Inspection·June 30, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #193 shuffled towards the door; within four to five feet of Resident #193, there were five male residents and one female resident either standing or walking by. There were no staff in the immediate area during this observation from 1:50 p.m. through to 2:03 p.m. At 2:07 p.m. a staff member came out from room [ROOM NUMBER]. The staff member was noted as CNA Employee B. Employee B. was asked if she had Resident #193 on her assignment. She revealed that she did not but has had her on her assignment in the past. Employee B. was shown that resident #193 was not clothed from her waist down and was out in the main hallway next to the nurse station, and with residents surrounding her. She looked over at Resident #193 and explained that she removes her clothes at times. CNA Employee B. explained that she could not tend to Resident #193 at that immediate time because she was in another room trying to dress another resident. Employee B. went back into another resident's room and closed the door behind her. Once she did that, Resident #193 was still observed out in the main hallway with no clothing on from her waist down and only wearing an adult brief. At 2:13 p.m. Employee B. came out of another resident's room and walked up to Resident #193 and brought her to her room and then closed the door to clothe her. It was observed Resident #193 was disrobed and exposed out in the main hallway with other residents, not wearing any pants or shorts/underwear, and not wearing any socks and shoes, with only wearing a shirt and an adult brief for at least twenty -three (23) minutes before staff intervened. On 6/28/2022 at 7:30 a.m. Resident #193 was observed lying in bed and on her side facing the wall. The linen was pulled down to her feet and she was observed with a long-sleeved shirt on but again not wearing any bottoms. From the hallway, Resident #193 was observed with her entire bottom exposed and wearing only an adult brief. Other residents were observed walking up and down the hallway, past Resident #193's room. At 7:40 a.m. an interview with Resident #193's assigned 7-3 shift care aide Employee C. revealed she floats all over the building but knows Resident #193. She was asked about the resident observed with no bottoms on she expressed the resident disrobes at times but has never seen her out from her room with no bottoms on. She revealed if residents are out in the hallways and not dressed, staff are to immediately bring them back to their rooms and try to redirect them and redress them. She also expressed if residents are in their rooms and in bed and not wearing appropriate clothing, they do try to shut the door so they cannot be seen from the hallway. Employee C. explained that however, other residents in the room will reopen the door. At 7:56 a.m. CNA employee C. walked by Resident #193's room and saw she was lying in bed over her covers and with only wearing a shirt but with no bottoms and exposing her entire lower body with wearing only an adult brief. The room door was all the way open. She entered the room and closed the door to resituate and cover the resident. It was determined that Resident #193 could be seen in her room, from the hallway, disrobed and exposed with no clothes on from her waist down, for at least twenty (20) minutes before staff intervened. On 6/30/2022 at 8:10 a.m. an interview with the LS1 [NAME] Secured Unit Manager revealed staff should always be monitoring residents and to maintain dignity. She revealed the unit does have several residents who disrobe and there should be staff to immediately redirect and or intervene, and to re dress or take to their rooms. The Unit Manager confirmed the times when Resident #193 was observed out in the main hallways not wearing any pants or underwear, all floor staff were either outside assisting with resident smoking supervision or were in rooms providing care and services to other residents. She also confirmed that she usually is seated at the nurse station throughout the day and she can see both halls. However, she revealed she also worked in other units in the building. On 6/30/2022 at 2:00 p.m. an interview with the Nursing Home Administrator revealed residents in the secured unit should be monitored and supervised at all times and residents should not be in that unit unrobed without staff in their immediate area to intervene or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 2 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few redirect. The Nursing Home Administrator did confirm the Unit Manager, Employee A. does sit at the nurse station through the shift and is able to see both hallways seated at the nurse station, but also confirmed Employee A. for the past week or so, has also been in charge of another unit outside of the Secured unit, and Unit Manager, Employee A. has had to pull double duty at the same time with both the Secured Unit and another unit outside the Secured Unit. The Nursing Home Administrator further confirmed the Secured Unit residents need to be supervised and monitored all day and that she needs to make sure Employee A. stays and works only in that unit. The Nursing Home Administrator also indicated there should be more staff intervention and redirection for those residents who disrobe and walk around the unit. Further, she revealed that female residents to include Resident #193 should be monitored more closely for disrobing and walking around the hallway or lying in her bed with the door open and disrobed. She revealed that staff should either close the door or go in the room and either educate her to pull over the covers, pull the privacy curtain or close the door. Review of Resident #193's medical record revealed she was admitted to the facility on [DATE] and was readmitted on [DATE]. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Schizophrenia, Psychosis, Mild intellectual disabilities, Mood disorder, History of falling, Anxiety and Dementia with behavioral disturbances. Resident #193 resides in the secure/dementia unit. Review of the current annual Minimum Data Set assessment, dated 6/2/2022 revealed: (Cognition/Brief Interview Mental Status or BIMS score 5 of 15; which indicates that the resident would not be able to answer questions about her financial and medical care); (Mood - documented as having trouble concentrating on things 12 - 14 days observed); (Behaviors - documented as having delusions, having verbal behavior symptoms towards others during 1-3 days observed); (Activities of Daily Living ADL Limited Assistance with one person physical assistance with Dressing, and Extensive Assistance with one person physical assistance with Personal Hygiene). Review of nurse progress notes dated from 1/20/2022 through to current date 6/29/2022, revealed the following notes with behaviors. - 5/17/2022 12:25 - Pt [patient] ambulating out in halls without shirt on screaming and yelling. Redirected back to room to get clothing on. Pt. continued to come into hall yelling this afternoon and pt reached nurses medication cart and started hitting and slapping self in the face with palms of her hands. Redirected with distraction. Will continue to monitor. There was only one note documented indicating resident disrobed. There were no other dates noting this as a continued behavior. Review of the current physician's order sheet (POS) dated for the month of 6/2022 revealed orders to include but not limited to: May reside on secure unit (start date 4/6/2022). Review of the current Care Plans with a next review date 9/8/2022 revealed the following areas: (a) Resident #193 is an Elopement risk related to dementia and mobility, likes to go to offices and sit and visit and get books. Not exit seeking or attempted to elope from facility, with interventions in place. (b) Resident #193 has following advance directives on record; Full Code Status, Health care proxy, Incapacity statement - not capable of giving informed consent regarding health care decisions. Incapacity statement signed and dated by Physician on 6/20/2014, with interventions in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 3 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0550 (c) Resident #193 has Impaired cognition and impaired thought process, with interventions in place. Level of Harm - Minimal harm or potential for actual harm (d) Resident #193 has Mood problem, looks pained, sad, and worried, makes negative statements, repetitive physical movements, and restlessness (hits self on head), with interventions in place. Residents Affected - Few (e) Resident #193 has Behaviors to include (outburst, strikes self in head, yells out, removes clothing, Throws items on the floor, Shows aggression to staff and other residents, Verbally and physically abusive when agitated, Takes items from others, Places self on floor, Hoards items, Follows behind staff, Bangs head with her hands, with interventions in place to include but not limited to: Psych consult; Anticipate and meet the resident's needs; Approach and speak in calm manner; Assist the resident to develop more appropriate methods of coping and interacting; Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; If reasonable discuss the resident's behavior; Intervene as necessary to protect the rights and safety of others; Monitor/document effectiveness; Remove the resident from the situation and take to an alternate location as needed. (f) Resident #193 requires some assistance with her daily care needs along with cueing and reminders to stay on task. Can be resistive at times, with interventions to include but not limited to: Arrange resident/patient environment as much as possible to facilitate ADL performance; Monitor conditions that may contribute to ADL decline, including psychiatric disorder; Provide cueing for safety and sequencing to maximize current level of function. (g) Resident #193 has impaired cognitive function or impaired thought processes r/t difficulty making decisions, impaired decision making, Psychotropic medication use, Problems understanding others, Problems making self-understood, with interventions to include but not limited to: Cue, Reorient and supervise as need; Monitor/document/report PRN any changes in cognitive functions, specify changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, mental status. On 6/30/2022 at 3:00 p.m. the Nursing Home Administrator provided the facility's Promoting/Maintaining Resident Dignity policy and procedure (not dated), for review. The policy revealed: It is the practice of this facility to protect and promote resident rights and teat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Guidelines included: 1. All staff members are involved in providing care to the residents to promote and maintain resident dignity. 2. During interactions with residents, staff must report, document and act upon information regarding resident preferences. 3. When interacting with a resident, pay attention to the resident as an individual. 4. Groom and dress residents according to resident preferences. 5. Random observations and/or verifications are conducted by the Director of Nursing Services or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 4 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0550 designee, to ensure compliance with this policy. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 5 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure one resident (#143) was free from the use of restraints out of one sampled resident for restraint usage. Residents Affected - Few Findings included: On 6/27/22 at 12:02 p.m., Resident #143 was observed in her room sitting in a high back wheelchair with a black thigh belt across her thighs. When an attempt to interview the resident was conducted Resident #143 would not speak. On 6/28/22 at 10:00 a.m., Resident #143 was observed in her room sitting in the high back wheelchair with a black thigh belt across her thighs. A review of the admission Record indicated Resident #143 was readmitted into the facility on 6/10/22 with a primary diagnosis of Huntington's Disease and other diagnoses included but were not limited to schizophrenia, abnormal posture, bipolar disease, mood disorder, and history of falling. A review of Section C: Cognitive Patterns of the Annual Minimum Data Set (MDS) dated [DATE] indicated the resident was rarely/never understood. A review of the current orders dated 6/2022 indicated no order for the thigh belt. There was no consent or evaluation in the medical record for the use of the thigh belt. Care plans initiated on 9/15/20 related to poor safety awareness, uncontrollable movements, and impaired mobility reflected the following intervention: Staff to check frequently to ensure thigh belt is in correct placement due to resident with uncontrollable jerking movements. On 6/30/22 at 11:55 a.m., the Director of Nursing (DON) reported Resident #143 had Huntington's disease. She stated therapy placed the thigh belt on her for positioning. The DON confirmed the resident could not take off the thigh belt. On 6/30/22 at 2:38 p.m., the DON reported she was told the resident could wiggle out of the thigh belt. On 6/30/22 at 3:23 p.m., the DON confirmed there was no assessment or evaluation completed related to the thigh belt. The policy provided by the facility Restraint Free Environment undated revealed the following: Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 6 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0604 Definitions: Level of Harm - Minimal harm or potential for actual harm Physical Restraint refers to any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: Residents Affected - Few Applying leg or arm restraints, hand mitts, soft ties, or vests that the resident cannot remove. Using devices in conjunction with a chair, such as trays, tables, cushions, bars, or belts, that the resident cannot remove and prevents the resident from rising. Compliance Guidelines: 4. A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint. 5. Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine: a. How the use of restraints would treat the medical symptom. b. The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released. c. The type of direct monitoring and supervision that will be provided during use of the restraint. d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place. e. How to assist the resident in attaining or maintaining his or her practicable level of physical and psychosocial well-being. 6. Medical symptoms warranting the use of restraints should be documented in the resident's medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptom. The care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 7 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide written notification of Transfer/Discharge to Resident Representatives and the Ombudsman for five residents (#24, #161, #188, #221, and #95) of five residents sampled for hospitalization. Findings included: On 6/28/22 at 10:44 a.m. Resident #24 was observed lying in the bed in his room. The resident was able to answer simple questions. The resident was observed with a hospital armband on and denied being hospitalized recently. A review of the medical record revealed Resident #24 was re-admitted to the facility on [DATE] with diagnoses including but not limited to Parkinson's Disease, Diabetes Mellitus, Malnutrition, and Hypertension. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 6/4/22 8:47 p.m. At approximately 4 pm staff notified writer that resident had loose stools. Resident was sitting in bed, alert and responsive, right then resident started vomiting clear liquids, VS [vital signs] 106/58, p [pulse] 62, r [respirations] 24, O2 [oxygen saturation] sat 88% RA [room air], placed on oxygen, notified [doctor name] with new order to send resident to ER [emergency room] to treat and eval [evaluate], 911 [emergency medical system] notified, resident transferred to [local hospital] via stretcher, left message for responsible to call back facility when available. A review of the Nursing Home Transfer and Discharge Notice dated 6/4/22 revealed Resident #24 was sent to the hospital due to needs cannot be met and a Resident Representative and phone number was listed on the document. On page 2 of the document a signature was present for the Nursing Home Administrator/Designee. No signature was noted for the Resident/Resident Representative area of the form. The Local Long Term Care Ombudsman Council area of the notice was dated for 6/4/22. On 6/27/22 at 12:46 p.m. Resident #161 was observed lying in bed with a sitter at the bedside. The resident was sleeping. The resident was unable to answer any questions related to care and services. A review of the medical record revealed Resident #161 was most recently admitted on [DATE] with a diagnoses including but not limited to metabolic encephalopathy, dementia, malnutrition, pseudobulbar affect, schizoaffective disorder, and anxiety disorder. A review of the MDS assessment dated 5/16 22 revealed a BIMS score was unable to be completed for the resident due to diagnoses and cognitive impairment. A review of the nursing progress notes revealed the following entry: 5/6/2022 at 9:27 a.m. Patient observed by staff demonstrating unsafe acts to herself and destroying (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 8 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some items in facility. Patient observed by staff tying her wrist in the blinds, patient wrist removed from blinds. Risk manager, unit manager, and nurse practitioner notified in facility. 911 called for transport to emergency room for increased AMS [altered mental status]. A review of the Nursing Home Transfer and Discharge Notice dated 5/6/22 revealed Resident #161 was sent to the hospital with no reason for discharge or transfer marked. A Resident Representative and phone number was listed on the document. On page 2 of the document a signature was present for the Nursing Home Administrator/Designee. No signature was noted for the Resident/Resident Representative area of the form. The Local Long Term Care Ombudsman Council area of the notice was blank. On 6/27/22 at 12:30 p.m. Resident #188 was observed seated in a wheelchair by the nurse's station. The resident was unable to answer any questions related to care and services. A review of the medical record revealed Resident #188 was most recently admitted to the facility on [DATE] with a diagnosis of diverticulitis, dementia, anxiety, mood disorders, malnutrition, depression, bipolar, insomnia, and psychosis. A review of the MDS assessment dated [DATE] revealed Resident #188 had a BIMS score of 99 indicating the resident was unable to complete the interview due to moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 6/20/22 10:52 a.m. Resident was noted to have a change of condition during medication rounds. He was less responsive, skin was cold and clammy, decreased respirations. His urinary output was minimal at 25 cc [cubic centimeters]. BP 98/61 O2 92 P65 R14. Per the paramedics his blood sugar 56. Spoke with doctor gave order to send the resident to hospital for evaluation. POA [power of attorney] was notified of the change of condition and the order to sent for evaluation. A review of the Nursing Home Transfer and Discharge Notice dated 6/18/22 revealed Resident #188 was sent to the hospital due to cannot met needs at facility. A Resident Representative and phone number was listed on the document. On page 2 of the document a signature was present for the Nursing Home Administrator/Designee. No signature was noted for the Resident/Resident Representative area of the form. The Local Long Term Care Ombudsman Council area of the notice was blank. A review of the medical record for Resident #221 revealed the resident was most recently admitted to the facility on [DATE] with a diagnosis of dementia, epilepsy, schizoaffective disorder, traumatic brain injury and major depressive disorder. A review of the MDS assessment dated [DATE] revealed Resident #221 had BIMS score of 12 indicating moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 5/8/2022 10:16 p.m. Resident found with shortness of breath, labored breathing, O2 80-86% on oxygen at 2 liters per nasal cannula, diminished lung sounds, with eyes closed and difficult ot arouse. Primary doctor notified with order to send to emergency room for evaluation and treatment. Message left with representative. A review of the Nursing Home Transfer and Discharge Notice dated 5/8/22 revealed Resident #221 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 9 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sent to the hospital due to cannot met needs at facility. A Resident Representative and phone number was listed on the document. On page 2 of the document a signature was present for the Nursing Home Administrator/Designee. No signature was noted for the Resident/Resident Representative area of the form. The Local Long Term Care Ombudsman Council area of the notice was filled in with 5/8/22. On 6/29/22 at 3:53 p.m. an interview was conducted with the Social Services Director (SSD) and the Director of Nursing (DON). The SSD stated the transfer and bed hold policy forms are given to him once nursing has completed the forms and sent the resident out of the facility. He stated he does not send any written notices to the Resident Representative or the Ombudsman. He stated he was not aware he needed to do this because he had misinterpreted the regulation. He stated he was aware now that he needs to do this and he will correct his practice. He stated he stopped sending notifications to the Ombudsman three months ago because he did not believe he needed to anymore. He stated the only time he sends out a written notification is when a resident is being given a 30-day notice of discharge. The DON verified his current practice and his misinterpretation of the regulation. On 6/30/22 at 10:01 a.m. an interview was conducted with Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM). Staff A, LPN UM stated the nurses are responsible for completing all paperwork for a transfer to the hospital for a resident. This includes the transfer form and the bed hold policy form. The Resident Representative is notified by telephone only by the nurse. The nurses do not send any paperwork in writing to the Representatives or the Ombudsman. The paperwork is sent to the medical records department for follow-up once the resident is out of the facility. A review of the facility policy entitled Transfer and Discharge (including AMA), undated and presented by the DON for review, indicated the following: Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. Policy explanation and compliance guidelines: .3 The facility may initiate transfers or discharges in the following limited circumstances: a The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. .c The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. .7 Emergency Transfers/Discharges-initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). a Obtain physician's orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. b Notify resident and/or resident representative. c Contact an ambulance service and provider hospital, or facility of resident's choice, when possible, for transportation and admission arrangements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 10 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0623 d Complete and send with the resident (or provide as soon as practicable) a Transfer Form . Level of Harm - Minimal harm or potential for actual harm .f the original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record. Residents Affected - Some .i Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer. j Provide transfer notice as soon as practicable to resident and representative. k Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. 2. A review of the admission Record for Resident #95 revealed that she was readmitted into the facility on [DATE]. The Nursing Home Transfer and Discharge Notice with an effective date of 03/31/22 indicated Resident #95 was listed as her own representative. She was discharged to a local hospital because her needs could not be met in this facility. The Notice received by section was not signed and dated. The form indicated the notice was given to Resident, Legal Guardian or Representative on 03/31/22, Local Long Term Care Ombudsman Council on 03/31/22, and Resident Clinical Record on 03/31/22. A review of the Order Summary Report dated 05/01/22 - 05/31/22 revealed the following order: Send to emergency room to evaluate and treat 05/27/22. The Nursing Home Transfer and Discharge Notice with an effective date of 05/27/22 indicated Resident #95 was listed as her own representative. She was discharged to a local hospital because her needs could not be met in this facility. The Notice received by section was not signed and dated. The form indicated the notice was given to Local Long Term Care Ombudsman Council on 05/27/22 and Resident Clinical Record on 05/27/22. A review of the order details dated 06/01/22 indicated the following order: send to emergency room. The Nursing Home Transfer and Discharge Notice with an effective date of 06/01/22 indicated Resident #95 was listed as her own representative. She was discharged to a local hospital because her needs could not be met in this facility. The Notice received by section was not signed and dated. The form indicated the notice was given to Local Long Term Care Ombudsman Council on 06/01/22 and Resident Clinical Record on 06/01/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 11 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide written notification of Bed Hold Policy to Resident/Resident Representatives for five residents (#188, #24, #221, #161, and #95) of five residents sampled for hospitalization. Findings include: On 6/28/22 at 10:44 a.m. Resident #24 was observed lying in the bed in his room. The resident was able to answer simple questions. The resident was observed with a hospital armband on and denied being hospitalized recently. A review of the medical record revealed Resident #24 was re-admitted to the facility on [DATE] with diagnoses including but not limited to Parkinson's Disease, Diabetes Mellitus, Malnutrition, and Hypertension. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 6/4/22 8:47 p.m. At approximately 4 pm staff notified writer that resident had loose stools. Resident was sitting in bed, alert and responsive, right then resident started vomiting clear liquids, VS [vital signs] 106/58, p [pulse] 62, r [respirations] 24, O2sat [oxygen saturation] 88% RA [room air], placed on oxygen, notified [doctor name] with new order to send resident to ER [emergency room] to treat and eval [evaluate], 911 [emergency medical system] notified, resident transferred to [local hospital] via stretcher, left message for responsible to call back facility when available. A review of the Bed Hold and In-house Transfer Policy dated 6/4/22 revealed listed in Signature-Resident area res [resident] unable to sign and date of 6/4/22. Under Signature-Family Member or Legal Representative there was a nurse signature and written was [power of attorney] verbally with a date of 6/4/22. On 6/27/22 at 12:46 p.m. Resident #161 was observed lying in bed with a sitter at the bedside. The resident was sleeping. The resident was unable to answer any questions related to care and services. A review of the medical record revealed Resident #161 was most recently admitted on [DATE] with a diagnoses including but not limited to metabolic encephalopathy, dementia, malnutrition, pseudobulbar affect, schizoaffective disorder, and anxiety disorder. A review of the MDS assessment dated 5/16 22 revealed a BIMS score was unable to be completed for the resident due to diagnoses and cognitive impairment. A review of the nursing progress notes revealed the following entry: 5/6/2022 at 9:27 a.m. Patient observed by staff demonstrating unsafe acts to herself and destroying items in facility. Patient observed by staff tying her wrist in the blinds, patient wrist removed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 12 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some from blinds. Risk manager, unit manager, and nurse practitioner notified in facility. 911 called for transport to emergency room for increased AMS [altered mental status]. A review of the Bed Hold and In-house Transfer Policy dated 5/6/22 revealed listed in Signature-Resident area Resident unable to sign and date of 5/6/22. Under Signature-Family Member or Legal Representative written was [power of attorney] verbal with a date of 5/6/22. On 6/27/22 at 12:30 p.m. Resident #188 was observed seated in a wheelchair by the nurse's station. The resident was unable to answer any questions related to care and services. A review of the medical record revealed Resident #188 was most recently admitted to the facility on [DATE] with a diagnosis of diverticulitis, dementia, anxiety, mood disorders, malnutrition, depression, bipolar, insomnia, and psychosis. A review of the MDS assessment dated [DATE] revealed Resident #188 had a BIMS score of 99 indicating the resident was unable to complete the interview due to moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 6/20/22 10:52 a.m. Resident was noted to have a change of condition during medication rounds. He was less responsive, skin was cold and clammy, decreased respirations. His urinary output was minimal at 25 cc [cubic centimeters]. BP 98/61 O2 92 P65 R14. Per the paramedics his blood sugar 56. Spoke with doctor gave order to send the resident to hospital for evaluation. POA [power of attorney] was notified of the change of condition and the order to send for evaluation. A review of the Bed Hold and In-house Transfer Policy dated 6/18/22 revealed listed in Signature-Resident area Resident unable to sign and date of 6/18/22. Under Signature-Family Member or Legal Representative written was [POA] verbal with a date of 6/18/22. A review of the medical record for Resident #221 revealed the resident was most recently admitted to the facility on [DATE] with a diagnosis of dementia, epilepsy, schizoaffective disorder, traumatic brain injury and major depressive disorder. A review of the MDS assessment dated [DATE] revealed Resident #221 had BIMS score of 12 indicating moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 5/8/2022 10:16 p.m. Resident found with shortness of breath, labored breathing, O2 80-86% on oxygen at 2 liters per nasal cannula, diminished lung sounds, with eyes closed and difficult ot arouse. Primary doctor notified with order to send to emergency room for evaluation and treatment. Message left with representative. A review of the Bed Hold and In-house Transfer Policy dated 5/8/22revealed listed in Signature-Resident area Resident wasn't able to sign and date of 5/822. Under Signature-Family Member or Legal Representative written was [POA] verbal with a date of 5/8/22. On 6/29/22 at 3:53 p.m. an interview was conducted with the Social Services Director (SSD) and the DON. The SSD stated the transfer and bed hold policy forms are given to him once nursing has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 13 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some completed the forms and sent the resident out of the facility. He stated he does not send any written notices to the Resident Representative or the Ombudsman. He stated he was not aware he needed to do this because he had misinterpreted the regulation. He stated he is aware now that he needs to do this and he will correct his practice. He stated he stopped sending notifications to the Ombudsman three months ago because he did not believe he needed to anymore. He stated the only time he sends out a written notification is when a resident is being given a 30-day notice of discharge. The DON verified his current practice and his misinterpretation of the regulation. On 6/30/22 at 10:01 a.m. an interview was conducted with Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM). Staff A, LPN UM stated the nurses are responsible for completing all paperwork for a transfer to the hospital for a resident. This includes the transfer form and the bed hold policy form. The Resident Representative is notified by telephone only by the nurse. The nurses do not send any paperwork in writing to the Representatives or the Ombudsman. The paperwork is sent to the medical records department for follow-up once the resident is out of the facility. A review of the facility policy entitled Transfer and Discharge (including AMA), undated and presented by the DON for review, indicated the following: Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. Policy explanation and compliance guidelines: .3 The facility may initiate transfers or discharges in the following limited circumstances: a The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. .c The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. .7 Emergency Transfers/Discharges-initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). a Obtain physician's orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. b Notify resident and/or resident representative. c Contact an ambulance service and provider hospital, or facility of resident's choice, when possible, for transportation and admission arrangements. d Complete and send with the resident (or provide as soon as practicable) a Transfer Form . .f The original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record. .i Provide a notice of the resident's bed hold policy to the resident and representative at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 14 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0625 time of transfer, as possible, but no later than 24 hours of the transfer. Level of Harm - Minimal harm or potential for actual harm j Provide transfer notice as soon as practicable to resident and representative. Residents Affected - Some k Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. 2. A review of the admission Record for Resident #95 revealed that she was readmitted into the facility on [DATE]. The Nursing Home Transfer and Discharge Notice with an effective date of 03/31/22 indicated Resident #95 was listed as her own representative. She was discharged to a local hospital because her needs could not be met in this facility. The Bed Hold and In-House Transfer Policy indicated that the resident was unable to sign. The form was dated 03/31/22. A review of the Order Summary Report dated 05/01/22 - 05/31/22 revealed the following order: Send to emergency room to evaluate and treat 05/27/22. The Nursing Home Transfer and Discharge Notice with an effective date of 05/27/22 indicated Resident #95 was listed as her own representative. She was discharged to a local hospital because her needs could not be met in this facility. The Bed Hold and In-House Transfer Policy indicated that the resident was unable to sign. The form was dated 05/27/22. A review of the order details dated 06/01/22 indicated the following order: send to emergency room. The Nursing Home Transfer and Discharge Notice with an effective date of 06/01/22 indicated Resident #95 was listed as her own representative. She was discharged to a local hospital because her needs could not be met in this facility. The Bed Hold and In-House Transfer Policy indicated that the resident was unable to sign. The form was dated 06/01/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 15 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0679 Provide activities to meet all resident's needs. 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 failed to provide an activities program based on the comprehensive assessment and care plan for one resident (#212) of one sampled for activities. Residents Affected - Few Findings included: Multiple observations were made of Resident #212. On 6/27/22 the resident was observed throughout the morning and at 2:10 p.m. in a specialized chair placed in a semi-reclined position with a foot plate positioned in the hallway against the wall outside of his room. He was awake and alert. On 6/27/22 at 2:14 p.m. Resident #212 gestured upon approach and said bed. He was asked if he wanted to go to bed and he nodded. On 6/27/22 at 2:17 p.m. the resident was observed gesturing to a Certified Nursing Assistant (CNA) who was walking in the hallway and saying bed. The CNA continued walking down the hallway. On 6/27/22 at 2:41 p.m. the resident was observed still in the hallway, awake and alert. On 6/28/22 at 10:05 a.m. Resident #212 was observed in his room in bed, he was awake and alert, the lights were off, the walls were bare of any decoration or personalization, and there was a television on a table at the foot of the bed unplugged. On 6/28/22 at 12:00 p.m. the resident was observed placed in specialized chair in semi reclined position against the wall in the hallway outside his room, he was awake and alert. On 6/28/22 at 1:00 p.m. Resident #212 was still in the hallway in the specialized chair. On 6/28/22 at 2:58 p.m. a group activity was observed on the 1st floor of the facility in the dining room; Resident #212 was not there. On 6/29/22 at 9:30 a.m. the resident was observed in bed, the lights were off, he was awake and alert, the television was still unplugged. At 12:00 p.m. on 6/29/22 the resident was observed still in bed, awake and alert with no stimulation in the room. A review of Resident #212's medical record revealed an admission record that documented diagnoses including Alzheimer's disease and major depressive disorder. The Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which meant he had severe cognitive impairment, and revealed he required extensive to total assistance for all mobility and activities of daily living (ADL) tasks. The MDS revealed a staff assessment of activity preferences: listening to music and participating in favorite activities. The care plan for Resident #212 revealed, [Resident #212] rely on staff to provide 1:1 (one to one) visits for more sensory/mental stimulation initiated 10/06/2020. The interventions, all revised 10/13/2020 were, Provide 1:1 visits 2xs (2 times) weekly .Provide music, conversations during visits .Take resident outdoors as tolerated when up for fresh air. Activities task documentation was reviewed for the past 30 days; no entries were found. The facility Activities Director was interviewed on 6/29/22 at 1:24 p.m. She stated the department was short-staffed which was impacting on the ability to meet all of the activity demands for the residents. She confirmed Resident #212 was not able to self-initiate activity participation and he required staff to initiate and provide all aspects of activity engagement. She