large knee effusion. The resident was stable enough to be admitted to the trauma surgery floor and placed in 15-pound traction to the left lower extremity. The trauma consults History & Physical, dated 3/23/25 at 10:23 p.m. showed the resident presented status post (s/p) fall from mechanical lift, complaining of left leg pain with obvious deformity. The patient reported having not walked in several years since having a stroke. Review of an acute care facility's Orthopedic Surgery Daily Progress Note dated 3/25/25 at 8:28 a.m. revealed Resident #1 was seen and examined at bedside. The note showed the orthopedic injury was a left closed femoral shaft fracture with a left femur retrograde intramedullary nailing on 3/24/25. The assessment showed the surgical dressing was to stay on operative sites until postoperative day 7 and the resident was essentially bedbound at baseline, was non-ambulatory, and utilized a mechanical lift for transfers at baseline Review of the acute care facility's Geriatric consult on 3/26/25 at 9:10 a.m. noted the resident was seen status post (s/p) fall from mechanical lift when getting out of wheelchair with left femur fracture and extension into the knee joint and possible posterior left calcaneous fracture. Review of Resident #1s Psychiatric Periodic Evaluation note dated 4/2/25 showed Social Services reported the resident recently had a fall which resulted in a hospitalization. The resident was found lying in bed watching television and when asked about the recent fall the resident informed the provider of being dropped from the mechanical lift while she was being transferred from her bed to her wheelchair. She reported that she broke her left femur and had to have surgery. The resident reported having a lot of pain since the fall and believed current pain medication was effective. The resident voiced frustration about her recent fall and broken femur but said she was happy to know the aide who dropped her was fired, voiced confidence with other staff, and denied anxiety or fear of having to use mechanical lift. An interview was conducted with Resident #1 on 4/23/25 at 10:40 a.m. The resident voiced her leg was hurting and began rubbing top of her left leg. The resident reported recently having surgery on left leg due to the girl decided to pivot her from the bed to wheelchair, then dropped her. The resident reported staff did not use the mechanical lift. The resident reported having rod in her leg. Resident #1 stated, I swear she didn't [use the mechanical lift]. If she had, I wouldn't be sitting in pain. The resident reported the CNA always used the mechanical lift with two people prior to the event. The resident stated the CNA picked her up to put her in the chair and dropped her. The resident stated to the staff, oh my leg, oh my leg, and informed the staff member of having to go to the hospital, before the nurse and CNA picked her up floor. After the staff members left, the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 4 of 18 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 04/25/2025 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 0600 reported propelling herself to the nursing station and informed the nurse of needing to go to the hospital. Level of Harm - Actual harm A telephone interview was conducted on 4/23/25 at 1:39 p.m. with the facility's Risk Manager Consultant (RMC). The RMC reported at the time of Resident #1s fall with resulting injury on 3/23/25, the previous Director of Nursing, Staff C, Registered Nurse (RN) was the Risk Manager. The RMC reported receiving a call on Tuesday 3/25/25 notifying her of a fall with fracture occurring over the weekend. Staff C, RN was asked where the investigation was and shared with RMC the statements gathered included the resident was transferred to her wheelchair and fell out of the chair after the Staff B, CNA was making the resident's bed. The RMC stated out of precaution, Staff C, RN was informed to do more additional investigation. The RMC stated Staff B, CNA completed a reenactment with Staff C, RN how the resident was transferred and exactly when the resident fell. Staff B, CNA confirmed during the reenactment of transferring the resident by herself. Staff B, CNA said after the resident transfer, Resident #1 slipped out of the chair and fell. The CNA was suspended for not following facility protocol for a 2-person mechanical lift transfer. The RMC directed someone from the facility to speak with the resident. The admission Director spoke to Resident #1 and reported the resident confirmed Staff B, CNA did everything right and the resident slipped from chair, not the lift. The facility received Resident #1's hospital records, which revealed the resident fell from the mechanical lift, at which time an immediate reporting was initiated. The resident informed the RMC, during a hospital interview she was almost to the chair and had fallen from the lift sling and confirmed Staff B, CNA, was the only aide present. The nurse, Staff A, RN, was interviewed and confirmed the lift was in the room, but did not see the transfer. Residents Affected - Few An interview was conducted on 4/23/25 at 2:44 p.m. with Staff A, RN. The staff member confirmed being the nurse assigned to Resident #1 on the evening of 3/23/25 and was at the nursing