Health inspection·October 6, 2021

F 0550 needed. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 10/05/21 at 1:06 PM with Staff D, CNA. Staff D stated that they [CNA's] have all been trained. Staff D said, We are supposed to sit at bed level and sit the resident at 45 degrees. Residents Affected - Few An interview was conducted on 10/05/21 at 4:28 PM with the Regional Nurse (RN) and Assistant director of nursing (ADON). The RN stated that CNAs should be sitting when assisting residents with meals. The RN said, If there is no chair in the room, they should grab a folding chair. Staff should never stand over a resident during meal assistance. The ADON stated that she would start in-services. The ADON said, it is about dignity. The ADON provided in-service training material on dining and dignity indicating, Patient's who need assist with dining must have their dignity maintained at all times. Employees must sit while feeding residents and only feed one resident at a time. A follow-up interview was conducted on 10/06/21 11:15 AM with the DON. The DON stated that staff should be seated at bed level. The DON stated that they started education last night, 10/05/21, and have made foldable chairs available. Review of the facility's policy titled, assistance with meals Revised July 2017, statement showed, residents shall receive assistance with meals in a manner that meets the individual needs of each resident. #2 Facility staff will serve resident trays and will help residents who require assistance with eating. #3 Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: (a) Not standing over residents while assisting with meals. Review of the facility's policy titled, Dignity revised February 2021, states that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: (e.) Provided with a dignified dining experience. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105149 If continuation sheet Page 2 of 8 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 105149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Healthcare and Rehabilitation Center 1301 16th St N 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not honor a resident's preference to receive therapy services for one (Resident #33) of twenty residents. Residents Affected - Few Findings included: During a facility tour on 10/04/21 at 10: 45 AM, Resident #33 stated that she had been at this facility since June 2021 and had not received any therapy. Resident # 33 said, I have been asking for over 2 months. Resident #33 said, Please look into it. I want to be able to take care of myself. I need therapy. I don't want to be a dependent for the rest of my life. Resident #33 stated that she had spoken to the Social Services Director (SSD) and the Director of Rehabilitation (DOR) about receiving restorative services. A review of Resident #33's electronic medical record (EMR) showed a resident information sheet revealing that Resident #33 was [AGE] years old and was admitted to the facility on [DATE]. Resident #33 was her own responsible party and was admitted with diagnoses to include, but not limited to insomnia, major depressive disorder, essential hypertension, other nontraumatic subarachnoid hemorrhage, hemiplegia unspecified affecting right dominant side, anoxic brain damage not elsewhere classified, other seizures, pain unspecified, Chronic Obstructive Pulmonary Disease (COPD) and Vitamin D deficiency. A quarterly MDS (Minimum Data Set) dated 08/31/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G- functional abilities showed that Resident #33 required extensive assistance with one person assist for activities of daily living (ADLs) including, bed mobility, dressing, eating, toilet use and personal hygiene. Resident #33 was totally dependent on 2 persons plus for transfers, locomotion on and off unit and bathing. A Care plan dated 06/03/21 showed that Resident #33 had a self-care deficit with dressing, grooming, bathing related to generalized weakness and chronic pain. Resident participated with ADLs with cues from staff. Interventions to include therapy to screen as indicated. A functional limitation screening conducted on 06/03/21, revealed that Resident #33 had severe range of motion (ROM) limitations on her upper and lower extremities. Resident #33 had 0 -25% functional ROM. The screening conducted by the director of rehab (DOR) indicated that an evaluation should be conducted. Review of the active physician orders for Resident #33 dated 10/06/21, showed no active orders for treatment or evaluation for OT (Occupational Therapy), PT (Physical Therapy), or ST Speech Therapy). The physician orders further revealed an order dated 06/03/21 stating may participate in restorative program as needed and as tolerated. Review of the restorative binder showed that Resident #33 was not receiving restorative services. An interview was conducted on 10/06/21 at 9: 04 AM with the SSD. She stated that Resident #33 came from a sister facility and was admitted for long term care. The SSD confirmed that Resident #33 had been asking for therapy or restorative services, most recent request was in the last three weeks. SSD stated that authorization paperwork for therapy services was sent to