Inspection·January 24, 2020

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a care plan that included instructions needed to provide care, related to the use of an elastic wrap bandage for 1 of 35 (#149) sampled residents. Findings included: Observations of Resident #149 on 1/22/20 at 8:41 AM revealed that the resident had an elastic wrap bandageto her left hand. It was noted that there was no medical tape on the bandage that would indicate when the elastic wrap bandage was placed on her hand. An interview with the resident at this time revealed that this bandage was old and was ok as it keeps her hand warm. Review of the resident's record revealed that this resident was admitted to the facility on [DATE]. Review of Resident #149's current care plan revealed no care plan in place for, and no mention of the use of, the elastic wrap bandage. Review of #149's record revealed that there was no current order for the use of a bandage to her hand. Review of an admission nursing note, dated 1/8/20 15:05, revealed nwb to lue d/t s/p fall with left wrist fx. Left wrist wrapped with ace wrap. skin underneath intact and clear. There was no other nursing notes related to the use of the elastic wrap bandage An interview 1/23/20 at 9:34 AM with Staff B, Licensed Practical Nurse, revealed that the resident wears the elastic wrap bandage for comfort and that it is not indicated by her physician to use it and that there is no order for the use of the elastic wrap bandage. On 1/23/20 at 10:15 AM, Resident #149 was observed wheeling herself out of her room. The resident was noted to be wearing the elastic wrap bandage. The elastic wrap bandage was noted to be dirty. An attempt to interview the resident at this time was unsuccessful, as the resident fanned this surveyor away and said it's fine. In an interview on 1/23/20 at 10:15 AM with Staff A, Certified Nursing Assistant, she reported and produced a clean elastic wrap bandage in the resident's room. Staff A made no attempts to encourage the resident to change the dirty elastic wrap bandage to the clean one. An interview on 1/24/20 at 11:24 AM with the DON revealed that she was not aware of the resident using an elastic wrap bandage and not aware of how the use of the elastic wrap bandage is to be monitored, related to cleanliness and to ensure that it is not applied too tight. The DON reported that her expectation is that the nurse would be following up on the use and cleanliness of the elastic wrap bandage. On 1/24/20 at 1:07 PM, the DON provided a physician's order, dated 1/24/20, to monitor circulation to left hand every shift, and a second physicians order to change (elastic) wrap to left hand as needed for soilage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 2 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility care plan titled Person Centered Care Planning, with a revised date of 12/2016, revealed that When admitted , each resident will have physician orders, dietary needs, medications, treatments, and preliminary discharge plans reviewed by the IDT and will have an interim care plan developed within 24 hours of admission, along with input from the resident and/or representative. This assures that the resident's immediate needs are met and his/her preferences are considered. This plan will be implemented as needed until the staff can conduct a comprehensive assessment and develop a complete interdisciplinary plan of care. Event ID: Facility ID: 105537 If continuation sheet Page 3 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, facility failed to ensure residents were free of accidents hazards, related to bed not maintained in the low position while in bed, for 1 of 35 (#52) sampled residents. Residents Affected - Few Findings included: On 01/21/20 at 11:15 am, Resident #52 was observed in bed at a high position. Resident #52 was observed awake with an uncontrollable cough. Resident #52 did not respond on command, but continued coughing. On 01/24/20 at 11:30 am, Resident #52 was observed in an elevated bed asleep. The resident did not awake when his name was called to arouse him. On 01/24/20 at 01:35 pm, an interview with Staff I, Licensed Practical Nurse, revealed Resident #52's bed level is changed during meal-times. Staff I stated The part of the meal tray that has the wheels cannot fit under the bed. We lift the bed so the tray can fit properly. On 01/24/20 at 01:52 pm, Resident #52 was observed in bed with the bed in high position. The resident was observed asleep with head of bed raised. On 01/24/20 at 01:57 pm Staff J, Licensed Practical Nurse accompanied surveyor into the resident's room. Staff J confirmed that Resident #52's bed was in the high position. Staff J stated that We reposition him throughout the day. Staff J stated, This is not the low position, but let me find the remote and I'll lower it. Review of Resident #52's facesheet revealed an admission date of 9/04/2017 with recent