station. Staff A, RN reported Staff B, CNA tried to pull the resident up with the mechanical lift. The CNA informed Staff A, RN of the fall and Staff A, RN observed the resident on the floor next to the bed and the mechanical lift was present. Resident #1 told Staff A, RN, It's not her fault and she slid and fell. Staff A, RN confirmed the resident, after returning from hospital, lied and was trying to protect Staff B, CNA. Staff A, RN stated he heard the mechanical lift may have messed up and the resident fell from the lift. The staff member re-enacted the positioning of the resident and confirmed the resident was sitting on crossed ankles, however, when describing the position, he said the right leg was bent in front of the resident and the left leg was bent back. Staff A, RN, said when the resident was on the floor, he and Staff B, CNA lifted the resident up off floor without the use of a mechanical lift. Staff B, CNA informed Staff A, RN the resident slid from the wheelchair and he informed the primary doctor and Director of Nursing (DON) of the fall, telling the DON the resident said she slid from the wheelchair and did not want to blame the CNA. Staff A, RN confirmed Staff B, CNA did not ask for assistance with the mechanical lift prior to the incident. An interview was conducted on 4/23/25 at 4:24 p.m. with the Nursing Home Administrator (NHA) and the Regional Nurse Consultant (RNC). The NHA reported not being at the facility for Resident #1's fall with injury. The NHA stated Staff B, CNA was supposed to have another person to assist with the transfer of Resident #1 but did the transfer by herself. The resident fell, the resident heard a pop, the nurse assessed the resident, and the resident went to the hospital. The incident happened on 3/23/25 at 7:00 p.m. and on 3/24/25 the facility was notified the resident suffered a fracture, however, the resident expressed falling out of the wheelchair. On 3/26/25, through the facility Quality Assurance Assessment and Compliance review of the fall to include review of hospital records, it was determined Resident #1 fell from the mechanical lift onto her knees. The NHA stated the resident said something different in the hospital when interviewed by staff. On 3/25/25, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 5 of 18 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 04/25/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few return demonstration of the incident was completed by Staff B, CNA for Staff C, RN, who was the previous Director of Nursing (DON). The re-enactment showed Staff B, CNA did not transfer the resident with a second person. The review of the facility's investigation revealed the following staff member statements: - 3/27/25 unknown time: Resident #1 reported I was going from chair to bed, I was almost in bed, when I slipped out of [mechanical lift] sling She said the CNA thought she was playing as they goof around. Nurse came in and helped pick her up. Per the statement, she picked me up then nurse came and picked me up. The statement was written by the Risk Management Consultant (RMC) - 3/23/25: Staff B, CNA wrote two statements, reporting the staff member was putting Resident #1 in chair with mechanical lift and the resident did not have footrests, so they slowly slid out of the wheelchair. - 3/23/25: Staff A, RN reported Staff B, CNA called out to him and witnessed Resident #1 next to her wheelchair. Resident #1 described to him that while the CNA was transferring, the resident slipped from the chair. Staff A, RN assessed the resident's pain, her injury, and received orders to send the resident to the hospital. - 3/26/25: A second interview of Staff A, RN conducted by RMC. The staff member confirmed the mechanical lift was in the resident's room on 3/23/25. Staff A, RN informed the RMC Resident #1 reported slipping from the wheelchair and it was not the CNA's fault. No one else was in the room, the mechanical lift was next to the bed, the wheelchair was next to bed, and the bed was in the lowest position. Staff B, CNA reported transferring the resident to the wheelchair and the resident slid out of the chair. The staff member reported he and Staff B, CNA put the resident in bed, put pain cream on her leg, and the resident stated she thought something popped. Staff A, RN and Staff B, CNA physically lifted the resident to bed after the assessment. The staff member reported the resident was wearing long silky pants and t-shirt and the resident resisted pulling up her pant leg because it hurt. During an interview on 4/23/25 at 12:10 p.m., the DON stated she was told Resident #1 slid out of the mechanical lift and both the resident and CNA informed the facility investigator of being transferred with one-person. During an interview on 4/23/25 at 12:19 p.m., Staff E, Registered Nurse/Unit Manager (RN/UM) reported not being at the facility on 3/23/25 but returned on 3/24/25. She stated based on many different stories, the CNA transferred Resident #1 and the resident ended up getting injured. The staff member reported the resident required a mechanical lift prior to the incident. Staff E, RN/UM stated everybody gets education regarding transferring during orientation and the CNA documentation system, which every CNA has access to, allowed staff to know how