Health inspection·September 23, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few completed for [Resident#10]. Speech and communication skills remain stable. Cognitive status is stable. No report on changes in social interactions. No changes in mood noted. Residents' ability to make adjustments to situations remain stable. No new behaviors report. Resident is compliant with care. Resident is agreeable to current plan of care. No psychological/psychiatric services indicated at this time.Review of the facility's REPORT TRACKING LOG, dated 6/1/25 to 8/31/25, revealed there was no allegation of abuse, neglect, exploitation reported to state agencies for Resident #10.An interview was conducted on 9/23/25 at 12:48 p.m. with the Risk manager (RM) who stated, My expectations are they would report it to me; abuse; physical and verbal abuse and mental abuse. Mental abuse could be anything like making a resident feel bad by their actions. if you make a resident feel bad, I guess it would be the response that the resident had to determine if they were affected by it. She was asked if Resident #10's grievance would be a reportable event, and the RM stated, If it was a change in the psychosocial. Did the residents wellbeing change due to the event? Did it affect the resident? If yes, then we would report it. The RM stated, in reviewing it [Resident #10's grievance] now I should have reported it. The RM said the facility completed a thorough investigation and education with the staff. The RM said they interviewed the resident, received statements from the nurses, interviewed staff, and completed abuse training and education. The RM said the grievance was looked at in terms of lack of good customer service and not abuse.An interview was conducted with the DON and the RM on 9/23/25 at 1:30 p.m. They DON and the RM said Resident #10 had behavioral issues before and there was a care plan in place for confabulation as well as her behaviors. The DON reviewed Resident #10's care plans and confirmed there were no care plans in place for behaviors or confabulation.Review of the facility's policy titled Abuse, Neglect, and Exploitation, with a review date of 1/11/2025 revealed Policy:Each resident has the right to be free from abuse, including verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. This prohibition applies to everyone, including, but not limited to, facility staff (employees, consultants, contractors, volunteers and other caregivers who provide care and services to residents on behalf of the facility) .I. DefinitionsThe definitions herein are supplemented by Any definitions set forth in state law or regulation that pertain to abuse or any of the terms defined below. abuse is the willful infliction of.intimidation, or punishment with resulting.mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain .mental, psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause.pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.MentalAbuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation.III TrainingFacility shall develop, implement, and maintain an effective training program for all new and existing staff, individuals providing serves under a contractual arrangement, and volunteers consistent with their expected roles. Training shall include at a minimum: activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse.dementia management and resident abuse prevention.Annual education and training is provided to all existing employees and other individuals as applicable. Training, at least annually, shall also include staffs' obligation to report to the relevant state agency and to one or more local law enforcement agencies any reasonable suspicion of a crime against residents of the facility either immediately, but no later than two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 2 of 8 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 09/23/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete hours after formulating the suspicion if the resident suffers serious bodily harm, or no later than 24 hours after forming the suspicion if the resident does not suffer serious bodily harm. IV Prevention of Abuse, Neglect, Exploitation of Residents, and Misappropriation of Resident PropertyThe facility will utilize the following techniques for prevention of abuse, neglect, exploitation of residents, and misappropriation of resident property: Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents.recognize signs of burnout, frustration and stress in employees that may lead to abuse.React to all allegations or questions from residents, family members, employees or visitors. Take appropriate actions when abuse, neglect, exploitation or misappropriation is suspected. Provide feedback to residents, staff and family members who voice grievances. Provide instructions to staff on care needs of residents. Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, . Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect.VII Response and reporting of Abuse, Neglect, Exploitation, and MisappropriationAnyone with knowledge or concerns about the care of a resident int eh facility must report suspected abuse to the Facility Administrator, abuse agency hotline or file a complaint with the state agency and adult protective services.immediately (but not alter than 2 hours after an allegation is made if the events that lead to the allegation involve abuse or results in serious bodily injury) or not later than 24 hours if the events that lead to the allegation do not involve abuse and do not result in serious bodily injury. Reporting and investigation should be in accordance with state law/regulation. Event ID: Facility ID: 105694 If continuation sheet Page 3 of 8 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 09/23/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure the identified needs for residents at high risk for fall interventions was effective and prevented falls with major injuries for two vulnerable residents (#7 and #8) out of eight residents sampled.Findings included:Review of the facility's Daily Census report provided on 9/22/25 at 6:12 a.m. showed 700 Unit had a census of 26.Review of the facility's Minimum Data Set (MDS) Resident Matrix dated 9/23/25 at 8:59 AM showed the 700 Unit 50% (13) of the residents had a fall and 34% (9) experience fall related injuries including fractures. 1. Review of Resident #8's admission record showed an admission to the facility on 7/1/2025 with diagnoses including dementia, fracture of left pubis, insomnia and displaced fracture of the olecranon process.Review of Resident #8's nursing admission evaluation, dated 7/1/25 showed a fall prevention interventions was started of Hi/low bed, anticipate needs as able and call light within reach when in room.Review of Resident #8's MDS dated [DATE], Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) summary score of 0, indicating severe cognitive impairment. Section GG, Functional Abilities shows the resident needs a helper to complete all self-care activities and when transferring from bed to chair.Review of Resident #8's care plan showed a focus on the resident had an actual fall and a pubis ramus fracture, initiated on 7/2/25 interventions included adequate lighting, anticipate needs, call light and frequently used items within reach, wearing nonskid footwear and glasses, fall risk assessments, 4p's rounding (check resident for any pain concerns, positioning needs, personal items are within reach and personal needs are being met), keep bed in low position. Floor mats x2, scoop air mattress, medication and laboratory review and started medication for sleep aid initiate on 7/31/25. Psychology/Psychiatry evaluation and therapy screening and evaluation on 9/1/25. Encourage resident to remain in a common area if restless/agitated, start antianxiety medications and the use of a pommel cushion on 9/1/25. Anti-tippers to wheelchair and hip protector's interventions added on 9/11/25. A care plan for left elbow fracture was initiated on 9/10/25. Review of Resident #8's Order summery report, dated 9/22/25 included the following orders neuro checks after a fall - 7/31/25, 9/1/25 and 9/7/25, left elbow skin tear wound care- 9/1/25, buspirone HCL 5mg two times daily for anxiety9/6/25, send to the emergency department for evaluation and possible treatment after a fall- 9/7/25, Naproxen 500 mg every 12 hours for left elbow fracture - 9/7/25, Tylenol extended release (ER) 650 mg every six hours for left elbow fracture- 9/7/25, lorazepam 0.5mg every 8 hours for anxiety 9/8/25, ice pack to left elbow status post (s/p) open reduction and internal fixation (ORIF) - 9/16/25 and lorazepam 0.5mg every 6 hours for anxiety and agitation - 9/17/25.Review of Resident #8's emergency department discharge instructions dated 9/7/25 showed acute displaced fracture of the olecranon with intra-articular involvement. The discharge instructions include ice to affected area, maintain splint and arm immobilizer, and elevate affected area for 24 hours and follow-up with orthopedic surgeon in 3-5 days. Review of Resident #8's progress notesOn 7/31/25 at 11:10 p.m., a post fall progress note showed injury was noted at the time of the fall right elbow and right knee bruise . Current .measures in place include call light education, 4P's, Hi/Lo bed, room close to the nurses' station, therapy evaluation, frequent checks On 9/6/25 at 11:49 a.m. a system note showed current preventative safety measures in place: call light education, 4P's, Hi/Lo bed, room close to the nurses' station, mat next to bed, activities/exercise, frequent checks; scoop mattress.On 9/6/25 at 12:11 p.m. an order note showed buspirone 5mg tab one tablet two times daily for anxiety, monitor for .dizziness, .insomnia, . anxiety . On 9/7/25 at 1:42 p.m., an incident SBAR note showed CNA (Certified Nursing Assistant) found resident sitting up on bedside mat with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 4 of 8 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 09/23/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some back against the bed in lowest position. [wearing] only brief and non-skid socks . No apparent injuries.On 9/7/25 at 1:48 p.m. an incident SBAR note showed .alerted by CNA that resident was on the floor near nurses' station. Patient was noted to be on her back on the floor holding her left wrist. Resident left in place supervised while 911 called.left at approximately 10:45 a.m.On 9/7/25 at 7:11 p.m. a clinical note showed Resident #8 returned to the facility, . acute displaced fracture of olecranon w/intra-articular involvement. Left