Health inspection·October 7, 2020

F 0584 - The bathroom door for resident room [ROOM NUMBER] was observed with holes in it. Level of Harm - Minimal harm or potential for actual harm - The wall section just under the window sill and above the a/c unit in resident room [ROOM NUMBER] was observed peeling off the wall and hanging in a manner where a resident could access it or scrape against it. Residents Affected - Some - The shower room in the unit and near room [ROOM NUMBER] was observed with six shower tiles and grout lines near the floor with black biogrowth. - The bathroom wall in resident room [ROOM NUMBER] was observed to have a rectangular hole where the toilet paper roll holder was usually located. Pink - wispy insulation and the rough edges of the dry wall were observed in the hole. The toilet paper holder was observed sitting on the top of the toilet tank, with the toilet paper still attached. - On 10/05/2020, Housekeeping Staff P was observed bringing his housekeeping cart onto the secured south unit at approximately 10:15 a.m. Staff P confirmed, he was just starting to clean on the South unit. The mop bucket, located on the cart, was noted to be half full of water. The sides of the bucket, the rim of the bucket and the attached wringer were noted to be soiled with a dark matter. The wringer was dry and the dark matter was easily rubbed off of the edges and the grating that was part of the wringer. The Housekeeper was not able to explain why the bucket was so dirty and how he would clean using this dirty bucket. The Housekeeping Manager confirmed, on 10/5/20 at 11 a.m. , that the bucket was dirty and not just stained. He determined that it was soiled by running his fingers over the rim of the bucket and the grating of the wringer, which easily dislodged the dark matter. The Housekeeping Manager asked Staff P, Housekeeper, to take the bucket out of service and scrub the bucket before cleaning the south unit. -On Sunday, 10/4/20 at 10:22 a.m., observation with Staff Member M, Certified Nursing Assistant (CNA), of the one shower room on the South Secured unit revealed trash littered the floor and the trash bins did not have bags in them. No toilet paper was available for the residents and one of the walls had a splattering of a brown substance across it. Staff M reported that there were no showers given on Sundays. On 10/7/20 at 9:43 a.m., the Assistant Director of Nursing (ADON) stated he was, embarrassed when the observation of the secured unit shower room was discussed. - On 10/4/20 at 11:41 a.m., observation of Resident #62's room revealed the wallboard behind the air conditioner unit was pulled away from the wall, and a screw was in the wallboard not attached to the wall. On 10/4/20 at 3:18 p.m., the Maintenance Director observed the wallboard and screw. He stated he was in the process of renovating the secured unit and did not know who put the screw in the board. He removed the screw with his fingers by pulling it and confirmed the area was a safety issue. The Maintenance Director stated, someone could get a skin tear. The window blinds in the room were also observed to be broken. -During observation on 10/5/20 at 9:15 a.m., three male residents were observed smoking on the screened patio of the secured unit. The area was noted with the following concerns: - a blue ball was observed in the area with the fire blanket that was deflated and had a black (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 2 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gateway 8600 US Hwy 19 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 0584 substance attached to it; Level of Harm - Minimal harm or potential for actual harm - a fabric and wooden chair that one resident was sitting in was mildewed and the wood was cracked. Residents Affected - Some - a water jug, sitting on a utility cart, had dust, dirt, and other debris on top of the lid. Inside the jug was water with a bug on the bottom of it. - 2 tiles were observed sitting near the blue ball. Staff Member O, Certified Nursing Assistant, who had been supervising the residents while they smoked, confirmed the bug inside the water jug. She stated that the jug was changed daily when they did group activities outside, but due to COVID-19 group activities had been canceled. She was unsure of when the jug had last been changed. On 10/5/20 at 10:00 a.m., the curved end of the handrail, outside of resident room [ROOM NUMBER], was not attached tightly to the wall. Closer observation revealed the handrail had a broken bracket that left a large washer and screw exposed. A steel bracket was observed underneath a portion of the handrail. 2. North unit: - The shower room near resident room [ROOM NUMBER] was observed with three tiles and grout lines in one of one shower stall with black biogrowth. - The shower room across from room [ROOM NUMBER] was observed with one of one shower stall with black biogrowth on six wall tiles and grout lines near the floor. - The main wall outside resident room [ROOM NUMBER] was observed with three splatters of a brown sticky liquid/substance. - The main wall outside and between resident rooms 119/121 was observed with six pink dried liquid splatters. - The main wall outside and between the nurses station and room [ROOM NUMBER] was observed with five brown, pink dried sticky splatters. - The main hallway at the exit door, and across from resident room [ROOM NUMBER], was observed with a spider web with a live spider and many insect carcasses. The web measured approximately nine inches long by eight to ten inches across. On 