Health inspection·December 11, 2024

F 0812 -A container of thickener powder with a cup stored in the powder. Level of Harm - Minimal harm or potential for actual harm -A second container of thickener powder contained a small brown foreign object. -Shelves being used to store food in the dry storage area were rusty and had dust and debris on them. Residents Affected - Many -The walk-in refrigerator had a covered plate of deviled with no date. -The walk-in refrigerator had an unlabeled paper bag on the shelf that contained an unlabeled plastic bag with unidentifiable food and liquid inside. -The walk-in refrigerator had a box of bacon wrapped in plastic. The plastic had been torn open and the bacon was sitting unwrapped. -The walk-in refrigerator had milk crates sitting directly on the floor. -The walk-in refrigerator had a lunch box containing a sandwich sitting on top of a tray eggs. -The walk-in refrigerator contained a rack with spilled mandarin oranges and a pan covered in liquid. -The walk-in freezer contained a blue unlabeled plastic bag tied in a knot. -There was a half empty bottle of green tea sitting on the food preparation table. -There were wires and a piece of insulation in the middle of the kitchen floor under a preparation table. -There was trash and spilled liquids on the floor behind the cart containing the coffee maker. -Two bottles of salad dressing were sitting on the floor being used to prop open the door to the dry food storage room. -The kitchen walls had dirt, grease, and spilled liquid on them. -There was a section of wall by the door in the kitchen that the tile had come off and there was an uncleanable surface. The section of missing tile was sitting on top of a preparation table. -The stainless food preparation tables in the kitchen were corroded and rusting. -There were dead bugs on the table with the coffee maker. -One of the stainless food preparation tables was broken and uneven. -A live roach was observed running across the floor under the three-compartment sink. -A plastic two drawer organizer was sitting on the second shelf of a food preparation area. The organizer was covered in dust, and spilled substances. The top drawer contained cereal and cake mix (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 2 of 6 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 12/11/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stored with disposable cups, lids, plastic bags and wrapping paper. The second drawer contained cups and disposable containers along with a stapler, highlighter and pair of eyeglasses. A second plastic storage bin was sitting on the shelf and it was also covered in dust and spilled substances. -Plates were sitting face up on the bottom shelf of the stainless preparation table and stainless bowls were sitting on a shelf with the useable surface face up. -The electrical outlet at the center food preparation area was heavily coated with dust, dirt and a stick substance. On 12/10/2024 at 3:45 p.m. an observation and interview was conducted in the facility's kitchen. Staff A, Dietary Aide was observed in the process of washing dishes with the dishwasher. Staff A demonstrated sanitizer testing. The test strip showed a result of less than 50 PPM (parts per millions). Staff A confirmed the results and stated the results should be between 50-100 PPM. Staff A stated dishes should be run back through. The Certified Dietary Manager (CDM) arrived in the dishwasher area and performed a second test and confirmed the results were less than 50 PPM. The CDC stated, It should be darker. The CDM confirmed the dishwasher was a low temperature/ chemical sanitizer dishwasher. An observation and interview was conducted on 12/10/24 at 3:53 p.m. with the CDM. The CDM was observed leaving her desk from doing paperwork without performing hand hygiene. She walked into the walk-in refrigerator and said the deviled eggs should have been dated/labeled. She looked at the paper bag containing the plastic bag of unidentifiable food and said, That shouldn't be in here. She said it was not labeled and was for a staff party. The CDM said the bacon should be wrapped in plastic and not left uncovered. She said the lunch box belonged to a staff member and should not be in the refrigerator. She then picked up the deviled eggs, lunch box, and paper bag and removed them from the refrigerator. The CDM said the gnats had been a problem in the kitchen since the beginning of October and they were treating them. She also looked in the dry storage room and said the bottles of dressing should not be on the floor propping the door open. She was observed moving the bottles to a shelf. She also said the cup should not have been stored in the thickening powder and she was observed removing it. The CDM had still not performed any hand hygiene. She was observed reaching into the second container of thickening power with her bare hands and taking out the brown foreign object. When asked what she would do with that thickening powder she said they would use it because It wasn't a bug or anything. The CDM reviewed pictures of the nourishment rooms. She said the rooms should be cleaned by housekeeping and cleaning the refrigerators and freezers is a team effort. She said juice should not have been in the refrigerator from 11/19/24 and all food should be labeled/dated. When discussing the broken seals on the refrigerator and freezer she stated Oh that's north unit. That fridge needs to be replaced. The CDM said there should be working thermometers in the refrigerator and freezer and she would replace them. She also said the freezer should not look the way it does and should not be dirty. On 12/11/2024 at 9:17 a.m., an observation and interview was conducted with Staff B, Dietary Aide. Staff B was in the process of washing dishes with the dishwasher. Staff B stated she had washed numerous trays of dishes through the dishwasher and stated she had not tested the dishwasher in the morning. Staff B performed a test strip with results less than 50 PPM. Staff B performed another with results less than 50 PPM and stated, It's getting there. The assistant CDM came to the service area and agreed the test strip was less than 50 PPM as Staff B continued to wash the dishes. The assistant CDM performed four separate tests and on the fourth