Resident #33's doctor upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105149 If continuation sheet Page 3 of 8 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 105149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Healthcare and Rehabilitation Center 1301 16th St N 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 0558 admission in June, but her doctor had not responded. SSD stated that DOR sent the paperwork. Level of Harm - Minimal harm or potential for actual harm On 10/06/21 at 09:08 AM, an interview was conducted with the DOR. She confirmed that Resident #33 had been asking for therapy since she moved in. The DOR stated that she had re-faxed the paperwork to request therapy about 2-3 weeks ago and had been waiting for the doctor to approve the script. When asked why Resident #33 had not be evaluated for therapy per her request, the DOR said, The initial screening was conducted on 06/14/21 when the resident was admitted , but I did not conduct further assessment because the doctor's office did not respond. The DOR explained that the initial fax was sent on 06/07/21 and a second request was faxed on 06/24/21. A third request was faxed on 09/15/21 following the resident's verbalized request for therapy. The DOR stated that she had not heard from the doctor's office. She stated that a resident who needed total staff assist and was using adaptive equipment should be evaluated. The DOR stated that the facility expectation was for all new residents to receive screening, evaluation, and a comprehensive care plan upon admission. Residents Affected - Few An interview was conducted on 10/06/21 at 9:30 AM with the DOR, Director of Nursing (DON), Regional Clinical Nurse, and the Nursing Home Administrator (NHA). The DON stated that there was a problem getting in touch with the doctor because the medical director contracted services out. The DON stated that a new doctor started last Friday and had reviewed all residents. The DON said, I don't know if they have reviewed [Resident #33's] file. The Regional nurse said she would look at the facility policy to see if an inhouse evaluation should have been initiated to determine resident's plan of care as they wait for the authorization. She said, Maybe we could have initiated restorative to help her maintain physical abilities. The DON stated that even though the resident had not been assessed, she had not lost her abilities. The DON agreed that a 4- month wait was not acceptable. The DON confirmed that Resident #33, who was fully dependent on staff, wore a splint, and used specialized feeding equipment, should have received some assessment to give staff direction on plan of care. Review of an undated facility assessment page 9 revealed that services are provided based on resident's need. The facility provides specific care or practices in transfers, ambulation, restorative nursing, contracture prevention / care, supporting resident independence in doing as much of these activities by himself / herself. The facility assessment stated that the facility provided PT, OT, ST. Review of the facility policy titled, dignity revised February 2021, #2 showed the facility culture supports dignity and respect by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105149 If continuation sheet Page 4 of 8 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 105149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Healthcare and Rehabilitation Center 1301 16th St N 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 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure that one (Resident #21) of four residents reviewed was notified prior to a room change. Resident #21 was admitted to the facility on [DATE] with a primary diagnosis of HB-SS Disease (Sickle Cell Anemia) with cerebral vascular involvement. Resident # 21's most recent Minimum Data Set (MDS), dated [DATE],Section C: Cognitive patterns, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 10/04/21 at 2:45 p.m. an interview was conducted with Resident #21. He stated that he was moved from his prior room a few days ago. Resident #21 stated that he was not notified of the room change ahead of time. The staff did not give him a chance to get out of bed, while still in bed, he was rolled across the hall to the new room. On 10/06/21 11:15 a.m. an interview was conducted with the Social Services Director. She stated that she did not initiate room changes, the Business Office was responsible for doing so. The process was to notify the resident of the room change, if they were not their own person (responsible party), they, the business office, would notify the family. They show the resident or family member the room and introduce them to their potential roommate. The room that Resident #21 was moved from was used for isolation and was the only private room in the facility. They needed the room for another resident that was being readmitted to the facility. The Social Services Director checked the progress note to see if there was any documentation related to the room change and could not find any. She stated that she was not in the facility the day that the move occurred but was notified via email by the Business office. She believed