Health inspection·August 24, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Quetiapine Fumarate oral tablet 200 MG Give one tablet by mouth two times a day related to Schizophrenia, ordered on 6/08/2023. Estradiol oral tablet 1 MG Give one by mouth one time a day for inappropriate sexual behavior, ordered on 6/23/2023. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 09, indicating severe cognitive impairment. In Section G: Functional Status the assessment revealed Resident #1 required extensive assistance by one person for locomotion on the unit, supervision by one person for eating, no impairment with range of motion for upper or lower extremities and utilized a wheelchair for mobility. A review of the Comprehensive Care Plan, last review date 5/18/2023, revealed Resident #1 had the following focus areas in place: Focus--Resident #1 is at risk for alteration in nutrition and hydration related to: Dx (diagnosis) Dementia, dysphagia and need for mech altered diet. Will take food from peers that may not always be appropriate for diet consistency due to Dx, may not understand that the food he takes is not his or that it is not safe for him .(Initiated 11/01/2020). Goal-- .Will not choke or aspirate through next 90 days . Interventions included but not limited to: Assist and encourage as needed with meals; Monitor and provide preferences as available; Monitor meal intake and offer alternate items as needed; Redirect as needed, offer alternate items as needed that are appropriate for his diet; Review in risk meetings as needed; Thickened liquids as ordered. Focus-Resident #1 has the following behavior problems: verbally and physically aggressive, easily agitated, entering other residents' rooms without permission, sexually inappropriate ., resident to resident altercations, takes food off other residents' trays (Initiated 7/28/2023). Goal-Resident #1 will have fewer episodes of disruptive behavior by next review date. Interventions included but not limited to: Anticipate and meet the resident's needs; Intervene as necessary to protect the rights and safety of others; Redirect the resident as necessary. A review of a Modified Barium Swallow Study Final Report, dated 3/09/2020, revealed a diagnosis after the study of moderate-severe oral with moderate pharyngeal phase dysphagia. The recommended oral diet was puree/honey. A review of Progress Notes for Resident #1 revealed the following: 8/13/2023 11:34 p.m. Resident was found unresponsive in room at 5:55 pm. Code was called Heimlich maneuver was provided while assisted to remove food out resident's mouth. Resident was brought to the floor and CPR was provided. Suction was provided to resident's mouth to remove and obstructions. EMT [Emergency Medical Technician] arrived and took over at 6:15pm. EMT took over CPR. Started an IV [Intravenous] bag via shin. Resident was intubated at 6:20pm EMT got at pulse at 6:28 pm and resident was taken to hospital at 6:30pm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 2 of 10 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 08/24/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 8/14/2023 2:12 a.m. res [resident] was admitted to ICU [Intensive Care] at [hospital name] with a diagnosis cardiac arrest. A review of the EMS patient care report, DOS (date of service) 8/13/2023, revealed the following narrative: Dispatched to [facility name] for the [AGE] year-old male cardiac arrest/ Staff states that she saw the patient 30 minutes prior and when she next saw the patient, he was sitting in his scooter unresponsive with food on his lap. Staff states that the patient is on a puree diet but had a sandwich next to him. Staff states that they moved the patient to the floor and started CPR. FD [Fire Department] states that they found the patient on the ground with chest compressions being performed by staff. FD states that the patient's airway had soft food in his airway that was suctioned as much as possible before placing a king airway. Patient was found to be in asystole. Patient has a history of dementia and Parkinson's. Patient was found supine on the floor with staff/FD, unresponsive with chest compressions and assisted ventilations being performed. Cardiac arrest post asphyxiation with ROSC [Return of Spontaneous Circulation]. Patient was carried to the stretcher via back board, secured X5 seat belts, and transported to the closest appropriate facility as documented without incident. All interventions as listed were performed with positive patient outcomes. Transfer of care was completed at patient's bedside with a verbal report given to ED [Emergency Department] nursing staff. A review of the hospital record Intensive Care Consultation report, dated 8/14/23 at 6:57 a.m., revealed the following: Reason for consult: Cardiac Arrest HPI (History and Physical Information): (Resident #1) is a [AGE] year-old male with a previous history of Parkinson's Disease who presents from nursing home after a cardiac arrest. Patient is currently intubated and sedated .Patient has had dysphagia for years and is on a soft/puree diet at his nursing facility. Around 5:00 p.m. the previous evening he was given his assigned dinner. Around 5:40 p.m. he was