admission date of 1/13/2020. Pertinent medical diagnoses of Encephalopathy, Parkinson's disease, dysphagia, cognitive communication deficit, muscle weakness and Dementia as of 1/13/2020. Review of Resident #52's physician's orders revealed the resident's bed was to be in low position when the resident is in bed for every shift. Order start date was 1/13/2020. The policy was requested related to physician orders being followed. The facility was unable to provide it. Record Review of Resident #54's care plan revealed the resident is at risk for falls related to confusion, Gait/balance problems, incontinence, unaware of safety needs, ASHD, CAD and weakness. Interventions included but not limited to Anticipate and meet the resident's needs. Date initiated was 05/02/2018 with Revision date of 10/11/2019. Review of Policy titled Summit Care Risk Management-Fall Risk Reduction Program, with Effective date of July 2015, Page 3 Section B. Reducing risk, 1. General safety precautions and interventions that may be used for all at-risk residents include but are not limited to: c) Maintaining bed in low position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 4 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medication storage, the facility failed to ensure that one (high hall) out of three medications carts were stored according to professional principles, related to the cart contained: medication without a resident identifier, medication without an active Physician order, and a torn controlled substance card holding a pill in place with a piece of tape, out of a total of six medication carts identified by the facility. Findings Included: On [DATE] at 11:45 a.m. the medication cart on high hall was observed, alongside Licensed Practical Nurse I (LPN I). A box contained a label for albuterol for 7 days. LPN I indicated that the last day for the medication was on [DATE]. She confirmed no active order was in place (photographic evidence was obtained). One box of debrox ear drops were noted that had a written date of [DATE]. The box had been opened, with the bottle tip missing its plastic seal. The box did not contain a resident identifier. LPN I confirmed the observation and said that ear drops are not for universal usage. An aerosol inhaler titled Flonase was dated for [DATE]. LPN I, at that time, reviewed current Physician orders for the resident. She confirmed that there was not a current order. The locked box was observed with a bubble card labeled for the controlled substance: Ativan 0.5 mg to give by mouth 3 times daily as needed for anxiety. The card contained handwritten discontinue (d/c) on the top left-hand corner. LPN I said that it was discontinued a few days ago. After a record review, it was determined by LPN I and the Unit Manager that it was stopped on [DATE]. Upon further review of the medication card, the back of the card revealed a piece of tape that covered the #3 pill location. A pill was identified being held in place with the tape that covered the torn package. On [DATE] at 12:30 p.m. an interview was conducted with the Director of Nursing about the medication carts storing medications without orders alongside active ordered medications. She did not respond. On [DATE] at 5:25 p.m. an interview was conducted with the facility Pharmacist. She indicated that the medications in the carts should be removed in a reasonable manner after there is no longer an active Physician order. She stated One week is a reasonable amount of time. In an ideal world it would be taken out of the cart when the order is completed. The Pharmacist was asked about the medication card for Ativan that indicated it was a controlled substance. The back of the card contained a piece of tape covering a torn opening of the packaging. The Pharmacist stated That should not happen. The medication should have been wasted with another nurse, indicating it should not be covered with a piece of tape. The facility provided a copy of their policy titled Disposition of Controlled Drugs, dated on February 2014: All controlled substance prescriptions that are no longer active orders due to discontinuation, discharge or death of a resident shall be destroyed in the facility by the Consultant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 5 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 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 Pharmacist, the Director of Nursing, and the Facility administrator or his (her) designee. Level of Harm - Minimal harm or potential for actual harm Procedure: Discontinued Medications and deceased Residents: Residents Affected - Few The remaining medications, the Control Drug Count Sheet and a copy of the Disposition of Medication form and Controlled Drug Disposition form shall be stored in a secure area that is not accessible to the nursing staff and is separate from the currently ordered medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 6 