test the results were at 50 PPM. The assistant CDM stated the dishwasher should be run through several times and tested each time until it reaches (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 3 of 6 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 12/11/2024 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 0812 the goal of 50-100 PPM. The CDM stated she will have the dishwasher serviced immediately. Staff B was observed putting the previously washed items on a rack with clean dishes to dry. Level of Harm - Minimal harm or potential for actual harm A follow-up observation was conducted on 12/11/24 at 9:27 a.m. in the kitchen of: Residents Affected - Many -The two bottles of salad dressing remained on the floor propping open the dry storage room door. -The shelves in the dry storage room had spilled sugar and small ants crawling on them. -There was a puddle of liquid in the middle of the dry food storage room. -The plastic storage containers continued to be covered in dust and crumbs. -The bacon in the refrigerator remained unwrapped. -The unlabeled blue plastic bag remained in the walk-in freezer. The bag was opened and observed to contain vegetables. -The milk cartons remained sitting directly on the floor in the walk-in refrigerator. -The plastic storage bins under the preparation table continued to have cake mix and cereal stored with disposable cups and lids. -The front of the reach-in refrigerator had dried liquid and food particles on the doors. An observation and interview was conducted on 12/11/24 at 9:27 a.m. in the kitchen. The CDM was sitting at her desk with her office door open five feet from the dry storage room. She walked out of her door and was asked about the two bottles of salad dressing sitting on the floor being used as a door prop. She stated, Oh, they put them back. The CDM said she did not know there were ants in the dry storage room. She observed the ants and said the shelves needed to be cleaned and she would call maintenance to see about getting a treatment. The CDM was asked about the unlabeled blue plastic bag in the walk-in freezer. She was adamant It was ice. The assistant dietary manager opened the bag and confirmed it was vegetables and not ice. The CDM said,It needs to be thrown out. It felt like ice An interview was conducted on 12/11/24 at 10:15 a.m. with the Maintenance Director and Regional Maintenance Director. They observed the wires and insulation in the middle of the kitchen floor and said it should be covered with a box, not exposed. An interview was conducted on 12/11/24 at 10:18 a.m. with the Assistant Dietary Director. She said the milk crates should not be sitting on the floor in the walk-in refrigerator. She looked at the dirty containers in the kitchen and said they should be cleaned daily. She looked inside the drawer of the two drawer storage container and said she did not know why food was in there with nonfood items. She was also observed looking at the food preparation tables and confirmed they have rust and corrosion on them. An interview was conducted on 12/11/24 at 12:30 p.m. with a service representative from the dishwashing chemical company. He reviewed the pictures of the sanitation test strips and confirmed the chemical concentration did not reach 50 PPM. He said they chemicals should have been tested on a plate surface instead of the trough and the concentration would probably be less there. He said the machine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 4 of 6 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 12/11/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many should be run 2-3 times then tested to ensure the temperature was up to 120 degrees Fahrenheit and the chemical sanitizer reached 50 PPM prior to washing dishes. A review of the facility's policy titled, Dishwasher Temperature, revised 10/19/2022 showed the following: Policy statement: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperature. A further review of the policy, showed the following explanation and compliance guidelines: 4. For low temperature dishwashers (chemical sanitization) a. The wash temperature shall be 120 degrees Fahrenheit. b. The sanitizing solution shall be 50-100 PPM (parts per million) hypochlorite chlorine on dish surface in final rinse. 5. If needed, run several empty dish racks through dishwasher to obtain the correct temperature and parts per million. 6. Chemical solutions shall be maintained at the correct concentration, based on periodic testing at least once per shift , and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded. 7. Water temperature shall be measured and record prior to each meal and/or after the Dishwasher has been emptied or re-filled for cleaning purposes. 8. Immediate action will be taken if dishwasher temperatures and/or chemical levels are inadequate. A review of the facility's policy titled, Food Safety Requirements, revised on 10/19/2022, showed the following: Policy statement: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety. Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. a. b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 5 of 6 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 12/11/2024 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 0812 c. Level of Harm - Minimal harm or potential for actual harm f. Employee hygienic practices. 3. Facility staff shall inspect all food, food products, and beverages for safe transport and Residents Affected - Many quality upon delivery/receipt and ensure timely and proper storage. . b. Dry food storage-keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents. d. Refrigerated storage foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation. ii. iii. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use -by date, or frozen (where applicable)/ discarded; and v. Keeping foods covered or in tight containers. 6. All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. a. Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. b. 7. Staff shall adhere to safety hygienic practices to prevent contamination of foods from hands or physical objects a. Staff shall wash hands according to facility procedures. (Photographic evidence obtained). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105486 If continuation sheet Page 6 of 6