confirmed he was care planned for 1:1 activities and said, he don't do the group. Regarding lack of documentation of any 1:1 activities performed with Resident #212 she said, you're probably not going to see it since we've been short for a while since the short staffing. She said, if it's not documented it's not done. On 6/29/22 at 2:24 p.m. the Activities Director followed up and confirmed there was no documentation Resident #212 had received 1:1 activities or any activities. She said she was starting an in-service that day with her staff on 1:1 activity documentation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 16 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0679 Review of undated facility policy titled Activities revealed: Level of Harm - Minimal harm or potential for actual harm It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 17 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and medical record review the facility failed to provide care and services four wound care of ulcers to one resident (#211) out of one sampled for wound care. Residents Affected - Few Findings Included On 6/27/22 at 10:18 a.m. Resident #211 was observed sitting in the hallway with both of his feet wrapped with a thick white kerlix dressing. The dressing to his left foot contained bright yellow moist drainage noted to be the size of a soft ball. The yellow drainage was surrounded by a dark brown color dried drainage. The resident had no socks or shoes covering the dressing and both of his feet rested on floor surface. On 06/28/22 at 9:55 a.m. Resident #211 was observed in the hallway speaking with Staff M, Physical Therapist. She said Resident #211 had just finished his therapy session and she was going to transport him back to his bedroom. Resident #211's bilateral feet appeared as the same soiled dressing from the day prior. Staff M confirmed the dressing to his feet contained the date of 6/26/22. Resident #211 was alert and stated, the dressing are not changed daily. No socks or foot coverings were in place on his feet and the dressings rested on the floor surface. Photographic evidence obtained. On 06/29/22 at 11:42 a.m. Resident #211 was in his bedroom and confirmed both dressing to his feet were changed yesterday. The dressing to his left foot contained a moderate amount of yellow to tan colored drainage. The resident stated, I need socks. Both of his wrapped feet rested on the floor surface. A review of the admission Record revealed Resident #211 had been residing at the facility for six months, with diagnosis including but not limited to, peripheral vascular disease, pain in unspecified foot, and chronic venous hypertension (idiopathic) with ulcers of bilateral lower extremity. A review of the Physician orders dated 05/25/2022 read cleanse wounds to left lateral lower leg with wound cleanser and pat dry. Apply skin prep to per ulcer skin. Apply xeroform, abdominal (Abd.) Pad. Wrap with kerlix and ace wrap daily and as needed (PRN) for soiling and dislodgement. every day shift for wound related to chronic Venous Hypertension (idiopathic) with ulcer of bilateral lower extremity. A review of the Treatment Administration Record (TAR) revealed for the month of June 2022, treatment was not performed on 06/10, 6/13, 6/15 and on 6/18/2022. On 6/23/2022 the treatment to the left lateral leg was discontinued with a new order in place. The new order read to cleanse wound to left lateral lower leg with wound cleanser. Apply skin prep to per-ulcer skin. Apply Medi honey and calcium alginate, Abd. Pad. Wrap with kerlix and ace wrap daily and PRN for soiling and dislodgement dated 6/24/2022. Upon further review of the TAR reflected omitted treatment to the left lateral leg on 6/25/2022. During the three days observation on 6/27, 6/28, and 6/29/22 no ace wrap was in place to the left lower extremity. Further review of TAR contained an order dated on 5/25/2022 to cleanse wound to right ankle with wound cleanser and pat dry. Apply skin prep to per ulcer skin. Apply xeroform, Abd. pad. to wound bed. Wrap with kerlix and ace wrap daily and PRN for soiling and dislodgement. every day shift for wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 18 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few related to PERIPHERAL VASCULAR DISEASE UNSPECIFIED for 30 days. The order was discontinued on 6/23/2022 with a new order. It read cleanse right lower leg with NS apply xeroform every day and Prn until resolved in the morning start date 6/24/2022. A review of the Treatment Administration Record (TAR) revealed for the month of June 2022, treatment was not performed on 06/10, 6/13, 6/15 and on 6/18/2022. Further review of the new order dated 6/24/2022 revealed the treatment was omitted on 6/25/2022. On 6/29/22 5:03 p.m. an interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator on the omission of dressing changes for Resident #211. The DON confirmed it was her expectation physician orders are followed. The DON was informed of the concern with the residents kerlix dressing with the drainage resting on the floor surface without a barrier in place. A review of the facility policy titled Clean Dressing Change copyright 2021. Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination. Physician orders will specify type of dressing and frequency of changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 19 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, the facility failed to 1. Adequately supervise thirty-two sampled residents to include resident (#193 and #10); and who reside in one of six units (LS1 [NAME] Secured) unit, during two of four days observed, on (6/27/2022, and 6/28/2022). It was determined Resident #193 was standing and walking out in the main hallways disrobed and not wearing any clothing on her lower part of her body, and with no staff supervision for long periods of time; 2. Failed to assure fall floor mats were placed while residents #721, #670, and #184 were in bed. Findings included: 1. On 6/27/2022 at 9:30 a.m. an interview with the Nursing Home Administrator and the Director of Nursing (DON) revealed the LS1 [NAME] unit is a Secured Unit, that houses thirty-two residents who either have diagnosis of Dementia and or Alzheimer's. The Administrator and DON further indicated the residents in that unit are in need of continual supervision and many who walk and wander throughout the unit and with some going in and out from other resident rooms. On 6/27/2022 at 11:30a.m. the LS1 [NAME] secured unit was entered for tour observations. The secured unit was observed with residents who are ambulatory and walk up and down the hallways, who have dementia and are not able to interview with relation to their care and services. Upon reaching resident #193's room, she was observed standing in the middle of her room wearing a long sleeved shirt and with her pants pulled all the way down to her ankles. She was only observed with a brief on and also not wearing any shoes or socks. Further, she started to shuffle towards the door. She was asked about her pants and if she needed any help. Resident #193 could not answer appropriately as she was not interviewable. Resident #193 resides in her room with two other residents. The bedroom door was observed wide open with Resident #193, who could be observed unclothed by any other resident and/or staff member that passes the room. The hallway was high trafficked with other residents walking at or near Resident #193's room. There were no staff observed in the immediate area, but there were four male residents observed walking up and down the hallway. At 11:50 a.m. Certified Nursing Assistant (CNA) Employee B. was observed to walk by the area and she was asked to come in the room to observe Resident #193. She saw her and went into the room and closed the door and assisted Resident #193 with re dressing. It was determined Resident #193 stood unclothed and within sight of everyone in the unit that passes her room for at least twenty (20) minutes, before staff were found to assist her. On 6/27/2022 at 1:50 p.m. the LS1 [NAME] Secured unit was again toured. Once entered from the double locked doors, Resident #193 was standing in the hall between the entrance to the secured unit dining room and the nurse station. She was observed wearing a blue colored long sleeved shirt and with no pants or bottoms. She was observed wearing only a brief and also not wearing any socks or shoes. Resident #193 was exposed from her waist down. She did not appear wet from incontinence episodes. Resident #193 shuffled towards the door; within four to five feet of Resident #193, there were five male residents and one female resident either standing or walking by. There were no staff in the immediate area during this observation from 1:50 p.m. through to 2:03 p.m. At 2:07 p.m. a staff member came out from room [ROOM NUMBER]. The staff member was noted as CNA Employee B. Employee B. was asked if she had Resident #193 on her assignment. She revealed that she did not but has had her on her assignment in the past. Employee B. was shown that resident #193 was not clothed from her waist down, and was out in the main hallway next to the nurse station, and with residents surrounding her. She looked over at Resident #193 and explained that she removes her clothes at times. CNA Employee B. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 20 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 - Some explained that she could not tend to Resident #193 at that immediate time because she was in another room trying to dress another resident. Employee B. went back into another resident's room and closed the door behind her. Once she did that, Resident #193 was still observed out in the main hallway with no clothing on from her waist down and only wearing an adult brief. At 2:13 p.m. Employee B. came out of another resident's room and walked up to Resident #193 and brought her to her room and then closed the door to clothe her. It was observed Resident #193 was disrobed and exposed out in the main hallway with other residents, not wearing any pants or shorts/underwear, and not wearing any socks and shoes, with only wearing a shirt and an adult brief for at least twenty -three (23) minutes before staff intervened. On 6/28/2022 at 7:30 a.m. Resident #193 was observed lying in bed and on her side facing the wall. The linen was pulled down to her feet and she was observed with a long sleeved shirt on but again not wearing any bottoms. From the hallway, Resident #193 was observed with her entire bottom exposed and wearing only an adult brief. Other residents were observed walking up and down the hallway, past Resident #193's room. At 7:40 a.m. an interview with Resident #193's assigned 7-3 shift care aide Employee C. revealed she floats all over the building but knows Resident #193. She was asked about the resident observed with no bottoms on she expressed the resident disrobes at times but has never seen her out from her room with no bottoms on. She revealed if residents are out in the hallways and not dressed, staff are to immediately bring them back to their rooms and try to redirect them and redress them. She also expressed if residents are in their rooms and in bed and not wearing appropriate clothing, they do try to shut the door so they cannot be seen from the hallway. Employee C. explained that however, other residents in the room will reopen the door. At 7:56 a.m. CNA employee C. walked by Resident #193's room and saw she was lying in bed over her covers and with only wearing a shirt but with no bottoms, and exposing her entire lower body with wearing only an adult brief. The room door was all the way open. She entered the room and closed the door to resituate and cover the resident. It was determined that Resident #193 could be seen in her room, from the hallway, disrobed and exposed with no clothes on from her waist down, for at least twenty (20) minutes before staff intervened. On 6/30/2022 at 8:10 a.m. an interview with the LS1 [NAME] Secured Unit Manager revealed staff should always be monitoring residents and to maintain dignity. She revealed the unit does have several residents who disrobe and there should be staff to immediately redirect and or intervene, and to re dress or take to their rooms. The Unit Manager confirmed the times when Resident #193 was observed out in the main hallways not wearing any pants or underwear, all floor staff were either outside assisting with resident smoking supervision, or were in rooms providing care and services to other residents. She also confirmed that she usually is seated a the nurse station throughout the day and she can see both halls. However, she revealed she also worked in other units in the building. On 6/30/2022 at 2:00 p.m. an interview with the Nursing Home Administrator revealed residents in the secured unit should be monitored and supervised at all times and residents should not be in that unit unrobed without staff in their immediate area to intervene or redirect. The Nursing Home Administrator did confirm the Unit Manager, Employee A. does sit at the nurse station through the shift, and is able to see both hallways seated at the nurse station, but also confirmed Employee A. for the past week or so, has also been in charge of another unit outside of the Secured unit, and Unit Manager, Employee A. has had to pull double duty at the same time with both the Secured Unit and another unit outside the Secured Unit. The Nursing Home Administrator further confirmed the Secured Unit residents need to be supervised and monitored all day and that she needs to make sure Employee A. stays and works only in that unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 21 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 The Nursing Home Administrator also indicated there should be more staff intervention and redirection for those residents who disrobe and walk around the unit. Further, she revealed that female residents to include Resident #193 should be monitored more closely for disrobing and walking around the hallway or lying in her bed with the door open, and disrobed. She revealed that staff should either close the door or go in the room and either educate her to pull over the covers, pull the privacy curtain or close the door. Residents Affected - Some Review of Resident #193's medical record revealed she was admitted to the facility on [DATE] and was readmitted on [DATE]. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Schizophrenia, Psychosis, Mild intellectual disabilities, Mood disorder, History of falling, Anxiety and Dementia with behavioral disturbances. Resident #193 resides in the secure/dementia unit. Review of the current annual Minimum Data Set assessment, dated 6/2/2022 revealed: (Cognition/Brief Interview Mental Status or BIMS score 5 of 15; which indicates that the resident would not be able to answer questions about her financial and medical care); (Mood - documented as having trouble concentrating on things 12 - 14 days observed); (Behaviors - documented as having delusions, having verbal behavior symptoms towards others during 1-3 days observed); (Activities of Daily Living ADL Limited Assistance with one person physical assistance with Dressing, and Extensive Assistance with one person physical assistance with Personal Hygiene). Review of nurse progress notes dated from 1/20/2022 through to current date 6/29/2022, revealed the following notes with behaviors. - 5/17/2022 12:25 - Pt [patient] ambulating out in halls without shirt on screaming and yelling. Redirected back to room to get clothing on. Pt. continued to come into hall yelling this afternoon and pt reached nurses medication cart and started hitting and slapping self in the face with palms of her hands. Redirected with distraction. Will continue to monitor. There was only one note documented indicating resident disrobed. There were no other dates noting this as a continued behavior. Review of the current physician's order sheet (POS) dated for the month of 6/2022 revealed orders to include but not limited to: May reside on secure unit (start date 4/6/2022). Review of the current Care Plans with a next review date 9/8/2022 revealed the following areas: (a) Resident #193 is an Elopement risk related to dementia and mobility, likes to go to offices and sit and visit and get books. Not exit seeking or attempted to elope from facility, with interventions in place. (b) Resident #193 has following advance directives on record; Full Code Status, Health care proxy, Incapacity statement - not capable of giving informed consent regarding health care decisions. Incapacity statement signed and dated by Physician on 6/20/2014, with interventions in place. (c) Resident #193 has Impaired cognition and impaired thought process, with interventions in place. (d) Resident #193 has Mood problem, looks pained, sad and worried, makes negative statements, repetitive physical movements and restlessness (hits self on head), with interventions in place. (e) Resident #193 has Behaviors to include (outburst, strikes self in head, yells out, removes clothing, Throws items on the floor, Shows aggression to staff and other residents, Verbally and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 22 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 - Some physically abusive when agitated, Takes items from others, Places self on floor, Hoards items, Follows behind staff, Bangs head with her hands, with interventions in place to include but not limited to: Psych consult; Anticipate and meet the resident's needs; Approach and speak in calm manner; Assist the resident to develop more appropriate methods of coping and interacting; Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; If reasonable discuss the resident's behavior; Intervene as necessary to protect the rights and safety of others; Monitor/document effectiveness; Remove the resident from the situation and take to an alternate location as needed. (f) Resident #193 requires some assistance with her daily care needs along with cueing and reminders to stay on task. Can be resistive at times, with interventions to include but not limited to: Arrange resident/patient environment as much as possible to facilitate ADL performance; Monitor conditions that may contribute to ADL decline, including psychiatric disorder; Provide cueing for safety and sequencing to maximize current level of function. (g) Resident #193 has impaired cognitive function or impaired thought processes r/t difficulty making decisions, impaired decision making, Psychotropic medication use, Problems understanding others, Problems making self understood, with interventions to include but not limited to: Cue, Reorient and supervise as need; Monitor/document/report PRN any changes in cognitive functions, specify changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, mental status. On 6/30/2022 at 3:00 p.m. the Nursing Home Administrator provided the Accidents and Supervision policy and procedure with last revised date (not indicated), for review. The policy indicated: Policy - The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: #3. Implementing interventions to reduce hazards and risks; #4 Monitoring for effectiveness and modifying interventions when necessary. Definitions - Accident refers to any unexpected or incident, which results in injury or illness to a resident; Environment refers to any environment or area in the facility that is frequented by or accessible to residents, including but not limited to the resident's room, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activities areas; Supervision/Adequate Supervision refers to intervention and means of mitigation of risk and environment hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks - The process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. (a.) All staff (e.g. professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident;. 2. Implementation of Interventions - using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes: (a) Communicating the interventions to all relevant staff, (b) Assigning responsibility, (d) Document intervention (e.g. plans of action developed by the Quality Assurance Committee or care plans for the individual resident), (e) Ensuring that the interventions are put into action, (i) Resident-directed approaches may include: (i) Implementing specific interventions as part of the plan of care, (ii) Supervising staff and residents, etc. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 23 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 3. Monitoring and modifications - Monitoring is the process of evaluating the effectiveness of care plan interventions. Modifications is the process of adjusting interventions as needed to make them more effective in addressing hazard and risks. Monitoring and modification processes include: (a) Ensuring that interventions are implemented correctly and consistently,(d) Evaluating the effectiveness of new interventions. Residents Affected - Some 4. Supervision - Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accident. Adequacy of supervision: (a) Defined by type and frequency, (b) Based on the individual resident's assessed needs and identified hazard in the resident environment. On 6/30/2022 at 3:00 p.m. the Nursing Home Administrator provided the facility's Secured Unit Resource Manual, (not dated), for review. The following was revealed: Purpose - Within facilities, structurally distinct parts of the facility may be designated as Secure Care Units (SCU) for residents who may need a smaller, more controlled environment. Such units shall be designated to encourage self-sufficiency, independence, and decision-making skills. The goal of the unit is to help the resident so the resident can transition back into the least restrictive environment. Criteria for admission - admission criteria for SCU are, but not limited to, the following: (a) Resident has a diagnosis of Dementia and/or mental health related disorders including behavioral problems related to a psychiatric diagnosis; (b) Residents with cognitive disorders associated with traumatic brain injuries, intellectual disabilities, or chronic mental illness may have needs that cannot be met in this setting but will be reviewed on a case-by-case basis; (e) the need for admission must be determined by the IDT consisting of a physician, the Social Service Director, and a registered nurse. The resident's family or advocate will be encouraged to actively participate in the decision making process. However, the final decision is based on meeting the resident's needs. If the resident does not have family, the Medical Director/Attending Physician, along with the IDT, will make the decision based on the needs of the resident. Commonly found (not all inclusive) diagnosis, disorders, and/or related problems are listed to help guide the referral process: Dementia, Cognitive Disorders, Mood Disorders, Psychiatric Disorders. Concerns to watch out for during transition period: Review for signs of increased behaviors, feeling of fear, and need for reassurance. Change plan as necessary, Observe for and review with open census staff and need for further 1 to 1 attendance at activities, dining, and smoking breaks. Change as necessary. Make sure that staff is documenting resident's behavior every day. Training requirements - In addition to the classroom instruction required in the CNA training program, each CNA assigned to the Secured Unit shall have additional training. There must be documentation showing that 100% of the staff working on the SCU have reviewed and signed the Secure Unit Covenant and has received initial and annual in-service training which shall include but not limited to the following subject areas: (a) Basic facts about the causes, progression and management of Alzheimer's Disease, Dementia, and related disorders, (c) Identifying and alleviating safety risks to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 24 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 resident. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Secure Unit (SCU) Covenant (not dated), revealed: Residents Affected - Some Behaviors should be seen as forms of communication. The SCU will typically experience more challenging behaviors than in other parts of the facility. Stakeholders should view behaviors as forms of communication and therefore, act as investigators to find the root cause of the behavior. Ensure that all basic needs have been met such as hunger, temperature, pain, toileting needs met, etc. Challenging behaviors are symptoms of disease process and should be respected as such. Resident behaviors should only be discussed only with stakeholders who need to know about them and should be communicated respectfully. Teamwork is imperative on all units but is especially critical on the SCU. Successful outcomes on the SCU cannot be attained without teamwork. Stakeholders should make a point of getting to know all residents on the unit including their likes, triggers and behavioral patterns. Monitoring the hallways should be a shared responsibility amongst the SCU staff. The charge nurse is expected to be the team leader and put processes in place to ensure that the hall runs smoothly and resident care and supervision exceeds standards. 