Health inspection·December 19, 2019

F 0584 i. Resident room [ROOM NUMBER] door was squeaking loudly when opening and closing. Level of Harm - Minimal harm or potential for actual harm j. Resident room [ROOM NUMBER] over the bed table was observed with the surface cracking and peeling. Also, the room ceiling vents and fan housing were observed caked with dust and debris. Residents Affected - Some k. Resident room [ROOM NUMBER] (b bed) over the bed table was observed cracked and peeling. Also the room door was observed squeaking loudly when opening and closing. (200 unit) l. Resident room [ROOM NUMBER] (b) was observed with an over the bed table chipping/peeling. (300 memory unit) m. Resident room [ROOM NUMBER] room door was squeaking loudly, (a bed) over the bed table with side plastic surface peeling and chipping. n. Resident room [ROOM NUMBER] room door was squeaking loudly, Air conditioner vents caked with debris, and (b bed), (c bed) over the bed tables peeling and chipping on the top and side surfaces. o. Resident room [ROOM NUMBER] room ceiling vent was caked with debris p. Resident room [ROOM NUMBER] room door was squeaking loudly and, (b bed) over the bed table was peeling and chipping. q. Resident room [ROOM NUMBER] (a bed) over the bed table was observed with the top and side surface peeling and chipping. r. Resident room [ROOM NUMBER] air conditioner vent was caked with dust debris, and the ceiling tiles sagging, (b bed) over the bed table peeling and chipping. s. Resident room [ROOM NUMBER] over the bed table top and side surface peeling and chipping. t. Resident room [ROOM NUMBER] room door was squeaking loudly, and (b bed), (c bed) over the bed tables were cracked and peeling. u. Resident room [ROOM NUMBER] room door was squeaking loudly, and the (b bed) over the bed table peeling and chipping. Also, the ceiling vents and tiles caked with debris. v. Resident room [ROOM NUMBER] room door squeaking loudly. w. Resident room [ROOM NUMBER] (a bed) over the bed table peeling and chipping. x. Resident room [ROOM NUMBER] room door was squeaking loudly, and ceiling vents were caked with dust debris. y. The smaller dining room on this unit was observed with two ceiling fans with fan blades caked with dust debris. Fans were observed on and running while residents were eating their meals and participating in group activities, directly under these fans. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 2 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0584 Photo graphic evidence was taken of ceiling fans and over the bed tables. Level of Harm - Minimal harm or potential for actual harm On 12/19/19 at 10:30 am an interview was conducted with the house keeping director and maintenance director. The Housekeeping director revealed that she implementing a new cleaning schedule program to include cleaning of air conditioner vents and ceiling vents, room fans, ceiling, fans. She further confirmed that upon her inspection today, 12/19/19, it was confirmed that there were dusty fan blades and ceiling vents. Residents Affected - Some Interview with Maintenance director revealed that is it his responsibility and nursing staff responsibility to maintain over bed tables. he confirmed there were many that needed to be replaced. He further added that over the bed tables with sharp edges can cause skin tear injuries. On 12/19/19 at 10:30 am during an interview with maintenance director he revealed that it is his responsibility to maintain resident door functions to include oiling door hinges to eliminate noise. He did not have a physical document to show the above areas are checked for function and maintenance. The Nursing Home Administrator also did not have a physical document schedule for review, to include ceiling vent, over the bed tables, and door maintenance. 2. On 12/17/2019 at 6:32 a.m. the main hallway with rooms 107 - 122 were observed with a floor tech (employee D) utilizing a mechanical high speed cleaning machine, that was very noisy. The floor tech was pushing the machine slowly up and down the hallway as residents were still sleeping. During this observation, the following resident rooms were observed with doors open and lights off (110, 111, 115, 116, 118 and 121). The floor tech continued to utilize this machine at and by these rooms from 6:32 a.m. through to 6:45 a.m. From 6:46 a.m. through to 6:50 a.m. the floor tech (employee D) was observed using the same loud machine up and down the main hallway passing rooms 101 - 106. The following resident room doors were observed open and with lights off: 106, 105, 104, 103, and 101. From 6:50 a.m. through to 6:58 a.m. Employee D. was again using the machine on the main hallway near resident rooms 107 - 122. Resident room doors were still open and with lights off. From 6:58 a.m. through to 7:03 a.m. Employee D. was observed utilizing the loud machine passing rooms 201 through 209. Resident room doors were open and with the following room lights off: 209, 208, 207, 205, 203, and 201. On 12/18/2019 at 6:42 a.m. a floor tech (employee D.) was observed in the 200 unit and Vacuuming door mats at exit door near and just outside room [ROOM NUMBER]. The Vacuum was loud and most residents were still in rooms sleeping. The following resident rooms were observed with lights off and doors open: 205, 207, 208, and 209. On 12/19/2019 at 6:32 a.m. this surveyor was seated in the One low Unit nurse station. Seated in that unit station, loud conversation and loud laughter could be overheard down the hall to included resident rooms 101 - 106. When walking down the hallway, the kitchen was located across the hallway between resident rooms [ROOM NUMBERS]. It was observed staff in the kitchen and were talking and laughing out loud and could be overheard throughout the entire hallway and through to the One Low Unit nurse station. Resident room doors 101, 102, 104, 105, and 106 were open all the way and with room lights off. Further, residents in these rooms were still in bed sleeping. The staff in the kitchen were overheard laughing and talking aloud from 6:32 a.m. to 6:40 a.m. At 6:40 a.m. staff observed this surveyor standing next to the kitchen door and closed some of the resident room doors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 3 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/19/2019 from 7:24 a.m. through to 7:29 a.m. the One High Unit station was observed with three staff members in the hallway to include resident rooms 126 - 128. One staff member was standing in the door way in resident room [ROOM NUMBER]. The staff were talking very loud with one another with residents in the room. At 7:30 a.m. the staff moved on to another hallway and at that point the Social Worker walked over to them and spoke with them and they began to be more quiet. Residents in rooms [ROOM NUMBERS] were observed in their rooms with lights off and still in bed with eyes closed. On 12/19/2019 at 7:48 a.m. the 1 High unit station was observed and overheard with staff calling out to one another. This surveyor was standing at the One High unit station and overheard a staff member calling out for staff member (Staff N, CNA). That employee opened resident room door 131 and said, what, I'm here. The other staff member called out, Come help me when your done, he replied out loud, Ok. The two were about forty-five to fifty feet apart and not on the same hallway. On 12/19/2019 at 1:00 p.m. an interview with the Housekeeping Director confirmed that her floor staff utilize floor cleaning and floor buffing machines a little before the 7-3 shift and also around 7:00 a.m. She indicated that her staff come into the building around 5:45 a.m. and start the cleaning process to include cleaning and buffing main throughway hallways. She indicated that the machines were used during a time when there is less resident traffic and did confirm that the times that the machine had been used, was probably a little too early and understands that residents are still sleeping. She also indicated that the machines will be checked as maybe they are louder than usual and need some maintenance to quiet them down. She provided floor cleaning schedules for the floor staff to include when floors are cleaned and buffed, but no specific times noted. On 12/19/2019 at around 5:00 p.m. an interview with the Nursing Home Administrator confirmed that staff utilize high speed floor cleaning and buffing machines early and perhaps that time of morning is not best and will be speaking with housekeeping to find better times to use the machines. 