Inspection·April 23, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few without a replacement. She stated that night, there was one nurse working and 2 CNAs in the entire building. She stated there would normally be 3-4 staff. She stated the facility ended her employment because the resident was a two-person assist, and she cared for him alone. Staff A said, I usually get help, but no one was available when I went into the room. She stated when the resident started to fall, she yelled out for help and the nurse (Staff C) came. The CNA stated she had worked with this resident many times before and knew he was dependent and needed staff to do everything for him. She stated prior to the incident, she had not received any education but only when she was hired two years earlier. She stated she could have reviewed the CNA task list to see this resident's care status. Staff A stated, I knew he was dependent for all care. I take full responsibility. Staff A stated the resident was injured, he suffered a bump on his head and was sent to the hospital. She stated the resident was non-verbal and could not express pain. She stated looking at his face, he looked like he was in some pain. She stated she and the nurse assisted the resident back to bed. Staff A stated she was suspended on [DATE]. She stated not much was said to her at the time, and she was not asked to give a statement at the time. She stated she was contacted on [DATE] and asked to come in and give a statement on [DATE]. Review of the admission Record for Resident #1 revealed he was originally admitted to the facility in 2013 and readmitted on [DATE] with diagnoses to include muscle wasting and atrophy, cerebral infarction due to unspecified occlusion, weakness, sepsis, muscle wasting, nontraumatic intracranial hemorrhage unspecified, hemiplegia and hemiparesis, unspecified dementia and contracture of right shoulder and elbow. Review of a SBAR (Situation, Background, Assessment, and Recommendation) form revealed a change in condition dated [DATE] at 11:39 PM. Situation: The Change In Condition/s reported on this Evaluation are/were: Falls, with New Testing Orders:- Send to ER (Emergency Room). Review of physician orders for Resident #1 showed an order dated [DATE] at 11:24 PM to send to ER to evaluate and treat. Review of a progress note dated [DATE] at 11:32 PM signed by Staff C, Registered Nurse (RN) showed: This PM, pt. [patient] rolled out of bed during pt. care. Pt. was assisted back into bed by this nurse and CNA. Pt. assessed for injury and noted to have swelling to R [Right] side of forehead. Pt. on anticoagulant therapy. Pt. denies pain at this time, pupils PEERLA [PERRLA - an acronym for Pupils are Equal, Round and Reactive to Light and Accommodation] bed in lowest position during incident. VS WNL [Vital signs within normal limits] and no deviation from baseline noted. This nurse notified MD [Medical Doctor] of clinical situation and received order to send to ER. DON [Director of Nursing] notified, and pt. is his own RP [Responsible Party]. Review of a Hospital transfer evaluation summary dated [DATE] revealed an assessment was conducted Pain location and description: Top of scalp - swelling top of right forehead. Under pain level assessment, the entry defaulted a numerical response with none noted. Review of a progress note dated [DATE] showed . Patient s/p (Status Post) fall. Patient denies any pain. Review of a progress note dated [DATE] showed . Patient's Right arm is contracted,. Patient has a knot to forehead . Review of weekly skin checks for Resident #1 revealed four skin checks had been completed in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 2 of 12 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 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 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 0600 period of four months ([DATE] through [DATE]), most recently on [DATE] showing the resident had a knot on forehead, top of scalp, and on [DATE] showing the resident has a knot on forehead, face. Level of Harm - Actual harm Residents Affected - Few Review of a Minimum Data Set (MDS) dated [DATE], showed in section C: Brief Interview for Mental Status (BIMS) score of 00, showing he was unable to complete the interview and indicated severe cognitive impairment. Section GG - showed the resident had functional limitation in range of motion impairment on one side to the upper extremity and impairment on both sides to the lower extremities. The resident was dependent for toileting hygiene requiring the assistance of 2 or more helpers to complete the activity. The resident was dependent for the ability to roll from lying on back to left and right side and return to lying on back on the bed. Resident #1 required the assistance of 2 or more helpers for this activity. The resident was dependent for sitting on side of bed to lying flat on the bed and dependent from lying on his back to sitting on the side of the bed with no back support. Review of Resident #1's [NAME] (a document used by staff with instructions specific to a resident's care needs) dated [DATE] showed the resident was dependent on staff, requiring assist of two for transferring, personal