10/7/2020 at 8:50 a.m., a facility wide tour was conducted with the Maintenance Director and the Housekeeping Director. They were provided with visual evidence of the above items. They were able to confirm all items and revealed that the areas should have been caught and cleaned or maintained through daily housekeeping rounds. The Housekeeping Director provided the daily and monthly cleaning schedule for review. He indicated that the ceiling vents and the room air conditioner filters wee cleaned once a month. He stated that they should be cleaned more frequently based on the observations. The Maintenance Director confirmed the condition of the walls in resident rooms and stated that he was not aware of it, but he was repairing walls in other rooms. The Housekeeping Director confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 3 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gateway 8600 US Hwy 19 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that during his rounds and his staff rounds, they should have caught the walls in disrepair and reported it immediately to the Maintenance Director. Interview with the North and South Unit Manager on 10/7/2020 both confirmed that if there were any cleaning or maintenance issues in resident rooms or other spaces, they write up job request forms and submit them to the Maintenance Director to fix. 3. An observation of the laundry room was completed, on 10/7/20 at 10:14 a.m., with the Assistant Director of Nursing (ADON) and the Housekeeping Manager. On each of the two washers was a lint filter which were both covered in lint/dust. The Housekeeping Manager did not know the purpose of the filters but stated one of the washers (#2) would just shut off. A notice attached to the washers under the filters indicated, Notice, Clean Filter Daily. The Housekeeping Manager stated the filters do not get changed daily. Photographic evidence was taken during the course of the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 4 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gateway 8600 US Hwy 19 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure one (#88) of 39 sampled residents had a care plan implemented related to supervision for frequent falls. Findings included: Record review of Resident #88 revealed an admission date of 08/31/2020 with a diagnosis of Dementia without behavioral disturbances. A Minimum Data Set (MDS) Assessment was completed on 09/05/2020, which identified the resident as participating in the Brief Interview for Mental Status (BIMS) but scoring a 99, indicating his answers were nonsensical. The MDS identified that he had problems with his short term memory and was moderately impaired for decision making. The MDS assessment identified the resident as needing limited assistance by two staff for bed mobility, extensive assistance by two staff for transferring, having an unsteady balance but able to stabilize on his own, able to walk in his room with limited assistance by one staff, and toileting with limited assistance by one staff . The MDS assessment was not able to determine his fall history, but he had not had a fall between his admission date of 08/31/2020 and the assessment date of 09/05/2020. A baseline care plan was developed at admission and identified the resident's admitting diagnosis as Traumatic Subdural Hemorrhage with loss of consciousness. He had physical and occupational therapy ordered. The initial goal for the resident related to falls was resident will remain free from fall related injury with the intervention documented as PT (physical ) therapy. A care plan was initiated on 09/16/2020 for the Focus area of the risk for falls and/or fall related injury, related to impaired balance, unsteady gait, poor safety awareness, and needs assistance with transfers. Interventions initially included the supervision of the resident during transfers and ambulation due to unsteady gait and impaired balance, as well as providing hands on assistance during transfers; observing for use of appropriate footwear and assist as needed; keep environment clean and free of clutter in the walkways, physical and occupation therapy screens as indicated, and reporting falls to the physician and responsible party. The care plan was revised on 09/25/2020, after the resident sustained two falls on 09/24/2020, both of which occurred in his room, to include the following interventions: encourage resident to stay outside of his room, around the nursing station when out of bed to wheelchair; and toilet upon rising, before and after meals, before bed and as necessary. The resident was observed on 10/04/2020 at approximately 12:30 p.m. in the hall, in his wheelchair, self propelling in front of his room and the nursing station. Later that day at 2:20 p.m., the resident was observed sitting on the floor in his room, with his back against the bedside table. His wheelchair was observed near the end of the bed, the length of his bed away from him. The nurses were made aware that the resident was on the floor and they entered the room to assess and assist him back into his wheelchair. Once the resident was assessed as having no injury or pain, and brought out in the hall so staff could supervise him, the nurse (Nurse Q) reported that he just laughed when they asked him what had happened. On 10/05/2020, at 10:05 a.m., Resident #88 was observed assisted back to his room by his aide, in his wheelchair. She confirmed that he had just had a shower. The nurse asked the aide to allow him to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 5 