to transfer a resident. During an interview on 4/23/25 at 5:02 p.m., the Nursing Home Administrator (NHA) stated Staff A, RN and Staff B, CNA should have used a mechanical lift to get Resident #1 off the floor following the resident's fall. During an interview on 4/23/25 at 5:13 p.m., the Registered Nurse Consultant (RNC) confirmed Staff B, CNA was suspended on 3/25/25 after it was identified there was not a second person assisting with the transfer of Resident #1. An interview was conducted on 4/24/25 at 9:44 a.m. with Staff G, Physical Therapist (PT). The staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 6 of 18 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 04/25/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few member stated Resident #1 was receiving both physical and occupational therapy. The resident used to be able to transfer years ago but declined due to motivation and wanting to use the mechanical lift. Staff G, PT reported Resident #1has been totally dependent on transfers for over a year and had a stroke on the left side and developed a contracture in the leg. Staff G, PT stated since Resident #1's injury from her fall, She's in so much pain, she can't stretch [her leg] like she used to. The resident was scheduled for 8 weeks of therapy but, most likely will extend care because of more that needs to be done. Review of the facility policy titled Abuse Prevention Program, last changed November 2024, revealed under Policy, the facility has designated implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, expectation, and misappropriation of residence property through education of staff and residents, as well as earlier identification of staff burnout, or resident behavior which may increase the likelihood of such events. The policy defined neglect as Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the policy titled Safe Operation of Resident Lifts Policy and Procedure, effective March 2022, revealed Facility is a low-lift environment. Use of Mechanical Lifts occur per the resident's care plan and otherwise indicated. . 1. Operation of mechanical lift: a. Refer to manufacturer lift manual. . 3. Training on use of mechanical lift a. Staff will be trained at orientation and annually with the competency and skills check off on the proper use of mechanical lifts. Review of the manufacturer manual for the mechanical lift revealed BEFORE using this product, this manual MUST be read and saved for future reference. The procedures in this manual MUST be performed by a qualified technician. The manual showed: . 7. Patient Lifting: - 7.1 Preparing the Lift for Use. -- Although [Brand Name] recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the healthcare professional for each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 7 of 18 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 04/25/2025 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 0600 individual case. Level of Harm - Actual harm Review of the policy titled Fall and Injury Reduction Policy, effective March 2023, revealed under Policy, the facility has designated and implemented processes, which drive to reduce the risk for falls and injuries. This policy guides the identification, implementation of appropriate interventions and management. It is expected that this policy will assist the facility with reducing the likelihood of a fall or injury while maintaining or maximizing dignity and independence through education of staff and residents, early identification of risk factors by collecting data, identifying resident behavior which may increase the likelihood of such an occurrence. Residents Affected - Few The policy revealed the following Guidelines: . Status Post witnessed/unwitnessed Fall or observed on floor event. 1. Nurse will evaluate the resident for signs/ symptoms of injury. 2. Do not move the resident from the floor until a nurse has evaluated. 3. If no signs/ symptoms of injury assist resident from floor using a Mechanical lift unless resident is can actively assist in getting off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 8 of 18 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 04/25/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to provide nursing staff with the competencies and skills to provide appropriate nursing services to one resident (#1) of three sampled residents related to 1.) not providing a safe mechanical lift transfer which resulted in a severe bodily injury, 2.) not accurately documenting the administrations of controlled medications, and 3.) failed to notify the emergency contact of the resident requiring a transfer to an acute care facility following a fall. Findings included: 1. Review of the facility's reportable log showed an event involving Resident #1 occurred on 3/23/25. The event resulted in Fracture/Dislocation/transfer outside. Review of the Situation, Background, Appearance, and Review and Notify, dated 3/23/25, revealed Resident #1 had a fall with worsening of chronic pain in the front left thigh and front left knee and rated the intensity of pain 7 of 10. The summary of staff observation and evaluation revealed the resident was complaining of left leg pain, pain condition was chronic, it was intermittent, and a need for x-ray or ultrasound for evaluation. The