Health inspection·February 14, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 2/5/2024 at 1:38 PM. Staff A, LPN stated on the evening of 1/20/2024 she was getting ready for her 30-minute break. She was walking toward the break room when she noticed people in Resident #1's room. She noticed Resident #1 had face trauma. Staff B, LPN, Staff C, CNA and Staff D, CNA were in the room and explained what they had witnessed. She called the supervisor. Staff A, LPN stated prior to leaving Resident #1's room to call the supervisor, she listened to what the other staff were asking Resident #1, to ensure she had the event accurate. Resident #2 was no longer in the room when she arrived. Resident #1 was her patient that night. The last time she saw Resident #1 was an hour prior, when the CNAs were providing care. An interview was conducted with Staff D, CNA on 2/5/2024 at 10:34 AM. Staff D, CNA stated Resident #1's call light was on, which was unusual because Resident #1 did not utilize the call light. When she arrived at Resident #1's room door, it was closed. She could hardly open the door. The door was jammed with a wheelchair behind it. She could see Resident #2 on top of Resident #1. She yelled for another CNA (Staff C, CNA); she and Staff C, CNA were able to push the door open. Resident #2 was pulling up his pants and sat down in the wheelchair. Staff D, CNA stated, she last provided care for Resident #1 at 2:35 AM on 1/20/2024 with Staff C, CNA. A follow up interview was conducted with Staff D, CNA on 2/13/2024 at 1:31 PM. Staff D, CNA stated the door to Resident #1's room was blocked by two wheelchairs, both wheelchairs had their wheels locked. This is why she couldn't get the door open by herself. She believes Resident #2 intentionally put the wheelchairs behind the door like that to prevent the door from opening. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 2/5/2024 at 10:05 AM. Staff B, LPN stated she was the nurse for Resident #2 on 1/20/2024. She was sitting at the East Unit nurses station charting when Resident #2 rolled by in his wheelchair. Resident #2 was heading toward lower east and Lifestyle 1 Units. Staff B, LPN continued to state, this is the first-time meeting Resident #2. Resident #2 appeared calm and not confused. Staff B, LPN continued to state, about 20 minutes later she heard a CNA screaming down the hallway [Resident #2 name] is on top of [Resident #1 name]. When Staff B, LPN arrived Resident #2 was standing next to Resident #1's bed pulling his pants, up from the knees. Staff B, LPN stated we were trying to get Resident #2 out of the room. Resident #2 was hitting me and the CNA. We got him out. Staff B, LPN stated [Resident #1 name]'s incontinent brief was ripped open on the side and her whole belly was exposed. The resident was crying, which was unusual, she never cries. The CNA and I got Resident #2 out of the room. Resident #1 Review of Resident #1's progress notes showed an eINTERACT SBAR Summary for Providers dated 1/20/2024 at 4:00 AM, authored by: Director of Nursing (DON). The document revealed the change of condition being reported was Trauma, including vital signs from 1/7/2024 The section titled Outcomes of Physical Assessment revealed: Mental Status Evaluation: No changes observed Functional status evaluation: No changes observed Behavioral Status Evaluation: Not clinically applicable to the change in condition being reported Respiratory Status Evaluation: Not clinically applicable to the change in condition being reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 2 of 20 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 02/14/2024 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 0600 Cardiovascular Status Evaluation: Not clinically applicable to the change in condition being reported Level of Harm - Immediate jeopardy to resident health or safety Abdominal/GI Status Evaluation: Not clinically applicable to the change in condition being reported Residents Affected - Few Pain Status Evaluation: Does the resident/patient have pain? No Skin Status Evaluation: Contusion Neurological Status Evaluation: Not clinically applicable to the change in condition being reported Nursing observations, evaluation, and recommendations are: resident was allegedly assaulted by another resident police risk manager and LNHA (Licensed Nursing Home Administrator) notified Primary care provider feedback: primary care provider responded with the following feedback: A. Recommendations: Send to ER . Review of Resident #1's facility progress note dated 1/20/2024 at 10:30 AM authored by the DON, revealed writer spoke with charge nurse at ER, resident is being admitted dx (diagnosis) alleged assault. CT (Computerized Tomography) scan done and all negative lab work done and wnl (within normal limits). Review of Resident #1's facility progress note dated 1/20/2024 at 10:34 AM authored by the DON, revealed Medical Director notified of alleged assault and resident being admitted to hospital, will have psych available to see resident upon return to the facility. Primary care physician is also aware of alleged incident and resident status. Review of Resident #1's facility NSG [Nursing] - Pain Evaluation - V2 dated 1/20/2024 at 4:00 AM authored by the DON revealed: The resident had pain in the past 5 days to the right eye and the resident is unable to describe. The remainder of the form is blank. Review of Resident #1's facility NSG - Weekly Skin Evaluation - V2 dated 1/20/2022 at 4:00 AM authored by the DON revealed: bruise to the right eye, and the resident refused further skin assessment noted discoloration and swelling to right eye per resident allegedly struck by another resident police risk and lnha notified Review of Resident #1's Patient Encounter Note from the resident's primary care provider dated 1/23/2024 revealed Resident #1 is being seen status post discharge from the hospital on 1/22/2024, after being admitted for observation on 1/20/2024 and admitted on [DATE] status post assault and possible sexual assault. Resident #1 was noted to have bilateral facial bruising and a missing front right tooth in the Emergency Department (ED). Computerized Tomography (CT) of the face shows right periorbital (tissue surround the opening in the skull for the eye) and prezygomatic (tissue surrounding the eye, temple, lower lid and cheek) soft tissue swelling, with partial desiccation (removal) of the right mastoid air cells (air cells protect the delicate structures of the ear and protect the temporal bone during trauma), and minimal mucoperiosteal thickening of the right maxillary sinus (inflammatory reaction of the mucous lining of the maxillary sinus. This condition may result from harmful actions caused by trauma). Patient seen in her room alert to self in no acute distress. Patient reports pain in her face. Pain is 7 out of 10. Patient is being followed by psychiatry, with medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 3 of 20 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 02/14/2024 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 0600 changes as needed. Level of Harm - Immediate jeopardy to resident health or safety Review of the Resident #1's hospital History and Physical record face dated 1/20/2024 at 6:20 AM revealed History of Present Illness [HPI]: Chief complaint: Traumatic injury HPI: [Resident #1] . brought to the hospital for facial injury . she had several bruises on the face. She also claims that she was sexually assaulted . a computerized tomography (CT) of the face showed, [Resident #1 name]'s impression of the CT: Right preorbital and prezygomatic soft tissue swelling. No acute fracture. Partial desiccation of the right mastoid air cells. Minimal mucoperiosteal thickening in the right maxillary sinus. Residents Affected - Few Review of Resident #1's Psychiatric Advanced Practice Registered Nurse (APRN) note date 1/22/2024 showed, Resident #1 returned from the hospital last night. Staff reports that [Resident #1 name] was involved in a resident-to-resident altercation where [Resident #1 name] was physically and sexually assaulted. [Resident #1 name] is alert and oriented to person and time. [Resident #1 name] is tearful on interview describing the assault . [Resident #1 name] reports he beat me up . My face is ruined. It hurts me badly. [Resident #1 name] reports significant emotional distress. Patient is currently unstable but requires no medication changes: I feel the symptoms are occurring due to acute stress disorder. [Resident #1 name] has a complex mental health history. Today we completed a Post Traumatic Stress Disorder (PTSD) checklist (PCL), score of 20 represents a clinically significant change. After reviewing prior documentation, it appears to be directly linked to this stressor/event. Despite most answers not at all, it is very evident based on the behaviors this event has caused significant emotional and physical distress. [Resident #1 name] is hypervigilant on interview, requesting coffee to calm her down, tearful and withdrawn. [Resident #1 name]'s speech is disorganized and includes frequent derailment. Despite [Resident # 1 name]'s mental status examination, the initial shock may have contributed to an acute on chronic psychotic event. [Resident #1 name] has treatment refractory psychosis and a trial of Clozapine may be warranted. I discussed medication to help ease the anxiety, but patient opposed additional medication. At this time, I recommend supportive care, coping strategies, and helping resident process the emotions given the little insight the resident has. [Resident #1 name] should continue self-care and getting adequate sleep. Review of Resident #1's Psychiatric Advanced Practice Registered Nurse (APRN) note date 1/19/2024 showed, . Patient report no signs of anxiety. Patient has no behavioral outburst. Patient is sleeping well with fair appetite. Patient has no signs of agitation. No other psychiatric symptoms observed. Patient is at baseline. No gradual dose reduction of medication is suggested. As per collected information and interview, it appears that the patient is doing well overall. The symptoms are causing no or at times only mild distress. An observation and interview were conducted with Resident #1 on 2/5/2024 at 12: 45 PM. Resident #1 was observed with yellow discoloration to the right side of her face from her eye to her chin. Resident #1 stated, I'm not good, my face hurts, I was attacked by a man . he hit me over and over again on my face. My face still hurts but ice and aspirin help. Resident #1 continued to state I did not know the man, I saw him in the smoke area. Resident #2 Review of Resident #2's Hospital Emergency Department Documents dated 12/23/2024 at 14:56 revealed: HPI: patient presenting with a complaint of agitation presenting from a nursing care facility where he escalated to hitting someone with a cane. Upon arrival he was initially calm he escalated again around 1630. Became instantaneously violent. ETO (Emergency Treatment Order) for medications given (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 4 of 20 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 02/14/2024 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 0600 at 1630 secondary to aggressive behavior of patient in impending threat to staff and the patient. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #2's hospital record titled History and Physical dated 12/24/2024 located in the facility medical record, revealed Resident #2 was admitted to the hospital on [DATE] from a (the previous) nursing home, for an unprovoked physical outburst leading to Resident #2 striking and injuring another resident causing a laceration that required closure. patient is psychotic, claiming that the resident told him she wanted to die, which she denied. Residents Affected - Few An interview was conducted with the Assistant Director of Nursing (ADON) from the previous nursing home on 2/12/2024 at 10:15 AM. The ADON remembers Resident #2 and the incident at their facility which required Resident #2 and another resident to be transferred out to the hospital. The female resident was resting her head on the table, not making a noise. Out of nowhere, Resident #2 started hitting her on the head with his cane. The female resident received lacerations to the head that required her to be transferred to the hospital for treatment. Resident #2 was sent to the hospital for a psychiatric evaluation and stabilization. Review of Resident #2's hospital Discharge Instructions dated 1/11/2024 at 11:02 AM a 10-page document, located in the facility's medical record, page 4 revealed Medications the following are listed: . (listing here limited to psychiatric mediations) Depakote 250 mg (milligram) oral delayed release tablet, one tablet two times per day; fluphenazine 25 mg/mL (milliliter) injectable solution, give 75 mg intramuscularly every two weeks; trazodone 50 mg oral tablet, one tablet at bedtime. Review of Resident #2's hospital Medication List - All Active Medications printed 1/8/2024, found in the facility's medical record (listing here limited to psychiatric mediations) reveals: Haldol 10 mg, = 2 tab(s), PO (by mouth), 2 x daily, 1/5/24, 21:00 EST, Routine Divalproex sodium (divalproex sodium 250 mg oral delayed release tablet) 250mg=1 tab (s), PO, 2xdaily, 0 refill(s), 12/26/23 9:32 EST, 1 Trazodone 50 mg, = 1 tab(s), PO, 1 x daily hs (at bedtime) #30 tabs, no refills, 1 Divalproex sodium (Depakote) 500 mg, = 1 tab(s), PO, EC tab, 2 x daily, 1/2/24, 09:00 EST, routine Fluphenazine (Prolixin Decanoate) 75 mg, = 3 mL, IM-intramuscular, injection, every 2 weeks, 12/28/23 Review of Resident #2's hospital Psychiatric Progress Note *Final Report* dated 1/8/2024, located in the facility's medical record with the section titled Assessment/Plan: revealed: Patient is a [AGE] year old man with a history of schizophrenia . was admitted to the hospital after he attacked another resident at his ALF. Given patients psychotic and violent behavior in the community patient is felt to be at high risk of imminent harm towards himself where he to be discharged in his current condition without further evidence of improvement and stability. Patient was started on Prolixin and transition to Prolixin decanoate. However, Prolixin was subsequently discontinued as proxy reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 5 of 20 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 02/14/2024 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 0600 that patient tends to refuse injections if they are occurring too often and would prefer, he be placed on something once a month as he has been more compliant with that in the past. Level of Harm - Immediate jeopardy to resident health or safety -Patients continue to show stability. He is stabilizing well on current medications . Allow time for medications to gain efficacy, and for discharge planning to occur. Residents Affected - Few -continue Haldol 10 milligrams PO twice daily with plans to titrate to Haldol decanoate -continue Depakote 500 milligrams PO bid for sub therapeutic VPA (Valproic Acid), a medication used to treat certain types of seizures. Steady state VPA 74.8 on 1/7 -Artane 2 milligrams nightly . Review of Resident #2 admission Record showed the resident was admitted on [DATE] with diagnoses that included: Schizophrenia- unspecified, Schizoaffective disorder - bipolar type, Major depressive disorderrecurrent- moderate, Other specified mood disorder , Type 2 Diabetes Mellitus without complications, Muscle Weakness, Unsteadiness on feet, Monoplegia