Health inspection·December 16, 2021

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Staff G stated that residents should have pillows on their beds. Staff G said, I'll correct that, I will make sure we get pillows. The residents should have comfortable furnishings in their rooms. On 12/15/21 at 1:30 p.m., an interview was conducted with the Staff H, RN/UM who confirmed that all residents are supposed to have appropriate linens. They should have pillows. Staff H said, I will conduct a walk through and make sure all residents have pillows. A follow up interview was conducted on 12/15/21 at 4:19 p.m. with the Director of Nursing (DON). The DON said residents should have pillows and personal effects and they were auditing all the rooms. The DON said, We will make sure the resident rooms look like the residents live here, not like we are housing them. The DON said, We will reach out to families to bring personal effects such as pictures. The DON stated this would help calm them down and dignify them. On 12/16/21 at 10:05 a.m., a facility tour of the South Unit was conducted. Rooms were noted with pillows and uniform white sheets. The resident rooms were observed without any personal effects, no blankets or bed covers, no pictures, memorabilia, or decorations. These rooms included 152, 143, 144, 156 158 bed B, 159, 161, 163, 162, 165, 164, 167 and 168. On 12/16/21 at 10:08 a.m., an interview was conducted with Staff H, RN/UM. The Staff H stated they have replaced pillows in the resident rooms and have contacted families about helping to personalize the rooms. Staff H, RN/UM said, We want residents to be comfortable. The UM did not know why the rooms did not have blankets or covers. 2. On 12/13/21 at 2:11 p.m. and on 12/14/21 at 12:51 p.m., Resident #306 was observed with loose blue jean pants, and holding onto his pants as he walked around so they did not fall. Resident #306 stated he would like a belt to keep his pants up. Resident #306 did not know what happened to his belt. On 12/15/21 at 12:56 p.m., an interview was conducted with Staff H, RN/UM. Staff H was asked why Resident #306 did not have a belt or fitted clothing. The UM stated that sometimes safety was the priority. Staff H was asked if a safety concern was the reason Resident #306 did not have access to a belt. Staff H said, No, not really. The UM stated he would call the resident's family and ask them to bring one. Staff H stated he thought the family took it [belt] home. On 12/15/21 at 2:55 p.m., Resident #306 was observed wearing a pair of jeans shorts, he was noted holding on to them as he walked around in his room. Resident #306 did not have access to his belt. On 12/15/21 at 1:45 p.m. the Regional Director Clinical Service stated there was no reason why the residents should not be wearing belts if they wanted to. The Regional Director Clinical Service said, They should be wearing fitted clothes. There is no rule about the belts. It is not our policy. The Regional Director Clinical Service stated they would make sure Resident#306 had a belt. An interview was conducted on 12/15/21 at 4:19 p.m. with the DON. The DON said, I reached out to my administration. They [residents] can have belts. It is not a facility policy. The DON stated that she preferred they have clothes that fit. A follow up was conducted with the Nursing Home Administrator (NHA) and DON on 12/16/21 at 10:40 a.m. The NHA stated the expectation would be for their residents to have comfortable facilities. The NHA stated she stressed the need for a clean comfortable environment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 2 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0557 Level of Harm - Minimal harm or potential for actual harm In an interview conducted with the Social Services Director (SSD) on 12/16/21 at 1:25 p.m. the SSD presented documentation showing an audit conducted for all the residents in the North and South Units. The audit confirmed the rooms in the South Unit did not have personal effects such as pictures on walls. The audit further identified eight residents with clothing that was poorly fitted or did not have a belt. The SSD said, We will definitely correct this. Residents Affected - Some Review of a facility policy titled, Dignity, revised February 2021, showed that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. #2. The facility supports dignity and respect for residents by honoring resident goals, choices, preferences, and beliefs. #13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 3 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately report an alleged allegation of neglect related to an elopement to regulatory agencies as mandated for one resident (#49) out of 41 sampled residents. Findings included: Review of Resident #49's admission Record revealed he was admitted on [DATE] from an acute care hospital with diagnoses of unspecified mood [affective] disorder, altered mental status and unspecified symptoms and sign involving cognitive functions and awareness. Further review of the admission Record revealed Resident #49 was deemed incapacitated and resided on the South Unit of the facility which is the facility's secured unit. On 12/13/21 at 10:25 a.m. an interview was conducted with Staff Z, Agency Certified Nursing Assistant (CNA) and she stated she was on a one to one with Resident #49 because he had jumped the fence. She was unsure when it happened. An interview was conducted on 12/13/21 at 10:45 a.m. with Staff Y, Social Services. He stated less than a month ago the resident jumped over the fence that is located around the outside area off the secured unit. The Resident was found in the ditch past the fence. On 12/14/21 at 10:28 a.m. Resident #49 was interviewed about jumping over the fence and he stated, I'm not worried about that, I just need to go