primary care clinician recommended at 7:30 p.m. to send patient to hospital for further evaluation and treatment. Review of a Progress Note, effective 3/23/25 at 8:18 p.m., revealed Resident #1 complained of left leg pain after sliding from the chair to the floor. The nurse did not find any neurological abnormalities other than pain and after 30 minutes the resident continued to have a 9 out of 10 rating of pain and around 8:15 p.m. the resident was sent to hospital for evaluation. Review of the acute care facility's physician attestation signed on 3/24/25 at 5:51 a.m., date of service on 3/23/25 at 10:23 p.m., revealed a trauma consultation for Resident #1 with a significant past medical history of hypertension, cerebrovascular accident (CVA) with left-sided deficits who presented with left-sided leg pain after falling off of her lift and onto her knees. The note revealed the resident did not walk at baseline and was unable to inform the physician on how long it had been since last walked. The workup in the Emergency Department (ED) included x-rays of the left ankle, femur, knee, and tibia/fibula with hip and pelvis x-rays. The results showed an acute fracture of the mid to distal femoral shaft with intra-articular extension to the knee joint with a large knee effusion. The resident was stable enough to be admitted to the trauma surgery floor and placed in 15-pound traction to the left lower extremity. The trauma consults History & Physical, dated 3/23/25 at 10:23 p.m. showed the resident presented status post (s/p) fall from mechanical lift, complaining of left leg pain with obvious deformity. The patient reported having not walked in several years since having a stroke. Review of an acute care facility's Orthopedic Surgery Daily Progress Note dated 3/25/25 at 8:28 a.m. revealed Resident #1 was seen and examined at bedside. The note showed the orthopedic injury was a left closed femoral shaft fracture with a left femur retrograde intramedullary nailing on 3/24/25. The assessment showed the surgical dressing was to stay on operative sites until postoperative day 7 and the resident was essentially bedbound at baseline, was non-ambulatory, and utilized a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 9 of 18 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 04/25/2025 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 0726 mechanical lift for transfers at baseline. Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. The electronic medical record included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, subsequent encounter for closed fracture with routine healing (created 3/1/23), and displaced transverse fracture of shaft of left femur subsequent encounter for closed fracture with routine healing (created 3/28/25). Residents Affected - Some Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview of Mental Status (BIMS) score was 15/15, indicating an intact cognition. The resident had Range of Motion (ROM) impairment on one upper extremity and bilateral lower extremities. The resident utilized a wheelchair for mobility, requiring substantial/maximum assistance for bed mobility, and was dependent upon staff for sitting to lying, lying to sitting, and for bed-to-chair transferring. The resident did not ambulate and the sit-to-stand ability was not applicable. The comprehensive assessment revealed the resident had frequent pain requiring scheduled and as needed pain medication. The resident was shown to have had a fall in the last month prior to admission/entry or reentry, no falls in the last 2-6 months, and had a fracture related to a fall in the 6 months prior to admission/entry or reentry. Review of Resident #1's care plan showed the resident had an Activities of Daily Living self-care performance deficit due to a cerebrovascular accident (CVA), weakness, unsteady gait, impaired mobility, decreased strength, recent fracture, and reduced mobility. The included interventions showed the resident was a total mechanical lift to chair of 2 assist with a large sling size (revised on 3/27/25). The history of the original care plan, created 6/7/23, showed the resident was a mechanical lift to chair of 2 without specifying a sling size, on 6/3/24 the resident was a mechanical lift to chair with 2 assist, revised on 2/12/25 to dependent, without mention of type of transfer to be utilized. An interview was conducted with Resident #1 on 4/23/25 at 10:40 a.m. The resident voiced her leg was hurting and began rubbing top of her left leg. The resident reported recently having surgery on left leg due to the girl decided to pivot her from the bed to wheelchair, then dropped her. The resident reported staff did not use the mechanical lift. The resident reported having rod in her leg. Resident #1 stated, I swear she didn't [use the mechanical lift]. If she had, I wouldn't be sitting in pain. The resident reported the CNA always used the mechanical lift with two people prior to the event. The resident stated the CNA picked her up to put her in the chair and dropped her. The resident stated to the staff, oh my leg, oh my leg, and informed the staff member of having to go to the hospital, before the nurse and CNA picked her up floor. After the staff members left, the resident reported propelling herself to the nursing station and