3. On 12/17/2019 at 6:53 a.m. Resident #100 was observed in her room in bed and with privacy curtain pulled, with the room dark. Resident #100 could be heard throughout the entire unit screaming and calling out and cursing out loud. While seated in the unit nursing station, the resident was overheard cursing repetitively and making other loud noises. The resident's room door was fully open and she continued to yell out and bang on what sounded like the over the bed table from at least 6:53 a.m. through to 7:04 a.m. There was a nurse, (Employee E.) at a medication cart two doors down preparing medications for another resident at another room. Aides were observed walking past the resident's room to other resident rooms. Nobody stopped to engage with Resident #100 to try and de escalate the resident from screaming out loud. At 7:05 a.m. an employee closed the door, but she did not go in the room. From 7:05 a.m. through to 7:13 a.m. Resident #100 continued to yell and scream and bang on various things in her room. Staff did not go in the room to assist and deescalate the resident until 7:13 a.m. At 7:15 a.m. nurse Employee E. and aide Employee F. went into the room to interact with the resident. Once the staff started speaking with the resident, she began to quiet down and eventually stopped cursing, yelling and banging. On 12/17/2019 at 7:13 a.m. an interview with the 11-7 shift nurse (outgoing) nurse, Employee E, who was standing at her medication cart between the resident's room and clinical reimbursement office, confirmed the resident was presenting with loud calling out screaming behaviors and she does that from time to time. Employee E. was asked if anyone went into the room to find out if there was something wrong with her or if anyone tried to go in the room to deescalate her. She indicated that staff do go in. Employee E. was asked if she was aware of any staff who went into the room recently from at least 6:50 a.m. through to 7:13 a.m. She could not verify if anyone went into the room during that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 4 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some time. She did confirm that staff did close the door and further confirmed the resident was still yelling and screaming. Employee E. could not provide details as to why the resident presented with those behaviors and said she was admitted pretty recently. She indicated that she would now go in the room to tend to resident. At 8:12 a.m. through to 8:15 a.m. Resident #100 continued to yell and scream out loud along with cursing and banging on the wall and bed. Staff went into the resident's room at 8:15 a.m. and interacted with her. She then began to quiet down and staff closed the door. On 12/17/2019 at 8:30 a.m. through to 8:50 a.m. the 200 unit was toured and interviewed six random residents related to the noise level early in the a.m. All six, who wished to remain confidential interview, revealed that staff come with the floor machine too early and sometimes it wakes them up. The six random residents also indicated that they can hear a resident yelling early in the a.m. and it's very loud. They indicated the resident carries on that way for long periods during the a.m. and night. Some of the resident's who were interviewed indicated that they brought these concerns to various staff (unknown), and things have not been getting better. On 12/18/2019 at 7:10 a.m. this surveyor was in the 200 lounge area and could overhear Resident #100 yelling and screaming out continuously. Her room was over thirty feet away and she could be overheard throughout the entire unit. Staff closed her door but she could still be overheard yelling out and screaming throughout the unit. At 7:18 a.m. staff finally went to room and spoke with the resident and worked to deescalate her with positive results. However, now at this time, three staff members Employee G., Employee H., and Employee I. were observed outside Resident #100's room and were talking out loud, which could be overheard throughout the entire unit. Staff were talking to each other about being out and having sick days for about five minutes. During this time the following resident rooms were observed with doors open and lights off, with residents still in bed: 202, 203, 203, 205, 207, 208. The staff members who were talking loudly were standing just outside resident room [ROOM NUMBER]. On 12/18/2019 at 8:30 a.m. five residents, who reside in rooms on the 200 unit, and who wished to remain confidential were interviewed; all revealed that staff are loud during shift change and also staff use loud machines early in the a.m. They all indicated that they have spoken with their aides about this but have not mentioned it any further to any other staff. They further indicated that they did not want to get anyone in trouble, so they have not mentioned it more than a couple of times The would however, like for staff to be more quiet during shift change and also whoever is running a loud machine early in the morning, they would like for them to do that at different times. On 12/19/2019 at 4:00 p.m. an interview with the Nursing Home Administrator indicated that all staff should be honoring resident rights and choices to include keeping a comfortable sound level when near residents and resident living areas. She indicated that staff should not be talking loudly in halls during shift change or during any time and should not be calling out for one another down the hallways. She further indicated that staff should ensure a unit is free from screaming residents, so other residents in the unit can be comfortable. The Nursing Home Administrator did not have a policy to include resident comfort/sound levels. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 5 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide catheter care to prevent the risk of infection for one Resident # 97 of one resident sampled related to storing the used catheter bag in the resident's night stand and reusing the bed bag and the leg bag daily. Findings Included: Review of the resident's record reflected Resident #97 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included toxic encephalopathy, unspecified injury of kidney, urinary retention, need for assistance with personal care, difficulty in walking and lack of coordination. Review of the medical certification for medicaid long-term care services and patient transfer form (3008) dated 12/7/19 reflected Resident #97's primary diagnosis of urosepsis on antibiotics for urinary tract infection with a midline catheter inserted on 12/7/19 to the right upper arm. Review of the hospital record dated 12/3/19 reflected the resident's chief complaint was fever, impression and plan included diagnoses of sepsis, acute complicated UTI, hematuria and acute encephalopathy. Review of physician orders showed, change catheter bag as needed dated 12/7/19, Change Foley catheter as needed for leakage/blockage or dislodgement as needed document in resident's record dated 12/7/19. Drain Foley catheter bag every shift and as needed dated 12/7/19. Foley catheter care daily and as needed for preventative measure and every day shift for preventative measure dated 12/7/19. Foley catheter to drainage bag for diagnosis of BPH (benign prostatic hypertrophy) with obstructive uropathy, catheter size #16 with 10 cc balloon. Observe every shift for observation dated 12/16/19. Irrigate Foley catheter with 30 ml of normal saline as needed for blockage/leaking or sluggishness as needed dated 12/7/19. Ivanz solution reconstituted 1 gram, inject one gram intramuscularly one time a day for UTI for 13 days from 12/9/19 to 12/23/19. Resident #97 stated he wore a leg bag which is kept in the bottom drawer of his night stand and when he gets in bed at night the nurse will exchange the leg bag with the bed bag and store the leg bag in the bottom of his night stand. Review of the Minimum Data Set, dated [DATE] reflected a brief interview for mental status of 15 meaning the resident was cognitively intact. During an interview on 12/16/19 at 11:40 a.m. with staff member F, CNA she confirmed the leg bag was put on during the day for the resident by the nurse and the bed bag was emptied but not cleaned out and stored in a clear