placed back into his room. When staff checked on him around 5:55 p.m. they found him unresponsive. They noticed he had gotten food from his roommate's plate and suspected he chocked .Upon arrival to the ED, patient was minimally responsive but otherwise hemodynamically stable. Hypothermia protocol as initiated, and patient was transferred to ICU for further management. Diagnosis, Assessment & Plan: Cardiac arrest secondary to Hypoxia Acute Hypoxic Respiratory Failure Aspiration secondary to Dysphagia . Death Event Note: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 3 of 10 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 08/24/2023 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 0689 Pronouncement of Death Level of Harm - Immediate jeopardy to resident health or safety Date: 8/15/2023 Residents Affected - Few Clinical assessment: blood pressure absent, cerebral unresponsiveness, pulse absent, pupils dilated/unreactive, respirations absent. Time: 1810 (6:10 p.m.) During an interview on 8/22/23 at 10:25 a.m. Staff A, Licensed Practical Nurse (LPN) stated she had worked at the facility for a long time. She stated the diet trays are checked by the nurse first to make sure the trays are accurate for each resident. She stated the aides are responsible for monitoring the residents on puree foods during their meals and they should keep them close so they can make sure the resident does not choke. She stated if the resident is able to eat on their own the staff have to go in and check on them often to make sure they are swallowing their food properly. During an interview on 8/22/23 at 11:15 a.m. Staff B, LPN stated residents who are on a puree diet have to be set up and assisted or monitored during their meals. She stated the staff have to keep a close eye out to watch for swallowing and choking when a resident is on a puree diet. During an interview on 8/22/23 at 11:55 a.m. Staff C, LPN stated she was the unit manager for the 2E and 2W nursing units. She said residents who receive altered diets are care planned, noted on the Kardex for staff information, and the food ticket will identify the consistency of the food and liquids for each resident. She stated she also keeps a list in the nourishment room of residents on honey and nectar thick liquids. She stated she updates the list if any diet changes occur for each resident. She stated she makes rounds during meals to observe staff assisting residents. She stated residents who can feed themselves may be out at the nurse's station during meals for closer observation. Staff C, LPN stated any changes in residents or concerns are discussed at morning team meeting and for residents with concerns about meals will be followed up with evaluation by speech therapy. During an interview on 8/22/23 at 12:25 p.m. with Staff D, Certified Nursing Aide (CNA) and Staff E, CNA they stated they had recent education and training related to assistance with meals for residents. They stated the education included: set up, checking liquids, oversight of residents during meals, elevating the head of the bed and not putting it down for 30 minutes after the meal, proper utensils, close monitoring to assure residents do not get the wrong food and risk choking, and monitoring of other residents to assure they do not give other food to residents at risk for choking. An interview was conducted with the Nursing Home Administrator (NHA), the Assistant Nursing Home Administrator (ANHA), and the Assistant Director of Nursing (ADON) on 8/22/23 at 1:56 p.m. They stated they were all are aware of the incident with Resident #1 and had conducted a full investigation and had reported the incident to all required agencies. The NHA stated the Director of Nursing (DON) was involved in the investigation at the time, but she is currently on leave. The ANHA stated she received notification from nursing Resident #1 was transferred to the hospital after the incident. She stated the incident occurred on a Sunday during the dinner meal. She stated the DON notified her at 6:19 p.m. The ANHA stated Staff E, LPN notified the DON after the incident because she was the nurse responsible for the care of Resident #1 on that evening. The NHA stated the incident was discussed over the phone with the ANHA and the DON right away and it was reported, and an investigation was begun. The ANHA stated Resident #1 was found in his wheelchair, unresponsive with food in his mouth, but they were unable to determine how much food he had consumed. She stated he had access to his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 4 of 10 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 08/24/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few roommate's dinner tray which was on the overbed table. She stated the roommate was not in the room. The ANHA stated Resident #1 liked to eat at the nurses' station, was able to eat on his own, and was on a puree diet. She stated the resident finished eating and could locomote on his own but slowly. She stated Resident #1 went back to his room on his own after the meal. She stated this was his routine. The ANHA stated Resident #1 had a history of taking other resident's food, but there had been no