that the Business Office Manager might have provided verbal notification to Resident #21. On 10/06/21 at 1:15 p.m. an interview with the Director of Nursing was conducted. She stated that the notification might not have been done. She would not make any excuses, if the resident stated he had not been notified than we must take his word for it. She received a text on the weekend notifying her of the room change for the resident. A review of the facility policy titled Room Change/Roommate Assignment, revised in March 2021 revealed, Policy Statement: changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change. Policy Interpretation and Implementation: 1. Resident room or roommate assignments may change if the facility deems it necessary. Resident preferences are taken into account when such changes are considered. 4. Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives) are given at least a (space left blank) hour/day advance written notice of such change. A. Advance written notice of a roommate change includes why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate. B. If a resident's roommate passes away, the resident will be allowed time to adjust before another roommate is moved into the room. 7. Documentation of a room change is recorded in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105149 If continuation sheet Page 5 of 8 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 105149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Healthcare and Rehabilitation Center 1301 16th St N 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to ensure the kitchen was maintained in a sanitary manner during two of two visits conducted on 10/04/21 at 9:37 a.m. and on 10/05/21 at 11:20 a.m., related to proper food storage, equipment and surface cleanliness, and storage of personal items in food prep and food storage areas. Findings included: An initial tour of the kitchen was conducted on 10/04/21 at 09:37 a.m. facilitated by the Certified Dietary Manager (CDM). An observation was made of Staff B, Dietary Aide standing in front of the food prep counter. Staff B was noted without a face mask. Staff B proceeded to grab her mask that was resting on the food prepping counter and held it on her right hand. A blue drinking cup with a straw and a cell phone were resting on the food prep counter. Next to the cell phone was a package of an opened snack and a small bag that was not opened. Also, on the counter were food service items including condiments in sachets and napkins. An interview was conducted on 10/04/21 at 9:38 a.m. with Staff B. Staff B stated that the items were her personal items. Staff B did not answer when asked if the items should be stored on the food prep counter. Staff B put on her face mask and walked away. The CDM stated that the items should not be on the food prep counter. On 10/04/21 at 9:38 a.m., an observation was made of dirt and a grimy substance on the floor by the dishwashing station. Food residue and papers were observed on the floor under the drying racks. On 10/04/21 at 9:38 a.m., a large piece of ham was noted thawing on the counter by the microwave. The CDM stated that he was just getting ready to cut it up for lunch. The CDM stated that he placed the meat on the counter when he arrived this morning. On 10/04/21 at 9:39 a.m., the stove was observed with oil and grease build up on the surface. The CDM stated that he usually cleaned the kitchen at the end of his shift. On 10/04/21 at 9:39 a.m. dirt, rust, and grimy matter was noted under the handwashing sink. Food substances were observed on the floor beside the ice machine. On 10/04/21 at 9:41 a.m., an observation was made of the ice machine noted with bio- growth on the inside of the door and inside the ice machine. The bio-growth was noted on surfaces touching the ice cubes. The CDM stated that he was not going to serve the ice to the residents. The CDM reported that he had stopped by the grocery store on his way to work and brought in some ice. The CDM said this was not the first time and that he bought the ice with his own money because he did not want to serve contaminated ice to the residents. The CDM stated that the administration did not know the ice machine had bio growth. The CDM said they were planning on cleaning the ice machine today, 10/04/21. The outside of the ice machine and the floor around it were noted with dark grimy substances, dirt, and debris. On 10/04/21 at 9:43 a.m., the bottom of the freezer was observed with a dried, frozen, red substance where the meat was resting. The freezer door was noted with icicles on the door frame and bio-growth and water dripping on food boxes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105149 If continuation sheet Page 6 of 8 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 105149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Healthcare and Rehabilitation Center 1301 16th St N 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 On 10/04/21 at 9:44 a.m., an unlabeled and undated disposable cup was observed on the shelf inside the freezer. The CDM stated that it was a shake that he had just made this morning. The CDM said, it should be dated and labeled. The floor of the second