Inspection·June 13, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents gets more attention than she does. Patient verbalizes paranoia if she does not have somebody sitting with her. The assessment also indicated that she seems to be the patient's baseline since she came in the facility. Will recommend a weighted blanket or anxiety straps on Geri chair as patient has a history of standing up and sitting down multiple times for safety awareness poor impulse control is a baseline. 2. Behavior note dated 4/21/2023 at 11:27, Writer spoke with patient. Patient reported anxiety when sitting in chair. Educated patient on weighted anxiety blanket. Patient reported that she would think about it. Patient verbalized paranoia about being alone, I can't be alone. 3. Psychiatry Nurse Practitioner Encounter note dated 5/5/2023 at 01:00, Awaiting weighted anxiety blanket, it has been ordered. 4. Behavior note dated 5/12/23 at 14:15 (2:15 p.m.), Resident removed weighted blanket and began hollering help. Assisted resident with putting blanket back on, but resident pushed it back off. 5. Health Status note dated 5/12/2023 at 20:11 (8:11 p.m.), Resident in her room with no behaviors or issues. Resident was sleeping at the start of the shift, she was awakened and consumed all of her dinner. Resident lying in bed with a weighted blanket at her feet. 6. Behavior note dated 5/15/2023 at 03:58, She asks for her blanket in specific her green blanket, then takes it off. 7. Behavior note dated 5/15/2023 05:45, Resident had a change of condition and was ordered and transferred to the ER related to Altered Mental Status, via hospital transport. 8. Social Service note dated 5/15/2023 at 11:47, Resident interviewed in regard to her having any concerns with her blanket. She reported, No. Social Services asking if she could remove it and she picked it up and handed it to the Assistant Nursing Home Administrator. Resident reported that she did not have any other concerns at this time. A review of the record revealed Resident #4 returned to the facility from the hospital on 6/9/2023. A review the nurse's progress notes dated from 6/9/2023 through 6/13/2023, and the Psychiatric Nurse Practitioner notes/assessments since 6/9/2023 admission, did not show use of aweighted blanket or the attempt to encourage the resident to use a weighted blanket. An interview on 6/12/2023 at 11:30 a.m., with the Psychiatric Nurse Practitioner, Staff A revealed she ordered the weighted blanket as a sensory object as a new intervention to decrease anxiety behaviors. She revealed once she recommended it on 4/21/2023, she was no longer involved with how the facility effectively care plans the device. She also revealed she did not speak with Resident #4's POA prior to her recommendation and said that would be something the facility nursing management would do. On 6/12/2023 at 3:15 p.m. a telephone interview was conducted with Resident #4's POA/Responsible Party. The POA revealed that she had been a part of quarterly care planning before and was involved with Resident #4's care and services. The POA said she was now aware Resident #4 was provided with a weighted blanket to use for her anxiety. She did not know how long the resident had been using it and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 2 of 8 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 06/13/2023 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said she had not been asked to sign a consent for the weighted blanket. She was not given information about the effects of the weighted blanket or the Risks and Benefits of the device. Resident #4's POA confirmed the resident did not have the ability to give consent for this device on her own. On 6/13/2023 at 11:30 a.m., an interview with the Nursing Home Administrator (NHA) revealed she was very knowledgeable about Resident #4 and the purchase and use of the weighted blanket. She said the blanket was not used as a restraint and the resident could remove it and had demonstrated removal of the blanket per her desire. The NHA said she ordered the weighted blanket on 4/27/2023. She said there was not an actual physician's order for this intervention, as it was just a blanket to be used to reduce anxiety. The NHA provided the following document for review: Final Details for Order, order placed on 4/27/2023 with a shipped out date of 4/29/2023 to include: 2 of [vendor name] Weighted Blanket (15 lbs. 48 x 72 Twin size) Cooling Breathable Heavy Blanket Microfiber Material with Glass beads big blanket for Adult all-season soft thick comfort blanket. The NHA confirmed she, the nursing department, nor anyone from the facility called Resident #4's POA to go over the decision to utilize a weighted blanket to reduce anxiety episodes. She confirmed the POA was not given the right to be notified of the device prior to use. She said the POA should have been provided with information , including the Risks and Benefits and given the opportunity to refuse or consent to the weighted blanket. The NHA revealed she did speak with Resident #4's POA related to the blanket, but it was well after it had been in use. On 6/13/2023 at 2:00 p.m., the Nursing Home Administrator (NHA) provided the facility's Resident Rights, policy and procedure with no implement date, for review. The policy had a copyright date of 2023. The Resident Rights policy and procedure Policy section revealed; The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The Policy Explanation and Compliance Guidelines section revealed the following, but not limited to: Resident Rights - The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1. Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the United States. (a.) The resident has the right to be free of interference, coercion, discrimination, and reprisal of his or her rights. (B.) In the case of a resident who has not been adjudged incompetent by the State court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by State law. (d.) The resident representative has the right to the resident's rights to the extent those rights are delegated to the resident representative. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 3 of 8 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 06/13/2023 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 0552 Level of Harm - Minimal harm or potential for actual harm 2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: (a.) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. Residents Affected - Few (b.) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (iii) The right to be informed, in advance, of changes to the plan of care. (c.) The right to be informed in advance, of the care to be furnished and the type of care giver or professional that will furnish care. (d.) The right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternatives or options he or she prefers. (e.) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 4 of 8 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 06/13/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to implement a care plan for one (Resident #3) of three residents sampled related to NPO ((nothing by mouth) status. Findings included: A review of Resident #3's admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to gastrostomy status, anoxic brain damage not elsewhere classified, unspecified white matter disease, and unspecified organism other pneumonia. A progress note, dated 5/4/23 at 11:33 p.m., described an incident that the writer (of the note) went into the residents room and saw the aide feeding the resident who is NPO. The note indicated that the resident had been given approximately one spoonful of food which the resident spat out. The note indicated the nurse assessed and suctioned the resident, and educated the aide on reading diet slips, checking name, room number, and bed number (of diet slip). The note did not identify if any food particles had been obtained from the oral cavity when Staff J had suctioned the resident. The review of Resident #3's Medication and Treatment Administration Records, May 2023, identified the following orders: - Enteral Feed Order, start 5/4/23 - every 4 hours bolus feed, Jevity 1.5, 1 can every 4 hours = 6 cans daily. - Enteral Feed Order, start 5/4/23 - every 4 hours Enteral 1 - Feeding: Administer Jevity 1.5 per G-tube via Bolus. Rate 237 milliliter (mL) per feeding 6 times a day. - Enteral Feed Order, start 5/4/23 - every 4 hours Enteral hydration: Bolus with 120 mL's water every 4 ours for hydration. - Oral suctioning as needed for excessive secretions every 6 hours as needed, start date 5/4/23. - Suction as needed (prn) as needed for congestion, start date 5/3/23, discontinued at 8:20 a.m. on 5/4/23. A review of the Resident #3's care plan identified the following: - (Resident) is at risk for malnutrition related to (r/t) low body mass index (BMI), dysphagia with dependence on enteral nutrition for meeting of needs, increased nutritional demand for wound healing, polysubstance abuse history, and 1/27/23 coughing on food and fluids - NPO status, initiated on 10/18/22 and canceled on 5/9/23 (5 days after resident was transferred). - (Resident) has decreased ability to perform Activities of Daily Living) ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to impaired cognition, activity intolerance, (and) impaired mobility, initiated on 10/18/22 revised and canceled on 5/9/23. The interventions identified Eating: NPO - receives enteral feeding, initiated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 5 of 8 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 06/13/2023 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 0656 4/11/23 and canceled on 5/9/23. Level of Harm - Minimal harm or potential for actual harm - 3/10/23 (Resident) has diagnosis of Emphysema and nodule to right lung per CT scan. Residents Affected - Few An interview was conducted on 6/13/23 at 9:24 a.m. with Staff I, Certified Nursing Assistant (CNA). Staff I admitted to working for the facility (not agency), vaguely remembered Resident #3, and had only worked with this resident one time. Staff I said she was told by an unidentified aide during rounds (at the beginning of her shift), that one of the residents in the room was a feed and Resident #3 was the only resident in the room at that time. Staff I said at the time of the meal service (dinner), two trays came for the room, one for A-bed and one for B-bed, Staff I glanced at the ticket, and admitted to not fully reading the resident name on it then began to feed Resident #3. Staff I stated the resident pushed his lips toward the spoon, the nurse came into the room and informed the aide the resident was NPO. Staff I reported the resident never let her put the food into his mouth. She said the resident became upset and started extra coughing and right there Staff I decided not to feed the resident. She said, I'm not a forceful person. An interview was conducted, on 6/13/23 at 10:48 a.m., with Staff J, Licensed Practical Nurse (LPN). Staff J stated on 5/4/23 at dinner time she brought Resident #3's roommate in the room to eat and observed the CNA feeding Resident #3. Staff J asked Staff I how the tray got to Resident #3 and asked her to look at the picture, name, and verify the room number. Staff J stated the tray that was being fed to Resident #3 was for a resident on a different unit, and was a regular diet from Lifestyle 2 (upstairs from the resident). Staff J reported notifying the Director of Nursing (DON) and Nursing Home Administrator (NHA), suctioning Resident #3 to see if any food was in there to get it out, and reported removing a couple pieces of corn out of mouth. Staff J reported the resident was gurgling on admission, 5/3/23. Staff J had not suctioned the resident prior to the event, and the resident was not wearing oxygen prior to the incident. Staff J throughout the night Resident #3's oxygen saturation was lowering so oxygen was applied, and as needed Tylenol was administered as the resident began running a low-grade temperature. Staff J contacted Resident #3's family and Hospice, the Hospice staff called Emergency Medical Services (EMS) to transfer resident to Hospice House. The dietary slip/meal ticket (obtained from CDM on 6/13/23 at 8:12 a.m.), dated 5/4/23, showed Resident #3 was NPO, had the residents name, room number with bed letter, and picture. The diet slip/ticket did not identify any food/drink/supplemental items that would be served to Resident #3. The menu for 5/4/23, that the CDM provided, identified that on 5/4/23 the primary dinner served to residents included buttered kernel corn. The Nutrition/Dietary note from Registered Dietician, dated 5/4/23 at 10:43 a.m., identified that Resident #3 received 6 cans of Jevity 1.5 daily (1 can every 4 hours). The note did not identify any other type of diet for Resident #3. The Health Status note, dated 5/4/23 at 12:50 p.m., indicated that Resident #3 was suctioned this shift due to excessive secretions. The note did not identify how many times the resident had been suctioned. The note indicated the vital signs for the resident were 128/86, 97.7 temperature, pulse 92, respirations were 20, and oxygen saturation was 97% on room air. The note identified that hospice nurse had been in to see the resident and at the time of the note, the resident was in bed eyes closed, respirations even and unlabored. A Health Status note, dated 5/4/23 at 8:19 p.m., indicated that Resident #3 had increased secretions and cough and a STAT chest X-ray was ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 6 of 8 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 06/13/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/4/23 at 11:40 p.m., Staff J noted that Resident #3 had increased secretions and cough, vital signs were 130/90, heart rate was 106, respirations 16, temperature was 98.2, and oxygen saturation on room air was 80%. The staff member documented oxygen was administered for shortness of breath, new orders were obtained for a STAT chest X-ray, hospice nurse and family member notified, and as needed Tylenol was administered with continued suctioning as needed. The staff member noted that oxygen saturation raised to 95% and resident was on 5 liters per minute (lpm) of oxygen, Resident resting comfortably in bed with (family member) by (resident) side. Hospice in facility to evaluate and new recommendations were to send resident to Hospice House. The note indicated Resident #3 left the facility via ambulance at approximately 11:00 p.m. On 6/13/23 at 11:24 a.m., an interview was conducted with Resident #3's Attending physician. The physician reported that the resident had aspiration syndrome and the next to the last time the resident came back with a feeding tube after not doing well with oral (intake). The expectation was for residents with NPO orders should be obvious, should not be getting fed orally. The physician stated the expectation was that staff know the resident was NPO and described that other facilities place signs up that identify the resident as NPO. The Assistant Director Nursing (ADON) stated on 6/12/23 at 3:04 p.m., that a spoonful of food was inadvertently fed to Resident #3 which was spat out and staff suctioned. The ADON stated that the facility addressed the incident with the aide, Staff I, and educated that if there were any changes with dietary status nurses inform aides of the changes during rounds. On 6/12/23 at 5:16 p.m., the Nursing Home Administrator (NHA) admitted to being aware that an aide reported feeding the resident one spoonful of food which Resident #3 spat out and the aide demonstrated that the resident pushed the food away with pursed lips and the nurse went in and immediately suctioned the resident. The NHA stated being pretty sure the resident came back from hospital with additional secretions that required additional suctioning and was to be transferred to Hospice House when a bed became available. An interview was conducted at 6/13/23 at 1:07 p.m., with the NHA, the Regional Nurse Consultant (RNC), Staff K (Licensed Practical Nurse (LPN)/Unit Manager), and Staff L (Facility Nurse Practitioner (NP). Staff L stated Resident #3 had been treated for recurrent pneumonia that the facility could not get rid of, the resident was sent for a pulmonary consult with results of right lower lobe nodule. The RNC stated that the first time the resident transferred to the hospital for pneumonia was in February (2023). The RNC said the resident had been sent to hospital numerous times for pneumonia, abnormal labs, and brown emesis. A telephone interview was conducted on 6/13/23 at 3:27 p.m., with the previous NHA, Staff M. Staff M reported that the DON, who was onsite at time of the incident, was onsite and it was reported that a newer aide gave Resident #3 a spoon of pureed food, the nurse had immediately suctioned the resident and it looked like the resident had spit everything out. The staff member stated that the nurse had called family, physician, and hospice. The facility incident log did not include the event on 5/4/23 involving Resident #3. The policy - Therapeutic Diet Orders, implemented on 11/3/2020, indicated that The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the reside's treatment/plan of care, in accordance with his/her goals and preferences. The explanation and compliance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 7 of 8 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 06/13/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete guidelines of the policy indicated that each residents nutritional status is assessed by the interdisciplinary team in accordance with assessment policies and Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. The policy - Serving a Meal, implemented 11/3/2020 and revised 11/29/2022, indicated that It is the policy of this facility to serve meals that meet the nutritional needs of the residents. The guidelines and explanation revealed that Diets should be served in accordance with the physician's order. Event ID: Facility ID: 105390 If continuation sheet Page 8 of 8