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gateway 8600 US Hwy 19 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few remain in the hall so they could watch him. The resident was observed with nonskid socks on, but they were ripped at the right toe area and at the left heel. The hole in the sock at the left heel was large enough to expose the heel, so it was resting on the floor. At 11:50 a.m., that same day the resident was observed to unlock the brakes on his wheelchair and self propel into his room. The Unit Manager was observed to enter the room and ask him if he needed anything? The resident said he wanted to eat lunch in his room. The Unit Manager agreed and set up the over bed table in front of him as the lunch meal would be served shortly. When his [NAME] socks were pointed out the Unit Manager, she agreed that they shouldn't have been put on as the holes did not provide much nonskid protection. After lunch, at 12:30 p.m. , the resident was observed alone in his room, with his meal tray removed, self propelling around the room with no supervision. On 10/07/2020 at 11:30 a.m., the Director of Nurses (DON) reviewed the fall reports that Resident #88 had since his admission [DATE]. The resident had three falls, all occurring in his room, when he was by himself. According to the DON, on 09/12/2020 at 6:50 p.m., the resident had been found on the floor in his room. An assessment indicated no injury, and the resident was assisted back to his wheelchair and brought out to the hall. The DON discussed two additional falls that had both occurred on 09/24/2020. At 10:27 a.m. on 09/24/2020, Resident #88 was found on the floor of his room, at the side of the bed, having been incontinent of a large amount of stool. Upon physical assessment, a bruise was noted to the left hip but the resident did not complain of pain. Two staff assisted to transfer the resident to the wheelchair. When the nurse contacted the physician to make him aware of the fall, the physician discontinued the resident's colace and miralax and ordered a x-ray of the hip. Later that same day, at 2:46 p.m., the nurse's note documented a loud noise coming from the resident's room. The resident was found on the floor by the bathroom with his nonskid socks intact. A skin tear was noted to his left forearm. The DON reported that the incident report describing this fall did not indicate whether he had been found incontinent. She confirmed that the incident reports were not detailed and she would expect information that included what he had been doing prior to the fall, who saw him, who interacted with him last, where was his call bell, what was the last time he had been toileted, and what was on his feet. After the fall reports were discussed, the DON was made aware of observations of Resident #88 which indicated the staff were not implementing the care plan related to encouraging the resident to remain in the hall for supervision and ensuring that appropriate footwear was in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 6 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gateway 8600 US Hwy 19 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interviews, the facility failed to ensure one (#94) of one resident sampled for tube feeding out of 6 residents in the facility received tube feed nourishment in accordance with the physician order for two of four days observed (10/4/20 and 10/5/20). It was determined that nursing staff did not start the feeding timely, and did not provided a physician's ordered flow rate of the product. Findings included: Review of the medical record for Resident #94 an original admission date in 2018 and a readmission from the hospital in September of 2020. Review of the cumulative diagnoses sheet revealed diagnoses of Pressure Ulcer Left heel, Dementia, Gastro-esophageal reflux (GERD), Pneumonitis due to inhalation of food and vomit, and unspecified protein-calorie malnutrition. Review of the current Physician's Order Sheet (POS) dated for the month October 2020 revealed the following relevant orders: 1. Enteral Feed one time a day Jevity 1.5 at 65 ml/hr for 20 hrs (off 4 hours). This order date was 9/24/2020 at 1300. There was another identical order written on 9/27/2020 at 900. 2. HOB elevated at least 30 degrees every shift with current order date 9/21/2020. 3. Nothing by mouth diet, NPO texture, not applicable consistency for nutrition with current order date 9/21/2020 1748. 4. Check residual every shift and record quantity. If more than 60 ml hold feeding for 1 hour and notify MD with current order 9/21/2020 2300. Review of the orders did not reflect a start and/or stop time for the enteral feeding. On 10/4/2020 at 9:00 a.m. during a tour of the facility, Resident #94 was observed in his room, lying in bed, and under the covers. He was noted with his eyes closed and with the call light button placed within his reach. Further observations revealed that there was a tube feeding system at the bedside. The pump was off and the tubing was not attached. A bag of the tube feeding product was hanging from the pole. The bag was labeled with the name of resident, room number, date: 10/4/2020, time 3:00 a.m., rate 60 ml, Formula Jevity 1.5 1000 cc 3:00 a.m. and staff initials. The bag appeared to be full. Continued observations on 10/4/20 at 11:30 a.m., 12:05 p.m., 1:30 p.m., and 1:58 p.m. revealed the resident was in bed, with the tube feeding system at the bedside in the off position and not hooked up to the resident. On 10/4/2020 at 2:03 p.m., a nurse was observed exiting the room. The resident was now observed