Health inspection·March 21, 2024

F 0550 -As resident allows, remove dentures at bedtime. Place in Nurse Med Cart for safety. Level of Harm - Minimal harm or potential for actual harm -Staff will assist with dressing as needed. -Staff will assist with oral care daily and as needed. Residents Affected - Few -Staff will assist with personal hygiene daily and as needed. -Staff will assist with dressing as needed. -Staff will assist with oral care daily and as needed. -Staff will assist with personal hygiene daily and as needed. On 03/21/24 at 9:44 AM, the Nursing Home Administrator said that they had no policy on dignity. On 03/21/24 at 11:10 AM, during an interview with the Director of Nursing, she was informed about the observation of the resident as the survey team arrived at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 2 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the proper fitting of a wheelchair for one resident (#514) out of eighty-four residents sampled for the abilities to maintain their independence. Residents Affected - Few Findings included: An observation was made on 3/18/24 at 9:15 a.m., of Resident #514 ambulating out of her room, pulling her wheelchair behind her with outstretched arms behind her and an attached urinary catheter hanging on the wheelchair. The resident was pleasant and sat in her wheelchair during the initial introductions. The resident had old bilateral bruises on her cheeks and a healing laceration to the bridge of her nose. An observation was made of the resident's feet not touching the ground and dangled approximately eight to ten inches from the floor. The resident denied self-propelling with her upper extremities and stated she could walk. For safety reasons the staff was immediately notified of this occurrence. A nursing staff member stated physical therapy was responsible for the wheelchairs and their location was on the same hallway down from the resident's room. A therapist was located and stated he was familiar with Resident #514 and would address the situation of the height of the wheelchair. An observation was made on 3/19/24 4:00 p.m. of Resident #514 in the hallway in the same wheelchair with her feet not touching the ground in the same position. An interview was conducted on 03/20/24 12:54 p.m. with the Director of Rehab, Physical Therapy Assistant (PTA). The Director of Rehab stated when a new resident was admitted after normal working hours, the nursing staff knew to obtain a wheelchair based on the admission initial screen. The Director of Rehab stated, a wheelchair will be placed prior to the new resident's admission into their room to ensure if the resident comes over the weekend and physical therapy has not seen the resident at least there is a means to assist resident in transport. Physical therapy would see all admissions within 24-48 hours. The Director of Rehab stated supply of wheelchairs was not an issue. The Director of Rehab was made aware of the observations and the interview with the physical therapy staff regarding the height of Resident #514's wheelchair. Record review of Resident #514 admission face sheet showed an admission date of 3/11/2024 with a primary diagnosis of nasal bone fractures subsequent encounter for fracture with routine healing, hemorrhage of bilateral orbit, repeated falls, difficulty in walking, ataxic gait, unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance, depression unspecified, glaucoma unspecified, and retention of urine. A review of physician orders showed an order for occupational and physical therapy to evaluate and treat dated 3/12/24. A request was made for a policy on Accommodation of Resident Needs but the facility did not have said policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 3 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Reviews (PASARR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for five (Residents #64, #16, #61, #103 and #98) out of seven residents sampled for PASARRs. Residents Affected - Many Findings included: Review of the electronic medical record (EMR) revealed Resident #64 was admitted to the facility on [DATE]. An admission record for the resident revealed a primary diagnosis of Alzheimer's and a secondary diagnosis of Dementia. Review of a level I PASARR for Resident #64 dated 7/27/22 showed qualifying diagnoses were not checked and a level II PASARR evaluation was not submitted. Review of the EMR revealed Resident #16 was admitted to the facility on [DATE]. An admission record for the resident revealed the resident had a diagnoses to include vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, epilepsy, unspecified, not intractable, without status epilepticus and depression. Review of a level I PASARR dated 05/22/15 showed the new diagnoses were not indicated and a level II PASARR evaluation was not submitted. Review of the EMR revealed Resident #61 was admitted to the facility on [DATE]. An admission record for the resident revealed diagnoses to include depression and Parkinsonism. Review of a level I PASARR for Resident #61 dated 12/04/23 showed qualifying diagnoses were not checked. Review of the EMR revealed Resident #103 was admitted to the facility on [DATE]. An admission record for the resident revealed diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression. Review of a level I PASARR for Resident #103 dated 02/29/24 showed qualifying diagnoses were not checked. Review of the EMR revealed Resident #98 was admitted to the facility on [DATE]. An admission record for the resident revealed diagnoses to include anxiety disorder, depression, mood disorder due to known physiological condition and personal history of other mental and behavioral disorders. Review of a level I PASARR for Resident #98 dated 1/25/24 showed qualifying diagnoses were not checked. On 03/21/24 at 9:43 a.m., an interview was conducted with the admissions coordinator, Registered Nurse (RN). She stated the hospital did PASARRS prior to the resident's admission. She stated she reviewed them to make sure they could meet the needs of the resident. She said, I generally do not review PASARRS for accuracy. I only make sure there are no mental issues that would require a level two PASARR. On 03/21/24 at 9:56 a.m., an interview was conducted with the Nursing Home Administrator (NHA). He stated if there were PASARR concerns, an RN would have updated. He stated the admissions nurse verified the PASARR was in place. He stated the Social Services Director (SSD) reviewed and ensured the accuracy of PASARR. He stated if it needed updating someone in the nursing team would update the PASARR. He said, We discuss it in morning meetings. They are pre admission and we are not required to revise them. The hospital is responsible for updating. We do not have anyone who has recently acquired a new diagnosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 4 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0645 Level of Harm - Minimal harm or potential for actual harm On 03/21/24 at 10:25 a.m. an interview was conducted with the Director of Nursing (DON). She stated the admissions nurse reviewed the PASARRS on admission. She stated they reviewed them in clinical meetings to make sure they were present. She said, We review to make sure it is there and accurate. If it is not accurate, the admissions nurse is to obtain the correct information from the admitting facility and start the processes of correcting the PASARR. Residents Affected - Many On 03/21/24 at 11:03 a.m. A follow -up interview was conducted with the NHA. He stated he had reviewed the PASARRs and acknowledged they were incorrect. He stated they are reviewing their processes to ensure compliance. Review of an undated facility policy titled, Coordination - Preadmission Screening and Resident Review (PASARR) Program showed, it is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review in accordance with state and federal regulations. 2.) Coordination includes (b.) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 5 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 interview and record review, the facility failed to provide activities of daily living (ADL) related to incontinence care for two dependent residents (#123 and #98) out of three sampled residents. Residents Affected - Few Findings included: 1. Review of Resident #123's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of quadriplegia, ataxia, muscle weakness, malignant neoplasm of an unspecified part of the bronchus or lung, and secondary malignant neoplasm of bone. An interview was conducted on 03/18/24 at 8:10 a.m. with Resident #123. She said for the last couple days only, she had not been changed as often. She said she should be changed at least once a shift but the 3:00 p.m. to 11:00 p.m. shift on 3/17/24 did not change her. She said she asked the 11:00 p.m. to 7:00 a.m. on 3/17/24 Certified Nursing Assistant (CNA) to change her when she came on shift, and she did. Resident #123 said she was not soaked thankfully. She said it happened one other time before that, but she could not remember the date or shift, but it was sometime within the last week. Resident #123 said the CNA was honest and said she forgot about me and that she was sorry. An interview was conducted on 3/19/24 at 9:48 a.m. with Resident #123 and she said she was not changed on the 11:00 p.m. to 7:00 a.m. shift last night (3/18/24). Review of Resident #123's Quarterly Minimum Data Set (MDS) dated [DATE] Section C, Cognitive Patterns revealed a brief interview for mental status (BIMS) score of 15 out of 15 indicating the resident's cognition is intact. Section GG revealed Resident #123 is dependent for Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement . According to the Self Care Coding dependent means helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Review of section H, Urinary Continence revealed Resident #123 is always incontinent of urine and bowel. Review of Resident #123's Toileting Hygiene Certified Nursing Assistant (CNA) documentation revealed on 3/17/24 there was no documentation Resident #123 was provided incontinence care on the 3:00 p.m. to 11:00 p.m. shift. Review of the documentation on 3/18/24 and 3/19/24 revealed no documentation Resident #123 was provided incontinence care for the 11:00 p.m. to 7:00 a.m. shift. Review of Resident #123's care plan revised on 11/8/2023 revealed [Resident #123] has bowel and bladder incontinence r/t [related to] Activity Intolerance, Impaired Mobility, Physical limitations. The goals revealed, The resident will remain free from skin breakdown due to incontinence and brief use through the review date. and The resident's risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. The interventions included: Clean peri-area with each incontinence episode . An interview was conducted on 3/19/24 at 9:00 a.m. with the Assistant Nursing Home Administrator (ANHA)/Risk Manager (RM). She said herself and the Social Worker spoke with Resident #123 and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 6 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 - Few resident confirmed she was not changed on two separate shifts. The ANHA/RM said she reviewed the documentation and confirmed there was no documentation by the CNA Resident #123 was changed. 