hygiene, and dressing. For bed mobility, the task list showed: Dependent assist of 2 to turn and/or reposition. For locomotion the resident was non-ambulatory, uses a wheel chair and was dependent on staff. Review of a care plan for Resident #1 initiated on [DATE] showed a focus - Resident #1 has an ADL (activities of daily living) self -care performance deficit as evidenced by: weakness, limited mobility, history of CVA (Cerebrovascular Accident). The goal showed the resident will maintain current level of self-performance with ADLs through next review date. Interventions initiated on [DATE] included: Resident was totally dependent upon staff for ADLs. Encourage resident to participate at highest functional ability. Bed Mobility: dependent assist of 2 to turn and/or reposition date initiated: [DATE]. Transfer: total mechanical lift to chair of 2; sling size: L date initiated: [DATE]. Toilet use, dependent assist of 2 for bowel incontinent care date initiated: [DATE]. Review of a focus in the same care plan initiated on [DATE] showed Resident #1 was at risk for fall or fall related injury because of: gait/balance problems, right sided weakness, poor safety awareness, impulsiveness, history of falls, and medication use. The goal showed - Resident will minimize the risk of fall through review date target date: [DATE]. Interventions included to: Lock brakes on bed, chair etc. before transferring date initiated: [DATE]. OT (Occupational Therapy/PT (Physical Therapy) referral for screen and treatment as needed. date initiated: [DATE]. Report falls to physician and responsible party revised on [DATE]. Anticipate and meet the resident's needs. Revised on [DATE]. Provide environmental adaptations: adequate glare free lighting, area free of clutter date revised on [DATE]. On [DATE] at 11:19 a.m., an interview was conducted with Staff B, LPN. She stated she heard that Staff A, CNA rolled the resident away from her, he hit his head, and had to be sent out. She stated he had a bump that had been slowly going down. Staff B, LPN confirmed Resident #1 required 2 staff assistance during all care. She stated to confirm transfer status, staff are expected to review the resident's care plan, review the CNA task list, or check with therapy on status. She stated the problem that night was that they did not have enough staff. She said, I believe 2 CNAs called off and they were not replaced. She stated this happened quite often. On [DATE] at 11:30 a.m., an interview was conducted with Staff E, CNA and Staff D, CNA. Staff D (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 3 of 12 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 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 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 0600 Level of Harm - Actual harm Residents Affected - Few stated a CNA had dropped Resident #1. She stated he had a bump on his head for days. She said, I think it is still there. Staff E stated this resident had always been dependent on staff for all care. She stated the problem that night was, They did not have enough staff. There is no one to help. How can you run this place with only 2 CNAs when all these residents need total care? Staff E stated she reviews the computer information to see the resident's care status. Staff E stated many times the residents are not changed, and it was passed on to the next shift because they did not have enough staff. She stated it was a set-up, what happened to Staff A, CNA was wrong. She was left without a choice. Staff E and D stated the administration does not care. On [DATE] at 1:15 p.m., an interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). The DON stated the incident happened on Saturday, [DATE]. He said, I was on PTO {Paid Time Off]. I became aware on Wednesday, the 26th. I put the fall on the incident log and corporate called back to get information on the 27th. They said because he was transferred to a higher level of care, we needed to report. The DON stated he called Staff A, CNA to come in for an interview. He stated on [DATE] he interviewed Staff A, and reading her statement he said, She was positioned on the right side of the resident's bed, resident was on his back, bed in low position, when attempting to change his sheet, she rolled him to the right, his deficit side, the momentum caused him to continue to roll. She immediately grabbed the lower body of the resident, which enabled her to maintain the position of the lower body on the bed while the right shoulder and forehead came into contact with the floor. She was lowering the bed lower while calling for help. The DON stated he interviewed the nurse. Reading Staff C's statement, he said, On [DATE] CNA approached this nurse and informed her the resident fell out of bed during patient care. The patient was assessed for injury and noted to have swollen the right side of the forehead. Patient is on anticoagulant therapy. Patient denies pain at this time, no deviation noted. CNA stated the bed was in low position when incident occurred and patient rolled, the nurse and CNA assisted the patient back to bed. Nurse notified the MD on the 22nd . MD gave orders to send patient to ER. The DON confirmed