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and medical record review, the facility failed to ensure that dental services were provided to one (#4) out of thirty-five residents for over for twenty months. Residents Affected - Few Findings Included: On 01/22/20 at 10:17 a.m., Resident #4 was observed lying in bed. He was asked if he had any problems chewing or swallowing. He made eye contact with stimuli. His lower bottom teeth were crooked and yellow in appearance. The lower left was lacking teeth. He was asked if he had any pain or soreness in his mouth, as he continued to watch the surveyor and not respond. On 1/23/2020 at 10:15 a.m., a wound care observation was conducted with the facility Wound Care Licensed Practical Nurse (WN). Resident #4 was observed lying in his bed and appeared comfortable when approached. He appeared receptive to the observation, as he did not demonstrate nor verbalize his rejection to the WN when he was asked. The WN went to his bedside as she asked him if he was in any pain. He only looked at her without any change noted to his face. She asked him for second time if he was in pain. Again, he just looked at her without any facial changes. The WN then informed the resident that if he had pain during the procedure, she would stop and have the nurse get him something. Resident #4's care plan indicated he was dependent for all care and services. The resident's last Brief Interview for Mental Status (BIMS), dated 1/2/2020, indicated it was not conducted due to the resident's severe impairment. Social service note, dated on 1/2/2020 at 1637, note text Resident #4 ( ) shows no significant changes for this quarterly review. He requires extensive assist with his ADLs. He has short term memory (STM) and long-term memory (LTM) impairment. Resident #4 has severe cognitive impairment, is rarely understood and sometimes understands. He does not verbalize often. Regarding mood assessment, staff interview conducted. Regarding consult, he's on a rotating schedule to be seen by podiatry (11/ 1/19) and eye doctor (9/12/19). Resident #4 is a long-term care resident and his family considers the Springs his home and does not want to be asked to return to the community on all assessments. He attends activities and is more a passive participant. His advanced directives include DNR code status. Social services to provide services as needed to share that his psychosocial needs are met. The quarterly review omitted dental services. On 1/23/2020 at 4:00 p.m.,the Social Worker Director (SWD) was asked for copies of the last visit to Resident #4 by the dentist. She confirmed his insurance was Medicaid. The last dental visit provided by the SW was dated on May 10, 2018. The SWD confirmed that was the last time Resident #4 had been seen by the dentist. On 01/24/20 at 12:49 p.m. the Nursing Home Administrator was asked about Resident #4 not having any dental services since 2018. She stated, He was admitted with missing teeth. And he does not complain of any mouth pain. They did not want dental services. She was informed that he had not responded to the surveyor when he was approached. She said, He doesn't know you. She was informed that he had not responded the day prior to the wound nurse, when asked a simple a yes or no question. She said I don't know about that. On 01/24/20 2:07 p.m. an interview was conducted with the SWD and the Social Worker Assistant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 7 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (SWA). As they both indicated at that time, they did not have any communication issues with the resident's granddaughter. They were able to get in contact with her. The SWD said the granddaughter lives out of state, and does not participate in the care plan meetings. On 1/24/2020 at 2:10 p.m. a phone call was placed to Resident #4s' granddaughter, and she was receptive to the interview. She was asked if she was aware that her grandfather had not been seen for routine dental screenings since 2018. She said that she sends over all of his money that he gets every month to the facility. She stated $5000.00 a month. The granddaughter said that I would think he would have dental benefits. He has VA benefits; it should be covered. They tell me if he sees the dentist, they will have to take away from the money I send them. The granddaughter raised her voice and stated, I don't have any extra money to send for the dentist. She was asked who had told her she would be responsible for the additional payment. She indicated it was the facility social workers. The granddaughter was asked if she wanted her grandfather to have dental services; she stated, I would love for him to have dental services On 1/24/2020 at 3:10 p.m. the SWD said that He will tell us if he has pain. But he doesn't have any pain. She was asked how she was able to tell he did not have dental pain. She said you can tell by his face. The SWD was asked about the dental visit that was dated May 10,2018. It was listed next visit: FMD Initially/Prophy After. She indicated that is put on all the residents' visits and did not indicate anything. FDM: Full Mouth Debridement (FMD) for Periodontal Evaluation - Dental Procedure Code Description. The American Dental Association describes a full mouth debridement as the gross removal of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation. Prophy: Prophylactic | Definition of Prophylactic by Merriam-Webster 1 : guarding from or preventing the spread or occurrence of disease or infection prophylactic therapy. 