2. During an observation of Resident #98 on 03/18/24 at 8:25 a.m., a private paid caregiver, Sitter A was observed in the room sitting by the resident's bed. Resident #98 stated he had sitters to help provide him with care. In an immediate interview, Sitter A stated she was an agency staff member who was employed by the resident's family to provide 1:1 care. She stated she provided this resident with all ADL (activities of Daily Living) care. She stated she worked with the resident 2-3 times a week. Sitter A stated Resident #98 was a 2-person assist and she was waiting for someone to help toilet the resident. On 03/18/24 9:56 a.m., Sitter A stated the resident was still waiting to be changed. She was heard saying, anybody . please help. Review of an admission record for Resident #98 showed the resident was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, ataxia following cerebral infarction, dysarthria, aphasia, dysphagia and other diagnoses. A quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #98 had a Brief Interview for Mental Status (BIMS) score of 12, indicating intact cognition. Section GG showed the resident was dependent for ADL's to include toileting hygiene, shower/bath, upper body dressing, lower body dressing, putting on or taking off footwear and personal hygiene. On 03/18/24 at 10:27 a.m., Sitter A was observed standing outside the resident's door looking around. She stated she was still waiting for assistance with toileting for the resident. She stated she had notified a staff member, Staff L, Licensed Practical Nurse (LPN)/Unit Manager. An interview was conducted on 03/18/24 at 11:01 a.m. with Staff L. She confirmed Sitter A came to her and asked for the aide assigned to that hall. Staff L said, Yes, she asked for assistance with toileting. I told her the aide was [Staff Z, Certified Nurse's Assistant (CNA)]. It was not that long ago. I did not check the time. It definitely was not 2 hours ago. Staff L stated she would have to follow-up. During an interview with Staff Z, CNA on 03/18/24 at 10:51 a.m., she stated this resident always had a sitter. She stated the sitter's responsibility was to provide ADL care for this resident. She said, the sitters normally ask for help if needed, but it depends on the sitter. The resident is a one person assist for toileting. She confirmed the private sitters provided care for Resident #98. On 03/18/24 at 10:53 a.m., an interview was conducted with Staff AA, CNA. She stated Resident #98 had a private sitter hired by the family. She stated the sitter was supposed to provide all care. She stated the family hired private agency staff. She said, We don't have anything to do with them. They should be providing training for those CNA's regarding caring for this resident. This resident is a 2-person assist, he needs total care, but he can roll in bed and assist during changing. Staff AA stated she did not know the resident was waiting to receive care. She stated the sitter did not mention it. She stated Sitter A had just pulled the call light asking to get him transferred out of bed. Staff AA stated she was assigned to this resident and had assisted Sitter A transfer the resident out of bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 7 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 - Few On 03/18/24 at 10:57 a.m., an interview was conducted with Staff W, Registered Nurse (RN). She stated she had not been notified that the resident had waited two hours to be toileted. She stated Sitter A came to her and asked what time the resident's appointment was. She said. She did not ask me about toileting. Many of the sitters that care for this resident do it independently. They only ask for help if transferring him. Review of a bowel and bladder elimination task log for this resident dated 03/08/24 to 03/21/24, showed there was no CNA documentation related to toileting all morning on 03/18/24. The review showed one incontinence documentation time stamped 1:27 p.m. There was no documentation for toileting between 03/17/24 at 4:29 p.m. and 03/18/24 at 1.27 p.m. Review of Resident #98's Care Plan dated 11/13/23 showed the resident was not care planned to receive ADL assistance from paid private care givers/sitters. The care plan showed an ADL focus indicating the resident has an ADL self-care performance deficit related to history of CVA with left hemiplegia, wounds on admission, non- ambulatory wheelchair user. Interventions included all staff to converse with resident while providing care, Invite the resident to scheduled activities. Offer a la carte activities such as books, magazines, cards, word puzzles, newspaper, or games. Provide with activities calendar. Notify resident of any changes to the calendar of activities. Review resident's activation needs with the family/representative. When the resident choose not to participate in organized activities, the resident prefers to watch television and visits for social and leisure activities. Assist with all ADLs as ordered/needed. Staff to assist with all ADL needs as necessary. On transfers, the resident requires assistance from staff, vanderlift x2 assist. Encourage the resident to participate to the fullest extent possible with each interaction. Encourage the resident to use bell to call for assistance. The CNAs are to monitor/document/report PRN (as needed) any changes, any potential for improvement. reasons CNA for self-care deficit, expected course, and declines in function. A follow-up interview was conducted on 03/20/24 at 12:11 p.m. with the Director of Nursing (DON). The DON confirmed the facility CNA's were responsible for providing care, including toileting/changing, giving showers/baths, ultimately all care. She said, It is not our expectation that the sitters provide personal care. The DON said, We will provide education to the sitters and resident to utilize the call light. I will initiate education for our staff. They are responsible for all care. Staff E, Assistant NHA stated regarding the companion waiting for assistance, she did not use the call light. The resident is alert. He should have utilized the call light. I will investigate and initiate education. On 03/20/24 at 01:42 p.m., The NHA stated they did not have a policy on ADLS to include toileting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 8 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 document an accurate initial skin assessment and obtain orders for an open area of the skin for one (Resident #515) out of four residents sampled for skin conditions (non-pressure related). Residents Affected - Few Findings included: An observation was made on 3/18/24 at 9:40 a.m., of Resident #515 in her bed with her left knee exposed during observation. An observation was made of a loose dressing dated 3/15/24 exposing wound from underneath [photographic evidence obtained]. Resident #515 stated no one had seen her knee but someone placed a dressing on top of her wound but could not recall when. The resident stated she is here for rehabilitation after a fall in which she sustained a radial fracture. An observation was made of the resident 's right arm in a sling. A second observation and interview were conducted on 3/19/24 at 9:00 a.m. with Resident #515. The resident's left knee was completely exposed with no dressing. The wound had a thick dried yellow eschar-like appearance and dark pink outer edge. The resident stated a doctor came late last night to see her for the first time. A review of the physician orders dated 3/19/24 were to cleanse skin tear to the left knee with normal saline and gently pat dry, cut xerofoam to size and apply to wound bed, and cover with a border gauze dressing at bedtime for left knee bacterial infection. A third observation was made on 3/20/24 at 10:20 a.m., the resident had a new intact and dated dressing over the left knee. Review of Resident #515 initial skin assessment dated [DATE] showed the resident had a laceration to right eye, skin tear to left knee, open area to left and right toes, bruising to bilateral forearms, excoriation to right chest, and discoloration to left chest. An interview was conducted on 3/20/24 at 9:15 a.m., with Staff M, RN/Post Acute Care Manager. Staff M, RN stated an admission data assessment was performed by the registered nurse upon admission to the facility, which included an initial skin assessment. After an initial assessment was complete and records were reviewed from the transferring facility, a call was placed to the physician to obtain orders. Staff M stated an order should have been placed to address the open left knee wound on Resident #515's knee upon her admission. A request was made for the policy and/or procedures for the initial assessment and obtaining orders but the facility denied such a policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 9 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #144 was admitted on [DATE]. Review of the admission record showed diagnoses included but were not limited to periprosthetic fracture around internal prosthetic left hip joint, other mechanical complication of internal left hip prosthesis, presence of left artificial hip joint, infection and inflammatory reaction due to internal left hip prosthesis, infection following a surgical procedure, anxiety disorder, and unspecified abnormalities of gait and mobility. Residents Affected - Few Review of the admissions, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 04 (severe cognitive impairment.); Section GG, Functional Abilities and Goals showed dependent in toileting, bathing and putting on/taking off footwear; Section M, skin conditions showed Resident #144 did have one or more unhealed pressure ulcers/injuries which included unstageable, deep tissue injury; and showed a surgical wound. Review of physician order summary and the February and March 2024, Treatment Administration Records (TAR) showed the following: Float heels while in bed start date 2/16/2024 to current. Skin Prep bilateral heels every shift start date 2/20/202 to current. Review of the TAR for March 2024 revealed the treatment was not documented as being completed on March 1 day shift, 2 night shift, 7 day shift, 8 day shift, and 9 day shift. Weekly skin checks Monday 3:00 p.m.