Resident #1 had a swollen forehead after the fall. He stated he thought prior to the incident, Resident #1 was a one person assist. He stated after the fall the care plan was updated to two person assist for all care. The DON said, He should have been a two-person all along. An interview was conducted with the NHA on [DATE] at 1:26 p.m. She stated she could not answer to why staff did not call her that weekend. She stated she thought they had notified the DON. She revealed she was notified by corporate on the 27th that she needed to file the report. She stated corporate said to obtain interviews and have the DON start education. The NHA said, I did not do a timeline. The incident was reported to AHCA [Agency for Health Care Administration] on [DATE]. It was late. She stated she became aware of the incident on Monday, [DATE], but it had occurred on [DATE]. When asked why it took two days to be notified, the NHA stated it was the weekend and the DON and Director of Rehab were on leave. The NHA stated when she became aware she notified corporate on [DATE] and suspended the CNA pending investigation. She stated she did not start her investigation. She stated she did not interview any other residents and did not interview the staff at the time. The NHA stated their process was to wait until corporate gave the go-ahead before contacting state agencies. The NHA stated this process affects her reporting and investigation timeline. She said, That is why the reporting was late. The NHA stated she did a root cause analysis and determined there was a staffing concern. She said, We had call-offs that we could not cover. I tried to call other staff, I offered a bonus, and no one picked up. She stated they did not meet staffing for that day. She stated one CNA called out and one was a no-show. The NHA stated the CNA should have asked for help. She stated she should have known the resident needed two staff for care. The NHA stated they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 4 of 12 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 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 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 0600 suspended the CNA pending investigation and initiated their investigation. She stated the DON had been educating staff. Level of Harm - Actual harm Residents Affected - Few An interview was conducted with the Regional Risk Manager on [DATE] at 2:11 p.m. She stated in their analysis, they discovered there was another problem. She stated the care plan was not active at the time. It had been resolved, meaning it would not have shown if it was a one or two staff assist. The staff would not have known the transfer status at the time. She stated they initiated a whole house audit. The Regional Risk Manager stated the CNAs are to notify the nurse or Minimum Data Set (MDS) Coordinator if the care plan was not showing. The Risk Manager said, They did not have access to [name of a document used by staff with instructions specific to a resident's care needs]. The Risk Manager did not know how many people were affected by the resolved care plans. During an interview on [DATE] at 2:29 p.m. an interview with the Traveling MDS Coordinator revealed she visits this facility once or twice a week. She stated the issue of the care plan resolving and the interventions not being visible was resolved for Resident #1. She stated she did not know why it was happening that way. She stated if a care plan intervention expired, The MDS nurse received a notification. The Traveling MDS Coordinator said, The problem is there is not an MDS nurse here all the time. The person is shared between this facility and the sister facility. If the previous MDS Coordinator received the notification, I would not know. She stated their goal was to continue auditing. She stated they realized the problem was also duplicated care plans with readmission from the hospital. The staff should not have started a new care plan. They should re-instate the old one. The MDS Coordinator said, Our investigation included review of his history, he was a 2-person. Staff were historically using 2 staff for all care. Today, if I were to assess him, he would definitely be a 2-person assist. The Traveling MDS Coordinator stated she was currently auditing other care plans to see if any other interventions had resolved. A follow-up interview was conducted with the Regional Risk Manager and the NHA on [DATE] at 2:53 p.m. The Risk Manager stated she would have expected staff to call the administration. She stated the fall should have been brought up in the morning meeting. The Risk Manager stated the Therapy Director, and the DON were off and that was why they missed the notification of the fall and hospital transfer. The NHA confirmed the IDT (Interdisciplinary Team) did not know. Review of a facility policy titled, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, effective February 2024 showed the facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives, and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. Procedure: 1. Update to Care Plans (a.) Ongoing updates to care plans are added by a member of the IDT, as needed. 