Inspection·May 20, 2021

F 0561 Level of Harm - Minimal harm or potential for actual harm Interview on 05/18/21 at 11:28 AM with the Activities Director who revealed that there is no scheduled smoking time, that residents can go out as they like. He reported that at this time there are only 2 people who need to be supervised while smoking. He reported that those residents who are on isolation are not allowed to smoke, they assist those residents with there smoking needs by shopping for the cigarettes for the resident. Residents Affected - Few Interview on 05/18/21 at 01:45 PM with the NHA (Nursing Home Administrator) revealed that the residents who are under isolation and smoke can still smoke and they are offered the patch. Review of the facility policy titled Resident Rights with a revision date of December 2016 revealed that 1. Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to:: e. self-determination; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review the facility failed to appropriately investigate the concerns of the resident council group and keep them apprised of the resolution of the concern bought up by the resident council group. Findings included: Review of the Resident Council meeting minutes for the months of March, April, and May 2021 identified concerns related to rude staff on the 11:00 PM-7:00 AM shift. Review of grievance dated 3/1/21 revealed that the activities director received a grievance from the Resident Council group related to Residents state the 11-7 staff are rude to them. The form indicated that the action that was taken to resolve the issue was In-serviced staff on customer service. Review of the facility education revealed that staff were in-serviced on 3/2/21 and 3/3/21 related to customer service and treating resident with respect and dignity. The grievance form indicated that the concern was resolved on 3/3/21, however there was no documentation that would indicate that the concern had been investigated and the area on the form that indicated that the residents were notified of the resolution and their satisfaction with the resolution was left blank. Review of grievance dated 4/6/21 revealed that the activities assistant received a grievance from the Resident Council group related to Residents state the 11-7 staff is rude. The form indicated that the action that was taken to resolve the issue was customer service (See attached). Review of the attached document revealed a facility education dated 4/9/21 related to customer service. The grievance form indicated that the concern was resolved on 4/9/21, however there was no documentation that would indicate that the concern had been investigated and the area on the form that indicated that the residents were notified of the resolution and their satisfaction with the resolution was left blank. Review of grievance dated 5/3/21 revealed that the Resident Council group filed a grievance related to Residents state the staff on the 11-7 shift are rude. The form indicated that the action that was taken to resolve the issue was Education given to staff related to customer service. Review of the facility education revealed that staff were in-serviced on 5/10/21 related to customer service. The grievance form indicated that the concern was resolved on 5/10/21, however there was no documentation that would indicate that the concern had been investigated and the area on the form that indicated that the residents were notified of the resolution and their satisfaction with the resolution was left blank. Interview with a group of 5 alert and oriented residents on 05/19/21 at 10:00 AM revealed that staff on the 3:00 PM-11:00 PM and the 11:00 PM-7:00 AM shift have bad attitudes and are rude to the residents. The group reported that they have brought this concern up multiple times during their Resident Council Meetings but have had no resolution and the staffs' bad behavior has continued. The group report that the staff involved are mostly agency staff who they believe are working at the facility only for a paycheck. An interview was conducted on 05/20/21 at 06:33 PM with the Activities Director who reported that when a concern is brought to the council meeting, he writes it up as a grievance and submits it to the social worker as she is the grievance coordinator. He reported that if the issues are still (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0585 present at the following meeting he will file another grievance. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 05/20/21 at 06:54 PM with the Director of Social Services/Grievance Coordinator who said that when she gets the grievance from resident council she will forward it to the appropriate department and in this case it was nursing. She reported that nursing does the in-service and then it comes back to her and she logs it back in and then she meets with the Administrator to go over it and then during angel rounds will check with the residents to see how things are going. She reported that for the months of March, April and May 2021, education of staff was the resolution related to the resident councils concerns. Residents Affected - Few An interview was conducted with on 05/20/21 at 07:21 PM with the Director of Social services and the Activities Director. The Director of Social Services confirmed that the follow-up section of the grievance form was left blank. She was unable to verbalize if an investigation