-11:00 p.m. - document in skin observation UDA (user defined assessment) start date 2/16/2024 to current. Santyl External Ointment 250 unit/GM - apply to right heel topically as needed for pressure injury if dressing is soiled or dislodged, start date of 3/20/2024. Santyl External Ointment 250 unit/GM - apply to right heel topically everyday shift for pressure injury, cleanse right heel with normal saline and gently pat dry. Apply and dime sized amount of Santyl to the wound bed then cover with a bordered gauze dressing start date 3/21/20224. Cleanse wound on right heel with normal saline, pat dry and cover with foam dressing start date of 2/17/2024 and discharged [DATE]. Review of the TAR for March 2024 revealed the treatment was not documented as being completed on March 1, 5, 7, 8, 9, 14, and 18/2024. Review of the Certified Nursing Assistant Task list revealed offload heels while in bed with an initiation date of 2/16/2024; and to apply skin prep to bilateral heels with an initiation date of 2/16/2024. Review of Resident #144 N Adv Skilled Evaluation dated 2/20/2024 at 23:24 revealed under Skin: Skin warm and dry, skin color WNL (within normal limits) and turgor is normal. Skin Issue #002: Pressure ulcer/injury. Location: Right heel. Skin Issue #003: Redness. Location Left heel. Under Functional: able to move RLE (right lower extremity: yes. Able to move RUE (right upper extremity): yes. Able to move LUE (left upper extremity) yes. Upper extremity ROM (range of motion): no impairment. Lower extremity ROM: impairment on one side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 10 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0686 Level of Harm - Minimal harm or potential for actual harm Review of the physiatrist note dated 2/23/2024, 2/26/2024, 3/4/2024, 3/6/2024, 3/11/2024, 3/13/2024, 3/19/2024 under Skin: visible areas intact, dressing to left hip, CDI (clean, dry, intact), not removed. Review of the primary care physician note dated 2/20/2024 revealed skin: no rash, + (positive) L (left) hip and leg wounds with multiple staples. Residents Affected - Few Review of N Adv Skilled Evaluation dated 2/23/2024 at 20:30 revealed under Skin: Skin Issue #006: Pressure ulcer/injury. Location: Right heel. Skin Issue #007: Redness. Location Left heel. Review of N Adv Skilled Evaluation dated 2/24/2024 at 19:17 revealed under Skin: Skin warm and dry, skin color WNL (within normal limits) and turgor is normal. Skin Issue #010: Pressure ulcer/injury. Location: Right heel. Skin Issue #011: Redness. Location Left heel. Review of N Adv Skilled Evaluation dated 2/25/2024 at 22:44 revealed under Skin: Skin warm and dry, skin color WNL (within normal limits) and turgor is normal. Skin Issue #002: Pressure ulcer/injury. Location: Right heel. Skin Issue #003: Redness. Location Left heel. Under Functional: able to move LUE (left upper extremity): yes. Able to move RLE (right lower extremity: yes. Able to move RUE (right upper extremity): yes. Upper extremity ROM (range of motion): no impairment. Lower extremity ROM: impairment on one side. Education/Notification: Safety concerns - note: at risk for falls: low bed, call light and frequently used items are within easy reach. Resident/responsible party is aware of diagnosis and plan of care. Resident/Responsible party states understanding. Review of N Adv Skilled Evaluation dated 2/26/2024 at 18:24 revealed under Skin: Skin Issue #010: Pressure ulcer/injury. Location: Right heel. Skin Issue #011: Redness. Location Left heel. Review of N Adv Skilled Evaluation dated 2/27/2024, 3/10/2024, revealed under Skin: Skin warm and dry, skin color WNL (within normal limits) and turgor is normal. Skin Issue #002: Pressure ulcer/injury. Location: Right heel. Skin Issue #003: Redness. Location Left heel. Under Functional: able to move LUE (left upper extremity): yes. Able to move RLE (right lower extremity: yes. Able to move RUE (right upper extremity): yes. Upper extremity ROM (range of motion): no impairment. Lower extremity ROM: impairment on one side. Education/Notification: Safety concerns - note: at risk for falls: low bed, call light and frequently used items are within easy reach. Resident/responsible party is aware of diagnosis and plan of care. Resident/Responsible party states understanding. Review of N Adv Skilled Evaluation dated 3/15/2024, revealed under Skin: Skin warm and dry, skin color WNL (within normal limits) and turgor is normal. Skin Issue #001: Pressure ulcer/injury. Location: Right heel. Education/Notification: Safety concerns - note: at risk for falls: low bed, call light and frequently used items are within easy reach. Resident/responsible party is aware of diagnosis and plan of care. Resident/Responsible party states understanding. Review of N Adv Skilled Evaluation dated 3/17/2024, 3/19/2024, and 3/20/2024, revealed under Skin: Skin warm and dry, skin color WNL (within normal limits) and turgor is normal. Skin Issue #001: Pressure ulcer/injury. Location: Right heel. Education/Notification: Safety concerns - note: at risk for falls: low bed, call light and frequently used items are within easy reach. Resident/responsible party is aware of diagnosis and plan of care. Resident/Responsible party states understanding. Review of the state form, 5000-3008, dated 2/15/2024 showed section T, left hip incision only. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 11 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Weekly Pressure Wound Note dated 2/19/2024, showed Resident #144 was admitted with the right heel pressure ulcer/injury; Stage: SDTI (Suspected Deep Tissue Injury), 36 mm by 37 mm, well defined round appearance. Signed on 2/21/2024. Review of the Weekly Pressure Wound Note dated 3/4/2024, showed Resident #144 was admitted with the right heel pressure ulcer/injury; Stage: SDTI, 34 mm by 35 mm, well defined round appearance. Signed on 3/8/2024. Review of the Weekly Pressure Wound Note dated 3/11/2024, showed Resident #144 was admitted with the right heel pressure ulcer/injury; Stage: SDTI, 34 mm by 35 mm, well defined round appearance. Signed on 3/20/2024. Review of the Weekly Pressure Wound Note dated 3/20/2024, showed Resident #144 was admitted with the right heel pressure ulcer/injury; Stage: SDTI, Current stage: unstageable, overall impression: worsening, slough tissue present (yellow, tan, white, stringy), wound has now opened revealing slough beneath, 100% slough in the wound bed, with serosanguinous drainage. Wound measures: 30 mm by 28 mm by 2 mm, peri-wound within normal limits, remains round and well defined. Signed on 3/20/2024. Review of the care plans showed Resident #144 had a pressure ulcer to the right heel, as of 2/19/2024. The goal was for the pressure ulcer to show signs of healing and remain free from infection. Interventions included but not limited to administering treatments as ordered and monitor for effectiveness as of 2/19/2024. Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document stats of wound perimeter, wound bed and healing progress report improvement and declines to the MD as of 2/19/2024. Float heels while in bed as of 2/19/2024. Monitor nutritional status. Serve diet as ordered, monitor intake and record. As of 2/19/2024. During an interview on 3/20/2024 at 9:17 a.m., Resident #144's daughter stated Resident #144 had a wound on her heels. The daughter stated, it takes a lot of reminding to get the staff to change the dressing to her heel. The daughter continued to state, when she came in today Resident #144 had on thick fuzzy socks with sneakers. Those socks were too thick for the sneakers, made the sneaker too tight. The daughter removed the fuzzy socks and noted drainage on the socks and in the shoe. The daughter stated she was finally able to get a nurse to look at the wound and place a dressing on it. She stated she was not happy when she arrived and noted the fuzzy socks on as they were too thick for the sneakers but now, she was glad this happened otherwise she might not have seen the heel. The daughter stated she would be taking the socks and insert home to clean and disinfect. The daughter stated the only prevention the facility educated her about was the elevating of heels while in bed, nothing about footwear occurred. On 3/20/2024 at 9:17 a.m., Resident #144's was observed sitting in the wheelchair, with sneakers on. The daughter was sitting on the resident's bed with the fuzzy socks and a shoe insert in her lap. The fuzzy socks were noted with a half dollar size circle on the heel, appeared wet. The shoe insert appeared wet with a red, brown fluid on the heel of the insert. An interview was conducted with Staff J, Certified Nursing Assistant (CNA) on 3/20/2024 at 2:54 p.m Staff J confirmed being Resident #144's CNA for the day. Staff J, CNA stated the night shift got Resident #144 up and dressed for the day, therefore Staff J had not seen Resident #144's heels. Staff J confirmed placement of skin prep on bilateral heels, daily. Staff J stated skin prep was available in the treatment carts, if the treatment carts were not unlocked the nurse would just hand us the key so we were able to get what we needed. Staff J stated, I just wipe the heel with the pad. We do (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 12 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0686 this for all the residents on this floor. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Staff P on 3/20/2024 at 3:04 p.m. Staff P confirmed utilizing the skin prep on the residents in the assignment. Staff P stated the nurse would give us the wipe or the key to the treatment cart so we could get. Staff P stated you just rub the wipe on the heels. Staff P stated, you don't really have to look at the heels just rub the wipe on them. Residents Affected - Few An interview was conducted with Staff FF, CNA and Staff GG, CNA on 3/20/2024 at 3:08 p.m Staff FF, and Staff GG confirmed utilizing the skin prep on the residents' heels. An interview was conducted with Staff N, Licensed Practical Nurse (LPN) on 3/20/2024 at 3:14 p.m Staff N confirmed the CNAs placed the skin prep on the residents' heels. If the treatment cart was not open for them, I just hand them the keys to the treatment cart. The CNAs could put skin prep on all residents' heels, the nurses then asked the CNA if they completed the task. If the CNA said yes, we (the nurse) documented this on the TAR. Staff N, LPN confirmed caring for Resident #144 and did not recall what the resident's heels look like. An interview was conducted with Staff O, Registered Nurse (RN) on 3/20/2024 at 9:48 a.m Staff O, RN confirmed the CNAs placed the skin prep on the residents' heels. An interview was conducted with Staff M, RN on 3/20/2024 at 10:28 a.m Staff M, RN confirmed CNAs completed skin prep to residents' heels if the skin was not impaired. Staff M, RN stated Resident #144 was admitted with impaired heels therefore CNAs should not have been doing the treatment. During an interview on 3/21/2024 at 9:57 a.m. Staff L, LPN Clinical Manager and Wound Nurse confirmed evaluating Resident #144's skin. Resident #144 was admitted with pressure injury on both heels. Staff L confirmed completing the weekly pressure wound note. Staff L stated the heels were both improving. Staff L stated only the nurse did skin prep on impaired heels and CNAs on intact heels, with no impairments. Staff L confirmed Resident #144 was admitted with impairments on bilateral heels and the CNAs should not have been placed the skin prep on her heels. Staff L confirmed review of the CNA task earlier and noted CNAs were performing the task. Staff L stated,I removed the task from the CNAs. Staff L reviewed the documentation in the medical record and confirmed the daughter was not educated that sneakers (shoes) were probably not a good idea to wear with the heel blister and Deep Tissue Injury (DTI). Staff L reviewed the Weekly Pressure Wound Note dated 3/11/2024 and was asked why it was signed yesterday. Staff