Health inspection·January 29, 2020

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure that needed services related to communication were provided for 1 of 50 (#12) sampled residents. Residents Affected - Few Findings included: Observations of Resident #12 on 1/26/20 at 10:14 AM revealed that the resident was sitting up in his bed with a trapeze overhead, and the TV on. The resident started to communicate by gestures and motioned for this surveyor to pass him a dry erase board and dry erase marker, which was located on the bedside table which was out of the reach of the resident. Review of the resident medical record revealed that this resident had diagnoses that included Aphasia. Observations on 1/28/20 at 8:15 AM of Resident #12 revealed him lying in bed watching TV. The resident tried to communicate to this surveyor with gestures, but could not be understood. This surveyor questioned the resident as to where his dry erase pen and board were; the resident pointed to the radiator. This surveyor assisted the resident by giving him the dry erase board which was on the radiator and out of the reach of the resident, but was unable to locate the dry erase pen. (Photographic evidence obtained) Observations on 1/28/20 at 8:36 AM of Staff A, Licensed Practical Nurse (LPN), revealed that she was communicating with the resident and found the residents dry erase pen under his bed. She reported that the residents basic means of communication is his dry erase board, she confirmed that the dry erase board should be in his reach, but for some reason she always found it out of his reach. At this time the resident with gestures and writing indicated that the fat girl always leaves it out of his reach. Review of the Quarterly Minimum Data Set, dated [DATE] revealed that this resident had unclear speech, is usually understood and usually understands others Review of the care plan with a revision date of 7/22/19 that the resident has an alteration in communication ability r/t (related to): (hx of CVA, history of cerebrovascular accident) AEB (as evidenced by): has absence of speech, dx(diagnosis)of aphasia, writes for communication, uses gestures (pointing, nodding head). Interventions include Utilize communication board as needed. Interview on 1/28/20 at 12:12 PM with the Director of Nursing (DON) revealed that the resident communicates using the communication board. She reported that the communication board should be with the resident, and not out of reach. A request was made for a facility policy related to communication, which was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 2 of 12 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 105422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Park FL Opco, LLC 8701 49th St N Pinellas Park, FL 33782 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review the facility failed to ensure that for each resident who has a an indwelling urinary catheter in place that there is appropriate justification for the use of the indwelling catheter for 1 of 50 (#168) sampled residents. Findings included: Observations of Resident #168 on 1/28/20 at 9:09 AM revealed that the resident had an indwelling urinary catheter in place. Review of the residents current physician orders revealed that on 1/14/20 the reason for the catheter was Urinary retention. Review of the hospital urology progress note dated 1/9/20 identified the resident with a diagnosis of urinary retention. Review of the 3008 transfer form dated 1/9/20 indicated that an area was checked off indicating urinary retention due to: ________(this area was left blank). Interview on 1/29/20 at 10:38 AM with the Director of Nursing (DON) revealed that she was not that familiar with Resident #168 and would need to research why the resident had a catheter. Interview on 1/29/20 at 1:47 PM with the DON revealed that the resident's diagnosis for the catheter is urinary retention. She was unable to verbalize or present any information that would indicate the cause of the urinary retention. She reported that there should have been a clarification. Interview on 1/29/20 at 2:49 PM with the DON revealed that she contacted the physician and received a clarification and that the reason for the catheter is to aide in wound healing. She provided a new physician order and an updated care plan. Review of the facility policy titled Urinary Continence and Incontinence-Assessment and Management with a revised date of October 2010 revealed the following: 4. Indwelling urinary catheters will be used sparingly, for appropriate indications only. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 3 of 12 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 105422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Park FL Opco, LLC 8701 49th St N Pinellas Park, FL 33782 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide care consistent with professional standards of practice for one (25#) of one dialysis residents reviewed of 5 total dialysis residents in the facility. Residents Affected - Few Findings included: An observation of Resident #25 on 01/27/20 at 12:15 p.m. revealed the resident was being assisted with her lunch meal. A review of Resident #25's clinical record admission Record showed an admission of 4/19/18, with diagnoses that included End Stage Renal Disease. The Quarterly Minimum Data Set (MDS) Assessment, dated 10/30/19, coded resident as receiving dialysis in Section O. The Quarterly MDS, dated [DATE], Section C, showed a Brief Interview Mental Status score of 13 (cognitively intact). A clinical record review of resident's re-admission Physician's Orders revealed resident to dialysis center every Tuesday, Thursday, Saturday (1/27/2020). Palpate the access site to feel the Thrill or use stethoscope to hear the Whoosh or Bruit of blood flow through the access site post dialysis Tues., Thurs., Sat (1/27/2020). Check dialysis site access site for signs of infection (warmth, redness, tenderness or edema) when performing routine care at regular intervals every shift site to upper left arm (1/27/2020). Do not use the access site (LEFT) arm to take blood pressure, blood samples, administer IV fluids, or give injections (1/27/2020). Dialysis access site: L arm Type of access: fistula (1/27/2020). A review of Resident #25's Care Plan, dated 1/13/2020 and updated on 1/23/2020, revealed a Nursing focus of Resident has potential for complications r/t (related to) hemodialysis for treatment of ESRD (End Stage Renal Disease). Shunt site: left arm. Receives dialysis on Tues/Thurs/Sat. at the contracted dialysis center (1/23/2020). The interventions included: Complete dialysis communicate tool on dialysis days and review upon return from dialysis (11/4/2019). Adjust medication schedule as required to accommodate for dialysis treatment (11/4/19). Vital signs as ordered and as needed. do NOT obtain BP reading from shunted arm (11/4/19). Labs as ordered- do NOT obtain blood draws from shunt site. Obtain lab values from dialysis center as needed; report results to physician as indicated (11/4/19). Monitor for bruit and thrill at shunt site (11/4/19). Observe for shunt site for changes in skin integrity and for s/sx of infection; notify physician if noted (11/4/19). Observe for s/sx (signs and symptoms) of complications such as bleeding, fluid volume overload, dehydration, hemorrhage, infection, notify physician if noted (11/4/19). A review of the Dialysis Services Agreement, dated January 2,2018, revealed terms of service, dialysis center obligations, care facility obligations, payment for services, insurance, Indemnification, termination of agreement, access to books and records, and miscellaneous provisions including compliance. A review of the Dialysis Communication Form, dated 1/16/2020: Document from the dialysis center showed, ***Please remember to remove bandages; will damage fistula when left on. A review of the Dialysis Communication form, dated 1/18/20 from the dialysis center, showed Needs hygiene - malodorous. Please remove bandages! CANNOT stay on more than 24 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 4 of 12 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 105422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Park FL Opco, LLC 8701 49th St N Pinellas Park, FL 33782 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the Dialysis Communication form, dated 1/21/2020 from the dialysis center, revealed Pt came in with bandage and sutures despite directions taken with pt. after last TX (treatment). Pt. also smells like she has not been bathed. A review of communication sheet from Dialysis form dated, 1/28/2010, revealed Pt access must have bandages removed after 24 hours!!! Called facility and spoke with (Staff member). A review of the Medication Administration Record/Treatment Administration Record for January 2020 revealed, Check dialysis access site for signs of infection when routine care at regular intervals every shift site to left upper arm every shift. Ordered 1/13/20 and d/c (discontinued) 1/27/20. There were no orders to remove the pressure bandage 24 hours after dialysis treatment. An interview was conducted on 01/29/20 at 08:43 a.m. with Staff member G., RN, Unit Manager. She has been at the facility over a year. She stated her staff nurse is responsible for checking the communication form. When Resident #25 comes back from the dialysis, the bandage is to be removed within 24 hours and the staff nurse should be changing the bandage as requested by the dialysis center. The Unit Manager stated, on Wednesdays, Fridays, and Sundays, the bandages will be scheduled to be removed. The Unit Manager submitted an order on 