Inspection·December 16, 2020

F 0656 1. Behavior problem related to crawling out of bed/playing with her feces increased agitation/anxiety Level of Harm - Minimal harm or potential for actual harm 2. Risk for falls related to fall history, limited mobility, unaware of safety needs with interventions to include but not limited to: Floor mats/Landing strips x 1 at bedside per Physician's Order on 6/8/2020. Residents Affected - Few On 12/16/2020 at 10:30 a.m. an interview with the East Unit Manager, who had Resident #49 on her assignment hall, revealed that Resident #49 did have a bed positioned up against the wall and there was supposed to be a floor fall mat on the right side of the bed at all times when she was in bed. The Unit Manager was asked if this was the same for weekends as well and she confirmed that it was. The Unit Manager was not aware of the fall mat not being in place on the floor when Resident #49 was in bed on Sunday, 12/13/2020. The Unit Manager was asked if the staff member who was doing 1:1 supervision with Resident #49's roommate would know Resident #49's care plan, and if she would have known that Resident #49 was to have the fall mat placed on the floor when she was in bed. The Unit Manager indicated that the person doing 1:1 supervision for the roommate would not know of the care plans and interventions for others in the room. On 12/16/2020 at 12:00 p.m. an interview with the Director of Nursing confirmed that the fall floor mat should always be placed on the floor when Resident #49 was in bed. The weekend Certified Nursing Assistant who worked 12/13/2020 during the 7-3 shift could not be reached for interview. The Director of Nursing did not have a fall floor mat policy for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105202 If continuation sheet Page 2 of 5 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 105202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apollo Healthcare & Rehabilitation Center 1000 24th St N Saint Petersburg, FL 33713 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview with the resident and facility staff, and review of the resident's medical record and facility policy, the facility failed to provide ordered treatment to promote bowel regularity to one Resident (#16), of 28 sampled residents. Findings included: During the initial tour of the facility, on 12/13/2020 beginning at 11 a.m., Resident #16 reported that he was uncomfortable and was not able to move his bowels. The resident's aide (Staff A) entered the room, and after speaking with the resident, left the room and reported that she would return to provide care. At approximately 12:30 p.m., the resident was observed sitting up in bed, but leaning to the right and supported on his right elbow, with his over bed table half way across the bed. On the table was his lunch, with half of his sandwich eaten. The resident was observed fidgeting in bed, and reaching for, then pulling back his hand, from his sandwich. When asked if he was okay, he didn't answer. When asked if the aide had helped him out, he reported no and began to curse the aide and the facility. As several nurses and supervisors were in the hall to assist with passing the lunch trays to residents, they were asked to come in to speak with the resident. The resident hedged when asked if the aide had come in and finally said he thought maybe she had. One of the nurses asked the aide to come in and speak with the resident. As Staff A, aide left the room, the surveyor asked what was happening. Staff A said she was going for supplies and the resident had confirmed that he was having trouble moving his bowels. Approximately 30 minutes later, the aide exited the room with several clear plastic bags of used supplies and linens, confirmed the resident had moved his bowels with the outcome of a large BM. A review was conducted of the Minimum Data Set Quarterly Assessment, dated 09/22/2020, which indicated the resident's BIMS (Brief Interview for Mental Status) score was a 9, indicating the resident's cognition was moderately impaired. The resident's Activities of Daily Living reflected extensive assistance with two staff for toilet use. He was assessed as being frequently incontinent of bowel. The resident had care plans developed initially on 05/06/2018 with a revision date of 08/27/2020, for the Focus area of Bowel incontinence. It reflected that Resident #16 was at risk for complications, and receives medication to ease bowel movements daily. A second care plan was noted for the Focus area of potential for constipation or for loose stools related to decreased motility and use/side effects of medication. Interventions for both care plans included: monitor bowel movement status; notify nurse of signs and symptoms of constipation; follow facility protocol for bowel management. A review was conducted of the nursing aide's documentation of the resident's bowel movements (BMs) for December 2020. From 12/03/2020 until 12/15/2020, the resident had three small BMs (on 12/11, 12/12 and 12/15); one medium BM (on 12/05) and one large BM (on 12/13). It was documented that the resident did not have a BM from 12/06 until 12/10, a total of 5 days. Review of the physician's orders for Resident #16 revealed orders (order date 