Health inspection·December 14, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Review of a progress note by [provider], dated 12/11/23, showed the reason for visit due to staff reporting patient exhibiting increase irritability and agitation yelling out continuously for staff assist till assisted by staff. States per staff and resident interview and resident is unstable. Assessment is that behavior is related to underlying mood disorder causing daily distress to resident with plan to complete medication changes. Increasing Valproic acid to 250 mg (milligrams) PO TID (by mouth three times per day). Residents Affected - Some Interview conducted on 12/13/23 at 1:58 p.m. with Staff A, SW/AIT stated Resident #22 should have had a new PASARR completed when the new diagnosis of schizoaffective disorder, bipolar type was added on 7/9/2023 to see if it would have prompted for a Level II PASARR. 4. Review of Resident #15's admission Record showed the resident was admitted originally on 10/22/19 and readmitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, schizoaffective disorder, bipolar type, and major depressive disorder, recurrent, unspecified. Review of Resident #15's PASARR Level I, dated 10/17/19, revealed bipolar disorder as a qualifying mental health diagnosis, and that a PASARR Level II was not required. 5. Review of Resident #97's admission Record showed the resident was admitted originally on 03/02/22 and readmitted on [DATE] with diagnoses to include Down Syndrome unspecified, unspecified dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, major depressive disorder, recurrent moderate, and generalized anxiety disorder. Review of Resident #97's PASARR Level I, dated 10/21/19, revealed bipolar disorder as a qualifying mental health diagnosis, and that a PASARR Level II was not required. During an interview on 12/13/23 at 1:00 p.m., Staff A, SW/AIT said she had been trained on how to complete and update the PASARR forms. She stated the PASARRs should be resubmitted when there is a change in the diagnoses or if there is a sufficient change with a resident mental status to see if the resident qualifies for a Level II (PASARR). PASARRs for newly admitted residents are reviewed during morning meeting by the interdisciplinary team to ensure the accuracy of the PASARRs. She said she was not the actual director of Social Services so she can't explain how the director is notified when new diagnoses are added, or when a resident has a change in order to submit for a Level II change. She stated the way the system is in [provider name], once they put the information in the system it would automatically trigger for a Level II PASARR to be completed. Resident #15's and #97's PASARRs should have been updated and resubmitted for a Level II and both residents' PASARRs needed to be updated. 7. Review of the admission Record for Resident #100 showed the resident was admitted on [DATE] with diagnoses of muscle wasting and atrophy and mixed receptive expressive language disorder. Review of Resident #100's PASARR Level I Assessment, dated 08/11/22, revealed no qualifying mental health diagnosis and that a PASARR Level II was not required. Review of Resident #100's medical record revealed a new diagnosis of psychotic disorder with delusions due to known physiological condition documented on 03/06/23 and the resident was not assessed for PASARR Level II. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 2 of 16 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 12/14/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Section I Active Diagnoses of the Minimum Data Set (MDS), dated [DATE], revealed a diagnosis of psychotic disorder and the resident was not assessed for PASARR Level II. A review of the care plan, initiated 05/03/23, showed a Focus area to include Resident #100 received an antipsychotic medication as ordered to help alleviate symptoms associated with psychotic disorder with delusions due to known physiological condition. He had episodes of extreme anxiousness, his anxiety escalates suddenly, and he was hostile and physically threatening. Interventions included to approach him calmly and attempt redirection with any of his behavioral outbursts as able. On 12/13/23 at 1:58 p.m., Staff A, SW/AIT confirmed the PASARR Level I did not reflect Resident #100's current psychiatric diagnosis and a PASARR Level II was not completed. Review of facility policy titled, Resident Assessment - Coordination with PASARR Program, dated 09/07/2022, showed: Policy: This facility coordinates assessment with the preadmission screening and resident review ( PASARR) program under Medicaid to ensure that individual with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the Stat's Medicaid rules for screening. a. PASARR level I -initial pre-screening that is completed prior to admission. i. Negative Level I Screen -permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. Based on record review, and interviews the facility failed to ensure the accuracy and revision of Preadmission Screening and Resident Review (PASARR) for seven residents (#1, #22, #50, #72, #100, #15, and #97) out of 36 sampled residents. Findings included: 1. A review of Resident #1's admission Record showed the resident was admitted