Health inspection·July 25, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few He had a stroke and was unable to void, he was supposed to be straight catheterized but they were not doing this at his facility and he ended up hospitalized with retention and Urosepsis from Klebsiella. I will write an order to change his catheter at his facility now and once a month with a 16 French Foley. I will also start him on prophylactic Methenamine to prevent further infections. Follow up in three months to reassess. A review of Resident 165's medical record revealed no further follow up to a urologist was noted until 7/17/2024. A review of Resident 165's physician progress notes, dated 7/17/2024, showed the following: Urology F/U [follow up] [physician name]: Retention, Void trial Resident #165 had three positive urinary tract infections (12/07/2024,10/07/2023 and 12/01/2022) for Proteus Mirabilis (a member of the bacterial family Enterobacteriaceae or E. coli). A search from the NIH (National Institute for Health), National Library of Medicine at (https://www.ncbi.nlm.nih.gov/books/NBK442017/) states proteus mirabilis is a gram-negative bacterium which is well known pathogen of the urinary tract, particularly in patients undergoing long-term catheterization [photographic evidence of article]. 2. Resident #60 was admitted to the facility on [DATE] with a primary diagnosis of urinary tract infection site not specified. Secondary diagnoses included atrial fibrillation, nonrheumatic aortic valve stenosis, peripheral vascular disease, fall, Type 2 Diabetes Mellitus with diabetic neuropathy, depression, and flaccid neuropathic bladder not elsewhere classified. A review of the July 2024 physician orders showed the following: -catheter change every month and PRN for malfunction or dislodgement -irrigate Foley catheter with 30-60 milliliters of normal saline as needed for blocked catheter A review of Resident #60's MDS, dated [DATE], revealed: -Section C- Cognitive Patterns a BIMS of 14 indicating cognition was intact. -Section H- Bladder and Bowel resident with an indwelling catheter. -Section H0200 Urinary Toileting Program marked as NO for trial of a toileting program. On 7/25/2024 at 2:00 p.m., an interview was conducted with Staff A, Registered Nurse (RN)/Unit Manager. Staff A stated a family member makes the arrangements for a resident to follow-up with doctor appointments. She stated follow-up appointments had not been arranged with a urologist regarding Resident #60's indwelling catheter. A review of the facility's policy titled Resident Rights, dated 1/22/2024, revealed the following: Policy: The resident has a right to a dignified existence self-determination, and communication with and access to persons and services inside and outside the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 2 of 10 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 105694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771 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 Planning and implementing care: Level of Harm - Minimal harm or potential for actual harm The resident has the right to be informed of, and participate in, his or her treatment, including the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. Residents Affected - Few A review of the facility's policy titled Urinary Catheters, dated 10/24/2023, revealed the following: Policy explanation and compliance guidelines: .4. Physician should document within the order for the use of the catheter, the diagnosis or clinical conditions making catheterization necessary. i. Documentation is the medical record should reveal attempts to manage the incontinence and increase bladder function without the use of an indwelling catheter; Bladder training programs, prompted voiding schedules or external catheters ii. Documentation in the medical record should reveal continual assessment for use of the catheter. iii. The plan of care should address catheter use, hydration programs and strategies to prevent urinary tract infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 3 of 10 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 105694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771 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, interviews, and record review, the facility failed to ensure the positive end-expiratory pressure (PEEP), a pressure applied by the ventilator at the end of each breath to prevent the collapse of the tiny air sacs in the lung, alarm was audible in accordance with professional standards for four residents (#61, #184, #101, and #130) out of thirteen residents requiring mechanical ventilation support. Residents Affected - Some Findings Included: 1. On 7/22/24 at approximately 9:55 a.m. Resident #61 was observed lying in bed with a tracheostomy tube connected to a LTV 1150 mechanical ventilator. A red-letter sign displaying PEEP OFF was observed on the front panel screen. According to the ventilator manufacturer the PEEP display on the LTV 1150 mechanical ventilator shows the pressure in the airway circuit at the end of expiration. Resident #61 was admitted to the facility on [DATE]. Resident #61's active diagnoses included metachromatic leukodystrophy (a rare genetic disorder that affects the brain and nervous system), cerebral palsy, and seizures. Resident #61's Minimum Data Set (MDS) assessment, dated 7/1/2024, revealed the following: -Section GG, Functional Abilities and Goals, showed impairment to both arms and legs, severely cognitively impaired and uses a wheelchair for mobility. Resident #61 required a helper for all activities of daily living, including rolling