2 : tending to prevent or ward off : preventive. www.merriam-webster.com > dictionary > prophylactic The Social Worker Assistant (SWA) was asked why Resident #4 had not been seen for yearly screenings. She stated, He doesn't have any issues to see a dentist. She confirmed his last BIMS score was zero, indicating he was severely impaired. The facility provided their policy titled Social services/Nursing-Dental Services that contained a revision date on October 2017. Policy: the facility will assist residents in obtaining both routine and 24-hour dental care. When necessary or requested, the facility will assist in making appointments by arranging transportation to and from the dental service location. The facility will try to minimize the financial burden on the resident by finding the lowest cost or no-cost transportation option to dental health care appointments. Routine dental services mean an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 8 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 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 0791 Level of Harm - Minimal harm or potential for actual harm For Medicaid paid residents, the facility will provide all emergency dental services in those routine dental services to the extent covered under the Medicaid state plan. The facility will inform the residents of the deduction for the incurred medical expense available under Medical state plan and will assist the resident in the reapplying for deduction. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 9 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to maintain the kitchen in a clean and sanitary manner, related to the dish machine, cleaning of dish cloths and a stove backsplash. Residents Affected - Few Findings included: Observations of the facility kitchen on 1/21/20 at 9:52 AM revealed that the dish machine had a dirty dish curtain stored on top of the dish machine and hanging over the clean side of the dish machine. Closer observations of the dish machine revealed that around the opening of the clean side of the dish machine was a white chalky substance. (Photographic evidence obtained) Continued observations at this time revealed a tray came out of the clean side of the dish machine, containing what was supposed to be clean cutlery. Closer observation of the tray revealed that there were 3 dish cloths mixed into the cutlery. When questioned why the dish cloths were mixed in with the cutlery, the Certified Dietary Manager (CDM) immediately pulled them out of the tray and mumbled those should not be in there. An interview, on 1/21/20 at 9:55 AM, with the CDM revealed that she would ensure that the dish machine is clean. She reported that she was not sure why the staff were washing the dirty dish cloths with the cutlery. She reported that the kitchen staff wwould be trained in the appropriate way to wash the cutlery and the dish cloths separately. Observations on 1/23/20 at 11:13 AM during the comprehensive tour of the kitchen revealed that this kitchen houses a 6 burner stove with an attached backsplash. Closer observations of the backsplash revealed that it was covered with brown/black greasy build-up which was easily removed with the tip of a pen. (Photographic evidence obtained.) Interview with the CDM at this time revealed that she was unsure as to when the backsplash to the stove was last cleaned. Review of the Daily/Weekly Cleaning List for Cooks does not reflect if or when the dish machine should be cleaned. Continued review of the list revealed that it indicated that the stove top should be cleaned, but does not indicate if or when the backsplash should be cleaned. A request was made for a policy for cleaning and maintaining the dish machine and the stove backsplash; these policies were not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 10 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 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, interview and medical record review, the facility failed to ensure that a standard infection control was utilized during incontinent care with one (#30) resident out of 35 sampled residents; that a blood monitoring device was cleaned and disinfected in-between three (60, 9 & 17) residents out of a total of nine residents with blood monitoring orders; contaminated dressing of bodily