reports of this happening recently that she was aware of. She stated when the resident was discovered unresponsive, CPR was started, the Heimlich maneuver was done, EMS was called, and suction to remove the food was done by the nursing staff. When EMS arrived, they took over and the resident was taken to the hospital. The ANHA stated a complete investigation was conducted with interviews and record review with all of the staff involved in the incident. She stated they developed a timeline and confirmed the roommate was not in the room at the time of the incident. The ANHA stated during the interviews with staff it was determined the roommate would often eat some of his food and then leave it and return later to finish it. She stated the staff on the unit were very consistent and knowledgeable about the residents and their patterns. The ADON stated education was immediately started with verbal educations related to aspiration, choking, and coughing during meals. She stated they also have an electronic learning center that has been assigned to all staff related to aphasia and aspiration. The NHA stated the facility has initiated a manager doing rounds during dinner times, and they are currently getting ready to open the dining room so residents can be monitored by staff easier during meal times. The NHA said it was everyone's job to monitor for eating, dietary, feeding and aspiration. He stated meal times are 'all hands-on deck.' The ADON stated the reason Resident #1 was eating in the hallway by the nursing station was because it was his social element and he preferred hanging out at the nursing station. She stated the staff liked to see him there due to his risk for falls. She stated staff would monitor his eating at the nursing station also. She stated Resident #1 rarely ate in his room. The NHA stated the staff should have verified the roommate's food tray was left in the room unattended and should have removed it and placed it back in the cart until the roommate returned. During an interview on 8/22/23 at 2:53 p.m. Staff F, LPN stated she was the nurse assigned to Resident #1 on the day of the incident. She stated the resident received his puree diet around 5:00 p.m. and he ate it at the nurses station in the hallway. Staff E, LPN stated she was giving medications at the cart when she saw Resident #1 messing with the meal trays on the cart. She stated he was pulling the trays off the cart and attempting to get food off the used trays. Staff E, LPN told Resident #1 to stop, and he was redirected back to his room. She stated she continued to pass medications and she did see him once and he was sitting in the room with the other residents in his wheelchair. She stated the second time she checked on Resident #1 he was slumped in chair and blue, she called a code. She stated she saw bread in his mouth and tried to get it out. She stated an aide came in to help lower the resident to the ground. She stated the crash cart arrived and other staff came in to assist. She stated Resident #1 was not breathing and had no pulse. She stated she suctioned stuff out of his mouth and they began CPR. She stated when EMS arrived, they took over care. Staff F, LPN stated Resident #1 had eaten his puree diet without any problems. She stated she was a float nurse and had not had Resident #1 in about two weeks. She stated she was aware the resident was care planned for taking other residents' food. She stated there was one tray in room that she thought was from the B bed, but she was not sure. She stated the tray was untouched. She stated the trays were passed around 5:00 p.m. and she found Resident #1 around 5:55 p.m. She stated EMS intubated the resident at facility and had used suction while they were there to clear the food. She stated she told paramedics the resident was choking on food from another resident's tray. During an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 5 of 10 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 08/24/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few interview on 8/23/23 at 9:29 a.m. with the Advanced Registered Nurse Practitioner (ARNP) She stated she was familiar with Resident #1 and had cared for him for about two years. She stated the resident was wheelchair bound and could move around the facility in his chair on his own. She stated he was a pleasant man but did have some behavioral issues. She stated she was not sure if he was being seen by psychiatry. She stated he had dysphagia and was on a puree diet for a long time. The ARNP said she was not aware of any issues related to Resident #1 taking food from other trays. She stated she was made aware of the incident when she came in on the Monday morning following the incident. The ARNP stated she was not informed of the reason why Resident #1 coded, but she read the note in the record and was aware the resident expired. She stated her expectation would be the staff watch and check on residents who are on puree diets to make sure they are safe during the meals. During an interview on 8/23/23 at 9:43 a.m. Staff G, Speech Therapist (ST) stated Resident #1 was at the facility for a long time and she had known him for several years. She stated the