Inspection·July 8, 2022

F 0645 Level of Harm - Minimal harm or potential for actual harm A facility policy titled Pre-admission Screening and Resident Review (PASRR,) dated 8/1/18, was reviewed. The policy stated PASRR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Guideline: Residents Affected - Few 2. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation result in determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care. 4. If an individual who enters a nursing facility as an exempted hospital discharge is later found to require more than 30 days of care, the State mental health or mental retardation authority must conduct an annual review within 40 calendar days of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105451 If continuation sheet Page 2 of 13 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 105451 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Health Center by Harborview 900 Beckett Way Tarpon Springs, FL 34689 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure one (Resident #99) of 32 residents reviewed, received treatment and care in accordance with professional standards of practice related to a change in condition, assessment, and following physician orders. Residents Affected - Few Findings included: An observation of Resident #99 was made on 7/6/22 at 2:44 p.m. The resident was lying in bed with her eyes closed. She had steri-strips on her left hand and a scabbed over wound on the right side of her nose. A review of admission records indicated Resident #99 was admitted on [DATE] with diagnoses including type II DM, unspecified dementia with behavioral disturbance, psychotic disorder with hallucinations due to known physiological condition, and anxiety. A review of Resident #99's orders indicated an order dated 3/5/22 for head-to-toe skin checks weekly with special instructions to complete non-pressure observations or wound management form if appropriate. A review of Resident #99's Minimum Data Set (MDS) dated [DATE] was conducted. Section C, Cognitive Patterns, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3, meaning she had severe cognitive impairment. Section F, Functional Status, indicated the resident needed a two+ person physical assist for transferring, bed mobility, and personal hygiene. Section F also indicated walking did not occur during the seven day assessment period. A review of Resident #99's electronic medical record did not show any skin checks being completed since 4/11/22. The medical record also did not note any accidents occurring recently or any wound/treatment orders for the resident's left hand. An interview was conducted with Staff H, Licensed Practical Nurse (LPN) on 7/8/22 at 9:57 a.m. Staff H stated the scabbed area on the right side of the resident's nose was from a cancerous spot that was removed. She stated she was unaware the resident had steri-strips on her hand. Staff H was observed entering the resident's room, uncovering the resident's arm, and assessing the steri-strips. She stated she did not know what happened. Staff H, LPN proceeded to go to the computer to review Resident #99's medical records. She indicated she did not see any information in the computer about the steri-strips or an accident. An interview was conducted with the Director of Nursing (DON) on 7/8/22 at 10:06 a.m. She stated she was not aware of the steri-strips on Resident #99's hand. She stated she didn't know they were there until Staff H called her a few minutes prior. The DON reviewed Resident #99's electronic medical record and stated, I don't see anything in here. The DON confirmed the scabbed wound on the resident's nose was due to a previous cancer removal. An interview was conducted with Staff D, LPN, Unit Manager (UM) on 7/8/22 at 10:24 a.m. Staff D stated she had no idea what happened to Resident #99, nothing had been reported to her. Staff D stated the accident should have been documented and reported to her. She stated even if she was not there at the time, she should have seen it in her morning report. She also stated the doctor should have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105451 If continuation sheet Page 3 of 13 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 105451 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Health Center by Harborview 900 Beckett Way Tarpon Springs, FL 34689 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 0684 been notified to receive treatment orders. Level of Harm - Minimal harm or potential for actual harm An additional interview was conducted with the DON on 7/8/22 at 12:20 p.m. The DON stated after speaking to a few staff members, she feels the injury to Resident #99's left hand could have occurred by hitting her hand when she was being transferred between the bed and her chair. The DON stated she did not know