on [DATE] with diagnoses not limited to subsequent encounter (for) diffuse traumatic brain injury with loss of consciousness of unspecified duration, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified bipolar disorder, unspecified anxiety disorder, and other seizures. Review of Resident #1's PASARR Level I, dated 11/22/22, did not include the resident's qualifying mental health diagnosis of anxiety disorder or the intellectual disability related condition of traumatic brain injury, and showed no PASARR Level II was required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 3 of 16 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 12/14/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Review of the Quarterly Minimum Data Set (MDS) with a target date of 8/1/23, and a 5-Day scheduled MDS, with a target date of 9/18/23, revealed Resident #1's diagnoses of traumatic brain injury and anxiety disorder. Review of the resident's Annual MDS, with a target date of 10/28/23, did not include the resident's diagnoses of anxiety disorder, or depression (other than bipolar) and did reveal the diagnosis of traumatic brain injury. Residents Affected - Some Review of the medical record revealed Resident #1's PASARR Level I was not revised by the facility following admission to include the mental health illness of anxiety disorder or the related condition of traumatic brain injury. Review of the medical record revealed the resident was not assessed for a PASARR Level II. During an interview on 12/13/23 at 2:13 p.m. Staff A, Social Worker/Administrator-in-training (SW/AIT) stated she was able to redo PASARRs as she had been a social worker for a long time. Staff A reviewed Resident #1's PASARR and medical diagnoses and confirmed the PASARR should have been redone to capture the resident's diagnoses of anxiety and traumatic brain injury. 2. A review of Resident #50's admission Record and comprehensive assessments showed the resident was admitted on [DATE] with diagnoses not limited to schizophrenia and moderate major depressive disorder. Review of Resident #50's PASARR Level I, dated 5/3/18, did not include the resident's qualifying mental health diagnosis of depression. The resident's PASARR Level II Summary Report, dated 5/24/18, did not include the diagnosis of depression. Review of Resident #50's Annual Minimum Data Set (MDS) with a target date of 4/28/23, Change in Status Assessment with a target date of 6/8/23, and a Quarterly MDS with target date of 9/8/23, revealed a diagnosis of depression (other than bipolar). Review of the medical record revealed Resident #50's PASARR Level I was not revised to include the resident's diagnosis of depression nor was the resident's PASARR Level II re-evaluated. During an interview on 12/13/23 at 1:59 p.m., Staff A, SW/AIT reviewed Resident #50's PASARR and medical diagnoses and said the PASARR should have been redone so it could have captured the resident's diagnosis of major depressive disorder. 3. A review of Resident #72's admission Record showed the resident was admitted on [DATE] with diagnoses not limited to unspecified severity (of) unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified mood disorder due to known physiological condition, unspecified recurrent major depressive disorder, and unspecified anxiety disorder. Review of Resident #72's PASARR Level I, dated 3/9/22, did not reveal the resident's diagnoses of unspecified mood disorder due to known physiological condition and unspecified anxiety disorder and that no PASARR Level II was required. Review of Resident#72's Quarterly MDS, with a target date of 8/9/23, revealed the resident's diagnosis of anxiety disorder. Review of the Annual MDS, with a target date of 10/31/23, included the diagnosis of anxiety disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 4 of 16 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 12/14/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/13/23 at 2:09 p.m. Staff A, SW/AIT reviewed Resident #72's PASARR and medical diagnoses and stated the PASARR should have been revised to capture the resident's mood and anxiety disorders. Staff A stated she couldn't say if the resident needed a PASARR Level II. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 5 of 16 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 12/14/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observations, interviews, and record review the facility failed to ensure the care plan for one resident (#18) out of 36 sampled residents was reviewed and revised to accurately reflect the fluid intake of the resident. Findings included: A review of Resident #18's admission Record revealed an admission date of 6/1/23 and included diagnoses not limited to hypo-osmolality and hyponatremia (sodium levels in blood are abnormally low), other specified disease of biliary tract, unspecified neuromuscular dysfunction of bladder, and presence of urogenital implants. An observation conducted on 12/14/23 at 8:25 a.m. revealed Resident #18 lying in bed, with an approximate half full large-sized bottle of commercially-produced water and a facility-provided foam cup on the over-bed table next to the resident's bed. A review of Resident #18's active care plan, initiated on 6/1/23, showed