resident was able to get around in his wheelchair. She stated she would do a quarterly screening on the resident to make sure his diet was appropriate. She stated he was on a puree honey thick liquids diet. She stated he had been on the diet for a long time because he was not able to masticate or swallow differing textures without problems. She stated her instructions to staff was to monitor Resident #1 during meals, but he could feed himself. The ST said she was unaware the resident was food seeking and she was not aware the resident was care planned for taking other resident's food but became aware after the incident occurred. The ST stated staff should be watching for any type of coughing, etc. while a resident on a puree diet is eating. During an interview on 8/23/23 at 9:53 a.m. Staff H, CNA stated she was working the floor during the evening of the event but was not assigned to care for Resident #1. She stated she started to pass trays and Resident #1 was trying to grab trays and food before she passed the trays. She stated she was assisting another resident and watching Resident #1 at same time. She stated Resident #1 eats 100% of the meal every time and eats well by himself. She stated after the meal she was picking up trays and saw the nurse redirecting Resident #1 to go to his room. She stated the nurse, and the resident were by the tray cart at the time. She stated about 10 minutes later she heard the nurse shout call a code. She said she went to the room and saw the nurse performing the Heimlich maneuver. She stated Resident #1 had food in his mouth and the nurse was trying to get it out. Staff H, CNA stated there was a tray in the room and she thought it belonged to B bed. She stated she gave a statement about the incident to the DON and ANHA and told the same story that she just relayed to surveyors. She stated she was aware Resident #1 was food seeking. She stated Resident #1 had sought food on a regular basis. She said she had seen the resident do this at least three times a week on the shifts she worked. She stated she had seen the resident food seeking in his room, in the hall, anywhere he was close to any food or drinks. She stated she was not aware he had dysphagia but was told Resident #1 ate his food too fast. She stated Resident #1 had to be watched to make sure he was safe. She stated Resident #1 was always seated in the hallway by the nurses station so he could be watched while eating. She said she would not leave a tray unattended in one of her rooms and if a resident was not in the room, she would store the tray in clean utility until resident was located. A telephone interview was conducted on 8/23/23 at 10:11 a.m. with the Medical Director (MD). The MD stated he was aware of Resident #1 and had discussed the resident in the psychotropic medical management meetings. He stated the resident was having increased behavioral issues. He stated he reviewed the resident's record and did not make any changes to his medications. He stated he was informed about the incident and what had occurred. He stated the resident had a choking incident as a result of accessing food that was not on his prescribed puree diet. The MD stated the incident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 6 of 10 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 08/24/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was discussed with the NHA, the ANHA and the DON. He stated the findings were Resident #1 had access to another resident's tray and we could have been more careful to ensure he and other residents did not have access to other foods. The MD said Resident #1 was highly cognitively impaired and did not understand the dangers of eating others food. The MD stated the plan was to reopen the dining room so better supervision can be provided. He stated he was not personally aware of the food seeking concerns with Resident #1. The MD stated the expectation was residents were not given food in room where it was difficult to observe/supervise the residents. During a telephone interview on 8/23/23 at 10:30 a.m. with the Power of Attorney (POA) he stated Resident #1 had a Traumatic Brain Injury (TBI) and several strokes and had been in the facility since 2019. The POA stated he visited with the resident once a quarter and was working with social services on getting some dental work done for Resident #1. The POA stated the first two phases had been completed. He stated the facility called him and the call went to voicemail on the date of the incident. He stated before he could call the facility back, the hospital called him and updated him. He stated he called facility back and the nurse talked with him and told him the resident got a hold of his roommate's food and he choked and went into cardiac arrest. The POA stated the hospital told him Resident #1 was in critical condition, and in the Cardiovascular Intensive Care Unit (CVICU). He stated the hospital was doing cooling therapy to try to limit damage to Resident #1's brain. He said when he was at the hospital with the resident, 'I just knew, there was no reaction.' He stated the doctors came in and told him they were assessing to see if the resident's was brain dead. The