Inspection·May 15, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a.m. and there are usually not housekeepers during the late night shift. She revealed upon her and other housekeepers arrival, they only attempt to clean rooms for residents who are already awake, or clean other non resident spaces. Staff K revealed once she enters rooms to clean, she and other housekeeping staff will generally empty the trash cans, sweep the floor and mop if needed. She revealed there are times she comes in and there are soiled floors. She could not say for sure if the floors were soiled after the day crew left for the night, or if the floors were not cleaned prior to the end of their shift. Staff K was not sure why trash cans in resident rooms were full and overflowing, nor was she sure why there was sticky floors with food debris and other refuse in resident rooms at the time housekeeping arrived this a.m. The Housekeeping Director was not available for interview. Interview with the Nursing Home Administrator revealed they did not currently have any type of housekeeping or room cleaning policy and procedure. The Nursing Home Administrator confirmed he did not have any current maintenance facility work orders or current purchase orders that would indicate the facility was actively working on the above listed concerns. He confirmed the dining room chairs and indicated that he did not realize the chairs were that worn. The Nursing Home Administrator revealed that floor staff and housekeeping, or any other staff that see furniture in that condition, should report those concerns to maintenance once they see it. The Nursing Home Administrator confirmed there were six dining room chairs with seats that were not maintained and in disrepair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105202 If continuation sheet Page 2 of 7 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 05/15/2023 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, facility record review, and staff interview, the facility failed to ensure kitchen spaces, kitchen equipment, and eating ware were maintained, clean and sanitary during two of two meal services observed. Observations included, 1. Ceiling tiles above food preparation tables were caked with dust and debris, 2. Dishes were not washed from the day before meal service, 3. Dish washing equipment rusted and eroding, 4. Meal trays served to residents soiled, cracked and chipped. Findings included: On 5/15/2023 at 5:50 a.m. the kitchen was toured and met with a Dietary Aide Staff A, who indicated she was recently transferred from another facility about two months ago. She revealed that this time of morning was her normal time when she comes in to work and works the kitchen for both the breakfast and lunch meal service. Also, in the kitchen was the a.m. and afternoon cook, Staff B. Staff B indicated he has been employed in the kitchen for about three years. Staff A and B both confirmed that they were the only two kitchen employees at the time and two others will be in by 6:30 a.m. Staff B revealed the tray line for the breakfast meal begins at around 7:30 a.m., and that tray carts go out to the halls. He also confirmed the community dining room is not open during the breakfast meal service. Staff A and B did not have names of the other staff who were due in at 6:30 a.m. Both Staff A and B were asked what time the Dietary Manager, Staff C arrives at the facility. They both revealed Staff C comes in at 9:00 a.m. or just after. They confirmed this was a normal occurrence for Staff C to come in at and after 9:00 a.m., which is after the entire breakfast meal service. While speaking with Staff A and B at 5:40 a.m. the following observations were made: 1. Five ceiling tiles/light covers at and near ceiling vents, located above the dish machine area and above the food prep table and steam table were observed caked with dust and debris. The areas with heavy debris were directly above where the cook was plating food from the steam table. Photographic evidence was taken. 2. The dish machine area to include the stainless steel dish return table was observed with two crates of soiled cups and bowls (approximately 20 cups and bowls total). It was determined that the crate of bowls and cups were from the previous dinner meal from 5/14/2023. Photographic evidence was taken. 3. The same area on the dish machine table was observed with 8 stacked soiled plates that also appeared to be from the previous meal service from 5/14/2023. Photographic evidence was taken. 4. The crates of soiled bowls and cups as well as the stack of plates were observed with over 5 small flying insects flying around the area and landing on the soiled bowls/plates/cups. There were also small flying insects flying around the floor drain and undercarriage of the dish washing machine. 5. Observations under the dish machine area revealed a metal heating booster, with what appeared to be a white soiled towel draped on it. Further observations revealed the top metal surface of the booster was heavily oxidized, rusted and with metal flaking off of it. The booster was also observed leaking a red rust type of liquid from the bottom of it, causing a red in color pooled liquid on the floor. The staining from the pooled liquid as well as the actual pool of liquid appeared to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105202 If continuation sheet Page 3 of 7 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 05/15/2023 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 - Many longstanding and did not just happen during the observation. Upon lifting the soiled towel most of the top metal lid to the booster was heavily eaten away from rust and exposing the inside components, as well as not leaving a cleanable surface. Photographic evidence was taken. 