Of upper limb, following cerebral infarction affecting left dominant side, Essential hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Hyperlipidemia, Gastro-Esophageal Reflux Disease (GERD), Fracture of one rib left sidewith routine healing. Review of Resident #2's Pre-admission Screen and Record Review (PASRR) Level II completed on 1/9/2024. Service recommendations indicated: Based on clinical of the submitted documentation and information, this individual is considered to have a Serious Mental Illness as defined in 42 CFR Part 483.102(b)(1) and F.A.C. 59G-1.040(2)(m) based on each of the categories of diagnosis, level of impairment and recent treatment. Specifically, this individual does have a major mental disorder with associated significant symptoms. Once psychiatrically cleared, given the information provided for the review, a nursing facility placement is determined to be appropriate due to the patient's medical needs, and the need for medication management. The patient does not appear independently capable of self- monitoring his health status, nutritional status, or self- administration and scheduling medical treatment. Specialized Services are deemed not necessary given the client does not appear to need acute inpatient psychiatric care at this time. It is recommended that the following rehabilitative services, of a lesser intensity than Specialized Services, are added to the patient's Comprehensive Person- Centered Nursing Care Plan: - Psychiatric medication management - Supportive counseling. Supportive services cannot be effectively provided in a less restrictive environment at this time are recommended to be provided at the nursing facility. If he is unable to return home, all efforts should be made to transition him to a less restrictive environment such as an Assisted Living Facility that can meet his mental health needs, if agreed upon by the treating physician. The patient should be encouraged to participate in socialization and enrichment activities appropriate for his level of function. Given his history, care staff should monitor for symptoms of psychosis, and report any problems to the treatment team. Should there be a significant change in his mental status, it is recommended that an additional Level II review should be conducted. Review of the care plan for Resident #2 initiated on 1/17/2024 with a revision date of 2/2/2024 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 6 of 20 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 02/14/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few with a focus of : (Resident #2) is/has potential to be physically and verbally aggressive along with alleged assault to other residents. Not easily redirected. Chooses not to take psychiatric medication. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; mental health services as needed/as ordered; monitor (document observed behavior and attempted interventions in behavior log; monitor/ document/report PRN and sign/symptoms of resident posting danger to self and others; Psychiatric/Psychogeriatric consult as indicated; when the resident becomes, agitated: intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Revisions to interventions were added 1/20/2024: One on One Intensive Supervision, BA 52 An interview was conducted with Staff R, LPN MDS (Minimum Data Set) Coordinator on 2/13/2024 at 10:23 AM. Staff R, LPN MDS confirmed responsibility for updating care plans, evaluating residents upon admission for the MDS and care plan needs. Staff R, LPN MDS continued to state when reviewing a resident who is a new admission she reviews the hospital paperwork, including nurses' notes, history and physicals, and discharge summaries. With the information gathered from the information she can develop care plans. This is how she developed the care plan for Resident #2 being physically aggressive and that Resident #2 had a history of being non-compliant in taking his medications. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 12 out of 15, meaning cognitively moderately impaired. Section E for Behavior indicated in the last 7 days from 1/17/2024 Resident #2 showed signs of hallucinations, delusions, wandering, physical and verbal behaviors directed towards other at least 1 to 3 days of the past 7. Review of the facility's progress notes for Resident #2 dated 1/11/2024 at 2:00 PM showed Resident #2 was admitted from the hospital. Admitting diagnosis schizophrenia patient is alert with some confusion. Able to make needs known. Patient is independent with ambulation and feeding. Continent of B&B (bowel and bladder). Denies any pain/discomfort at this time. No open areas noted. Appetite good, fluid intake adequate. Took medications without difficulty. Patient stated dentures were lost. Wears glasses, hearing adequate no hearing aids. Will continue to monitor. Review of Resident #2's facility Order Summary Report Active orders as of 1/11/2024 revealed the following physician orders: (listing psychiatric medications only) 1.Depakote 250 mg by mouth two times a day, order and start date 1/11/2024 2.Fluphenazine Decanoate Injection Solution 25mg/ml inject 1 dose intramuscularly one time a day every 14 days Order date 1/11/2024, start date 1/12/2024. The mg per dose was not listed. 3.Trazadone HCL Oral tablet 50 mg, give 50 my by mouth at bedtime order and start date 1/11/2024. Review of Resident #2's facility Order Summary Report Active Orders as of 1/20/2024 revealed the following physician orders: . (listing psychiatric mediations only) 1.Depakote 250 mg by mouth two times a day, order and start date 1/11/2024 2.Fluphenazine 25 mg/mL, inject 25 mg intramuscularly one time only order date 1/19/2024, start (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 7 of 20 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 02/14/2024 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 0600 date 1/22/2024 (after discharge) Level of Harm - Immediate jeopardy to resident health or safety 3.Fluphenazine Decanoate 25 mg/mL, inject 50 mg intramuscularly every 14 day(s) - order date 1/19/2024, start date 2/5/2024 (after discharge) Residents Affected - Few 4.Haldol 5 mg/mL, inject 5 mg intramuscularly every 6 hours as needed for 14 days - order and start date 1/12/2024 5.Trazodone 50 mg, give 50 mg by mouth at bedtime, order and start date 1/11/2024 Review of progress note dated 1/12/2024 at 2:02 AM showed . Resident #2 was restless this shift. Resident constantly in and out of the room, opening and shutting the door, turning the TV and lights on and off, room mate (sic) yelling at him to stop going in and out and turning the TV and lights on and off because he is waking up the other room mates (sic) in the room. Resident able to make needs known, speech slurred, and observed talking to himself. Attempted to redirect resident but he seems very anxious and on edge. Will continue to monitor resident closely. Review of progress note dated 1/12/2024 at 4:10 AM showed Resident #2 sat at nurse's station willing stating I'm here because I helped kill a lady, because she wanted to kill herself. Resident then elaborated that he didn't feel like there was anything wrong with helping her because he felt like he was doing the right thing since she wanted to die. Writer attempted to redirect resident's attention multiple times. At approximately 3:45 AM, he went back to his room and is now asleep in bed. Resident appears to be A & O x 4 (alert and oriented to person, place, time and event) and is able to make his needs known though his speech is sometimes hard to understand. No S/S (signs and symptoms) of SOB (shortness of breath) or distress noted, Will continue to monitor closely. Review of Psychiatric Advanced Practice Registered Nurse (APRN) note for date of service 1/12/2024 showed