4. On 6/27/22 at 12:12 p.m. during a tour of the 1 [NAME] unit of the facility fall mats were observed on the floor in front of the bed for Resident #184 and Resident #721. Neither resident was present in the room at the time of the observation. The review of the medical record revealed Resident #184 was admitted to the facility on [DATE] with a diagnoses, including but not limited to, dementia, Cerebral Vascular Accident, altered metal status, arthritis, hypertension, psychosis, anemia, schizophrenia, pseudobulbar affect, and hemiplegia/hemiparesis affecting left side. A review of the Order Summary dated 6/29/22 revealed no order for fall mats for Resident #184. A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #184 required extensive physical assistance by two persons. A review of the Comprehensive Care Plan for Resident #184 indicated the following: Focus: Fall Risk-Resident #184 is at risk for falls related to impaired cognition and mental illness. Resident #184 does not understand fall risks, her own limitations, or surroundings. Resident #184 also has impaired mobility with weakness (initiated on 10/7/20). Goal: Risk of sustaining fall related injuries will be minimized through next review. Interventions include but not limited to: follow facility fall protocol. Review of the Fall Risk Evaluation dated 6/13/22 revealed Resident #184 was at risk with a score of 11. On 6/28/22 at 10:32 a.m. Resident #184 was observed moving around the hallways in a wheelchair. She was observed going in and out of resident rooms in her chair. At 11:27 a.m. the fall mat was observed on the floor in front of the resident's bed. The resident was not in the room at the time of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 25 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 observation. Level of Harm - Minimal harm or potential for actual harm A review of the medical record revealed Resident #721 was admitted to the facility on [DATE] with a diagnoses, including but not limited to, major depressive disorder, dementia, muscle weakness, protein calorie malnutrition, restlessness, and agitation. Residents Affected - Some A review of the Order Summary dated 6/29/22 revealed no order for fall mats for Resident #721. A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #721 required limited physical assistance by one to two persons. A review of the Comprehensive Care Plan for Resident #721 indicated the following: Focus: Fall Risk-Resident #721 is at risk for falls and fall related injury related to abnormal gait. Chooses not use rollator (initiated on 4/20/22). Goal: Minimize risk for falls and fall related injuries through next review date. Interventions include but not limited to: follow facility fall protocol, needs a safe environment with even floors free from spills and/or clutter. Review of the Fall Risk Evaluation dated 5/21/22 revealed Resident #721 was at risk with a score of 13. A review of the incident logs revealed Resident #721 had three falls in the month of May 2022. The medical record revealed a fall on 5/6/22 with no injuries, a fall on 5/16/22 with no injuries, and a fall on 5/21/22 that required hip x-rays which were negative for injury. On 6/29/22 at 2:48 p.m. The fall mat was observed on the floor on the left side of the bed. Resident #721 was not present in the room at the time of the observation. The bed appears to have been made for the day and is clean. On 6/29/22 at 4:01 p.m. an interview was conducted with the Director of Nursing (DON). She stated all falls are reviewed at the morning meetings. She stated all fall interventions are determined at the meeting for each resident. She stated interventions are added or deleted at the time of the meetings. She indicated fall mats are an intervention and should be on the care plan for each resident is used. She stated the fall mat is to be placed by the bed when the resident is in bed for safety if they fall out of bed. She stated the aide is responsible for taking up the fall mat when the resident is out of bed to prevent it from becoming a trip hazard. She stated there does not have to be an order in the record for the fall mat. On 6/30/22 at 10:01 a.m. an interview was conducted with Staff A, Licensed Practical Nurse (LPN) Unit Manager (UM). Staff A stated fall mats are not used a lot in the facility. She stated the aides are responsible for placing them on the floor and taking them up off the floor as they care for the residents. She indicated the aides are directed to take them up in the morning after residents are out of bed and put them down when the resident is returned to bed for safety. She confirmed the mats should not be left on the floor when a resident is out of bed due to the risk of trip hazard. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 26 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 A review of the policy entitled Fall Prevention Program, undated and supplied by the DON for review, indicated the following: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Residents Affected - Some Policy explanation and compliance guidelines: 1-The facility utilizes a standardized risk assessment for determining a resident's fall risk. .4-The nurse will refer to the facility's high risk of low/moderate risk protocols when determining primary interventions. 5-Low/Moderate Risk Protocols: a-Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to: i-A clear pathway to the bathroom and bedroom doors ii-Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. iii-Call light and frequently used items are within reach. iv-Adequate lighting. v-Wheelchairs and assistive devices are in good repair. .6-High Risk Protocols: a-the resident will be placed on the facility's Fall Prevention Program .b-Implement interventions from Low/Moderate Risk Protocols. .d-Provide additional interventions as directed by the resident's assessment, including but not limited to: i-Assistive devices 3. On 06/28/2022 at 10:32 a.m. Resident #670 was observed in bed, no floor mats on the floor or anywhere in the room. On 06/28/2022 at 12:06 p.m. Resident #670 was observed in bed, no floor mats on the floor or anywhere in the room. On 06/28/2022 at 1:02 p.m. Resident #670 was observed in bed, no floor mats on the floor or anywhere in the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 27 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 On 06/29/2022 at 9:36 a.m. Resident #670 was observed in bed, no floor mats on the floor or anywhere in the room. On 06/29/2022 at 12:00 p.m. Resident #670 was observed in bed, no floor mats on the floor or anywhere in the room. Residents Affected - Some On 06/29/2022 at 4:19 p.m. Resident #670 was observed in bed, no floor mats on the floor or anywhere in the room. Photographic evidence obtained. On 06/29/2022 during the 4:19 p.m. observation, Resident #670's nurse, Staff E, Licensed Practical Nurse (LPN) was asked to observe and witness the absence of floor mats. During this observation Resident #670's bed was observed pushed away from the wall and she was positioned in the bed with her right leg hanging out of the bed. Staff E stated this happened frequently and that the resident pushed herself in the bed away from the wall. Staff E stated the resident had been known to fall. She confirmed there were no floor mats in the room. Staff E consulted the care plan in Resident 670's medical record upon request and confirmed floor mats were listed as a fall prevention intervention. She stated if an intervention was documented in a care plan, it should be implemented. She stated it was up to the Certified Nursing Assistants (CNAs) to ensure floor mats to manage use of floor mats. Review was conducted of Resident #670's medical record. The admission record revealed diagnoses including abnormal posture and hemiplegia (partial paralysis) affecting left side of body. The Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 which meant the resident had some cognitive impairment. The MDS revealed the resident required maximal to total assistance for all mobility. Progress notes revealed a note dated 6/09/2022: Patient was found on the ground by her bed. Patient was found on the left side next to the bed. Patient is unable to recall events. Patient denies injuries. No injuries noted to patient. Review of the care plan revealed, [Resident #670] is at risk for falls/injuries r/t (related to) use of psychotropic medications, impaired cognition with poor safety awareness, left hemiplegia, TBI (traumatic brain injury) and seizures. Interventions included, Floor mat to Left side when in bed revised 10/05/2021. The care plan also revealed, [Resident #670] has the following behavior problems: .throwing herself on the floor from bed .attempting to slide out of bed . Review of the CNA task list for Resident #670 revealed Floor mat to Left side when in bed. An interview was conducted with the facility Director of Nursing (DON) on 06/29/2022 at 4:03 p.m. She stated use of floor mats should be in the care plan and if in the care plan should be implemented. She stated fall mats were usually placed on the floor when a resident was in bed and removed when a resident was out of bed so as not to be a tripping hazard. An interview was conducted with the DON and the facility Risk Manager (RM) on 06/30/33 at 10:09 a.m. They confirmed that if floor mats were documented in the care plan as an intervention, the expectation was that they were implemented. The RM said, CNAs are technically in charge of that .it's on their Kardex (task list). Observations of Resident #670 in bed without floor mats in place were revealed to the DON and RM. The RM stated she did rounds in the facility to ensure floor mats were in place but said, I haven't gone past her (Resident #670's) room this week on my rounding. 2. An observation was conducted for Resident #10 on 6/27/22 at 11:37 a.m. Resident #10 was lying in her bed asleep. A Certified Nursing Assistant (CNA) was asleep sitting in a chair 3-4 feet away (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 28 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 - Some from the resident's bed. The CNA remained asleep with the door being knocked on twice and hello being called out to her. Surveyor walked around CNA and verified her eyes were closed and her chin was resting on her chest. A review of admission records indicated Resident #10 was admitted on [DATE] with diagnoses including blindness, dual sensory impairment, bilateral hearing loss, conversion disorder with seizures or convulsions, schizophrenia, and bipolar. A review of Resident #10's orders indicated orders for intensive supervision day and evening shifts for safety and every 15-minute monitoring on night shift for safety. A review of Resident #10s care plans revealed care plans for falls risk, dependence on staff, bilateral blindness, seizure disorder, cognitive function, and communication deficit. Resident #10's care plan for behavior problems indicated behaviors including aggressive towards staff and peers, easily agitated, entering other resident's rooms without permission, grabbing/touching others inappropriately, physically aggressive, and biting self. The interventions listed included Intensive supervision day and evening shifts and every 15-minute monitoring on night shift. These interventions have been in place since 7/7/21. An interview was conducted with the Director of Nursing (DON) on 6/27/22 at 3:52 p.m. The DON stated the Resident #10 is on one-to-one supervision due to her blindness and deafness. The DON stated the resident will grab people. The DON stated the CNA should be in eyesight of the resident at all times. She stated the CNA should never be sleeping. An interview was conducted on 6/29/22 at 11:45 a.m. with Staff J, CNA. Staff J was assigned to the current shift as Resident #10's one-to-one CNA. Staff J stated the resident is able to walk around the halls with assistance and is able to get out of bed on her own but will run into walls and oth[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 29 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 6/27/22 at 12:30 p.m. Resident #188 was observed sitting in a wheelchair across from the nursing station. A Foley catheter bag was observed on the floor under the wheelchair. Photographic evidence was obtained. A Certified Nurse Aide (CNA) Staff B was passing by the resident and an interview was conducted with the aide. The aide stated, the Foley was sitting up on the crossbar but the bag fell off on to the floor. She indicated Resident #188 was not sitting in his own chair which has a better crossbar. Staff B wheeled Resident #188 to his room. She stated they were going to change the Foley bag to a leg bag. Resident #188 was re-admitted to the facility on [DATE] with diagnoses, including but not limited to, diverticulitis, dementia, disc degeneration, anxiety, mood disorders, malnutrition, cerebral vascular accident, bipolar, dysphagia, depression, insomnia, and psychosis. A review of the Order Summary Report revealed an order for discontinue Foley dated 6/27/22. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. A review of the Comprehensive Care Plan for Resident #188 did not indicate the resident had a Foley catheter as a focus area. A review of the facility policy entitled Indwelling Catheter use and removal, undated and provided by the DON for review, indicated the following: Policy: It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice. Policy explanation: Indwelling urinary catheters are catheters that remain in the bladder to assist with urinary elimination. The use of indwelling catheters for managing incontinence in not appropriate and increase the risk of urinary tract infections. While there are some justifications for indwelling catheter use in the long-term care setting, prompt removal of such catheters is indicated when inappropriately used. Compliance guidelines: 1-the resident will not be catheterized unless the resident's clinical condition demonstrates that catheterization is necessary. 2-Residents that admit with an indwelling catheter or subsequently receives one with be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that the catheter is necessary. 3-The facility will conduct ongoing assessments for residents at risk for urinary catheterization or on residents with indwelling catheters to determine if the catheter needs to be continued or removed if the catheter is no longer necessary. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 30 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 4-If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: .b-timely and appropriate assessments related to the indication for use of an indwelling catheter. Residents Affected - Few .d-Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures. .7-Additional care practices include: a-Recognition and assessment for complications and their causes and maintaining a record of any catheter-related problems. b-Attempt to remove the catheter as soon as possible when continued catheter use is not indicated. c-Monitoring for excessive post void residual, after removing a catheter that was inserted for obstruction or overflow incontinence. d-Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter. e-Securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder. 8-Catheters and drainage bags should be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised Based on observations, record reviews, and interviews, the facility failed to ensure orders were followed related to catheter care for three residents (Resident #207, #188, and #218) out of the sampled five residents. Findings included: 1. On 06/27/22 at 11:52 a.m., Resident #207 was observed in bed in his room. There was a very offensive urine odor in the room. The resident had a catheter, and the tubing was observed with thick gray sediment. On 06/28/22 at 9:53 a.m., Resident #207 was observed in bed in his room. There was a strong urine odor in the room. The catheter tubing appeared unclean, with thick grey sediment. On 06/30/22 at 10:25 a.m., Resident #207 was observed in bed in his room. The catheter tubing was observed with thick gray sediment and tan clots and there was a very strong urine odor in the room. A review of the admission Record indicated Resident #207 was initially admitted into the facility on [DATE] with diagnoses that included but were not limited to cerebral palsy, disorder of urea cycle metabolism, acute kidney failure, and retention of urine. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 31 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 resident was rarely/never understood. Level of Harm - Minimal harm or potential for actual harm The Order Summary Report revealed the following active orders as of 06/30/22: Catheter care with soap and water every shift Residents Affected - Few Foley catheter to straight bag drainage for diagnosis of indwelling Irrigate Foley catheter with 30 ml normal saline PRN for blockage or sluggishness Resident to go to urology monthly for catheter change A review of the Treatment Administration Record (TAR) for June 2022 revealed the following: Resident to go to urology monthly for catheter change. There was a check in the box for the night shift on 06/15 and 06/16. The number 9 was in the box for the day and evening shift. According to the chart codes, 9 means other and see progress notes. A Medical Professional Progress Note dated 05/20/22 revealed a follow up was requested by the nurse for a leaking suprapubic catheter. The nurse reported that the catheter was leaking from the insertion site. The assessment/plan indicated to follow up with urology for a consult. A Health Status Note dated 05/19/22 revealed the patient was on alert for a new catheter. Catheter has leakage from insertion site and return in tubing. Provider notified and referred to Urologist for appointment. A Medical Professional Progress Note dated 05/10/22 revealed a follow up was requested by nurse for dislodged Suprapubic Catheter. The nurse instructed to send patient out to the emergency room for replacement. A Health Status Note dated 05/10/22 revealed the patient returned from the hospital with a new suprapubic catheter patent and in place. On 06/30/22 at 9:53 a.m., Staff G, Registered Nurse (RN), reported the resident did not go out to the scheduled urology appointment in June and the scheduling coordinator would know why he did not go out to the appointment. Staff G, RN, reported the resident fills the catheter up every shift. He reported the urine odor in the room was from the resident playing and sticking things in his private parts. He reported the thick mucus like substance in the catheter tubing was due to the resident being on a thickened liquid diet. Staff G also reported Resident #207 had recently ripped his catheter out. On 06/30/22 at 1:07 p.m., the Director of Nursing (DON) reported the resident had a urology appointment scheduled on June 24th, but the doctor called to cancel the appointment due to an emergency. The appointment was rescheduled to July 1st. The DON stated the resident had not had the catheter changed since 05/10/22. 2. An observation of Resident #218 was conducted on 06/28/2022 at 10:00 a.m. He was seated in a wheelchair in the doorway of his room with his back facing the hallway. The tubing from his catheter was observed running underneath the seat of the chair from the front to the back and the catheter bag (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 32 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 was observed hanging from the top of chair above bladder height. Photographic evidence obtained. Level of Harm - Minimal harm or potential for actual harm Review of Resident #218's medical record was conducted. The admission record revealed diagnosis of obstructive and reflux uropathy. The Treatment Administration Record (TAR) for June 2022 revealed an order for Foley catheter. His care plan revealed, The resident has indwelling catheter related to urinary retention/obstructive uropathy. Interventions included, Position catheter bag and tubing below the level of the bladder and away from entrance room door. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 33 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure behavioral and side effect monitoring was conducted with the use of psychotropic medications for one resident (#188) of five resident sampled for unnecessary medications. Findings included: 6/27/22 at 12:30 p.m. Resident #188 was observed seated quietly in a wheelchair by the nurse's station. He was unable to answer questions related to care and services. Resident #188 was admitted to the facility on [DATE] with a diagnosis of dementia, anxiety, mood disorders, major depressive disorder, bipolar, insomnia, and psychosis. A review of the Order Summary Report dated 6/29/22 revealed Resident #188 was prescribed the following medications: -Divalproex Sodium tablet delayed release 250 mg (milligrams) give one tablet by mouth two times a day for anxiety. -Lorazepam tablet 1 mg give one by mouth three times a day for anxiety. -Melatonin tablet 3 mg give two tablets by mouth at bedtime for insomnia. -Paroxetine Hydrochloride tablet 10 mg give one tablet by mouth one time a day for unspecified mood affective disorder. -Trazodone Hydrochloride tablet 50 mg give one tablet by mouth at bedtime for anxiety at bedtime. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Section N: Medications indicated the resident was on antianxiety and antidepressant medications. A review of the Comprehensive Care Plan revised on 6/27/22 revealed the following: Focus: Resident #188 is at risk for complications related to the use of psychotropic drugs antianxiety and antidepressant. Goal: Will have the smallest most effective dose without side effects throughout the next review. Interventions included but not limited to: Monitor for continued need of medication as related to behavior and mood; Monitor for side effects and consult physician and or pharmacist as needed; Monitor/document/report as needed any adverse reactions to therapy. A review of the Medication Administration Record (MAR) dated 6/1/22 through 6/30/22 indicated no behavioral or side effect monitoring had been initiated for Resident #188 since his readmission on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 34 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0758 [DATE]. Level of Harm - Minimal harm or potential for actual harm 06/28/22 at 10:38 a.m. Resident #188 is observed up in a chair in the lunch area. The resident appeared clean, dry and has no odors. No behaviors or signs of distress noted. Residents Affected - Few On 6/29/22 at 2:05 p.m. an interview was conducted with the Director of Nursing (DON). She stated it is the nurse's responsibility to enter the side effect and behavioral monitoring order into the record for residents prescribed psychotropic medications. She stated the system has a box to check when the medication is entered into the orders that will trigger the side effect and behavioral monitoring for psychotropic medications. The DON verified the side effect and behavioral monitoring would be on the MAR and recorded per shift by the nurses. On 6/30/22 at 10:01 a.m. an interview was conducted with Staff A, Licensed Practical Nurse (LPN) Unit Manager (UM). She stated side effect and behavioral monitoring for psychotropic medications is initiated on admission by the admitting nurse. She stated the nurses know all of the medications that require side effect and behavioral monitoring. Staff A stated if is it not done on admission a UM will try to catch it and correct it. She stated in the morning meeting they review all records and correct errors then as well. She confirmed no side effect or behavioral monitoring was present in the record for Resident #188 and stated she would enter it into the record now. A review of the facility policy entitled Behavior Management Plan, undated and supplied by the DON for review, revealed the following: Policy: Residents who exhibit behavioral concerns may require a behavior management plan to ensure they are receiving appropriate services and interventions to meet their needs. The interdisciplinary team, including the family member, should develop a behavioral plan for each resident with identified behaviors through the RAI process. Policy explanation and compliance guidelines: 4-Behaviors should be documented clearly and concisely by facility staff. Documentation should include specific behaviors, time and frequency of behaviors, observation of what may trigger behaviors, what interventions were utilized, and the outcomes of the interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 35 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 - Few 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 observations, interviews, and policy reviews facility failed to 1) properly secure one of twelve medication carts, two of six narcotics boxes, and prescription medication for three residents (#14, # 47, and # 49) and one unknown resident and 2) ensure one of six refrigerators was at a proper temperature for medication storage. Findings include: On 6/27/2022 at 10:50 a.m. the 1 [NAME] (Secured Unit) was entered for a tour. The nurses' station area was observed with six residents standing up and ambulating in the hallways. There were four additional residents seated in various chairs across from the nurse station as well. Residents in this unit are monitored and supervised routinely and have cognitive inabilities where they cannot speak to their medical care and daily routines. At 11:00 a.m. the nurse station area was still observed with approximately 6-8 residents either standing at and near the station or seated in chairs across from the station. There were no staff in the immediate area. Further observations of the area revealed a clear plastic sleeve with a cracked in half tablet, orange in color. Two residents were observed to walk over the tablet. Again, there were no staff in the immediate area during first observation At 11:06 a.m. an employee, Staff D, was observed pushing a cart full of supplies past the nurse station. She stopped immediately where the sleeved tablet was and said, Oh, that should not be there. She picked up the plastic sleeve and verified it was a tablet medication of some kind. She took the sleeved tablet and looked around for a staff member. She