informed the nurse of needing to go to the hospital. A telephone interview was conducted on 4/23/25 at 1:39 p.m. with the facility's Risk Manager Consultant (RMC). The RMC reported at the time of Resident #1s fall with resulting injury on 3/23/25, the previous Director of Nursing, Staff C, Registered Nurse (RN) was the Risk Manager. The RMC reported receiving a call on Tuesday 3/25/25 notifying her of a fall with fracture occurring over the weekend. Staff C, RN was asked where the investigation was and shared with RMC the statements gathered included the resident was transferred to her wheelchair and fell out of the chair after the Staff B, CNA was making the resident's bed. The RMC stated out of precaution, Staff C, RN was informed to do more additional investigation. The RMC stated Staff B, CNA completed a reenactment with Staff C, RN how the resident was transferred and exactly when the resident fell. Staff B, CNA confirmed during the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 10 of 18 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 04/25/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reenactment of transferring the resident by herself. Staff B, CNA said after the resident transfer, Resident #1 slipped out of the chair and fell. The CNA was suspended for not following facility protocol for a 2-person mechanical lift transfer. The RMC directed someone from the facility to speak with the resident. The admission Director spoke to Resident #1 and reported the resident confirmed Staff B, CNA did everything right and the resident slipped from chair, not the lift. The facility received Resident #1's hospital records, which revealed the resident fell from the mechanical lift, at which time an immediate reporting was initiated. The resident informed the RMC, during a hospital interview she was almost to the chair and had fallen from the lift sling and confirmed Staff B, CNA, was the only aide present. The nurse, Staff A, RN, was interviewed and confirmed the lift was in the room, but did not see the transfer. An interview was conducted on 4/23/25 at 2:44 p.m. with Staff A, RN. The staff member confirmed being the nurse assigned to Resident #1 on the evening of 3/23/25 and was at the nursing station. Staff A, RN reported Staff B, CNA tried to pull the resident up with the mechanical lift. The CNA informed Staff A, RN of the fall and Staff A, RN observed the resident on the floor next to the bed and the mechanical lift was present. Resident #1 told Staff A, RN, It's not her fault and she slid and fell. Staff A, RN confirmed the resident, after returning from hospital, lied and was trying to protect Staff B, CNA. Staff A, RN stated he heard the mechanical lift may have messed up and the resident fell from the lift. The staff member re-enacted the positioning of the resident and confirmed the resident was sitting on crossed ankles, however, when describing the position, he said the right leg was bent in front of the resident and the left leg was bent back. Staff A, RN, said when the resident was on the floor, he and Staff B, CNA lifted the resident up off floor without the use of a mechanical lift. Staff B, CNA informed Staff A, RN the resident slid from the wheelchair and he informed the primary doctor and DON of the fall, telling the DON the resident said she slid from the wheelchair and did not want to blame the CNA. Staff A, RN confirmed Staff B, CNA did not ask for assistance with the mechanical lift prior to the incident. Review of the policy titled Fall and Injury Reduction Policy, effective March 2023, revealed under Policy, the facility has designated and implemented processes, which drive to reduce the risk for falls and injuries. This policy guides the identification, implementation of appropriate interventions and management. It is expected that this policy will assist the facility with reducing the likelihood of a fall or injury while maintaining or maximizing dignity and independence through education of staff and residents, early identification of risk factors by collecting data, identifying resident behavior which may increase the likelihood of such an occurrence. Review of the policy titled Safe Operation of Resident Lifts Policy and Procedure, effective March 2022, revealed Facility is a low-lift environment. Use of Mechanical Lifts occur per the resident's care plan and otherwise indicated. . 1. Operation of mechanical lift: a. Refer to manufacturer lift manual. . 3. Training on use of mechanical lift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 11 of 18 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 04/25/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a. Staff will be trained at orientation and annually with the competency and skills check off on the proper use of mechanical lifts. Review of the manufacturer manual for the mechanical lift revealed BEFORE using this product, this manual MUST be read and saved for future reference. The procedures in this manual MUST be performed by a qualified technician. The manual showed: . 