fluids were removed after completion from one (#4) resident environment; and that supervision was provided to one (#23) of one resident with conjunctivitis to prevent recontamination. Residents Affected - Some Findings included: 1. On 1/21/2019 at 10:50 a.m., Resident #30's bedroom door was closed. As the door was knocked on, a faint response stating just a minute could be heard. At that exact time, a nurse was present and stated the resident was being provided with care. She said we could go in. On entrance to the bedroom, a pair of pants, a soiled incontinent product, a towel and wash cloth laid strewn on the floor bare surface. The nurse said softly, Let me get some gloves. The curtain divider was partially obscuring the resident as she was getting assistance with her incontinent product. The Certified Nursing Assistant (CNA) then assisted Resident #30 into her wheelchair and said that the resident will start taking off her clothes on her own after an incontinent episode, indicating she had reached her just in time. The resident smiled at that time when she was approached. She was asked if she was going to activities. While still smiling, she said I can't hear you. Her left hearing aid was not hooked over the top of her ear; it dangled toward the top of her shoulder. The CNA, with the same gloves on, repositioned the hearing aid over the top of the oxygen tubing that was also positioned behind the left ear. She then bent down and picked up the washcloth and additional linen off the floor and placed it inside of the bag. The assistant then removed the gloves from her hands and exited the bedroom, walking right past the sink that was next to the doorway. The assistant walked down the hallway and used a punch pad to access the biohazard room that was across from the Unit One nursing station; opened the door with her right hand and tossed the bag into a bin; turned around and exited the room. The biohazard room was observed with a sink and faucet. An interview was conducted with the assistant at that time; she said she was Certified Nursing Assistant D. She was asked about hand hygiene practice after leaving Resident #30's bedroom. She stated I left the room with dirty linen. I always do it that way. Leave the room with dirty linen. Then I wash my hands. 2. On 1/22/2020 at 4:12 p.m., medication observation pass was conducted with Licensed Practical Nurse G (LPN G). She said Resident #60 was due for her blood glucose monitoring. LPN G entered the resident's bedroom and washed her hands for nine seconds and returned to the medication cart. She removed a container of bleach wipes and took it into the resident's bedroom and set it on top of her over-the-bedside table. She removed one of the wipes from the container and cleaned the top of the table, then used a paper towel to dry the tabletop. LPN G then removed the container of bleach wipes from the bedroom and placed it on top of the medication cart's bare surface. LPN G removed the glucose device from the drawer of the medication cart and cleaned the device for twenty-five seconds and placed it inside of a plastic cup. LPN G said that the device needed to dry for four minutes. Resident #60 was alert and receptive to the observation of the procedure. After the resident's blood glucose was obtained, the nurse returned to the medication cart and cleaned the device for four seconds, and placed it inside of a plastic cup. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 11 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 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 At 4:35 p.m., Registered Nurse E said that Resident #9 had an ordered blood glucose check at the time. Resident #9 was receptive to the observation process. After the procedure was performed, RN E went to the sink and set the device on top of the sink edge while she performed hand hygiene. She then picked up the device and returned to the medication cart. RN E cleaned the device for five seconds and placed it in the bottom drawer and said it would dry. Residents Affected - Some At 4:48 p.m. LPN G said she had a second blood glucose monitoring that could be observed for Resident #17. She removed the meter from the medication cart and placed it on top of the cart. She confirmed the meter had not been used after Resident #9. LPN G gathered the supplies that were needed for the procedure, and entered the bedroom with the container of bleach wipes. The container was set on top of the resident's over-the-bedside table. The tabletop was cleaned with a bleach wipe. LPN G then removed the container from the bedroom and placed it back inside of the medication cart's bottom right hand drawer. LPN G cleaned Resident #17's finger and used the lancet to obtain a blood sample. As LPN G picked up the meter and brought it towards the resident's finger, she was asked to stop. LPN G was asked to leave the bedroom at that time; as she did the Director of Nursing