elbow fiberglass splint .On 9/14/25 a system note showed the Interdisciplinary Team (IDT) met regarding falls from 8/31/25, and 9/7/25, laboratory results reviewed, melatonin started, therapy to screen, psych visit started with anti-anxiety medications, encourage resident to be placed in the common area if seem restless/ agitation and pommel cushion .On 9/16/25 at 8:41 PM a clinical note showed Resident #8 returned from the hospital after ORIF procedure.On 9/18/25 Primary Care Physician (PCP) note showed Resident #8 ‘s history included an unwitnessed ground level fall with left inferior pubic ramus fracture, no surgical intervention. On 9/16/25 left elbow ORIF due to left elbow fracture from a ground level fall. Post-operative expectations will be non-weight bearing to operative extremity and wear cast for approximately 2 weeks.Review of Resident #8's documentation survey report, dated September 2025, flow sheet documentation showed for fall risk, encourage resident in common areas if seem restless/agitated, fall mats x2 and, hip protector as tolerated, flow sheet documentation started on 9/9/25.During an interview on 9/22/25 at 3:10 p.m. Resident #8's representative (RR) said, there are only so many caregivers for the number of residents. The RR spends nine hours daily in the facility and assists with feeding lunch and dinner. The RR reminds staff to toilet Resident #8 after meals.During an interview on 9/22/25 at 6:30 a.m. Staff A, Licensed Practical Nurse (LPN) said during the 11:00 p.m. -7:00 a.m. the 700UUnit is staffed with two Certified Nursing Assistants (CNA) and one nurse. Staff A, LPN described post fall interventions and did not mention there was a post fall huddle.During an interview on 9/22/25 at 6:48 a.m. Staff B, CNA described post fall interventions and did not mention there was a post fall huddle.During an interview and review on 9/22/25 at 1:07 PM with the Risk Manager (RM), Director of Nursing (DON), Assistant Director of Nursing (ADON) about Resident #8's fall incidents and the facility investigations, the RM said the resident has had four falls since admission. During the review of Resident #8's falls the RM said on 9/7/25 at 7:40 a.m. Resident #8 was found beside her bed. The DON said in the common areas staff can keep an eye on her. On 9/7/25 at 10:26 a.m. Resident #8 was found on the floor in the hallway by the nurse's station the resident complained of left arm pain and was sent to the emergency room (ER). Resident #8 sustained a left elbow fracture and required surgery. After the investigation the facility did not verify allegations of serious bodily injury and neglect because Resident #8's plan of care was followed and adequate supervision was provided. In discussion of Resident #8's additional falls the RM said on 8/31/25 at 8:80 p.m. Resident #8 was found sitting on the mat next to her bed and on 7/30/25 at 8:00 a.m. was found lying on the floor next to her bed, both incidents were unwitnessed, and the resident did not sustain any injuries.During an interview on 9/23/25 at 9:19 a.m. with the Director of Rehabilitation (DOR) said Resident #8 had been on the therapy case load since admission to the facility. Resident #8 had transitioned to a platform walker, due to left elbow fracture the resident is unable to weight bear and was transitioned to hand hold assistance. 2. Review of Resident #7's admission record showed an admission date on 6/16/25 with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and anxiety.Review of Resident #7's admission evaluation, dated 8/29/25 showed a history of falling in the past 1-6 months and the current fall preventative measures in place are 4P's as appropriate, Hi/Lo bed, anticipate needs as able and call light within reach.Review of Resident #7's MDS admission, dated 6/22/25, Section C, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 5 of 8 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 09/23/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Cognitive Patterns showed a BIMS summary score of 1 indicating severe cognitive impairment. Section GG, Functional Abilities showed the resident needs partial/moderate assistance with toileting and chair to bed transfers. Review of Resident #7's care plan had a focus of an actual fall, initiated on 6/17/25, interventions included adequate lighting, non-skid socks/well-fitted shoes, therapy screen/evaluation routine rounding schedule i.e. 4P's rounding, bed on safe transfer height (just below the knee, call light and frequently used items are within reach. The fall reduction program was initialed on 6/18/25 and the anti-roll back wheelchair. Medication and laboratory review was completed on 7/18/25. The next intervention was for staff to offer toileting after lunch and Resident #7's representative was educated about light use and providing activities of daily living (ADL) as assistance on 8/4/25. Encourage the resident to be in common area during meals and when seen awake at night was initiated on 8/12/25. The use of a helmet and hip protector as tolerated was added on 9/3/25 and floor mats x2 and scoop mattress initiated on 9/8/25.Review of Resident #7's order summary report showed orders including, order dated 6/16/25 PT evaluation and treatment, order dated 7/18/25 neuro checks after a fall, order dated 8/4/25 neuro