Health inspection·September 29, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 09/28/23 at 4:30 p.m., an interview was conducted with the DOR and Staff L, OT. Staff L stated Resident #1 had hemiplegia weakness on core muscles and had recently worked with her on wheelchair mobility, self-feeding, lower-level ADLs, and positioning. Staff L stated Resident #1 tended to lean posteriorly for lower leg support. Staff L stated she tried to adjust the resident's wheelchair to manage trunk stance. Staff L said, She had a positioning trough which was closer to her a lap and would impact how far she sat from the table. I switched it to a lap tray. The original one which she had at the time of the accident did not work. She tends to lean to the left. Her hips should be positioned better to support her trunk. Since her last hospital visit, she has been weaker. She has a bunch of comorbidities and weakness post-hospitalization. The DOR stated they looked to see if she needed adaptive equipment and determined she did not. She needed a regular cup to allow better grip. Staff L said, we determined using a [disposable foam] cup was not appropriate for her use. It was not the safest for her. She should have been served with regular kitchen wear. On 09/28/23 at 4:23 p.m., hot liquid assessments for Resident #1 were reviewed with the DON and the ADON. The DON stated if the assessment resolved in 2 or more checkmarks of yes, it would indicate the resident was at risk of burns. The assessments conducted on 12/22/23 and 08/17/23 showed the resident scored a 2 indicating the resident was not at risk. The assessments revealed on question 2, Functional limitations and contractures, the resident was observed not to have any limitations, contrary to her history of left side impairment. The DON said, We learned the assessment is not a good tool for this situation because she had a dominant side that was functional, her right side, even though she was totally impaired on her left side. She stated the impairment affected Resident #1's trunk control and positioning. The DON stated they were looking at other factors that may have contributed to the incident such as impaired judgement. Review of an OT treatment note date 08/17/23 showed, Patient custom wheelchair is modified to provide additional support to L UE (left upper extremities) as currently used trough is ineffective as patient is contracted and limbs falls off due to poor fit of device. Device is removed and lap tray installed. Review of an OT treatment note date 08/28/23 showed, Patient is observed in dining room as she returns from hospital following spillage of hot liquids. Screen is completed and a number of factors appear to have contributed to the accident. OT to address positioning primarily to ensure patient is optimal level of neutral, to ensure good body to table/food distance and fine motor control to ensure that self-feeding is managed at maximum level of 1, and safety with potential need for adaptive equipment to manage hot liquids. Review of a document titled, Occupational Therapy Treatment Encounter Note(s) showed on 08/18/23, an assessment was conducted on Resident #1 as follows, splint applied to left hand/wrist and lap tray installed for light sustained stretch. 2. Right upper extremity is flexion/abduction and with digits in extension results to promote normalized position of effected limb, prevent worsening of contractures. Patient educated on safe mobility while in chair using compensatory movement patterns. PN (Proprioception) completed and self-feeding goals incorporated into patient's plan of care due to event related to spilling hot soup. Recommendations made related to proper positioning to allow for increased safety and independent self-feeding. AE (Acute exacerbation) to be trialed as per patient needs. Patient stated understanding of need for upright sitting so that table/food is easily accessible. Staff collaboration with good return demonstrated. Modifications to chair continues as per patient response and further need to address safety slip and fall from chair and spilling of soup both of which appear to be related to positioning. Chair is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 2 of 18 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 09/29/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few dumped appropriately to ensure hips remain centered with decreased tendency for posterior pelvic tilt. Additional support posteriorly to increased height of back support to promote mid trunk flexion. Further head support is placed to ensure head remains in alignment and in neutral. The above modifications allow for optimal ability to participate in tabletop activities, namely self-feeding. Continue to monitor for safety and patient comfort. Review of a Resident Information Record dated 09/29/23 showed on 8/17/23 new diagnoses were added. A burn of second degree of left forearm sequela, a burn of second degree of abdominal wall sequela and a burn of second degree of other site of trunk, subsequent encounter. On 8/25/23 a new diagnosis of local infection of the skin subcutaneous tissue, unspecified was indicated. Review of a progress note dated 08/16/23 at 22:30, Resident spilled soup while eating dinner. Abdomen with clear fluid filled blister, forearm with open area. MD and family notified. Skin prep applied to blister, forearm cleansed with NS (normal saline), TAO ([NAME] Antibiotic Ointment) and wrapped with gauze. Therapy screen completed. Site is painful . Review of an 8/17/23 the SBAR (Situation Background Assessment Recommendation) revealed resident received a burn to her left lower abdomen and left lower arm PCP (primary care physician) responded with orders to cleanse with TAO and dressing applied. The SBAR dated 08/17/23, marked [late entry] signed by the ADON (Assistant Director of Nursing) showed, A Change in Condition (CIC) evaluation was conducted following a trauma incident. Resident received burn to resident's left lower abdomen and left arm. PCP was contacted with instructions to cleanse with NS TAO and dressing applied. A skin observation note dated 08/17/23, signed by the ADON, showed, Resident has new skin impairment. Resident received burn to her abdomen and left lower arm from hot liquid. Abdomen - left lower abdomen measurements 15 cm x 8 cm, left lower arm 9 cm x 6.5 am. An SBAR assessment was completed for new skin impairment. Treatment orders were obtained. Responsible party was notified. Review of Resident #1's Medication Administration Record (MAR) dated 08/01/23 to 08/31/23 revealed Resident #1 received new medications related to burn wounds as follows: Ascorbic Acid Tablet 500 milligram. Give 1 tablet by mouth one time a day for supplement to promote wound healing. Medication was administered from 08/18/23 to 08/21/23. Stat oral liquid - Protein. Give 45 ml (milliliters) by mouth two times a day for wound healing. Medication was administered from 08/18/23 to 08/21/23. Doxycycline Monohydrate 100 mg capsule. Give 1 tablet orally two times a day for wound burn for 14 days. Medication was administered from 08/18/23 to 08/21/23. Norco Oral Tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for pain. Medication was administered from 08/17/23 to 08/20/23 for complaint of left arm and abdomen burned areas. Review of Resident #1's Medication Administration Record (MAR) dated 09/01/23 to 09/30/23 revealed Resident #1 continued to receive new medications related to burn wounds as follows: Doxycycline Hyclate oral tablet 100 mg. Give 1 tablet by mouth two times a day for cellulitis for 14 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 3 of 18 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 09/29/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Stat oral liquid - Amino acids Protein hydrolysate. Give 45 ml (milliliters) by mouth two times a day for wound healing for 30 days. Tramadol HCI tablet 50 mg. Give 1 tablet by mouth every 6 hours as needed for moderate and severe