to the pharmacy to get cream for this rash I have on my legs. Review of Resident #49's Minimum Data Set (MDS) dated [DATE] revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status score of a 6 out 15 indicating severe cognitive impairment. Further medical record review revealed an elopement evaluation dated 10/14/2021 which revealed a score of 19 indicating the resident was at high risk for elopement. Review of Resident #49's order summary report as of 12/16/21 revealed a physician order dated 11/4/21 with no end date for one on one supervision every shift for increased behaviors. Review of the facility's Reportable log for November 2021 did not reveal a reportable incident for Resident #49. An interview was conducted on 12/14/21 at 3:35 p.m. with Staff X, Licensed Practical Nurse (LPN). She stated she was [Resident #49's] nurse that night. The residents were outside doing a smoke break, there was a staff member out there. I heard the CNA yell I need help; I need help! I was at the nurse's station. She said the patient, [Resident #49] climbed the fence. I called the supervisor immediately then the supervisor took over. I was at the nurse's station. [Resident #49] was found outside in the ditch. We had other staff members going to get him. [Staff W, CNA, Staff V, and Staff U, LPN], they went outside, and they brought the resident back in. When he came back, I did a full body assessment and there were no injuries. He did not resist coming back and I called the Psych doctor, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 4 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few primary doctor and the healthcare surrogate to notify them. The Director of Nursing took over and was able to get orders from the physicians. We put him on a one to one. We did a head count to make sure everyone else was accounted for in the whole facility. No one else was missing at that time. From the time I was notified that he was climbing over the fence to the time he was escorted back in couldn't have been more than 15 minutes, everyone was on it. He was safe and had no injuries. He was an elopement risk prior to this incident that's why he is on the locked unit. On 12/14/21 at 3:53 p.m. Staff W, CNA was interviewed. He said, I have worked here 12-13 years. The residents were outside on their smoking break [Staff D, CNA], the CNA who was monitoring the smoking break, said [Resident #49's] over the fence. [Staff D, CNA] kept her eye on the resident, and I went out the side door by the clock in station and he wasn't in the ditch, he was almost in the ditch. I just reached my hand out and I said you don't have to go into work today [Resident #49], because all day he was talking about how he needed to go to work. When I said you don't have to go to work today, he said are you sure? I said yes. He took my hand and walked back in the building with me. He didn't have any injuries. [Staff D, CNA] was new to the smoking area, she has worked here for a while but she was new to watching the smoking, but she knew [Resident #49] and she kept her eye on him because when I walked out the door, she said I see him he's that way and she pointed towards the street; then that's when I saw him just outside the side door in the grass partly in the ditch, but not really. Maybe he thought he could do that because he didn't know [Staff D, CNA] but [Staff D, CNA] knew him. Review of Resident #49's progress note dated 11/3/21 at 7:30 p.m. created by Staff X, LPN revealed, staff member bringing residents in from south secure unit smoking area outside yelled for help saying resident is jumping the fence. Other nurse and staff members ran out to assist. This writer called 3p.m.-11p.m. supervisor and notified her. Further review of Resident #49's progress notes revealed a note dated 11/4/21 at 5:21 p.m. Created by Staff S, the 3-11p.m. supervisor, On 11/3/21 at approximately 7:30 p.m. while in a meeting with DON (Director of Nursing) and North Manager this writer was notified by nurse that resident on south secure unit jumped the fence. This writer ran to south unit to assist, upon arrival was updated on what had occurred. This writer ran out the side of the facility off the secure unit and was met with two facility staff CNA's assisting resident back to secure unit. Directed resident nurse to notify medical doctor and Power of Attorney/Healthcare Proxy of incident. Further progress note review revealed a note dated 11/4/21 at 5:32 p.m. Created by the DON. The note documented, On 11/3/21 at approximately 7:30 p.m. this writer was in a meeting with the north unit manager and 3-11 supervisor, when 3-11 supervisor received notification that resident on secure unit jumped the fence this writer paged over head for assistance, and Nursing Home Administrator notified. This writer then proceeded to the front parking lot and around to the side of the building, did not encounter resident or any staff member. Upon entering south secure unit observed resident at nurses' station with nurse and staff members, resident appeared agitated and pacing, repeatedly stating I have to be at work by 6 in the morning. Directed nurses to do a head-to-toe assessment and place resident on one-on-one supervision. This writer spoke with Nurse practitioner covering for the resident's primary physician, verbal orders received for one time Haldol 5mg (milligram) IM (intramuscular) may repeat in fifteen minutes if resident remains combative and agitated. An interview was conducted with the DON on 12/15/21 at 10:30 a.m. she stated on 11/3/21 I was in the facility in my office, and I had the 3p.m.