Health inspection·July 18, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the effectiveness of the system. The wall above A bed's headboard contained a patched area of wall approximately the size of a soccer ball. The edges of the bathroom mirror were de-silvering. A raw piece of lumber was nailed vertically to the left side exterior of the bathroom vanity. One of three vanity lightbulbs was missing. The wall mounted toilet paper dispenser was missing the toilet paper holder rod. 161 - The edges of the mirror in room [ROOM NUMBER]'s bathroom were de-silvering. One of three vanity lightbulbs was out. The wall mounted toilet paper dispenser was missing the toilet paper holder rod. The wall behind room [ROOM NUMBER]'s door contained a golf ball sized hole within a softball sized patched area. The dresser designated for B bed had missing laminate/vinyl which spanned the length of the dresser top and exposed the underlying particle board. 160 - room [ROOM NUMBER] contained two residents and had no privacy curtains. The dresser designated for A bed had one of six drawers with functional handles/knobs. Some of the hardware present was mismatched. The front and top of the dresser showed wear and tear as evidenced by scratch marks on all forward facing surfaces and discoloration on the top where the original dark wood stain had worn away. 158 - room [ROOM NUMBER] was a double occupancy room, but only B bed was occupied at the time. The wall behind A bed's headboard contained an approximately 4-foot-long patched area. The door of A bed's nightstand was missing a knob. The window wall and headboard wall for B bed contained approximately 4 patched areas. 156 - Across from the bathroom door in room [ROOM NUMBER] is an area of patched wall approximately 1.5 x 2.5 feet. The side and rear wall surrounding the wardrobe belonging to A bed contained approximately 3 patched areas. The wall above B bed's headboard contained 3 patched areas. The wall above the rear left corner of B bed's dresser contained two patched areas, one of which was approximately 1.5 x 1.5 feet. The bathroom mirror was de-silvering around the edges and most notably in the bottom left corner. The bathroom floor is originally beige in color but stained black around the toilet from the vanity to the wall. The bathroom walls were visibly rough and uneven with layers of patchwork. 154 - In room [ROOM NUMBER], the floor in front of the air conditioner contained a broken tile. The wall in-between A and B bed's nightstands contained a patched area approximately 1.5 x 1 feet. 152 - In room [ROOM NUMBER]'s bathroom, the wall mounted toilet paper dispenser was missing the toilet paper holder rod. Two of three vanity lightbulbs were out. The floor around the toilet was dirty and in disrepair. 146 - The top of the dresser in room [ROOM NUMBER] designated for B bed was scratched and peeled away in the front middle and front left corner. In room [ROOM NUMBER]'s bathroom, the wall mounted toilet paper dispenser was missing the toilet paper holder rod. One of three vanity lightbulbs was out. The left side of the bathroom vanity had a raw piece of plywood nailed to it. The bathroom contained a light-colored floor but the areas around the base of the toilet and vanity contained a buildup of a dark brown substance. 144 - The wardrobe in room [ROOM NUMBER] designated for A bed contained a mismatched set of drawers, one of which had no handle. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 2 of 8 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 07/18/2023 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 143 - The dresser in room [ROOM NUMBER] designated for B bed contained 3 of 6 drawers with no knobs. The stain on the top of the dresser was also worn away in areas exposing the lighter color below the surface. 142 - The wall in room [ROOM NUMBER] next to A bed's wardrobe contained black horizontal scuff marks and a patched area of wall. There were also approximately 5 small, patched areas of wall above A bed's headboard. The dresser designated for B bed had four of eight knobs missing. The dresser contained signs of wear and tear like chipped surfaces. The set of drawers on the wardrobe designated for B bed contained mismatched hardware. The wheelchair cushion designated for B bed contained dried food debris. 141 - In room [ROOM NUMBER], the floor at the base of the left side doorframe (from hallway) contained broken tile. The wall next to A bed was missing the rubber baseboard leaving the damaged wall behind it exposed. The rubber baseboard was also peeled away from the wall in the bathroom behind the toilet, around the vanity, and on two other walls. 140 - The wardrobe in room [ROOM NUMBER] designated for B bed contained a set of drawers with a missing handle. The exterior coating of the wardrobe door was peeling away around the bottom edges. All three drawers of the nightstand designated for B bed were misaligned and in need of repair. In the bathroom, a potent urine smell was present, and the floor contained yellow discoloration around the toilet. The bathroom contained a white patch of unpainted wall the size and shape of a soap dispenser to the right of the vanity. Approximately 5 patched areas were present on other walls of the bathroom. 139 - In room [ROOM NUMBER], the floor at the base of the right-side doorframe (from hallway) contained broken tile. 138 - In lieu of hardware, the wardrobe door in room [ROOM NUMBER] designated for A bed contained a makeshift handle made of fabric. The A bed was made but contained a stained pillowcase and soiled bed linens. 