pain. Norco Oral Tablet 5-325 mg. Give 1 tablet by mouth every 6 hours as needed for pain. Residents Affected - Few The care plan showed an ADL focus revised on 08/18/23, showing the resident had an ADL self-care performance deficit associated with limited mobility, CVA (Cerebral Vascular Accident) with the left sided hemiplegia. Interventions related to eating showed the resident was able to feed self after set up. The care plan showed a focus indicating Resident #1 was at risk for injury related to hot liquids due to poor trunk control initiated on 08/19/23. Interventions included to complete hot liquid evaluation as scheduled, fluids were served at proper temperature, occupational therapy to screen with decline in function, and ensure resident maintained upright position when served hot liquids. Review of skin/wound care notes for Resident #1 revealed: On 08/17/23 resident was seen. History of present illness (HPI), Location: Left forearm and left lower abdomen. Quality: Patient is able to advise if in pain, Severity: Moderate, Timing: When palpitated burn, Context: 2nd degree burn. Modifying factors: pain is relieved with medication. Associated Signs and Symptoms: Limited mobility; history MRSA (Methicillin-Resistant Staphylococcus Aureus) HPI Description: As per nursing staff this was an acquired burn from soup, patient has had a CVA which limits use of her abilities . Doxycycline for cellulitis associated with wound. Diagnosis included: Burn of second degree of abdominal wall, initial encounter and burn of second degree of left upper arm, initial encounter. Orders: Doxycycline 100 mg po BID x 14 days. Wound Care: Cleanse wound with normal saline and Xeroform dressing. Wound #3: Left forearm, Partial thickness 9.0 cm length x 6.5cm width 45.946 cm^2 area. Wound #4: Left abdomen, Partial thickness, 15 cm length x 8cm width 94.248 cm^2 area, erythema, peri wound tenderness. On 09/11/23 Resident #1 was seen for wound care. Wound #1 Partial thickness wound, wound bed has slough present 75% of wound bed covered in serous drainage, moderate no odor, No tunnelling/undermining present. Well defined wound edges no signs of infection observed, wound is unchanged. Wound #2 Full thickness wound, wound bed has slough tissue 75% of wound bed covered with serosanguineous drainage, moderate amount of discharge well defined wound edges, no signs of infection. Wound is unchanged from previous. Left Abdomen: length 3.5cm/ width 12 cm / depth 0.1 cm Left forearm: length 8cm / width 2cm / depth 0.1cm. On 9/11/23 wound care was provided. Weeks of treatment: 3. Left arm: Partial thickness burn. Patient consented to debridement. Wound description: Full thickness without exposed support structures. Wound Margin: Distinct, outline attached. Under Assessments: Wound #3, pre-procedure diagnosis of wound #3 is a second-degree burn located on the left forearm. There was an excisional of skin/subcutaneous tissue debridement with a total of 12 square centimeters performed by the wound doctor. Blade (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 4 of 18 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 09/29/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety material removed includes subcutaneous tissue after achieving pain control using Lidocaine. A minimum amount of bleeding was controlled with pressure. Round #4: pre procedure diagnosis of wound #4 is a second-degree burn located on the left abdomen, lower quadrant. There was an excisional skin/subcutaneous tissue debridement with a total of 24 square centimeters performed by the wound doctor. Blade material removed includes subcutaneous tissue after achieving pain control using Lidocaine. A minimum amount of bleeding was controlled with pressure. Residents Affected - Few On 9/25/23 Resident #1 was seen for wound care. The wound assessment note showed, Resident #1 has wounds, MD notification 09/25/23, Family notification 09/25/2023, Followed by wound care. Resident denied pain, no new orders received care Resident aware of wound progress and orders, care plan reviewed and updated. Abdomen-Wound #1: Full-thickness wound, wound bed has slough present, 50% of wound covered . Epithelizing wound edges. There are signs of infection present. Wound shows signs of improvement. Left forearm: Wound#2: Partial thickness wound, wound bed have slough tissue present. 75% of wound bed covered .scant drainage, epithelializing wound edges. Wound shows improvement. Abdomen: 2.5cm L/ 10.0cm W/ 0.1cm D and Left Forearm: 4.5cm L/ 1.4 cm W/ 0.1 cm D. On 09/28/23 at 3:16 p.m., an interview was conducted with Staff G, CNA. He stated he was assigned to Resident #1 the day she was burned. He stated he was working in the dining room with the evening supervisor (Staff J, RN) and was assisting passing coffee and juice to the residents, but not the tomato soup. He stated the meal was already served and the residents were eating. He stated [Resident #1] did not ask him for soup. He said, I believe someone else passed the soup to her. In the middle of them eating, one of the resident's on the same table called me and said [Resident#1] had spilled something on herself. I went to the kitchen, asked for cold water and a towel, and wiped her up. I took her to her room to change her clothes. I did not notice any difference in her skin when I was wiping her at that time. There were blisters later in the evening. I did not know she was badly burned at that time. I told the nurse [Staff K, LPN] when I observed the blisters. She helped me change her. She saw her skin. It was pink/red. On 09/28/23 at 3:25 p.m., a telephone interview was conducted with Staff K, LPN (agency). She stated she remembered she was passing medications after dinner when a CNA (Staff G) stated (Resident #1) had spilled hot soup on herself and asked for help changing her. Staff K said, In that moment, I saw her arm. It was red. I called the supervisor [Staff J, RN] just to make her aware of the redness. l saw the redness in her left chest and stomach area. It did not look like a burn until I went in when the aide was changing her for bed. He [Staff G] came and got me because the areas were starting to blister. I notified the supervisor again and she called the MD and notified the DON. I did not think it would blister that quickly. Within 2 hours she was full of blisters on her left arm and stomach. Staff K stated the resident did not complain of pain at the moment. She stated the resident's skin was irritated. Staff K stated she wrote a progress note and received doctor's orders to treat the burned areas. On 09/28/23 at 09:15 a.m., an interview was conducted with Staff F, Certified Dietary Manager (CDM)/Kitchen Manager. She stated Resident #1 was burned with soup on 08/16/23. She stated the incident happened in the dining room. Staff F said, I don't know exactly who served the soup. The dish machine was not working, we used regular serving bowls for all the other residents and a disposable foam cup for [Resident #1]. The resident did not receive soup with her tray. She requested and received tomato soup after we were done serving. The resident was served hot tomato soup in an 8-ounce disposable foam cup because we were out of bowls. I did not know if she required special equipment. It was a last-minute request. I don't think we in the kitchen knew whom the soup was going to. Staff F stated the soup was requested outside of the tray line and was taken straight to the resident upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 5 of 18 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 09/29/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few preparing it. She stated they conducted an investigation and determined the resident's dexterity was the problem, more than the beverage itself. She said, the problem was not the beverage which was served or the container in which it was served. It was the resident's dexterity. Staff F stated dexterity meant the resident's ability to use her hands. She stated