-11p.m. supervisor and the unit manager for North. The supervisor received a call from a nurse on the south unit and I'm quoting who went over the fence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 5 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that's when we all jumped up. I do not know where the other two headed but I headed from my office toward the front door grabbed the phone at the reception area and I paged a code [NAME] 3 times and I ran out the front door towards US-19 in the parking lot. I made a right, if you were facing US-19 and I stood there and I'm looking down the building waiting for a resident, for staff, I see no one. I had my cell phone I called my Administrator and I informed her. I hang up because no one came. I went down the side of the building I came into the building from the side door where the clock in station is. I went to the secure unit where my staff and the resident were. I started my investigation. I needed to know who, what, when, where. I had just found out some of the residents had returned in from the smoking area. The staff told me [Staff D, CNA] was supervising residents outside and that [Resident #49] had climbed the fence when she was in the process of bring a resident in who was in a wheelchair. She heard the fence rattling that's what made her turn around and she saw that [Resident #49] was climbing the fence and she yelled for help. She had yelled he jumped the fence! When I learned it was [Resident #49] who climbed the fence I directed the nurse to call the doctor, family or healthcare surrogate, do a head to toe, put him on a one to one and call the Psych physician. Then I wanted to know which one of my staff brought him into the building and the staff said [Staff W, CNA] and [Staff R, CNA]. They were not by the nursing station so I had [Staff D, CNA] show me where she was outside after she had yelled for help. If you go out the secure unit door there is an upper part, the screened in porch area, she heard the fence, saw him climbing, yelled for help she watched him the whole time. I found [Staff R, CNA] and [Staff W, CNA] in the breakroom so I asked them what happened. They said they heard [Staff D, CNA] screaming for help, they were on the secure unit at the time. [Staff D, CNA] had directed the staff to go on the other side of the fence where the resident was so [Staff W, CNA] and [Staff R, CNA] ran off the secure unit and out the door by the time clock and ran down the right side of the building. Both CNAs said the minute they went out the door they saw [Resident #49] and I wanted to know where he was and how he was. So I had them take me to show me. [Staff R, CNA] said [Staff W, CNA] had taken [Resident #49] by the hand and [Staff W, CNA] said he just put his hand out and [Resident #49] grabbed him and he kept saying he needed to go to work and they just walked with him to the side door and the [Staff V, LPN] let them in the side door because they can't get in the side door from the outside. By the time they got into the door my supervisor, [Staff S] was there and encouraged the resident and talked to him and he went back on the secure unit. Then, the DON took the surveyor outside and reenacted what her staff said. The DON brought the surveyor out the side door by the clock in station and immediately looking to the right she Pointed to where the resident was found. The resident was approximately 100 yards from the side door squatting down next to the drain ditch. The DON and the surveyor walked to the exact spot the resident was found. The side door of the building was visible and the back patio smoking area was visible. The DON stated the resident climbed the chain link fence just past the screened in porch area. It was observed there was a ramp leading down from the screened in porch area to the outside patio area both surrounded by an approximately 8ft chained linked fence. Inside of the chained linked fence was an approximate 4 foot tall handrail going down the ramp and against the chained linked fence. The DON stated at the time it was getting dark, it wasn't dark yet. She also stated if she had to give a timeline it had to of been less than a few minutes from the time the call was placed to the supervisor to the time she went back on the unit and saw the [Resident #49]. The DON continued to say he [Resident #49] was on one to one, he was taken care of, they did a head to toe they didn't find anything on him. After I finished with the staff interviews, I called my Nursing Home Administrator (NHA) back told her what happened, the NHA was different from the NHA we currently have but she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 6 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the abuse coordinator at the time, and I notified her of what happened and my investigation. It was not reported to the state agencies. Me and the NHA discussed it and she had asked me questions and I was able to answer them and she said ok this wasn't an elopement and I expressed to her that at no time did my staff lose site of the resident. Yes, he climbed the fence but my staff had eyes on him the whole time so it was my understanding since my staff had eyes on him the whole time that's why we didn't believe it was an elopement. The DON confirmed Resident #49 was at an elopement risk prior to this event, he is on the secure unit, and her expectation is that he did not leave the fenced in area. The DON stated, I know what you are thinking he did make it over the fence, that day that this incident happened we had an all staff meeting at 3:00 p.m. and we covered elopement, we had therapy CNAs, Nurses, and we educated about elopement at 3:00 p.m. I directed the 3:00 p.m.