1/28/2019. She stated after she received several requests from the center to make sure resident's bandage was changed, Staff member G made an order to administer the treatment. On 01/29/20 at 02:45 p.m., an interview was conducted with the Director of Nursing (DON), RN. She stated, the expectation is to follow the instructions of the dialysis center and if they (the facility nursing staff) have a question they can call the dialysis center for clarification. The DON revealed the Unit Manager (Staff Member G) added the order to remove the bandage on 1/28/20 for nursing staff to comply. On 01/29/20 at 06:56 p.m., an interview was conducted with the Assistant Director of Nursing. She stated and verified the nurses are supposed to check the dressings and check the dialysis center communication book on the day after the treatment. She stated, the pressure bandage should be removed the following day after dialysis. On 01/29/20 at 06:59 p.m., an interview was conducted with Staff member O, LPN. She stated when the resident returns from dialysis, she checks the vitals, gets resident a snack and asks Certified Nursing Assistant to check for personal care. Staff member O stated she completes the communication form upon resident's return. A review of the Policy and Procedure on End Stage Renal Disease, Care of a Resident, revised October 2010, revealed the Policy Statement: Resident with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The Policy Interpretation and Implementation revealed at 1. Staff caring for residents with ESRD, including resident receiving dialysis care outside of the facility, shall be trained in the care and special needs of these residents. 2. Education and training of staff includes, specifically: g. The care of grafts and fistulas. Under Documentation the policy revealed, The general medical nurse should document in the resident's medical record every shift as follows: 4. Any part of report from dialysis nurse post-dialysis being given. 5. Observations post- dialysis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 5 of 12 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 105422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Park FL Opco, LLC 8701 49th St N Pinellas Park, FL 33782 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to accurately account for controlled substances and dispose of controlled substances in a timely manner after the discontinuation of the medication or the discharge of the resident in one (300-1) out of three medication carts reviewed for medication storage and labeling. Findings included: An observation of the medication cart #1 on the 300-hall was conducted, on 1/29/20 at 3:01 p.m., with Staff Member C, Licensed Practical Nurse (LPN). Staff Member C stated the outgoing/oncoming nurses count the medication cards and the tablets/capsules with each other before and after each shift. The observation revealed a blister-pack card with contained Tramadol 50 milligram (mg) tablets. The Controlled Drug Disposition for the medication indicated 20 tablets were on hand and a tablet was last administered on 1/28/20. A count of the medication inside the blister-packs indicated 19 tablets. Staff Member C confirmed the count of 19 tablets. The staff member stated she was told in report that Staff Member D, LPN, had administered a tablet at 9:50 a.m. on 1/29/20. Staff Member D arrived to the cart and verified the package contained 19 tablets and one was given at 9:50 a.m. which was not documented. During the observation of the medication cart controlled substance drawer revealed several blister packs of medications and an envelope containing one patch of Fentanyl separated from other controlled medications. Staff Member C indicated the medications were either discontinued or the resident had been discharged . The blister packs contained the following medications: - Twenty-four Tramadol 50mg tablets. The last administration date was 12/24/19. The instructions indicated 2 tablets by mouth every 8 hours as needed pain. - One 50 microgram/hour (mcg) Fentanyl patch. The Controlled Drug Disposition indicated the medication had been discontinued. The last administration date was 12/29/19. The return-not anticipated Minimum Data Set, dated [DATE], indicated the resident was discharged on 12/31/19. Staff Member C confirmed the resident had been discharged . - Twenty-three tablets of Hydrocodone - Acetaminophen (APAP) 5/325 mg tablets. The last day of administration was 12/30/19. Per the return-not anticipated Minimum Data Set, dated [DATE], indicated the resident was discharged on 12/31/19. Staff Member C confirmed the resident had been discharged . - Twenty-nine tablets of Tramadol 50 mg tablets. The Controlled Drug Disposition indicated the medication was last administered on 5/13/19. On 1/29/20 at 4:18 p.m., the Director of Nursing