2. Dates and documentation on the care plan when (a.). New, revised, or discontinued Problems, Goals, or Interventions are dated for the date the documentation was made. (b.) Problems and Goals have IDT approaches and Interventions to assist the resident in their goal attainment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 5 of 12 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 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 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 0600 Level of Harm - Actual harm Residents Affected - Few Review of a facility policy titled, Fall and Injury Reduction Policy effective [DATE] showed the facility has designated and implemented processes, which strive to reduce the risk for falls and injuries. This policy guides the identification, implementation of appropriate interventions, and management. It is expected that this policy will assist the facility with reducing the likelihood of a fall or injury while maintaining or maximizing dignity and independence through education of staff and residents, early identification of risk factors by collecting data, identifying resident behavior which may increase the likelihood of such occurrence. Review of a facility policy titled, Abuse Prevention Program, reviewed [DATE] showed the facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff bum out, or resident behavior which may increase the likelihood of such events. Definitions: Neglect - Failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Procedure: The facility has implemented the following processes in an effort to provide residents, visitors and staff with a safe and comfortable environment. - The Administrator is responsible for designating an Abuse Coordinator. - The designated shift supervisor is identified as responsible for immediate initiation of the reporting process. - The Administrator, DON and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. - The Administrator, DON and/or designated individual are also ultimately responsible for the following: Implementation, Ongoing monitoring, Investigation, Reporting and Tracking and Trending. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 6 of 12 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 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 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 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to report allegations of abuse in a timely manner for two (#1 and #3) of two residents sampled for abuse and neglect. (Cross reference F600 and F610) Findings included: 1. Review of a hospital visit summary for Resident #1 dated 03/23/25 at 3:22 a.m. showed Resident #1 was seen due to a fall with diagnoses of fall, initial encounter, resulting in a head injury. Review of the admission Record for Resident #1 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include muscle wasting and atrophy, cerebral infarction due to unspecified occlusion, weakness, sepsis, muscle wasting, nontraumatic intracranial hemorrhage unspecified, hemiplegia and hemiparesis, aphasia and unspecified Dementia. An interview was conducted with the Nursing Home Administrator (NHA) on 04/23/25 at 1:26 p.m. revealed she did not initiate the investigation for the incident on 03/22/25 until 03/27/25. She stated she could not answer to why staff did not call her that weekend when the incident occurred. She stated she thought they had notified the Director of Nursing (DON). She revealed she was notified by corporate on the 27th [of March 2025] that she needed to file a report. She stated corporate said to obtain interviews and have the DON start education. The NHA said, I did not do a timeline. The incident was reported to AHCA [Agency for Health Care Administration] on 03/27/25. It was late. She stated she became aware of the incident on Monday, 03/24/25, but it had occurred on 03/22/25. When asked why it took two days to be notified, the NHA stated it was the weekend, and the DON, and the Director of Rehab were on leave. The NHA stated when she became aware, she notified corporate on 03/24/25 and suspended the Certified Nursing Assistant (CNA) pending investigation. She stated she did not start her investigation then. She stated she did not interview any other residents and did not interview the staff at the time. The NHA stated their process was to wait until corporate gave her the go-ahead before contacting state agencies. The NHA stated this process affects her reporting and investigation timeline. She said, That is why the reporting was late. 2. On 04/23/25 at 11:35 a.m. an interview was conducted with Resident #3. She stated she had reported some staff member for being rough and loud with her. She said, They can't talk to me just anyhow. She stated she did not know if the issue was resolved. She stated she did not know what they did about it, but she had filed a grievance. Review of Resident #3's admission record showed she was originally admitted on [DATE] with diagnoses to include encephalopathy, muscle wasting and atrophy, weakness and morbid (severe) obesity. A MDS (Minimum Data Set) assessment dated [DATE] showed the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating intact mental cognition. An