-11:00 p.m. Supervisor to go to the North and South Units to do a head count and everyone was accounted for. I did a risk assessment to see if we could do anything different, like was the locked door not working or something. There were no issues that I identified at the time. The risk assessment was completed on 11/4/21, the IDT (interdisciplinary) team and maintenance came with me. I had asked how come I don't have a second door to the screen room and Maintenance had told me that was a safety issue, and since it was starting to get dark; I had Maintenance check all the lighting and that was working, and there is also lighting in the patio area. Review of the facility's policy Resident Elopement Risk Management Guidelines Version 1.1, dated May 2021 revealed, Purpose the facility will strive to provide a safe environment for residents and implement measures to identify resident at risk for elopement, as well as preventative measures to minimize elopement. Definition ELOPEMENT-An elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so. Review of the facility's policy Resident mistreatment, Neglect and Abuse Prohibition Guidelines Version 1.1 dated May 2021 revealed .definitions .Mandated reporting: is a legal obligation for mandated reporters to formally report suspected, believed, or witnessed abuse, neglect or mistreatment of residents in accordance with state and federal laws Reporting/Response regulations require employees that provide services to elderly persons or dependent adults (mandated reporters) to report instances of abuse, neglect, or misappropriation/exploitation of resident property to the state agency (AHCA), Department of Children and Families (DCF) and local law enforcement agency within 2 hours if the alleged violation involves abuse or results in serious bodily injury or as soon as practically possible within 24 hours of detection if the alleged violation does not involve abuse and does not result in bodily injury. All employees are required to promptly report the facts of known or suspected instances of abuse to their direct supervisor on duty, Abuse Coordinator, Administrator, and/or Director of Nursing (either directly or anonymously), so that the facility responsibilities to protect the residents and promptly investigate occurrences may be et. The facility administration is required to report the state licensing authority any knowledge of actions by a court of law which would indicate an employee is unfit for services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 7 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 observations, interviews and record review, the facility failed to ensure a care plan problem area with a goal and interventions was developed related to Isolation Precautions, for one resident (#156) of forty-one sampled residents Findings included: On 12/13/2021, 12/14/2021, 12/15/2021 and 12/16/2021 Resident #156's room was approached and the door was closed. Further observations revealed the front of the door had a posted sign that indicated, Attention, Droplet Precautions. The sign detailed what type of Personal Protective Equipment (PPE) one should wear upon entering the room. Also, the front of the door had hanging Personal Protective Equipment to include gowns, gloves and masks. It was determined that Resident #156 was in this room and was on Isolation Precautions. (Photographic Evidence Obtained) Resident #156 resided in the room alone. During all days observed, Resident #156 was noted in her room and in bed. An interview on 12/14/2021 at 9:00 a.m. with Staff A, Certified Nursing Assistant (CNA) , and Staff B, Licensed Practical Nurse (LPN)/Unit Nurse, who had Resident #156 on their assignment, both confirmed Resident #156 was a newly admitted resident and she was on Contact precautions and is in a room that was isolated for observations. They both confirmed that only when providing hands on care; staff are to follow the PPE instructions as noted on the door. Staff A and B both revealed that Resident #156 does not currently have an infection and the Contact was precautionary only. Neither knew if Resident #156 was care planned for Isolation precautions. An interview with Resident #156 on 12/14/21 at 10:00 a.m., while she was in her room, confirmed she was just admitted to the facility a few days ago and was unsure what Isolation, or Contact precautions meant. On 12/15/2021 at 10:00 a.m. an interview with the Director of Nursing (DON) revealed Resident #156 was a new admission from the hospital and when newly admitted , they (residents) are put on Isolation as a precautionary for a period of fourteen days. The DON confirmed Resident #156 does not currently have any type of infection but will still be monitored as part of their policy and protocol. On 12/16/2021 at 9:00 a.m. an interview with Staff C, CNA, who had Resident #156 on her work assignment; confirmed the resident was on Isolation precautions but was not really aware of the reason. She revealed that she believes the resident does not have an infection but is on precautions anyway. She was unable to say what type of PPE she was supposed to wear when providing care in the room. Review of the medical record revealed Resident #156 was admitted to the facility on [DATE] and was admitted from the hospital. Review of the current diagnosis sheet revealed diagnoses to include: dementia, and adult failure to thrive. Review of the current Order Summary Report dated for the month 12/2021 revealed Resident #156 was not currently receiving any medications or treatments for any type of infections. The orders did reveal an order to include: Isolation Droplet precaution - Presumptive for COVID on admission every shift for 14 days with the start order date of 12/10/2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 8 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 Review of the nurse progress notes dated from 12/9/2021 to 12/16/2021 did not indicate any documentation of Resident #156 with a current infection. Review of a nurse progress note (admission), dated 12/9/2021 at 04:26 (a.m.), revealed; On droplet precautions. Residents Affected - Few Review of a nurse