Health inspection·June 4, 2021

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one (Resident #59) of three residents sampled for accidents had an accurate and current Minimum Data Set related to the use and placement of an elopement prevention alarm. Findings included: A review of Resident #59's Face Sheet, revealed a current admission date of 09/11/2015 with medical diagnoses of viral pneumonia, muscle weakness, unspecified mood affective disorder, and chronic obstructive pulmonary disease. Resident #59's MDS [Minimum Data Set] 3.0 Nursing Home Quarterly . dated 03/15/2021, revealed under Section C: Cognitive Patterns a Brief Interview for mental Status score of 14; indicating an intact cognition. Under Section G: Functional Status, it was revealed Resident #59 required extensive assistance with one-person for transfers, dressing, and personal hygiene. Resident #59 has a mobility device of a wheelchair. A review of Resident #59's Physician Order Report, revealed an active general order, dated 11/25/2019-Open Ended for wanderguard to Left ankle. A review of Resident #59's Progress Notes revealed a notation dated 11/25/2019 stating Resident found in w/c [wheelchair] in parking lot of facility. Resident easily redirected and brought back into facility. When asked why she had gone to parking lot, resident stated I was going to my son-in-laws, I have to make the rice, . New Order received for wanderguard and refer to pysch . Wanderguard placed to L. [left] ankle An observation and interview on 06/02/2021 at 1:23 p.m. with Resident #59 revealed no wanderguard placed on the Resident's person. Resident #59 was sitting in a wheelchair with a rolled-up towel held in her contracted left hand. Resident #59 stated she has had a contracted hand for a long time and her left leg was weak. During an interview on 06/03/2021 at 8:31 a.m. with Staff C, Registered Nurse/Unit Manager revealed if a resident is ordered an elopement alarm bracelet a physician order is placed into the online medical system and checked each shift for placement. If the elopement alarm bracelet is discontinued, then the active order is canceled after approval from the doctor. A progress note would be entered explaining why the elopement alarm bracelet was removed and an e-mail would be sent to the MDS/Care Planning department to have the information updated and reflected in the resident's online medical record. He stated currently there were no residents on his unit with an elopement alarm bracelet. A review of General Order, start date 11/25/2019 revealed an order to Check wanderguard to L. ankle for proper functioning daily . with a discontinue date of 11/20/2020 with a discontinue reason of Condition resolved. A review of the MDS dated [DATE] and the MDS dated [DATE] under Section P: Restraints and Alarms that Resident #59 revealed Resident #59 was coded for daily use of a Wander/elopement alarm. During an interview on 06/03/21 at 10:11 a.m. with Staff P, RN, Staff Q, RN and Staff R, LPN revealed all three staff members had duties of creating and coding for MDS and were considered MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105616 If continuation sheet Page 2 of 13 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 105616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinators. The procedure for MDS includes gathering information from the computer chart, staff, the resident regarding their activities of daily living to ensure an accurate and up to date MDS record. If a discrepancy is found during the review process, then the MDS Coordinators will go to the direct care staff. Additionally, one of the RNs (Staff P or Staff Q) must sign off for Staff R since she is an LPN upon completing an MDS. Staff Q, RN reviewed Resident #59's MDS record and confirmed the coding selection for an elopement alarm being used daily. A policy review of MDS Completion and Submission Timeframes, revised July 2017, revealed . Our facility will conduct and submit assessments in accordance with current federal and state submission timeframes . Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105616 If continuation sheet Page 3 of 13 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 105616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure that the behaviors, outcomes, and non-pharmaceutical interventions were monitored for one (#396) out of five residents sampled for unnecessary medications. Findings included: Resident #396 was admitted on [DATE]. The Face Sheet included diagnoses not limited to mild recurrent Major Depressive Disorder and a history of falling. An observation, on 6/1/21 at 10:52 a.m., Resident #396 was observed sitting in a chair next to the resident's bed. On 6/4/21 at 12:06 p.m., the resident was observed sitting up in bed watching television, and with a walker at the bedside. Resident #396's Medication Administration History for June 2021 indicated the resident was receiving the following psychotropic medications: - Aripiprazole (Abilify) 15 milligram (mg) tablet once a day for depression, started 5/28/21. - Sertraline (Zoloft) 50 mg tablet once a day for depression, started 5/28/21. The Medication History, printed on 6/2/21 at 2:04 p.m., for Resident #396 did not include monitoring for the resident's behaviors related to the administration of