which staff member applied steri-strips to the resident. She stated the nurse should have assessed the resident and called the doctor for treatment orders. She confirmed steri-strips should not have been applied until orders from the doctor were obtained for cleaning and/or treatment. She also stated an additional order should have been entered for monitoring for signs and symptoms of infection. The DON stated an event should have been entered to capture the who, what, when and where of what happened and what orders were received from the doctor. She stated she had no idea if the wound was cleaned or treated properly. She stated she did assess the area herself today, and did not see any current signs and symptoms of infection. Residents Affected - Few Staff D, LPN, UM entered a progress note on 7/8/22 at 1:04 p.m. The note stated the resident had a skin tear on her left hand. The doctor was notified, and orders were received to cleanse daily and keep steri-strips on until they fell off. Staff should monitor every shift. On 7/8/22 at 2:06 p.m., the DON indicated the resident's last skin check was completed in April. She confirmed there was a current order for weekly skin checks and those had not been completed as ordered. The Nursing Home Administrator (NHA) stated for some reason the order did not cross over to the treatment administration record. He stated Certified Nursing Assistants (CNA) look at the resident's skin when they were showering them and filled out a sheet for the nurses to review. He confirmed nurses should be completing a full skin assessment weekly according to the doctor's order. A facility policy titled Skin Integrity Policy, dated 6/9/22, was reviewed. The policy stated the facility will ensure that based on the comprehensive assessment of a resident: 1. A resident received care, consistent with professional standards of practice, to prevent avoidable skin integrity issues and does not develop avoidable skin integrity issues unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing. Procedures: 4. The licensed nurse shall initiate applicable Skin Integrity documentation if a new area of impairment is identified. A facility policy titled Change of Condition, dated 11/6/19, was reviewed. The policy stated the facility will evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay evaluation information to physician and to document actions to include but not limited to the following: -Accident which results in injury and/or has the potential for requiring physician intervention. A job description for registered nurse and licensed practical nurse was provided by the NHA. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105451 If continuation sheet Page 4 of 13 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 105451 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Health Center by Harborview 900 Beckett Way Tarpon Springs, FL 34689 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 0684 job description included: Level of Harm - Minimal harm or potential for actual harm -Complete accident/incident reports, as necessary Residents Affected - Few -Transcribe physician's orders to resident charts, cardex, medication cards, and treatment/care plans, as required. -Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care. -Notify the resident's attending physician when the resident is involved in an accident or incident. -Notify the resident's attending physician and responsible party when there is a change in the resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105451 If continuation sheet Page 5 of 13 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 105451 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Health Center by Harborview 900 Beckett Way Tarpon Springs, FL 34689 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 0692 Provide enough food/fluids to maintain a resident's health. 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 #97) of four residents reviewed for nutrition services was monitored for weight change and intake at meals. Resident #97 was noted to have lost 37 lbs., a 14% weight loss, over a two-month period, even though he was not on a physician ordered weight loss program. Residents Affected - Few Findings included: A review of Resident #97's electronic medical record revealed the resident weighed 256 pounds (lbs.) on 4/4/2022 and 219 lbs. on 6/9/22. This was a weight loss of 37 lbs., calculated to be a 14.45% weight loss in 2 months, which the facility's policy identified as severe. According to the facility's policy titled Weighting and Measuring Height Policy Resident, dated 3/22/22, a loss of 7.5% or greater is described as a severe weight loss. A review of admission records indicated Resident #97 was admitted on [DATE] with diagnoses including adult failure to thrive, acute