progress note (COVID monitoring), dated 12/11/2021, revealed; On enhanced barrier precautions. Review of a nurse progress note (COVID monitoring), dated 12/13/2021, revealed; On enhanced barrier precautions and is not on quarantine. Review of a nurse progress note (COVID monitoring), dated 12/15/2021, revealed; On enhanced barrier precautions and is not on quarantine. Review of the current care plans with the next review date of 3/10/2022 did not reveal or indicate any problem areas, goals or interventions related to Resident #156 being on Isolation Precautions while in her room. On 12/15/2021 at 11:10 a.m. an interview with the MDS (Minimum Data Set)/Care Plan Coordinator confirmed Resident #156 was ordered for Isolation Precautions and there was no care planning problem area to include goals and interventions related to that. The MDS/Care Plan Coordinator revealed since Resident #156 did not have an active infection, she stopped at the assessment and did not develop a care plan for isolation. She revealed the isolation is a precaution for residents who were admitted from the hospital and observed as isolation precautions for fourteen days. The MDS/Care Plan Coordinator continued to say this area should have been care planned to indicate the reasoning with goals and interventions. She further confirmed they usually care plan any resident who is on isolation precautions, whether or not they have an infection. A review of the policy titled, Care Plans, Comprehensive Person-Centered, with a revision date of 12/20216, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Policy Interpretation and Implementation revealed the following: #8 The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; k. Reflect treatment goals, timetables and objectives in measurable outcomes; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 9 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 o. Reflect currently recognized standards of practice for problem areas and conditions. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 10 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, family interview, staff interview and record review the facility failed to provide a timely discharge for one resident (#45) out of 41 sampled residents. Resident #45 had an increase in anxiety related to her discharge which resulted in an increase in her antianxiety medications. The facility was made aware on 9/9/21 that all Comprehensive Assessment and Review for Long-Term Care Services (CARES) applications must be submitted via email. The application was not resubmitted until 9/28/21. Residents Affected - Few Findings included: An interview was conducted with Resident #45 on 12/13/21 at 11:00 a.m. The resident was observed walking independently, dressed in day clothes, hair and makeup done, clean and well-kept. The resident said can you please help me. I have been here for 3 months and no one will help me. The hospital made a mistake and sent me here. I live at an Assisted Living Facility (ALF), I tripped and had a compression fracture to my Spine at T12. The hospital sent me here to do therapy but I didn't really need it. They may have come in once to help. After about the third day of tripping my back has felt fine. I can walk I can do everything myself. They have me on this secured unit and no one can help me get back to my ALF where all my stuff is. I do not need to be here and my brother is paying for both places and he is not very happy about that. He tells me I should just call a cab and leave but I'm starting to get frustrated because I ask why I can't go back to my home and everyone keeps telling me they are waiting on my level of care I don't even know what that is and no one will explain it to me. I want to yell at someone because I'm so angry about it but I know if I do yell, they will think I'm crazy and believe that I really do belong here. Can you please help me because no one else will listen to me or help me. Review of Resident #45's Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns documented a Brief Interview for Mental Status revealed a score of 12 out of 15 indicating moderate cognitive impairment. Review of Resident #45's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. The resident was incapacitated, and her Power of Attorney was a family member. The resident had a primary diagnosis of; fracture of T11-T12 vertebra, with routine healing. Other diagnoses include but were not limited to dementia without behavioral disturbances, major depressive disorder, and anxiety disorder. A family interview was conducted on 12/14/21 at 10:24 a.m. with Resident #45's Power of Attorney. He said, I am trying to get my sister on Medicaid for financial reasons for her ALF. The ALF is costing $3,000.00 a month. The situation was we sold her condo and moved her to an ALF and now the money from the condo is gone. She has been at the ALF for 4 years. I want her to go there, all her stuff is there. I just can't afford to pay out of pocket for the ALF. I am retired and paying $3,000.00 a month is a lot and has become a financial burden on me. We are waiting on trying to get her on Medicaid, but this has been going on now since July (2021). The facility initially said it would take 60 days to get that going and now they are saying that it may take another 60 days or more. We don't want to lose the place at her ALF just because we are waiting for Medicaid to get approved. The Social Services Director said [Resident #45] can't leave because she will go to the bottom of the Medicaid list. We got a call from Medicaid on November 30th, 2021, and they just asked us medical questions. [Resident #45] was only supposed to go to the nursing home for rehab since she had a fall and fractured her T11 and T12. She was fine before leaving the hospital but, since she had a back