freezer was also noted with a red substance smeared on the bottom surface, next to a bag of french fries. Residents Affected - Some On 10/04/21 at 9:47 a.m., a grocery store plastic bag was observed on the top shelf of the refrigerator next to yogurt cups. The bag was not labeled or dated. The CDM stated it was an employee's meal. The CDM stated that staff should not store their food in that refrigerator. On 10/04/21 at 9:48 a.m., a green filter in the beverage dispensing unit was noted blanketed with dirt and dust. The CDM stated that maintenance staff cleaned the beverage machine. The CDM could not remember the last time the filter was cleaned or changed. On 10/04/21 at 9:49 a.m., a blue drinking cup with a straw, a bag of opened snack, and a blue lunch bag were observed on the shelf below the food prep counter. These items were stored on food service items including tea bags, condiments, cup lids and exposed silverware and serving utensils. On 10/04/21 at 9:49 a.m., an interview was conducted with Staff B. Staff B stated that this was her cup and her personal items. Staff B stated she had removed them from the top of the prepping counter and stored them on the shelf below. Staff B said the items should not be stored on a food prep station. On 10/04/21 at 9:50 a.m., a green bucket was observed under the hand washing sink collecting water. The floors were noted with dirt and food remains. On 10/04/21 at 9:51 a.m., the floor underneath the stove was noted with dust, dirt, papers, and food stuff. An observation was made of two large flour containers stored on a lower shelf underneath the microwave counter, noted with dirt and grease. Dates and labels were not legible from wear and dust. On 10/04/21 at 9:56 a.m., a tour of the dry food storage area was conducted. An unlabeled and undated container with a yellow - flour looking substance was noted. Another undated, unlabeled container with a white - flour looking substance was noted below it. The CDM stated that this was fish fry mix. The CDM said, I know it should be labeled and dated. The floors in the dry good storage area were noted with papers, dirt, and dust. 10/04/21 10:00 a.m., an interview was conducted the CDM. The CDM stated they had a cleaning checklist and that they were just about to clean the kitchen after breakfast service. The CDM stated that the expectation was to keep the kitchen clean and sanitary. The CDM stated that employees' personal items should not be stored in the food prep areas and the resident's food storage units. On 10/05/21 at 11:20 a.m., a tour of the kitchen was conducted. The CDM stated that they had cleaned the ice -machine. A note was observed on the machine stating, Ice machine has been cleaned and sanitized. The CDM stated that they will make sure the ice machine was cleaned regularly to prevent bio-growth. On 10/05/21 at 11:21 a.m., an observation was made of bio growth on the freezer and refrigerator doors. Bio growth was observed on the corners of the freezer next to a bag of french fries. The CDM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105149 If continuation sheet Page 7 of 8 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 105149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Healthcare and Rehabilitation Center 1301 16th St N 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 said, I missed that. Level of Harm - Minimal harm or potential for actual harm On 10/05/21 at 11:25 a.m., a second observation of the dish washer drainage compartment was noted with dirty, murky water, and food residue. The CDM stated that he would clean it after lunch dishes. Residents Affected - Some On 10/05/21 at 11:32 a.m., an observation was made of a shelf with clean baking trays noted with grimy dirt, food particles, and dust. The CDM stated that this shelf was for storing clean items. The kitchen floor corners and walls were noted with food stains and grimy black matter. (Photographic evidence was obtained.) In an interview conducted on 10/05/21 at 11:32 a.m., the CDM said, We cleaned a lot. The building is old. They need to replace the floors. An interview was conducted on 10/05/21 at 4:32 p.m. with the Nursing Home Administrator (NHA) and Director of Nursing (DON). They were notified of concerns in the kitchen related to housekeeping and unsanitary surfaces. The NHA stated he would make it his priority to address the concerns. The DON stated that they would follow-up. Review of a facility policy titled, Next level hospitality services with a heading, environment dated October 2019, states that it is the center policy that all food preparation areas, food service areas and dining areas will be maintained in a clean and sanitary condition. Action steps (1.) The dining service director will ensure that the physical plant is maintained in clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. (4.) The dining service director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and services. A policy titled, Equipment dated October 2019 states that it is the center policy that all food service equipment is clean, sanitary, and in proper working order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105149 If continuation sheet Page 8 of 8