in bed and transferring from bed to wheelchair. -Section O, Special Treatments, Procedures, and Programs showed Resident # 61 requires oxygen therapy, invasive mechanical ventilation, tracheostomy care and suctioning. Review of Resident # 61's orders, active as of 7/24/24, showed the following: -End-tidal carbon dioxide (ETCO 2), (adequacy with which carbon dioxide (CO 2) is carried in the blood back to the lungs and exhaled), check once per shift and as needed. -Fraction of inspired oxygen (FiO2), (the concentration of oxygen to maintain sat [oxygen saturation], a measurement of how much oxygen is in the blood) greater than 92%. -Lavage and suction every shift for increased secretions, pressure alarm on when in room for respiratory care, dated 11/5/22. -Ventilator heater on when in room every shift for vent care, dated 11/05/22. -Ventilator settings Tidal Volume (VT) 330, respiratory rate (RR) 12, pressure Support (PS) 10, PEEP 6, check and document every four hours what actual settings six times per day for respiratory care, dated 4/27/22. -Ventilator alarm six times a day for monitor alarms [sic], dated 7/22/24. -PEEP alarm set at (+) 10, (-) 3 every shift, dated 7/23/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 4 of 10 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 105694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771 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 Review of Resident # 61's care plan, dated 4/21/22, focused on potential impaired gas exchange due to dependence tracheostomy and ventilator. The goal was to maintain a patent airway and oxygen saturation levels greater than 94%. The interventions included monitor for signs and symptoms of respiratory infections/ distress, ventilator orders per medical doctor (MD) orders. 2. On 7/22/24 at 10:10 a.m. Resident #184 was observed lying in bed with a tracheostomy tube connected to an LTV 1150 mechanical ventilator. A red-letter sign displaying PEEP OFF was observed on the front panel screen. According to the ventilator manufacturer the PEEP display on the LTV 1150 mechanical ventilator shows the pressure in the airway circuit at the end of expiration. Resident #184 was admitted to the facility on [DATE]. Resident #184's active diagnoses included respiratory failure with hypoxia (low blood oxygen), Hypoxic ischemic encephalopathy (HIE) (brain injury that happens around birth when oxygen or blood flow to the brain is reduced or stopped), cerebral palsy, epilepsy, and intellectual disabilities. Resident #184's MDS, dated [DATE], revealed the following: Section C, cognitive patterns, showed cognitive skills for daily living is severely impaired, Section GG, Functional Abilities and Goals, showed impairment of both arms. A helper does all the effort with all activities of daily living including rolling in bed. Resident #184 uses a wheelchair for mobility. Section O, Special Treatments, Procedures, and Programs showed Resident # 184 requires oxygen therapy, invasive mechanical ventilation, tracheostomy care and suctioning. Review of Resident #184's active orders as of 7/1/24 showed orders to include: -ETCO2 check once each shift and as needed, -Fi02 to maintain sats greater than 92% every shift, -give cough assist for three cycles every six hours, -lavage and suction every shift as needed for increased secretions, -pressure alarm on when in room every shift, dated 1/4/24, -respiratory treatments two times per day, -vent heater when in room, -ventilator settings check and document six times per day what actual settings are RR 10, PC 15, inspiratory time 1.0, PS 10, PEEP 12 -Fi02 to maintain sats greater than 92% six times per day for respiratory care. Review of Resident # 184's care plan, undated, focused on tracheostomy, the goal is Resident #184 will not have signs or symptoms of infection. The interventions include lavage and suction for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 5 of 10 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 105694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771 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 increased secretions. A second care plan focused on Resident #184's oxygen therapy. The goal is Resident #184 will not have signs or symptoms of poor oxygen absorption. The interventions include monitor for signs and symptoms of respiratory distress and report to the medical doctor. During an interview on 7/22/24 at 11:00 a.m. Staff L, Licensed Practical Nurse (LPN) said she did not know why the ventilator PEEP alarms were turned off. During an interview on 7/22/24 at 11:05 a.m. Staff I, LPN, Unit Manager (UM), referred the question to the respiratory therapist. During an interview on 7/22/24 at 11:18 a.m. Staff E, Respiratory Therapist (RT) confirmed the PEEP alarms were off. Staff E, RT said the alarm is triggered when resident's hiccups or when there is water in the high pressure tubing and pointed to a clear plastic tubing connected to the blue corrugated ventilator tubing. Staff E said the RT checks the ventilators every four hours. During an interview on 7/22/24 at 1:06 p.m. with the Director of Nursing (DON), Regional Nurse Consultant (RNC) and the Nursing Home Administrator (NHA), the NHA said the facility's leadership team is aware of the concerns related to the PEEP alarms and they are in discussions and will implement corrective measures today. During an interview on 7/22/24 at 3:18 p.m. with the Pediatric Medical Director, Nursing Home Administrator (NHA), Director of Nursing (DON), Regional Nurse Consultant (RNC) and Assistant Nursing Home Administrator ANHA). The Pediatric Medical Director