7. Patient Lifting: - 7.1 Preparing the Lift for Use. -- Although [Brand Name] recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the healthcare professional for each individual case. 2. Review of Resident #1s April Medication Administration Record (MAR) revealed the following orders: - Ordered 3/28/25: Oxycodone oral tablet 5 milligram (mg) - Give 1 tablet by mouth every 4 hours as needed for pain. Discontinued on 4/7/25. - Ordered 4/7/25: Oxycodone oral tablet 10 mg - Give 1 tablet by mouth every 4 hours as needed for pain. Review of Resident #1s Controlled Drug Declining Inventory Sheet for Oxycodone Immediate Release (IR) 5 mg tablets revealed 40 tablets were received on 4/1/25 and 24 tablets were to be disposed of on 4/7/25, showing the resident received 16 tablets between 4/1/25 and 4/7/25. A review of Resident #1s April MAR showed the resident received 12 doses of 5 mg Oxycodone. A comparison of the residents' MAR and inventory sheet revealed staff documented the resident received doses of oxycodone on 4/5/25 at 10:25 a.m., 2:30 p.m., and 7:00 p.m. and a dose on 4/6/25 at 10:00 a.m., which were not recorded on the MAR. Review of Resident #1s Controlled Drug Declining Inventory Sheet for Oxycodone 10 mg tablets revealed 42 tablets was received on 4/7/25 with one tablet remaining for disposal on 4/24/25, showing the resident received 41 doses of the medication. The resident's April MAR showed the resident received 32 doses of Oxycodone 10 mg, revealing a discrepancy of 9 doses. Review of the inventory sheet showed staff documented the resident received a dose on the following days and times, which were not recorded on the MAR: 4/8/25 at 8:00 p.m., 4/12/25 at 10:00 a.m., 4/14/25 at 8:32 a.m., 4/16/25 at 2:00 p.m., 4/17/25 at 9:30 a.m., 4/19/25 at 10:00 a.m. and 4:00 p.m., 4/20/25 at 4:08 p.m., and a third dose on 4/23/25 (unreadable time). The following doses recorded discrepancies in the times of administration when compared with MAR and inventory sheet: - 4/11/25 per MAR administered at 6:00 a.m., inventory sheet recorded time of 7:30 a.m. - 4/13/25 per MAR administered at 9:41 a.m., inventory sheet recorded time as 9:00 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 12 of 18 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 04/25/2025 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 0726 - 4/14/25 per MAR administered at 4:25 p.m., inventory sheet recorded time as 5:00 p.m. Level of Harm - Minimal harm or potential for actual harm The inventory sheet revealed a disclosure reading: For every dose of a drug listed under the Controlled Substances Act, the information required below must be given in full. The information must be filled in at the time the drug is administered and not at some future date. Failure to do so is punishable under law by fine or imprisonment or both. Ink or indelible pencil must be used. Residents Affected - Some An interview was conducted on 4/25/25 at 12:11 p.m. with the Director of Nursing (DON). The DON stated staff are to document in the electronic record and the inventory sheet when the medication was administered. She reviewed Resident #1s April MAR and the 5 mg and 10 mg Oxycodone inventory sheets and confirmed the discrepancies between the documentation on MAR and the inventory sheets. Review of the policy titled Medication Administration - Controlled Substances dated 11/17 revealed under Policy, Controlled Medications are substances that have an accepted medical use (medications which fall under U.S. Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependency. These medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations. The policy revealed under Procedures: . 2. The Director of Nursing and the Consultant Pharmacist establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, and determine that drug records are in order and then an account of all controlled drugs that's maintained and periodically reconciled. . 4. When in controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and removing dust from controlled storage: (Note: refer to state regulations for particulars regarding scheduled classes and proper storage.) a. Date and time of administration. b. Amount administered c. Signature of the nurse administering the dose 5. Administer the controlled medication and document dose administration on the MAR. 3. A review of Resident #1's skilled nursing facility (SNF)/nursing facility (NF) to hospital transfer form, dated 3/23/25, revealed the resident is documented as the resident representative and was notified of the transfer/aware of clinical situation. Further review of the form revealed no documentation of a family member being notified of the transfer to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 13 of 18 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 04/25/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident #1's Situation-Background-Assessment-Recommendation (SBAR) Communication Form dated 3/23/25 and completed by Staff A, Registered Nurse (RN), did not reveal documentation under name of family/health care agent notified. A review of Resident #1's Progress Notes dated 3/23/25 at 8:18 p.m. revealed the resident was discharge to the hospital after she sustained a fall and was complaining of pain. The Progress Notes did not reveal documentation the family member/emergency contact was notified or contacted related to the resident's change in condition. On 4/23/25 at 10:40 a.m., an interview with Resident #1 and her family member revealed the family member did not find out, until a week