Health inspection·October 12, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/11/2023 at 8:00 a.m. Staff E, LPN/CRS stated Resident #11 has behaviors of putting staff out of the room, spitting at staff, and throwing his dishes on the floor and at staff. She also stated he does not like staff of color and prefers Caucasian staff. She also stated preference for Caucasian caregivers was not care planned. She confirmed she assists with updates to the MDS, and care plans and it was not done. Residents Affected - Few During an interview on 10/11/2023 at 9:00 a.m. Staff G, Certified Nursing Assistant (CNA) stated Resident #11 has behaviors of screaming, yelling at staff, spitting at staff, and throwing his dishes. She said he has stated he does not like Black people. During an interview on 10/12/2023 at 8:00 a.m. Staff F, CNA stated Resident #11 spits at staff, throws his dishes on the floor and does not like people of color. She provides as much care as he allows, which at times is a snack or beverage. During an interview on 10/11/2023 at 1:30 p.m. Staff E, LPN/CRS stated the behavior monitoring form listed under CNA tasks in the electronic medical record revealed Resident #11 was exhibiting behaviors for the past 30 days and there was no update to the care plan post the Interdisciplinary Care Team (IDT) meeting held on 9/29/2023. She reviewed the progress notes that revealed Resident #11 was having behaviors of throwing his tray, spiting at staff, refusing meals and medications. During an interview on 10/12/2023 at 12:34 p.m. the NP stated Resident #11 had behaviors prior to admission, a room change was done where he would have more Caucasian staff to assist in care. She stated per report from staff after the room change his behaviors improved but now, they are escalating again. She also stated staff are aware of his refusal for staff of color to provide his care. She confirmed the resident had behaviors of refusing care, medications, meals, and behaviors of spitting at staff, throwing meal trays on the floor, throwing urinal and feces on the floor. During an interview on 10/12/2023 at 2:00 p.m. with the Assistant Director of Nursing (ADON) and the Social Service Director (SSD) both stated they were not aware Resident #11 was continuing to have behaviors such as spitting at staff, throwing his urinal and feces on the floor, refusing medications, and meals. Both also stated they were aware of the room change but not that it was related to the need to have more Caucasian staff. Review of the Psychiatric Periodic Evaluations, dated 8/1/2023, 8/8/2023, and 9/5/2023 completed by the Consultant NP revealed: * 8/1/2023 - this is a follow up for psychotropic medication management and assessment of mood and behaviors, plan. - Haldol gel 10 milligrams (mg)/milliliter (ml) apply 1 ml topically at 5 pm daily, - Notify practitioner of significant changes or concerns - Monitor for symptoms of exacerbation of psychiatric conditions. Also revealed, resident is at lowest effective dose of medications. * 8/8/2023 - resident continues to refuse medications, treatments, personal care which is why the Haldol was ordered in a gel, resident is only getting his meds 50% of the time therefore increasing the Haldol to twice a day and reassess medications in a week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 2 of 24 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 10/12/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few * 9/5/2023 - resident was moved to a different hall with a higher concentration of Caucasian nurses. Plan is to continue Haldol and Risperdal, discontinue Invega Susitna as resident refuses, current meds. Staff states there has been at this time some improvement in behaviors. Review of a progress note, dated 9/7/2023 at 12:24 p.m. by Staff U, LPN/UM, revealed Resident threw lunch tray on the floor after the CNA delivered it, she asked why, and the resident did not reply. Review of a progress note, dated 9/7/2023 at 10:36 p.m. by Staff U, LPN/UM revealed Resident threw his full urinal on the floor and was observed yelling out for food. Snack provided and resident continued to yell out. Review of the Medication Administration Records from August 1, 2023 - September 26, 2023 revealed Resident #11 refused medications on 34 days. Review of the progress notes from August 1, 2023 - September 2023 documented behaviors of refusing medications, refusing meals, inappropriate display of behaviors to staff, refusing care, screaming, and yelling. Review of the policy and procedure titled, Resident Assessment Instrument: MDS Completion by Discipline, dated October 2023, revealed social services is responsible for sections; cognitive patterns, mood, behavior; nursing is responsible for functional status. Nursing is responsible for completion and signature. Review of policy and procedure titled, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, effective March 2017 and revised September 2023, revealed: Policy: 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 wellbeing, in accordance with the comprehensive assessment and plan of care. Procedure: 2. Daily updates to care plans are added by a member of the IDT at the time the change is implemented, the intervention is needed, or other care plan revision is indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting. 3. Dates and documentation on the care plan a. New, revised, or discontinued Problems, Goals or Interventions are dated for the date the documentation is made. b. Problems and Goals have IDT approaches and Interventions to assist the resident in their goal attainment. 