a Focus for ADL (Activities of Daily Living) related to the resident's self-care performance deficit which included an intervention, dated 8/15/23, instructing staff of NO WATER CUP AT BEDSIDE (on a fluid restriction). The Focus revealed the resident was non-adherent with medication regime causing an alteration in functional abilities. Further review of the resident's care plan revealed a Focus, initiated on 7/23/23, indicating the resident had dehydration or potential fluid deficit r/t (related to) diuretic medication usage. The interventions of this Focus included: - Encourage the resident to drink fluids of choice, initiated on 7/23/23; - Ensure that (resident) has cold water whenever possible, initiated 7/23/23; and - Educate the resident/family/caregivers on importance of fluid intake, initiated 7/23/23. The review of Resident #18's current, as of 12/14/23, and discontinued physician orders did not reveal a current physician order revealing the resident's fluid restriction. A review of discontinued physician orders revealed an order, started on 8/18/23 and discontinued on 8/23/23, of the resident had been on a fluid restriction of 1500 milliliters (mL) per day. On 12/14/23 at 9:58 a.m. the Director of Nursing stated Resident #18 was not on fluid restrictions. She stated the resident was on hospice (services) so it was all about quality of life. An interview was conducted on 12/14/23 at 3:33 p.m. with Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM) and Staff C, Minimum Data Set Coordinator. Staff B, LPN/UM stated Resident #18 was not on fluid restrictions. Staff C stated a care plan was changed when there was a change (in condition) and quarterly. Staff B and C reviewed Resident #18's care plan and confirmed the active intervention showed the resident was on fluid restrictions. Staff C stated it (care plan) should have been revised and she missed it. Staff C reported being responsible for all care plans in the whole building. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 6 of 16 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 12/14/2023 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 0699 Provide care or services that was trauma informed and/or culturally competent. 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 interviews, the facility failed to ensure one resident (#17) of one sampled resident, who was diagnosed with Post Traumatic Stress Disorder (PTSD), was provided care and services to account for experiences and preferences, nor did staff address the resident's needs by minimizing triggers and/or re-traumatization. Resident #17's direct care staff were unaware of trauma behaviors, and were not aware of what to monitor for, with relation to PTSD behaviors. Residents Affected - Few Findings included: On 12/11/23 at 12:05 p.m., Resident #17 was observed in bed in her room. During an attempt to interview Resident #17, she was asked if staff were providing appropriate care to her. She yelled, No! She was then asked if she would like to explain, and she yelled I'm not telling you! A review of the admission Record showed Resident #17 was originally admitted to the facility on [DATE] with diagnoses to included bipolar disorder, current episode manic severe with psychotic features, major depressive disorder, anxiety disorder, and PTSD. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating cognitively intact. Section D Mood showed Resident #17 was feeling down, depressed, or hopeless for 2-6 days over the last two weeks. Section E Behavior indicated Resident #17 showed verbal behavioral symptoms directed toward others 1 to 3 days and rejection of care 1 to 3 days. Section I Active Diagnoses showed Resident #17 had diagnoses to include anxiety disorder, depression, bipolar disorder, and PTSD. Review of the Complete Evaluation dated 12/14/20 (upon admission) completed by the psychiatric nurse practitioner showed Resident #17 reported a history of bipolar disorder, PTSD, and anxiety. Reports that bipolar has been life long and anxiety and PTSD symptoms started after she served in the military. The last Social Services Trauma Screen dated 10/01/22 revealed the resident did not have a history of trauma and/or PTSD. A review of the Progress Notes revealed the following: A psychiatry follow up note dated 12/11/23 showed summaries of the past notes to reveal the following: on 04/11/23, the patient was anxious, on 05/15/23, the patient was anxious, on 05/18/23, the patient was depressed and anxious, on 07/31/23, the patient was depressed, on 08/10/23, the patient was depressed, on 08/24/23, the patient had insomnia, on 09/11/13, the patient was depressed, and on 10/12/23, the patient was depressed. A medication administration note dated 12/10/23 indicated the resident refused and smacked the writer's hand that was holding the medication. A dietary note dated 11/21/23 revealed Resident #17 utilized a melamine dinner plate because of her history of throwing her meal trays. An Interdisciplinary Team (IDT) Care Conference note dated 11/19/23 revealed Resident #17 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 7 of 16 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 12/14/2023 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 0699 behaviors of having