brace, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 11 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0660 Level of Harm - Minimal harm or potential for actual harm ALF wanted her to get therapy. Well, she got a little therapy, but she isn't getting it anymore. The ALF even came to the nursing home and assessed [Resident #45] to make sure she can be independent at her ALF, and they said she can come back, she can do everything on her own. I just don't want her to lose her room at the ALF but, it seems that she is stuck at the nursing home, and no one knows when she'll be able to leave. I really hope you can help us because we need help. Residents Affected - Few An interview was conducted with the Director of Rehab and with Staff Q, Doctor of Physical Therapy (DPT) on 12/14/21 at 1:20 p.m. they indicated Resident #45 came to the facility for rehab because she had a TLSO (thoracic lumbar sacral orthotic). She started both physical therapy and occupational therapy on 7/15/21 and she was discharged from therapy on 7/28/21 because she met all her goals. Physical therapy was working on balance with gait and transfers and occupational therapy was working on upper body dressing, lower body dressing, safety with performing toileting tasks and donning and doffing her TLSO. The only goal she has not met yet for physical therapy is the patient will negotiate community obstacles including ramps, uneven surfaces, steps, curbs, with supervision with no assistive device or least restrictive assistive device. The Director and the therapist indicated at this time this goal has not been assessed. The Director of Therapy indicated the resident was only at the facility waiting for her Medicaid application to get approved and they have been told Medicaid is behind on their applications. Review of Resident #45's Psychiatric Evaluation dated 10/20/21 revealed, .patient is seen today per staff request for anxiety. Patient was observed by the nurse's station on the phone attempting to call lawyers because she was placed here by accident from the hospital. Staff reports that it is a daily occurrence and reports that patient frequently goes up to the nurse's station daily, several times a day to discuss discharge or attempt to call people on the phone about being discharged to go home. Patient was seen later in her room eating lunch. Patient reports she has history of irritable bowel syndrome which flares up with her anxiety. Reports her anxiety is high at this time due to her belief that she was discharged to the wrong facility. Patient reports anxiety occurs daily and occurs all day long and reports having difficulty sleeping at times due to anxiety. Staff reports no acute changes or concerns in appetite and sleep. Staff reports she is compliant with medications with no issues .Recommendations: at this time increase Buspar (Antianxiety medication) 7.5mg (milligrams) BID (twice a day) for anxiety. An interview was conducted with Staff Y, Social Services on 12/13/21 at 10:50 a.m. and he said Resident #45 is waiting on her level of care to come back from CARES. We have been waiting on that for over 60 days CARES is backed up. Staff Y, Social Services could not explain what a level of care was. An interview was conducted with the Admissions Director on 12/15/21 at 12:47 p.m. she indicated that she was the one who submits the Medicaid applications, and she received Resident #45's level of care last week. The process is everything starts with the Medicaid application. It is completed online then the facility collects the clinical and financial information and sends the clinical information to Elder Affairs (CARES) to determine the level of care. The financial information is sent to the Department of Children and Families (DCF) to determine the liability or if the patient is eligible. Not until Elder Affairs gives the level of care to DCF, DCF will not give the final decision if Medicaid is approved or not. The whole process between applications, document submissions, level of care and determination by DCF takes approximately 60 days. Elder Affairs is taking longer than 60 days and we have information they are behind by like three months. The admission Director indicated the business office usually sends all of the Medicaid application (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 12 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0660 Level of Harm - Minimal harm or potential for actual harm packets to Elder Affairs but the facility didn't have anyone in the business office at the time, so she faxed Resident #45's Medicaid packet. Then she was informed she had to send the packet by email not by fax. Review of the Send Result Report dated 8/9/21 revealed a referral cover sheet to CARES for applicant: Resident #45 revealed a fax result of ok. Residents Affected - Few Review of emails provided by the Admissions Director revealed an email dated 9/9/21 at 8:48 a.m. and documented, Hi, we got a phone call from CARES saying that they are receiving the requests via fax when the requests should be emailed to them. Can you please make sure all request for LOC (level of care) are emailed to CARES? On 9/9/21 at 11:34 a.m. an email from the Department of Elder Affairs was sent to the Admissions Director indicating every email submission to CARES must be submitted to [email provided]. Further email review revealed on 9/28/21 at 10:33 a.m. an email from CARES to the admission Director revealed, this case was closed on 8/30/21 because a referral packet was not received for this client, after several attempts were made to your facility for such. The case will be reopened as of today since the referral packet is included with this email. Review of Resident #45's care plan dated 7/15/21 revealed [Resident #45] is here for short stay placement related to dementia: Resident representative clearly express desire to discharge from facility. Plans to discharge from facility when medically cleared. Goal: resident/representative will participate in discharge planning process throughout stay to ensure safe discharge. Interventions included: Assess needs of patient/family beginning on the day of admission and continue assessment during stay Discuss discharge plans with resident/representative. keep involved in discharge process. Involve therapy during stay in facility as applicable Discuss progress toward discharge throughout stay Obtain discharge order from physician as needed Determine need for outside services: home health, DME (durable medical equipment), Meals on wheels-contact provider and set up services. An interview was conducted on 12/16/21 at 3:00 p.m. with the Director of Nursing and Nursing Home Administrator, they confirmed Resident #45 was only at the facility waiting for her Medicaid application to be approved. The DON also indicated standard practice is to start discharge at the time of admission and there is not a policy on that. Review of the facility's Transfer or discharge, preparing a resident for, revised December 2016 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 13 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0660 revealed: Policy Statement Residents will be prepared in advance for discharge. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 14 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and policy review the facility failed to ensure resident smoking materials were secured for three of four days (12/13/21, 12/14/21 and 12/15/21) on one unit (North Unit) of two units for seven residents (#39, #91, #18, #76, #74, #37, and #15) for a total sample of seven residents who smoked on the North Unit. Findings included: 1. During a facility tour on 12/14/21 at 12:12 p.m., Resident #39 was observed in her room, sitting on her bed. Resident #39 stated that she smokes whenever she likes day or night. Resident #39 stated she was an independent smoker and holds on to her cigarettes and lighter. Resident #39 stated that she holds on to a pack of cigarettes at a time. Resident #39 stated that she hides them under the seat of her wheelchair cushion. The admission Record showed Resident #39 was admitted to the facility on [DATE]. A Quarterly Minimum Data Set (MDS) for Resident # 39 Section C for Cognitive Patterns showed a Brief Interview for Mental Status score of 15, indicating intact cognition. Section G, Functional Status showed Resident #39 requires limited assistance with ADLs (activities of daily living). A care plan initiated on 04/28/21 showed that Resident #39 smokes independently and has been informed of the new facility smoking policy. The goal indicated Resident #39 will demonstrate safe smoking practices. An intervention of the goal stated the resident will maintain smoking materials in a designated area. A Quarterly Smoking Evaluation conducted on 10/07/21 under the Summary of Review Section C, Maintenance of Smoking Materials showed Resident #39 must request smoking materials from staff. 2. On 12/14/21 at 3:52 p.m. a tour of the smoking area was conducted and seven residents (#15, #18, #91, #37, #74, #39 and #76) from the North Unit were observed in the courtyard smoking independently. An observation of the area showed designated smoking area signs, smoking aprons hanging by the door, and metal cigarette receptacles available on each table. An interview was conducted with Resident #91. Resident #91 stated they smoke anytime they want to. Resident #91 stated he holds on to a pack of cigarettes at a time, but the rest are locked up. Resident #91 said, I keep my lighter and smokes on my person. The admission Record showed Resident #91 was re-admitted to the facility on [DATE]. The admission MDS for Resident #91 dated 11/04/21 Section C-Cognitive Patterns, showed the resident was unable to complete the BIMS assessment. A smoking care plan initiated on 01/27/21 showed Resident #91 smokes independently and has been informed of the new facility smoking policy. The goal indicated that Resident #91 will demonstrate safe smoking practices. An intervention of the goal stated the resident will maintain smoking materials in a designated area. A Quarterly Smoking Evaluation conducted on 11/02/21, under Summary of Review, Section C, Maintenance of Smoking Materials showed Resident #91 must request smoking materials from staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 15 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. An interview was conducted with Resident #18 on 12/14/21 at 3:54 p.m. Resident #18 confirmed they [residents on the North Unit] smoke anytime. Resident #18 stated that he keeps his cigarettes and lighter on him. The admission Record showed Resident #18 was re-admitted to the facility on [DATE]. A Quarterly MDS for Resident #18 dated 09/22/21 Section C - Cognitive Patterns showed Resident #18 had a BIMS of 15 indicating intact cognition. A smoking care plan initiated on 01/27/21 showed Resident #18 smokes independently and has been informed of the new facility smoking policy. The goal indicated Resident #18 will demonstrate safe smoking practices. An intervention of the goal stated the resident will maintain smoking materials in a designated area. A Quarterly Smoking Evaluation conducted on 12/14/21, under Summary of Review, Section C, Maintenance of Smoking Materials showed Resident #18 must request smoking materials from staff. 