L stated I revised the note, but I don't remember what I revised. Staff L could not comment on why a pressure note had not been completed on 3/18/2024. An interview was conducted with the Director of Nursing (DON) on 3/21/2024 at 10:24 a.m The DON stated both nurses and CNAs applied skin prep. The nurse used skin prep to help bandages adhere to peri-wound. CNAs utilized skin prep for protection for heels. Nurses utilize skin prep for any impaired skin, DTIs, and pressure ulcers. Skin Prep pads were located in the CNA closet or in bins behind the nurses' desk. The DON stated the treatment carts should not be unlocked unless in the visual site of a nurse and the nurse should never give her keys to a CNA. The DON reviewed Resident #144's medical record and stated, both feet need to be monitored for skin injuries. CNAs should not be completing skin prep. The DON continued to state the facility provided education and competencies to CNAs on applying skin prep. Review of an in-service titled CNA Task facilitator/Credentials: Staff L, LPN on 11/17/2022, Notes: CNAs can apply skin prep to affected areas on residents. The sign in sheets had a total of 38 CNAs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 13 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few signatures. Attached to the sign in sheets was a Skin Prep steps: Step 1 - skin should be clean and dry prior to application of skin prep. Step 2 apply a uniform coating over entire area you wish to protect, i.e., around stoma, under dressing, catheter site, etc. Step 3 skin prep will dry in approximately 30 seconds. If you miss an area that you intended to cover, wait until the original area of application has dried, then reapply to the missed area. Step 4 for maximum protection, and optional second coating of skin prep may be applied and allowed to dry before covering area with dressing or other adhesive product. Step 5 if skin prep is applied to an area with skin folds or other skin-to-skin contact, make sure that skin contact areas are separated to allow the coating to thoroughly dry before returning to normal position. Removal: step one the removal of adhesive products may also remove skin prep, so reapplication is necessary anytime the adhesive products are changed. Step 2 removal of skin prep is not necessary before application. Clean and dry the area and apply fresh skin prep as directed above. An interview was conducted with Resident #144's physician on 3/21/2024 at 12:52 p.m The physician stated he was quite familiar with Resident #144. He did not recall anything about her heels but could not recall everything about all patients. The orders for the heels could be from him or his Advanced Practice Registered Nurse (APRN) who assisted with patient calls and visits. The physician stated he was not familiar with the protocols for nursing facility's treatment protocols of CNAs. He said he would assume CNAs would not be performing any type of treatment on a patient who had skin impairments. Review of the facility's policy, Wound Management Program, effective on 1/24 showed: Purpose: The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment and prevention of pressure as well as, non-pressure related wounds. Process: 1. All residents admitted to facility will have a skin integrity risk evaluation performed at the time of admission, in conjunction with each quarterly and annual assessment, with any significant change assessment and as deemed necessary by the interdisciplinary team; This includes the development of a newly identified pressure ulcer. The admitting nurse is responsible for initiating the form ending after they total score, sign, and date. The admitting nurse will then be responsible for initiating the appropriate interventions such as ensuring treatment order(s) are in place, pressure reduction devices are ordered and or requested, i.e., specialty mattress and wheelchair cushions, and the interim care plan is initiated. 2. The Admitting nurse will be responsible for informing the unit manager or designee of the wound so that the wound can be then documented. 3. The director of nursing or designee will be responsible for the creation of the monthly cumulative report of all facility wounds. 4. Weekly during the scheduled weekly skin evaluation the nurse responsible for that week's evaluation will document the wounds on the weekly skin check. When there is noted deterioration in the wound the nurse will notify the physician and consult for additional treatment orders. This process will continue weekly until the wound is healed. 5. The facility utilizes an outside wound care specialists, to assist with wound management and treatment, who provides weekly visits to residents with wounds. The wound description information obtained from this provider will be scanned into the electronic medical record and maintained under the document section. 6. The unit manager or designee will be responsible for completing the weekly wound evaluation utilizing the information obtained during that week's skin visit. 7. Once the wound has been identified as being healed, the physician as well as the resident and/or residents' representative will be notified, and this notification will be documented in the resident's clinical record. 8. The nurse identifying the wound as being healed will notify the unit manager or designee that the wound is healed, and the unit manager or designee will document on the appropriate wound log that the wound is healed. Point of emphasis: the facility complies with state and federal guidelines as it relates to wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 14 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0686 prevention and definitions. Adherence to this program is under the direction of the DON. Level of Harm - Minimal harm or potential for actual harm Review of the facility document titled PROCEDURE SUBJECT: Skin Prep Application. The documents is not dated. PROCEDURE: the purpose of this procedure is to provide guidelines for the application of skin prep. 1. Assemble equipment and supplies needed. 2. Identify the resident and explain the procedure. 3. Place the resident's trash can within easy reach. 4. Position the resident for comfort. 5. Perform hand hygiene. 6. Put on clean gloves. 7. Remove the barrier wipe from wrapping and wipe over area(s) of bony prominence and/or high friction. 8. Reposition the resident for comfort as needed. 9. Remove gloves and perform hand hygiene. 10. Document and report any changes to resident's skin integrity. Residents Affected - Few Based on observation, interview, and record review, the facility did not ensure care to prevent pressure ulcer development and promote the healing of existing pressure ulcers/injuries for two (Resident #47 and #144) of two residents sampled for skin and pressure ulcers. Findings Included: A review of Resident #47's admission record revealed an admission date of 10/12/23 with diagnoses not limited to dementia, chronic respiratory failure, high blood pressure, peripheral vascular disease, cerebral infarction with left side weakness, and bed confinement. The following orders: -Order dated 10/13/23, Do Not Resuscitate (DNR). -Order dated 11/29/23, Comfort measures only (CMO) include the following, transfer to hospital or ER if desired by resident and Health Care Surrogate. Initiate invasive artificial nutrition if desired by resident or Health care surrogate. Initiate IV Hydration if desired by resident or Health care surrogate. Procedures per physician order. Initiate antibiotics if desired by resident or health care surrogate. -Order dated 12/12/23 Regular diet mechanical soft texture (texture modified diet for residents with chewing and swallowing difficulties), thin Liquids consistency, super (fortified) cereal and super doughnut at breakfast. -Order dated 12/12/23, Pleasure foods and drinks by family / Power of Attorney (POA). -Order dated 1/25/24, [name brand of nutritional supplement] one time a day. -Order dated 3/5/24, cleanse sacral pressure injury with normal saline and gently pat dry daily. Fill wound cavity with silver impregnated calcium alginate then cover with a border dressing. Reapplication if dressing is soiled or dislodged. -Order dated 3/6/24, encourage pt to drink water specifically every shift -Order dated 3/15/24, for one packet of Juven two times a day by mouth (PO) -Order dated 3/15/24, for [name brand of nutritional supplement] clear one time a day 237 ml PO may substitute with [name brand of nutritional supplement]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 15 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0686 On 3/6/24 Resident # 47's weight is 101.4 Lbs. and on 2/6/24, weight is 105.0 Lbs. Level of Harm - Minimal harm or potential for actual harm On 2/29/24 Resident #47's labs results for total protein level is 6.1 g/dL, the normal range is 6.0-8.3 and albumin level is 2.8 g/dL and the normal range is 3.5-5.7 g/dL. On 3/4/24 Resident #47's lab results for total protein level was 5.6 g/dL and albumin level is 2.8 g/dL. Residents Affected - Few Resident #47's Minimum Data Set (MDS), significant change in status, dated 3/15/24 showed the following: -Section C, Cognitive Patterns, Brief Interview for Mental Status (BIMS) showed a score of 00, indicating severe impairment. -Section H, Bowel and Bladder showed Resident #47 is always incontinent of bowel and bladder. - Section K, Swallowing and Nutritional Status, showed weight loss of 5% or more in the last month or 10% in the last 6 months. -Section M, Skin Conditions showed Resident #47 has an unhealed pressure ulcer over a bony prominence. Resident #47 had a stage 3 pressure ulcer which was not present upon admission. Skin and Ulcer/Injury treatments included a pressure reducing device for chair and pressure reducing device for bed. The resident was not on a turning or repositioning program, and there were no nutrition or hydration interventions to manage skin problems. A review of Resident #47's care plan initiated on 8/25/23 showed the following. Focus: Resident #47 has a pressure injury to the sacrum. Goal: Resident #47 pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions to include: - Administer treatments as ordered and monitor for effectiveness. - Assess, record and monitor wound healing weekly. Measure length, width and depth. - Report improvements and declines to the medical doctor (M.D.) -Follow facility policies and protocols for the prevention/treatment of skin breakdown. -Monitor nutritional status. Serve diet as ordered, monitor intake and record. - Monitor and document and report as needed (PRN) changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size include length, width, depth and wound stage. -Obtain and monitor lab and diagnostic work as ordered. Report results to MD and follow up as indicated. Weekly treatment documentation to include measurement of each area of skin breakdown's width, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 16 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0686 length, depth, type of tissue and exudate. Level of Harm - Minimal harm or potential for actual harm A review of Resident #47's