plastic bag tied in the bottom drawer of the night stand. Staff member F, CNA opened Resident #97's bottom drawer of the night stand, donned gloves and opened the clear plastic bag and revealed a catheter bed bag dated 12/6/19 which smelled of urine. Staff member F, CNA stated the long tube gets cleaned with alcohol on the end where it is connected but nothing goes in the tube or bag to clean the catheter. Staff member F, CNA stated this was repeated daily by the nurses. During observation of Resident #97 on 12/16/19 at 12:03 p.m. an unknown therapist, told Staff G, LPN that the resident's leg bag was leaking. Staff member G, LPN obtained a new catheter and went to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 6 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few see the resident. The nurse returned with the new catheter and said the resident's leg bag was disconnected and she reconnected it. During an interview on 12/16/19 at 1:25 p.m. with staff member G, LPN she stated Resident #97 came in for a fracture and the Foley catheter was supposed to come out prior to the urologist appointment. Staff member G, LPN stated that the resident gets a new catheter every day when he gets up and goes to bed. Staff member G, LPN stated that a catheter bag should not be in the resident's bottom drawer dated 12/6/19. During an interview on 12/17/19 at 9:55 a.m. with Resident #97, he stated they are not keeping the catheter in the bottom drawer anymore. Now they are using a new one when they change from the bedside bag to the leg bag. The resident stated that he was not feeling well today and had a rough night. The resident was observed lying in bed with a bedside drainage bag dated 12/16/19 draining yellow urine. A new unopened catheter leg bag was observed on top of the bedside table. During an interview on 12/17/19 at 2:15 p.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON stated she prefers the staff to change the resident to a leg bag catheter by cleaning the tip with alcohol and emptying out the catheter bag then placing the catheter in a plastic bag to be reattached the next day by the nurse after cleaning the connector with alcohol. The DON stated she was not aware the catheters were single use and confirmed on the catheter label that the bags were single use. The DON stated she would start in-servicing staff immediately and training them to use a new bag every time. The DON confirmed the facility did not have a Foley catheter storage policy. (photographic evidence obtained of catheter bag labels.) The NHA stated, how would you even know that we store the bags in a drawer if the drawer is closed? During an interview on 12/19/19 at 12:05 p.m. with the DON she confirmed in-services were started on catheter bags and storage. According to: Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) III. Proper techniques for urinary catheter maintenance. A. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. 1. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html#anchor_1552413731 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 7 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0694 Provide for the safe, appropriate administration of IV fluids 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 observation, interview and record review the facility failed to maintain two Residents #97 and #207's IV sites consistent with professional standards of practice of 4 residents sampled by failing to obtain physician orders for Resident #97 to change an IV catheter dressing from 12/7/19 to 12/16/19 and documenting Resident #207's IV dressing was changed when it was not. Residents Affected - Few Findings Included: 1. During an interview and observation on 12/16/19 at 11:37 a.m. with Resident #97, he stated that he has a PICC (peripherally inserted central catheter) intravenous access in his right upper arm and lifted his shirt to reflect the date on the dressing of the PICC line as 12/7/19. The resident stated the dressing had not been changed since he returned from the hospital and confirmed he received antibiotics for a urinary tract infection. Review of the Minimum Data Set, dated [DATE] reflected a brief interview for mental status of 15 meaning the was resident was cognitively intact. During an interview on 12/16/19 at 11:40 a.m. with Staff member F, CNA she confirmed the date on the IV dressing was 12/7/19 and stated the resident was on his way to the shower. Review of the record reflected Resident #97 was admitted on [DATE], readmitted on [DATE] for diagnoses that included toxic encephalopathy, unspecified injury of kidney, pancytopenia, anemia, thrombocytopenia, decreased white blood cell, delirium, dehydration, and urinary retention. Review of the medical certification for medicaid long-term care services and patient transfer form (3008) dated 12/7/19 reflected Resident #97's primary diagnosis of urosepsis on antibiotics for urinary tract infection with a midline catheter inserted on 12/7/19 to the right upper arm. Review of the hospital record dated 12/3/19 reflected the resident's chief complaint of fever, impression and plan included diagnoses of sepsis, acute complicated UTI, hematuria and acute encephalopathy. Review of the physician orders reflected the resident's IV: change injection cap every 7 days and as needed. Injection cap to be changed after each blood draw and as needed every 7 days dated 12/16/19. IV: change IV administration set every 24 hours for intermittent infusions dated 12/16/19. IV: change IV dressing every 7 days and as needed for soiling and or dislodgement dated 12/16/19. IV: document IV site appearance every shift: dated 12/7/19. Normal saline flush solution, use 10 ml intravenously every 8 hours for preventative measure when IV is not in use, flush each catheter lumen with 10 ml normal saline every 8 hour dated 12/7/19. Ivanz solution reconstituted one gram one time a day for urinary tract infection for 13 days started on 12/9/19 ending 12/23/19. During an interview with staff member G, LPN on 12/16/19 at 1:25 p.m. she confirmed she just changed the IV dressing for Resident #97 after his shower. She stated she did not recall the date on the dressing and stated she had changed it before. Staff member G, LPN was asked to verify the physician order and documentation related to other IV dressing changes. Staff member G, LPN reviewed the physician orders and stated she could not find an order and had not documented on the dressing change. The nurse stated she could not pull up the medication administration record or treatment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 8 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administration record to locate previous dressing changes and could not locate any orders related to changing the IV dressing. 2. During observation of Resident #207 on 12/16/19 at 10:30 a.m., Staff member A, LPN confirmed the PICC line dressing on Resident #207's left upper arm was dated 12/8/19 and confirmed the dressing was past the date it should have been changed. Staff member A, LPN stated the PICC line was not being used and would be discontinued due to improving or stable white blood cell count although the white cell count still remained elevated. During an interview on 12/16/19 at 11:31 a.m. with staff member A, LPN he confirmed new orders for a chest x-ray related to dark colored mucous from the resident's tracheostomy and confirmed the PICC line dressing was changed. Review of the medication admission record for December reflected IV: Change IV dressing every 7 days as well as needed or dislodgement. Every evening shift every 7 days for prevention measures dated 12/12/19. Review of the MAR for December 12/12/19 reflected a check mark that the IV dressing was changed. An as needed order for dressing change was documented as completed on 12/16/19. Review of the medication admission record (MAR) for December reflected Normal Saline flush solution, Use 10 ml intravenously every 8 hours for maintain patency when IV is not in use, flush each lumen with 10 ml normal saline every 8 hours. Left upper arm dated 12/12/19. Review of the MAR reflected on 12/14/19 and 12/15/19 at 6:00 a.m. not checked as flushed. During an interview on 12/19/19 at 11:51 a.m. with the Director of Nursing (DON) stated that she had begun inservicing on IV care. Review of the facility policy and procedure for IV site care and maintenance related to