kidney failure, hyperosmolality and hypernatremia, dysphagia, hypokalemia, and gastro-esophageal reflux disease (GERD) without esophagitis. A review of orders indicated a diet order, dated 6/28/22, for regular, nectar thickened liquids, dysphagia (dys) puree diet. Food served in bowls, no salt packet, no straws, frozen treat with lunch and dinner, and 1200 milliliter (ml) fluid restrictions as well as an order for meal and fluid consumption tracking for breakfast, lunch and dinner. A review of Resident #97's vital sign log indicated the resident weighed 258.6 lbs. upon admission [DATE]) with a body mass index (BMI) of 40.5. On 4/4/22 the resident weighed 256 lbs. with a BMI of 40.09. There was no weight recorded in May. On 6/7/22 the resident weighed 219 lbs. The resident was reweighed on 6/9/22 with a confirmed weight of 219 lbs. with a BMI of 34.3. There had been no weights recorded since 6/9/22. A review of the resident's meal consumption logs from the previous 10 days (6/27/22 to 7/6/22) was completed. The log indicated the resident had eaten less than 50% of eight of ten breakfast meals, less than 50% of the last nine lunches, and 51% - 75% of dinner on one of ten meals reviewed. No dinner intake was documented for nine of the ten meals reviewed. Resident #97's Minimum Data Set (MDS) admission assessment, dated 3/14/22, was reviewed. Section K, Swallowing/Nutritional Status, indicated the resident had coughing or choking during meals or when swallowing medications and had complaints of difficulty or pain with swallowing. Section K stated the resident was 67 inches in height with a weight of 255 lbs. and he had no weight gain or loss in the last month of 5% or more or 10% or more in the last six months. The quarterly MDS, dated [DATE], was also reviewed. Section C, Cognition, indicated Resident #97 had a brief interview for mental status (BIMS) score of 7, indicating severely impaired cognition. Section K, Swallowing/Nutritional Status, indicated the resident had coughing or choking during meals or when swallowing medications. It stated the resident was 67 in height with a weight of 219 lbs. Section K also stated there had been no weight loss or gain of 5% or more in the last month or 10% or more in the last six months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105451 If continuation sheet Page 6 of 13 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 105451 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Health Center by Harborview 900 Beckett Way Tarpon Springs, FL 34689 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 0692 A review of medication orders since admission was conducted. Resident #97 was taking Bumetanide, a diuretic on and off since admission, as well as receiving IV fluids. His orders included: Level of Harm - Minimal harm or potential for actual harm 2.0 Cal supplement 120 cc with meals from 3/18/22 to 4/6/22 Residents Affected - Few Bumetanide 1 mg twice a day for edema from 3/29/22 to 6/10/22 and from 6/15/22 to 6/24/22. Bumetanide 1 mg once a day for edema from 6/24/22 to 6/28/22 D 5% and 0.9% sodium chloride 1 Liter Intravenous (IV) at 75 ml/hour(hr.) x 1. 5/31/22 one time at 1730 and one time at 2200 Sodium Chloride 0.45% parenteral solution 50 ml/hr. IV 100 ml/hr. now then discharge. Stat labs after IV therapy. 6/9/22 5% dextrose injection 100 ml/hr. IV x 1 hour until new orders. 6/21/22 Lactated Ringers parenteral solution 1 Liter IV at 100 ml/hr. one time. 6/30/22 Dextrose 5% in water (D5W) parenteral solution 100 ml/hr. IV. Start 7/1/22 and continue through 7/4/22 A review of physician progress notes revealed Resident #97 was sent to the hospital on 6/17/22 with hypernatremia. He was treated and returned. He was also sent the hospital on 7/1/22 for penile bleeding. He returned to the facility on an antibiotic, Keflex, for a UTI. A review of Speech Therapy notes indicated Resident #97 was receiving therapy from 3/8/22 to 3/28/22, from 5/23/22 to 6/10/22 and again from 6/16/22 to 6/29/22. The therapy was all geared toward swallowing function. The Discharge summary dated [DATE] noted: CNAs required consistent education and training with decreased follow through with recommended swallowing guidelines. Max encouragement and redirection throughout P.O. (oral intake) Patient overwhelms easily and increased anxiety with visual of P.O and required one food item and drink item presented at a time. A speech therapy encounter note, dated 6/29/22, stated Speech Language Pathologist (SLP) re-educated patient and staff on swallowing guidelines; positioning, recommended diet and liquids, compensatory strategies, signs/symptoms of aspiration, and precautions. Patient and staff verbalized understanding and agreement. Patient has cognitive-communicative barriers to comprehension and recall. Nectar liquids tolerated status