the antipsychotic medication, Aripiprazole and the antidepressant medication, Sertraline. A continued review of the history did not identify staff were monitoring for the side effects related to the above medications, non-pharmaceutical interventions utilized, or the outcome of the medications. The baseline care plan for Resident #396 indicated that the resident was alert and cognitively intact, had a history of falls, received psychotropic medications and did not have any behavior concerns. A revised care plan indicated that the resident was at risk for side effects related to the use of psychotropic medications, use of antipsychotics and antidepressants for the diagnosis of depression. The interventions related to the resident's use of psychotropic medications instructed staff to observe for signs and symptoms of side effects. A review of the observations and progress notes for Resident #396 did not indicate that the staff had noted any behaviors or side effects related to the administration of the resident's psychotropic medication. At 10:53 a.m. on 6/4/21, the Director of Nursing (DON) reviewed the physician orders for Resident #396 and confirmed that the target behaviors should be monitored and there should be an order for monitoring. He stated that the facility does a double-check of the chart and does not know why this resident's chart was missed. The policy, Behavioral Assessment, Intervention, and Monitoring, revised March 2019, indicated that behavioral symptoms will be identified using facility-approved behavioral screening tools and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105616 If continuation sheet Page 4 of 13 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 105616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete comprehensive assessment and that the facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. The policy Interpretation and Implementation identified that the nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: onset, duration, intensity, and frequency of behavioral symptoms. The management portion of the policy indicated that non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. The monitoring portion of the policy identified that if antipsychotic medications are used to treat behavioral symptoms, the Interdisciplinary team (ID) will monitor their indication and implement a gradual dose reduction, or document why this cannot or should not be done. The ID will monitor for side effects and complications related to psychoactive medications. Event ID: Facility ID: 105616 If continuation sheet Page 5 of 13 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 105616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716 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 observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed, and twenty-six errors were identified for five (#398, #395, #70, #63, and #31) of five residents observed. These errors constituted an 83.87% medication error rate. Residents Affected - Some Findings included: 1. On 6/2/21 at 10:11 a.m., an observation of medication administration with Staff Member T, Licensed Practical Nurse (LPN), was conducted with Resident #398. Staff T was observed administering the following medications: - Clopidogrel 75 milligram (mg) orally - Glipizide 5 mg orally A review of the Physician Orders for Resident #398 revealed the above medications were scheduled to be administered at 9:00 a.m. and the following medication orders: - Clopidogrel 75 mg orally once a day - Glipizide 5 mg orally once a day At 10:23 a.m. on 6/2/21, Staff T noted the medications, after the administration, as it was a late administration, then after a computer glitch she reentered the medication comment as charted late. 2. On 6/2/21 at 10:35 a.m., an observation of medication administration with Staff Member T, Licensed Practical Nurse (LPN), was conducted with Resident #395. Staff T was observed administering the following medications: - Vitamin B12 500 microgram (mcg) orally - Spiriva handihaler 2 inhalations - Losartan Potassium 2-50 mg tabs (100 mg) orally - Ferrous Gluconate 324 mg orally - Furosemide 40 mg orally - Dulera 100mcg/5mcg 1 inhalation A review of the Physician Orders for Resident #395 revealed the above medications were scheduled to be administered at 9:00 a.m. and the following medication orders: - Vitamin B12 500 mcg orally once a day - Spiriva Respimat 1.25 mg/actuation 2 puffs once a day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105616 If continuation sheet Page 6 of 13 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 105616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716 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 - Losartan 100 mg orally once a day Level of Harm - Minimal harm or potential for actual harm - Ferrous Gluconate 324 mg orally twice a day - Furosemide 40 mg orally once a day Residents Affected - Some - Dulera 100-5 mcg/actuation 2 inhalations twice daily On 6/2/21 at 10:41 a.m., Staff Member T confirmed the medications for Resident #398 and #395 were late and it was due to the residents needing more attention, taking the vital signs for all the residents (COVID-19 monitoring), a resident with Alzheimer's was up and walking, and interruptions. At 3:42 p.m. on 6/2/21 the staff member stated technically charted late and administered late were the same thing. 