section 6/5 page one of 3 dated 4/08 reflected Purpose to prevent local and systemic infection related to the IV site. Transparent membrane dressing no gauze over site are changed every 7 days and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 9 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 observation, interview and record review, the facility failed to provide tracheostomy care and tracheal suctioning consistent with professional standards of practice for one (Resident #207) of one sampled resident with a tracheostomy resident in regards to lack of needed suctioning. Residents Affected - Few Findings Included: Review of Resident #207's record reflected the resident was admitted on [DATE] with diagnoses that included chronic respiratory failure with hypercapnia, tracheostomy status, dysphagia, gastrostomy status, chronic kidney disease, anemia, unspecified focal traumatic brain injury with loss of consciousness, muscle wasting and atrophy, lack of coordination, abnormal posture, need for assistance with personal care, systemic lupus. Review of the admission summary progress note dated 12/11/19 at 6:30 p.m. reflected Resident #207 was alert, non verbal and required total assistance of 1 to 2 person for activities of daily living. Trach size 8 shiley, g-tube, foley catheter, fecal pouch with coccyx excoriated. Review of the medical certification for medicaid long term care services and patient transfer form dated 12/11/19 reflected the resident's primary diagnoses included acute respiratory failure, Methicillin resistant staphylococcus aureas (MRSA) colonized. During observation of Resident #207 on 12/16/19 at 10:30 a.m., the resident was noted in a double room without isolation precautions. Resident #207's name was not posted at the door. Resident #207's bed and feet could be observed from the doorway. After knocking and asking the roommate for permission to enter, Resident #207 was observed on an airmattress with the head of the bed elevated, a tracheostomy tube was present covered in brown thick mucous with oxygen at 2.5 liters and humidity set at 35%. The tube feeding set at 75 ml per hour with 675 ml infused of fibersource HN. During the observation of Resident #207, staff member A, LPN walked in through the adjoining restroom and asked if anything was needed. Staff member A, LPN was asked about the thick brown mucous from the tracheostomy and confirmed the resident needed suctioning and was unsure of the resident's orders for oxygen and humidity as the resident was admitted last week. Staff member A, LPN was observed hand washing and donning gloves then suctioning the thick brown mucous with a yankauer suction (oral suctioning tool) to the tracheostomy tube and surrounding area. Staff member A, LPN stated the resident did not need deep suctioning and the inner trach was changed weekly not daily. Staff member A, LPN completed the suctioning with the yankauer suction, replaced the suctioning tool in the pouch, then doffed gloves and washed hands. Staff member A, LPN did not listen to the resident's lungs and stated that he did not like to perform deep suctioning often as he felt it was not needed. He left the room to verify the orders of the oxygen and humidity and returned stating the orders were for 2 liters of oxygen, humidity at 28% and deep suction or yankauer suction as needed. During an interview on 12/16/19 at 11:31 a.m. with staff member A, LPN he confirmed new orders for a chest x-ray related to the dark colored mucous from the tracheostomy. During an interview with Resident #207's mother on 12/16/19 at 12:41 p.m. she stated he was smiling and would look at her when he was admitted but he does not do that now. During an observation and interview on 12/17/19 at 2:46 p.m. Staff member A, LPN gathered supplies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 10 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 - Few for tracheostomy care and placed aluminum foil, on the tray table, a replacement size 8 shiley trach. Staff member A, LPN auscultated the lungs and stated they were clear and placed the tube feeding on hold. The resident was noted with bright yellow thick mucous on the sponges around the tracheostomy and on his chest. The resident was observed for wounds around the neck prior to starting. Staff member A, LPN doffed gloves, washed hands and donned gloves to open the suction kit and trach cleaning kit with the size 8 shiley. Staff member A, LPN stopped and stated this kit has the wrong collar and threw all of the equipment away and doffed gloves and left the room. Staff member A, LPN then returned and washed hands, donned gloves, opened the trach suctioning kit, cleaning kit, size 8 shiley, and the separate package with the collar. Staff member A, LPN opened the water bottle from the suctioning kit and threw the suctioning kit in the garbage, doffed gloves and donned sterile gloves without hand washing. Staff member then removed the soiled dressings from the trach and without cleaning around the trach, removed the old trach and replaced with the new one after practicing in the air how to remove and replace the trach. A new collar was placed on the resident and the sterile gloves were removed. Staff member A, LPN washed hands and donned gloves then spilled the sterile water on the floor and across the table. Staff member A, LPN stopped and doffed gloves, washed hands and obtained a new cleaning kit, opened the kit and the sterile water and placed the sterile water in with the sponges to clean the trach and chest. Staff member A, LPN then washed hands and donned gloves. Staff member A, LPN cleaned the tracheostomy area and neck with the sponges. Staff member A, LPN stated that the resident did not need to be suctioned during trach care and changing of the trach then replaced the oxygen collar after cleaning all of the yellow and brown mucous from inside the collar with the remaining sponges. Staff member A, LPN responded that he used all of the sponges and needed to open a new kit to get another sponge to place around the trach site and under the collar. The resident was without the oxygen collar from 3:18 p.m. to 3:32 p.m. Staff member A, LPN was not observed checking the resident's oxygen saturation or pulse prior to removing the trach or after replacing the collar. Staff member A, LPN restated that the resident did not need to be suctioned with the trach cleaning or replacement of the trach. Staff member A, LPN stated that he could have checked the oxygen saturation during the process but did not. Review of the MAR for December reflected Ipratropium Bromide solution one vial via trach every 8 hours for shortness of breath dated 12/12/19. Review of the MAR did not reflect lung sounds documented since admission. Review of the treatment administration record (TAR) for December reflected the tracheostomy type shiley size 8, trach care daily and as needed, clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Every day shift for preventative measure signed off daily. Review of the TAR for suction of tracheostomy from 12/11/19 to 12/18/19 did not reflect Resident #207 received suctioning. Review of the physician orders reflected on 12/11/19 to change trach collar, mask and oxygen weekly as well as needed for preventative measure, change trach collar, mask and oxygen weekly and as needed every night shift every Sunday for preventative measure. Dispose of suction catheter and tubing after each use and replace with a new one as needed for prevention. Humidified oxygen per Trach as needed for shortness of breath. Nebulization of albuterol every shift for preventative measure, pre-treatment evaluation one vial via updraft. Record lung sounds (clear, diminished or crackles) dated 12/12/19. Oxygen at 2 liters via trach as needed for shortness of breath dated 12/11/19. Suction trach reason for care: amount suctioned, characteristics of secretions: color, odor, viscosity, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 11 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 - Few appearance of ostomy, (redness, drainage, open areas surrounding skin issues, device use to secure trach, resident tolerance to procedure) as needed for preventive measures dates 12/11/19. Tracheostomy type: shiley size 8, trach care daily and as needed clean inner cannula and replace. cleanse tracheostomy site with normal saline, pat dry, cover with drain sponge daily and as