care plan focus was actual impairment related to incontinence, impaired mobility, non-ambulatory, pressure areas and fragile skin. Residents Affected - Few Goals to include the following: Dated 12/26/22, Resident #47 will maintain or develop clean and intact skin by the review date. Interventions to include the following: - Dated 11/27/23, Resident #47 will have wound nurse consult and support devices evaluated for pressure reduction. - Dated 5/2/23, staff will use caution with care/transfers due to Resident #47's fragile skin. - Dated 12/26/22, staff will encourage good nutrition and hydration to promote healthier skin. - Dated 2/26/22, staff will follow facility protocols for treatment. - Dated 1/31/23, staff will turn and reposition. - Dated 12/26/22, staff will monitor and document location, size and treatment of skin injury. Staff will report abnormalities, such as failure to heal, signs and symptoms of infection, wound maceration (softening) etc. to the medical doctor. - Dated 12/26/22, each week staff will document treatment including measurement of the area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. On 12/26/22 the following care plan was initiated for Resident #47. The focus was bowel and bladder incontinence related to dementia and impaired mobility. The goal was Resident #47 will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions dated 1/23/24 include skin checks per protocol. Dietician assessment dated [DATE] revealed significant weight loss in the last 6 months -10.7% and 17.4 Body Mass Index (BMI). Resident #47's oral intake of meals was between 26-100% and consumed 50% of supplements. A review of Resident 47's wound Evaluation and Management Summaries showed the following:The chief complaint was Resident #47 had wounds on the sacrum. The measurements for stage 4 full thickness pressure wound on the sacrum showed: - On 3/5/24 the sacrum wound size is length is 2.5, width is 2.5, depth is 1.6 cm, and the total surface area is 6.25 cm² - On 3/12/24 the sacrum wound size is length is 3.5, width is 2.5, depth is 2.2 cm, and the total surface area is 8.75 cm² (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 17 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0686 Level of Harm - Minimal harm or potential for actual harm During an interview on 3/19/24 at 12:09 p.m., Resident # 47's family member said the only concern with the facility was following wound care orders, making sure dressings were done. On 03/20/24 at 1:37 p.m. Staff L, Licensed Practical Nurse (LPN), Unit Manager (UM) was observed changing Resident 47's dressings. No issues were identified. Residents Affected - Few On 03/21/24 at 11:57 a.m. an interview was conducted with the Minimum Data Set (MDS) Coordinator, she said on 3/18/24, Resident #47's MDS was revised due to significant changes, related to weight loss and pressure ulcers. The MDS coordinator said she was aware of new ulcers by reviewing physician orders. On 3/20/24, during an interview with the dietician, she said the nursing staff documents the amount of nutritional supplements the resident consumes. The dietician said she is a member of the Interdisciplinary Team (IDT) and contributed to discussions related Resident #47 nutritional intake. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 18 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0695 Provide safe and appropriate respiratory care 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 observations, staff interviews, and medical record reviews, the facility failed to ensure that seven (#555, #28, #43, #87,#37, #58, and #96) seven randomly observed residents who received respiratory care, had their respiratory equipment (e.g., oxygen tubing, nebulizers) properly stored while not in use, and dates on the residents' oxygen tubing. Residents Affected - Some The findings included: 1. On 03/18/24 at 12:25 p.m., Resident #555, who had pneumonia, was receiving oxygen via nasal cannula at 1.5 liters/minute according to the flow meter on the standard oxygen concentrator (a machine that uses room air to make oxygen for people who need supplemental oxygen). There was no date on oxygen tubing, so that the staff would know how long the tubing has been in use. Resident #555 current physician's orders included the following related to respiratory care: -Has/is the resident experienced shortness of breath while lying flat? If yes, please create a health status note stating shortness of breath while lying flat and any interventions put in place. every shift for monitoring, start date: 01/29/24 at 2300 hours (11:00 p.m.) , discontinued on 03/15/24 at 1636 hours (4:36 p.m.), and restarted 03/15/24 at 2300 hours (11:00 p.m.). -Take and record vital signs every shift, or at other frequencies, as needed. Start date: 03/15/24 at 2300 (11:00 p.m.). -Albuterol Sulfate (a medication used to treat wheezing and shortness of breath caused by breathing problems) Inhalation Nebulization Solution (a liquid medicine that turns into a fine mist to breathe in through a mask or mouthpiece) (2.5 mg/3 ml) 0.083% 1 vial inhale orally every 6 hours related to pneumonia, start date, 02/01/24 at 0600 hours (6:00 a.m.), discontinued on 03/15/24 at 1636 hours (4:36 p.m.). -Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 ml) 0.083%, 3 milliliters inhale orally every 6 hours as needed for shortness of breath/wheezing, start date, 03/15/24 at 2100 (9:00 p.m.) hours. -Mucinex Oral Tablet Extended Release 12 Hour 600 mg (Guaifenesin) (a cough medication that loosens congestion in the chest and throat), give 600 mg by mouth every 6 hours as needed for congestion/cough, start date on 03/15/24 at 2100 hours (9:00 p.m.) . There were no orders for oxygen administration. Review of Resident #555's March 2024 vital signs in the medical record, indicated Resident #555's oxygen saturation rates (the percentage of oxygen in a person's blood) ranged from 95 to 96% (normal range 95% to 100), and the resident's respirations ranged from 17 to 18 breaths/minute (normal range - 12 to 20 breaths per minute). The resident was recently admitted on [DATE], and the most current Minimum Data Set, a Discharge Assessment, return not anticipated, dated 02/20/24 and OBRA (Omnibus Budget Reconciliation Act) admission assessment dated [DATE] indicated no shortness of breath and no oxygen use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 19 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #555 had a care plan for ineffective airway clearance, initiated and created on 03/15/24. The care plan goal was for Resident #555 to be free of respiratory distress, with a target date of 06/13/2024. The care plan interventions included: encourage use of incentive spirometer (a medical device that helps a person take slow deep breaths to prevent lung problems after surgery); evaluate capillary refill (a simple test used to evaluate blood circulation in peripheral tissue); evaluate for cough; evaluate for shortness of breath; evaluate lung sounds; evaluate pulse oximetry (measurement of blood oxygen levels); evaluate respiratory rate and effort; and head of the bed elevated. On 03/21/24 at 11:18 a.m., the Director of Nursing (DON) was interviewed and informed about Resident #555's oxygen tubing that was not dated. She confirmed in the resident's medical record that the resident was on oxygen via nasal cannula at 1.5 L/min. The DON stated that the nurse should have dated that [oxygen tubing]. During facility tours on 03/18/24 at 10:03 a.m., 03/19/24 at 2:05 p.m. and 03/20/24 at 10:11 a.m., observations were made of Resident #28's nebulizer and mask on top of a chair. The nebulizer was not in a bag. The nebulizer was observed exposed to the elements during three of three days of observations. Review of an admission record for Resident #28 revealed she was admitted to the facility on [DATE]. Review of physician orders for Resident #28 dated 03/21/24 showed there were no orders for the nebulizer machine, and it's use. During a facility tour on 03/20/24 at 10:04 a.m., an observation was made of Resident #43's oxygen tubing and nasal cannula placed on her wheelchair seat. The tubing and cannula were not stored in a bag. They were exposed to the elements. Review of physician orders for Resident #43 dated 03/21/24 showed Oxygen 2 liters via NC (nasal cannula) to keep saturation greater than 88% may use with humidifier as needed every shift for SOB (shortness of breath) dated 01/24/24. On 03/20/24 at 10:36 a.m., an interview was conducted with Staff L, Licensed Practical Nurse (LPN). She stated respiratory equipment should be secured in a bag to prevent contamination. It should be cleaned after each use, labeled, and stored in a bag. She stated the facility had a respiratory therapy team that did rounds and ensured equipment such as oxygen and nebulizers were stored appropriately. On 03/20/24 at 12:27 p.m., an interview was conducted with the Director of Nursing (DON). She stated respiratory equipment should be cleaned after each use and stored in a clean dated bag. The DON said, respiratory equipment should not be left exposed to the elements. A follow up interview was conducted on 03/20/24 at 1:54 p.m. the Assistant Director of Nursing (ADON) and the current Infection Preventionist (IP) and the former IP. The ADON/IP stated related to the facility's infection control practices, the respiratory team changes all tubing every Monday. She stated everything was to be stored in a plastic bag. She stated nebulizers were to be cleaned and air dried, stored in a bag that was labeled and dated. On 3/18/2024 at 7:44 a.m., Resident #87's nebulizer machine was observed on the bedside table. The tubing and mask were sitting on the machine, unbagged. (Photographic Evidence Obtained) On 3/18/2024 at 8:14 a.m., Resident #37's nebulizer machine was observed on the bedside table. The tubing and mask were lying on the floor, next to the bedside stand, unbagged. (Photographic Evidence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 20 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0695 Obtained) Level of Harm - Minimal harm or potential for actual harm On 3/18/2024 at 8:35 a.m., Resident #58's nebulizer machine was observed on the bedside table. The tubing and mask were sitting on the machine, unbagged. (Photographic Evidence Obtained) Residents Affected - Some On 3/18/2024 at 8:55 a.m., Resident #96's nebulizer machine was observed on the bedside table. The tubing and mask were sitting on the machine, unbagged. (Photographic Evidence Obtained) An interview was conducted with Staff K, Certified Nursing Assistant (CNA) on 3/19/2024 at 11:25 a.m Staff K stated the tubing and mask should be in a bag. An interview was conducted with Staff O, Registered Nurse (RN) on 3/20/2024 at 2:00 p.m Staff O stated nebulizer masks should be placed in a bag after use. Staff O validated that many on the floor were not in bags, review of photo confirmed they should be in bags and anyone could the mask place in bag. Staff O stated, you were too early, I noted the masks just after you had toured the unit. An interview was conducted with the Director of Nursing (DON) on 3/21/2024 at 10:24 a.m The DON