stated her expectation was for narcotics to be verified and counted every shift; before and after. When asked how often narcotics are destroyed, the Director stated usually 2-3 times a week. The Director stated she was only one person and would expect staff to notify her or flag her down if controlled substances needed to be destroyed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 6 of 12 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 105422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Park FL Opco, LLC 8701 49th St N Pinellas Park, FL 33782 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The policy titled, Controlled Substances, dated 2001 and revised December 2012, indicated the facility shall comply with all laws, regulations, and other requirements to handling, storage, disposal, and documentation of schedule II and other controlled substances. The policy interpretation and implementation revealed nursing staff must count controlled medications at the end of each shift, the nurse coming on duty and the nurse going off duty must make the count together, and document and report any discrepancies to the Director of Nursing Services. The policy titled, Discarding and Destroying Medications, dated 2001 and revised October 2014, indicated medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. The policy identified destruction of a controlled substance must tender it non-retrievable, meaning the process permanently alters the physical or chemical properties of the substance so that it is no longer available or usable, and cannot be illegally diverted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 7 of 12 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 105422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Park FL Opco, LLC 8701 49th St N Pinellas Park, FL 33782 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview the facility failed to ensure one (#61) out of six residents sampled for use of unnecessary medications was free of significant medication error in regards to the resident not receiving an anticoagulant according to physician orders. Residents Affected - Few Findings included: Resident #61 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses of presence of cardiac pacemaker, unspecified atrial fibrillation, and unspecified peripheral vascular disease. An observation of Resident #61, on 1/26/20 at 12:49 p.m., revealed a resident sitting in a wheelchair next to his bed. During the observation, Resident #61 stated his blood glucose had crashed today and the nurse had to give him orange juice. On 1/28/20 at 9:45 a.m., the resident was observed sitting in the lobby with other residents awaiting a Resident Council meeting, and on 1/29/20 at 10:28 a.m., Resident #61 was observed propelling self in a wheelchair from the lobby area towards the elevator. A review of Resident #61's January Medication Administration Record (MAR) revealed the resident received Coumadin 7.5 milligrams (mg) at bedtime from 1/1 to 1/6/20. The MAR indicated Resident #61 was hospitalized on [DATE] prior to the administration. The acute facility's discharge medication indicated the Resident was to receive Warfarin (Coumadin) 7.5 mg daily. The MAR indicated Resident #61 received 7.5 mg at bedtime on 1/11 - 1/13/20. A sheet of telephone orders indicated the last order written was, on 1/13/20, regarding the resident's Wellbutrin and did not address the resident's dosage of Coumadin. The review of PT/Prothrombin time and International Normalized Ratio (INR) results indicated the following: - 1/14/20: PT/INR - 23.3/1.95. A notation indicated an order to increase Coumadin 10 mg for 2 days then 8 mg daily, and to discontinue (d/c) previous order. The notation was undated and unsigned by the person giving or taking the order. - 1/21/20: PT/INR - 29.5/2.45. A notation on the results sheet indicated no new orders at this time (NNO @ this time). - 1/28/20: PT/INR - 71.10/5.81. The notation on the results sheet instructed staff to hold x 3 days and recheck. The MAR indicated Resident #61 did not receive Coumadin on 1/14/20 and received Coumadin 10 mg on 1/15 - 1/16/20. The MAR revealed an order for Coumadin 4 mg - 2 tablets (8 mg) one time a day, the daily administration was x'd out and did not reveal the resident received 8 mg of Coumadin during the month of January. Per the MAR, Resident #61 did not receive Coumadin on 1/17/20. The Attending physician note, dated 1/17/29, instructed staff to continue Warfarin Sodium (Coumadin) 5 mg orally once a day for paroxysmal atrial fibrillation and the hospital and current medication lists were reconciled. The MAR revealed Resident #61 was administered 5 mg of Coumadin on 1/18-1/19/20 and 1/25-1/26/20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 8 of 12 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 