3. On 6/2/21 at 5:22 p.m., an observation of medication administration with Staff Member T, Licensed Practical Nurse (LPN), was conducted with Resident #70. The staff member stated that the insulin was late and the time of administration needed to be adjusted as the meal trays did not arrive until now. After obtaining a blood glucose level of 160 from Resident #70, Staff T was observed dispensing the following medications: - Metformin 500 mg orally - Ondanasetron 4 mg as needed orally - Potassium Chloride 20 milliequivalent (mEq) orally - Furosemide 20 mg orally - Novolog FlexPen 100 unit/milliliter - 2 units subcutaneously Staff Member T was observed placing an insulin pen needle on the FlexPen, rolled the pen between her hands, she dialed the pen to 2 units, turned the pen upside down, and with the needle facing the facility floor the nurse depressed the injection knob. The LPN turned the injection knob to 2 units, entered the resident room and administered the dispensed medications at 5:40 p.m., as the resident was observed sitting in bed eating the evening meal. A review of the Physician Orders for Resident #70 revealed the following medication orders and the scheduled time of administration: - Metformin 500 mg orally twice a day, 9 a.m. and 5 p.m. - Ondansetron Hydrochloride (HCl) 4 mg orally every 6 hours as needed - Potassium Chloride extended release 20 mEq orally twice daily, scheduled 9 a.m. and 5 p.m. - Furosemide 20 mg orally twice a day, scheduled at 9 a.m. and 5 p.m. - Insulin Aspart U-100 solution; per sliding scale: If blood Sugar is 151 to 200 units give 2 units, scheduled before meals and at bedtime; 6 a.m., 11 a.m., 4 p.m., and 8 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105616 If continuation sheet Page 7 of 13 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 105616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716 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 - Some During the administration of the medication Staff Member T stated the purpose of priming the pen was to remove the air bubble from the pen. She confirmed that the air bubble moved away from the needle when the pen was turned upside down and was not removed when she had primed the pen. According to the NovoLog manufacturers instruction insert, located at https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLog%20FlexPen% instructed users in priming of the pen: - Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: - E. Turn the dose selector to 2 units. - F. Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. - G. Keep the needle pointing upwards, press the push button all the way in. The dose selector turns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. 4. On 6/3/21 at 10:42 a.m., an observation of medication administration with Staff Member U, Licensed Practical Nurse (LPN), was conducted with Resident #63. Staff U was observed dispensing the following medications: - Amlodipine 10 mg oral tablet - Buspirone 10 mg oral tablet - Divalproex Delayed Release 125 mg oral tablet - Aspirin Low Dose 81 mg chewable tablet - Ocular Vitamin 2 oral tablets The resident refused the medications. A review of the Physician Orders for Resident #63 revealed the above medications were scheduled to be administered at 9:00 a.m. and the following medication orders: - Amlodipine 10 mg orally once a day - Buspirone 10 mg orally twice a day - Depakote (Divalproex) Delayed Release 125 mg orally once a morning - Aspirin Delayed Release/Enteric coated 81 mg orally once a day - AREDS 2 orally twice a day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105616 If continuation sheet Page 8 of 13 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 105616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716 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 5. On 6/3/21 at 10:51 a.m., an observation of medication administration with Staff Member U, Licensed Practical Nurse (LPN), was conducted with Resident #31. Staff U was observed dispensing the following medications, following obtaining a blood glucose level of 272: - Aspirin Low Dose Chewable 81 mg orally Residents Affected - Some - Carvedilol 3.125 mg orally - Bumetanide 1 mg orally - Gabapentin 300 mg orally - Nifedipine 30 mg Extended Release orally - Linzess 145 mcg orally - Magnesium Oxide 400 mg orally - MultiVitamin tablet orally - Ondansetron Disintegrating 4 mg orally - Bupropion 100 mg tab Sustained Release orally - Polyethylene Glycol 17 grams (gm) mixed with 4 ounces of water - Insulin Aspart, 100 unit/milliliter vial, 9 units subcutaneously A review of the Physician Orders for Resident #31 revealed the above medications were scheduled to be administered at 9:00 a.m. and the following medication orders: - Aspirin Delayed Release/Enteric Coated 81 mg oral once a day - Carvedilol 3.125 mg oral twice a day - Bumetanide 1 mg oral twice a day - Gabapentin 300 mg oral twice a day - Nifedipine Extended Release 30 mg oral twice a day - Linzess 145 mcg oral once a day - Magnesium Oxide 400 mg oral once a day - MultiVitamin oral once a day - Ondansetron Disintegrating 4 mg every 4 hours orally (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105616 If continuation sheet Page 9 of 13 