with the tube feeding system on. Observation of the tube feeding pump revealed it was operating at a flow rate of 65 ml/hr. The bag still appeared full, just as it was on 10/4/20 at 9:00 a.m. Immediately following this observation, interview with Nurse E revealed that she had just hooked up the tube (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 7 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gateway 8600 US Hwy 19 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few feeding and turned on the pump. She did not know why it was not on at 3:00 a.m. as per the bottle label. She reported that she believed that it goes on at 1:00 p.m. She confirmed the tube feeding system was not tuned on until now, 2:03 p.m. On 10/5/2020 at 7:20 a.m., Resident #94 was observed in her room and lying in bed with the Head of Bed (HOB) elevated approximately 35 degrees. The lights in the room were observed off. The resident was observed with his call light in reach and eyes closed. Further observations revealed the resident was receiving tube feeding nourishment with the pump on. The following was observed on the nourishment bottle label: 1. Jevity 1.5, 2. Resident name, 3. Room number, 4. Date of 10/5/20, 5. Start time 3:00 a.m. to be ran at 60 ml hr. Review of the tube feed system pump, which was on, read on the digital screen that the flow rate was set at 55 ml. The bottle appeared to have about 750 ml's remaining. On 10/5/2020 at 7:50 a.m., the resident's room was approached and entered with the North Unit Manager. She confirmed that the nourishment bottle read Jevity 1.5, resident name, room number, date 10/5/20, and start time 3:00 a.m. to be ran at 60 ml hr. The Unit Manager further confirmed that the tube feeding system pump read a flow rate of 55 ml. On 10/5/2020 at 8:55 a.m., the North Unit Manager revealed that she had confirmed with the 11 PM to 7 AM shift nurse that the bag/bottles are placed on the system pole early every day after the stop time. She did confirm that the tube feeding system was not turned on until 2:00 p.m. on 10/4/2020 and it should have been turned on at 1:00 p.m. The Unit Manager further confirmed the flow rate was not correct this morning and does not know why it was not at the right flow rate. She confirmed the pump was providing 55 ml/hr. Review of the Nutritional risk assessment dated [DATE] revealed a summary: Increased Tube Feeding 65 ml/hr jevity 1.5 x's 20 hrs = 1950 kcal, 82g pro, zinc sulfide 220 mg daily x's 14 days, vit c 500 mg twice a day. Review of the current Minimum Data Set (MDS) assessment (5 day) dated 9/25/2020 revealed: Short Term and Long Term memory problem and moderately impaired decision making skills; Activities of Daily Living (ADL) - total dependence with Eating; Nutrition - Parenteral feeding- yes. On 10/4/2020 at 1:00 p.m., Resident #94's care plans were reviewed with a next review date of 12/20/20. The following relevant focus areas were identified: - Has potential for complications related to risk for aspiration pneumonia. Is NPO with enteral feeding with interventions to include: Vital signs as ordered, Labs as ordered, Assess lung sounds and respiratory functions, report changes to MD as indicated; observe for signs and symptoms (s/s) of recurring infection, notify the Medical Doctor (MD) if noted. - Risk for social isolation due to dementia with behavioral disturbances and anxiety. Has a feeding tube and is NPO at this time. - Risk for complications associated with enteral feedings due to dysphagia, is NPO and receives enteral feeding to meet nutritional and hydration requirements with interventions to include: Verify tube feeding placement as ordered, check enteral feeding residuals as ordered, administer feeding and flushes as ordered, keep HOB at 45 degrees during enteral feeding as ordered, weights ordered and as needed, perform stoma site care as ordered, routine Registered Dietitian (RD) assessment, Speech (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 8 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gateway 8600 US Hwy 19 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Language Pathologist (SLP) screen as indicated, observe for complications related to (r/t) enteral feeding, aspiration, dehydration, update MD if noted. - At risk for an alteration in nutrition and/or hydration . Resident is on tube feeding as ordered. Weight below ideal body weight (IBW) with interventions in place as reviewed to include: Provide diet as ordered, Encourage adequate intake at meals, Encourage adequate fluid intake, Supplements as ordered, RD consult as needed. On 10/6/2020 at 10:04 a.m., the North Unit Manager indicated that the Physician had just changed the flow rate of the Jevity 1.5 tube feeding nourishment from 65 ml/hr to 75 ml/hr. She indicated that the order was now clarified in the medical record to reflect that change. The North Unit Manager, confirmed that the resident had the incorrect flow rate on 10/5/20 as observed. On 10/6/2020 at 2:00 p.m., the facility's Registered Dietitian indicated that it was the responsibility of nursing staff to place and turn on the tube feeding system. She would expect that the run time and flow rate were monitored by a nurse and that she had not been made aware of the wrong flow rate on 10/5/2020, until 10/6/2020. She further revealed that she had recommended an increase of flow rate to the nourishment tube feed today, to make up for the loss from 10/5/2020. On 10/6/2020 at 10:50 a.m., the Nursing Home Administrator and Director of Nursing provided the Enteral Nutrition policy and