later, Resident #1 was in the hospital. The family member stated, no one knew. He said he called the facility the day she was in the hospital and was told she was at a doctor's appointment. The family member said he called the facility again to see if Resident #1 was back from the doctor's appointment, and was told they didn't know where she was and someone signed her out. On 4/23/25 at 2:44 p.m., an interview was conducted with Staff A, RN. He said he was assigned to Resident #1 the day she fell and went to the hospital on 3/23/25. He confirmed he communicated with the Director of Nursing (DON) immediately about the change in condition and also notified the physician who gave orders to discharge the resident to the hospital. On 4/24/25 at 2:29 p.m., a phone interview was conducted with Resident #1's family member, who is her emergency contact (EC). She stated, I was made aware of the fall later. She said Resident #1 called her to tell her she was in the hospital, but the facility did not call her. She said Resident #1 called her on 3/24/25, while she was in the hospital, and told her she had fallen. The EC said the facility normally called her when there was an issue, but this time they did not. She stated, I'm supposed to be her first call when she goes to the hospital or if she has an emergency. She said when she initially talked to Resident #1, she didn't specify which hospital because, She was out of it. The EC stated, I had to call around and find out which hospital. The EC said she called another resident at the facility to find out where Resident #1 was. She confirmed she called the facility and was told Resident #1 was at [Hospital name], but she wasn't there. She found out Resident #1 was at another hospital. On 4/25/25 at 11:39 a.m., an interview was conducted with the Director of Nursing (DON). She said staff are supposed to call the family when there is a change in condition and complete a risk event note, where they are supposed to call the family, and doctor, and document. The DON said risk events are reviewed the next morning at the clinical meeting. They review the event note to see if the family was notified. She stated, They should be documenting in the medical record about that notification. A review of Resident #1's risk event note was conducted with the DON on her computer. She said usually under action is where staff is supposed to document the family notification. She confirmed she did not see notification to the family when Resident #1 went to the hospital. A review of the facility's policy titled Notification of Resident/Patient Change in Condition, effective October 2021, revealed the following under Policy: Nurses will notify the resident/resident representative, if there is a crucial/significant change in the resident condition. The policy revealed under 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 14 of 18 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 04/25/2025 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 0726 person(s) to whom you spoke. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 15 of 18 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 04/25/2025 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interviews, the facility did not ensure a Registered Nurse (RN) was providing services for eight consecutive hours a day, seven days a week, for the period of 4/6/25 to 4/12/25. Residents Affected - Many Findings included: A review of the staff schedule dated 4/5/25 - 4/6/25 revealed the nursing staff on each shift (10:45 p.m. 7:15 a.m., 6:45 a.m. - 3:15 p.m., and 2:45 p.m. - 11:15 p.m.) were all Licensed Practical Nurses (LPNs) and RN was indicated next to a staff name that was crossed out. On 4/24/25 at 3:34 p.m., an interview was conducted with the Director of Nursing (DON). She said the facility completed their staffing based on census to determine how many Certified Nursing Assistants (CNAs) and nurses they need per day. She said between calling and requesting off, they haven't had enough staff on certain days and she finds out afterwards when staff do not come in, After the fact. She confirmed the facility is supposed to have an RN on duty and, Maybe the RN called off that day. She said she doesn't know because she was out of town. The DON said when she was out of town, a DON from another building came to assist with coverage. A review of the facility's policy titled Staffing, effective August 2024, revealed the following: Policy: The Administrator and Director of Nursing are responsible to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable, physical, mental and psychosocial well-being of each resident, as required by federal law and sufficient staff to meet applicable state law requirements (including minimum staffing ratios). Staffing is monitored on an ongoing basis through reviews conducted by the Facility. The facility Administrator and Director of Nursing should evaluate staffing on a daily basis. Procedure: . 1. Monitor the census and resident special care needs daily. 