stated, If the PEEP alarm is the only thing off, other alarms would trigger. He said, The PEEP is an extra caution alarm, if disconnected other alarms would alert staff. The Pediatric Medical Director said he expects RTs to follow orders and adjust per orders. He said alarms are there for a reason To protect the patient. During an interview on 7/23/24 at 12:45 p.m. with Staff H, Respiratory Therapist (RT), said he is familiar with the LTV 1150 mechanical ventilator, and it is the only ventilator currently in use at the facility. Staff H, RT said the low PEEP alarm indicates the resident is losing pressure, this affects oxygenation and may be triggered by disconnection from the machine, a mucus plug or improper seal of the tracheostomy tube cuff. He stated the high PEEP alarm may indicate there is air trapping which could be caused by a mucus plug, coughing, hiccups or high inspiratory pressure. He stated when the PEEP alarm is triggered by the ventilator the resident is assessed to identify issues with the resident, tracheostomy tube or the ventilator. The RT stated the resident may require suctioning, check the cuff, or administer a breathing treatment. Staff H, RT said, I would never turn off alarms, not my practice unless there is a doctor's order, this is for safety. He said the Florida Board of Respiratory Care does not endorse turning off ventilator alarms without a physician's order. 3. Resident #101 was admitted to the facility on [DATE] with diagnoses to include sleep apnea and acute tracheitis without obstruction. An observation was conducted on 7/22/2024 at 10:56 a.m. revealed Resident #101 was lying in bed, with the ventilator display reading PEEP OFF. A review of Resident #101's physician orders for July 2024 revealed the following: -7/22/2024 1:00 p.m. for ventilator alarms on, six times a day for alarm check. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 6 of 10 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 105694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771 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 -7/22/2024 for PEEP (positive end expiratory pressure) alarm set at +20 and -20 (high and low setting at which the alarm will activate) every day and night shift for monitor settings. -7/23/2024 7:00 a.m. for PEEP alarm set at +11 and -6 every day and night shift for monitor settings. (Photographic Evidence Obtained) Residents Affected - Some A review of Resident #101's progress notes revealed: -7/23/2024 6:43 p.m., Incident SBAR (situation, background, assessment, and recommendation) Nurse's Description: On 7/22/2024 noted PEEP alarm reading off on the ventilator, setting in place. Resident's description of what happened: n/a Witnesses? Yes/No: Staff K, Respiratory Therapist (RT) Injuries?: None Immediate Actions taken: Assessment of child complete, vital signs stable, oxygen saturation 99%. No noted Respiratory distress. No ill effects noted. Alarm turned on. Predisposing factors: Notifications: Medical Director notified. Family member notified. During an interview on 7/23/23 at 10:00 a.m. with Staff H, Respiratory Therapist, he stated that ventilator alarms go off frequently. He stated if he is with another child, the nurses check on the child that has the alarm and notify him if they need any further assistance. Staff H stated most alarms reset themselves and can be caused by movement, coughing, or sometimes mucous obstructions. He stated an alarm can be flashing on the ventilator screen but does not indicate it is a current alarm. The previous alarm will flash on the screen until it is cleared. Staff H stated this way; anyone can tell what alarm the child had last. He stated he did not know if there was any memory on the ventilator that stored previous alarms. Staff H stated he would not turn off any alarm unless ordered by a doctor because every alarm has a reason. 4 Resident #130 was admitted to the facility on [DATE] with diagnoses to include pneumothorax, other chronic respiratory diseases originating from perinatal period, paralysis of vocal cords and larynx, disturbances of salivary secretion, tracheostomy, and dependence on respirator (ventilator). An observation was conducted on 7/22/2024 at 10:56 a.m. Resident #130 was lying in bed. Resident #130's ventilator display read PEEP OFF. A review of Resident #130's physician orders for July 2024 revealed: -7/22/2024 1:00 p.m. for ventilator alarms on, six times a day for monitor alarms. -7/23/2024 7:00 a.m. for PEEP alarm set at +11 and -3. A review of Resident #130's progress notes revealed: -7/23/2024 7:02 p.m., Incident SBAR Nurse's Description: On 07/22/2024 noted PEEP alarm reading off on the ventilator, settings in place. Resident's description of what happened: N/A Witnesses? Yes/No: Staff K, RT Injuries?: NONE Immediate Actions taken: Assessment of child complete, vital signs stable, oxygen saturations 99%, no noted respiratory distress, no ill effects noted. Peep alarm turned on. Predisposing factors: Notifications: Medical Director notified. Family member notified. Review of the facility's policy titled Mechanical Ventilator, dated 7/22/24, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 7 of 10 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 105694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771 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 Policy Level of Harm - Minimal harm or potential for actual harm Residents who require mechanical ventilation will be cared for in accordance to Federal, State and local guidance and with current standards of practice. Residents Affected - Some Definition: Mechanical Ventilation may be defined as a life support system designed to replace or support normal ventilator lung function . Compliance Guidelines: 1. The facility will ensure that there is sufficient numbers of trained, competent, qualified staff, consistent with State practice acts/laws when providing mechanical ventilation. 