checks after a fall, order dated 8/11/25 neuro checks after a fall, on 8/25/25 increase trazodone from 50mg to 100 mg at bedtime, order dated 9/1/25 monitor .skin tear left forearm (LFA) after a fall ., order dated 9/2/25 neuro checks and send to the emergency room (ER) after fall, order dated 9/4/25 [NAME] Program consult, comfort measures only and morphine sulfate 20mg/ml give 0.25 ml every 8 hours, order dated 9/5/25 follow -up x-ray lumbar spine history of compression fractures and pain and tramadol 25 mg give 1 tablet every six hours as needed, order dated 9/8/25 floor mats x2 and scoop mattress.Review of Resident #7's hospital discharge instructions, dated [DATE] Impression: Lumbar (L)1 compression fracture, new from 8/27/25. Follow-up with neurosurgery for further evaluation treatment of L1 compression fractureReview of Resident #7's progress notes showed the following:Review of a behavior note, dated 8/25/25 showed Resident #7 .out of bed (OOB) and self-propels in wheelchair .Review of a system note, dated 8/25/25, showed current fall measures in place are call light education, room close to the nurses' station, anti-rollback for wheelchair, activities/exercises, frequent checks, scoop mattress. No new interventions required at this time.Review of a system note, dated 8/25/25, Fall IDT met regarding resident falls from 7/18, 8/3, and 8/11- staff offering toileting after lunch, staff educated [family] call light use/ assistance of activities of daily living (ADL. PCP to adjust Trazodone, staff to encourage resident in common area during meals.Review of a clinical note dated 8/30/25 at 12:30 PM Resident observed barefoot walking down the hallway. Resident observed yelling and fell onto the floor right before writer can get to her Small skin tear noted to left forearm measuring approx. 0.5cm X 0.2cm with minimal bleeding.Review of a clinical note dated 8/30/25 at 12:30 PM Resident observed barefoot walking down the hallway. Resident observed yelling and fell onto the floor right before writer can get to her Small skin tear noted to left forearm measuring approx. 0.5cm X 0.2cm with minimal bleeding.Review of a system note dated 9/9/25, Fall IDT met regarding resident falls from 7/18/25, 8/3/25, 8/11/25 and 8/21/25- staff to encourage resident in common area during meals, therapy, staff to encourage resident in common area when seen awake at night, helmet and hip protector as tolerated .Review of an incident note dated 9/2/25 at 11:43 p.m. showed Resident was found lying on the dining room floor, few steps from her wheelchair holding her head .Called EMS [emergency medical services] for transfer resident was unable to say if she hit her head.Review of note dated 9/3/26 at 2:13 a.m. showed Resident #7 returned from the Emergency Department at 1:00 a.m.Review of palliative care note dated 9/13/25 showed follow-up for comfort measure .she has been hospitalized 3x since 8/3/25 for recurrent falls.During an interview on 9/23/25 at 12:40 p.m. the Life Enrichment Director (LED) provided a one-page memo (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 6 of 8 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 09/23/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some titled,Fall Reduction Program, undated. The memo includes the name of the participants 16 participants with an asterisk (indicating previous fall) in front of six names. The memo also contained the participants' room numbers, diet and a 4:00 p.m.to 10:00 p.m. scheduled tasks. The LED said the Fall Reduction Program is provided in the 200 Unit dining area. He had one designated LE staff assigned to the 700 Unit during the day shift.On 9/23/25 at approximately 1:40 p.m. the LED presented an updated fall reduction program memo, listing the names of 14 participants, he said this is the second memo provided by the nursing team. He started the LED role on 5/14/25 and received the first updated memo two weeks ago. The LED signed and dated the memo he provided. During an interview on 9/23/25 at 12:20 p.m. with Staff F, CNA, 700 Unit Life Enrichment staff (LE) said during the evening shift a designated nursing staff member's focus was primarily one on one with residents who are agitated. The activities include touch therapy techniques (hand and back massages, fidget [devices], coloring, etc.) Staff F, CNA, LE said when residents are positioned in front of the nurses' stations, nurses get busy.On 9/23/25 at 1:59 p.m. During a discussion of the Fall Reduction program, Staff G, LPN said the program is usually on the 3:00 p.m.