4. Develop daily staffing patterns that allocate positions per unit, per shift, and by assignment. Ongoing Monitoring: 1. Monitor open positions and call offs throughout the day and respond to staffing needs as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 16 of 18 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 04/25/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, record reviews, and interviews, the facility failed to maintain an accurate accounting of narcotic medication for one resident (#1) of one resident sampled for the administration of pain medication. Findings included: On 4/23/25 at 10:40 a.m. Resident #1 was observed sitting in the Dining Room with a family member. The resident reported her legs and hands were hurting while rubbing the top of left leg and the oxy was not working. The resident reported a recent surgery to the left leg due to a staff member pivoting her to transfer. Review of Resident #1s quarterly Minimum Data Set (MDS) assessment, dated1/8/25, revealed a Brief Interview of Mental Status score of 15 of 15, indicating the resident was cognitively intact. The assessment revealed Resident #1 was dependent upon staff for sit to lying, lying to sit, and bed to chair transferring. The assessment showed the resident received scheduled and as needed pain medication for occasional pain. Review of Resident #1s April Medication Administration Record (MAR) revealed the following orders: - Ordered 3/28/25: Oxycodone oral tablet 5 milligram (mg) - Give 1 tablet by mouth every 4 hours as needed for pain. Discontinued on 4/7/25. - Ordered 4/7/25: Oxycodone oral tablet 10 mg - Give 1 tablet by mouth every 4 hours as needed for pain. Review of Resident #1s Controlled Drug Declining Inventory Sheet for Oxycodone Immediate Release (IR) 5 mg tablets revealed 40 tablets were received on 4/1/25 and 24 tablets were to be disposed of on 4/7/25, showing the resident received 16 tablets between 4/1/25 and 4/7/25. A review of Resident #1s April MAR showed the resident received 12 doses of 5 mg Oxycodone. A comparison of the residents' MAR and inventory sheet revealed staff documented the resident received doses of oxycodone on 4/5/25 at 10:25 a.m., 2:30 p.m., and 7:00 p.m. and a dose on 4/6/25 at 10:00 a.m., which were not recorded on the MAR. Review of Resident #1s Controlled Drug Declining Inventory Sheet for Oxycodone 10 mg tablets revealed 42 tablets was received on 4/7/25 with one tablet remaining for disposal on 4/24/25, showing the resident received 41 doses of the medication. The resident's April MAR showed the resident received 32 doses of Oxycodone 10 mg, revealing a discrepancy of 9 doses. Review of the inventory sheet showed staff documented the resident received a dose on the following days and times, which were not recorded on the MAR: 4/8/25 at 8:00 p.m., 4/12/25 at 10:00 a.m., 4/14/25 at 8:32 a.m., 4/16/25 at 2:00 p.m., 4/17/25 at 9:30 a.m., 4/19/25 at 10:00 a.m. and 4:00 p.m., 4/20/25 at 4:08 p.m., and a third dose on 4/23/25 (unreadable time). The following doses recorded discrepancies in the times of administration when compared with MAR and inventory sheet: - 4/11/25 per MAR administered at 6:00 a.m., inventory sheet recorded time of 7:30 a.m. - 4/13/25 per MAR administered at 9:41 a.m., inventory sheet recorded time as 9:00 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 17 of 18 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 04/25/2025 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 0755 - 4/14/25 per MAR administered at 4:25 p.m., inventory sheet recorded time as 5:00 p.m. Level of Harm - Minimal harm or potential for actual harm The inventory sheet revealed a disclosure reading: For every dose of a drug listed under the Controlled Substances Act, the information required below must be given in full. The information must be filled in at the time the drug is administered and not at some future date. Failure to do so is punishable under law by fine or imprisonment or both. Ink or indelible pencil must be used. Residents Affected - Few An interview was conducted on 4/25/25 at 12:11 p.m. with the Director of Nursing (DON). The DON stated staff are to document in the electronic record and the inventory sheet when the medication was administered. She reviewed Resident #1s April MAR and the 5 mg and 10 mg Oxycodone inventory sheets and confirmed the discrepancies between the documentation on MAR and the inventory sheets. Review of the policy titled Medication Administration - Controlled Substances dated 11/17 revealed under Policy, Controlled Medications are substances that have an accepted medical use (medications which fall under U.S. Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependency. These medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations. The policy revealed under Procedures: . 2. The Director of Nursing and the Consultant Pharmacist establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, and determine that drug records are in order and then an account of all controlled drugs that's maintained and periodically reconciled. . 4. When in controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and removing dust from controlled storage: (Note: refer to state regulations for particulars regarding scheduled classes and proper storage.) a. Date and time of administration. b. Amount administered c. Signature of the nurse administering the dose 5. Administer the controlled medication and document dose administration on the MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105117 If continuation sheet Page 18 of 18