Resident #1 had some limitations. She confirmed the resident was served hot soup in a disposable foam cup and consequently suffered burns. Staff F stated they should have considered lag time the time it takes from the moment food is scooped into a serving dish and when it is served to the resident. She stated that would have helped the soup to cool down. On 09/28/23 at 2:18 p.m., an interview was conducted with Staff E, Activities/CNA. She stated she assisted residents with little things like getting water. She stated she was working in the dining room and was assisting with serving when Resident #1 burned herself with hot soup. She stated Resident #1 sat in the far-right corner of the dining room, probably 10 steps from the serving window. She stated the resident did not need assistance with feeding at the time, but she was now at the new restorative table, meaning her diet was downgraded and someone had to sit with her. Staff E stated the resident was served tomato soup because she had requested it. Staff E stated she went to the window and asked Staff A, the Cook, for the soup. She stated she heard Staff A say they were out of bowls. She stated she heard Staff F, CDM/ Kitchen Manager instruct Staff A to put the tomato soup in a coffee cup. Staff E stated she did not see how the soup was prepared. She confirmed she received the soup from Staff A in a disposable foam cup and handed it to Staff G, CNA who was assigned to the resident. Staff E stated she could not recall the soup being hot to touch. She stated she handed it to Staff G who brought it to the resident. Staff E stated she was at the front of the dining room when she heard Staff G stating he needed a towel because (Resident #1) had wasted the tomato soup. Staff E stated she grabbed a towel from the service counter and handed it to Staff G. Staff E stated at the time she did not realize Resident #1 had suffered significant burns. On 09/28/23 at 2:30 p.m., an interview was conducted with Staff H, Corporate Registered Dietician (RD). She said, the facility's policy is not specific to re-heating meals, however you would assist a resident if food needed to be re-heated. It should be heated to 165 degrees for 15 seconds. You check the temperature, and if it is above 180 degrees you wait for it to cool before you serve. She stated the facility staff failed to wait for the soup to cool down prior to serving it. She stated she would not recommend putting food in a microwave for 3 minutes and serving it without checking temperature. Staff H stated different microwaves heat at different levels so she would expect to stop and check after every 15 seconds. She stated there was no regulation on how hot is too hot. She stated she would expect staff to check the temperature every 15 seconds during the re-heating process. Staff H said, Everyone should use common sense. Staff H stated Resident #1 requested and received some soup which she picked up from the rim of the cup and she had put her finger through it. Staff H stated the resident spilled the soup on herself, causing the burns. She stated the resident had some blistering that appeared later from the soup burn. Staff H confirmed the blisters were caused by hot soup. She stated blistering occurred at temperatures above 125 degrees. On 09/28/23 at 2:40 p.m., a telephone interview was conducted with Staff I, Facility RD. She stated she was informed a resident had burned themselves with hot soup. She stated they immediately started in-services on hot liquids. Staff I stated she expected foods and liquids to be served at proper temperatures. She said, I heard the resident was having trouble holding the cup because she was served in a [disposable foam] cup. I don't know how she burned that quickly. She stated they had regular soup dishes, but the dish machine was down. Staff I stated the policy on re-heating any food was to heat it, bring it to temperature and then re-test the temperature. Staff I said, We should test the temperature after heating and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 6 of 18 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 09/29/2023 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 0600 before you bring it out to the resident. Level of Harm - Immediate jeopardy to resident health or safety On 09/28/23 at 2:53 p.m., an interview was conducted with Staff J, RN/evening Supervisor. She stated she was working the day Resident #1 burned with soup. Staff J said, I was in the dining room during dinner and a CNA, I can't remember whom, said that [Resident #1] spilled soup on herself. That CNA cleaned her up with soap and water wiped her up and she was fine. Her skin was pink at that time. Later, before the end of the shift, I checked on her. Her abdomen on the left side and her left arm were pink and red in color. You could tell the hot soup had scalded her skin but there were no blisters at the time. Staff J stated she forgot to document her observations. She stated she did not put in any skin assessments or progress notes. She stated she called the doctor and the DON. She said, There were no orders at that time. It was too busy that night I had other patients to take care of and I forgot to write something. Staff J stated she entered her notes a couple days later. Residents Affected - Few On 09/28/23 at 3:39 p.m., an interview was conducted with the DON. She stated she received a phone call from the evening supervisor (Staff J, RN) around 10:30 p.m. and was notified Resident #1 spilled hot soup on herself and she had no issues. The MD had also been notified. The DON stated the following day she read the 24-hour report and called Staff J to review the incident. She stated they went through the report again because the resident had developed blisters. The DON stated she had the Assistant Director of Nursing (ADON) assess Resident #1. The ADON reported to the DON the resident had open blisters on her abdomen and left arm. The DON stated she initiated an investigation and spoke to the staff to see what had happened. She stated they called the doctor who came in and saw the resident. The DON said, My investigation from my perspective was that it appeared to be an isolated incident which prompted further assessments like hot liquid assessments for all the residents. The DON stated there were no other residents who complained about safety of hot liquids. She stated they did skin checks and mouth checks, and no concerns were observed. The DON said, The incident prompted us to start working with OT [Occupational Therapy] on the way residents who have CVA [cerebrovascular accidents], and physical limitations are more at risk especially due to positioning. The DON stated OT referrals were made for those who were identified to be at risk. On 09/28/23 at 4:03 p.m., an interview was conducted with the ADON. She stated the following day they had reviewed the 24-hour report and read Resident #1 spilled soup on herself. She stated originally the report showed just pink skin was observed. The ADON stated she conducted an assessment on Resident #1 and at the time blisters had developed on her left arm and stomach area. The ADON stated she interviewed the staff to find out what had happened and contacted the family and the doctor. The ADON said, We did not know what really happened. I learned she was in the dining room and wasted soup on her arm. I received orders from the doctor. I did a CIC and skin sweep on her. I observed she had red and pink areas, and the first layer of skin was not there. Her skin had rolled to the side. It had blistered and broken on her stomach. We notified the wound care doctor. The ADON stated her investigation revealed the hot soup was provided to the resident in a (disposable foam) cup. She stated the soup was hot, just made out of the kitchen. The ADON stated when Resident #1 went to pick it up it, it fell over. The ADON stated Resident #1 had prior CVA and left side weakness. The ADON stated the resident required accommodation with meal