needed dated 12/12/19. Review of the 12/18/19 progress note at 1:26 a.m. reflected the resident was transferred and admitted to the hospital for sepsis, pneumonia, UTI (urinary tract infection) and abnormal labs. During an interview on 12/19/19 at 11:51 a.m. with the Director of Nursing (DON) she confirmed that the resident was sent to the hospital for elevated labs and confirmed his last labs were completed on 12/13/19. The DON stated that she interviewed the nurses who told her they changed the inner trachs and completed trach care daily. The DON confirmed that the yankeur should only be used for oral secretions and not the trach tube. The DON stated that she had begun inservicing on tracheostomy care. Review of in-service training for trach care dated 8/7/19 reflected the staff trained by the respiratory therapist using a packet titled trach care consisting of 20 pages dated 2013 on page 6 reflected: a physician order for percentage of humidity, oxygen liters per minute should be obtained. On page 9 describing tracheostomy care reflected tracheostomy care should be performed at least once a day or more often if required. A bold reminder at the bottom of the page reflected trach care is not a sterile procedure, suctioning a patient is. Page 10 tracheal suctioning reflected 1) set suction machine at the correct pressure for adults 100-120 mm/hg, 5) open sterile water for flushing the line 7) suctioning is a sterile procedure place sterile gloves on 8) Attach a sterile catheter to suction connective tubing. Keep gloves sterile. 9) Gently insert the catheter into the tracheostomy tube until resistance is met. Page 11 Indications for Suctioning: Always verify physician order: suction is done as needed and at the following times: if mucus is coughed up from the trach tube and can be seen at the trach opening. Before and after tracheostomy tube change. Patient is unable to cough up his/her own mucous. A note at the bottom of the page reflected: Suctioning is done by placing a catheter through the trach tube. Sterile technique must be used. Staff member A, LPN signed off as receiving training on 8/7/19. Review of tracheostomy care from respiratory practice manual, 4.7.1, 2 pages, dated 10/19 reflected: 6. suction resident as needed or ordered. 11. disconnect resident oxygen circuit with nondominant hand if applicable. 14. disposable inner cannula: unlock, remove, and discard inner cannula with the nonsterile nondominant hand in plastic bag or trash can. 13. replace disposable inner cannula with sterile hand and resume reconnect to oxygen source, as ordered. 14. removed soiled gauze from the tracheostomy site. clean around stoma using 4x4 gauze or Q tip soaked with sterile water or normal saline. Clean each of the four quadrants separately. 18. remove soiled gloves. 19. wash hands thoroughly, 20. apply clean gloves, 21. place drain sponge between the trach tube and residents skin. 22. secure trach tube with clean trach ties or trach tube holder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 12 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 Based on interviews, observations, and record review, the facility failed to provide dialysis care and services in accordance with professional standards of practice, related to not following physician orders for medications administration one resident (#52) of one resident sampled for dialysis services of a total of 43 residents. Residents Affected - Few Findings included: Review of the admission record for Resident #52 revealed an admission date of 4/17/18. The diagnoses include chronic kidney disease, dependence on renal dialysis, essential (primary) hypertension, angina pectoris. Review of the Care plan revealed a problem area, HEMODIALYSIS, Resident #52 has an intervention for dialysis treatment Tuesday, Thursday and Saturday, initiated on 4/25/18. A review of Active Physician orders revealed an order for Resident # 52 to have dialysis on the following days Tuesday, Thursday, Saturday, the order also revealed dialysis center name, transportation arrangements, Dr. contact information, chair time and for a transport bag meal/snack to be provided, the order was entered 10/19/19. Another order was reviewed and stated Hold Medication on Dialysis Day order was entered 10/19/19 with an indefinite ending date. A second review of the active physician orders later that week revealed an order was placed to HOLD ALL B/P (blood Pressure) medications prior to dialysis days. Tues, Thurs, Sat every day shift every Tues, Thurs, Sat, this order was entered 12/19/19 with no end date documented. Review of the Medication administration record (MAR) for the month of December 2019 reflects that all medications ordered for morning administration, were given every day of this month. An order for Isosorbide Dinitrate Tablet 30mg (milligrams) to be given 1 tablet by mouth one time a day for HTN (Hypertension, High Blood Pressure), with an active date of 10/19/19. During an interview with Resident #52 on 12/18/19 at 9:00 AM, the resident was observed in the room, lying in bed, covered with his jacket. He was observed to be well dressed and groomed. He stated everything was ok. Transportation for treatment is now well coordinated, it used to be bad. He stated I don't normally eat lunch and they do not buy apples anymore, I ask for a peanut butter sandwich no jelly, they make it and it is soggy by the time I can eat it. An interview was conducted on 12/18/19 at 11:57 AM with Staff B, Licensed Practical Nurse (LPN) he stated nurses receive the order and enter the order in the system. In the case the doctor requires medication to be given on a day, the nurse will enter or reenter the order and then schedule the medication by leaving out the specific days. Medication will not appear in the MAR. To schedule the days, you check mark the days you want the medication to be given. An interview was conducted on 12/18/19 at 1:03 PM with Staff B, LPN and Staff A, LPN. Staff A, LPN confirmed that Resident #52 has an order to Hold Medication on Dialysis days, the order had been placed on 10/19/19 with an indefinite end date. Staff A, LPN, confirmed all medication with a check mark and an initial reflect that medication had been given. Staff A, LPN reviewed MAR for the month of December 2019 and confirmed MAR reflects medication was given every day to include dialysis days. Staff A, LPN continued reviewing order to hold medication. Order information was expanded (Photograph) for review and Staff B, LPN reviewed order and stated the order had not been scheduled. Referring to the dates on the order were not checked, to reflect when to hold or give the medication, therefore the order is not reflected on the MAR. The order did not have scheduling details ordered, so it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 13 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 does not appear in the MAR. The nurses would not know, not to give the medications on dialysis days. Level of Harm - Minimal harm or potential for actual harm An interview conducted with the Director of Nursing (DON) on 12/19/19 at 2:48 PM. She confirmed a check mark and an initial on the MAR under the corresponding date and besides the corresponding medication reflect, it was administered. She then reviewed the MAR for Resident #52 and confirmed order to HOLD B/P medications on dialysis days Tuesday, Thursday and Saturday. The DON reviewed the documentation of administration for Isosorbide Dinitrate Tablet 30mg HTN on the morning of Thursday, 12/19/19 and she confirmed HTN medication was documented as given. The DON said expectations are that nurses are to follow physicians' orders accordingly. Residents Affected - Few Review of policy titled Physician orders with an effective date of November 2017 and revised September 2018 revealed on section 3 of 16. Medication orders should include a. route, b. dosage, c. frequency, d. strength, e. reason for administration, f. stop date and on section 5 of 16. states, Clarify unclear written orders by reviewing with the physician and documenting clarification on the physician telephone orders form, or in the electronic medical record, as a clarification order. Section 12 of 16. States Confirm the accuracy of orders, review orders daily in the clinical meeting to confirm accuracy in the transcription and identify errors of omission. A review of policy titled Dialysis Management (Hemodialysis) revealed section 11 of 19. Medications are given at times for maximum effectiveness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 14 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews, and review of facility policy, the facility failed to ensure proper disposal of medications during medication administration for 2 (Resident #91 and Resident #101) of 6 residents observed for medication administration. Findings included: A review of the manufacturer guidelines for the medication Lacosamide (www.vimpat.com) revealed that Vimpat (a name brand of the generic medication lacosamide), is a federally controlled substance under Schedule 5 (CV) because it can be abused or lead to drug dependence. An observation was made on 12/18/19 at 09:41 AM of medication administration in the 100 hallway with Staff Member B, Licensed Practical Nurse (LPN) administering medications. Staff Member B prepared 6 medications for administration for Resident #91: Acidophilus 250 milligrams (mg) via percutaneous endoscopic gastrostomy (PEG) tube once daily Apixaban 5mg via PEG tube two times daily Gabapentin 100mg via PEG tube three times daily Lacosamide 200mg via PEG tube two times daily Levetiracetam 750mg via PEG tube two times daily Polyethylene Glycol 17 grams via PEG tube once daily Staff Member B prepared each medication in a separate medication cup before entering Resident #91's room to administer medications. During the medication administration, Resident #91's PEG tube became occluded and no medications were administered as a result. After medication administration was finished, Staff Member B disposed of each medication by putting them inside of a bottle of liquid medication disposer, including the controlled medication Lacosamide. After disposal of the medications, Staff Member B stated that Resident #91 did not receive any of the medication due to his PEG tube being clogged and that the facility procedure is to dispose of the medications in the liquid medication disposer. Staff Member B stated that normally, disposal of a controlled medication requires another licensed nurses signature as a witness to the disposal of the controlled medication. Staff Member B did not give a reason why the disposal of the controlled medication Lacosamide went unwitnessed by another licensed nurse at the facility. An observation was made on 12/19/19 at 08:47 AM of medication administration in the 100 hallway with Staff Member J, Registered Nurse (RN) administering medications. Staff Member J prepared 8 medications for administration for Resident #101: Aspirin 81 mg by mouth (PO) once daily Celexa 5mg PO once daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 15 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0755 Famotidine 20mg PO once daily Level of Harm - Minimal harm or potential for actual harm Amlodipine 5mg PO twice a day Benztropine 0.5mg PO once daily Residents Affected - Few Depakote Sprinkles 125mg PO twice a day Metformin 1000mg PO twice a day Namenda 10mg PO twice a day Staff Member J prepared 7 of the 8 medications by putting them into a medication cup. Staff Member J then disposed of 7 medication wrappers as well as a dose of Depakote Sprinkles 125mg that was still in the plastic wrapper into a trash can. Staff Member J acknowledged that she disposed of the Depakote Sprinkles 125mg on accident in the trash can and removed another dose of the medication from the medication cart for administration. Staff Member J administered all 8 medications to Resident #101 without difficulty. After administration of the medications, Staff Member J performed hand hygiene and administered medications to another resident. Staff Member J did not remove the dose of Depakote Sprinkles 125mg from the trash can. Staff Member J stated that medications are not disposed of in the regular trash and acknowledged that education was just completed regarding the new process for disposing of medications. Staff Member J also stated that she was going to remove the dose of Depakote Sprinkles 125mg and dispose of it properly before moving on to the next resident but did not do so. An interview was conducted on 12/19/19 at 04:35 PM with the facility's Director of Nursing (DON) regarding expectations regarding medication disposal. The DON stated that they are transitioning to a new system of medication disposal which involves different medications being stored in different bins, but stated that nurses may still use the drug buster liquid as a way of disposing medications. The DON stated that any controlled medication that is disposed of requires another licensed nurse's signature to act as a witness of the disposal. The DON also stated that medications should not be disposed of in a regular trash can and that nurses should follow the medication disposal policy. A review of the facility policy titled Disposal of Medications, Syringes, and Needles, last updated on 12/2012, revealed that a controlled medication disposition log, or equivalent form, shall be used for documentation and shall be retained as per federal privacy and state regulations. The log shall contain the resident's name, medication name and strength, prescription number, quantity/amount disposed, date of disposition, and signatures of required witnesses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 16 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0773 Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify and notify the physician of elevated laboratory results for one Resident #207 of the 43 sampled residents. Resident #207's physician ordered repeat labs on 12/13/19 after reviewing elevated lab results on 12/12/19. The 12/13/19 labs were received reflecting a further increase in white blood cell counts; the facility failed to follow through and notify the physician from 12/13/19 to 12/18/19. During chart review on day three of the re-certification survey, the 12/13/19 labs were identified without physician notification or follow up. The facility then obtained stat (immediate) orders for lab testing on 12/18/19. The results of the stat lab tests identified critical values resulting in Resident #207's transfer to the hospital. Findings Included: Review of Resident #207's record reflected the resident admitted on [DATE] with diagnoses of chronic respiratory failure with hypercapnia, tracheostomy status, dysphagia, gastrostomy status, chronic kidney disease, anemia, unspecified focal traumatic brain injury with loss of consciousness, muscle wasting and atrophy, lack of coordination, abnormal posture,need for assistance with personal care, systemic lupus. Review of Resident #207's laboratory results dated [DATE] collected at 5:30 a.m. showed: white blood cell count of 12.4 K/uL (normal 3.8 to 10.8), red blood cell count of 3.09 M/uL (normal 4.40 to 5.80), hemoglobin *verified by repeated analysis 8.5g/dL (normal 13.8 to 17.2), hematocrit 26.1% (normal 41.0 to 50.0). Written at the bottom of the lab results reflected a message for the ARNP (Advanced Registered Nurse Practitioner) left at 2:03 p.m., and also: Please do serum and urine osmolarity, urine sodium, CMP (comprehensive metabolic panel) and CBC (complete blood count) in am and send FOBT (fecal occult blood test) times 3, signed the physician on 12/12/19. Review of Resident #207's laboratory results dated [DATE] collected at 5:20 a.m. showed: white blood cell count of 14.5 K/uL (normal 3.8 to 10.8), red blood cell count of 3.26 M/uL (normal 4.40 to 5.80), hemoglobin 8.8 g/dL (normal 13.8 to 17.2), hematocrit 27.4% normal 41.0 to 50.0) an arrow next to the WBC reflected the lab was higher and out of range without a signature or new orders. Review of Resident #207's laboratory results dated [DATE], 2:00 p.m. completed stat (immediate) showed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 17 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0773 white blood cell count of 26.4 K/uL (normal 3.8 to 10.8) Critical High * verified by microscopic examination, Level of Harm - Actual harm red blood cell count of 3.44 M/uL (normal 4.40 to 5.80), Residents Affected - Few hemoglobin 9.3 g/dL (normal 13.8 to 17.2), hematocrit 28.3 % (normal 41.0 to 50.0). During an interview on 12/18/19 at 10:37 a.m., staff member A, LPN confirmed that he wrote a progress note on 12/13/19 at 2:27 p.m. after leaving a message for the nurse practitioner and stated that he would have given the oncoming