-11:00 p.m. shift, an extra CNA who does not have an assignment, calms residents down, sometimes residents are gathered in the common area to watch TV, they have dolls, offer coloring, go to the patio or medication. Staff G, LPN said she does not know anything about compassionate touch techniques to calm residents. On 9/23/25 at 2:10 p.m. during a follow-up interview Staff F, CNA, LE in reference to staff knowledge of the compassionate touch technique to calm residents said I was teaching it and haven't had a class in a while. The new aides probably don't know how to do it.During an interview and review on 9/22/25 at 1:07 PM with the Risk Manager (RM), Director of Nursing (DON), and Assistant Director of Nursing (ADON). The DON said the 700 Unit is the secured unit and has various types of activities and therapeutic intervention to alleviate anxiety. The ADON said there is Fall Reduction Program with intervention including aromatherapy, Compassionate Touch Program and post fall huddles. The RM said the facility meets with RR of residents with multiple fall incidents to discuss the plan of care including the need for a companion or sitter, if the family can afford the services. At the conclusion of the meeting a negotiated risk agreement is completed. The RM said the facility has not completed a negotiated risk agreement for Resident #8 .On 9/23/25 at 2:41 p.m. during a follow up interview and review of the facility's Fall Reduction Program with the DON and ADON. The DON said the Fall Reduction Program is being developed and currently does not have a facility policy or procedure. The program was started in April, trying to identify things we can improve on. The DON said she is not aware all staff members on the 700 Unit have not received compassionate touch technique training and clarified the intervention to consult Physical Therapy (PT) after each fall does not apply for residents who are currently on the therapy case load. The DON said the 700 Unit hall monitor walks the hall during the evening meal. During the fall huddle the Unit Manager, DON/ ADON or supervisor, therapy and the risk manager meet where the incident occurred. Review of a facility policy titled, Fall Prevention Program, reviewed on 1/23/25 showed-Policy: An individualized fall prevention program is implemented for each resident to ensure the safest environment possible. Even though the facility cannot prevent falls, each resident will be assessed-for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Policy-Explanation and Compliance -Guidelines:The facility utilizes a standardized risk assessment for determining a resident's fall risk. 1a) The risk assessment categorizes residents according to low, moderate, or high risk. 1b) For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment.Upon admission, the nurse will complete a fall risk assessment along with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 7 of 8 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 09/23/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete admission assessment to determine the resident's level of fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk and individual needs.The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions.High Risk Protocols i. Indicate fall risk on care plan. ii. Implement interventions from Low/ Moderate Risk Protocols. iii. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. iv. Provide additional interventions as directed by the resident's admission, quarterly or significant change assessment. v. Appropriate interventions will be individualized to the safety needs of the resident.b. Low, Moderate Risk Protocols:i. Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to:1. A clear pathway to the bathroom and bedroom doors.2. Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bee3. Call light and frequently used items are within reach.4. Adequate lighting.5. Wheelchairs and assistive devices are in good repair.6. Implement routine rounding schedule.7. Monitor-for changes in resident's cognition, gait, ability to rise/sit, and balance.8. Encourage residents to wear shoes or slippers with non-slip soles when ambulating.9. Ensure eyeglasses, if applicable, are clean and the resident wears them when ambulating.10. Monitor-vital signs in accordance with facility policy.11. Complete a fall risk assessment every 90days. Update care plan interventions as needed as resident's condition changes.Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness.b. The-plan of care will be revised as needed.When any resident experiences a fall, the facility will:Assess the resident.Complete-a-Post-Fall Incident-report.Place the resident on the Falling Star program for a period of 30 days or longer if determined.Notify physician and family.Review the resident's care plan and update as indicated.Document all assessments and actions.Obtain witness statements in the case of injury.Review of a facility policy titled, Post Fall assessment policy, reviewed on 10/14/24 showed the following:Policy: All residents will be assessed immediately who fall to identify causative factors that may be related to the fall. Upon this assessment, actions will be taken to decrease the potential for future falls.Procedure:The nurse will respond to the resident sustaining a fall.The nurse will perform a head-to-toe assessment and notify the physician as needed.The nurse will document in the medical record.The family will be notified.The DON or Supervisor on duty will be notified should there be a severe injury enough to require transportation to the hospital.The nurse will initiate an incident/accident report.All falls will be reviewed by the Interdisciplinary team who will make additional recommendations as needed for the resident's safety and document in the medical records. Changes as appropriate will be made on the resident's care plan and communicated to the nursing staff.Nursing will implement the recommendations and monitor that preventive measures are consistently followed. Event ID: Facility ID: 105694 If continuation sheet Page 8 of 8