into the concerns was made and if the residents were aware of the resolutions and if they were satisfied with the resolution. The Director of Social Services was unable to provide any documentation that would indicate that an investigation into the resident council concerns had occurred. The Director of Social Service reported that she understood that she should be ensuring resident satisfaction of the resolution of their concerns. Review of the facility policy titled Grievances/Complaints, Filing with a revised date of 5/2020 revealed that The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure three (#88, #124, #102) of 54 residents sampled were provided services to maintain grooming, and personal and oral hygiene. Residents Affected - Some Findings included: 1) On 5/17/21 at 2:55 p.m. Resident #88 was observed self-propelling his wheelchair in the hallway of his unit. He was wearing a pair of white shorts and presented with a dark yellow colored stain just below his waistline and on both sides of his groin. A staff member was in the hallway and was asked about his soiled clothing. She looked at the resident and stated, you need to go to your room and get your shorts changed before you go outside. She then turned his wheelchair around and transported him to his bedroom. At 3:35 p.m. Resident #88 remained in his bedroom when Staff Member B, Certified Nursing Assistant entered the bedroom with a blood pressure cuff, and temperature probe. She was observed as she was performing his blood pressure check. She was overheard telling the resident he needed to wait to go outside. She then stated, I have to finish getting vital signs and then I'll be back to help you change your clothes. At that time, the resident's roommate was overheard asking for a blanket. Staff B then left the bedroom. Resident #88 was approached and was receptive to an interview as he was sitting in his wheelchair. He was still wearing the white shorts with the dark yellow colored stains. He said that he likes to go outside but had to wait until his shorts were changed. The resident said that he was not able to change his shorts on his own. He said he even needed help to get on the commode. At 3:40 p.m. an interview was conducted with Staff B as she confirmed she was caring for Resident #88 and his roommate. She stated, When I came on my shift, I seen him, and I was trying to find the day shift staff member who left him like that. Staff B was asked, and she confirmed that he had asked for help in changing his clothes. She stated, I told him I would be back after I finished getting all of my vital signs. She additionally confirmed the roommate had asked for a blanket. Staff B stated, he already had a blanket. I'll get him another one after am done with my vital signs. Staff B said her shift started at 2:45 p.m. At 3:45 p.m. an interview was conducted with Staff Member J, Unit Manager as she confirmed it was her expectation when a resident asks for assistance they are assisted in a timely manner. She stated, that the vital signs are not due until 5:00 p.m. Staff J was overheard as she spoke to staff B that she needed to prioritize her duties. That would be in assisting the resident and their needs. At 4:00 p.m. Staff J was observed as she entered Resident #88's bedroom, one hour and fifteen minutes after first observed with soiled/incontinent clothing. Medical record review was conducted for Resident #88 which revealed on the admission Record form a diagnosis of diabetes and hypertension. The Minimum Data Sheet, dated on 4/13/2021, indicated he received diuretic therapy daily. The Data Sheet revealed he was frequently incontinent of bladder. Review of Care Plans with a focus on an alteration in elimination AEB (date initiated 8/14/18 and revised 4/17/20) (as evidenced by): is incontinent of bowel and bladder r/t (related to) recent decline in mobility, staff to assist with incontinence needs, wears a brief. Goal: resident will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some clean, dry and odor free. Check resident upon rising, before/after meals and at HS (bedtime) for incontinence: perform incontinence care prn. On 5/20/21 at 11:56 a.m., an interview was conducted with the Nursing Home Administrator and the Regional Nurse H. When asked, the NHA indicated she was not aware that the resident had to wait in soiled clothing over an hour for assistance. 2) On 05/17/21 11:33 a.m. Resident #124 was observed lying in his bed. He made eye contact when approached and was non-verbal. He appeared comfortable receiving oxygen through a tracheostomy, while a feeding machine was running at his bed side. His hair was unclean. His scalp and hair follicles presented with copious amounts of dried flaky pale yellow fragments. On closer observation his left ear contained moderate amount of the flaky yellow fragments. Medical record review of the admission Record revealed a diagnosis of respiratory failure, aphasia and dysphasia following cerebral infarct. Current Physician orders (May, 2021) were reviewed. There was no current treatment was in place for his scalp. Further record review of his care plan (Initiated 8/14/2018, Revised 4/17/2020) revealed a Focus, has a self-care deficit with dressing, grooming, bathing and requires total assist with all care. Goal: resident will have clean, neat appearance daily. Interventions: Provide total staff assistance with dressing, grooming, bathing. Staff