136 - In room [ROOM NUMBER], the dresser designated for A bed contained four of four drawers with loose knobs and one of these drawers was missing a knob. The dresser contained signs of wear and tear like chipped and scratched surfaces. The top of the nightstand designated for B bed contained a warped surface and liquid stains. In the bathroom, the rubber baseboard was missing from the wall to the right of the door. 135 - In room [ROOM NUMBER], the wall corner just to the left of the doorway (from the hall) was in disrepair and missing the rubber baseboard. The flooring at the base of both sides of the doorframe was damaged as it contained broken tiles. The wall beneath the air conditioning unit was damaged as evidenced by discoloration and exposed layers of drywall material. 134 - In room [ROOM NUMBER], the wardrobe designated for B bed was missing one of two drawers. 133 - The blinds in room [ROOM NUMBER] were in disrepair as evidenced by broken slats. 132 - In room [ROOM NUMBER], the dresser designated for B bed contained a broken handle, scratches, and chipped paint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 3 of 8 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 07/18/2023 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 Day room [ROOM NUMBER] contained a rusted two-drawer filing cabinet. Day room [ROOM NUMBER] also contained damaged wall where a sink and soap dispenser had been removed. A wooden box was nailed to the wall to conceal the plumbing. The door to the closet that stores the activities supplies in day room [ROOM NUMBER] has a hole where a doorknob had previously been as well as missing paint around the knob. Residents Affected - Some The mosaic tile floor of the shower room contained mismatched sections of tiles. The shower floor contained dark brown stained tiles and grout. The shower walls contained areas of brown stained grout. The ceiling air vent by the nurses' station contained droplets of condensation and black biological growth. The mechanical lift by the smoking patio was uncovered and contained a layer of gray film. Hair was spun around the wheels. On 7/11/2023 at 3:27 PM, during the aforementioned tour, the Nursing Home Administrator (NHA) approached this surveyor to inquire about the concerns identified so she could get them addressed overnight. The surveyor stated that it would be difficult for the facility to address all environmental areas of concern by tomorrow. Due to the extent of concerns and the fact that evidence gathering was still in progress, the surveyor walked the NHA through room [ROOM NUMBER] as an example and pointed out the concerns noted in the tour above. Regarding the wheelchair utilized by A bed, she stated housekeeping is responsible for deep cleaning wheelchairs every other month and nursing staff are supposed to be wiping down resident equipment daily/after each use. The NHA questioned the environmental concerns pointed out by the surveyor. When asked if her home looks like this (patched areas of wall, furniture in disrepair, etc.), she replied No. On 7/12/2023 at 9:56 AM, an interview was conducted with the Director of Maintenance/Environmental Services. He stated he has been in this role since the end of October (2022). He added that he has an assistant that started around the middle to end of January (2023). When asked if there's a system in place to ensure all resident rooms were audited at some regular interval to identify needed repairs/maintenance, he replied No. He added that the rooms he is in regularly are those of residents who clog the plumbing several times a day. When asked for the primary reason the memory care unit appeared in its current condition, he stated that it has been a slow process because they try not to have maintenance activities affect the residents, so they try to keep work and projects limited and confined to small areas. He added that he would like to make faster progress. When asked if there was any furniture that had been reported on any maintenance logs as needing replacement, he replied No. He added that the previous administration had mentioned the intent of having some furniture replaced. On 7/12/2023 at 10:26 AM, an interview was conducted with Staff I, Housekeeper. She stated she works 4 days per week and strictly on the memory care unit (South). She further stated she has worked at the facility for about 6-7 months. When asked to describe the protocols and procedures for cleaning shared resident equipment (e.g., lifts) and individual resident equipment (e.g., wheelchairs and walkers), she stated that housekeeping does not clean those items. She added that housekeeping handles linens, but not resident equipment. Staff I continued that she is also a certified nursing assistant (CNA) and when she is working as a CNA, she will wipe down equipment after use. Staff I stated that when she is working as a housekeeper, if she sees a wheelchair that is really bad, she will wipe it down. Staff I further stated that the night staff sometimes get a team together to clean resident wheelchairs while residents are asleep. When asked how she handles identified items in need of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 4 of 8 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 07/18/2023 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 repair or replacement while she is in resident rooms cleaning, she stated she often sees the Maintenance