04/27/2018) for Milk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105202 If continuation sheet Page 3 of 5 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 105202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apollo Healthcare & Rehabilitation Center 1000 24th St N Saint Petersburg, FL 33713 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Magnesia Suspension 400 mg/5 ml - give 30 ml by mouth every 24 hours as needed for no BM in 3 days at bedtime. Review of the Medication Administration Record for December 2020 revealed the listing for the Milk of Magnesia to be given if no BM in 3 days. There was no documentation that the medication had been given, even though it was documented that the resident had not had a BM for five days in a row. In an interview with the Nurse Unit Manager (Staff C) and the Nurse Educator (Staff B) on 12/16/2020, beginning at 9:35 a.m., the facility's electronic medical record was described as being able to send an alert to the nurse based on the nursing aide's documentation. It was explained that the medical record software would trigger an alert to the nurse, which would need to be acted upon before a subsequent note or action could be taken. During the interview, the nurses confirmed there didn't seem to have been an alert sent to the nurse, as the prn (as necessary) medication had not been given and there was no nurse's note explaining why not. The nurse's notes for the month of December were reviewed and noted for documentation that the resident received milk of magnesia on 12/01/2020 for no BM in 3 days. There were no nurse's notes after 12/01/20 related to the documentation that the resident had not had a BM in over 3 days. The facility's policy, Bowel Management (revised 07/2015) was reviewed and noted: It will be the standard of the facility to ensure the residents have regular bowel movements with no significant time frame between bowel movements (usually three days, unless inconsistent with resident's routine bowel habit.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105202 If continuation sheet Page 4 of 5 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 105202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apollo Healthcare & Rehabilitation Center 1000 24th St N Saint Petersburg, FL 33713 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 and staff interview, the facility failed to ensure the kitchen was maintained in a sanitary manner related to outdated product, fan coverings in the walk-in refrigerator coated with a black wet residue, packages stored in the walk-in freezer, and a microwave oven with uncleanable inside surfaces. Findings included: During the initial tour of the main kitchen, on 12/13/2020 beginning at 9:55 a.m., a bread rack was observed full of packaged bread. Observation of the packaged loaves of bread revealed use by dates on the packages indicated several loaves of bread were out of date. Four loaves of wheat bread had a use by date of 11/18/20; five loaves of wheat bread had a use by date of 11/06/2020; thirteen loaves of wheat bread had a use by date of 12/03/2020; and one half of a bag of hotdog rolls had a use by date of 11/20/2020. The Cook, Staff D, who had been identified as being in charge, reported when asked why there was so much bread that was out of date, that most of the residents don't like the wheat bread so it doesn't get used. The walk-in refrigerator had containers of food that were out of date. A large zip-lock bag of diced ham was dated 12/03 and a container of rice pudding was dated 12/08. The cook reported that bagged product in the refrigerator is usually kept for 5-7 days before being thrown out. A container half full of sour cream with a manufacturer's date of 11/03 was noted without a date indicating when it had been opened. Staff D reported that they followed the manufacturer's date as to when to discard an item, but then confirmed there was no date as to when the product was opened, so there was no way to know how long it should be kept. In the back of the walk-in refrigerator, the two protective plastic cages around the fans were noted to be soiled with a black, wet, fuzzy residue, some of which had broken off and was streaming out from the cage with the air from the fan. Inside of the walk-in freezer two boxes of product, one containing biscuits and one containing meat patties, were noted with the bag inside of the box, open to the air. Staff D confirmed the boxes should have been closed up and the product inside not open to the cold air. In the dining room adjacent to the kitchen a microwave oven was noted on the counter. The inside edge of the frame of the microwave oven was noted to have peeling enamel, exposing a rusted surface. On the back wall of the microwave oven, the enamel coating was noted to have come off, exposing a rusted surface. The back wall was also noted to be an off gray-black color. (photographic evidence obtained) In an interview with the Dietary Manager, conducted on 12/15/2020 at approximately 12:00 p.m., it was confirmed that staff should be looking at the dates of the products and dating when products are opened, to be sure they were discarded when appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105202 If continuation sheet Page 5 of 5