set up which meant to open everything for her and place within reach. The ADON stated resident #1 fed herself and only needed supervision. The ADON said, It was an accident, we can improve on a lot of things. It was not intentional. It made me look at things differently, like consider other factors including positioning and diagnosis. The ADON stated supervision in the dining room was provided by the nurses and the CNAs. She stated they should know each resident's meal preferences, positioning, and level of supervision. On 09/28/23 at 4:30 p.m., an interview was conducted with the DOR and Staff L, OT. Staff L stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 7 of 18 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 09/29/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 had hemiplegia weakness on core muscles and had recently worked with her on wheelchair mobility, self-feeding, lower-level ADLs, and positioning. Staff L stated Resident #1 tended to lean posteriorly for lower leg support. Staff L stated she tried to adjust the resident's wheelchair to manage trunk stance. Staff L said, She had a positioning trough which was closer to her a lap and would impact how far she sat from the table. I switched it to a lap tray. The original one which she had at the time of the accident did not work. She tends to lean to the left. Her hips should be positioned better to support her trunk. Since her last hospital visit, she has been weaker. She has a bunch of comorbidities and weakness post-hospitalization. The DOR stated they looked to see if she needed adaptive equipment and determined she did not. She needed a regular cup to allow better grip. Staff L said, we determined using a [disposable foam] cup was not appropriate for her use. It was not the safest for her. She should have been served with regular kitchen wear. On 09/28/23 at 5:01 p.m., a follow-up interview was conducted with Staff F, CDM. She stated the microwave in the kitchen was used to reheat food. She said, we do not use it a whole lot. If I do, I will put the food to be warmed in a microwavable bowl and heat it to 165 degrees for 15 seconds and if the temperature is greater than 180 degrees, wait to send it out. Staff F stated they had established a holding/cooling/lag time/rest period for anything 180 degrees and above. Staff F confirmed prior to this day, 09/28/23, she had provided education on monitoring food temperatures on the tray line, but not necessarily on re-heating food in the microwave. A telephone interview was conducted on 09/28/23 at 11:26 a.m. with Resident #1's wound care Physician. He stated he saw her wounds to the left forearm and the left abdomen right after the burns occurred and initially there was blistering but then both wounds developed necrotic tissue. He stated both wounds had to be debrided to remove the necrotic tissue. He stated during that procedure lidocaine was used to numb the area, a 13-inch blade was used to cut out the necrotic tissue, a compression gauze was used to stop the bleeding and treatment dressings were applied to both wounds. He stated the abdomen wound developed an infection of cellulitis and antibiotics were ordered. He said, Both of the wounds were improving, but once you have a wound, you will lose your skin, granulated tissue will grow back, and [Resident #1] will have permanent scarring. That goes for any wound. A telephone interview was conducted with Resident #1's Primary Care Physician (PCP) on 09/29/23 at 10:38 a.m. He stated he had been working with Resident #1 for 5 years and was very familiar with her. He stated he was made aware of the resident getting burned by soup. He stated he saw her the day after it happened, and he could not recall what degree of burns she had sustained. He stated they had been treating the wounds and had seen the resident weekly including yesterday, (09/28/23), he stated the wounds were covered, clean, and intact and the resident appeared to be comfortable. On 09/28/23 at 5:16 p.m., an interview was conducted with the Nursing Home Administrator (NHA), Regional Nurse Consultant (RNC) and the DON. The NHA said, on 08/17/23 during stand-up meeting the 24-hour report revealed Resident #1 had spilled soup on herself while attempting to drink it. The NHA stated she contacted the state abuse agency and the police department and reported the incident as abuse and the report was not accepted. She stated the resident was assessed and had blisters on her upper abdomen and left arm. The NHA stated the DON had interviewed the resident and she had said her thumb had punched a hole in the cup causing it to spill on her. The NHA said, We focused on maintaining appropriate dietary temperatures and serving food in suitable containers. In the investigation we reviewed temperature logs and saw the soup was documented to have been served at 180 degrees. I interviewed the [NAME] (Staff A). I asked him how he served the soup he said he served it in a [disposable foam] cup. The NHA stated they suspended Staff A pending investigation. She stated on 08/22/23 they educated dietary staff on ensuring food temperatures are taken at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 8 of 18 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 09/29/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete beginning and end of meal service and if the dish machine malfunctions, the [NAME] will make menu adjustments to ensure hot liquids are not served if they did not have appropriate dishes. The NHA stated they educated staff not to serve soup in paper products. The NHA stated on 08/22/23 a QAPI (Quality Assurance Performance Improvement) was held at which they determined the burn was not caused by their staff negligence. The NHA said, The root cause was the type of container the soup was served in. The resident squeezed the cup while she was drinking and that caused the thumb to go through the cup causing the soup to spill on the resident. The RNC stated the resident chose not to use the spoon. The RNC said, We determined if the resident would have used a different container, the soup would have been okay. The resident caused the accident because her nails poked the cup. She did not want to cut her nails and she did not want to use the spoon. The RNC confirmed it was their responsibility to ensure the resident had an appropriate container for the soup. The NHA stated on 09/28/23 they re-interviewed Staff A, [NAME] because they heard the surveyors were asking about re-heating food. The NHA stated Staff A said he had served two soups that day, a veggie s[TRUNCATED] Event ID: Facility ID: 105422 If continuation sheet Page 9 of 18 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 09/29/2023 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 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 observations, interviews, record review, physician interview, and facility policy review, the facility failed to ensure one Resident (#1) out of 13 residents with hemiparesis and hemiplegia diagnoses were free from hazards during meal service. Resident #1 is a vulnerable adult with a history of hemiplegia and hemiparesis affecting the left non-dominant side, dysphagia, and muscle weakness. On 08/16/23, during evening meal service, Resident #1 requested a bowl of soup. The facility staff provided Resident #1 with a cup of bubbling hot tomato soup that had been warmed in a microwave for approximately 3-4 minutes and was not cooled prior to serving. The soup was served in an 8-ounce disposable foam cup and was not checked for temperature before it was served to Resident #1. The resident who does not have use of her left arm reached to the hot cup with her right arm, dropped the cup of soup on herself and suffered 2nd degree burns to her left forearm and the left side of her abdomen. Resident #1 suffered pain, infection of the skin and subcutaneous tissue and permanent body disfigurement related to scarring as a result of the facility's failure to ensure this resident's