delusions, anxiety, occasional yelling out and inappropriate language. Level of Harm - Minimal harm or potential for actual harm A psychiatry (psych) subsequent note dated 11/13/23 showed the resident was more alert and had mild symptoms of depression. Patient reports she was feeling a little anxious. Residents Affected - Few A psychiatry subsequent note dated 09/13/23 showed the resident was seen due to being unstable. Patient had been with increased confusion. The patient was non-compliant with medication and had periods of agitation. Nurse reported patient refused medications intermittently. Review of the progress notes dated from 11/01/2023 to present did not reveal any specific behaviors related to PTSD, nor did the notes or psych. services notes indicate any past PTSD behaviors. It could not be determined why Resident #17 had a diagnosis of PTSD. The only reference showing the resident had a history of PTSD was from the Complete Evaluation dated 12/14/20 (upon admission) completed by the psychiatric nurse practitioner. The behavior care plan initiated on 02/07/23 revealed a focus area to include the following: Resident #17 was at risk for impaired or inappropriate behaviors related to diagnoses of bipolar disorder with delusions, manic psychosis, paranoia, PTSD, and the discontinuation of psychotropic medications due to her refusals. She will throw her meal tray onto the floor, will not eat, kicks, hits, yells obscenities, and also refuses medications. She had delusional thoughts and relived past trauma events associated with diagnosis of PTSD, history of confabulation, and associates based events with current present time. Interventions included anticipate and meet her basic needs, apply topical antianxiety and anti-psychotic medications as ordered, and minimize potential for the resident's disruptive behaviors of kicking over meal trays by offering as needed antianxiety medications and reapproaching and offering meals after antianxiety medications given. The mood care plan initiated on 07/19/23 revealed a focus area to include the following: Potential for mood state issues related to delusions, bipolar with psychotic features, manic psychosis, and PTSD. Resident had tendency to relive past trauma and/or confabulates past events or overheard events as reality. Interventions included consultation with psychological/psychiatric per order, encourage and allow open expression of feelings, observe for effectiveness/side effects of medications as ordered, and reinforce appropriate expression of feelings. Per review of the PTSD care plans, it did not specify a reason or specific behavior related to trauma. The care plan did not specify what types of behaviors she would need to be monitored for, nor did it mention what type of behaviors that needed to be reported to the Physician with regards to past trauma. Training related to PTSD specifically for Resident #17 was requested and not provided. On 12/14/23 at 09:00 a.m., Staff F, Certified Nursing Assistant (CNA), stated she works with Resident #17 every Tuesday, Wednesday, and Thursday. The resident moved to another unit, but staff brought her back to the unit that she was in now so Staff F, CNA, could be her aide due to her being calmer. She had to be in a private room due to behaviors. She was screaming at the top of her lungs saying men were climbing in the window to rape her. She would sometimes say it was staff and other men. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 8 of 16 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 12/14/2023 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #17 had moments where she would scream at the top of her lung and when you go in the room, she would say that was not her screaming. The resident would turn the call light on and say she didn't turn it on when entering the room to see what she needed. Two staff members must always provide care to her due to her attacking staff and throwing herself on the floor. The resident likes to hit you from the back. She once snatched a housekeeper by her hair from the back. She now has cancer and was upset about that. She was also upset about her son not being able to see her in the facility. Something happened between them before she came here, stated Staff F, CNA. Resident #17 reported to her that she sees a shadow who was a tall male CNA in her room, and he was having sex with everyone on the unit. Staff F, CNA, reported she was aware that the resident had PTSD because the resident told her she had PTSD and it had something to do with the military. She was never told by staff that the resident had PTSD and they have never discussed any triggers with her. Staff have told her to report behaviors, but nothing related to her having PTSD. Staff F, CNA, reported she just usually lets the nurse know the resident was yelling. She revealed nobody had ever told her that Resident #17 had PTSD nor has anyone explained to her the reason for PTSD and how to look for behaviors related to any type of trauma. She also confirmed she had not been educated or in serviced with relation to PTSD behavior monitoring specifically for Resident #17. On 12/14/23 at 9:16 a.m., Staff G, Registered Nurse (RN), reported she had Resident #17 routinely. The resident was very