POA made Resident #1 a Do Not Resuscitate (DNR) at the hospital. He stated the Neurologist saw Resident #1 and confirmed the resident was brain dead. The POA stated the ventilator was removed and the resident expired shortly after on Tuesday 8/15/23 at 6:10 p.m. The POA stated Resident #1 was on a puree diet for years because he would choke with regular food. The POA stated he had asked at several care plan meetings if the resident would ever be able to eat normal food, and he understood the answer was no. The POA stated Resident #1 was in the care of the funeral home and he had not received any death certificates at the time. During an interview on 8/23/23 at 10:48 a.m. Staff I, CNA stated she was the CNA assigned to Resident #1. She stated she was assisting residents with their meals at the time of the incident. She stated Resident #1 had already been served by another staff member and had eaten his food at the nursing station. She said she was aware Resident #1 was on a puree diet and was a risk for choking. She said she was aware the resident was food seeking. She stated she did not leave resident trays unattended in a resident's room. She stated she heard the code blue called and went to the room and helped the nurse get him onto the floor. She stated the nurse was getting food out of his mouth and was also suctioning. Staff I, CNA said it was about ½ sandwich that was in his mouth and she though it was a Philly Steak sandwich. During a telephone interview on 8/23/23 at 11:14 a.m. Staff J, CNA stated she was present on the date of the incident, and she was very familiar with Resident #1. She said she worked doubles on the weekend and was normally assigned to care for Resident #1 but on that date, he was assigned to a different CNA. She stated she was turning a resident and heard the code called and ran to the room. She said the nurse was trying get him resident to 'cough it up'. She stated Resident #1 was not alert and they got him unbuckled from his chair and tried the Heimlich maneuver and then got him on the floor. She stated it was evident he was choking on food. She stated there was bread in his mouth, and it belonged to his roommate. Staff J, CNA said Resident #1 attempted to get food off the carts and from other residents' trays all the time. The CNA stated Resident #1 would try to get food not on his diet every day. She stated she gave a statement and told the same story she conveyed to surveyors. She stated supervising a resident at meal time means she has to make sure they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 7 of 10 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 08/24/2023 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 0689 are swallowing correctly and not coughing or choking on their food. Level of Harm - Immediate jeopardy to resident health or safety A review of the facility policy entitled Meal Supervision and Assistance, implemented on 1/2022 and revised on 4/2023, revealed the following: Residents Affected - Few Policy: The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes: -Identifying hazards and risks -Evaluating and analyzing hazards and risks -Implementing interventions to reduce hazards and risks -Monitoring for effectiveness and modifying interventions when necessary Compliance Guidelines: 1 The facility will utilize a systemic approach to ensure safety throughout the resident's environment and among all staff. 2 The facility will develop and implement an individualized care plan based on the Resident Assessment Instrument (RAI) to address the resident's needs and goals, and to monitor the results of the planned interventions such as adequate supervision during meal time . Facility immediate actions to remove the Immediate Jeopardy included: --On 8/14/23 to 8-23-23 RN/ADON and/or designee, initiated education for meal supervision and aiding residents who have been prescribed a modified diet. These educations included verbal and online education courses 100% completion between in person, online and telephone education obtained on 8-23-2023. --On 8/23/23 the IDT (Interdisciplinary Team) reviewed MDS section K05102 for mechanically altered diet for all residents requiring assistance and or supervision with meals. ADON / designee reviewed care plans to identify current residents who have been prescribed a modified diet and require assistance with meals. Results of these audits were forwarded to the ad-hoc QAPI meeting held on 8/23/2023. For residents identified in the audit, care plans were revised, and ADL task list were updated to include aiding and supervision with meals. --On 8/14/23 an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting was conducted with the facility leadership team as well as the Medical Director to review the incident involving Resident #1. --On 8/23/23 an Ad Hoc QAPI meeting was conducted with the facility leadership team as well as the Medical Director to review IJ F 689 Abatement plan. Root Cause Analysis was completed. PIPs (Performance Improvement Plans) were developed based on audits completed to ensure adequate compliance with F689. Root caused determined to be lack of supervision. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 8 of 10 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 08/24/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few --On 8/23/2023 Additional staff members are now assigned to round throughout the building on both floors to provide additional supervision to ensure all residents get the appropriate meal and they are supervised until all trays are returned to kitchen. Staff educated to remove trays from patients' rooms after meal is completed and/or if the patient is not eating the dinner tray or not in the room. The tray would be placed back in the food cart until the patient is ready to eat. New dietary orders to also to be reviewed daily to assure all diet change orders are documented and reviewed. All audits will be reviewed after each meal by the Administrator/Designee to ensure compliance daily for 30 days. --Facility removed immediacy as of 8-23-23. Verification of the facility's removal plan was conducted by the survey team on 08/24/2023. Beginning on 8/24/23 at 11:50 A.M. Interviews were conducted with 59 staff members including: 20 licensed nurses, 26 CNAs, a receptionist, an activities aide, 2 business office staff, the Physical Therapy Director, and 7 housekeeping staff. The staff members were able to state they had been trained and were knowledgeable about the new policies. On 8/24/23 starting at 11:50 a.m. dining observations were conducted on the second-floor units. The nurse was observed to check all carts for accuracy of the trays for each resident. During the tray pass, staff were observed checking trays for accuracy. The manager and nurses were visible on the unit. Staff from administration were observing and supervising tray pass and resident dining. Staff were observed assisting residents with their meals. No trays were left unattended during the observations. On 8/24/23 starting at 12:30 p.m. Dining observations were conducted on the first-floor units. On the secured unit, all trays were observed to be checked by the nurses on the unit prior to passing them out. Trays were distributed to residents in rooms first and all residents were observed to be in the room at the time of the tray delivery. Trays were then brought to the dining room area and were checked again and placed in front of residents in the dining area. There were 21 residents in the dining room for the lunch meal and there were 4 staff members present in the dining room to monitor the meal in the secured unit. On 8/24/23 at 12:46 p.m. the dining room on the first floor was observed to be locked and not in use. An interview was conducted with Staff K, LPN. She stated the dining room was being cleaned and renovations were being done in preparation to open it up and begin serving residents once again in the dining room. On 8/24/23 at 12:49 p.m. the dining trays for the lunch meal were served on the Lifestyle 1 unit. Trays were checked by the nurses to assure correct meals for each resident and then the meal tray pass began. Trays were verified by staff as they were delivered into the resident rooms. All trays delivered to the rooms were placed in front of a resident and set up. No trays were observed to be delivered to any resident not in the room. Trays for residents needing assistance with meals were delivered last so staff could assist with the meal. The Unit Managers/Nurses/Activities staff/Business office personnel were all present in the hallways to assist with monitoring during the meal service. A review of a IJ removal plan book, supplied by the facility, was conducted on 8/24/23 at 1:45 p.m. during an interview with the ANHA and NHA. They stated they were able to educate all the staff on duty and 100% were completed as of 8/23/24. On 8/23/2023 an electronic medical record message was put in to notify all staff of mandatory education. They stated they also sent out a text message to all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 9 of 10 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 08/24/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete staff and 100% of staff received this message. They stated all staff receive the texting and clinical staff get both messages. The message will appear every time the staff sign in to the computer. They stated there were no changes to the policy. They stated there were five trainings for the dietary concerns related to the supervision, policy, aspiration, dysphasia, and choking with interventions for the staff to complete online. They stated the education had been ongoing since 14th of August. They stated they had made sure 100% had completed the supervision education and no staff will be allowed to work until the education is completed in the future. The NHA stated during the work week the extra person will be the managers on days and evenings for the meal service. The night shift is to be mindful of any food source. On the weekend it will be the staffing coordinators who are nursing assistants that will be the extra set of eyes at meal service. The NHA stated a Quality meeting was completed on 8/14, 8/23, and regularly done today on 8/24. He stated they did a Performance Improvement Plan (PIP) on the inc[TRUNCATED] Event ID: Facility ID: 105390 If continuation sheet Page 10 of 10