was standing in the hallway. LPN G was asked about the process of cleaning the glucose device. She said after the device is used, it is to be cleaned and dried for four minutes. She was asked what the cleaning instructions for the bleach wipes indicate. She stated, We used to clean the device for four minutes, but it wrecked the machines. She indicated the last time she had cleaned the machine for the manufacturer's recommended time was when you guys were here. The DON indicated the glucose device needs to be cleaned per the bleach wipes instructions. At 5:33 p.m. an interview was conducted with Registered Nurse H; she said that the normal procedure for cleaning the blood glucose device is by using a bleach wipe. You clean it twice, as she demonstrated, wiping the front and back of the device, and letting it dry for four minutes. She was asked if she had any training on the device; she said that an in-service was held and she was trained by the risk manager. On 01/23/20 11:31 a.m., an interview was conducted with the Risk Manager. She said that she had trained the licensed staff on cleaning the blood glucose meters. She stated I might have gotten it mixed up and said the dry time was four minutes, not the wet time. On 1/24/2020 at 12:42 p.m. the DON provided a list of current residents that resided in the facility with an active order for blood glucose monitoring. The list contained a total of nine residents. The facility provided a copy titled Maintenance that contained a revision date of February 2017. Cleaning and disinfecting guidelines due to CMS's F-tag 441 guideline on infection control, it is (company name)'s policy to advise healthcare professionals to clean and disinfect blood glucose meters between each resident test to avoid cross-contamination issues. Our cleaning and disinfecting guidelines are as follows: option 1: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicidal wipe. To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. Many wipes act as both a cleaner and disinfectant, so if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 12 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 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 The facility policy,Nursing - Blood Glucose Meter Cleaning and Disinfecting with a revision date of February 2017: The facility will prevent the spread of infection by cleaning and disinfecting blood glucose meters according to the manufacturer's recommendations between resident use. Procedure: Blood glucose meters will be wiped with PDI super Sani-cloth (bleach) germicidal disposable wipes after each use. The meter will be wiped down completely and left wet for two (4) minutes to remain a wet surface when allowed to air dry according to the manufacturer's directions each time it is and disinfected. If the meter is visibly soiled with blood, the blood will be cleaned off with one germicidal wipe and the meter will be disinfected with a second germicidal wipe and allowed to air dry before next use. The facility bleach wipe container of Sani-cloth bleach germicidal disposable wipe indicated on the front label that it disinfects in four minutes. Directions for use: to clean, disinfect and deodorize; use a wipe to remove heavy soil unfold clean wipe and thoroughly wet surface treated surface must remain visibly wet for a full four (4) minutes. Use additional wipes if needed to assure continuous four-minute wet contact time. (Photographic evidence obtained). 3. On 1/23/2019 at 10:15 a.m., a wound care observation was conducted with the facility Wound Care Licensed Practical Nurse (WN). Resident #4 was observed lying in his bed and appeared comfortable when approached. He appeared receptive to the observation as he did not demonstrate or verbalize his rejection to the WN when he was asked. The WN went to his bedside as she asked him if he was in any pain. He only looked at her without any change noted to his face. She asked him for second time if he was in pain. Again, he just looked at her without any facial changes. The WN then informed the resident if he had pain during the procedure, she would stop and have the nurse get him something. The supplies were placed on top of a paper towel border on top of the resident's bedside table. The supplies consisted of 4 x 4 gauze dressings, two normal saline ampules, two tubes of santly ointment in a plastic bag, one Q-tip applicator, calcium alginate rope and allevyn life foam dressing, and one pair of scissors in a plastic bag. With the assist of a nursing assistant, Resident #4 was positioned to his right hip. The WN removed the old dressing from the resident's left ischium. An odor was immediately present. The WN confirmed the odor as musty and said that he had just finished an antibiotic. The old dressing was noted with a moderate amount of drainage that was presented as pink, with scattered yellow drainage. The dressing was disposed of, along with her gloves, in