Resident #2 endorses hallucinations. Patient reports he doesn't know what the 'voices' are saying 'they talk to each other'. Patient's speech is dysarthria (difficulty speaking because the muscles you use for speech are weak) of patient gets frustrated with interviewer and states 'stop asking me all the questions'. Interview was ended. Patient was visited on smoke patio where he was irritable and difficult to redirect. Patient is restless in and out of his room repeatedly, yelling at staff. Assessment and plan for Resident #2 shows patient is unstable requiring medication changes. I feel the symptoms are occurring due to exacerbation of underlying psychotic disorder. The symptoms are occurring almost daily and causing severe distress. I decided to start Haldol 5 mg (milligrams) intramuscularly (IM) every 6 hours PRN (as needed) for 14 days for schizophrenia. Review of Resident #2's progress note dated 1/16/2024 at 1:18 PM showed Unit manager (UM) was discussing patient care with this nurse. She was facing me while I was sitting at the nurse desk computer. This resident rolled up to the UM back and hit her very hard in the lower back. Staff removed the resident from his attack on the unit manager. He stated he wanted food. This nurse provided him with a PBJ (Peanut Butter and Jelly) sandwich, and he was satisfied with it. Admin arrived, assessed this patient PRN (as needed) IM was provided. Review of Resident #2's facility MAR revealed the order for Haldol 5 mg, IM every 6 hours as needed for mood disorder was administered one (1) time on 1/16/2024 at 12:13 AM. Review of Resident #2's Facility Medication Administration Record (MAR) revealed an order with a start date of 1/12/2024 at 1:45 PM for Haldol 5 mg, IM every 6 hours as needed for mood disorder. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 8 of 20 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 02/14/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few MAR showed Resident #2 was not administered this medication on 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/17/2024, 1/18/2024, 1/19/2024 or 1/20/2024. An interview was conducted with Staff K, LPN, Unit Manager (UM) on 2/13/2024 at 1:00 PM. Staff K, LPN stated she was standing at the station (on 1/16/2024) and Resident #2 punched me in the back, it was shocking. The nurse she was speaking with administered an injection, he calmed right down, and no further events occurred that evening. An interview was conducted with Staff M, RN on 2/13/2024 at 10:50 AM. Staff M, RN confirmed she witnessed the event of 1/16/2024 with the UM. Staff M, RN stated I had him in the morning and was charting at nurses' station. The UM was at the nurse station opposite of me standing with her back to the hallway. Suddenly, the UM made a startling noise, Oh. Resident #2 had punched her in the lower back. Resident #2 stated he wanted a sandwich. Staff M, RN stated He would just explode big action and then be fine. Review of Psychiatric Advanced Practice Registered Nurse (APRN) note for date of service 1/16/2024 showed Resident #2 examined. Patient is aggressive when he wants something and does not get it immediately. Patient is difficult to redirect. Patient is combative and his behavior is erratic. Patient is sleeping and eating well. Patient is tolerating current medication. Assessment and Plan: Patient is unstable requiring medication changes: As per collected information due to exacerbation of an underlying schizoaffective disorder. The symptoms are occurring almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms. Continue Haldol for schizophrenia, Trazodone for depression and Divalproex for mood disorder. Increase Fluphenazine to 50 mg/ml every 14 days. Review of the MAR showed the resident was not given this increased dose of medication. Review of Resident #2's progress notes dated 1/17/2024 at 4:00 AM showed Resident #2 purposely keeping other residents awake with TV. This writer asked resident to turn down TV to be respectful to other residents. Resident #2 then proceeded to slam door, slam nightstand and yell throughout the shift. An interview was conducted on 2/05/2024 at 3:15 PM with Staff J, CNA. Staff J, CNA stated Resident #2 had verbally threatened staff. On the evening of 1/17/2024 he had the volume on the TV very loud. Resident #2 became angry and very aggressive in his room, we just stood in the doorway and made sure he didn't attack his roommates. Resident #2 finally calmed down on his own. Every day was horrible with him. We would keep his door open for safe keeping of the other roommates. An interview was conducted with Staff C, CNA on 2/5/2024 at 1:58 PM. On 1/18/2024 Resident #2 was upset and combative on smoke patio, he wanted a cigarette. Resident #2 was chewing cigarette butts from the ground, saying he was going to beat the ladies up. Staff L, Registered Nurse (RN) came out and resident calmed down. Resident went to his room with Staff L, RN. An interview was conducted on 2/13/2024 at 12:52 PM with Staff F, CNA. Staff F, CNA recalled the event on 1/18/2024 on the smoking patio with Resident #2. Staff F, CNA explained, the smoking area closes for about 15-20 minutes to accommodate shift change. Residents are usually lined up waiting for the patio to resume. Resident #2 was there waiting, he already appeared agitated. Resident #2 was upset about not getting his cigarettes first, before everyone else. Resident #2 started yelling. I had heard he could be aggressive, so I did not want to turn my back on him. I wanted to get him a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 9 of 20 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 02/14/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete cigarette so he would calm down. He became more combative. I told the other staff member to call a Code Grey. I started to back up while facing him. Resident #2 continued to yell, 'I'm going to get you, etc', Resident #2 stood up out of his wheelchair and started to walk toward me. I was walking backwards and fell. Resident #2 fell to his knees at the same time. Staff F, CNA said Resident #2 immediately calmed down. Staff F, CNA was able to assist Resident #2 back into the wheelchair. Staff F, CNA stated the Director of Nursing (DON) arrived to the patio and took over from there. Resident #2 was in his wheelchair at this point and was given a cigarette. Staff F, CNA confirmed he had not[TRUNCATED] Event ID: Facility ID: 105390 If continuation sheet Page 10 of 20 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 02/14/2024 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 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 observation, interview, facility record review, hospital record review, and policy review the facility failed to ensure adequate supervision to prevent physical and psychosocial harm to one (Resident #1) of three residents reviewed. On 1/20/2024 at approximately 3:35 AM Resident #1 was punched repeatedly in the face and sexually assaulted by Resident #2 in Resident #1's room. The facility failed to provide supervision of Resident #2, who was exhibiting poor impulse control, combativeness, erratic behavior, aggressive behavior and was difficult to redirect. This failure created a situation that resulted in serious injury to Resident #1 and resulted in the determination of Immediate Jeopardy on 1/17/2024. The findings of Immediate Jeopardy were determined to be removed on 1/29/2024 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings include: An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 2/5/2024 at 1:58 PM. Staff C, CNA stated, on the evening of 1/20/2024, she was sitting at nurse station, charting. Staff D, CNA was assigned to Resident #1's room. Staff D, CNA was on the split assignment (assigned to rooms