to anticipate residents needs with ADLS (activities of daily living). On 05/18/21 at 3:55 p.m. Resident #124 was observed lying in bed. More than 24 hours later, his scalp and hair remained unchanged with a copious amount of dried flakes/scales of pale yellow fragments. At 4:12 p.m. Staff Member I, Licensed Practical Nurse was asked about the resident and stated, I did not know when his shower day was. Staff B was in the hallway and stated out loud I gave him a shower last night. When asked about his hair she stated, I washed his hair with a special shampoo the nurse gave me. I scrubbed his head really hard to get off the flakes. She said the shampoo was orangish red in color. Staff Member I said that he was new to the unit, and was transferred from a different hall. He indicated he did not know the resident. Staff I said that he did not know if the resident had an order for a special shampoo. After reviewing the Physician orders, he stated, he did not have an order for medicated shampoo. Staff I opened the treatment cart that revealed two bottles of Ketoconazole 2 % shampoo for the resident. Directions stated to apply topically on Monday and Thursday. The pharmacy delivery date was 3/29/21 and on 2/26/21. Staff I confirmed that both bottles had been opened, and both bottles contained over seventy five percent of shampoo. At 4:25 p.m. an interview was conducted with Staff Member J, Unit Manager as she provided Resident #124's shower sheet. The shower sheet was dated 5/17/2021 that revealed handwritten documentation bed bath. At that time staff B approached the desk and was asked about the documentation on the shower sheet that reflected a bed bath. Staff B confirmed she had given a bed bath and not a shower. She went on to state me personally I like to put them in the shower. But when I ask for a portable oxygen tank as he needs to be hooked up on oxygen, the nurses are like he has a trach and needs oxygen. Staff B was asked and stated, I take a face rag and get it really wet. I put shampoo on it. So, I did a shampoo and bath in bed. I do my best. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the skin sheet showed, this sheet is to be completed by the C.N.A. twice weekly on the residents shower days. On days if C.N.A. notices ANYTHING unusual on the resident's skin. Staff B was asked about his hair, she stated, the nurses see what I see. I don't feel like I need to document it they already know about it. Staff J, Unit Manager (UM), was asked and confirmed she was unaware of any issues with the resident. At that time staff J and the Regional Nurse W went to Resident #124's bedroom and confirmed that his scalp was concerning, and indicated a treatment would be needed. Staff J stated, he had been seen by our wound physician who is a dermatologist. His hair had not been like that before he went to the hospital. She said that she had not seen the resident for a while. Staff J proceeded to look at the resident's current orders and stated, the shampoo order was a 30 day order, and then it falls off. Further medical record review found Ketoconazole shampoo 2% apply to scalp topically every day shift Monday, Thursday for tinea versicolor for 30 days ended on 5/1/2021. Tinea versicolor is a common fungal infection of the skin. The fungus interferes with the normal pigmentation of the skin, resulting in small, discolored patches. These patches may be lighter or darker in color than the surrounding skin and most commonly affect the trunk and shoulders. Signs and symptoms include: Patches of skin discoloration, usually on the back, chest, neck and upper arms, which may appear lighter or darker than usual. Mild itching, Scaling. Tinea versicolor often recurs, especially in warm, humid weather. Causes: The fungus that causes tinea versicolor can be found on healthy skin. It only starts causing problems when the fungus overgrows. A number of factors may trigger this growth, including: Hot, humid weather, Oily skin, Hormonal changes, and a weakened immune system. https://www.mayoclinic.org/diseases-conditions/tinea-versicolor/symptoms-causes/syc-20378385. On 5/20/2021 at 11:00 a.m. an interview was conducted with Staff J, UM. Staff J stated, there had been a full time nurse caring for resident #124. But she no longer works here. 3) On 5/17/21 at 10:50 a.m. Resident #102 was lying in his bed and was receptive to the interview process. He appeared comfortable as he said that he was the facility Resident Council President, and had been at the facility for a few years. When he smiled, he was observed missing a couple of his front teeth. He was asked if staff provided him set up in the morning for his oral care. He smiled, again, and stated I can't do it myself as he slightly lifted his arms and hands from his chest. The joints to his hands were noted with deformity. He was then asked if staff brush his teeth for him daily. He stated, No, but when my dad visits once a week I will sometimes ask him. When asked he stated, I haven't had a dental cleaning in years. I have bad insurance. Medical record review revealed an admission Record form that indicated he was in his mid-forties. Diagnosis information contained lack of coordination, early onset cerebellar ataxia, and pain in joint. Further record review revealed diagnosis of [NAME] ataxia. The Minimum Data Sheet was reviewed that was dated 4/6/2021 that revealed Brief Interview for Mental Status score of 15. The