nurse that report and expected them to follow up. Staff member A, LPN stated he did not work the weekend and was not aware that the labs were not followed up on. During an interview on 12/18/19 at 10:47 a.m. the Director of Nurses (DON) was notified of the abnormal lab result from 12/13/19 and stated, the nurses review the labs and notify the physician of the results. If there are no new orders the labs go in the physician box to sign, then in the resident's chart. If the nurse has new orders or does not get a response, they continue to call back and notify of the results and document in a progress note. During an interview on 12/18/19 at 11:02 a.m. with the resident's nurse practitioner, she stated she was in earlier today and did not see the labs from 12/13/19. She stated that she was told by the nurse that the resident's vitals were stable and gave orders to pull the PICC (peripherally inserted central catheter) intravenous line. The nurse practitioner stated that she saw the resident but was not aware of the 12/13/19 labs as they should have been faxed to the office and placed in the chart. The nurse practitioner stated if the labs were elevated they should have been ordered daily until they were at baseline or under 10 for the white blood cell count and she was unaware that labs were redrawn on 12/13/19. The nurse practitioner stated she saw the resident and that her notes must be at the office still. The nurse practitioner stated that she will have the office send her notes over and will contact the nurse to reorder stat labs. She stated that she was told the labs were lower and ordered the PICC line to be removed due to the information she received from the nurse. Review of the note from a physician or nurse practitioner obtained via fax from the nurse practitioner's office on 12/18/19 at 12:10 p.m. The follow-up note reflected the nurse practitioner did not document lab information received, reviewed or plan of care, documented the resident was alert and oriented times 3 with normal cranial nerves II to XII, normal sensation and strength. Heent/Neck: no neck stiffness or pain, Musculoskeletal: no limitation in motion, no muscle or joint pain, no muscle weakness, no swelling or redness in joints. Neurologic: good coordination, good memory and speech, no numbness and tingling. During an interview with Staff member A, LPN on 12/18/19 at 12:00 p.m. he stated the labs get ordered online and go in the lab book. Staff member A, LPN stated that he does not fax results to the physician's office unless they are completely normal. Staff member A, LPN stated that he never faxed the 12/13/19 results to the physicians office, just called and left a message with the ARNP and let the oncoming nurse know that a message was left. During an interview with the DON on 12/18/19 at 12:13 p.m. she stated the nurse has the ability to go online and check the labs. The DON went online and printed the labs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 18 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0773 Level of Harm - Actual harm Residents Affected - Few During an interview with with Resident #207's Physician on 12/19/19 at 2:55 p.m., he confirmed he was in the building on 12/12/19 and saw Resident #207's labs from 12/12/19 and ordered repeat labs to be done on the 13th. The physician stated he did not evaluate or review the resident's information. He confirmed the labs were all that he looked at and the nurse stated Resident #207's vitals were stable. The physician said that when the labs done on 12/13/19 were reviewed the facility should have called the on call person to let them know the results. The physician stated he comes to the facility every Thursday but did not evaluate the new resident or documents other than the labs from 12/12/19. The physician stated he could not see Resident #207 on 12/12/19 due to receiving 7 to 10 new admissions that day and was not able to see them all. The physician restated the nurse told him the vitals were stable and he would normally see all new residents but that day he had about 8 to 10 new admissions. The physician stated he was unsure of how often the ARNP comes. The physician stated he ordered labs for the next day and never heard about the resident after 12/12/19. During observation of Resident #207 on 12/16/19 at 10:30 a.m., the resident was noted in a double room without isolation precautions. Resident #207's name was not posted at the door. Resident #207's bed and feet could be observed from the doorway. After knocking and asking the roommate for permission to enter, Resident #207 was observed on an airmattress with the head of the bed elevated, a tracheostomy tube covered in brown thick mucous with oxygen at 2.5 liters and humidity set at 35%. The urine draining from the catheter was noted a straw yellow. The tube feeding set at 75 ml per hour with 675 ml infused of fibersource HN. During the observation of Resident #207, staff member A, LPN walked in through the adjoining restroom and asked if anything was needed. Staff member A, LPN was asked about the thick brown mucous from the tracheostomy and confirmed the resident needed suctioning and was unsure of the residents orders for oxygen and humidity as the resident was admitted last week. Staff member A, LPN observed hand washing and donning gloves then suctioning the thick brown mucous with a yankauer suction (oral suction tool)to the tracheostomy tube and surrounding area. Staff member A, LPN stated the resident did not need deep suctioning and the inner trach was changed weekly not daily. Staff member A, LPN completed the suctioning with the yankauer then doffed gloves and washed hands. Staff member A, LPN did not listen to the residents lungs and stated that he did not like to perform deep suctioning often as he felt it was not needed. He left the room to verify the orders of the oxygen and humidity and returned stating the orders were for 2 liters of oxygen, humidity at 28% and deep suction or yankauer suction as needed. Staff member A, LPN confirmed the PICC line dressing on Resident #207's left upper arm was dated 12/8/19 and confirmed the dressing was past the date it should have been changed. Staff member A, LPN stated the PICC line was not being used and would be discontinued due to improving or stable white blood cell count although the white cell count still remained elevated. During an interview on 12/16/19 at 11:31 a.m. with staff member A, LPN he confirmed new orders for a chest x-ray related to the dark colored mucous from the tracheostomy and confirmed the PICC line dressing was changed. During an interview on 12/19/19 at 8:15 a.m. with staff member B, LPN she confirmed Resident #207 was sent out to the hospital for critical labs but she had not worked with him. Review of the progress notes dated 12/18/19 at 6:30 p.m. reflected the nurse documented the resident sent out to the hospital by the ARNP for critical labs and the resident's mother was in the building at the time and notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 19 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 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 0773 Review of the 12/18/19 progress note at 1:26 a.m. reflected the resident was admitted to the hospital for sepsis, pneumonia, UTI and abnormal labs. Level of Harm - Actual harm Residents Affected - Few During an interview on 12/19/19 at 11:51 a.m. with the Director of Nursing (DON) she confirmed that the resident was sent to the hospital for elevated labs and confirmed his last labs were completed on 12/13/19. The DON stated that she had begun inservicing on tracheostomy care, IV care and following up on labs. Review of in-service training completed on 7/19/19 reflected lab services/physician included Notification of the physician on any abnormal lab results, Physician should be made aware of all critical labs immediately. If unable to reach physician within two hours of stat labs or critical lab values, contact facility medical director for further orders. Review of the notification of resident/patient change in condition policy from clinical guidelines manual 5.1.1, one page dated 2/19 reflected 1) Notify the physician resident/ resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day. a) If the nurse responsible for the care of the resident is remaining with the resident and us unable to place the telephone calls, another nurse will place the calls. 