interview on 4/23/25 at 12:30 p.m. with the NHA revealed on 03/04/25 Resident #3 stated the CNA (Staff F) was rough with her when providing care, and she did not like the CNA's approach. The NHA stated the resident was receiving care on 03/04/25 and the NHA was notified on 03/05/25 sometime in the afternoon. She stated she reported the allegation on 3/5/25 at 3:50 p.m. She stated it was a day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 7 of 12 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 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 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 late. The NHA stated she reviewed the grievance form. She stated she did not ask the perpetrator to write a statement. She did not ask the CNA what rough with her meant. She stated she did not speak to any other staff about it. She said, I see. I could have asked more questions. The NHA stated she did not report this allegation of abuse. On 04/23/25 at 3:02 p.m. an interview was conducted with the NHA regarding a second incident for Resident #3 that occurred on 02/28/25. The NHA stated the state agency for adult protective investigations had come to the facility to investigate an allegation of abuse. She stated a family member had contacted the state agency to report that the therapist (Staff G, Occupational Therapist - OT) physically shakes and yells at the resident to wake her up when he is in her room. The NHA stated the state agency interviewed the resident and did not substantiate the allegation. The NHA stated state agency did not interview Staff G. The NHA stated she did not obtain a statement from Staff G, OT. She stated she interviewed one CNA who generally works the area. She stated the CNA (Staff H) stated on a few occasions (Resident #3) said she does not want to get up because she does not like them (referring to therapy). The CNA stated she yells, get out, don't touch me and therapy staff leave and come back later. The NHA stated she did not follow-up on these statements. She stated she did not interview any other staff on the day Resident #3 alleged abuse from Staff G, OT. An interview on 4/23/25 at 3:33 p.m. with the Regional Risk Manager revealed Resident #3's incident with Staff G, OT was reported to the facility by the state agency on 02/28/25. The Risk Manager stated the incident happened on 2/21/25. The Risk Manager stated this was not reported timely. She stated, I need to ask why. It does not make sense. An interview was conducted with the NHA on 4/23/25 at 3:49 p.m. The NHA stated regarding the incident with Staff F, CNA, they did not substantiate it. She stated we resolved it the same day. We did not report. The NHA stated, an allegation is an allegation. We should have reported. She stated corporate has to review incidents prior to reporting them, which affects their reporting timeline. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 8 of 12 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 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to investigate thoroughly and timely allegations of abuse for two (#1 and #3) of two residents sampled for abuse and neglect. Residents Affected - Few (Cross reference F600 and F609) Findings included: 1. Review of a hospital visit summary for Resident #1 dated 03/23/25 at 3:22 a.m. showed Resident #1 was seen due to a fall with diagnoses of fall, initial encounter, resulting in a head injury. Review of the admission Record for Resident #1 revealed he was originally admitted to the facility in 2013 and readmitted on [DATE] with diagnoses to include muscle wasting and atrophy, cerebral infarction due to unspecified occlusion, weakness, sepsis, muscle wasting, nontraumatic intracranial hemorrhage unspecified, hemiplegia and hemiparesis, aphasia and unspecified dementia. On 04/23/25 at 11:42 a.m., an interview was conducted with Staff A, Certified Nursing Assistant (CNA) assigned to Resident #1 the day the resident fell on [DATE]. She stated she had worked 3 p.m. - 11 p.m. and Resident #1 was her last resident to provide care for. She said, I was changing the bed when he started to fall off the bed. I tried to catch him to save the fall, but I could not. She stated, As I wrote in my statement, I lowered the bed and was trying to lower it some more as I was holding on to him. I was alone in the room. I knew he needed two people. He cannot do anything for himself. Staff A stated Resident #1 could not hold on to the side rail/enabler because his right hand was contracted. She said, I know I should have asked for help. It was my fault. I take responsibility for not asking for help. The CNA stated they were understaffed that day because someone called off and there was no replacement. Staff A stated she was suspended on 03/24/25. She stated not much was said to her at the time, and she was not asked to give a statement at the time. She stated she was contacted on 03/26/25 and asked to come in and give a statement on 3/27/25. An interview was conducted with the Nursing Home Administrator (NHA) on 04/23/25 at 1:26 p.m. revealed she did not initiate the investigation for the incident on 03/22/25 until 03/27/25. She stated she could not answer to why staff did