post upgrade on 6/28/22 with no signs/symptoms of aspiration 100% of trials. Treatment modifications to overcome barriers: collaborate with nursing, discussion with interdisciplinary team, eliminate distractions, implement multi-modality grading and cueing, quiet location for treatment and use low stimulation environment for treatment. A review of the nutrition assessments and notes did not reveal that the RD followed through with any of the SLP's recommendations, such as smaller, more frequent presentations of his meal components as snacks. The SLP who worked with the resident was unavailable for interview. The resident had swallow studies completed on 5/26/22 and 6/29/22 with the following results: An x-ray of the esophagus on 06/29/2022 for dysphagia, oropharyngeal phase indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105451 If continuation sheet Page 7 of 13 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 105451 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Health Center by Harborview 900 Beckett Way Tarpon Springs, FL 34689 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gastroesophageal reflux was present. A video swallow test was conducted on 05/26/2022 which showed no cough or other evidence of aspiration or penetration (into the lungs). An observation was made of Resident #97 on 7/5/22 at 8:07 p.m. A bag of D5W IV solution was noted hanging next to the bed, not currently running. Resident was sleeping covered up. A midline on his right arm was visible. A second observation was made on 7/7/22 at 9:44 a.m. The resident was in bed with the head of the bed elevated, watching TV. Resident had a midline in his right arm. His body was completely covered with the exemption of his head and arms. Attempts were made to speak with the resident, but he only grunted. An interview with the Director of Nursing (DON) was conducted on 7/7/22 at 11:56 a.m. The DON reviewed the resident's electronic medical record and stated the only note from the Registered Dietician (RD) was a diet clarification on 6/9/22. She stated the RD reviews each resident upon admission and would send recommendations for the resident's weight loss, weight gain, food preferences, or diet changes. The DON reviewed the dietician recommendations book and found two recommendations from the RD regarding Resident #97. The first recommendation was from 6/9/22, a change in diet from hospital diet of 2 gm Na+ to No salt packet continue dys (dysphagia) pureed, NTL, food in bowls, no straws was recommended. The second was dated 6/17/22. This recommendation was again to discharge the 2 gm Na+ diet. Pureed, No salt pack, HTL, food in bowls, frozen treat lunch and dinner. The DON confirmed the RD is not actively following this resident. An interview was conducted with the Registered Dietician on 7/7/22 at 12:08 p.m. She stated she did an initial assessment when Resident #97 was admitted to the facility. The RD stated she was not currently following the resident for weights. She stated residents have weekly weights for 4 weeks then go to monthly weights unless they need to continue with weekly. She said she did not know why the resident was not weighed in May and she could not explain why the resident did not trigger for her to track him for weight loss. She stated, the way the reports come in, it may not have tracked. The RD reviewed the Nutrition Evaluation completed at Resident #97's admission. She stated in her initial plan she wanted the resident to have a gradual weight loss to ideal body weight of 193 pounds, but she typically did not want them to lose weight initially until they were done with their initial problem (what they were admitted for ). She stated she would not recommend losing weight from the get-go and that was why she did not have a weight loss plan in place to track him. She stated 14.45% weight loss in two months would not be considered gradual weight loss, but there could be some allowance in that. She stated she would have been following him for weights if it would have triggered on her report. She confirmed she did review the percent of breakfast, lunch and dinner consumed. She stated it was a team effort and she would expect the team to communicate to her something was happening so she could put him back on weekly weights. The RD stated she initially had him on a supplement, Med Pass, due to his intake not meeting his current needs. She stated the Med Pass was later discontinued. She also stated she did not know why the resident was on IV fluids and fluid restrictions. A request was made for the staff to get a current weight on Resident #97. The RD provided a requested copy of the Nutrition Evaluation completed upon admission. The evaluation was dated 3/15/22 with a completion date of 7/7/22. The evaluation stated the resident showed poor intake related to complaint of pain/discomfort swallowing, even with pureed foods. It stated he had a history of Adult Failure to Thrive, and a GI consult was scheduled. The initial plan of care was listed as the following: Obese resident (BMI>30) shows chewing, swallowing, and self-feeding issues, altered labs, with inadequate oral intake and risk of malnutrition indicated per MNA (Mini Nutritional Assessment) score. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105451 If continuation sheet Page 8 of 13 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 105451 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Health Center by Harborview 900 Beckett Way Tarpon Springs, FL 34689 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Goal: Resident will safely consume adequate nutrition/hydration, without excess, as evidenced by resolution of infection with no s/s of dehydration, choking, aspiration or further complaints of discomfort or pain while swallowing; improved labs; with grad weight loss advised closer to adjusted ideal body weight of </= 193# once medically stable. Plan: Monitor and document intake of food and fluids, offering assistance as needed and offering alternative at meals as needed Monitor weights per facility protocol (weekly x 4 weeks upon admission then monthly when stable), referring to MD/RD for further intervention as indicated. An interview was conducted with the Nursing Home Administrator (NHA) on 7/7/22 at 1:15 p.m. He stated he would have expected the RD to have a plan for weight loss in place to achieve the goal she put in place at admission. He stated he would also expect the RD to be following Resident #97 due to his weight loss and other health concerns. He stated the amount of weight loss the resident had should have triggered for her and she should have been following. The NHA stated it is the job of the RD to ensure those things happen. An interview was conducted with the DON on 7/7/22 at 1:50 p.m. The DON stated the RD should have had an initial weight loss plan related to her goal, if the plan was for him to lose weight. She stated she would have expected the RD to have been aware of the Resident's weight loss and be following him. At 1:17 p.m. on 7/7/22 a current weight for Resident #97 was entered into the electronic medical record. The resident's current weight was 181 lbs. with a BMI of 28.35. This calculated to be a -17.35% weight loss from 6/9/22 to 7/7/22 and a -29.3% weight loss from 4/4/22 to 7/7/22. An interview was conducted with Staff E, Certified Nursing Assistant (CNA) on 7/7/22 at 1:46 p.m. Staff E stated she assisted Resident #97 with eating his lunch. She stated she must feed him, and he ate about 30% of his meal. She stated he did not eat much and would begin to cough/choke. She stated when he began to cough/choke, they (CNAs) took the tray out and end the meal. An interview was conducted on 7/12/22 at 1:17 p.m. with the facility medical director. She stated she was unaware Resident #97 had such a large weight loss. She confirmed diuresis alone would not cause the resident to lose 29.3% of his body weight in 3 months. She stated sometimes weight loss could be higher if food intake was not great or a different method of weighing was used, but either way she would expect the registered dietician to be following the resident. The doctor stated if the resident had been on a weight loss plan for obesity, a gradual weight loss would be 1-2 lbs. a week or approximately 8 lbs. a month. She said going from 219 lbs. to 181 lbs. in a month is not gradual. It is definitely too quick. She said based on his medical issues and initial nutrition evaluation (upon admission), she would have expected the RD to be following the resident and for his weights to be tracked. The doctor stated when the resident was being fed and began coughing/choking the meal should not be taken away and ended. She said that absolutely shouldn't happen. She stated the resident should be given a break and then attempt to eat more food. She stated if the problem continued the team needed to know so they could work on different methods or different diets/meals. The doctor stated she did try to speak with the resident last month about how he was eating, but he did not want to talk about it. She stated she did often base things on how the resident felt and appeared versus just numbers. She stated she did not feel like he had been negatively affected by the weight loss, but now that she was aware of how severe the loss was, she was going to do a malignancy work up to ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105451 If continuation sheet Page 9 of 13 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 105451 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Health Center by Harborview 900 Beckett Way Tarpon Springs, FL 34689 