Health inspection·September 3, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and medical record review, the facility failed to implement interventions for a fall care plan for one (#16) of four residents sampled for accidents out of a total resident sample of 39. Findings included: On 08/31/21 at 8:19 a.m., Resident #16 was observed sitting on the right side of the bed. A floor mat was visible on the floor to the left of the bed. A second floor mat was observed propped against the wall behind the door. On 09/01/21 at 8:22 a.m., Resident #16 was observed sitting in his wheelchair. The floor mat on the left side of the bed was placed on the floor with the front left corner caught on the wheel of bed. The other floor mat was observed propped against the wall. On 09/01/21 at 12:35 p.m., Resident #16 was observed in bed. The floor mat placed on the left of the bed was not placed flat on the floor, and the corner edge of the mat was still caught on the bed. Photographic evidence was obtained. Review of the Resident Face Sheet for Resident #16 revealed diagnoses of muscle weakness, difficulty in walking, muscle wasting and atrophy, and unsteadiness on feet. Review of the resident's most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 9 indicating moderate cognitive impairment and no history of falls. Review of Resident #16's Care Plan dated 5/28/21 revealed Resident #16 was at risk of falls related to muscle weakness. Interventions included: Fall mat to left and right side of bed when in bed Review of Resident #16's Nursing Progress notes revealed that on 8/16/21 Resident #16 was found sitting on the floor next to the bed. The resident stated that he slid to the floor. Resident uses bed controller in unsafe manner, he puts the bed as high as it will go. The resident returned to bed, and assessment completed with no signs or symptoms or complaints of injury. Physician and friend notified. On 09/01/21 at 3:05 p.m., Staff E, Certified Nursing Assistant (CNA), stated that if the resident was at risk for falls, the nurse would contact the physician to get an order to use floor mats. The mats should be always used and be placed on both sides of the bed. Staff E reported that Resident #16 does not like having the floor mats and insisted the one on the right side of the bed be removed. Staff E stated she has received training/in-service regarding the use of floor mats. The CNA staff look at the care plan to find out if the residents need floor mats, and that if she has any concerns, she would let the hall nurse know. On 09/01/21 at 3:04 p.m., Staff D, Registered Nurse (RN), stated that if a resident was a fall risk, had a history of falls or had a fall in the facility, the use of mats would be care planned. Floor mats are generally up when the resident was out of bed and put down when the resident was in bed. If the CNA staff have any concerns they will notify the hall nurse, who will follow up with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 2 of 12 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St New Port Richey, FL 34653 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 0656 resident's physician and the Director of Nursing (DON). Level of Harm - Minimal harm or potential for actual harm On 09/02/21 at 10:52 a.m., an interview was conducted with the DON and Nursing Home Administrator NHA. The NHA stated that residents were assessed on admission for history of falls, or if they were a fall risk due to medical conditions. The decision to implement safety measures including use of floor mats was the decision by the Interdisciplinary Team (IDT). The IDT meet every morning to discuss resident falls. The use of floor mats was documented in the care plan, and no physician order was required. Floor mats should be down when the resident's in bed and up when the resident's out of bed. Floor mats should be on both sides of the bed for resident safety. Residents Affected - Few On 9/3/2021 the DON provided the Comprehensive Care Plans policy and procedure with an effective date of 4/6/2015 and last review date of 7/19/2018. The policy statement revealed: A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, and goals and preferences. The Guidelines of the policy and procedure revealed: Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Following pertinent areas to include, revealed: 1. The nurse/Interdisciplinary Team (IDT) develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The Comprehensive Care Plan will be developed with participation form the resident, resident's family or resident representative as indicated. 2. Each resident's Comprehensive Care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on resident's strengths; d. Reflect the resident's expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetable and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Include any specialized services or specialized rehabilitative services to be provided as identified in the PASRR (pre-admission screening and resident review) recommendations; h. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; i. Enhance optimal functioning of the resident by focusing on a rehabilitative program; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 3 of 12 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St New Port Richey, FL 34653 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 0656 j. Reflect currently recognized standards of practice for problem areas and conditions; Level of Harm - Minimal harm or potential for actual harm 3. The Comprehensive Care Plan will include the goals for admission and desired outcomes gathered from the resident and the resident representative. Residents Affected - Few 4. Care Plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 4 of 12 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St New Port Richey, FL 34653 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, medical record review and policy review, the facility failed to ensure the safety and supervision for one (#36) of four residents sampled for accidents related to Resident #36 self propelling through a busy parking area, positioning himself off of the facility property with no orders for leave of absence, and smoking cigarettes unsupervised in an area with high vehicle traffic. Findings included: On 9/2/2021 at 7:57 a.m., Resident #36 was observed in the front parking lot, as viewed from the conference room window. Resident #36 was observed self propelling while seated in his wheelchair. The resident was using both hands to turn the wheels to propel. His right foot was placed on a foot pedal and his left foot was amputated from below the knee. He was observed to propel on the paved throughway where cars drive to park. The resident continued heading towards the south entrance of the parking lot where vehicles would enter. Resident #36 continued to the entrance of the parking lot and continued out to the sidewalk, near a two lane road. There was approximately thirty feet of paved incline to the sidewalk. The resident appeared to become tired from self propelling using only his arms all the way up to the sidewalk. Once he reached the sidewalk, he positioned himself in an area in between the driveway to enter into the facility and another driveway to enter an adjacent Assisted Living Facility. Observations revealed both driveways were busy with vehicles entering to park. Resident #36 was observed at 8:02 a.m. to pull out cigarettes and a smoking lighter from his left jacket pocket and started smoking a cigarette. During that time he left the facility and sat in the area to smoke, it was observed with light rain. Photographic evidence was obtained. On 9/2/2021 at 8:15 a.m., the Nursing Home Administrator (NHA) was brought to the conference room to look out the window to see where Resident #36 was located. The NHA confirmed that the resident was off the property and was smoking. She indicated that the resident could sign himself out and that he was a safe smoker. She revealed that she was not aware of how Resident #36 got to the community sidewalk, but confirmed that vehicles to include cars and large delivery trucks drive in through the one way area to the facility's parking lot. During the interview with the NHA, a large garbage truck was observed coming up the driveway near the area where Resident #36 was seated and smoking. The NHA revealed that Resident #36 can self check himself out and in from the facility and should have signed himself out using the sign in/sign out log. On 9/2/2021 at 8:25 a.m., the sign in/sign out log was reviewed at both nurses stations. Resident #36 was not in any of the logs. This was confirmed by the Director of Nursing (DON) who reviewed the logs and could not see any evidence that the Resident had signed in/out. On 9/2/2021 at 8:48 a.m., the DON was observed to walk out to the resident and assist him back to the facility. On 9/2/2021 at 9:15 a.m., an interview attempt was made with Resident #36. Resident #36 refused to speak with the survey team. On 9/2/2021 at 10:20 a.m., an interview with the DON confirmed she was familiar with Resident #36 and was outside this morning with him to walk back from the outside sidewalk to the inside of the facility. She confirmed that Resident #36 did not sign himself out and she could not provide evidence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 5 of 12 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St New Port Richey, FL 34653 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that he signed himself out LOA on any date. The DON was provided both Leave Of Absence Binders, from the A/B and C/D units for review. She confirmed Resident #36 was not in either of the books. She confirmed that he has gone out to the sidewalk and street to smoke in the past and this was not the first time. The DON reviewed Resident #36's medical records to include the current month 9/2021 and last month's 8/2021 Physician's Order Sheet. She confirmed that Resident #36 did not have an order for LOA. She further confirmed by reviewing the current care plans that Resident #36 was not care planned for LOA. The DON also confirmed that she could not find an acknowledge form or understanding of smoking rules that was signed by Resident #36. Review of Resident #36's medical record revealed he was admitted to the facility in March of 2021. Review of the advance directives revealed the resident was his own responsible party. Review of the admission diagnosis sheet revealed diagnoses to include tremors, muscle weakness, difficulty in walking, need for assistance with personal care, and chronic obstructive pulmonary disease (COPD). Review of the current Minimum Data Set (MDS) quarterly assessment, dated 6/16/2021 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident's cognition was intact. Review of the Elopement evaluation dated 7/22/2021 revealed Resident #36 had the ability to exit the facility and