safety during meal service. The facility's failure to monitor food temperatures prior to food service and failure to provide supervision and assistance to a vulnerable resident with physical limitations resulted in the determination of Immediate Jeopardy on 8/16/23. The findings of Immediate Jeopardy were determined to be removed on 9/29/23 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: Review of a Resident Information Record dated 09/29/23 showed Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident was her own responsible party. She was admitted with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Dysphagia following cerebral infarction. Review of the physician's active orders dated 09/29/23 showed Resident #1 was on a regular diet, pureed texture, nectar thickened fluids consistency for nutrition related to COPD. An interview and observation was conducted on 09/28/23 at 10:00 a.m. with Resident #1. The resident was observed to be in her wheelchair with her portable oxygen on via nasal cannula. The resident appeared clean, well-kept, and dressed in day clothes. She was observed to have a bandage on her left forearm dated 09/27/23, 7a.m-3 p.m. and signed. The resident said, I burned myself. She said it was carelessness. I picked up the soup, it was in a cup, and it was just falling on me like a waterfall. It hurts, the pain is an 8 to 10, achy and throbbing. I cannot move my left arm, it is paralyzed. The resident stated she did not need help with eating. On 09/28/23 at 12:04 p.m., Resident #1 was observed in the dining room for lunch. The resident was observed sitting in her wheelchair with three other residents at the table. The resident was observed leaning to her left. Her right arm was stretched out on the table, trying to reach the spoon in front of her. The resident was served pureed brat (sausage), mashed potatoes with gravy and apple juice. Resident #1 used only her right arm. Her left arm had a contracture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 10 of 18 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 09/29/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of a Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Section G - Functional status showed the resident was totally dependent on staff for Activities of Daily Living (ADLS) to include bed mobility, dressing, personal hygiene, and toileting with a two-person physical assistance required. The resident was totally dependent on staff for locomotion on and off unit. Resident #1 required supervision and set up for eating. Section G0400 assessment of functional limitation Range of Motion (ROM) showed on her upper extremities, Resident #1 was impaired on one side of the shoulder, elbow, wrist, and hand. The lower extremity evaluation revealed impairment on one side to the hip, knee, ankle, and foot. Section G0600 mobility assessment showed the resident used a wheelchair. Section K assessment of swallowing and nutritional status showed the resident had possible symptoms of swallowing disorder due to coughing or choking during meals or when swallowing. Section K0510 showed the resident received a mechanically altered diet. On 09/28/23 at 12:20 p.m., an interview was conducted with Staff A, Cook. He stated he was the evening cook, and he was on duty on 08/16/23 the day Resident #1 was burned with hot soup. He stated they had already finished serving dinner when a Certified Nursing Assistant (CNA) came and requested soup for a resident. He stated he could not remember who the CNA was and did not know the resident who was to receive the soup. He said, I had a small amount of tomato soup left. I normally make it for 3-4 residents. The tomato soup was an additional option to the meal. It was already cold. I put it in the microwave. I heated it for 3-4 minutes and gave it to the CNA in a [disposable foam] cup. When it came out of the microwave, it was hot and steamy just like any other foods. It was bubbling hot. I put it in a [disposable foam] cup because we did not have any regular dishes. The dishwasher was not working. I filled it to the top. It was a small cup. I handed it to the CNA. I think it had a lid, but it was one of those that don't stay on. The [NAME] confirmed he did not wait for the soup to cool down before handing it to the CNA to serve Resident #1. Staff A said, honestly I did not check the temperature. Staff A stated the next thing he heard was a resident was burned by the tomato soup. He said, it was the CNA's fault. The CNA should not have given it to her like that. She should have known it was hot. He stated he did not know the facility's expectation on re-heating food in the microwave. Staff A stated if he knew the resident had use of only one arm, he would have made sure it was cooler. Staff A said, I did not expect the resident was going to pick it up and put it in her mouth straight away. Staff A stated what he could have done differently was not serve that soup all together. A wound observation was conducted on 09/28/23 at 12:44 p.m. with Staff B, Licensed Practical Nurse (LPN) Agency. She performed wound care on Resident #1's left arm burn, and her left abdomen burn. When Staff B removed Resident #1's left arm bandage she stated, Wow that looks better the wound was observed to be clean, linear from her upper forearm, just below her antecubital, down to her mid forearm that tapered down to a point. The wound bed was reddish pink and contained slough to the lower left portion of the wound edge. Staff B stated I saw the wounds the day after this happened and this wound was long. It went from above her antecubital down to her forearm about 9 centimeters (CM) long and 2CM wide. You can see the pink areas around the wound, that's the scarring. Staff B removed the resident's left abdominal dressing and said yeah, this one looks better too. The wound was clean, wide, linear, and wrapped around from the front of the abdomen to her side. The wound bed was pink with 2 separate white areas that were deeper than the rest of the wound. The wound had a light purple border surrounding the wound. Staff B said this wound is deeper, and it was the worst of the 2 wounds. It used to take 2 boarder dressings to cover it but now it only needs one and you can also see the scarring around the wound, so it became smaller. Staff B confirmed Resident #1 received antibiotics for the abdominal wound. During the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 11 of 18 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 09/29/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few wound observation on 09/28/23 at 12:44 p.m., Resident #1 said I went to the ICU (Intensive Care Unit) and the doctor said my burns were bad and that I needed to have a burn doctor come look at them and they might have to send me to [a local hospital burn unit] but, the burn doctor came and said they didn't need to transfer me to the other hospital that they weren't that bad. I used to have a spot on my [chest] but that's all healed up. And they tell me they are getting better. My stomach is more tender than the other one. Review of a Resident Information Record dated 09/29/23 showed on 8/17/23 new diagnoses were added. A burn of second degree of left forearm sequela, a burn of second degree of abdominal wall sequela and a burn of second degree of other site of trunk, subsequent encounter. On 8/25/23 a new diagnosis of local infection of the skin subcutaneous tissue, unspecified was indicated. Review of an undated article titled, Burn depth. Nature Reviews Disease Primers, showed burns extending into the underlying skin layer (dermis) are classed as partial thickness or second-degree. These burns frequently form painful blisters. These burns range from superficial partial thickness, which are homogenous, moist, hyperemic and blanch, to deep partial thickness, which are less sensate, drier, may have a reticular pattern and do not blanch. Source: https://www.nature.com/articles/s41572-020-0145-5/figures/1 Review