not call her that weekend. She stated she thought they had notified the Director of Nursing (DON). She revealed she was notified by corporate on March 27th that she needed to file a report. She stated corporate said to obtain interviews and have the DON start education. The NHA said, I did not do a timeline. The incident was reported to AHCA [Agency for Health Care Administration] on 03/27/25. It was late. She stated she became aware of the incident on Monday, 03/24/25, but it had occurred on 03/22/25. When asked why it took two days to be notified, The NHA stated it was the weekend, and the DON, and the Director of Rehab were on leave. The NHA stated when she became aware she notified corporate on 03/24/25 and suspended the CNA pending investigation. She stated she did not start her investigation then. She stated she did not interview any other residents and did not interview the staff at the time. The NHA stated their process was to wait until corporate gave her the go-ahead before contacting AHCA or DCF (Department of Children and Families). The NHA stated this process affects her reporting and investigation timeline. On 04/23/25 at 11:35 a.m. an interview was conducted with Resident #3. She stated she had reported some staff member for being rough and loud with her. She said, They can't talk to me just anyhow. She stated she did not know if the issue was resolved. She stated she did not know what they did about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 9 of 12 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 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 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 0610 it, but she had filed a grievance. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #3's admission record revealed an original admission on [DATE] with diagnoses to include encephalopathy, muscle wasting and atrophy, weakness and morbid (severe) obesity. An MDS (Minimum Data Set) assessment dated [DATE] showed the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating intact mental cognition. Residents Affected - Few Review of a grievance concern report for Resident #3 showed on 03/05/25 the Social Serviced Director (SSD) had received a grievance showing, Resident did not like the CNA's approach. Under action taken, the form showed the SSD, Spoke to the CNA [Staff F], he said he came in and provided care to the resident and there were no issues. Under resolution, it showed the NHA reported the incident as a reportable, CNA was suspended, and the grievance was marked resolved the same day. The SSD stated the incident had happened the previous day. He did not know why it was not reported until 03/05/25. An interview on 4/23/25 at 12:30 p.m. with the NHA revealed on 03/04/25 Resident #3 stated the CNA (Staff F) was rough with her when providing care and she did not like the CNA's approach. The NHA stated the resident was receiving care on 03/04/25, and the NHA was notified on 03/05/25 sometime in the afternoon. She stated she reported the allegation on 3/5/25 at 3:50 p.m. She stated it was a day late. The NHA stated she reviewed the grievance form. She stated she did not ask the perpetrator to write a statement. She did not ask the CNA what rough with her meant. She stated she did not speak to any other staff about it. She said, I see. I could have asked more questions. The NHA stated she did not report this allegation of abuse. On 04/23/25 at 12:56 p.m., Staff F, CNA said I had her that Friday night. Staff F stated he found out the following Monday there was a problem. He said, I was told not to go to that room, they said she was making comments against me and to protect myself, I should stay away. He stated the resident had made allegation about another male employee before. He said, I did not take it seriously. Staff F stated he did not write a statement. He stated no one said anything about a statement. He stated that week he did not go back to the room. He said, I was suspended 8 days. When I returned, I made sure to avoid her. I still do if I am scheduled to care for her, I switch out. Staff F stated he did not receive education regarding this incident. He said, I just resumed my normal life. I just avoid her. A follow-up interview with the NHA on 04/23/25 at 1:04 p.m. revealed she did not have statements from other staff or residents regarding the allegation of abuse for Resident #3. She stated she was unable to find them at this moment. She said, I do not have them right now. The NHA confirmed she had not conducted an investigation to the allegation of abuse. She confirmed they did not educate staff regarding the incident. On 04/23/25 at 3:02 p.m., an interview with the NHA regarding a second incident for Resident #3 that occurred on 02/28/25 was conducted. The NHA stated DCF had came to the facility to investigate an allegation of abuse. She stated a family member had contacted DCF to report that the therapist (Staff G, Occupational Therapist - OT) physically shakes and yells at the resident to wake her up when he is in her room. The NHA stated DCF interviewed the resident and did not substantiate the allegation. The NHA stated DCF did not interview Staff G. The NHA stated she did