a garbage can that was next to the bedside. The wound opening appeared the size of a quarter with an irregular shaped border. The edges of the wound presented as macerated between two to four o'clock. The surrounding skin was pink and intact with old scar tissue just lateral to the left side of the wound opening. The wound bed had appeared white in color and noted to tunnel between 12 and 3. The depth was not able to be determined due to the extent of the tunneling. After the dressing was completed, the WN washed and dried her hands. She then removed the tube of santly that had not been used as it remained inside of a plastic bag, never opened, and returned it to the treatment cart. The supplies that were used, along with the soiled wound dressing, were left in the bedroom in the garbage can. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 13 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 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 Medical record review for Resident #4 indicated an order for Levaquin tablet 750 mg give 1 tablet by mouth one time a day for wound for two weeks with a stop date (D/C) date on 1/22/2020. The DON was asked for a copy of the facility procedure related to the disposal of soiled wound dressings. The facility provided a copy of their policy titled Dressings, Soiled/Contaminated with a revision date of August 2009. Policy statement: All soiled/contaminated dressings must be handled in a safe and sanitary manner and must be incinerated or disposed of following decontamination or containment. Policy of Interpretation and Implementation 1. Disposable items such as bandages, applicators, gauze pads, etc., that are soiled or contaminated with infective material, blood, or bodily fluids must be placed in a plastic bag and removed from the resident's room upon completion of any procedure. 4. On 1/22/20 at 1:18 p.m., Resident #23 was in the hallway propelling his wheelchair and was receptive when approached. He was observed with both of his eyes red in color and the upper eye lashes containing a moderate amount of crusted dark yellow matter. He was asked if his eyes his eyes hurt. He stated, It feels like I have sand in them. On 01/23/20 at 11:10 a.m. Resident #23 was in his bathroom as Certified Nursing Assistant K (CNA K) was in the bedroom. She was asked how much assistance was given to Resident #23 related to his morning care. She stated, He is very independent with his own care. We will change the linen on his bed and make his bed. At that time, Resident #23 exited the bathroom and smiled. Both of his eyes were pink in color. The upper and lower eye lashes presented with a moderate amount of dark yellow colored crusted residual. He said that he had washed his face and eyes. But it hurts having to rub them. CNA K said You have to hold the washcloth to the eyes for a while to loosen up. She added They drain a lot just like . (his roommate). She was asked how long his eyes had been draining; she indicated she was not for sure how long, as she only works as needed. The medical record was reviewed and revealed he had been residing at the facility for a year. Physician orders were reviewed that were dated on 1/15/2020 for Tobramycin solution 0.3% 1 drop in both eyes two times day for DX (diagnosis) conjunctivitis until 1/23/2020. Further review of Physician Progress note dated on 12/10/2019 Subjective: Patient is being seen today for left eye conjunctivitis. This began yesterday; patient had had drainage and crusting. Plan start patient on TobraDex 2 drops 3 times daily for 5 days. Progress Physician orders contained an order for tobramycin solution 0.3% instill 2 drops in left eye twice a day five days dated on 12/10/2019. This indicated Resident #23 had been treated for two months for conjunctivitis. On 01/23/20 at 12:35 p.m., an interview was conducted with the Director of Nursing, who is also the facility Infection Control Preventionist, related to Resident #23's eye infection. She said, When it was first identified, we had him stay in his bedroom for over the weekend. The DON was asked if the medical record had reflected this. She said that it did. The medical record for Resident 23's stay (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 14 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 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 in his bedroom over the weekend could not be located. Level of Harm - Minimal harm or potential for actual harm At 12:40 p.m., Resident #23 was in his bedroom and was receptive to an interview along with the DON. He was asked if his eyes were feeling better. He then picked up a washcloth that was lying inside of a plastic container/bin that was sitting on top of his bed. The container had also contained his shaving cream and other personal hygiene items. He said I have a new washcloth. Resident #23 was asked about his new washcloth, and he said that sometimes they run out of