on two separate halls). Staff C, CNA stated she passed Resident #1's room [ROOM NUMBER] minutes earlier and Resident #1 was in her bed asleep with the door open. Staff C, CNA stated [Resident #1 name]'s call light went on. [Staff D name, CNA] went to answer the call light. [Staff D name, CNA] yelled for me that the door was jammed and there was a man on top of [Resident #1 name]. I ran to the room. We pushed the door open. [Resident #2 name] was in the chair naked, putting his clothes on. I was yelling for nurses to come. When the nurses arrived, we tried to get him out of the room. [Resident #2 name] started punching me and one of the nurses. [Resident #2 name] left the room followed by a nurse. [Resident #1 name] wanted to go to bathroom, so we assisted. [Resident #1 name]'s eyes were swollen shut, her face was bloody, and she was crying. The nurse assisted [Resident #1 name] from there. Staff C, CNA stated she later spoke to Resident #1. Resident #1 told me He tried to rape me but couldn't get 'it' in, so he stuck his finger up me. Staff C, CNA stated after Resident #1 left her room for a cigarette with the nurse, we changed the linens on her bed and found her tooth. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 2/5/2024 at 1:38 PM. Staff A, LPN stated on the evening of 1/20/2024 she was getting ready for her 30-minute break. She was walking toward the break room when she noticed people in Resident #1's room. She noticed Resident #1 had face trauma. Staff B, LPN, Staff C, CNA and Staff D, CNA were in the room and explained what they had witnessed. She called the supervisor. Staff A, LPN stated prior to leaving Resident #1's room to call the supervisor, she listened to what the other staff were asking Resident #1, to ensure she had the event accurate. Resident #2 was no longer in the room when she arrived. Resident #1 was her patient that night. The last time she saw Resident #1 was an hour prior, when the CNAs were providing care. An interview was conducted with Staff D, CNA on 2/5/2024 at 10:34 AM. Staff D, CNA stated Resident #1's call light was on, which was unusual because Resident #1 did not utilize the call light. When she arrived at Resident #1's room door, it was closed. She could hardly open the door. The door was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 11 of 20 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 02/14/2024 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 jammed with a wheelchair behind it. She could see Resident #2 on top of Resident #1. She yelled for another CNA (Staff C, CNA); she and Staff C, CNA were able to push the door open. Resident #2 was pulling up his pants and sat down in the wheelchair. Staff D, CNA stated, she last provided care for Resident #1 at 2:35 AM on 1/20/2024 with Staff C, CNA. A follow up interview was conducted with Staff D, CNA on 2/13/2024 at 1:31 PM. Staff D, CNA stated the door to Resident #1's room was blocked by two wheelchairs, both wheelchairs had their wheels locked. This is why she couldn't get the door open by herself. She believes Resident #2 intentionally put the wheelchairs behind the door like that to prevent the door from opening. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 2/5/2024 at 10:05 AM. Staff B, LPN stated she was the nurse for Resident #2 on 1/20/2024. She was sitting at the East Unit nurses station charting when Resident #2 rolled by in his wheelchair. Resident #2 was heading toward lower East and Lifestyle 1 Units. Staff B, LPN continued to state, this is the first-time meeting Resident #2. Resident #2 appeared calm and not confused. Staff B, LPN continued to state, about 20 minutes later she heard a CNA screaming down the hallway [Resident #2 name] is on top of [Resident #1 name]. When Staff B, LPN arrived Resident #2 was standing next to Resident #1's bed pulling his pants, up from the knees. Staff B, LPN stated we were trying to get Resident #2 out of the room. Resident #2 was hitting me and the CNA. We got him out. Staff B, LPN stated [Resident #1 name]'s incontinent brief was ripped open on the side and her whole belly was exposed. The resident was crying, which was unusual, she never cries. The CNA and I got Resident #2 out of the room. Resident #1 Review of Resident #1's progress notes showed an eINTERACT SBAR [Situation, Background, Assessment, Recommendation] Summary for Providers dated 1/20/2024 at 4:00 AM, authored by: Director of Nursing (DON). The document revealed the change of condition being reported was Trauma, including vital signs from 1/7/2024 The section titled Outcomes of Physical Assessment revealed: Mental Status Evaluation: No changes observed Functional status evaluation: No changes observed Behavioral Status Evaluation: Not clinically applicable to the change in condition being reported Respiratory Status Evaluation: Not clinically applicable to the change in condition being reported Cardiovascular Status Evaluation: Not clinically applicable to the change in condition being reported Abdominal/GI Status Evaluation: Not clinically applicable to the change in condition being reported Skin Status Evaluation: Contusion Pain Status Evaluation: Does the resident/patient have pain? No calmyNeurological Status Evaluation: Not clinically applicable to the change in condition being reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 12 of 20 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 02/14/2024 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 Nursing observations, evaluation, and recommendations are: resident was allegedly assaulted by another resident police risk manager and LNHA (Licensed Nursing Home Administrator) notified Primary care provider feedback: primary care provider responded with the following feedback: A. Recommendations: Send to ER . Residents Affected - Few Review of Resident #1's facility progress note dated 1/20/2024 at 10:30 AM authored by the DON, revealed writer spoke with charge nurse at ER, resident is being admitted dx (diagnosis) alleged assault. CT (Computerized Tomography) scan done and all negative lab work done and wnl (within normal limits). Review of Resident #1's facility progress note dated 1/20/2024 at 10:34 AM authored by the DON, revealed Medical Director notified of alleged assault and resident being admitted to hospital, will have psych available to see resident upon return to the facility. Primary care physician is also aware of alleged incident and resident status. Review of Resident #1's facility NSG [Nursing] - Pain Evaluation - V2 dated 1/20/2024 at 4:00 AM authored by the DON revealed: The resident had pain in the past 5 days to the right eye and the resident is unable to describe. The remainder of the form is blank. Review of Resident #1's facility NSG - Weekly Skin Evaluation - V2 dated 1/20/2022 at 4:00 AM authored by the DON revealed: bruise to the right eye, and the resident refused further skin assessment noted discoloration and swelling to right eye per resident allegedly struck by another resident police risk and lnha notified Review of Resident #1's Patient Encounter Note from the resident's primary care provider dated 1/23/2024 revealed Resident #1 is being seen status post discharge from the hospital on 1/22/2024, after being admitted for observation on 1/20/2024 and admitted on [DATE] status post assault and possible sexual assault. Resident #1 was noted to have bilateral facial bruising and a missing front right tooth in the Emergency Department (ED). Computerized Tomography (CT) of the face shows right periorbital (tissue surround the opening in the skull for the eye) and prezygomatic (tissue surrounding the eye, temple, lower lid and cheek) soft tissue swelling, with partial desiccation (removal) of the right mastoid air cells (air cells protect the delicate