Director in passing and will verbally express needs and he will write it down, or she will have him paged or she will write it down in the logbook. When asked what type of memory care unit concerns she has brought to the Maintenance Director's attention over the last 6 months, she stated clogged plumbing, mold, and hand sanitizer dispensers coming loose from the wall in common areas. Residents Affected - Some On 7/12/2023 at 10:48 AM, an interview was conducted with the Housekeeping Manager. She stated she has been at the facility for about a year. When asked to walk through housekeeping's cleaning process, she stated their routine is to wipe down windowsills, air conditioning units, tops of wardrobes, handles, bedrails as well as empty bed mattresses, clean cords, dust off lights, disinfect call lights, and clean IV (intravenous) poles containing obvious spills. When asked about the cleaning process for resident equipment, she stated that wheelchairs are power washed on a bi-monthly basis for each unit, the South Unit is done one month and then the North Unit the next, but her team is not responsible for this. When asked if that included lifts she replied, No. The Housekeeping Manager added that there was a meeting held by the NHA about a month ago in which they were directed to start cleaning the lifts once a month. The Housekeeping Manager explained that there was an individual in central supply who used to have this duty, but they are no longer doing it and it has since been reassigned to housekeeping. When asked who is responsible for bed linens, she replied that CNAs change out bed linens, but housekeeping washes them. When asked if she conducts any quality assurance checks of staffs' work, she said there are rooms that are assigned to be deep cleaned daily and she checks those rooms which includes completion of a form in which she checks a box for satisfaction or unsatisfaction. When asked how she handles unsatisfactory audits, she stated she approaches the staff and lets them know it was a miss and that it needs to be redone. When asked if there is any sort of re-education that is provided as part of that process, she replied that she just refers them back to the terminal cleaning checklist which covers all items to address. On 7/12/2023 at 12:09 PM, an interview was conducted with Staff F, CNA. Staff F stated she has worked at the facility for approximately 5 years and is solely assigned to the memory care unit (South). When asked to provide examples of items she would report to maintenance for repair/replacement, she stated broken furniture, broken toilets, stuff hanging off the wall, broken lights, and problems in the shower room such as a non-functional shower hose or no warm water. When asked to explain the facility's process for reporting these concerns, she stated there's a maintenance logbook at the nurses' station to enter the date, time, location (e.g., resident room, dayroom, etc.), reporter's name, and summary of concern. When asked if she had identified any reportable issues today, she replied Yes, we noticed the hand sanitizer dispenser was hanging off the wall in the dayroom. Maintenance took care of it right away. When asked if there was anything else that seemed in need of repair/replacement, particularly in resident rooms, she replied No. When asked if the furniture all appeared to be in good working condition, she replied, Well, no, there are drawers that are broken but maintenance is aware of that, and I'm told it is going to be replaced. When asked if the resident rooms appeared homelike, she replied No, not all of them, it could be better. Review of the facility's Safe and Homelike Environment policy and procedure implemented 6/24/2023 revealed In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. The policy defined environment as any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. The policy further provided the following definition of sanitary includes but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 5 of 8 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 07/18/2023 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 stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. Section 3 of the policy revealed Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Section 4 of the policy revealed The facility will provide and maintain bed and bath linens that are clean and in good condition. Section 6 of the policy stated, The Maintenance Director will perform periodic rounds to ensure functioning lights. Review of section 9 which included general considerations revealed Report any furniture in disrepair to Maintenance promptly. Review of the facility's Cleaning and Disinfection of Resident-Care Equipment policy and procedure implemented 6/24/2023 revealed the Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC (Centers for Disease Control and Prevention) recommendations in order to break the chain of infection. Item 3 under Policy Explanation and Compliance Guidelines revealed Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include: . b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. c. Direct care staff are responsible for cleaning single-resident equipment when visibly soiled, and according to routine schedule (where applicable). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 6 of 8 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 07/18/2023 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. Based on interview and record review, the facility failed to report a reasonable suspicion of a crime to law enforcement for 1 of 4 incidents reviewed. (Resident #3). Law enforcement was not notified after a 30-day supply of the anti-anxiety/ anti-seizure medication Klonopin was found to be missing from the medication cart, was never signed in as received and was not entered on the facility's controlled substance inventory list. The findings include: Review of a facility reported incident that was submitted on 5/6/2022 regarding an allegation of misappropriation of resident property revealed the Nursing Home Administrator (NHA) at the time of the incident submitted the report and initiated an investigation. According to the report's investigative findings, Resident #3 had diagnoses of autistic disorder, schizophrenia, anxiety disorder, and hypertension. Further review revealed the nurse caring for Resident #3 on 5/5/2022 noticed that the card for Klonopin 0.5 mg was not in the narcotic box on the cart. A nurse then called the pharmacy and confirmed that it was delivered on 5/4/2022. Staff A, Licensed Practical Nurse (LPN), was the nurse to receive the medication from the pharmacy on the morning of 5/4/2022. The medication was not entered on the controlled substance inventory list and the requisition sheet from the pharmacy was missing. The nurse and evening supervisor searched for the card of medication on all medication carts, but it was not located. The report indicated that the resident representative and the abuse registry were both notified on 5/6/2022. There was no indication the incident had been reported to law enforcement. Upon entrance to the facility on 7/11/2023 at approximately 8:20 AM, the surveyor met with the Director of Nursing (DON) and requested all documentation pertaining to the aforementioned facility reported incident. On 7/12/2023 at approximately 11:00 AM, a telephone interview was conducted with the former Nursing Home Administrator (NHA) in the presence of the current NHA, the Regional Clinical Director, and the Divisional Risk Manager. The surveyor stated that so far during this complaint investigation, there has been no evidence that law enforcement was notified. When asked if the incident was reported to law enforcement for investigation, the former NHA responded, Yes, it was. It would be in the investigative file. When asked who would have been responsible for notifying law enforcement, she replied the (former) DON. Following this interview, the current NHA went to search for evidence that a report was made to law enforcement but was unable to locate the documentation in the facility's investigative file. On 7/12/2023 at approximately 12:00 PM, the current NHA reported that she called the Pinellas Park Police Department and was informed she would have to submit a public record request since the incident was from 2022. The surveyor invited the NHA to share any documentation received from the request even if it was after survey exit. By 7/18/2023, no additional information pertaining to the police report had been received from the facility. On 7/18/2023 at 10:38 AM, a telephone interview was conducted with Police Records Technician from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 7 of 8 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 07/18/2023 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 Pinellas Park Police Department. At the request of this surveyor, the Police Records Technician reviewed the 2022 reports/intakes in their computer system and stated that no report in which Resident #3 was the alleged victim or Staff A was the alleged perpetrator had been received by the department. Review of the facility's Narcotic Management and Destruction policy and procedure implemented 2/18/2023 revealed that the drug diversion process includes Notify police and follow additional guidance provided by them. Review of the facility's Reporting Reasonable Suspicion of a Crime policy and procedure implemented 9/27/2022 revealed It is the policy of this facility pursuant to Section 1150B of the Social Security Act, to report any reasonable suspicion of a crime against a resident of this facility. Review of section 5 under Policy Explanation and Compliance Guidelines revealed notification will include Each covered individual's independent obligation to report the suspicion of a crime against a resident or individual receiving care and services from the facility directly to law enforcement. Further review of section 5 revealed the timeframe requirements for reporting reasonable suspicion of crimes as follows: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion no later than 24 hours after forming the suspicion. The policy also stated, Although it remains the responsibility of each covered individual to ensure that his/her individual reporting responsibility is fulfilled, in addition to reporting directly to law enforcement and the State Survey Agency, it is the policy of this facility that employees also report suspicions to the Administrator, or designee. The policy continued that The Administrator, or designee, will then assist the covered individual with reporting requirements and ensure specified timelines are met accordingly for both the initial and follow-up investigation reports and any other State level required reporting. Further review revealed Examples of situations that would be considered crimes in all subdivisions include, but are not limited, to: . g. Drug diversion for personal use or gain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 8 of 8