went behind the nurse station and at that time a nurse walked up, and Staff D told the nurse where she found the pill and proceeded to hand it to her. Photographic evidence of where the pill was lying could not be taken, as there were too many residents in the immediate area standing or walking past it. It was observed the sleeved tablet medication was lying on the floor, with no staff around, and with many residents ambulating in the immediate area from at least 10:50 a.m. through to 11:06 a.m. On 6/30/2022 at 7:15 a.m. an interview was conducted with Staff D. She revealed she had been trained and in-serviced in relation to finding loose pills/medications and if found, will pick it up and hand it to the nurse. Staff D. confirmed she did hand the pill to the nurse, but could not remember what the nurses name was, as she works for a nursing agency. An observation was conducted on 6/28/22 at 12:50 p.m. of a small side table in the 1 East back hallway, next to room [ROOM NUMBER]. The top drawer of the cart was slightly open. Upon closer inspection it was discovered the top drawer contained prescription medication including Nystatin power for Resident #47 and #49 and Triamcinolone CRE 0.1% for Resident #14. The side table had no locks. Photographic evidence obtained. Residents are frequently moving up and down this hallway walking or in their wheelchairs. An observation was conducted on 6/28/22 at 3:35 PM of the side table still in the hallway with the same unsecured medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 36 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 - Few An interview was conducted with Staff H, Licensed Practical Nurse (LPN) on 6/28/22 at 3:40 p.m. She stated she was just coming on to her shift. She confirmed the side table was not a medication or treatment cart and medication should not be in the table. She stated the treatment cart was currently on the other hallway. Staff H immediately removed the medication. An interview with the Director of Nursing (DON) was conducted on 6/28/22 at 3:50 p.m. The DON was showed a photograph of the side table. She stated medication should not in the table, it should be in a locked treatment cart or medication cart. She stated she would provide the facility medication storage policy. A tour of the 1 East and 1 [NAME] medication storage rooms was conducted with Staff A, Registered Nurse (RN), Unit Manager (UM) on 6/29/22 at 8:09 a.m. The refrigerator in the 1 East medication room contained a narcotics box as well as other prescription medications. The narcotics box was not properly secured to the refrigerator and was easily removed. The thermometer inside the 1 East refrigerator read 55 degrees Fahrenheit. The 1 [NAME] narcotics box was also not secured inside of an unlocked refrigerator and was easily removed. Both the 1 East and 1 [NAME] narcotic boxes contained narcotics at the time. Photographic evidence obtained. An interview was conducted with Staff A, RN, UM on 6/29/22 at 8:35 a.m. She stated the narcotics boxes were both previously secured to the refrigerators, but she hadn't checked them in the last couple of days. She stated she knew the narcotic box had to be attached to the refrigerator. She confirmed 55 degrees Fahrenheit was too high of a temperature for the refrigerator. She stated the temperature could be that high because I just cleaned it this morning. An interview with the DON was conducted on 6/29/22 at 8:38 a.m. The DON stated the narcotic boxes must be attached the refrigerator. She stated she has checked one since she has been in the facility but has not gone around the facility to check them all. On 6/30/22 at 2:35 p.m. a medication cart on the 1 East back hall was observed to be unlocked. There was no staff members in the hallway. Residents were moving about the unit. After 2-3 minutes, a nurse walked around the corner at the end of the unit near the nurses' station. The LPN, Staff I, stated the medication cart was hers. She explained she was at the cart charting and the Certified Nursing Assistant (CAN) needed something and she walked off not realizing she didn't lock the cart. She stated she is so sorry and continued to lock the cart. Photographic evidence obtained. An interview was conducted with the DON on 6/30/22 at 4:00 p.m. She stated she expected medication carts to be locked at all times. The facility policy titled Medication Storage was reviewed. The policy stated, it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication storage rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The policy's explanation and compliance guidance included: 1a. All drugs and biologicals will be store in locked compartments under proper temperature control. 1c. During a medication pass, medications must be under the direct observation of the person (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 37 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 administering medications or locked in the medication storage area/cart. Level of Harm - Minimal harm or potential for actual harm 2b. Schedule II controlled mediations are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in a refrigerator. Residents Affected - Few 6. Refrigerated products 6b. Temperatures are maintained within 36-46 degrees Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 38 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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, staff interview, and record review, the facility failed to ensure the kitchen and kitchen equipment were sanitary and maintained during four of four days observed (6/27/2022, 6/28/2022, 6/29/2022, and 6/30/2022). The kitchen was observed with peeling and chipped paint on equipment over the food preparation tables, rusted pipes and ducts that were over food preparation areas, food not stored appropriately in the walk-in refrigerator, pools of raw meat blood on the floor of the walk-in refrigerator, and refrigerator motor housing dripping rust color liquid on a vented bag of onions. Findings included: On 6/27/2022 at 10:00 a.m., 6/28/2022 at 11:00 a.m., 6/29/2022 at 11:00 a.m., and 6/30/2022 at 9:30 a.m., kitchen tours were conducted with the Dietary Manager. During the tours of the kitchen, the following was observed: 1. The overhead metal duct work directly above the table where clean dishes come out from the dish washing machine was observed heavily peeling and chipping. There were pieces of the chipped and peeling paint on the top surface of the actual dish machine. 2. The ceiling directly above the three-compartment sink was observed with a long metal pipe expanding the entire length of the room. Further observations revealed the metal pipe was heavily rusted and oxidized, with rust bits either falling or about to fall below in the three-compartment sink. 3. The ceiling areas directly above one of two food preparation station tables and directly above the steam table, where food is held, was observed with caked on dust debris. The debris was falling or about to fall on exposed and prepped food. The ceiling area directly above and between the steam table and the oven/range, revealed heavy dust/debris falling or about to fall on the prep and cook surfaces. 4. Most of the kitchen space where food is prepared, served, and stored, was observed with over twenty knat-like insects flying around and landing on ceilings, walls, exposed food, packaged food, floors, and staff. 5. The walk-in refrigerator was observed with pooled raw meat blood on the floor. The pooled blood was approximately eight inches by eight inches. 6. The walk-in refrigerator floor was observed with eight cups of ice cream, one half full bottle of water, and a large bag of opened mixed bag of vegetables lying directly on the floor under the food shelves. Most of the food items were on the floor all the way back and under the food storage rack. It appeared the items were on the floor for a long period of time. The walk-in refrigerator floor was sticky and soiled with black color grime. 7. The walk-in refrigerator mounted motor fan unit was observed leaking brown/rust colored liquid and dripping down the face housing and down onto a full large, netted bag of onions. The drips were observed to land on the exposed onions. 8. The walk-in freezer was observed with ice buildup along the back wall under the fan motor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 39 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 housing. The ice appeared to have been built up for a long period of time. Level of Harm - Minimal harm or potential for actual harm 9. The LS2 [NAME] Unit Nourishment pantry was observed with a mechanical ice making machine. The catch tray of the ice maker was observed with heavy oxidation that was green, yellow, and white in color. Further, the inside and outside of the ice chute was observed with gelatinous pink and black biogrowth, as well as white, yellow, and green oxidation. Residents Affected - Some The LS2 [NAME] Unit Nourishment pantry was observed with a drawer full of approximately fifty various packaged snacks. It was observed many exposed cookie crumbs, exposed entire cookies which were not in the package, and other exposed food crumbs in the drawer. 10. The LS2 East Unit Nourishment pantry was observed with black biogrowth on and near the sink backsplash, overhead cabinets, and the floor. The floor was also observed with various debris to include empty straw covers, crumpled papers and napkins, cup lids, plastic eating ware and various condiment packets. The trash can in the nourishment pantry was overfilling and spilling out on to the floor. Note: This observation was observed at 9:30 a.m. and the trash can should not have been that full at this time of day. Photographic evidence was taken with regards to the above listed observations. On 6/30/2022 at 10:00 a.m. an interview with the Dietary Manager revealed there is a daily cleaning schedule for the entire kitchen and dietary staff are assigned a different task. He provided the daily cleaning schedule and it revealed tasks such as: cleaning of walls, floors, cooking, and food preparation equipment are all to be thoroughly cleaned. There were no sign off sheets, just a sheet with expected cleaning tasks. The Dietary Manager revealed Maintenance is responsible for cleaning the ceilings and vents but did not know how often they came in the kitchen clean the dust/debris. Further interview with the Dietary Manager revealed there was not as specific policy and procedure with relation to kitchen cleaning maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 40 of 41 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 105390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balanced Healthcare 4250 66th St N Saint Petersburg, FL 33709 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm Based on interview, medical record review, and facility policy review the facility failed to notify two resident representatives (# 79 and 105) by 5:00 p.m. on the calendar day once a COVID-19 positive case was confirmed by the facility out of three residents sampled for notifications. Residents Affected - Few Findings Included: On 6/30/2022 at 3:15 p.m. an interview was conducted with the Director of Nursing (DON) who verbalized the last three residents that had tested positive for COVID-19 at the facility. A review of Resident #79's medical record contained a copy of a Lab Results Report which revealed a positive result of COVID-19 dated 6/22/2022. A review of Nursing Progress Notes dated 6/22/2022 at 11:46 p.m. read the resident was transferred to the isolation unit. The medical record did not reflect documentation of the emergency contact being notified of the change in condition. A medical record review for Resident #105 contained a copy of laboratory results which revealed a positive test for COVID-19 on 6/22/2022. A review of Nursing Progress notes dated 6/22/2022 indicated the resident had a room change to the isolation unit. A further review of the notes did not reflect documentation of notification to the resident family member related to the change of condition. On 6/30/2022 at 3:46 p.m. an interview was conducted with the Nursing Home Administer (NHA) who stated she notifies family and representatives of COVID-19 results by e-mail. The NHA said the process of individual family notification was conducted by the Assistant Director of Nursing (ADON). The NHA added the ADON had left last week, and family notification had not been provided timely. A review of the facility policy titled Novel Coronavirus Prevention and Response Revised: 2/21/2022 Policy: This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus. Definitions: Coronavirus is a virus that causes mild to serve respiratory illness. 6. Procedure when COVID-19 is suspected or confirmed: a. Notify physician, Director of Nursing, Infection Preventionist, and family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 41 of 41