isolated, down, and sad about the situation with her having cancer. Staff G, RN, reported Resident #17 had PTSD on her list of diagnoses, but she did not know why. She reported she was not aware of any triggers to look for related to PTSD. She monitors the resident for behaviors related to her medications. She also confirmed she had not been educated or in serviced with relation to PTSD behavior monitoring specifically for Resident #17. On 12/14/23 at 9:57 a.m., an interview was conducted with Staff A, Social Worker, Administrator in Training, and the Administrator. Staff A, Social Worker, Administrator in Training, stated she assisted the social services director with completing assessments. For residents with PTSD, they would complete the trauma informed screening to get more history on the diagnosis. The Administrator stated they would ask psych to see the resident to see if the resident needed any assistance related to the trauma. PTSD would be placed on the care plan specifically related to the incident. The Administrator confirmed Resident #17 had PTSD as it was listed on her face sheet. She reported the care plan stated the resident relives events associated with PTSD. At 10:05 a.m., the Administrator stated she would review the psych notes to see why the resident had PTSD. She reported the resident had tons of psych notes. A trauma informed screening was completed related to the hurricane evacuation. The trauma informed screen from October did not show anything related to PTSD and the old trauma informed screening was retired. The Administrator stated she found a psych note that indicated the resident reported PTSD started after she served in the military. She stated she expected psych to do a deeper dive to see what happened in the military with the resident. She stated, It doesn't appear that a deeper dive was conducted. The Administrator stated the provider did not do a deeper dive to provide staff with additional education on the PTSD diagnosis. She stated psych seen all residents last year in October and if something would have triggered on the trauma informed screening, she expects psych to follow up. On 12/14/23 at 10:48 a.m., the Director of Nursing (DON) reported a trauma informed screening should be completed for residents with PTSD. You must find out if the resident was comfortable talking about the trauma to find out the triggers. The care plan should be very individualized, and it should be listed on the care plan for the sake of communication and on the [NAME]. If the patient had triggers, they should be on the care plan. There needs to be a conversation. Psych must be involved and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 9 of 16 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 12/14/2023 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 0699 Level of Harm - Minimal harm or potential for actual harm the interprofessional team. Let's dig into it and find out what happened and what are the triggers to avoid re-traumatization stated the DON. The care plan was very individualized, and you need to see what's the root cause to avoid causing any problems for other people. Best practice was to educate the staff, specifically to the resident. Residents Affected - Few The policy provided by the facility, Trauma Informed Care implemented on 09/07/22 revealed the following: Policy: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. 4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals to develop and implement individualized care plan interventions. 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 10 of 16 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 12/14/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to administer antibiotics for the duration as prescribed by the provider for one resident (#72) out of five residents sampled for unnecessary medications. Residents Affected - Few Findings included: Review of Resident #72's admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to unspecified obstructive and reflux uropathy and unspecified protein-calorie malnutrition. On 12/11/23 at 10:01 a.m., Resident #72's door held an isolation caddy and was posted with a sign showing Contact Precautions, the resident and roommate was not observed in the room. An interview was conducted with Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM), on 12/11/23 at 10:07 a.m. The staff member stated Resident #72 was on contact precautions due to extended spectrum beta-lactamase (ESBL) in the urine. The staff member reported not knowing where the resident was. The staff member stated, on 12/11/23 at 10:08 a.m., the resident was downstairs in the Dining Room drinking hot chocolate. On 12/14/23 at 8:22 a.m., Resident #72 was observed lying bed, the door to the room was posted for Contact precautions. Review of Resident #72's December 2023 Medication Administration Record (MAR) revealed on 12/3/23 at 5:00 p.m. the facility received an order for the antibiotic, Ciprofloxacin 500 milligram (mg) to be administered two times a day for Urinary Tract Infection (UTI) for 7 days. The MAR showed the order was administered at 5:00 p.m. on 12/3/23, held at 9:00 a.m. on 12/4/23, and was discontinued at 1:18 p.m. on 12/4/23. A continued review of Resident #72's