of Hospital records showed Resident #1 was admitted to [name of hospital] on 08/21/2023 and discharged on 08/25/23. The resident was admitted to the ICU (intensive care unit) with acute respiratory failure. During her stay, Resident #1 was seen for burn wounds. On 08/21/23, the record showed Resident #1 had a left forearm burn, left abdominal burn and a left nipple burn. The hospital admission record showed a dermatology/integumentary assessment was conducted revealing erythematous patch with fluid-filled bullae and medial forearm consistent with burn, no evidence of purulent drainage, no warmth. Hospital records revealed photographic evidence of Resident #1's burns showing an abdomen burn on the left side extending from below her naval towards her left side and a left arm burn showed an elongated wound from mid arm to triceps muscle, above her elbow. Review of Hospital care notes showed on 08/22/23 patient [Resident #1] was examined at bedside. Wound care saw her the day before and wrapped her burns and applied Silvadene on her abdomen/left forearm. The patient stated she was in no pain as long as she was taking her medications. A hospital care note dated 08/24/23 showed Resident #1 stated her burns are hurting this morning. On 8/25/23, Patient stated that her burns are slightly painful this morning. Patient's left forearm and abdominal burn marks were covered with bandages and maintained by wound care with application of silver sulfadiazine cream. Review of a progress note marked late entry effective 08/16/23 by Staff C, Registered Nurse (RN) evening Supervisor showed Resident in main dining room on first floor, summoned by one of the CNAs, resident had slipped [sic] soup on herself. Went to resident assessed resident. Resident left arm and left side of abdomen pink/red in color. Resident was cleaned up in dining room. Immediately resident was brought in resident's w/c [wheelchair] to room, washed areas with soap and water and changed into clean gown by CNA. Reported to primary nurse to monitor resident. Notified DON [Director of Nursing]. Notified [name of doctor], Primary Care Physician [PCP] and did not respond with any orders. 2200 checked on resident before end of shift - resident in bed resting quietly, site to abdomen and left arm remained pink/red. Resident stated feels better, no blisters at this time. Left OTA [Open to Air]. MD [Medical Doctor] notified by assigned nurse. Review of a progress note dated 08/16/23 at 22:30, Resident spilled soup while eating dinner. Abdomen with clear fluid filled blister, forearm with open area. MD and family notified. Skin prep applied to blister, forearm cleansed with NS (normal saline), TAO ([NAME] Antibiotic Ointment) and wrapped (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 12 of 18 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 09/29/2023 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 0689 with gauze. Therapy screen completed. Site is painful . Level of Harm - Immediate jeopardy to resident health or safety Review of an 8/17/23 the SBAR (Situation Background Assessment Recommendation) revealed resident received a burn to her left lower abdomen and left lower arm PCP responded with orders to cleanse with TAO and dressing applied. The SBAR dated 08/17/23, marked [late entry] signed by the ADON (Assistant Director of Nursing) showed, A Change in Condition (CIC) evaluation was conducted following a trauma incident. Resident received burn to resident's left lower abdomen and left arm. PCP was contacted with instructions to cleanse with NS TAO and dressing applied. Residents Affected - Few An IDT (Interdisciplinary Team) note dated 08/17/23 revealed, Resident alert and oriented, able to make complex needs known. Recent BIMS on 06/30/23 score of 13. Spoke with resident regarding accident with soup, resident states the following, Resident decided not to use available spoon and when picking up cup of soup by brim to bring it to face and consume, resident's nail was caught in cup and soup spilled .Abdomen assessed with clear fluid filled blisters observed without erythema to surrounding site, site measuring 18 x 8 cm (centimeters), left arm assessed with popped blisters, measuring 9 x 6.5 cm. MD notified by assigned nurse at the time of incident with NO (new orders) to cleanse with normal saline, TAO and dry dressing and skin prep to closed blister. MD in to see resident on this day and telehealth visit completed by wound doctor with new orders along with antibiotics. Therapy screen referral completed for dexterity assessment and ADL assessment related to eating. Hot liquid screen completed. Plan of care reviewed and updated. A physician's progress note dated 08/17/23 revealed, patient scalded herself on hot soup causing a second-degree burn patient was eating hot soup when it accidentally fell on her lap and scalded her thigh, Silvadene cream BID (twice daily) is ordered to affected areas x 14 days as well as wound care. A skin observation note dated 08/17/23, signed by the ADON, showed, Resident has new skin impairment. Resident received burn to her abdomen and left lower arm from hot liquid. Abdomen - left lower abdomen measurements 15 cm x 8 cm, left lower arm 9 cm x 6.5 am. An SBAR assessment was completed for new skin impairment. Treatment orders were obtained. Responsible party was notified. Review of Resident #1's Medication Administration Record (MAR) dated 08/01/23 to 08/31/23 revealed Resident #1 received new medications related to burn wounds as follows: Ascorbic Acid Tablet 500 milligram. Give 1 tablet by mouth one time a day for supplement to promote wound healing. Medication was administered from 08/18/23 to 08/21/23. Stat oral liquid - Protein. Give 45 ml (milliliters) by mouth two times a day for wound healing. Medication was administered from 08/18/23 to 08/21/23. Doxycycline Monohydrate 100 mg capsule. Give 1 tablet orally two times a day for wound burn for 14 days. Medication was administered from 08/18/23 to 08/21/23. Norco Oral Tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for pain. Medication was administered from 08/17/23 to 08/20/23 for complaint of left arm and abdomen burned areas. Review of Resident #1's Medication Administration Record (MAR) dated 09/01/23 to 09/30/23 revealed Resident #1 continued to receive new medications related to burn wounds as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 13 of 18 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 09/29/2023 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 0689 Doxycycline Hyclate oral tablet 100 mg. Give 1 tablet by mouth two times a day for cellulitis for 14 days. Level of Harm - Immediate jeopardy to resident health or safety Stat oral liquid - Amino acids Protein hydrolysate. Give 45 ml (milliliters) by mouth two times a day for wound healing for 30 days. Tramadol HCI tablet 50 mg. Give 1 tablet by mouth every 6 hours as needed for moderate and severe pain. Residents Affected - Few Norco Oral Tablet 5-325 mg. Give 1 tablet by mouth every 6 hours as needed for pain. Review of a care plan for Resident #1 showed a focus initiated on 08/17/23, [Resident #1] has 2nd degree burns on her left forearm, LLQ (left lower quadrant) of abdomen. The resident sustained these burns while attempting to pick up a cup of soup (with her unaffected hand) and bring it to her mouth. Interventions included to document weekly length x width x depth x odor, progress, or lack of progress. Provide protein and other nutritional supplements to promote wound healing as ordered. Provide wound care to affected areas as ordered. Report signs and symptoms of infection, failure to heal, abnormalities, maceration, etc. of burned area to MD. The care plan showed an ADL focus revised on 08/18/23, showing the resident had an ADL self-care performance deficit associated with limited mobility, CVA (Cerebral Vascular Accident) with the left sided hemiplegia. Interventions related to eating showed the resident was able to feed self after set up. The