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nothing else was causing the weight loss. The medical director said she would expect Resident #97's weight loss to have been brought to her attention. A facility policy titled Weighting and Measuring Height Policy Resident, dated 3/22/22, reviewed. Policy stated: the organization will strive to maintain residents' usual body weight or desirable body weight range, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being. To help monitor and/or identify residents at nutritional risk, the organization will establish a baseline weight and a schedule for weighting residents thereafter, per current professional standards of practice. Severe weight loss is described as greater than 5% in 1 month, greater than 7.5% in 3 months, or greater than 10% in 6 months. Responsible roles included registered dietician, director of nursing, licensed nurse, certified nursing assistant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105451 If continuation sheet Page 10 of 13 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 105451 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Health Center by Harborview 900 Beckett Way Tarpon Springs, FL 34689 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure post dialysis care was provided for two (Resident #30 and #7) of two residents reviewed for dialysis Residents Affected - Few Findings included: During a facility tour on 07/06/22 10:14 AM, Resident #30 was observed in his room being assisted by a staff member. Resident #30 was preparing to leave for dialysis. An attempt to interview the resident was not successful. Resident #30 was not easily understood but responded to yes and no questions. When asked if he had a snack or lunch packed for later, Resident #30 stated he did. Review of Resident #30's electronic medical record (EMR) showed the resident is [AGE] years old and was admitted to the facility on an 04/14/22 with diagnosis to include chronic kidney disease, unspecified. Review of physician orders for Resident #30 dated 04/14/22 - 07/07/22 showed: Medications administered prior to dialysis as ordered by physician. Receives dialysis at [name of facility] on Monday, Wednesday, and Friday at 11:15 a.m. No B/P (blood pressure) / blood draws or IV's (intravenous) to access arm. Vital signs prior to dialysis, once a day on Monday, Wednesday, Friday 07:00-15:00. Diet: meal consumption, add fluid consumption to task at Breakfast, Lunch and Dinner Renal diet. One can of Nepro daily. Weigh resident monthly, once a day on second Wednesday of the month. Review of resident # 30's weight record showed the resident was last weighed on 4/27/22 and a weight noted at 158.2. No other weights were documented. The physician orders did not show orders to provide post dialysis care. A Care plan for Resident #30 dated 04/14/22 showed a problem category: Resident requires dialysis due to Dx (Diagnosis): of end stage renal disease. Resident goes to dialysis M-W-F at 11:30 a.m. Catheter to left upper chest. The goal indicated resident will be free from complications such infection / altered skin integrity/ significant weight loss or gain due to receiving dialysis. An approach included to monitor weight and report excessive weight loss or gain to physician. Review of the dialysis book for Resident #30 showed only three dialysis communication forms: 4/25/22: an incomplete form without information from the facility was noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105451 If continuation sheet Page 11 of 13 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 105451 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Health Center by Harborview 900 Beckett Way Tarpon Springs, FL 34689 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 4/27/22 an incomplete form without information from the facility was noted. Level of Harm - Minimal harm or potential for actual harm 7/1/22: a completed form was noted. Residents Affected - Few Review of the Residents vitals log showed Resident #30 did not have vitals logged consistently before dialysis and no monitoring was documented for after dialysis care. The three post dialysis forms did not show documentation related to post dialysis care, weights, vitals, bruit / thrill monitoring. On 07/07/22 at 03:10 PM, an interview was conducted with the Director of Nursing (DON) The DON stated the dialysis office had not been sending the forms back, they (nursing staff) had to call and get them. When asked when she last called or obtained the copies, the DON stated she did not know and would follow up with the Unit Manager. The DON stated the nurses were expected to do vitals. The DON could not confirm if post dialysis care was being provided. The DON stated for Resident #30, the nurse who received the orders did not push through the orders for post dialysis