6. There were many (over forty) black in color plastic trays used to hold plates of food, cups of liquid, napkins and eating utensils. These trays are sent out each meal to residents while either in their rooms or in the main dining room. At least twenty of these trays were observed in disrepair with what appeared to be white oxidation and with cracked and chipped off ends, leaving sharp edges. The kitchen was toured at 6:30 a.m., with the same above listed observations. Two addition kitchen aides, Staff D and E had just arrived and were preparing for the breakfast meal service. Staff D and E both confirmed that the Dietary Manager has not arrived at the facility yet, and does not usually arrive until after 9:00 a.m. Staff A, B, D, and E did not know why the Dietary Manager doesn't come in until 9:00 a.m. or after. Another kitchen cook, Staff F arrived at the facility around 7:15 a.m. Interviews with Staff A, B, D, E and F at that time revealed they were not sure why there were crates of soiled dishes on the dish washing machine rack, and that the previous night shift must not have collected and washed all the dishes. They all also confirmed there were small flying insects at and near the soiled dishes, as well as under the dish washing machine and the floor drain. They all indicated that they have had a small fly problem for awhile now, and that an outside company has come out to treat but the flies keep coming back. At 11:00 a.m. the kitchen was toured again and the Dietary Manager was still not in the building to speak with. Interviews with Staff A, B, D, and E at that time indicated there was a daily cleaning schedule with cleaning expectations, but they did not know where it was. None of the staff interviewed could explain how and when the Ceiling tiles/vents are cleaned, when dishes are expected to be cleaned by, why soiled towels were draped over eroding mechanical equipment, and when serving trays are observed for cleanliness and maintenance. On 5/15/2023 at 11:25 a.m. the kitchen was toured with the Nursing Home Administrator. He confirmed the above listed observations of concern and indicated he did not have any current plans or work/repair purchase orders, nor any listed kitchen renovations to show the areas were identified and being worked on. He further confirmed he could not at that time verify why there were areas not maintained and sanitary as the Dietary Manager had not come in yet to be interviewed. The Nursing Home Administrator revealed he would look for the kitchen cleaning schedule to provide for review. The Nursing Home Administrator as of 1:30 p.m. was not able to provide the daily kitchen cleaning schedule for review. Throughout the morning from 5:40 a.m., 7:30 a.m. and 11:25 a.m., The Director of Nursing, the Nursing Home Administrator and Dietary Kitchen staff were all asked to have the Dietary Manager speak to the State surveyor upon his arrival. However, as of 1:30 p.m., just prior to the survey inspection exit, the Dietary Manager was not available or made himself available for interview. It was determined the Dietary Manager was not in the building from at least 5:40 a.m. through to 1:00 p.m. It could not be confirmed what type of cleaning is performed either generally, or deep cleaned on a daily basis; nor was the day shift kitchen staff aware of what the cleaning schedule entailed. The Nursing Home Administrator revealed that it is the Maintenance Department's responsibility to clean the ceiling vents and ceiling tiles and indicated that the TELS system notifies when the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105202 If continuation sheet Page 4 of 7 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 05/15/2023 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 - Many ceiling vents are to be cleaned. However, he confirmed the ceiling vents and tiles surrounding the vents were caked with dust/debris. He confirmed the areas should be cleaned more frequently. Interview with the Maintenance Director at 1:35 p.m. confirmed the ceiling vents/tiles in the kitchen were soiled and dusty. He revealed that they needed to be cleaned more often and that kitchen staff should also help to make him aware if the vents/tiles need to be dusted. The Maintenance Director also confirmed the small flying insects and indicated this has been a recent ongoing problem and he has been looking to purchase electronic fly traps for the kitchen. He also indicated that the pest control comes in routinely to treat for pests. He confirmed they cannot have an effective pest control program if staff leave unwashed and soiled dishes overnight in the kitchen. The Nursing Home Administrator did not have a Kitchen Cleaning/Maintenance policy and procedure for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105202 If continuation sheet Page 5 of 7 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 05/15/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff and resident interviews, and facility record review, the facility failed to maintain an effective pest control program related to small flying insects in areas to include: One of one main dining rooms, the kitchen, the main activities room, and one of three unit station areas (south wing). Residents Affected - Some Findings included: On 5/15/2023 During observations in the main dining room at 5:50 a.m., 10:00 a.m., during lunch meal service at 12:30 p.m. and again at 1:00 p.m., the main dining room was observed with over ten small flying insects near and at the sink area, near and at where the tray carts were stored near the kitchen entrance doors, and throughout the dining room at various tables. On 5/15/2023 during first tour of the kitchen at 5:50 a.m. and while interviewing the Kitchen Aide Staff A and the Kitchen [NAME] Staff B, the area near the dish machine and on the dish machine side table were two crates with what appeared to be food soiled bowls and cups. Also, there was a stack of seven food soiled plates in the same area. Upon interview with the Staff A and B, they both revealed that staff from the night before must not have washed all the dishes and that they were from the previous night's 5/14/2023 dinner meal service. Staff A and B confirmed several small flying insects flying around the crates of soiled eating ware. They were not sure where the insects came from but indicated the flying insects have been in the kitchen on and off for some time (exact timeframe not given). They also confirmed more flying insects under the dish machine carriage and near the floor drain. During the lunch meal service at 12:30 p.m. there were over ten residents seated at tables eating their lunch meal. It was further observed small flying insects were flying around tables where residents were seated as well as flying off and on resident meal trays. Random resident interviews with three residents who wished to remain confidential, revealed that the bug problem has been getting worse in the dining room and also in their rooms over the past few weeks. They have notified their nurse and maintenance director but with no resolution. On 5/15/2023 at 6:00 a.m. and 9:10 a.m. interviews with Direct care Staff G, H, I, and J, all revealed that they have noticed small flying insects, roaches, and ants in resident rooms, around the nurse stations, in the dining rooms, activities rooms and in the shower rooms. They were aware on how to report pests and have done so in the past but also revealed it does not appear that the pest control treatments are working. Staff G, H, I, and J, also revealed that residents do complain about bugs every so often. During the 7-3 shift on 5/15/2023 random resident interviews with five residents who all wished to remain as confidential interviews, all revealed that there are bugs to include small flying insects, ants and cockroaches throughout the building. They all indicated the pests have been ongoing for awhile and they have spoken to staff to include their nurse and maintenance director but pest control does not seem to get any better. On 5/15/2023 at 1:20 p.m. an interview with the Maintenance Director revealed the facility does have a current pest control service, which treats about once a week. He further revealed that he has made request calls for treatment other than scheduled visits with relation to ants, cockroaches and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105202 If continuation sheet Page 6 of 7 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 05/15/2023 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 0925 Level of Harm - Minimal harm or potential for actual harm small flies. He confirmed through observation tour in the kitchen there were flying insects at and around the dish machine drain, the undercarriage of the dish washing machine, and in other areas throughout the kitchen. He revealed that he was planning on ordering an electronic fly trap which should take care of the insects in the kitchen. He was not sure where the insects were coming from, but did confirm that it had been reported from kitchen staff that the fly problem keeps coming back. Residents Affected - Some The Maintenance Director also confirmed flying insects in the dining room, the south wing hall unit station and revealed he was not aware of them in those areas until just now. He did not know how or where the insects came from. On 5/15/2023 the Maintenance Director provided and explained the current pest control program contract and treatment log. The log indicated last routine pest treatment visits on: 3/7/234, 3/13/23, 3/21/23, 4/16/23, 4/21/23, 5/6/23, 5/7/23. The log indicated facility was trea ted for various pests to include ants, roaches, spiders. Specifically, the pest control company treated for flies on 5/6/203 and 5/7/2023. On 5/15/2023 The Nursing Home Administrator provided the Pest Control policy and procedure (not dated), for review. The Policy Statement revealed; Our facility shall maintain an effective pest control program. The Policy Interpretation and Implementation section of the policy revealed; 1. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services to be provided by (named pest control company). 3. Windows are screened at all times. 4. Only approved FDA and EPA insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105202 If continuation sheet Page 7 of 7