care plan showed a focus indicating Resident #1 was at risk for injury related to hot liquids due to poor trunk control initiated on 08/19/23. Interventions included to complete hot liquid evaluation as scheduled, fluids were served at proper temperature, occupational therapy to screen with decline in function, and ensure resident maintained upright position when served hot liquids. Review of skin/wound care notes for Resident #1 revealed: On 08/17/23 resident was seen. History of present illness (HPI), Location: Left forearm and left lower abdomen. Quality: Patient is able to advise if in pain, Severity: Moderate , Timing: When palpitated burn, Context: 2nd degree burn. Modifying factors: pain is relieved with medication. Associated Signs and Symptoms: Limited mobility; history MRSA (Methicillin-Resistant Staphylococcus Aureus) HPI Description: As per nursing staff this was an acquired burn from soup, patient has had a CVA which limits use of her abilities . Doxycycline for cellulitis associated with wound. Diagnosis included: Burn of second degree of abdominal wall, initial encounter and burn of second degree of left upper arm, initial encounter. Orders: Doxycycline 100 mg po BID x 14 days. Wound Care: Cleanse wound with normal saline and Xeroform dressing. Wound #3: Left forearm, Partial thickness 9.0 cm length x 6.5cm width 45.946 cm^2 area. Wound #4: Left abdomen, Partial thickness, 15 cm length x 8cm width 94.248 cm^2 area, erythema, peri wound tenderness. On 09/11/23 Resident #1 was seen for wound care. Wound #1 Partial thickness wound, wound bed has slough present 75% of wound bed covered in serous drainage, moderate no odor, No (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 14 of 18 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 09/29/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few tunnelling/undermining present. Well defined wound edges no signs of infection observed, wound is unchanged. Wound #2 Full thickness wound, wound bed has slough tissue 75% of wound bed covered with serosanguineous drainage, moderate amount of discharge well defined wound edges, no signs of infection. Wound is unchanged from previous. Left Abdomen: length 3.5cm/ width 12 cm / depth 0.1 cm Left forearm: length 8cm / width 2cm / depth 0.1cm. On 9/11/23 wound care was provided. Weeks of treatment: 3. Left arm: Partial thickness burn. Patient consented to debridement. Wound description: Full thickness without exposed support structures. Wound Margin: Distinct, outline attached. Under Assessments: Wound #3, pre-procedure diagnosis of wound #3 is a second-degree burn located on the left forearm. There was an excisional of skin/subcutaneous tissue debridement with a total of 12 square centimeters performed by the wound doctor. Blade material removed includes subcutaneous tissue after achieving pain control using Lidocaine. A minimum amount of bleeding was controlled with pressure. Round #4: pre procedure diagnosis of wound #4 is a second-degree burn located on the left abdomen, lower quadrant. There was an excisional skin/subcutaneous tissue debridement with a total of 24 square centimeters performed by the wound doctor. Blade material removed includes subcutaneous tissue after achieving pain control using Lidocaine. A minimum amount of bleeding was controlled with pressure. On 9/25/23 Resident #1 was seen for wound care. The wound assessment note showed, Resident #1 has wounds, MD notification 09/25/23, Family notification 09/25/2023, Followed by wound care. Resident denied pain, no new orders received care Resident aware of wound progress and orders, care plan reviewed and updated. Abdomen-Wound #1: Full-thickness wound, wound bed has slough present, 50% of wound covered . Epithelizing wound edges. There are signs of infection present. Wound shows signs of improvement. Left forearm: Wound#2: Partial thickness wound, wound bed have slough tissue present. 75% of wound bed covered .scant drainage, epithelializing wound edges. Wound shows improvement. Abdomen: 2.5cm L/ 10.0cm W/ 0.1cm D and Left Forearm: 4.5cm L/ 1.4 cm W/ 0.1 cm D. On 09/28/23 at 3:16 p.m., an interview was conducted with Staff G, CNA. He stated he was assigned to Resident #1 the day she was burned. He stated he was working in the dining room with the evening supervisor (Staff J, RN) and was assisting passing coffee and juice to the residents, but not the tomato soup. He stated the meal was already served and the residents were eating. He stated [Resident #1] did not ask him for soup. He said, I believe someone else passed the soup to her. In the middle of them eating, one of the resident's on the same table called me and said [Resident#1] had spilled something on herself. I went to the kitchen, asked for cold water and a towel, and wiped her up. I took her to her room to change her clothes. I did not notice any difference in her skin when I was wiping her at that time. There were blisters later in the evening. I did not know she was badly burned at that time. I told the nurse [Staff K, LPN] when I observed the blisters. She helped me change her. She saw her skin. It was pink/red. On 09/28/23 at 3:25 p.m., a telephone interview was conducted with Staff K, LPN (agency). She stated she remembered she was passing medications after dinner when a CNA (Staff G) stated (Resident #1) had spilled hot soup on herself and asked for help changing her. Staff K said, In that moment, I saw her arm. It was red. I called the supervisor [Staff J, RN] just to make her aware of the redness. l saw the redness in her left chest and stomach area. It did not look like a burn until I went in when the aide was changing her for bed. He [Staff G] came and got me because the areas were starting to blister. I notified the supervisor again and she called the MD and notified the DON. I did not think it would blister that quickly. Within 2 hours she was full of blisters on her left arm and stomach. Staff K stated the resident did not complain of pain at the moment. She stated the resident's skin was irritated. Staff K stated she wrote a progress note and received doctor's orders to treat the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 15 of 18 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 09/29/2023 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 0689 burned areas. Level of Harm - Immediate jeopardy to resident health or safety An interview was conducted with Staff D, LPN, Unit Manager on 09/28/23 at 10:05 a.m. She said, [Resident #1] was burned by a hot liquid. I was not here that day. She was burned on her abdomen and her arm. What we found out is her nail or something had put a hole in the cup, and it spilled on her and burned her. Her dressings get changed daily and every Monday she is seen by the wound care physician. I saw the wounds on Monday with the wound care physician and they are both getting better. Both of the wounds are superficial. The abdomen wound has sloughing and the skin around it is red. After she was burned, she had cellulitis around the wound and was on antibiotics for 10 days, but I think she has completed them. Staff D stated the antibiotics would help the wounds get better. She stated the wound on the arm did not have any slough and it was also improving. Residents Affected - Few On 09/28/23 at 09:15 a.m., an interview was conducted with Staff F, Certified Dietary Manager (CDM)/Kitchen Manager. She stated Resident #1 was burned with soup on 08/16/23. She stated the incident happened in the dining room. Staff F said, I don't know exactly who served the soup. The dish machine was not working, we used regular serving bowls for all the other residents and a disposable foam cup for [Resident #1]. The resident did not receive soup with her tray. She requested and received tomato soup after we were done serving. The resident was served hot tomato soup in an 8-ounce disposable foam cup because we were out of bowls. I did not know if she required special equipment. It was a last-minute request. I don't think