was not determined to be at risk for elopement. Review of the Smoking evaluations dated 3/23/2021 at 2:01 p.m. and 9/1/2021 at 12:40 p.m. revealed Resident #36 was determined to be a safe smoker. Review of the current care plans with last review date of 7/28/2021 revealed the following areas: a. Activities of Daily Living (ADL) self care deficit related to muscle weakness. Interventions included: Locomotion as Independent. b. Smokes and at risk for safety concerns related to desire to smoke with intervention to include but not limited to: Resident and responsible party will be oriented to the smoking policy and smoking areas, demonstrate ability to physically hold the smoking device while smoking, and resident will be supervised while smoking at all times. c. Risk for falls related to below the knee amputation (BKA) with interventions in place to include: cueing for safety awareness. d. Risk for alteration in mood, behavior, cognition, and level of functioning due to recent restrictions regarding visitation. The current visitor restrictions have the potential to cause resident to experience adverse psychosocial changes such as an increase in depressive and anxious signs/symptoms that have the potential to negativity affect my well being with interventions in place. Further review of all the care plans, did not reveal any problem areas, with goals and interventions related to the ability to go on LOA. On 9/3/2021 at 12:50 p.m., an interview with the care plan coordinator revealed if a resident was ordered for LOA, there was usually a care plan that was initiated with interventions. She confirmed that Resident #36 was not care planned for LOA and that there was no order for LOA as well. On 9/3/2021 a follow up interview with the NHA at 10:00 a.m. confirmed Resident #36 was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 6 of 12 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St New Port Richey, FL 34653 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 0689 assessed or care planned to go on LOA, even just off the property line to smoke. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy and procedure titled, Resident Leave of Absence most recently revised on 11/7/2018 revealed: Residents Affected - Few Policy Statement: The organization promotes person-centered care and affords leave from the facility based on physician approval. A leave of absence (LOA) is a period of time the resident is away from the facility while maintaining the status of a resident of the facility. Definitions: Therapeutic leave is defined as an absence from the facility for purposes other than required hospitalization. Guidelines: 1. Residents will be afforded therapeutic leave from the facility based on physician orders and approval; 2. A resident who wishes to take an unsupervised leave of absence may do so contingent upon each of the following: The completed and signed written release of responsibility for Leave of Absence form; Approval of the Licensed Health Professional; Documentation of Interdisciplinary agreement; Inclusion of the Leave of Absence in the care plan; The therapeutic Leave of Absence will be consistent with the resident's goals for care and included in the comprehensive assessment (when applicable) and incorporated into the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 7 of 12 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St New Port Richey, FL 34653 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one (#73) of one resident sampled for dialysis out of 3 facility residents receiving dialysis. Residents Affected - Few Findings included: Review of Resident # 73's admissions record revealed that he was admitted to the facility in October of 2020 with diagnoses that included type 2 diabetes mellitus, end stage renal disease, and dependence on renal dialysis. Review of the Minimum Data Set Assessment (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicates that Resident # 73 was cognitively intact. Review of Resident # 73's medical records revealed no documentation of communication between the facility and the dialysis center related to his status prior to and after hemodialysis treatment. A review of Resident # 73 care plan dated 10/26/2020 and edited on 8/24/21 under the category Dialysis revealed: Resident #73 is at risk complications related to ESRD (End Stage Renal Disease) and dependent on Hemodialysis. Interventions included: -Communicate with dialysis center regarding medication, diet, and lab results. Coordinate resident's care with dialysis center. On 09/02/21 at 9:54 a.m., the facility's Dialysis communication sheet or form was requested from the Director of Nursing (DON). On 09/02/21 at 12:56 p.m., the DON stated that because of the pandemic, paperwork was not being sent to the dialysis center with the residents. She stated that paperwork was being faxed to maintain communication with the dialysis center. The faxed communication documents were requested from the DON. On 09/03/21 at 10:44 a.m., follow-up interview with the DON revealed she was unable to provide communication sheets for the past 30 days. She provided two communication sheets, one dated 7/30/21 and the other dated 8/4/21. The dialysis communication sheets were not completed in their entirety. The section under the subheading Dialysis nurse completes this section post Dialysis was not completed. On 09/03/21 at 2:36 p.m., Staff D, Registered Nurse (RN), stated that dialysis communication sheets were not being used between the facility and the dialysis center. She stated that the DON was in the process of putting together a hemodialysis (HD) binder two weeks ago for residents on dialysis, but she does not know what happened to that process. On 09/03/21 at 2:52 p.m., Staff K, RN stated that the facility does not have any form of communication in place to communicate with the dialysis facility. She stated that the dialysis center would call the facility and fax information for a resident if there were any changes or adjustment in medications or any other procedures or problems, but the facility has not been sending or faxing communication information prior to dialysis services to communicate with the dialysis center. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 8 of 12 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St New Port Richey, FL 34653 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's Dialysis Transfer Agreement dated 12/2/2014 revealed, #3 under the subheading Designated Resident Information, Facility shall make its best effort to provide appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to Center. This information, shall include, but not limited to, where appropriate, the following: (E) Treatment presently being provided to the Designated Resident, including medications and any changes in a patient condition (physical or mental), change in medication, diet, or fluid intake. Event ID: Facility ID: 105275 If continuation sheet Page 9 of 12 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St New Port Richey, FL 34653 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, interviews and facility record review, the facility failed to ensure it had an effective pest control program with regards to flying insects observed in resident spaces to include one of one main dining room, hallways, and one of one kitchen, during four of four days observed, (8/31/2021, 9/1/2021, 9/2/2021, and 9/3/2021). Residents Affected - Many Findings included: On 8/31/20212 at 11:00 a.m., the main dining room was observed for the lunch meal service. The dining room was a very large open area located in between both the 100/200 and 300/400 unit stations. Further, the middle of the dining room was observed with double doors that led to the smoking area/courtyard. The dining room was observed with ten tables with thirty residents seated throughout the area. While interviewing several random residents at least twelve medium sized flying insects (possible house flies) were observed on the table tops and then started buzzing around the tables. There were three residents that were in the immediate area while being interviewed. Two of the residents were observed to swat away the flies with their hands. There were also several flies that were observed to land on Resident #19's face, food, mustache and eyebrows. Resident #19 along with another resident, Resident #60 confirmed that many bugs and flies have been in the facility and buzzing around the dining room for weeks now. Photographic evidence was obtained. On 8/31/2021 the lunch meal service started at 11:40 a.m. There were over twenty medium sized flying insects buzzing around many of the tables in the dining room and where residents ate. At 11:52 a.m. the meal tray cart arrived from the kitchen and staff immediately started to pass trays to residents at tables. During the entire meal service and while residents were eating, residents were observed to swat at the buzzing flies around their table. Flies had been observed landing on various residents and their plates of food and drinks. On 8/31/2021 at 12:08 p.m. an observation and interview with Resident #33 and Resident #19, who were seated at a table together, confirmed the buzzing flies around them and were attempting to swat them away with their hands and cloth napkins. Residents #33 and #19 both revealed they, along with many other residents, have constantly complained about the huge fly problem for months now and nothing has been done other than the facility putting up an air blaster at the door that leads outside to the smoking area/courtyard. On 9/1/2021 at 7:45 a.m., the main dining room was observed for the breakfast meal service. During that time there were five residents seated in their wheelchairs, at tables in the room. Further observations revealed at least seven medium sized flying insects buzzing around various tables and landing on residents wheelchairs and tables. Two of the residents were observed to swat away flies for a period of time. On 9/1/2021 at 9:20 a.m., a group activity was beginning in the the main dining room. Ten residents were seated at various tables and at least fifteen flies were observed flying/buzzing around the residents and landing on their heads, shoulders, hands, face, and on the tables. Most of the residents were observed to swat at the flies while participating in the group activities. Residents were overheard speaking to one another about the fly problem. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 10 of 12 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St New Port Richey, FL 34653 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 Residents Affected - Many On 9/1/2021 at 11:19 a.m. the main dining room was observed with eighteen residents seated at various tables and awaiting the lunch meal service. Further observations revealed twenty flies buzzing around the residents in the main dining room. Some residents were swatting the flies away with their hands. On 9/2/2021 at 5:50 a.m. and 7:00 a.m., the main dining room and 200/300 nursing station were observed with over ten flies buzzing around the tables and desks. There were no residents present at the time. Further observations of the double doors that leads to the smoking area/courtyard revealed a large electronic air blast curtain affixed to the wall above only one of the doors. This electronic air curtain had been observed operating and functioning appropriately. However, the device only covered one of the two doors that led outside to the smoking area/courtyard. These doors were observed to open and close multiple times throughout the day. Photographic evidence was obtained. On 9/2/21 at 7:30 a.m. the main dining room was observed with twelve residents seated at six tables. The residents were served their breakfast trays at 8:00 a.m. During their dining experience, there were over ten flies observed at and near the residents. Flies were observed to land on and off of the residents' food, resident,s and their chairs/wheelchairs. Some residents were observed to swat at the flies and were talking with one another about the fly problem. On 9/2/2021 at 11:30 a.m., a kitchen tour was conducted. The food prep area, food holding area/steam table were observed with five medium sized flying insects. The flies were observed to land on various kitchen equipment and food prep surfaces. Interview with two cooks, Employees G and H revealed that they have had a facility-wide problem with flies the past few weeks and more since the recent heavy rains. They revealed pest control comes and maintenance treats, but the flies just keep coming back. On 9/2/2021 at 12:00 p.m., the main dining room was observed with over twenty-five residents seated at various tables. During the entire meal service, there were approximately fifteen medium sized flying insects buzzing and flying around residents and landing on food items, resident wheelchairs, and landing on residents' faces, arms and hair. Most residents were observed swatting the flies away with their hands. Staff were observed to swat at flies as well. On 9/3/2021 at 9:10 a.m., random interviews with six residents who all wished to remain anonymous revealed the facility has had a fly problem for months now and they, along with other residents have routinely complained about them. They revealed their dining experience was terrible with flies landing all over them and their food. They have reported to staff with no correction. On 9/2/2021 at 11:00 a.m., a resident group meeting was held with three random residents, to include Residents #25 and #33 and #60. The residents expressed that there was a huge fly problem in the facility and that there were flies in spaces to include their rooms, bathrooms, shower rooms, hallways and mainly in the main dining/activity room. The residents indicated that they continue to complain about the flies, but it does not seem to get any better. Resident #25 revealed he was provided with a fly swatter to swat flies in her room. On 9/3/2021 at 7:20 a.m., the C/D wing nurse desk was observed with a bright green fly swatter with left over remnants of dead insects on it. Interview with two nurses, Employees J and I, confirmed the fly swatter at the desk and continued to say, we use it for the large fly problem we are having here. Employee I also stated, I don't know what's going on lately with the flies, but it's awful. Neither nurse knew if the pest control company had visited recently and both had told maintenance about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 11 of 12 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St New Port Richey, FL 34653 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 the problem in the past. Level of Harm - Minimal harm or potential for actual harm On 9/3/2021 at 7:40 a.m., the main dining room was observed with seven residents seated at tables. They were provided with their breakfast meal and began to eat. While they were eating there were ten medium sized flying insects landing on and off the residents' food, tables, heads and arms. Residents were observed trying to swat flies away with their hands. Residents Affected - Many On 9/3/2021 the Director of Nursing (DON), provided the facility's pest control contract and log for review. A Review from March 2021 through the current month of September of 2021 revealed normal pest control treatment had occurred but no specific treatment to include houseflies, or any type of flying insects was noted. The contract was reviewed and it was current between the pest control company and the facility. On 9/3/2021 at 11:00, the Maintenance Director and Nursing Home Administrator (NHA) were interviewed related to the pest control program and the flies observed throughout the facility. The Maintenance Director and NHA confirmed that their pest control company comes routinely at least once a month and treats for various pests/bugs. The NHA and the Maintenance Director confirmed the housefly issue as of recent and have tried different interventions to include putting up a door air blast curtain at the double doors that lead from the dining room to the smoking porch. They confirmed that the house flies must be coming from somewhere else. Neither the NHA or the Maintenance Director could say exactly when the house fly issue started. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 12 of 12