4. A review of the smoking care plans and smoking evaluations for Residents #15, #37, #37, #74 and #76 also showed the residents should maintain smoking materials in a designated area and must request smoking materials from staff. On 12/14/21 at 3:57 p.m., an interview was conducted with Staff D, Certified Nursing Assistant (CNA). Staff D was observed walking into the smoking area where the seven residents (#15, #18, #91, #37, #74, #39 and #76) were smoking. Staff D stated that the residents who were smoking at the time were independent and did not require supervision. Staff D explained that residents who need assistance or are assessed as dependent smokers follow a smoking schedule. Staff D stated that an assigned staff member comes to the courtyard with the residents' cigarettes and lighters stored in a box. Staff D stated the box is secured in the nurses' unit. Staff D stated this was not the practice for independent smokers in North Unit. Independent smokers hold on to their smoking materials. On 12/14/21 at 3:59 p.m., an observation was made of Staff E, Registered Nurse (RN) and evening supervisor in the smoking courtyard. Staff E approached Resident #18 and asked him if she could use his lighter. Resident #18 handed his lighter to Staff E. Staff E was observed lighting a cigarette for an unidentified resident. An immediate interview was conducted with Staff E. Staff E confirmed that independent smokers have been assessed to come and go on their own. Staff E said, they keep their lighters and smokes on them. On 12/15/21 at 9:25 a.m. an observation was made of Resident #39, #15 and #76 outside on the courtyard smoking. The residents had their cigarettes on them and lighters. These residents stated they keep their smoking materials on them all the time. On 12/15/21 at 1:55 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated that North Unit smokers [#15, #18, #91, #37, #74, #39 and #76] have a box where they keep cigarettes and lighters. The NHA stated they have a schedule, but if they are deemed to smoke unsupervised, they can come and go on their own. When asked about their smoking materials the NHA stated the residents should get their articles for smoking and then go outside. When asked if the residents were permitted to hold on to their cigarettes and lighters the NHA said, No, they are supposed to turn them in. Residents should not be holding on to their cigarettes and lighters they acknowledged the policy. The NHA said, If staff are allowing them to, they should not. Now that I know, I will follow-up with the residents and staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 16 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 12/16/21 at 10:26 a.m., an interview was conducted with Staff F, Staffing Coordinator. Staff F was observed stationed by the North area exit door. Staff F was noted with a sign in/out log. Staff F stated that each resident has to sign in/out when receiving their cigarettes and lighters. Resident # 39 was observed signing out her smokes and lighter. Review of the facility's smoking policy titled, Smoking Policy - Residents, revised 02/14/2020, showed, #12 residents are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Resident's smoking paraphernalia will be kept in a designated secure location. Event ID: Facility ID: 105486 If continuation sheet Page 17 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interview and record review the facility failed to ensure one of one walk in freezers was operating in a manner to be free from ice blocking and heavy frosting. It was observed that heavy ice was formed on the ceiling, motor fan housings, shelving, and various packaged food items for two days of four days observed (12/13/2021 and 12/16/2021). Residents Affected - Few Findings included: On 12/13/2021 at 9:56 a.m. a facility kitchen tour was conducted with the floating kitchen manager. Upon approaching the walk in freezer, the outside digital thermometer screen was not able to be read. The screen read what appeared to not be numbers. It did not indicate what the internal temperature was. Once the door was opened and the freezer was entered, it was observed with approximately five foot shelving on either side of walls and the back wall. Above the right side shelving, was observed with a double plastic fan housing with a motor attached. Further observations revealed heavy ice build-up on the ceiling in front of the fan housing, on both fan housing cases, and very large ice chunks built-up on the tubing leading from the motor to the side wall Also, there was heavy ice blocking/build-up on the top right shelf under the fan and motor housing, as well as heavy ice blocking/build up on three packages of food items. Several blocks of ice were noted approximately four inches in diameter. The ice build-up on the packages of food items were approximately three to four inches thick in areas. (Photographic Evidence Obtained) On 12/16/2021 at 11:00 a.m. another kitchen tour was conducted with the oncoming kitchen manager. The oncoming kitchen manager indicated they had removed the ice blocking/build-up and have a work order with maintenance. The walk in freezer was approached and the door was opened. Once entered, the large amount of ice blocking had been removed. However, it appeared that the same areas were already starting to build up with frosting/icing. It was determined that the ice building was an ongoing issue. An observation of the internal thermometer revealed a temperature of minus thirteen degrees Fahrenheit. It was determined that the freezer held appropriate temperatures inside. An interview at this time with the oncoming kitchen manager revealed the floating kitchen manager was not aware of how long the ice had been building in the freezer. She was unsure if there were any work orders with maintenance with relation to the heavy ice build-up. It was confirmed through interview with the Maintenance Director and the Nursing Home Administrator on 12/16/2021 at 1:00 p.m., there were no current work orders with regards to the kitchen walk in freezer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 18 of 18