procedure with a revision date of 11/2018. The policy statement revealed, Adequate nutritional support through enteral nutrition is provided to residents as ordered. The policy interpretation and implementation revealed, #10. Enteral feedings are scheduled to try to optimize resident independence whenever possible (e.g. at night or during hours that do not interfere with the resident's ability to participate in facility activities); #11. The Nurse confirms that orders for enteral nutrition are complete. Complete orders include: e. Volume and rate of administration; #12. The provider will consider the need for supplemental orders, including: a. confirmation of tube placement. Photographic evidence was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 9 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gateway 8600 US Hwy 19 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observations, facility file review, and staff interviews, the facility failed to post the required Nurse Staffing Information to show the census, number of licensed and unlicensed staff working for each shift and the actual hours worked was posted for review daily. Residents Affected - Many Findings included: On Sunday 10/4/2020 from the time of facility entrance at 8:50 a.m. and observed again at 9:30 a.m. and 11:20 a.m., the front lobby area was observed with information sheets near the reception desk. The Daily Nurse Staffing form was posted on a cork board next to the reception desk window. There were two of these forms posted, one dated 9/17/2020 and the other dated 9/16/2020. A full tour of the facility was conducted on 10/4/20 and no evidence could be located with this information outside of the old forms found in the reception/front desk area. On 10/5/2020 at 8:35 a.m., the facility's reception area was observed to have the same Daily Nurse Staffing form posted with dates 9/16/20 and 9/17/20. Interview with the receptionist, Employee F, at the time of observation revealed she was unaware of who was responsible for the posting of this information. She stated that she would have to ask someone. On 10/5/20 at 8:37 a.m., the Nursing Home Administrator came out to the lobby and confirmed that the Daily Nurse Staffing form posted was not current and had been updated since 9/17/2020. The Nursing Home Administrator revealed that it was the Staffing Coordinator's responsibility, but she had walked out around 9/17/2020, and no longer worked for the facility. The Nursing Home Administrator also confirmed that she did not have an alternate person to update the Daily Nurse Staffing form and would find one immediately. The Nursing Home Administrator confirmed there were no other places this information would be posted in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 10 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gateway 8600 US Hwy 19 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and policy review, the facility failed to ensure medications were labeled properly and expired medications were disposed of, for two (Cart 2 South, Cart 3 North) of three medication carts observed during the medication storage task. Findings included: An observation, on 10/6/20 at 10:45 a.m., of Cart 2 South was completed with Staff Member K, Licensed Practical Nurse/Nurse Supervisor (LPN). The observation revealed a bottle of Latanoprost 0.005% ophthalmology solution, opened 8/15/20. The pharmacy label indicated the bottle of Latanoprost should be discarded after 6 weeks. The Unit Manager confirmed the medication should have been discarded on 9/26/20. An open, undated, container of Breo Ellipta 100/25 inhalation was observed. The pharmacy label attached to the Breo Ellipta indicated that it should be discarded 6 weeks after opening. An observation of the North 3 medication cart was completed, on 10/6/20 at 11:07 a.m., with Staff Member J, Licensed Practical Nurse (LPN). An Asmanex HFA inhaler was observed to be open and undated. The pharmacy label for the Asmanex indicated the inhaler should be discarded 45 days after opening. Two bottles of Lumigan 0.01% ophthalmology solution were observed as opened and undated. According to https://allergan-web-cdn-prod.azureedge.net/allergan/allergannewzealand/media/allergannewzealand/products/lumigan-nz Lumigan ophthalmology solution contains a preservative which helps prevent germs growing in the solution for the first four weeks after opening the bottle. After this time there is a greater risk that the drops may become contaminated and cause an eye infection. A new bottle should be opened. One bottle of Combigan 0.2-0.5% ophthalmology solution was observed as opened and staff had dated the pharmacy label as opened on 8/31/20 and expire (exp) on 9/29/20. According to https://www.drugs.com/uk/pdf/leaflet/1076219.pdf, the user pamphlet for Combigan indicated that the bottle should be discarded four weeks after opening to assist with the prevention of infections. Staff Member K confirmed the observations of the North 3 Medication cart. Review of The Storage of Medications policy, dated 2001 and Revised April 2007, indicated the following: - Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. - Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 11 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gateway 8600 US Hwy 19 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 0761 Level of Harm - Minimal harm or potential for actual harm - Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications. Photographic evidence was obtained. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 12 of 12