score of 15 indicated Intact cognitive response. Friedreich's ataxia (FA) is a neuromuscular disease that mainly affects the nervous system and the heart. FA's major neurological symptoms include muscle weakness and ataxia, a loss of balance and coordination. FA mostly affects the spinal cord and the peripheral nerves that connect the spinal cord to the body's muscles and sensory organs. FA also affects the function of the cerebellum, a structure at the back of the brain that helps plan and coordinate movements. (It does not affect the parts of the brain involved in mental functions, however.) Onset is typically between 10 and [AGE] years of age, but FA has been diagnosed in people from ages 2 to 50. FA progresses slowly, and the sequence and severity of its progression is highly variable. https://www.mda.org/disease/friedreichs-ataxia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0677 Level of Harm - Minimal harm or potential for actual harm On 5/20/21 02:10 p.m. Resident #102 was approached and invited the surveyor into his room. He was asked about the facility providing oral care. He stated, no one has brushed my teeth today. He was asked if he had a toothbrush he stated no. The Resident's teeth were observed with a small amount of pink debris between the left canine. He was asked if he was having any problems with his teeth. He stated, they all hurt. I just want to get them all taken out. Residents Affected - Some At 2:15 p.m. an interview was conducted with Staff Member K, Certified Nursing Assistant who confirmed he provided care and services to Resident #102 at least 4 days a week. He was asked at that time if he provided oral care for him. He stated yes. He was asked if he could find the resident's toothbrush. He said, yes. He entered the resident bedroom and walked up to the tall dresser that the television sat on top of. He opened the top drawer and rummaged through the drawer for a few seconds. Staff K then looked over to the resident and stated, where your toothbrush? The resident that remained lying in bed stated, I don't have a toothbrush. Staff K looked a second time inside of the drawer and removed a tube of toothpaste. The tube appeared unused. Staff K was asked if he brushes the resident's teeth. He stated, a few days ago. Resident #103 stated, No you didn't. Review of Physician orders, dated 9/27/2018, May consult podiatry, dental, audiology, optometry, wound services as needed. Review of the care plans (Initiated 3/6/2019 and revised 4/17/2020) revealed focus in alteration in dentition AEB (as evidenced by) he is some missing teeth. He requires staff assist with oral care. Interventions: provide assist with oral care. Care plan for self-deficit in dressing, grooming, bathing, and eating r/t impaired mobility dx Friedrich's ataxia (Initiated 3/5/2019 and Revision on 10/20/20). He has impaired Upper Extremity /Lower Extremity (UE/LE) range of motion (ROM) r/t to generalized weakness, spasticity, and muscle weakness. Resident does not participate in most ADLs Interventions: Provide total staff assistance with dressing, grooming, bathing. Further review of the care plans identified the resident with strength in cognitive function AEB is oriented to person. Place and time (Initiated 12/11/0218, Revision on 12/11/2018). Short term/ long term (ST/LT) memory are intact. Is able to make daily decisions independently. On 5/20/2021 at 2:30 p.m. an interview was conducted with Nursing Home Administrator and the Staff Member J, Unit Manager. When asked staff J confirmed that his teeth should be brushed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observations, and interviews the facility did not ensure appropriate treatment and services were in place for a central line and did not ensure that practice standards were followed related to the a central intravenous catheter for one resident (#83) of three residents with central lines. Residents Affected - Some Findings included: Resident #83 was admitted to the facility most recently on 4/23/2021 with a diagnosis of UTI (urinary tract infection), according to the face sheet in the admission record. A review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form (AHCA form 3008), dated 4/19/21 reflected a left Mid line IV (intravenous) access inserted 4/22/21. Review of the physician's order dated 4/23/21 revealed Resident #83 was receiving Ertepenem Sodium solution reconstituted 1 Gm use 1 gram intravenously one time a day for UTI for 3 days. The order status reflected it was completed on 4/25/21. A review of the physician's orders in the electronic medical record revealed an order that had been discontinued on 5/13/21, change transparent dressing to IV site as needed for IV site care, use securement device with each dressing change. Further review revealed another IV site care order dated 5/13/21, change transparent dressing to IV (intravenous) site every day shift every 7 days for IV site care, use securement device with each dressing change. Review of the MAR (medication administration record) for the month of April 2021 revealed the dressing change on the Mid line IV site was signed on 4/28/21. Further review showed the IV antibiotic, Ertapenem, had been administered on 4/24/21, 4/25/21, and completed on 4/26/21. Review of the TAR for the month of May 2021 showed the IV dressing change to the Midline was signed on 5/5/21 and 5/12/21. There were no further dressing changes signed. Review of the physician's orders for the month of May 2021, revealed there were no further IV medications ordered. Review of the policy, Central Venous Catheter Dressing Changes, revised April 2016, revealed the following: Purpose The purpose of this procedure is to prevent catheter related infections that are associated with contaminated, loose, soiled, or wet dressings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0694 Preparation Level of Harm - Minimal harm or potential for actual harm 1. Check the state's nurse practice act for LPNs regarding scope of practice for changing a central venous catheter dressing. Residents Affected - Some 2. A physicians order is not needed for this procedure General guidelines 1. Apply and maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry, and intact. 