washcloths. He pointed to a used washcloth that was hanging off his dresser drawer handle. He said that he uses it sometimes more than once. The DON indicated if he had been reusing his washcloths, he could possibly re-contaminate his eyes. She confirmed that this is the second time he had been treated for conjunctivitis. Residents Affected - Some On 01/24/20 at 10:40 a.m., the DON said that she had talked with several of the staff members that take care of Resident #23. They had confirmed they were aware Resident #23 reuses his washcloth, and that they remove it. She also said that Resident #23's physician had seen Resident #23 and reordered his eye drops for 5 more days. On 1/24/2020 at 11:00 a.m., Resident #23's bedroom was noted with a used washcloth for a second day hanging off his dresser drawer handle (photographic evidence obtained). Pink eye (conjunctivitis) Is an inflammation or infection of the transparent membrane (conjunctiva) that lines your eyelid and covers the white part of your eyeball. When small blood vessels in the conjunctiva become inflamed, they're more visible. This is what causes the whites of your eyes to appear reddish or pink. Pink eye is commonly caused by a bacterial or viral infection, an allergic reaction. Though pink eye can be irritating, it rarely affects your vision. Treatments can help ease the discomfort of pink eye. Because pink eye can be contagious, early diagnosis and treatment can help limit its spread. Symptoms: The most common pink eye symptoms include: Redness in one or both eyes Itchiness in one or both eyes A gritty feeling in one or both eyes A discharge in one or both eyes that forms a crust during the night that may prevent your eye or eyes from opening in the morning Tearing Preventing the spread of pink eye Practice good hygiene to control the spread of pink eye. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 15 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 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 For instance: Level of Harm - Minimal harm or potential for actual harm Don't touch your eyes with your hands. Wash your hands often. Residents Affected - Some Use a clean towel and washcloth daily. Don't share towels or washcloths. Change your pillowcases often. https://www.mayoclinic.org/diseases-conditions/pink-eye/diagnosis-treatment/drc-20376360. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 16 of 17 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 105537 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Boca Ciega Bay 1255 Pasadena Ave S, Suite C South Pasadena, FL 33707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain all kitchen equipment in a safe operating condition, related to 2 of 6 (top left, top middle) burners on the stove and a reach-in refrigerator located in the satellite kitchen. Residents Affected - Few Findings included: Observations of the main kitchen and the satellite kitchen during the comprehensive tour of the kitchen on 1/23/20 at 11:13 AM revealed that the main kitchen houses a 6-burner stove. Close observation of the stove revealed that the top left burner and the top middle burner did not have pilot lights lit. Continued observations of the stove at this time revealed that the Dining Service Director lit both burners with a cigarette lighter. Both burners were turned on and then turned back off. The pilot light on the back center burner remained lit; however there was no pilot light on the rear left burner. The Dining Service Director reported that this was the second time this week that he had to light the pilot lights. Continued interview with the CDM and the Dining Service Director revealed that they both were not sure when the last time the pilot lines had been cleaned, and they were both unsure if this concern had been reported for repair. Continued comprehensive inspection revealed that this facility houses a satellite kitchen. It was noted that the satellite kitchen housed 4 reach-in refrigerators. Closer observation of 1 reach-in refrigerator that had dished canned fruit and cake stored in it, had a a broken rubber gasket approximately 12 inches long. Closer observation revealed that for this 12-inch area, the gasket was not attached to the refrigerator door and did not allow a positive suction to allow temperatures to be maintained (Photographic evidence obtained). Observation of the thermometer located inside the refrigerator revealed a reading of 44 degrees. The temperature of a bowl of apples was read at 58 degrees. Interview with the CDM at this time revealed that the items in this fridge were prepped this morning. Review of the facility's instructions for inspecting kitchen small appliances revealed that staff are to 1. Visually inspect all appliances for damage 5. Test functionality of appliances and proper operation of all controls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105537 If continuation sheet Page 17 of 17