105422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Park FL Opco, LLC 8701 49th St N Pinellas Park, FL 33782 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 0760 per an order for Coumadin 5 mg on Saturday and Sunday. Resident #61 received 7.5 mg on 1/20-1/24 and 1/27/20 per a physician order. Level of Harm - Minimal harm or potential for actual harm The progress notes for Resident #61 indicated the following: Residents Affected - Few - 1/14/20: Coumadin increased to 10 mg x 2 days then 8 mg daily. - 1/21/20: PT/INR received and nno orders at this time - 1/28/20: received PT/INR results and physician notified with new orders to hold (Coumadin) for 3 days and recheck. The progress notes did not reveal any other documentation of a change of Resident #61's Coumadin dosage. During an interview, on 1/29/20 at 4:37 p.m., Staff Member A, Licensed Practical Nurse (LPN), confirmed she was Resident #61's usual nurse. Staff Member A stated she does not always write a telephone order, sometimes the physician gives a verbal order directly, but does make a note in the computer regarding the order. The staff member confirmed she wrote the order on 1/14/20 for increasing the Coumadin to 10 mg and stated she spoke with the Nurse Practitioner (NP) on 1/21/20 regarding the resident's PT/INR results and did not receive an order to change the dosage. Staff Member A confirmed she had spoken with the NP on 1/28/20 and received the order to hold the residents Coumadin for 3 days. A review of Resident #61's orders with the LPN was conducted, she confirmed the resident had received 7.5 mg of Coumadin on Monday - Friday and 5 mg on Saturday and Sunday. She stated a new order was received to increase the Coumadin to 10 mg for 2 days then to decrease the dosage to 8 mg daily. When asked where the order for 5 mg had come from and why the 8 mg of Coumadin was discontinued on the same day it was to be started, she stated she did not know. The LPN stated the documentation could be off if a nurse was using the same computer as she used to review, as the date on the screen was 1/30/19 at 5:11 p.m. The staff member verified there was no telephone order written to decrease Coumadin to 7.5 and 5 mg. She stated, I'm sorry I just don't know where it came from. Resident #61's care plan indicated the resident was at risk for abnormal bleeding and increased bruising related to (r/t) use of anticoagulant/aspirin (ASA) for the treatment of atrial fibrillation (a-fib). The interventions instructed nursing staff to obtain labs/diagnostics as ordered, report results to physician, and follow up as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 9 of 12 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 105422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Park FL Opco, LLC 8701 49th St N Pinellas Park, FL 33782 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility record review, the facility failed to properly store and label food items in the kitchen refrigerator, and failed to appropriately maintain the freezer compartments for two of two refrigerators in the 2nd and 3rd floor nursing unit nourishment rooms. Findings included: At 9:52 a.m., an observation in the dry storage area revealed (3) spaghetti pastas wrapped in plastic wrap with no date. Photographic evidence obtained. Dented cans were stored on the second shelf from bottom with no sign indicated dented cans. The Kitchen manager stated the sign fell off. During the initial tour on 01/26/20 at 10:03 a.m., an observation of the Walk in Cooler, there were (2) plastic wrapped portions of bologna had no date. Photographic evidence obtained. Further review of the walk-in-cooler revealed a lunch bag for a dialysis resident dated 1/16/2020. Photographic evidence obtained. The Kitchen Manager stated the resident is no longer in the building. The Kitchen Manager discarded the dialysis lunch bag. At 10: 21 a.m., a tour of the Freezer revealed a bag of frozen potatoes opened with no date. Photographic evidence obtained. A second tour of the kitchen was conducted on 01/28/20 at 01:29 p.m. with the Certified Dietary Manager (CDM) and Kitchen Manager. At 2:08 p.m., an observation of the 2nd floor Nourishment Room revealed there was no thermometer in the refrigerator/freezer. The CDM stated she took it out earlier so the kitchen could calibrate it. The freezer was observed with built-up ice on the sides and bottom of freezer compartment. Photographic evidence obtained. The Kitchen Manager verified and stated, Dietary is responsible for making sure the refrigerators and freezers are cleaned and defrosted. The maintenance department works together to keep it clean. At 2:12 p.m., an observation of the 3rd floor Nourishment Room revealed the refrigerator/freezer displayed built up ice in the freezer compartment. Photographic evidence obtained. 