2. Change dressings if any suspicion of contamination is suspected 4. After original insertion of central venous access device (CVAD), the dressing will consist of gauze and TSM. This must be changed within 24 hours a. Replace with sterile transparent dressing. b. Use gauze under the TSM if there is drainage from the catheter insertion site. 5. change transparent semi permeable membrane TSM dressings at least every 5 to 7 days and PRN when wet, soiled, or not intact. On 5/18/21 at 9:52 AM an observation was conducted. Resident #83 was in his room watching television in his bed. His left upper arm had a single lumen central catheter line visible below his sleeve. The dressing was not intact at the bottom where it was lifting away. The only portion of the date visible due to faded ink at the time was the first number, which was a four, indicating the dressing was last changed in April. On 5/19/21 at 9:44 AM an observation and interview was conducted with Staff X, RN (registered nurse) unit manager (UM). Staff X, RN UM said Resident #83 was admitted on IV antibiotics. He has completed those. Staff X, RN UM confirmed the first number on the date on the single lumen Midline dressing was a four. The full date was visible and upon closer observation, it was a very faded 4/22. Staff X, RN UM said she was not sure what the second number was. Staff X, RN UM also confirmed the dressing was not intact. Staff X, RN UM said she believed the dressing changes are once a week. There is a house order to change it every seven days. On 5/19/21 at 10:27 AM an interview was conducted with the ADON (assistant director of nursing), who was the acting interim DON (director of nursing). The ADON said the central line dressings have to be changed every seven days. On 5/19/21 at 10:31 AM an interview was conducted with the NHA (nursing home administrator). The NHA said she vaguely heard about the concern. The ADON is the risk manager. On 5/19/21 at 10:57 AM a follow up interview was conducted with Staff X , RN UM. She said they have a call out to the physician to see if they can discontinue the mid line IV catheter. Staff X, RN UM also confirmed the IV antibiotic was discontinued in April. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/20/21 at 2:21 PM an interview was conducted with Staff Y, LPN (licensed practical nurse). Staff Y, LPN said he had a central line to the right upper arm. It was for IV antibiotics. She thinks the central line was for one or two more doses of IV antibiotics. She said if the central line was inserted at the facility then twenty-four hours later the dressing has to be changed. If they came with it, we assess it. We put an order in for every seven days from the day of admission if it was dated the same day. Staff Y, LPN reviewed the April and May MAR with surveyor and confirmed she signed the dressing change on April twenty-eighth and May twelfth. She said she was not aware the dressing was dated 4/22 yesterday. She wasn't here yesterday so she can't speak to that. She does not recall what happened in April. She said there was an emergency on May twelfth. She brought the dressing change supplies to the room and got called away to an emergency. She must have forgotten the dressing change and signed the treatment in error. She doesn't know if the physician was aware the antibiotic was discontinued a day or so after Resident #83 came to the facility. She said she signs the treatments after she does them. She said she must have signed the treatment in error. According to the Centers for Disease Control and Prevention Checklist for Prevention of Central Line Associated Blood Stream Infections at https://www.cdc.gov/hai/pdfs/bsi/checklist-for-clabsi.pdf Clinicians should: Handle and maintain central lines appropriately Comply with hand hygiene requirements. Bathe ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis. Scrub the access port or hub with friction immediately prior to each use with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol). Use only sterile devices to access catheters. Immediately replace dressings that are wet, soiled, or dislodged. Perform routine dressing changes using aseptic technique with clean or sterile gloves. · Change gauze dressings at least every two days or semipermeable dressings at least every seven days. · For patients [AGE] years of age or older, use a chlorhexidine impregnated dressing with an FDA cleared label that specifies a clinical indication for reducing CLABSI for short-term non-tunneled catheters unless the facility is demonstrating success (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0694 at