we in the kitchen knew whom the soup was going to. Staff F stated the soup was requested outside of the tray line and was taken straight to the resident upon preparing it. She stated they conducted an investigation and determined the resident's dexterity was the problem, more than the beverage itself. She said, the problem was not the beverage which was served or the container in which it was served. It was the resident's dexterity. Staff F stated dexterity meant the resident's ability to use her hands. She stated Resident #1 had some limitations. She confirmed the resident was served hot soup in a disposable foam cup and consequently suffered burns. Staff F stated they should have considered lag time the time it takes from the moment food is scooped into a serving dish and when it is served to the resident. She stated that would have helped the soup to cool down. Review of a document titled, Food Temperature Chart, dated 08/16/23, showed soup was served for dinner. The log revealed acceptable temperature range for soup should be between 140-165 degrees Fahrenheit. The log confirmed at tray line the temperature of the soup was recorded at 180 degrees Fahrenheit. Review of a PubMed article titled, Hot Soup! Correlating the severity of liquid scald burns and biomedical properties, dated May 2016, revealed, While the temperature of the soup is obviously the most important fact in determining the degree of burn, we also find that more viscous fluids result in more severe burns, as the slower flowing thicker fluids remain in contact with the skin for longer. Furthermore, other factors can also increase the severity of burn such as a higher initial fluid temperature, a greater fluid thermal conductivity, or a higher thermal capacity of the fluid. Our combined experimental and numerical investigation finds that for average skin properties a very viscous fluid at 100°C, the fluid must be in contact with the skin for around 15-20s (seconds) to cause second degree burns, and more than 80s to cause a third- degree burns. Source: https://pubmed.ncbi.nlm.nih.gov/26796241/ On 09/28/23 at 12:08 p.m., an interview was conducted with the Director of Rehabilitation (DOR). She was observed assisting residents in the dining room during a meal. She stated Resident #1 used her right hand only. She stated the resident fed herself. She stated the resident had not been herself (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 16 of 18 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 09/29/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few since the burn incident and had shown decreased performance. She stated they had offered to assist the resident with her meal and moved her to the restorative table. She stated all residents required supervision for safety during meal and support for positioning as needed. On 09/28/23 at 2:18 p.m., an interview was conducted with Staff E, Activities/CNA. She stated she assisted residents with little things like getting water. She stated she was working in the dining room and was assisting with serving when Resident #1 burned herself with hot soup. She stated Resident #1 sat in the far-right corner of the dining room, probably 10 steps from the serving window. She stated the resident did not need assistance with feeding at the time, but she was now at the new restorative table, meaning her diet was downgraded and someone had to sit with her. Staff E stated the resident was served tomato soup because she had requested it. Staff E stated she went to the window and asked Staff A, the Cook, for the soup. She stated she heard Staff A say they were out of bowls. She stated she heard Staff F, CDM/ Kitchen Manager instruct Staff A to put the tomato soup in a coffee cup. Staff E stated she did not see how the soup was prepared. She confirmed she received the soup from Staff A in a disposable foam cup and handed it to Staff G, CNA who was assigned to the resident. Staff E stated she could not recall the soup being hot to touch. She stated she handed it to Staff G who brought it to the resident. Staff E stated she was at the front of the dining room when she heard Staff G stating he needed a towel because (Resident #1) had wasted the tomato soup. Staff E stated she grabbed a towel from the service counter and handed it to Staff G. Staff E stated at the time she did not realize Resident #1 had suffered significant burns. On 09/28/23 at 2:30 p.m., an interview was conducted with Staff H, Corporate Registered Dietician (RD). She said, the facility's policy is not specific to re-heating meals, however you would assist a resident if food needed to be re-heated. It should be heated to 165 degrees for 15 seconds. You check the temperature, and if it is above 180 degrees you wait for it to cool before you serve. She stated the facility staff failed to wait for the soup to cool down prior to serving it. She stated she would not recommend putting food in a microwave for 3 minutes and serving it without checking temperature. Staff H stated different microwaves heat at different levels so she would expect to stop and check after every 15 seconds. She stated there was no regulation on how hot is too hot. She stated she would expect staff to check the temperature every 15 seconds during the re-heating process. Staff H said, Everyone should use common sense. Staff H stated Resident #1 requested and received some soup which she picked up from the rim of the cup and she had put her finger through it. Staff H stated the resident spilled the soup on herself, causing the burns. She stated the resident had some blistering that appeared later from the soup burn. Staff H confirmed the blisters were caused by hot soup. She stated blistering occurred at temperatures above 125 degrees. On 09/28/23 at 2:40 p.m., a telephone interview was conducted with Staff I, Facility RD. She stated she was informed a resident had burned themselves with hot soup. She stated they immediately started in-services on hot liquids. Staff I stated she expected foods and liquids to be served at proper temperatures. She said, I heard the resident was having trouble holding the cup because she was served in a [disposable foam] cup. I don't know how she burned that quickly. She stated they had regular soup dishes, but the dish machine was down. Staff I stated the policy on re-heating any food was to heat it, bring it to temperature and then re-test the temperature. Staff I said, We should test the temperature after heating and before you bring it out to the resident. On 09/28/23 at 2:53 p.m., an interview was conducted with Staff J, RN/evening Supervisor. She stated she was working the day Resident #1 burned with soup. Staff J said, I was in the dining room during dinner and a CNA, I can't remember whom, said that [Resident #1] spilled soup on herself. That CNA cleaned her up with soap and water wiped her up and she was fine. Her skin was pink at that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 17 of 18 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 09/29/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Later, before the end of the shift, I checked on her. Her abdomen on the left side and her left arm were pink and red in color. You could tell the hot soup had scalded her skin but there were no blisters at the time. Staff J stated she forgot to document her observations. She stated she did not put in any skin assessments or progress notes. She stated she called the doctor and the DON. She said, There were no orders at that time. It was too busy that night I had other patients to take care of and I forgot to write something. Staff J stated she entered her notes a couple days later. Residents Affected - Few On 09/28/23 at 3:39 p.m., an interview was conducted with the DON. She stated she received a phone call from the evening supervisor (Staff J, RN) around 10:30 p.m. and was notified Resident #1 spilled hot soup on herself and she had no[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 18 of 18