December MAR showed the resident was to be on contact isolation for ESBL in urine from 12/5 to 12/12/23. The MAR revealed an order for Ertapenem Sodium injection solution reconstituted 1 gram (GM) - inject 1 gram intramuscularly every 24 hours for UTI for 7 days, started on 12/5/23. The MAR showed the 12/5/23 dose of the antibiotic was not administered and was administered on 12/6, 12/7, 12/8, 12/9, 12/10, and 12/11/23, revealing Resident #72 received 6 out of the 7 ordered doses of the antibiotic. During an interview on 12/14/23 at 2:24 p.m., the Director of Nursing (DON) confirmed Resident #72 had been on an antibiotic for ESBL in urine, it's concluded. The DON reviewed Resident #72's December MAR and confirmed the resident had not received the antibiotic for the ordered 7 days. She stated the resident had been started on Cipro but that doesn't count. During an interview on 12/14/23 at 11:03 a.m., an request was made to the Director of Nursing to provide the policy for Medication Administration, it was not received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 11 of 16 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 (X3) DATE SURVEY COMPLETED A. Building 12/14/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty-three medication administration opportunities were observed and seven errors were identified for three residents (#30, #77, and #64) of five residents observed. These errors constituted a 21.21% medication error rate. Residents Affected - Few Findings included: 1. On 12/13/23 at 8:17 a.m., an observation of medication administration with Staff D, Licensed Practical Nurse (LPN) was conducted with Resident #30. Staff D dispensed the following medications: - Albuterol Sulfate 90 microgram (mcg) handheld inhaler - Budesonide Formoterol 80/4.5 handheld inhaler - Vitamin C 500 milligram (mg) over-the-counter (otc) tablet - Hydrocortisone 20 mg tablet - Lisinopril 10 mg tablet - Risperidone 0.5 mg - 2 tablets - Potassium Chloride 10 milliequivalent (meq) Extended Release (ER) tablet. Staff D poured approximately 120 milliliters (mL) of nutritional supplement in a plastic cup and confirmed dispensing 2 (handheld) inhalers and 6 oral tablets. The staff member administered one puff of the Albuterol inhaler, then offered the nutritional supplement to the resident, who accepted a sip of it. Staff D administered the oral medications, offering the resident a sip of the nutritional supplement, and administered one inhalation of Budesonide, again offering the resident a sip of the supplement. An unknown aide moved the resident from the hallway into the resident room and the staff member entered the resident's bathroom, dispensing of the nutritional supplement (as evidence of returning to hall without cup) and washing hands before returning to the medication cart. Review of Resident #30's Medication Administration Record (MAR) showed the following physician orders and documentation: - Ascorbic Acid 500 mg tablet - Give 2 tablet by mouth one time a day for Vitamin supplement. Staff D documented this order had been administered despite only one tablet having been dispensed and confirmed. - Potassium Chloride Oral Solution - Give 10 meq by mouth one time a day for vitamin supplement. Staff D administered one tablet of Potassium stating the liquid Potassium was on order must be a new order. Staff D documented 10 meq of Potassium Oral Solution had been administered. - Albuterol Sulfate HFA 108 (90 base) microgram (mcg/act) aerosol solution - Give 2 puffs by mouth four times a day for shortness of breathing (sob), wheezing. Staff D documented this order had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 12 of 16 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 12/14/2023 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 0759 administered despite the observation of one puff had been administered. Level of Harm - Minimal harm or potential for actual harm - Symbicort Inhalation Aerosol 80-4.5 mcg/act (Budesonide Formoterol Fumarate Dihydrate) - 2 puffs inhale orally two times a day for wheezing. Rinse mouth after use. The observation showed one puff was administered and Resident #30 was given and swallowed nutritional supplement after the administration. Residents Affected - Few - Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 250-50 mcg/act (Fluticasone-Salmeterol),- 1 puff inhale orally two times a day for wheezing/shortness of breath (sob), rinse mouth after use. Staff D documented the administration of this inhaler. The observation and confirmation by Staff D of 2 inhalers had been dispensed showed this inhaler had not been administered. The Medication Admin Audit Report, dated 12/14/23, revealed Staff D had documented this medication had been administered at 8:26 a.m. on 12/13/23 along with the other observed medications. The website, Medlineplus.gov, (https://medlineplus.gov/druginfo/meds/a623022.html) educated users of Symbicort (Budesonide-Formoterol Fumarate Dihydrate) After inhalation, rinse your mouth with water and spit the water out; do not swallow the water. The observation of administration to Resident #30 did not reveal Staff D had offered water to the resident. 