5. Comprehensive Plan of Care b. The comprehensive care plan describes or includes: i. The services that are to be furnished and goals that reflect the Resident's wishes, choices and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 3 of 24 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 10/12/2023 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 0641 exercise of rights. Level of Harm - Minimal harm or potential for actual harm ii. Any services that would normally be provided, but are not provided due to the resident's exercise of rights including the right o refuse treatment and any alternative means or options to address the problem. Residents Affected - Few iii. The needs, strengths and preferences identified in the comprehensive resident assessment. iv. Prevention of avoidable declines in functioning or functional levels. v. Standards of current professional practice. vi. Adequate information provided to make informed choices regarding treatment. 6. Quarterly Update of the Plan of Care b. The IDT members make a quarterly care plan review note within the designated disciplines progress notes that includes; i. If goals are met or unmet. ii. If care plan will remain in effect for the resident. 8. Care Plan Meeting g. Nursing i. Review current diagnosis, tests or procedures, treatments (wounds, rashes, etc.), discuss current interventions and risk of further breakdown if applicable, recent or pending referrals, Physician Consults, Restorative, medications, pain management plan, behavioral management plan, special needs, risk of falls and current interventions . i. Social Services i. Review any changes needed to face sheet information .mental health, recent changes in cognition, behaviors and socialization and approaches .that may need to be addressed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 4 of 24 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 10/12/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to revise the individual comprehensive care plans for two residents (#77 and #11) out of 34 sampled residents. Findings included: 1. Review of Resident #77's admission Record showed Resident #77 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes without complications. A review of the active October 2023 physician orders for Resident #77 showed a physician order dated 07/13/23 as, Insulin Lispro Solution 100 UNIT/[milliliter] ML inject 5 unit subcutaneously before meals for diabetes mellitus. A second physician order dated 08/11/23 showed, Accu-check per order related to diabetic monitoring of Hypo/Hyperglycemia activity. as needed for hyper/hypoglycemia. A review of the comprehensive care plan showed a focus of DIABETES MELLITUS: [Resident #77] has diabetes Mellitus as evidence by: Type 2 Diabetes. The goals showed, Minimize effects of Hypoglycemia and Hyperglycemia and monitor for diabetic complications. The Interventions showed, Blood glucose Monitoring as ordered (Refer to order for current orders- Before Breakfast 70-105 mg/dl [milligram/deciliter], Before lunch or dinner: 70-110 mg/dl, One hour after meals: less than 160 mg/dl. two hours after meals: Less than 120 mg/dl, Between 2-4 AM: Greater than 70 mg/dl, For blood glucose less than 70 administer food or glucose per manufacturers recommendations and notify MD(medical doctor) date initiated 09/09/2020 and May Obtain Blood Glucose as needed for symptoms of Hypo/Hyperglycemia and notify MD, date initiated 09/09/20. Review of the Annual Minimum Data Set (MDS), dated [DATE], showed in Section C - Cognitive Patterns Resident #77 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact). During an interview on 10/11/23 at 2:03 p.m. Resident #77 confirmed the diagnosis of Type II Diabetes and stated staff did not check her blood sugars on a regular basis. Resident #77 stated staff did administer insulin before every meal. Review of Resident #77's Medication Administration Record for October 2023 showed Resident #77 was administered Insulin Lispro Solution 100 units/ml three times a day before meals from 10/01/23-10/11/2023. The October 2023 MAR showed Resident #77 had no Accu-checks administered for the dates 10/01/23-10/22/23. Review of Resident #77's vitals page showed Resident #77's last Accu-check was administered on 07/07/23. During an interview on 10/11/23 at 3:22 p.m., Staff K, Licensed Practical Nurse (LPN) stated Resident #77 had controlled diabetes so staff did not do regular Accu-checks on Resident #77. Staff K, LPN stated Resident #77 had routine scheduled insulin only. Staff K, LPN stated Resident #77 was alert and oriented and could tell staff if she felt bad. Staff K stated Resident #77 had not had an order for scheduled Accu-checks for blood sugars in over a year. During an interview on 10/12/23 at 11:12 a.m. the Director of Nursing (DON) reviewed Resident #77's care planned intervention that showed, Blood glucose