2. The facility will identify who is responsible for the following: c. Setting the ventilator: d. Monitoring the ventilator; e. Response to ventilator alarms; 3. The physician/ practitioner will write an order for the mechanical ventilation to include at a minimum the mode, rate, tidal volume, oxygen concentration, and desired level of positive end expiratory pressure (PEEP), and pressure support, if applicable. (Include any other pertinent information for the order.) 5. Appropriate staff will be trained and maintain competency in the use of mechanical ventilation to include: c. Use and maintenance of the ventilator system according to manufacturer's instructions g. Responding to alarms . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 8 of 10 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 105694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assess and monitor a dialysis catheter per facility policy for one resident (#191) out of one resident sampled for dialysis. Residents Affected - Few Findings included: On 07/24/24 at 11:48 a.m. Resident #191 was observed sitting in a bedside chair in the room. The resident's shirt was protruding on the upper right chest wall area. The resident lifted his shirt up to show surveyor his dialysis catheter site located on the upper right chest wall. The resident stated he has been off dialysis for a couple weeks and was supposed to get his shunt out soon. A review of the medical record revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (ESRD), urinary tract infection, and Type II Diabetes Mellitus with diabetic neuropathy. A review of the Form 3008, dated 04/23/24, showed the following: -Section V treatment devices IV [Intravenous Therapy]/PICC [Peripherally Inserted Central Catheter]/ Portacath. Access box is check-marked with type listed as right subclavian D.L [double lumen] dialysis site. Review of the physician orders for July 2024 revealed: - No Blood Draws or BP[Blood Pressures] on RUE[Right Upper Extremity] due (Dialysis port). - Change dressing (RU [Right Upper] chest dialysis port). every day shift every Wed [Wednesday]for (RU chest dialysis port) Dressing change protocol. AND as needed for (RU chest dialysis port) Dressing change protocol. When soiled or dislodged. Dated 07/24/24 at 1:08 p.m. - Monitor area (RU chest dialysis port) for s/s [signs and symptoms] of infection (redness, heat, drainage or bleeding). every shift for (RU chest dialysis port). Dated 07/24/24 at 1:02 p.m. Review of the Minimum Data Set (MDS), dated [DATE], revealed: - Section O showed special treatments, procedures and programs section J1. Dialysis marked yes, section 01. IV marked yes. - Section M showed the application of nonsurgical dressing marked yes. - Section C showed a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. Review of the nurse's progress notes, for July 1, 2024, through July 23, 2024, revealed no daily assessment or monitoring documentation of a dialysis shunt site. Review of the nurse progress note on 07/24/24 at 1:12 p.m. showed Order for site being monitored q [every] shift for s/s of infection obtained and weekly dressing change and PRN if is soiled or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 9 of 10 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 105694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771 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 0698 dislodged. Orders entered in [electronic health system]. Staff will monitor. Level of Harm - Minimal harm or potential for actual harm Review of the care plan, dated 04/25/24, revealed: Residents Affected - Few - A focus of Resident has potential for spread of MDRO [multidrug-resistance organism] related to presence of dialysis port (an indwelling medical device; chronic wound, infection or colonization with a CDC targeted MDRO when Contact Precautions do not apply) Date Initiated: 04/29/2024 Revision on: 07/24/2024. - A focus of RESOLVED: Receives dialysis r/t [related to]: ESRD [End stage Renal Disease] Date Initiated: 04/25/2024 Revision on: 07/24/2024 Resolved Date: 07/24/2024. An interview was conducted on 07/24/24 at 12:43 P.M. with Staff A, Registered Nurse (RN). She stated Resident #191's dialysis catheter was still in place. She stated she would expect an order in place to check the port site until it is removed and stated there was no order currently in place. An interview was conducted on 07/24/24 at 1:24 PM with the Director of Nursing (DON). She stated Resident #191 was last dialyzed on 07/01/24 and his dialysis catheter was still in place. She stated her expectation would be a physician's order in place for monitoring the dialysis site and a dressing change order for the duration of the dialysis catheters presence. Review of the facility policy titled Dialysis Communication and Site monitoring, dated 11/28/2016 and reviewed on 10/24/2023, revealed the following: .Procedure #6 The shunt site is to be assessed daily and documented in the clinical chart. If there is any change or problems noted with the shunt site, these are to be documented in the medical record with a nurse note and the MD is to be notified for follow up. Procedure #7 If dialysis does not occur for any reason, the facility will: notify MD for further orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 10 of 10