Inspection·May 5, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with the Director of Nursing (DON) on 5/5/22 at 1:52 p.m. she said, I did a building wide sweep on anticoagulants and seizure medications at the end of April to see who needs yearly labs or labs at certain intervals. The DON confirmed Resident #59 refused her labs on 4/21/22 and said, But, she just had her Keppra and Depakote labs taken on 2/28/22 and I just talked to the physician and he said she wouldn't need labs in April if she just had them in February because she's ordered to have them every 6 months . one thing we could have done better is documented the resident refused and the nurse should not have signed it off as completed when it was not. Review of the facility's policy Laboratory Services effective January 1, 2020, revealed Policy: The facility will provide or obtain laboratory services to meet the needs of its residents/patients. The facility will be responsible for the quality and timeliness of services whether provides by the facility or an outside agency. The laboratory selected to perform the tests will be Medicare approved. Procedure: 1. Assure laboratory tests are completed and results provided to the facility within timeframes normal for appropriate intervention. 2. Provide or obtain laboratory services only when ordered by the physician. 3. Assure Nursing notified the physician promptly of the findings . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105293 If continuation sheet Page 2 of 4 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 105293 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Egret Cove Center 550 62nd St S Saint Petersburg, FL 33707 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to appropriately secure medications in the entrance of two resident rooms (Rooms #18 and #305); and failed to ensure appropriate storage of medications in three of three medication carts located on 100 (South Hall), 300 and 400 (North Halls). Findings included: During an observation of room [ROOM NUMBER], on 05/03/2022 at 9:42 a.m., a small oval blue pill was observed at the entrance of the resident room. An immediate interview of Staff A, Licensed Practical Nurse (LPN), revealed the nurse was in the middle of medication administration and confirmed the presence of the unsecured tablet at the entrance of resident room [ROOM NUMBER]. She stated, I can't own it, I don't think it is mine. (PHOTOGRAPHIC EVIDENCE OBTAINED) On 05/03/2022 at 1:15 p.m., during an interview with Staff A, (LPN), she said she informed the Director of Nursing (DON) of the unsecured pill and disposed of the medication in the pill buster. On 05/03/2022 at 3:34 p.m., an interview was conducted with the DON. The DON indicated Staff A informed her of the observations and revealed Staff A performed all her medication checks, and counted her medications earlier in the day. The DON stated, I haven't identified this as a trend, but I will bring it to the Quality Assurance (QA) committee. On 05/03/2022 at 9:59 a.m., an observation was conducted of room [ROOM NUMBER]. During the observation, one round white pill was located at the entrance of the room. An immediate interview was conducted with Staff B, Registered Nurse (RN), assigned to room [ROOM NUMBER]. Staff B, (RN) verified the presence of the unsecured white pill at the entrance of the resident room, and stated, Looks like it was spit out, it has some blurred scoring on it. I have no idea how that got there. An interview was conducted with the DON on 05/04/2022 at 11:37 a.m. She was informed of the observation of an unsecured tablet at the entrance of room [ROOM NUMBER]. The DON indicated she had not known there was another room that had a loose pill in the entrance. The DON stated, There should be no loose pills located anywhere in the facility. She further indicated that when the survey team found the unsecured tablet earlier in the day, she and the Nursing Home Administrator (NHA), held an in-service for staff related to watching for unsecured medications, and ensuring the residents consumed their medications prior to leaving resident rooms. On 05/05/2022 at 9:59 a.m , an observation of the 400 Hall (North) medication cart included eight unsecured tablets. Staff C, Registered Nurse (RN) confirmed the presence of the unsecured tablets. On 05/05/2022 at 10:20 a.m., an observation of the medication cart on 300 Hall (North) included one half of an unsecured blue tablet located in the narcotic box, one loose white capsule located on the side in a small open space in the narcotic drawer, and two loose tablets located in the third and sixth drawer from the top of the medication cart. Staff D Licensed Practical Nurse (LPN) confirmed the presence of the unsecured medications. (Photographic Evidence Obtained.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105293 If continuation sheet Page 3 of 4 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 105293 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Egret Cove Center 550 62nd St S Saint Petersburg, FL 33707 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 05/05/2022 at 10:40 a.m., an observation of 100 Hall (South) medication cart revealed one unsecured white tablet in the second draw, one unsecured tablet in the 4th draw, and one unsecured yellow capsule sitting on top of the medication box. Staff E, (LPN) confirmed the presence of the unsecured tablets. On 05/05/2022 at 11:33 a.m., an interview was conducted with the DON who was informed of the unsecured tablets located in all three (3) medication carts. During the interview the DON said the nursing staff brought her the unsecured tablets and she directed the staff to destroy the tablets in the pill-buster. She said the nursing staff rip the packages with pills, and the pills had the potential to fall out in the cart and box. She stated, There should be no loose pills in the medications in the carts. She further indicated the facility would immediately initiate audits. A review of the facility policy titled Medication Storage Section 4.1, dated of 09/2018, Pages 01 and Page 02, revealed under Policy Statement: Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: 1. The pharmacy dispenses medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers. 15. Medication storage should be kept clean, well lit, organized and free of clutter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105293 If continuation sheet Page 4 of 4