2. On 12/13/23 at 8:44 a.m., an observation of medication administration with Staff E, Registered Nurse (RN) was conducted with Resident #77. Staff E dispensed the following medications: - Aspirin 81 mg chewable over-the-counter (otc) tablet - Vitamin B12 1000 microgram (mcg) otc tablet - Cranberry 425 mg otc tablet - Docusate sodium 100 mg otc geltab - Vitamin D3 5000 international unit (iu) (125 mcg) otc tablet - Calcium + D3 600 mg/10 mcg otc tablet - Simethicone 80 mg chewable otc tablet - Xifaxan 550 mg tablet - Gabapentin 600 mg tablet - Cyclobenzaprine 10 mg tablet - Oxycodone 10 mg tablet. Staff E informed Resident #77 of the unavailability of the scheduled Lactulose and Advair. The staff member reported and documented the physician would be/had been notified of the unadministered medications. During the observed administration Resident #77 refused the tablet of Simethicone. Review of Resident #77's December Medication Administration Record (MAR) showed an order for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 13 of 16 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 12/14/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Cranberry Oral Tablet 450 mg - Give 1 tablet by mouth one time a day for urinary health maintenance. Staff E had documented 450 mg's of Cranberry had been administered despite the observed administration of a 425 mg tablet of Cranberry. 3. On 12/13/23 at 11:35 a.m., an observation of medication administration with Staff E, RN was conducted with Resident #64. The staff member obtained a blood glucose level of 315 from the resident. The staff member removed a Novolog Flexpen prescribed to the resident, dialed the insulin pen to 8 units (per sliding scale), applied a needle to the pen, and injected into the resident's upper left arm. The observation revealed Staff E had not primed the Novolog insulin pen prior to injection. Immediately following the observation, on 12/13/23 at 11:45 a.m., Staff E reported never heard of priming the insulin pen or giving an airshot. The staff member demonstrated the process used and reported turning the pen with needle facing floor so the air pocket rose to the top then moves it into position to inject. The manufacturer instructions for the use of a Novolog Flexpen, located at https://www.novologpro.com/administration-options/insulin-pens.html, revealed Giving the airshot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing. The instructions read: - E. Turn the dose selector to select 2 units; - F. Hold your Novolog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. - G. Keep the NovoLog® FlexPen® needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the NovoLog® FlexPen® and contact Novo Nordisk at [PHONE NUMBER]. A small air bubble may remain at the needle tip, but it will not be injected. During an interview on 12/14/23 at 10:58 a.m., the Director of Nursing (DON) stated the expectation was for staff to administer medications per the 5 rights: right time, right dose, right route, right patient, and right medication. A review of the observed errors was disclosed to the DON. During the interview on 12/14/23 at 11:03 a.m., the DON confirmed the Novolog (insulin) pen was supposed to be primed prior to use and staff were just educated on the priming of insulin pens due to having to order needles from pharmacy so staff were told to remember to prime the pens. She stated Staff E's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 14 of 16 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 12/14/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm statement of being unaware to prime the pen was not true. The DON stated she agreed with findings related to Resident #30, #77, and 64. A request was made to the DON for the facility's Medication Administration policy and an insulin pen procedure which was not received. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 15 of 16 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 12/14/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm 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 review of the facility's policy, the facility failed to ensure opened food was labeled and dated in one of one kitchen. Residents Affected - Some Findings included: On 12/11/23 at 9:30 a.m., an initial tour of the kitchen was conducted with the Assistant Dietary Manager. The following was observed in the reach in cooler: opened sliced cheese wrapped in saran wrap with no date, opened ham wrapped in saran wrap with no date, an opened bag of diced chicken with no date, and an opened bag of shredded cheese with no date. In addition, a container of liquid substance with no label or date was observed underneath the food preparation table. (Photographic Evidence Obtained) The Assistant Dietary Manager stated he wasn't sure what was in the container while smelling it. Additionally, an opened bag of biscuits with no date was observed in the walk-in freezer. All findings were confirmed by the Assistant Certified Dietary Manager during the tour. The policy provided by the facility and titled, Date Marketing for Food Safety, undated, revealed the following: Policy The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Policy Explanation and Compliance Guidelines for Staffing: 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105422 If continuation sheet Page 16 of 16