01/28/20 01:29 PM - A second tour of the kitchen was conducted with the CDM and Dietary Manager. During the tour, an interview was conducted with staff member J, Cook. She was observed cooking sausage and potatoes for the dinner meal on the grill. She stated if she is putting away food during prep, you are to wrap up the product and write the open date and label the item. On 1/28/20 at 2:25 p.m., an interview was conducted with staff member K, Dietary Aide, employed 1 year. She stated her job is to set-up tray line, check trays, prepare desserts and snacks. Staff member K revealed if making a sandwich, it is wrapped and dated. An interview was conducted with the Administrator on 01/29/20 at 05:31 p.m. He verified and stated it is the responsibility of the kitchen to maintain the cleanliness of the nourishment room refrigerators by defrosting the freezers. He stated the housekeeping department cleans the floors, dietary cleans the inside and the maintenance department helps to remove the refrigerators for thorough cleaning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 10 of 12 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 105422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Park FL Opco, LLC 8701 49th St N Pinellas Park, FL 33782 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the Policy and for Food Receiving and Storage, no date of creation, revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. The Interpretation and Implementation revealed, #6. Dry foods that are that are stored in bins will be removed from original packaging, labeled and dated (use by date). #7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). #13 c. revealed, Food items and snacks kept on the nursing unit must be maintained: Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. #15. revealed, Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from the food storage. A review of the facility policy and procedure on Cleaning Guidelines for Refrigerators, no date of creation, revealed, #1. Remove all food from the refrigerator. Sort out and throw away all that is not usable. The facility did not submit a policy and procedure for cleaning guidelines for freezers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 11 of 12 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 105422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Park FL Opco, LLC 8701 49th St N Pinellas Park, FL 33782 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview and record review the facility failed to ensure that staff followed appropriate infection control procedures related to handwashing after providing personal care. Residents Affected - Few Findings included: Observations on 1/27/20 at 7:53 AM of Staff B, CNA (Certified Nursing Assistant) revealed this staff person was walking down the hall on the third floor using 2 fingers to hold a glove which was holding and carrying a clear garbage bag that contained soiled items. The CNA was observed to open the door of the soiled utility room throw the soiled bag in, while holding the door open with his left foot. A resident was noted to engage the CNA in a conversation related to his need for coffee, at this time the CNA then approached the resident to confirm how he wanted his coffee. When the conversation was done the CNA walked down the hallway and went to the nutrition room located by the nurses station on the 3rd floor, opened the door and walk in and proceeded to make a cup of coffee. While in the nutrition room another staff person entered and asked the CNA to make a second cup of coffee for another resident. The CNA was observed to make both cups of coffee and take them out to the nurses station where both residents were waiting and proceeded to hand the cups of coffee to the residents. At 8:00 AM this surveyor intervened and asked the CNA to make fresh coffee for the 2 residents. Interview with Staff B, CNA on 1/27/20 at 8:01 AM confirmed that he did not wash his hands after handling soiled items and before making the coffee for residents. He reported that he was distracted by a resident. He reported that he knows that he is supposed to wash his hands before and after resident care. Interview on 1/29/20 at 4:52 PM with the Director of Nursing (DON) revealed that she was made aware of the incident and that the staff person reported that he did wash his hands. She reported that all staff have been trained in universal precautions and to wash hands in between each resident. Review of the facility policy titled Handwashing/Hand Hygiene, with a revised date of August 2015 revealed the following: 7. Use an alcohol-based hand rub containing at least 62% alchol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; p. Before and after assisting a resident with meals; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 12 of 12