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 105616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716 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 - Bupropion HCl Sustained Release 100 mg oral twice a day Level of Harm - Minimal harm or potential for actual harm - Polyethylene Glycol 17 gm oral once a day Residents Affected - Some - Novolog FlexPen U-100 (Insulin Aspart), scheduled at 11 a.m., per sliding scale before meals and at bedtime. - If blood sugar is 251 to 300 give 9 units. - Docusate Sodium 100 mg oral twice a day The observation indicated that Staff U did not dispense or administer Docusate Sodium 100 mg orally that was scheduled twice daily at 9 a.m. and 9 p.m. and had administered a chewable tablet of low-dose Aspirin versus the ordered enteric coated tablet. A review at 12:35 p.m. on 6/3/21 did not indicate that the physician/provider was notified prior to the administration of late medications for Resident #63 and/or #31. An interview was conducted, on 6/3/21 at 11:46 a.m., with Staff Member U, LPN. The staff member stated the reason the medications were late was that it was a heavy load, have 30 patients, and by the time I'm down to her (end of hallway) they're late. The Director of Nursing (DON) stated, on 6/4/21 at 10:53 a.m., that he was aware of some of the medication administration issues and that the facility was looking at implementing a liberalized medication pass. He acknowledged that priming a Novolog pen was to be done with the needle upwards. The policy titled Administering Medications, revised April 2019, identified that Medications are administered in a safe and timely manner, and as prescribed. The policy's Interpretation and Implementation indicated the following: - The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. - Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. - Medications are administered in accordance with prescriber orders, including any required time frame. - Medications are administered within one (1) hours of their prescribed time, unless otherwise specified (for example, before and after meal orders). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105616 If continuation sheet Page 10 of 13 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 105616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716 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. During observation of Medication Administration, on 6/3/21 at 10:51 a.m., Staff Member U, Licensed Practical Nurse (LPN), removed a Novolog vial from the medication cart for Resident #31. The Novolog vial was dated as opened on 4/8/21 and was to be discarded after 28 days. The staff member was unable to locate any other Insulin Aspart vial or FlexPen in either the medication cart or medication refrigerator. Staff U called the pharmacy for permission to remove Insulin Aspart from the emergency drug kit. 2) An observation of the medication cart for the east hall of the second floor was conducted on 06/03/21 at 9:25 AM. The cart was unattended in the hallway in close proximity to the nursing station, several residents were observed self-propelling in the area. The DON confirmed that the cart could be opened and should be locked when unattended by the nurse. Staff A, LPN stated that she was responsible for the cart and had left it for a minute to care for a resident concern, she confirmed that the cart should not be left unlocked when unattended, and stated that it was not safe to do so especially when there were residents in close proximity. An observation later that morning, at 10:00 AM on the first floor revealed a similar occurrence with the west cart left unattended and unlocked. The nursing home administrator (NHA) confirmed that the cart was open. He confirmed that the cart should not be left unlocked when unattended. Staff B, LPN returned to the cart and confirmed that she was responsible for leaving it unlocked, she stated that she had recently received education related to making sure the cart was never left unlocked and when unattended. A review of the Facility's policy on medication storage with a revised date of April 2019 stated, paragraph 8. Compartments (including, but not limited to, drawers, . carts, and boxes) containing drugs and biologicals are locked when not in use. And paragraph 9. Unlocked medication carts are not left unattended. Based on observations, interviews and record review the facility failed to 1) maintain drugs and biologicals used in the facility in a safe, secure, and orderly manner for three medication carts (Second floor East and [NAME] medication carts, and First floor [NAME] cart) of five medication carts as evidenced by insulin pens and insulin vials without documented opened-on dates, and 2) the facility failed to secure the contents of two (first floor west, second floor east) of five medication carts observed during survey. Findings included: 1) On 6/4/21 at 12:18 p.m. an observation of the medication cart for the Second-Floor East hall was conducted. Staff L, Licensed Practical Nurse (LPN) was present during the observation. In the top left drawer of the cart, a Levemir FlexTouch pen was observed stored in a bag, with no open or expiration date documented. A Kwikpen of Lispro insulin was stored in a bag without an opened-on date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105616 