monitoring. The DON stated they did not transcribe orders as ordered. Review of the record for Resident #7 showed the resident is [AGE] years old and was admitted to the facility on [DATE] with a diagnosis to include End Stage Renal Disease. Review of Resident #7's physician orders dated 09/01/21 - 07/07/21 showed: Dialysis on Tuesday and Saturday, chair time 11 a.m. at [name of facility], pick up time 9:30 a.m. Medications administered prior to dialysis as ordered by physician. Monitor for bleeding from CVC (central venous catheter) site after dialysis once a day Review of the record did not show post dialysis care was provided. A care plan for Resident #7 with a start date of 10/07/21, showed resident #7 has a diagnosis of chronic renal failure and has the potential for complications from dialysis. Has dialysis on Tuesday and Saturday. An interview was conducted on 07/08/22 at 09:53 AM, with Staff A, LPN (licensed practical nurse). Staff A stated Resident #7 went to dialysis twice a week. Staff A stated for pre dialysis prep, the CNA's (certified nurse's aides) assisted the resident to get ready, dressed, and made sure they had a snack or meal to go. The nurse took vitals and administered medications. Staff A stated post dialysis was supposed to be the same, check vitals and monitor bruit and thrill. Staff A stated she did not know if this resident's bruit and thrill were being monitored. On 07/08/22 at 10:10 AM, an interview was conducted with Staff B, LPN. Staff B stated he had one resident who was on dialysis. He stated the CNA's helped the resident get ready in the morning. He said he made sure the resident brought his folder along to dialysis. Staff B did not know if vitals should be checked but he would find out from the DON. He did not know about post dialysis care because he was not normally in the building when the resident returned. On 07/08/22 at 10:15 AM, an interview was conducted with Staff C, RN / MDS (registered nurse / (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105451 If continuation sheet Page 12 of 13 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 105451 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Health Center by Harborview 900 Beckett Way Tarpon Springs, FL 34689 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few minimum data set). Staff C stated she was working on updating the care plans and orders for the residents on dialysis. Staff C stated she was notified yesterday the orders did not include pre and post dialysis care. She stated the orders should include monitoring the resident's site for bleeding, check bruit and thrill, and take vitals. Staff C stated they would update orders, care plans, and educate the nurses on the expectation. On 07/07/22 at 04:50 PM, an interview was conducted with the DON. The DON stated the orders to monitor the resident post dialysis were missed. The DON stated they should have been entered. The DON stated she would expect to see active orders which should include to check bruit and thrill and shunt every shift and to monitor site for bleeding after dialysis. The DON stated she would review the orders for both residents and make sure they were in place. 07/08/22 at 11:58 AM, a follow -up was conducted with the DON. The DON stated Resident #30 should have been weighed, monthly per orders. The DON stated they missed it. The DON stated the plan was to start weighing the residents per orders. The DON said, we just did not do a good job with that. We did not weigh him as required. The plan is to review the dialysis communication forms to make sure they capture all the orders with post care expectations. The DON stated she would educate all the nurses on the expectations. Review of a facility policy titled, care of residents receiving dialysis, last revised 8/7/19, showed guideline steps 2. Observe for hemorrhage secondary to heparin therapy during dialysis. 3. Observe for infection or clotting of the access area. 4. Observe that dressing remains intact. 5. Observe catheter limb clamps are secure Review of a facility policy titled, review of physician orders, last revised 11/6/19, showed it is the standard of this facility that physician orders are reviewed daily to ensure delivery of applicable care, tracking of change of condition, and updating care plans are consistently provided. Review of a job description titled, charge nurse (LPN or RN) dated 03/2021, showed an expectation to: provide direct nursing care to the residents. Cooperate with other resident services when coordinating nursing services and be certain that the resident's total regimen is maintained. Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices. Review the resident's chart for specific treatments . as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105451 If continuation sheet Page 13 of 13