structures of the ear and protect the temporal bone during trauma), and minimal mucoperiosteal thickening of the right maxillary sinus (inflammatory reaction of the mucous lining of the maxillary sinus. This condition may result from harmful actions caused by trauma). Patient seen in her room alert to self in no acute distress. Patient reports pain in her face. Pain is 7 out of 10. Patient is being followed by psychiatry, with medications changes as needed. Review of the Resident #1's hospital History and Physical record face dated 1/20/2024 at 6:20 AM revealed History of Present Illness [HPI]: Chief complaint: Traumatic injury HPI: Resident #1 . brought to the hospital for facial injury . she had several bruises on the face. She also claims that she was sexually assaulted . a computerized tomography (CT) of the face showed, Resident #1's impression of the CT: Right preorbital and prezygomatic soft tissue swelling. No acute fracture. Partial desiccation of the right mastoid air cells. Minimal mucoperiosteal thickening in the right maxillary sinus. Review of Resident #1's Psychiatric Advanced Practice Registered Nurse (APRN) note date 1/22/2024 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 13 of 20 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 02/14/2024 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 showed, Resident #1 returned from the hospital last night. Staff reports that Resident #1 was involved in a resident-to-resident altercation where Resident #1 was physically and sexually assaulted. Resident #1 is alert and oriented to person and time. Resident #1 is tearful on interview describing the assault . Resident #1 reports he beat me up . My face is ruined. It hurts me badly. Resident #1 reports significant emotional distress. Patient is currently unstable but requires no medication changes: I feel the symptoms are occurring due to acute stress disorder. Resident #1 has a complex mental health history. Today we completed a Post Traumatic Stress Disorder (PTSD) checklist (PCL), score of 20 represents a clinically significant change. After reviewing prior documentation, it appears to be directly linked to this stressor/event. Despite most answers not at all, it is very evident based on the behaviors this event has caused significant emotional and physical distress. Resident #1 is hypervigilant on interview, requesting coffee to calm her down, tearful and withdrawn. Resident #1's speech is disorganized and includes frequent derailment. Despite Resident # 1's mental status examination, the initial shock may have contributed to an acute on chronic psychotic event. Resident #1 has treatment refractory psychosis and a trial of Clozapine may be warranted. I discussed medication to help ease the anxiety, but patient opposed additional medication. At this time, I recommend supportive care, coping strategies, and helping resident process the emotions given the little insight the resident has. Resident #1 should continue self-care and getting adequate sleep. Review of Resident #1's Psychiatric Advanced Practice Registered Nurse (APRN) note date 1/19/2024 showed, . Patient report no signs of anxiety. Patient has no behavioral outburst. Patient is sleeping well with fair appetite. Patient has no signs of agitation. No other psychiatric symptoms observed. Patient is at baseline. No gradual dose reduction of medication is suggested. As per collected information and interview, it appears that the patient is doing well overall. The symptoms are causing no or at times only mild distress. An observation and interview were conducted with Resident #1 on 2/5/2024 at 12: 45 PM. Resident #1 was observed with yellow discoloration to the right side of her face from her eye to her chin. Resident #1 stated, I'm not good, my face hurts, I was attacked by a man . he hit me over and over again on my face. My face still hurts but ice and aspirin help. Resident #1 continued to state I did not know the man, I saw him in the smoke area. Resident #2 Review of Resident #2's Hospital Emergency Department Documents dated 12/23/2024 at 14:56 revealed: HPI: patient presenting with a complaint of agitation presenting from a nursing care facility where he escalated to hitting someone with a cane. Upon arrival he was initially calm he escalated again around 1630. Became instantaneously violent. ETO (Emergency Treatment Order) for medications given at 1630 secondary to aggressive behavior of patient in impending threat to staff and the patient. Review of Resident #2's hospital record titled History and Physical dated 12/24/2024 located in the facility medical record, revealed Resident #2 was admitted to the hospital on [DATE] from a (the previous) nursing home, for an unprovoked physical outburst leading to Resident #2 striking and injuring another resident causing a laceration that required closure. patient is psychotic, claiming that the resident told him she wanted to die, which she denied. An interview was conducted with the Assistant Director of Nursing (ADON) from the previous nursing home on 2/12/2024 at 10:15 AM. The ADON remembers Resident #2 and the incident at their facility which required Resident #2 and another resident to be transferred out to the hospital. The female resident was resting her head on the table, not making a noise. Out of nowhere, Resident #2 started (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 14 of 20 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 02/14/2024 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 hitting her on the head with his cane. The female resident received lacerations to the head that required her to be transferred to the hospital for treatment. Resident #2 was sent to the hospital for a psychiatric evaluation and stabilization. Review of Resident #2 admission Record showed the resident was admitted on [DATE] with diagnoses that included: Schizophrenia- unspecified, Schizoaffective disorder - bipolar type, Major depressive disorderrecurrent- moderate, Other specified mood disorder, Type 2 Diabetes Mellitus without complications, Muscle Weakness, Unsteadiness on feet, Monoplegia Of upper limb, following cerebral infarction affecting left dominant side, Essential hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Hyperlipidemia, Gastro-Esophageal Reflux Disease (GERD), Fracture of one rib left side-with routine healing. Review of Resident #2's Pre-admission Screen and Record Review (PASRR) Level II completed on 1/9/2024. Service recommendations indicated: Based on clinical of the submitted documentation and information, this individual is considered to have a Serious Mental Illness as defined in 42 CFR Part 483.102(b)(1) and F.A.C. 59G-1.040(2)(m) based on each of the categories of diagnosis, level of impairment and recent treatment. Specifically, this individual does have a major mental disorder with associated significant symptoms. Once psychiatrically cleared, given the information provided for the review, a nursing facility placement is determined to be appropriate due to the patient's medical needs, and the need for medication management. The patient does not appear independently capable of self- monitoring his health status, nutritional status, or self- administration and scheduling medical treatment. Specialized Services are deemed not necessary given the client does not appear to need acute inpatient psychiatric care at this time. It is recommended that the following rehabilitative services, of a lesser intensity than Specialized Services, are added to the patient's Comprehensive Person-Centered Nursing Care Plan: - Psychiatric medication management - Supportive counseling. Supportive services cannot be effectively provided in a less restrictive environment at this time are recommended to be provided at the nursing facility. If he is unable to return home, all efforts should be made to transition him to a less restrictive environment such as an Assisted Living Facility that can meet his mental health needs, if agreed upon by the treating physician. The patient should be encouraged to participate in socialization and enrichment activities appropriate for his level of function. Given his history, care staff should monitor for symptoms of psychosis, and report any problems to the treatment team. Should there be a significant change in his mental status, it is recommended that an additional Level II review should be conducted. Review of the care plan for Resident #2 initiated on 1/17/2024 with a revision date of 2/2/2024 with a focus of : (Resident #2) is/has potential to be physically and verbally aggressive along with alleged assault to other residents. Not easily redirected. Chooses not to take psychiatric medication. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; mental health services as needed/as ordered; monitor (document observed behavior and attempted interventions in behavior log; monitor/ document/report PRN and sign/symptoms of resident posting danger to self and others; Psychiatric/Psychogeriatric consult as indicated; when the resident becomes, agitated: intervene before agitation escalates, guide away from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 15 of 20 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 02/14/2024 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 source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Revisions to interventions were added 1/20/2024: One on One Intensive Supervision, BA 52 An interview was conducted with Staff R, LPN MDS (Minimum Data Set) Coordinator on 2/13/2024 at 10:23 AM. Staff R, LPN MDS confirmed responsibility for updating care plans, evaluating residents upon admission for the MDS and care plan needs. Staff R, LPN MDS continued to state when reviewing a resident who is a new admission she reviews the hospital paperwork, including nurses' notes, history and physicals, and discharge summaries. With the information gathered from the information she can develop care plans. This is how she developed the care plan for Resident #2 being physically aggressive and that Resident #2 had a history of being non-compliant in taking his medications. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 12 out of 15, meaning cognitively moderately impaired. Section E for Behavior indicated in the last 7 days from 1/17/2024 Resident #2 showed signs of hallucinations, delusions, wandering, physical and verbal behaviors directed towards other at least 1 to 3 days of the past 7. Review of the facility's progress notes for Resident #2 dated 1/11/2024 at 2:00 PM showed Resident #2 was admitted from the hospital. Admitting diagnosis schizophrenia patient is alert with some confusion. Able to make needs known. Patient is independent with ambulation and feeding. Continent of B&B (bowel and bladder). Denies any pain/discomfort at this time. No open areas noted. Appetite good, fluid intake adequate. Took medications without difficulty. Patient stated dentures were lost. Wears glasses, hearing adequate no hearing aids. Will continue to monitor. Review of Resident #2's facility Order Summary Report Active orders as of 1/11/2024 revealed the following physician orders: (listing psychiatric medications only) 1. Depakote 250 mg (milligrams) by mouth two times a day, order and start date 1/11/2024 2. Fluphenazine Decanoate Injection Solution 25mg/ml (milliliter) inject 1 dose intramuscularly one time a day every 14 days Order date 1/11/2024, start date 1/12/2024. The mg per dose was not listed. 3. Trazadone HCL Oral tablet 50 mg, give 50 my by mouth at bedtime order and start date 1/11/2024. Review of Resident #2's facility Order Summary Report Active Orders as of 1/20/2024 revealed the following physician orders: (listing psychiatric mediations only) 1. Depakote 250 mg by mouth two times a day, order and start date 1/11/2024 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 16 of 20 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 02/14/2024 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 Fluphenazine 25 mg/mL, inject 25 mg intramuscularly one time only order date 1/19/2024, start date 1/22/2024 (after discharge) Level of Harm - Immediate jeopardy to resident health or safety 3. Residents Affected - Few Fluphenazine Decanoate 25 mg/mL, inject 50 mg intramuscularly every 14 day(s) - order date 1/19/2024, start date 2/5/2024 (after discharge) 4. Haldol 5 mg/mL, inject 5 mg intramuscularly every 6 hours as needed for 14 days - order and start date 1/12/2024 5. Trazodone 50 mg, give 50 mg by mouth at bedtime, order and start date 1/11/2024 Review of progress note dated 1/12/2024 at 2:02 AM showed . [Resident #2 name] was restless this shift. Resident constantly in and out of the room, opening and shutting the door, turning the TV and lights on and off, room mate (sic) yelling at him to stop going in and out and turning the TV and lights on and off because he is waking up the other room mates (sic) in the room. Resident able to make needs known, speech slurred, and observed talking to himself. Attempted to redirect resident but he seems very anxious and on edge. Will continue to monitor resident closely. Review of progress note dated 1/12/2024 at 4:10 AM showed [Resident #2 name] sat at nurse's station willing stating I'm here because I helped kill a lady, because she wanted to kill herself. Resident then elaborated that he didn't feel like there was anything wrong with helping her because he felt like he was doing the right thing since she wanted to die. Writer attempted to redirect resident's attention multiple times. At approximately 3:45 AM, he went back to his room and is now asleep in bed. Resident appears to be A & O x 4 (alert and oriented to person, place, time and event) and is able to make his needs known though his speech is sometimes hard to understand. No S/S (signs and symptoms) of SOB (shortness of breath) or distress noted, Will continue to monitor closely. Review of Psychiatric Advanced Practice Registered Nurse (APRN) note for date of service 1/12/2024 showed [Resident #2 name] endorses hallucinations. Patient reports he doesn't know what the 'voices' are saying 'they talk to each other'. Patient's speech is dysarthria (difficulty speaking because the muscles you use for speech are weak) of patient gets frustrated with interviewer and states 'stop asking me all the questions'. Interview was ended. Patient was visited on smoke patio where he was irritable and difficult to redirect. Patient is restless in and out of his room repeatedly, yelling at staff. Assessment and plan for [Resident #2 name] shows patient is unstable requiring medication changes. I feel the symptoms are occurring due to exacerbation of underlying psychotic disorder. The symptoms are occurring almost daily and causing severe distress. I decided to start Haldol 5 mg (milligrams) intramuscularly (IM) every 6 hours PRN (as needed) for 14 days for schizophrenia. Review of Resident #2's progress note dated 1/16/2024 at 1:18 PM showed Unit manager (UM) was discussing patient care with this nurse. She was facing me while I was sitting at the nurse desk computer. This resident rolled up to the UM back and hit her very hard in the lower back. Staff removed the resident from his attack on the unit manager. He stated he wanted food. This nurse provided him with a PBJ (Peanut Butter and Jelly) sandwich, and he was satisfied with it. Admin arrived, assessed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 17 of 20 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 02/14/2024 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 this patient PRN (as needed) IM was provided. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #2's facility MAR revealed the order for Haldol 5 mg, IM every 6 hours as needed for mood disorder was administered one (1) time on 1/16/2024 at 12:13 AM. Residents Affected - Few Review of Resident #2's Facility Medication Administration Record (MAR) revealed an order with a start date of 1/12/2024 at 1:45 PM for Haldol 5 mg, IM every 6 hours as needed for mood disorder. The MAR showed Resident #2 was not administered this medication on 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/17/2024, 1/18/2024, 1/19/2024 or 1/20/2024. An interview was conducted with Staff K, LPN, Unit Manager (UM) on 2/13/2024 at 1:00 PM. Staff K, LPN stated she was standing at the station (on 1/16/2024) and Resident #2 punched me in the back, it was shocking. The nurse she was speaking with administered an injection, he calmed right down, and no further events occurred that evening. An interview was conducted with Staff M, RN on 2/13/2024 at 10:50 AM. Staff M, RN confirmed she witnessed the event of 1/16/2024 with the UM. Staff M, RN stated I had him in the morning and was charting at nurses' station. The UM was at the nurse station opposite of me standing with her back to the hallway. Suddenly, the UM made a startling noise, Oh. Resident #2 had punched her in the lower back. Resident #2 stated he wanted a sandwich. Staff M, RN stated He would just explode big action and then be fine. Review of Psychiatric Advanced Practice Registered Nurse (APRN) note for date of service 1/16/2024 showed [Resident #2 name] examined. Patient is aggressive when he wants something and does not get it immediately. Patient is difficult to redirect. Patient is combative and his behavior is erratic. Patient is sleeping and eating well. Patient is tolerating current medication. Assessment and Plan: Patient is unstable requiring medication changes: As per collected information due to exacerbation of an underlying schizoaffective disorder. The symptoms are occurring almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms. Continue Haldol for schizophrenia, Trazodone for depression and Divalproex for mood disorder. Increase Fluphenazine to 50 mg/ml every 14 days. Review of the MAR showed the resident was not given this increased dose of Fluphenazine. Review of Resident #2's progress notes dated 1/17/2024 at 4:00 AM showed [Resident #2 name] purposely keeping other residents awake with TV. This writer asked resident to turn down TV to be respectful to other residents. [Resident #2 name] then proceeded to slam door, slam nightstand and yell throughout the shift. An interview was conducted on 2/05/2024 at 3:15 PM with Staff J, CNA. Staff J, CNA stated Resident #2 had verbally threatened staff. On the evening of 1/17/2024 he had the volume on the TV very loud. [Resident #2 name] became angry and very aggressive in his room, we just stood in the doorway and made sure he didn't attack his roommates. [Resident #2 name] finally calmed down on his own. Every day was horrible with him. We would keep his door open for safe keeping of the other roommates. An interview was conducted with Staff C, CNA on 2/5/2024 at 1:58 PM. On 1/18/2024 Resident #2 was upset and combative on smoke patio, he wanted a cigarette. Resident #2 was chewing cigarette butts from the ground, saying he was going to beat the ladies up. Staff L, Registered Nurse (RN) came out and resident calmed down. Resident went to his room with Staff L, RN. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 18 of 20 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 02/14/2024 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 An interview was conducted on 2/13/2024 at 12:52 PM with Staff F, CNA. Staff F, CNA recalled the event on 1/18/2024 on the smoking patio with Resident #2. Staff F, CNA explained, the smoking area closes for about 15-20 minutes to accommodate shift change. Residents are usually lined up waiting for the patio to resume. Resident #2 was there waiting, he already appeared agitated. Resident #2 was upset about not getting his cigarettes first, before everyone else. [Resident #2 name] started yelling. I had heard he could be aggressive, so I did not want to turn my back on him. I wanted to get him a cigarette so he would calm down. He became more combative. I told the other staff member to call a Code Grey. I started to back up while facing him. [Resident #2 name] continued to yell, 'I'm going to get you, etc', [Resident #2 name] stood up out of his wheelchair and started to walk toward me. I was walking backwards and fell. [Resident #2 name] fell to his knees at the same time. Staff F, CNA said Resident #2 immediately calmed down. Staff F, CNA was able to assist Resident #2 back into the wheelchair. Staff F, CNA stated the Director of Nursing (DON) arrived to the patio and took over from there. Resident #2 was in his wheelchair at this point and was given a cigarette. Staff F, CNA confirmed he had not informed anyone of the falls (his or the Resident's). Review of Resident #2's progress note dated 1/20/2024 at 7:47 AM revealed, [Resident #2 name] went by nurses' station (East Unit) in his wheelchair around 3:15 AM about 20 minutes later the Certified Nursing Assistant (CNA) from Lifestyle 1 unit came running down the hall way (sic) telling me to come the other nurse and I ran down the hallway to the CNA . she was stating [Resident #2 name] was naked laying on top of the female resident in her room on her bed . when I got to room [Resident #2 name] was pulling up his pants . female resident whos (sic) room it was was (sic) laying on bed on her back . her pull up was tore off she was covering her face and crying . the other nurse, CNA and I were questioning [Resident #2 name] and trying to remove this resident from the room . [Resident #2 name] began cursing at staff and hit both me (in the chest) and the CNA . this resident then proceeded to go back to his room . I followed this resident to insure (sic) the safety of the other resident . Police called . call placed to DR (doctor) and after and update order to call psychiatric practitioner to have resident (sic) admitted to an acute psychiatric unit. Review of the Hospital History and Physical dated 1/20/2024 revealed Resident #2 presents under BA (Baker Act) at his facility .[Resident #2] has been with increased agitation, irritability, and combativeness. Review of Resident #2's Facility MAR dated 1/1/2024 to 1/31/2024 revealed the following psychiatric medications: Fluphenazine 25 mg/mL inject one dose intramuscularly one time a day every 14 days, order start date of 1/15/2024 at 0900 and a discharge date of 1/19/2024 at 1544. Resident #2 was administered this medication once on 1/15/2024. The mg per dose was not specified. Haldol 5 mg, IM every 6 hours as needed for mood disorder. Start date of 1/12/2024 at 1:45 PM. Resident #2 was administered this medication once on 1/16/2024 at 12:13 AM. Trazodone HCl oral tablet 50 mg by mouth at bedtime Start date of 1/11/2024 at 2100 and a discharge date of 1/20/2024 at 1142. Resident #2 was administered this medication on 1/11/2024, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/17/2024, 1/18/2024, and 1/19/2024. Divalproex Sodium Oral Table Delayed Release 250 mg, give 250 mg by mouth two times a day, order start date of 1/11/2024 at 1700 and a discharge date of 1/20/2024 at 1142. Resident was administered this medication at 0900, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/17/2024, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 19 of 20 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 02/14/2024 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 1/18[TRUNCATED] Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105390 If continuation sheet Page 20 of 20