preventing CLABSI with baseline prevention practices. Level of Harm - Minimal harm or potential for actual harm Change administrations sets for continuous infusions no more frequently than every 4 days, but at least every 7 days. Residents Affected - Some · If blood or blood products or fat emulsions are administered change tubing every 24 hours. · If propofol is administered, change tubing every 6-12 hours or when the vial is changed. Promptly remove unnecessary central lines Perform daily audits to assess whether each central line is still needed. Healthcare Organizations should: Educate healthcare personnel about indications for central lines, proper procedures for insertion and maintenance, and appropriate infection prevention measures. Designate personnel who demonstrate competency for the insertion and maintenance of central lines. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of central lines. Provide a checklist to clinicians to ensure adherence to aseptic insertion practices. Reeducate personnel at regular intervals about central line insertion, handling and maintenance, and whenever related policies, procedures, supplies, or equipment changes. Empower staff to stop non-emergent insertion if proper procedures are not followed. Ensure efficient access to supplies for central line insertion and maintenance (i.e. create a bundle with all needed supplies). Use hospital-specific or collaborative-based performance measures to ensure compliance with recommended practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, medical record review, and manufacture's directions the facility failed to ensure three (400 unit cart #1, 100 unit cart #1, and 300 unit cart #2) of four sampled medications carts had medication and biologicals stored not past the expiration date, and/or failed to document an open on date. Findings Included: 1. On 5/17/2021 at 1:00 p.m. medication cart #1 on the 400 unit was observed with the following: An oral inhaler Combivent. The inhaler did not contain an open on date. The instructions on the inhaler read to discard three months after opening. A second oral inhaler labeled Breo-ellipta did not contain an open on date. The label indicated to discard 6 weeks after opening. A bottle was labeled assure platinum strips. The bottle did not contain an open on date. vial labeled NovoLog contained an open on date 4/8/2021. The labeled on the bottle read expired 28 days after opened. Indicated last day on 5/6/2021. An insulin vial labeled Lantus was identified and did not have an open on date. Prescription Lantus is a long-acting insulin used to treat adults with type 2 . After 28 days, throw your opened Lantus pen away-even if it still has insulin in it. www.lantus.com. The Regional Nurse H was present at the time during the findings and confirmed the observations. 2. On 5/19/2021 at 10:10 a.m. medication cart #1 on the 100 unit was observed to contain a box of glucose gel in a tube. The box was opened and revealed the tube original seal had been removed and was covered with a piece of white tape. Staff U, Unit Manager was present and confirmed the observation and stated, it should not be in the cart. 3. At 11:00 a.m. medication cart #2 on the 300 unit was observed with the following: Three vials of NovoLog insulin. All the vials contained an open on date. All the vials were expired. A box labeled ear wax softener was identified that had been opened. The box did not contain an open on date nor did it include a resident identifier. A box that contained blood sugar testing solutions had been opened. The box did not contain an open on date. Staff F, Unit Manager was present during the findings. She confirmed that the insulin vials had expired and should have been removed from the cart. She indicated that the open box of ear drops is not used for multiple residents. That a resident name should have been on it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility provided a copy of their policy titled Storage of Medications dated 09-20218. Policy: medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. Procedures: General Guidance: 8. Outdated, are immediately removed from inventory, disposed of according to procedures for medications disposal, and reordered from pharmacy if current order exists. III. Expiration Dating (Beyond-Use Dating) 1. Expiration dates of dispensed medications shall be determined by the pharmacist at the time of dispensing. 3. Certain medications or package types, multiple dose injectable vials, and blood sugar testing solutions and strips require an expiration date shorter than the manufactures expiration date once opened to ensure purity and potency. 8. All expired medications will be removed from the active supply and destroyed in accordance with the facility policy, regardless of amount remaining. Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in regards to not following appropriate infection control related use of PPE (personal protective equipment) for rooms under contact and droplet precautions, failure to ensure that a cleaning and disinfecting process was utilized after use of a multiuse glucometer device for 4 (#27, #9, #12, #77) residents, and failure to practice hand hygiene prior to donning and after doffing gloves. Residents Affected - Some Findings included: 1. Observation of the 200 hall on 05/17/21 at 10:10 AM revealed that every room door on this unit had a pink laminated sign which indicated Please see nurse before entering room Before entering you must apply: The following items were checked for each room: Apply gloves; Apply Face Mask; Apply gown; Apply goggles. Observations on 05/17/21 at 10:12 AM of Staff N, CNA (Certified Nursing Assistant) revealed that the staff donned full PPE (gown, gloves, face mask and goggles) and entered room [ROOM NUMBER] where the nurse and another aide were providing care and asked them if they needed assistance. When the pair said no the aide left room [ROOM NUMBER] and entered room [ROOM NUMBER] without changing her PPE. Observations on 05/17/21 at 10:15 AM of Staff O, LPN (Licensed Practical Nurse, Agency Staff) who said that the entire 200 unit was on isolation, one room for scabies, one room for a rash (possibly shingles), 5 rooms are on isolation due to the residents leaving the facility, one room for isolation for ESBL (Extended Spectrum Beta-Lactamase) in the urine, everyone else on the 200 unit was on droplet precautions. She reported that all staff should wear appropriate PPE and remove isolation gowns prior to exiting the room. She reported that no one should come out of the rooms with the gowns on. On 05/17/21 at 10:20 AM an observation was conducted of a maintenance man, Staff P, entering room [ROOM NUMBER] with a maintenance cart. He was observed to engage the window bed in conversation and he changed her T.V and set it up. The maintenance man did not don any PPE other than a surgical mask. Observation on the room door showed a pink isolation sheet indicating the PPE needed for that room was: gloves, gown, mask and goggles. During an interview with Staff P, Maintenance Assistant he said that he does not need to wear anything special to go into the room on this unit just his surgical mask. On 05/17/21 at 10:26 AM a staff person was observed to exit room [ROOM NUMBER], come down the hall to the nurses cart and ask the nurse for a pen. Interview with Staff Q, PT (physical therapist) confirmed that he left room [ROOM NUMBER] that was under isolation to speak to the nurse and did not remove his PPE before exiting the room. He reported that the facility had a positive Covid case about a week and a half to 2 weeks ago. On 05/17/21 at 10:53 AM an observation of Staff R, CNA revealed that she left room [ROOM NUMBER] dressed in full PPE (gown, gloves, face mask and goggles), walked down the hall and entered room [ROOM NUMBER]. She reported that she forgot to take off the PPE before exiting room [ROOM NUMBER] because she was in a rush to obtain a cell phone charger that was left in room [ROOM NUMBER]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 05/17/21 at 12:26 PM observations revealed that Staff R, CNA left room [ROOM NUMBER] with full PPE on and when she saw this surveyor she went back into the room and took off the PPE. Observation on 05/17/21 at 12:32 PM with Staff N, CNA walked out of room [ROOM NUMBER] in full PPE, and took off her gloves and gown in the hallway and placed the soiled PPE in the regular garbage at the nurses station. Observation on 05/17/21 at 12:35 PM of Staff N, CNA walked out of room [ROOM NUMBER] with full PPE on. When she saw this surveyor, then stepped back into the room and took the PPE off. On 05/17/21 at 12:52 PM Staff N, CNA reported all isolation gowns should go into the garbage in the resident room. She reported that she always takes off the gown in the room but does not remember taking the gown off in the hallway and placing it in the garbage can at the nurses station. Interview on 05/17/21 at 12:58 PM with Staff O, RN (Registered Nurse), reported that staff should not be coming out of the isolation rooms with the isolation gowns on. She reported that gowns should be discarded in the trash can in the resident room prior to exiting the room. Observations on 05/17/21 at 01:15 PM of the 200 hall, a staff person was noted to enter room [ROOM NUMBER], then exit the room and then enter room [ROOM NUMBER]. He was observed to not be wearing any PPE other than a surgical mask. Interview with the staff revealed he was Staff S, Rehab Director. Interview with the staff at this time he reported that full PPE to include the isolation gowns and gloves should be worn when entering the rooms on this unit. He reported that he did not really go into the rooms he just stepped in, but did not reach all the way to the patient. On 05/19/21 at 08:42 AM an observation of a staff person was noted entering rooms [ROOM NUMBER] twice to retrieve meal trays, and then exiting the rooms with trays. The staff person did not don any PPE other than the surgical mask that she was wearing. Interview with the staff at this point revealed that she was Staff T, CNA from an agency and when asked what the pink sign posted on each of the doors meant she reported that it means to put on gown and shield and gloves but that she did not need that because she was not providing care she was only picking up the trays. The staff reported that she did not know what type of precautions were in place. Interview on 05/19/21 at 08:45 AM with Staff U, RN/unit manager revealed that all staff are to wear full PPE, gown, gloves, mask and goggles when entering resident rooms on the 200 hall. She reported that she will educate staff. Review of the facility policy titled Personal Protective Equipment-Using Gowns with a revised date of September 2010 under the sub-heading of Miscellaneous revealed the following: 1. Use gowns only once and then discard into an appropriate receptacle inside the exam or treatment room. 8. After completing the treatment or procedure , gowns must be discarded in the appropriate container located in the room. 10. Soiled gowns must not be worn in break rooms, lobbies, or into any area in which contamination of equipment is likely to occur. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. On 05/17/2021 11:55 a.m. Staff Member A, RN was observed as she gathered supplies for a blood glucose procedure for Resident #27. She removed the glucometer from the medication cart and placed it on a white foam tray along with alcohol pads, a lancet and a glucose strip. After the procedure was performed while still in the bedroom, she cleaned the meter with a alcohol wipe and placed the meter inside of her right uniform pocket. She was asked about the process and she said, I clean it with an alcohol wipe. Staff A exited the bedroom and returned to the medication cart where she cleaned the meter with a bleach wipe and immediately placed it inside of the medication cart top drawer. No disinfecting was observed. On 05/18/21 at 03:41 p.m. Staff Member I, Licensed Practical Nurse was asked and stated I can show you a glucose check right now as he pushed his medication cart to Resident #9's bedroom door. Staff I removed the glucometer from the medication cart and placed it on a white foam plate, along with a cup and an bleach wipe. After the procedure was performed he placed two bleach wipes around the meter and placed it back on the foam tray that was now sitting next to the sink. No cleaning was identified at that time. Staff I was observed as he prepared medications, sanitized his hands and donned clean gloves. Staff I placed the vial of insulin inside of the cart, a set of keys inside of his pocket and locked the cart with his gloved hands. After the medications were administered Staff I walked over to the glucometer and removed the bleach wipe from the meter, doffed his gloves and donned clean gloves without practicing hand hygiene. Staff I exited the bedroom and with a new bleach wipe cleaned the meter. At 3:54 p.m. Staff I removed a second glucometer from the cart, placed it on top new foam tray. He said that each cart has two meters and confirmed they are used on multiple residents. He indicated that he had a second glucometer test for Resident #12. Staff I donned clean gloves and removed a bleach wipe from its container and placed it inside a cup. He doffed the gloves and then donned clean gloves without practicing hand hygiene. After the procedure was performed, he placed a bleach wipe around machine. After the meter sat for approximately 3 minutes, he removed the wipe and performed the same procedure by wiping the meter. Staff I was asked and stated, the process after use is that it's wrapped for 3 minutes, then cleaned, and let it air dry for 2 minutes. On 5/19/2021 at 11:15 a.m. Staff Member G, Licensed Practical Nurse gathered the supplies for a glucometer procedure for Resident #77. She entered the bedroom holding the meter in her right hand. The meter was placed on the bed side table without a barrier. She donned clean gloves without practicing hand hygiene. The lancet was used on the resident's finger. Staff G then placed her right hand inside of her uniform right pocket and removed a bottle of glucose strips. The bottle was opened, and one strip was removed. The bottle was placed back inside her pocket. After the procedure was completed Staff G removed her gloves and with bare hands cleaned the meter with a bleach wipe. She then placed the meter in a cup. Staff G was asked at that time and stated It has to sit 3 minutes in the cup. It has to be completely dry. No disinfecting process was observed. On 5/20/2021 at 10:20 a.m. Staff Member F, Unit Manager was asked and verbalized the process of cleaning and disinfecting the glucometer. She stated, its cleaned with a bleach wipe and with a second wipe it is wrapped for 3 minutes. She confirmed the meter is to remain wet for a contact time of 3 minutes. Staff F asked was that not observed, stating I had my back to the procedure. I was on the computer. She confirmed that she was able to overhear the process. And stated I heard you ask her about the process. She told you the meter has to sit for 3 minutes in the cup to be completely dry. The facility provided a policy titled Blood Sampling- Capillary (finger sticks), revised September 2014. Purpose The purpose of this procedure is to guide the safe handling of capillary-blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105491 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 105491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Gandy 4610 S Manhattan Ave Tampa, FL 33611 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete sampling devices to prevent transmission of bloodborne disease to residents and employees. General Guidelines 1. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident use. Steps in the procedure: 1. Wash hands. 2. [NAME] gloves. 3. Place blood glucose monitoring device on a clean field. Review of Recommended Practices for Preventing Bloodborne Pathogen Transmission during Blood Glucose Monitoring and Insulin Administration in Healthcare Settings revealed, Blood Glucose Meters: Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html Event ID: Facility ID: 105491 If continuation sheet Page 18 of 18