stated, I expect the tubing to be changed, dated and bagged. The facility did not provide the requested policy and procedure for oxygen equipment storage prior to survey exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 21 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to ensure Nurse Staffing Information was posted accurately for four of four days. Residents Affected - Many Findings included: An observation was conducted on 3/18/2024, 3/19/2024, 3/20/2024, and 3/21/2024 at various times throughout the days, at the front entrance of the facility, and each facility nurse station (total of 4 floors). A Staff Posting Report, which reports the number of nursing staff assigned in the facility for the day, was not observed. An interview was conducted with the Staffing Coordinator on 3/21/2024 at 12:20 PM. The Staffing Coordinator stated the total numbers were posted by the receptionist at the front desk. The Night Nursing Supervisor placed the posting at the reception desk, in a plastic frame. An interview was conducted with the Receptionist on 3/21/2024 at 12:45 PM. The Receptionist stated that she was not sure what report the surveyor was referring to and stated there was no posting of staff here [in the Reception area]. An interview was conducted with the Nursing Home Administrator (NHA) on 3/21/2024 at 1:39 PM. The NHA stated the Nurse staffing with total numbers for the facility was posted on each unit. A request was made on 3/21/2024 at 1:40 PM for a facility policy related to the Staff Posting Report to the NHA. A facility policy was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 22 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-seven medication administration opportunities were observed, and eight errors were identified for five residents (#455, #56, #43, #125, and #12) of ten residents observed. These errors constituted a 21.62% medication error rate. Residents Affected - Few Findings included: On 3/19/24 at approximately 8:24 a.m., Staff B, Licensed Practical Nurse (LPN) was observed preparing and administering Resident #455's medication. Staff B checked Resident #455's blood pressure, it was 151/69 and heart rate was 72 beats per minute prior to preparing the medication. Staff B prepared and administered Insulin 3 units. The following medications were prepared and administered: Flomax 0.4, Clonidine 0.1, Eliquis 5 mg 2 tablets (blood thinning medication, requires monitoring for signs or symptoms of bleeding), Finasteride 5 mg, Gabapentin 300 mg, Metformin 500 mg, Metoprolol 50 mg (Blood pressure check ordered including parameters of when it is safe to administer), Nifedipine 60 mg, Metformin 500 mg. A review of Resident #455's physician orders revealed Insulin was ordered at 7:30 a.m. before breakfast and the medication was administered late and after Resident #455 had eaten breakfast. Eliquis 5 mg 2 tablets (blood thinning medication which required physician notification for signs or symptoms of bleeding). No documentation Resident #455 was checked for signs or symptoms of bleeding. On 3/19/24 at 12:31 p.m., during an interview with the Director of Nursing (DON) she said she expected residents receiving Eliquis to be monitored for signs and symptoms of bleeding. She reconfirmed Resident #455 did not have orders to monitor for bleeding. On 3/19/24 at 9:15 a.m., Staff A, LPN was observed preparing and administering medications. A review of Resident #43's physician's order revealed an order for atorvastatin calcium 20 mg by mouth once daily at 8:00 a.m. Staff A said Resident #43 was not awake and the medication would be administered late. On 3/19/24 at approximately 4:00 p.m., Resident #43's morning medication administration record was reviewed and there was no documentation the medications were given late, or the physician was notified. On 3/19/24 at 9:25 a.m., Staff A, LPN was observed preparing and administering medications. A review of Resident #125's physician's order showed an order for Famotidine 20 mg by mouth (PO) twice daily at 7:30. Staff A said Resident #125 was not awake and the medication would be administered late. On 3/19/24 at approximately 4:00 p.m., Resident #125's morning medication administration record was reviewed and there was no documentation the medication was given late, or the physician was notified. On 3/20/24 at 9:15 a.m., Staff D, Registered Nurse (RN) was observed preparing and administering Resident #12's medications. Staff D handed Resident #12 fluticasone propionate inhaler and fluticasone propionate nasal spray to self-administer. Resident #12 self-administered both medications. A review of Resident #12's physician orders revealed self-administration of medications was not prescribed. An order dated 3/24/23 for fluticasone propionate aerosol give two puffs by mouth two times a day at 8:00 a.m. and 6:00 p.m. and to rinse mouth with water after use. Staff D did not observe or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 23 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few instruct Resident #12 to rinse her mouth after inhaling the medication or prior to leaving the resident's room and documenting medications were administered. On 3/20/24 at 8:52 a.m., an observation of medication administration with Staff D was conducted for Resident #56. A review of Resident #56's physician's orders revealed the orders for ipratropium-albuterol Inhalation Solution 0.5-2.5 inhale orally every 4 hours as needed and Combivent Respimat inhalation aerosol Solution 20-100 MCG/ACT 1 puff inhale orally two times a day. Staff D did not administer or observe self-administration of Combivent Respimat and Ipratropium-Albuterol. Resident #56 told Staff D the inhaled medications were taken, Staff D administered Eliquis 5 mg, and documented medications were administered on Resident #56's Medication Administration Record (MAR). A review of Resident # 56's physician orders did not show an order for medications to be self-administered by the resident. On 3/20/24 at 12:31 p.m., an interview was conducted with the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the Assistant Nursing Home Administrator (ANHA). The DON said the facility had the following expectations for residents who self-administered medications: a physician order, a resident assessment for self-administration of medications and care plan that focused on medication self-administration. A review of the facility policy titled, Administering Medications, effective date 1/24, Policy Statement section revealed medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation section: -the director of nursing services or designee will supervise and direct all nursing personnel who administer medications and/ or have related functions. -medications must be administered in accordance with the orders, including any required time frame. -Medication shall be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders), resident absence, or unexpected circumstances occur. -if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document in the EHR Or initial and circle the MAR space provided for that medication and dose. -residents may self-administer their own medication only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. When approved, the facility shall follow the safety guidelines established for medication safe keeping in the room. -if a resident uses PRN medications frequently, the attending physician and the interdisciplinary care team, with support from the consultant pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for frequent pure end use, and consider whether a standing dose of medication is clinically indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 24 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for six (Residents #56 #107, #54, #43, #133, and #407) on three of three floors (2nd, 3rd and 4th floors) and did not ensure medication and treatment carts were secured on two of three floors (2nd and 3rd floors). Photographic evidence was obtained. Findings included: On 3/19/24 at 9:15 a.m. Staff B, Licensed Practical Nurse (LPN) left a brown glass medication bottle on top of the medication cart when she went to administer medications to a resident. The cart was not positioned where it was always visualized by Staff B. On 3/20/24 at 12:50 p.m. the 3rd floor medication storage rooms and medication carts were observed, and an interview was conducted with Staff L, Licensed Practical Nurse (LPN), Unit manager (UM). Staff L said a resident with multi dose medications such as eyedrops should be labeled with open date, use by date, and staff's initials. The number of days the medication should be used was found on the medication label or in the resident's medication administration record (MAR). The 3 east medication cart bottom drawer contained particles and a dry sticky liquid (Photographic Evidence Obtained). Staff L immediately removed the contents and cleaned the drawer. There was a resident provided over the counter medication bottle labeled with the resident's first name only. Staff L immediately added a room number to the bottle. A bottle of COVID reagent solution was stored in the medication drawer. Staff L immediately removed the bottle. Staff L confirmed the reagent should not be in the medication cart. (Photographic Evidence Obtained). On 3/20/24 Staff D, Registered Nurse (RN) was observed labeling a new bottle of Timolol Maleate Solution 0.5 % and labeled the bag containing the solution with the expiration date of 7/2025. When inquired how the expiration date was determined, Staff D said the expiration date was 30 days from the date the medication was opened. He relabeled the bag containing the medication. (Photographic Evidence Obtained). On 3/20/24 Resident #56 had the medications listed below stored in the second drawer of her chest of drawers in her room. The following medications did not contain medication labels, including the resident's name and directions of how to use the medications: Ipratropium-Albuterol Inhalation Solution, Combivent Respimat Inhalation Aerosol Solution and Albuterol Sulfate HFA 108 aerosol solution. (Photographic Evidence Obtained) On 3/20/24 at 12:31 p.m. during an interview with the Director of Nursing (DON), she said medications designated to a single resident should have medication labels. The DON said a pharmacy request had been sent to the pharmacy to replace Resident #56's medications for medication with the resident's specific medication labels. On 3/21/24 at 8:49 a.m., a tour of the 4th floor medication storage rooms and medication carts were observed and revealed the 4th floor North medication cart contained a dirty (particles and sticky liquid) drawer. (Photographic Evidence Obtained). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 25 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 - Some 03/21/24 at 10:53 a.m., the 2nd floor medication storage rooms and medication carts were observed, and an interview was conducted with Staff H, LPN. Isolation masks and eye protections items were stored on the countertop in the medication room. Staff H, LPN said the items should not be in here we have a storeroom. On 3/19/2024 at 9:52 a.m., Resident #407 had a zip lock bag with a pharmacy label sitting on the desk next to the bed. The label on the bag showed: SSD CRE 1% (Silver Sulfadiazine Cream 1%). (Photographic Evidence Obtained) An interview was conducted with Staff O, Registered Nurse (RN) on 3/20/2024 at 2:00 p.m. Staff O, RN stated no medication should be left at the resident bedside, room or bathroom. An interview was conducted with the Director of Nursing (DON) on 3/21/2024 at 10:24 a.m. The DON stated, I expect medications to be secured in the treatment cart. Review of the facility policy titled Storage of Medications dated 1/24 shows: Policy Statement: the facility share store all drugs and biologicals in a safe, secure, and orderly manner. Policy interpretation and implementation: 1 drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2 the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Three drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Four the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Five drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications. 6 antiseptics, disinfecting, and germicide used in any aspect of resident care must have legible distinctive labels that identify the contents and the directions for use, and shall be stored separately from regular medications. 7 compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) Containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Eight drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each residence medication shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 9 medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses station or other secured location. Medications must be stored separately from food and must be labeled accordingly. 10 only persons authorized to prepare and administer medication shall have access to the medication room, including any keys. On 03/18/24 at 7:47 a.m., an observation was made of an unlocked treatment cart, outside room [ROOM NUMBER] near the 300-nursing station. Photographic evidence obtained. On 03/18/24 at 7:50 an observation was made of Staff W, Registered Nurse (RN) walking over to the 300 North treatment cart and locking it. An observation was conducted on 03/20/24 from 11:40 a.m. to 11:51a.m. of the second-floor treatment cart unlocked in the resident hallway with 2 residents sitting in their wheelchairs next to the unlocked treatment cart. On 03/20/24 at 11:51 a.m., the DON was observed to walk over to the treatment cart and lock it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 26 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 On 03/19/24 at 9:12 a.m., an observation was made of a cream-colored round tablet on the floor at the foot of the bed in Resident #107's room. On 03/19/24 at 9:15 a.m., Staff X Licensed Practical Nurse (LPN) (Agency) observed the tablet on the floor. She stated she did not know what it was, but she would check. Residents Affected - Some On 03/19/24 at 9:17 a.m., Staff X stated the tablet was Melatonin 3 mg. She stated it might have been dropped the night before. She stated the expectation was for the nurses to observe the resident during medication administration to make sure they swallowed their meds. Review of Resident #107's physician orders dated 03/21/24 showed the resident was prescribed Melatonin 3 mg one tablet by mouth at bedtime for insomnia. During a facility tour on 03/19/24 at 9:29 a.m., a white oval tablet was observed on the floor next to the door frame of a resident room. Staff A, LPN was notified of the observation. She stated she did not know what it was, but she would find out. On 03/19/24 at 9:32 a.m. Staff Y, Director of the Assisted Living Facility who was covering hall 300 stated the tablet was for Resident #54. He stated the tablet was Amlodipine and the resident had an order for it. He stated Staff A reported this resident had refused all her medications that morning. He said, It may have been from yesterday. Review of Resident # 54's physician orders dated 03/21/24 showed the resident was prescribed Amlodipine 10mg, give one tablet by mouth at bedtime for hypertension. In a follow up interview with Staff A on 03/19/24 at 9:45 a.m., she stated she did not administer the resident's amlodipine because her blood pressure was outside parameters. She stated she did not pull the tablet. She stated she did not know if it was from the day before. She stated the facility practice was to stay and watch the resident take their medications. She stated this resident liked her medications spoon-fed to her whole one tablet at a time. She stated the expectation was to explain to the resident what they were taking and watch them take the medications. During a facility tour on 03/20/24 at 9:59 a.m., an observation was made of a Nystatin powder bottle at Resident #43's bedside. Review of Resident # 43's physician orders dated 03/21/24 revealed the resident did not have orders for Nystatin powder. An interview was conducted with the Director of Nursing (DON) on 03/20/24 at 12:24 p.m. The DON stated she was notified there were residents with medications at bedside. She said, Unless the resident has self-administration orders, all meds should be secured and administered by the nurse. The expectation is if a resident wanted to keep meds at bedside, we would assess for visual assessment competency and assess the ability to self-administer. She stated it should be documented in the care plan if they were approved for self-administration. She confirmed prescribed medications should have been secured. 3. On 03/18/24 at 10:34 a.m., while observing Resident #133's room, there was a large tube of Voltaren gel (a topical medication that provides temporary relief of joint pain) on the resident's over the bed table. The Voltaren gel did not have a prescription label on it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 27 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 On 03/19/24 at 9:16 a.m., there was a large tube of Diclofenac gel (generic medication for Voltaren gel) on Resident #133's nightstand and a large tube of Voltaren gel on his over the bed table. Photographic evidence obtained. There was no prescription label on the Diclofenac gel. There was 4 bottles of Vashe wound solution (prescription-only product that cleanses, irrigates, moistens, and debrides acute and chronic wounds) stored on the windowsill in Resident #133's room. Photographic evidence obtained. Residents Affected - Some Resident #133 stated he got these wound solutions from the Veteran's Administration (VA). The Vashe wound solution bottles had prescription labels from the VA, not the facility. He said the facility Wound Nurse applied the Vashe wound solution to his wound. There was a physician's order for Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical)), apply to back, knees topically two times a day for back/knee pain 4 grams, ordered on 03/6/23. However, there was no care plan related to Resident #133's back and knee pain or self-administration of medications. On 03/21/24 at 11:17 a.m., during an interview with the Director of Nursing, she was informed about Resident #133's medications stored in his room. She said she would have to find out about that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 28 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, and serve food according to food safety standards, as evidenced by the following: -Refrigerated ready-to-eat, pureed Time/Temperature Control for Safety Food was not dated correctly. -Raw chicken was not covered while stored in the walk in refrigerator to prevent contamination of other stored food and equipment. -Clean eating equipment was not inverted while being stored to prevent contamination. -Clean trays and cooking equipment was not stored to protect from contamination from impelled or falling dead insects and insect fragments from an insect electrocution device. -The facility dish machine did not have an affixed with an easily accessible and readable data plate by the manufacturer that indicated the machine's design and operation specifications. -Two ice storage bins in the third and fourth floor nourishment rooms were not clean to sight. -Multiple Imperial nutritional shakes stored in the fourth floor nourishment room were not marked with legible dates or not date-marked with a date to indicate when the food must be consumed or discarded within 14 days after thawing. -The Director of Food Service indicated that they had no system for monitoring the reheating temperatures of pre-plated pureed food. -A pan of raw fish was not protected from contamination in that it was being prepared in the 3 compartment dish washing sink. -Direct care staff were touching one resident's ready-to-eat food with their bare hands. These practices have the potential to affect 169 residents out of 171 residents who consume the facilities food. The findings included: 1. During the Initial Kitchen Tour on 03/18/24 at 07:10 AM, there were multiple plates of pre-plated pureed food stored on two sheet pans on a cart in the walk-in refrigerator designated for meat food storage, which were dated 1/15, not 3/15. The Assistant Food Service Director witnessed the observation and stated that the staff must have used the wrong date. He stated that this pre-plated pureed food was prepared in advance and cooled down to be served on another day and was reheated in the steamer. In the same walk-in, there were six sheet pans with multiple raw chicken pieces stored on them in a pan rack that were not covered. Photographic evidence obtained. Additionally at 07:15 AM, there were multiple plates of pre-plated pureed food stored on three (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 29 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 - Some sheet pans on a cart in the walk-in refrigerator designated for milk food storage that which were dated 1/15, not 3/15. Photographic evidence obtained. During the Initial Kitchen Tour on 03/18/24 at 07:20 AM, there was an insect electrocution device installed on a wall near clean equipment on the milk side of the kitchen. There was a tray dollie stored underneath this device and a rack of clean pots and pans stored on the right side of the unit, which was not conducive to preventing dead insects and insect fragments from being impelled onto or falling on exposed food and clean equipment. Photographic evidence obtained. During a follow up visit on 03/20/24 at 12:34 PM, the ADC dish machine was observed not to be affixed by the manufacturer with an easily accessible and readable data plate that indicated the machine's design and operation specifications, including the temperatures required for washing, rinsing, and sanitizing; pressure required for the fresh water sanitizing rinse; and conveyor speed The Director of Food Service was present at the time of the observation and he looked for a data plate and could not find one. During an observation on the third floor nourishment room on 03/20/24 at 08:59 AM the inside of the grey ice storage bin had some black colored substance near the interior hinge of the lid. Photographic evidence obtained. During an observation on 03/20/24 at 09:10 AM in the fourth floor kitchen area, which was not in use. The interior of the meat microwave oven had old, dried food spatter. There were multiple dishes stored on shelves that were not inverted and multiple beverage glasses stored in racks that were not inverted. There was a small Christmas tree stored on a shelf with boxes of dishes in the same area. Photographic evidence obtained. Additionally, observation of the 4th floor nourishment room refrigerator/freezer unit, there was multiple 4 oz. containers of Imperial nutritional shakes stored in the refrigerator unit. The dates marked on the Imperial shakes was illegible and one Imperial shake was not dated. The Imperial nutritional shake label states to use the product within 14 days after thawing. Photographic evidence obtained. Also, the inside of the grey ice storage bin had some black colored substance near the interior hinge of the lid. Photographic evidence obtained. During another follow up visit on 03/21/24 at 02:02 PM, The Director of Food Service was asked if they were doing any temperature monitoring for reheating pre-plated pureed food. He responded they don't record the reheating temperatures. He said they used to mold their pureed foods, but were not doing that at this time. The Director of Food Service was asked for the facility policy on the preparation of the pureed food. The Director of Food Service provided an undated policy, titled, Puree Mold Preparation Guidelines, which included . 