2) Document the Nurse's notes, the time of notification was made and the names of the person(s) to whom you spoke. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 20 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During observation of Resident #2's room with an isolation supply caddy hanging on the door on 12/17/19 at 9:26 a.m. staff member M, CNA entered the room without a gown and gloves, walked out and came back in the room. Staff member M, CNA stated she took out a tray and was going to assist the resident now. An unknown staff member approached the room and donned a gown and gloves to enter with clean laundry at 9:32 a.m. when the staff member exited she used hand sanitizer after leaving the room. At 9:40 a.m. an unknown dining aide gowned and gloved and went into the room. After leaving she also hand sanitized once closing the door. Staff member M, CNA left the room and hand sanitized at 9:40 a.m. Residents Affected - Few Staff member M, CNA returned at 9:46 a.m. with another staff member K, CNA. Staff member K, stated to staff member M that she needed to wear a gown and gloves when going into an isolation room regardless of what they were doing. Staff member M, CNA stated she was told something else and was not happy about the miscommunication. During an interview with the DON on 12/18/19 at 5:30 p.m. she stated the staff should be wearing personal protective equipment when entering a room with an isolation caddy on the door. Review of Resident #2's record reflected a diagnosis of ESBL (Extended spectrum beta-lactamase) in urine receiving Ertapenem sodium solution 1 gram one time a day for ten days. Based on observations, record review and interview, the facility failed to operationalize the infection control program with regards to staff not utilizing personal protective equipment (PPE), when entering rooms of residents who were on isolation precautions for 2 (#91 and #2) of 3 residents observed. Findings included: 1. Resident #91 was admitted to the facility on [DATE] with diagnoses of non-traumatic subdural hemorrhage, gastrostomy status, and generalized anxiety disorder. A review of Resident #91's care plan revealed that Resident #91 had fecal infection related to Clostridioides Difficile (C. Diff) with interventions for isolation precautions, contact precautions, an administration of anti-infective medication as ordered. A review of Resident #91's physician's orders revealed orders for Vancomycin Hydrochloride (HCl) Suspension 125 milligrams (mg) via percutaneous endoscopic gastrostomy (PEG) tube every 6 hours for C. Diff infection for 10 days and Isolation Precautions for C. Diff infection. An observation was made on 12/18/19 at 09:19 AM of Staff Member K, Certified Nurses Assistant (CNA) providing care to Resident #91 inside of his room. Staff Member K was wearing personal protective equipment (PPE), consisting of gloves, a disposable gown, and a face mask during the observation. During the observation, another staff member entered the doorway to assist Staff Member K with Resident #91's care. Staff Member K was observed assisting the other staff member with donning a gown while wearing gloves. Staff Member K was not observed changing gloves or performing hand hygiene after performing care for Resident #91 or before assisting the other staff member with donning PPE. Staff Member K then wheeled a mechanical lift into Resident #91's room and closed the door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 21 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation was made on 12/18/19 at 09:28 AM of Staff Member K bringing the mechanical lift out of Resident #91's room and wheeling the lift into the hallway with gloves and gown still donned. Staff member L, CNA, then took the mechanical lift into room [ROOM NUMBER] to provide care for another resident. Staff Member L was not observed sanitizing the lift before taking it into room [ROOM NUMBER]. At 09:33 AM, Staff Member L was observed exiting room [ROOM NUMBER] and wheeling the mechanical lift into the unit shower room. An observation was made on 12/18/19 at 09:41 AM of medication administration in the 100 hallway with Staff Member B, Licensed Practical Nurse (LPN) administering medications. Staff Member B prepared 6 medications for administration for Resident #91. Staff Member B prepared each medication in a separate medication cup before entering Resident #91's room to administer medications. Staff Member B also performed hand hygiene and donned PPE, consisting of gloves, a disposable gown, and a face mask before entering the room. Staff Member B then gathered supplies for medication administration, including 2 cups of water and an irrigation syringe used to administer medications via PEG tube. After positioning Resident #91 and connecting the syringe to the PEG tube, Staff Member B began the medication administration process. During medication administration, two observations were made of Staff Member B's personal cell phone ringing inside of her pocket. In each instance, Staff Member B was observed reaching into her pocket with her gloved left hand to prevent her cell phone from ringing. Staff Member B did not remove gloves or perform hand hygiene before reaching into her pocket. Also during the observation, Resident #91's PEG tube became occluded and Staff Member B attempted to troubleshoot the occlusion. Staff Member B adjusted her glasses and put them on her forehead during the observation with a gloved left hand. Staff Member B did not change gloves or perform hand hygiene prior to touching the glasses on her face. After having difficulty with medication administration due to the occlusion of the PEG tube, Staff Member B terminated the procedure and began to clean up Resident #91's care area. Staff Member B was observed removing her gloves, then proceeded to wipe down Resident #91's bedside table and handle Resident #91's irrigation syringe used for administering PEG tube medications with ungloved hands. Staff Member B then removed her gown and mask, performed hand hygiene, and exited the room. An interview was conducted following the procedure with Staff Member B. Staff Member B stated that during the procedure, her glasses started to fog up due to wearing the mask, so she had to adjust her glasses to see better. Staff Member B also stated that she would not normally reach into her pocket with gloved hands to touch personal items inside of her pocket and stated you got me. An interview was conducted on 12/18/19 at 02:15 PM with Staff Member B regarding resident care equipment inside of isolation rooms. Staff Member B stated that Resident #91 was on contact isolation precautions for C. Diff. infection. Staff Member B stated that Resident #91 was transferred by mechanical lift and required 2 staff members to assist with the transfer. Staff Member B stated that she would normally take the mechanical lift to the shower room to be sanitized, but she wheeled it into the hallway until after she removed her PPE. Staff Member B also stated that she thought Staff Member L was going to take the lift to the shower room to be sanitized, but she did not. An interview was conducted on 12/18/19 at 02:26 PM with Staff Member L, CNA regarding using the mechanical lift on another resident after it was used for a resident on contact isolation precautions. Staff Member L stated that she did not recall taking the mechanical lift into room [ROOM NUMBER] after it was used for Resident #91 and stated that she took the lift into the shower room to be sanitized before taking it into room [ROOM NUMBER]. An interview was conducted on 12/19/19 at 03:43 PM with the facility's Director of Nursing (DON) regarding infection control. The DON stated that anyone going into an isolation room should be wearing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 22 of 23 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 105749 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Rehabilitation and Nursing Center 7101 Dr Martin Luther King Jr St N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm the appropriate PPE and should not bring a lift out of the resident on isolation precautions room without using disinfectant wipes to clean the equipment. The DON stated that all other equipment in isolation rooms is dedicated to the resident and disposable. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 23 of 23