If continuation sheet Page 11 of 13 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 105616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716 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 A Novolin 70/30 Flexpen was observed with no open date documented. Level of Harm - Minimal harm or potential for actual harm An open Levemir multi-dose vial (MDV) was observed with an open date of 3/23/21, and a pharmacy label stating discard after 28 days. (Photographic Evidence Obtained). Residents Affected - Some In the right bottom drawer of the cart a one-half white pill and four white loose pills were observed. In the third drawer of the cart two red round pills, one white round pill and one-half white pill, loose were observed. In the second drawer of the cart one white round pill, and two half white loose pills were observed. An interview was conducted with Staff L, LPN. Staff L stated that she had worked there for two months and did not know who should do the cart cleaning. Staff L, LPN left the cart during inspection, and Staff J, Unit Manager, replaced her and stated it was the expectation that all insulin pens and (MDV) were dated when they were removed from the refrigerator and that the carts were to be cleaned daily. On 6/4/21 at 12:42 p.m. an observation of the medication cart for the Second-floor [NAME] hall was conducted. Staff K, Registered Nurse (RN) was present during the observation. In the top drawer, a Novolog FlexPen was observed stored in a bag with no date as to when it was removed from the refrigerator. A variety of insulin pens were observed not stored in bags, two of the pens had open dates documented, but none of the pens had resident identifying information. A NovoLog Flexpen was observed with an open date of 4/19/21, the discard date was covered by a label. A Novolin 70/30 Flexpen was observed with no open date. A Levemir Flexpen was observed with no open date. An open Lantus multi-dose vial stored in a container was observed with an open date of 4/11/21. An open Lantus 100 unit multi-dose vial stored in a container was observed with no open date. An open Novolog multi-dose vial stored in a container was observed with an open date of 3/16/21 (Photographic Evidence Obtained). In the right third drawer of the cart one oblong white pill, one red pill, and one white oblong pill were observed loose in the drawer. In the left second drawer, one loose blue round pill was observed. In the left second drawer one loose white oblong pill, and one oval orange loose pill were observed. Staff K, RN, stated that all staff should keep the medication cart clean. She stated that she was not sure how long open multi-dose vials or insulin pens could be stored out of the refrigerator. Staff K also stated that she would check with the pharmacy regarding correct storage of insulin. On 6/4/21 1:15 p.m. an observation of the medication cart for the First-floor [NAME] hall was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105616 If continuation sheet Page 12 of 13 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 105616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716 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 conducted. Staff C, RN/Unit Manager was present during the observation. Level of Harm - Minimal harm or potential for actual harm An insulin pen was observed stored in a bag with no open date (Photographic Evidence Obtained). In the right second drawer one loose purple oblong pill and one loose round white pill were observed. Residents Affected - Some An interview was conducted with Staff C, RN/Unit Manager who stated that this is wrong and confirmed that all insulin pens and multi-dose vials should be dated when removed from the refrigerator and opened. He also stated that he would follow up with the staff to ensure that the medication carts would be kept clean and tidy and the correct dating procedures would be followed. A review of the facility policy titled, Storage of Medications, effective date 2001 and revised April 2019, revealed: Policy Statement: The facility stores all medications and biologicals in a safe, secure, and orderly manner. Policy, Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. 3. Nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 10. Resident medications are stored separately from each other to prevent the possibility of mixing medications between Residents. 11. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Mediations are stored separately from food and labeled accordingly. Review of the manufacturer instructions related to the storage and use of Insulin multi-dose vials and pens revealed that when stored at room temperature, MDVs and pens should be discarded 28 days after opening. Levemir MDV and Flexpen should be discarded 42 days after opening. Humolog Kwickpens, https://www.humalog.com/taking-humalog/using-u100-u200-kwikpen#using-humalog-u-100-u-200 Levemir, https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/LevemirIFU.pdf Novolog insulin is a Novomed product, https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLog%20FlexPen% Novolin 70/30 pens, https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLogMix7030IFU.p FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105616 If continuation sheet Page 13 of 13