2. Place plates on 2 hotel pans then cover with aluminum foil and place in steamer for 10-15 minutes until it reaches temp of 165 degrees. On 03/21/24 at 02:19 PM during a follow up visit to the kitchen, a staff was removing fish fillets from a pan that was put in the empty 3rd compartment of the 3 compartment sink, which was not a preparation sink in the presence of the surveyor and the Director of Food Service. On 03/21/24 at 02:31 PM, an interview was conducted with the Director of Food Service and he was informed of all of the issues that were identified related to food safety. He stated that the 4th floor dining room was closed at the beginning of COVID-19 pandemic and has not reopened. They started in December 2023 to get supplies to reopen the dining room, and they found that the air conditioning wasn't working right. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 30 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 - Some 2. During an observation conducted on 03/18/24 at 08:15 AM Staff V, Certified Nursing Assistant (CNA) was observed to have a resident's breakfast tray on top of the meal cart which was located in the hallway across from the resident's room. Staff V was observed putting jelly on the resident's toast and holding the corner of the piece of toast with her bare hands. Staff V said she was setting up a resident's plate because her hands were shaky. Staff V finished spreading the jelly on the toast and brought the tray into the resident's room and came out and sanitized her hands. On 03/18/24 at 08:35 AM Staff V was observed to remove a resident's breakfast tray from the meal cart, place it on top of the meal cart, open a jelly packet, remove the plastic from a cereal container, remove the cap to the milk, and remove the lid from the breakfast plate. She walked with the meal uncovered from the meal cart located outside of room [ROOM NUMBER] and walked into room [ROOM NUMBER] and provided the meal tray to the resident. An observation was conducted on 03/18/24 at 08:38 AM. Staff V, CNA was observed to remove a meal tray from the meal cart, place it on top of the meal cart, she removed the covering to the jelly packet, removed the plastic covering from the cereal container, and remove the lid to the main breakfast plate. She was observed to spread butter on top of the toast with a knife and hold the corner of the bread with her bare fingers. She then walked the uncovered meal tray from the meal cart located outside of room [ROOM NUMBER] and walked across the hall and placed the meal tray in front of a resident in her room on the bedside tray table. Staff V placed a clothing protector on the resident, closed the resident's curtain partially, and walked out of the room without offering the resident any hand hygiene. The resident was observed to eat her meal independently. Staff V walked over to the meal cart, closed the doors to the meal cart, and discarded the wrappers located in the plate covering and sanitized her hands. An interview was conducted on 03/18/24 at 08:22 AM with the Director of Nursing (DON). She said staff should be setting up the meal trays at the tables not on top of the meal carts. An interview was conducted on 3/21/24 at 3:00 PM with the Nursing Home Administrator. He said staff should not be touching resident food with their bare hands. He said the staff should be using utensils to assist in preparing resident meals. Review of the facility's Food Handling policy undated, revealed. Intent: It is the policy of the facility to procure, store, prepare, distribute, and serve food under sanitary conditions following proper sanitation and food handling practices to prevent the outbreak of foodborne illness in accordance with State and Federal Regulations. Procedure: .3. Ready-to-eat foods should not be touched with care hands . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 31 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 Based on observation and staff interview, staff failed to offer hand hygiene before meals to three (#30, #111, and #555) of three randomly observed residents, who ate in their rooms, during two of two facility meals on the same floor. Additionally, two nurses failed clean or disinfect the wrist blood pressure cuff before or after use and failed to perform hand hygiene before administering four (#12, #76, #141, and #445) of 13 residents' medications. Residents Affected - Some The findings included: 1, During the Dining Observation Task during breakfast on 03/18/24 at 08:38 AM, Certified Nursing Assistant (CNA), Staff T served Resident #111's breakfast in his room. The CNA, Staff T set up the resident's food and she asked the resident if he wanted condiments. CNA used a knife and a fork to put jelly on his toast. CNA, Staff T did not offer hand hygiene to the resident before he ate. The CNA, Staff T put the toast in Resident #111's hand to eat. During breakfast observation on 03/19/24 at 08:25 AM CNA, Staff U brought Resident #30 her breakfast tray to her room and set up her meal. CNA, Staff U did not offer any hand hygiene to Resident #30 before giving the resident a banana without peel to eat with her hand. During breakfast observation on 03/19/24 at 08:30 AM, CNA, Staff S brought Resident #555 her breakfast tray in the room and CNA, Staff S did not offer any hand hygiene before the meal. On 03/21/24 at 11:36 AM, during an interview with the Director of Nursing, she was made aware that the CNAs did not offer hand hygiene before meals to residents who eat in their room. 2. An observation was conducted on 03/18/24 at 08:38 AM. Staff V, CNA was observed to remove a meal tray from the meal cart, place it on top of the meal cart, she removed the covering to the jelly packet, removed the plastic covering from the cereal container, and remove the lid to the main breakfast plate. She was observed to spread butter on top of the toast with a knife and hold the corner of the bread with her bare fingers. She then walked the uncovered meal tray from the meal cart across the hall and placed the meal tray in front of Resident #141 in her room on the bedside tray table. Staff V, CNA placed a clothing protector on the resident, closed the resident's curtain partially, and walked out of the room without offering the resident any hand hygiene. The resident was observed to eat her meal independently. 3. During an observation on 3/19/24 at 8:24 a.m. of Resident #455's medication administration. Staff B, Licensed Practical Nurse (LPN) did not clean or disinfect the wrist blood pressure cuff before or after use. Staff B did not perform hand hygiene before or after testing blood pressure and administering medications. During an observation on 3/19/24 at 8:26 a.m. of Resident #141's medication administration. Staff B, Licensed Practical Nurse (LPN) did not clean or disinfect the wrist blood pressure cuff before or after use. Staff B did not perform hand hygiene before or after testing blood pressure and administering medications. During an observation on 3/20/24 at 8:26 a.m. of Resident #76's medication administration. Staff D, Registered Nurse (RN) did not clean or disinfect the wrist blood pressure cuff before or after use. Staff D did not perform hand hygiene before or after testing blood pressure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 32 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 During an observation on 3/20/24 at 9:16 a.m. of Resident #12's medication administration. Staff D, Registered Nurse (RN) did not perform hand hygiene before or after administering medications. A review of the facility policy titled, Administering Medications, effective date 1/24, Policy Statement section revealed medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation section: staff shall follow established facility infection control procedures (e.g., hand washing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications as applicable. Event ID: Facility ID: 105504 If continuation sheet Page 33 of 34 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain an ongoing antibiotic stewardship program for two out of three months reviewed. Residents Affected - Many Findings included: Review of the facility's infection prevention documentation showed no documentation related to an ongoing surveillance of resident infections and antibiotic orders for the months of February and March of 2024. On 3/20/24 at 1:50 p.m., an interview was conducted with the current Infection Control Preventionist (IPC), who was also the Assistant Director of Nursing as well as assistant manager to the unit managers on the second and third floor. The IPC transitioned to this role in January 2024. During the interview, the ICP was unable to produce their monthly antibiotic stewardship program reports for the month of February and March to date for this year. The ICP stated the goal was to run weekly reports with the attempt to concurrently review the use of current residents' antibiotic orders and based on the McGreer's criteria to meet the criteria for an infection and the appropriate antibiotic was ordered with an end date. A review of the facilities policy and procedure titled: Infection Prevention and Control Program effective January 2020 showed an Antibiotic Stewardship as follows: [The facility] uses McGreer criteria to determine if the resident needs an antibiotic. If the resident does not meet the criteria, then the physician is asked not to prescribe an antibiotic as the first measure. Antibiotics should be changed if indicated in culture and sensitivity. The facility reports to the Department of Health as indicated, infections are discussed in the monthly QA / Q API meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 34 of 34