not obtain a statement from Staff G, OT. She stated she interviewed one CNA who generally worked in the area where Resident #3 resided. She stated the CNA (Staff H) stated on a few occasions (Resident #3) said she does not want to get up because she does not like them (referring to therapy). The CNA stated she yells, get out, don't touch me and therapy staff leaves and comes back later. The NHA stated she did not follow-up on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 10 of 12 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 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few these statements. She stated she did not interview any other staff on the day Resident #3 alleged abuse from Staff G, OT. On 04/03/25 at 3:20 p.m. an interview was conducted with Staff G, OT. He said, I was accused of raising my voice with her [Resident #3]. He stated he spoke with the NHA briefly but did not provide a statement to the NHA or DCF. He stated neither of them interviewed him. He stated he was suspended for 5 days and when he returned, he was told everything was not founded. He stated he did not receive any education. On 04/03/25 at 3:23 p.m. an interview with the Regional Risk Manager revealed they should have asked the perpetrators (Staff F, CNA and Staff G, OT) to provide statements. She stated they should have spoken to other staff. During an interview on 04/03/25 at 3:28 p.m., the NHA confirmed she should have obtained statements and educated all staff. Review of a facility policy titled, Abuse Prevention Program, reviewed November 2024 showed the facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff bum out, or resident behavior which may increase the likelihood of such events. Investigation: An Event Report is initiated. NHA or designee is notified and will initiate and conclude a complete and thorough investigation within the specified timeframe. Investigation may include, but may not be limited to: - Resident statements/interviews. - Employee statements/interviews. - Visitor statements/interviews. - Observation of resident(s), staff, environment. - Document review i.e., chart reviews, policy review, education programs, appropriate resource review (such as medical literature); and - Re-enactment of event. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 11 of 12 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 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain medical records in accordance with professional standards and policy for weekly skin evaluations and assessments for one (#1) of two residents sampled. Findings included: Review of a facility policy titled, Wound Prevention and Treatment Overview, effective October 2021 showed - The facility strives to ensure that a Resident/Patient entering the facility without ulcers does not develop them unless the individual's clinical condition demonstrates they were unavoidable. The facility implements the following interventions to prevent the development of pressure ulcers: - Identify Residents/Patients at risk & the specific factors placing them at risk then implement an individualized Plan of Care based on the identified factors. - Reduce occurrence of pressure over bony prominences to minimize injury. - Protect against the adverse effects of external mechanical forces (pressure, friction, shear). - Increase the awareness of ulcer prevention through educational programs. The facility also recognizes the most vigilant nursing care may not prevent the development &/or worsening of ulcers in high-risk categories. In those cases, efforts will be directed at the following: Managing risk factors. Providing therapeutic intervention. Providing treatment. Procedure: Review skin integrity on a weekly basis as a proactive approach enabling the facility staff to identify possible changes in skin integrity/condition. Review of weekly skin checks for Resident #1 revealed four skin checks had been completed in a period of four months (January 2025 through April 2025), most recently on 03/29/25 showing the resident had a knot on forehead, top of scalp, and on 03/28/25 showing the resident has a knot on forehead, face. Review of the admission record for Resident #1 revealed he was admitted to the facility in 2013 and readmitted on [DATE] with diagnoses to include muscle wasting and atrophy, cerebral infarction due to unspecified occlusion, weakness, sepsis, nontraumatic intracranial hemorrhage unspecified, hemiplegia and hemiparesis, aphasia, unspecified dementia and contracture of right shoulder and elbow. On 04/23/25 at 3:40 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated Resident #1's skin checks should be completed weekly as scheduled. The DON reviewed Resident #1's electronic record for the months of January 2025 through April 2025 and stated there were only four skin assessments documented on 1/4/25, 2/2/25, 3/28/25 and 3/29/25. The DON said, There should be more than that. They should be documented weekly. I see they are not done. I don't know what to tell you. We missed it. The DON stated they should have assessed and documented skin checks for Resident #1 on a weekly basis per their facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 12 of 12