Monitoring as ordered (Refer to order for current ordersBefore Breakfast 70-105 mg/dl, Before lunch or dinner: 70-110 mg/dl, One hour after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 5 of 24 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 10/12/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meals: less than 160 mg/dl. two hours after meals: Less than 120 mg/dl, Between 2-4 AM: Greater than 70 mg/dl, For blood glucose less than 70 administer food or glucose per manufactures recommendations and notify MD with initiated date 09/09/2020. The DON stated, we would refer to the current order dated 08/11/23, Accu-check per order related to diabetic monitoring of Hypo/Hyperglycemia activity. as needed for hyper/hypoglycemia. The DON confirmed the intervention did show blood glucose ranges but stated that may just be an auto filled response to the care plan. The DON stated she would have to find out for sure from Staff H, Registered Nurse (RN)/Clinical Reimbursement Director (CRD). The DON stated, If the PRN [as needed] blood glucose order ever gets discontinued, we would go by the blood glucose range in the first intervention. During an interview on 10/12/23 11:25 a.m. Staff H,RN/CRD stated interventions on care plans were not physician orders. Staff H, RN stated the blood sugar ranges noted in Resident #77's comprehensive care plan interventions were not physician orders and could be disregarded as the intervention stated, blood glucose monitoring as ordered. Staff H stated she did not see any reason to revise the care plan because it said to refer to the current order and that would be what would be followed for treatment. 2. Review of the admission Record for Resident #11 revealed he was admitted to the facility on [DATE] from an acute care hospital. admission diagnoses included paranoid schizophrenia. On 10/9/2023 at 8:00 a.m. Resident #11 was observed being served his breakfast by Staff E, Licensed Practical Nurse/Clinical Reimbursement Specialist (LPN/CRS) and the meal was being served in a disposable container. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section E - Behavior Resident #11 had no physical behaviors directed towards other (e.g. such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behaviors directed towards others (e.g. threatening others, screaming at others, cursing at others), or other behavioral symptoms not directed toward others such as hitting or scratching self, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Further review showed Resident #11 did not show the behavior of rejecting care. Section G - Functional Status showed the resident required total assistance with activities of daily living. Review of Resident #11's care plan, initiated 12/23/2021 and revised 10/6/2023, revealed a Focus area related to Behavior: The resident is noted with the following behaviors: Delusional thinks he is a female, thinks he has a vagina, thinks he gave birth to a daughter, thinks his brother poisoned him and so he will only eat certain foods at times, fabricates stories related to (r/t) care and services. Only wants to be shaved once a year, prefers a beard. Refuses medication, care, blood glucose and food at times. Pushes plates off tray and breaks them. Paper products put in place. Resident will throw his urinal with urine in it on the floor. Will urinate on the floor at times and will throw soiled brief on the floor. Hit, spit at staff resist care. Will put stool on the floor. Will remove his clothing, prefers to only wear brief or gown. During an interview on 10/10/2023 at 10:15 a.m. with Staff I, Certified Nursing Assistant (CNA) she stated she was not providing all care to Resident #11 today. She stated he does not like us, so other staff provide his care. I do answer his call light and get what he needs as he allows. During an interview on 10/11/2023 at 8:00 a.m. Staff E, LPN/CRS stated Resident #11 has behaviors of putting staff out of the room, spitting at staff, and throwing his dishes on the floor and at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 6 of 24 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 10/12/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff. She also stated he does not like staff of color and prefers Caucasian staff. She also stated preference for Caucasian caregivers was not care planned. She confirmed she assists with updates to the MDS, and care plans and it was not done. During an interview on 10/11/2023 at 9:00 a.m. Staff G, Certified Nursing Assistant (CNA) stated Resident #11 has behaviors of screaming, yelling at staff, spitting at staff, and throwing his dishes. She said he has stated he does not like Black people. During an interview on 10/12/2023 at 8:00 a.m. Staff F, CNA stated Resident #11 spits at staff, throws his dishes on the floor and does not like people of color. She provides as much care as he allows, which at times is a snack or beverage. Review of the Interdisciplinary Team (IDT) progress note, dated 9/26/23, signed by Staff E, LPN/CRS showed the care plan was updated and addressed medications, weight, diet, and advanced directives. There was no evidence the resident's room was changed to a different hall with a higher concentration of Caucasian nurses or the resident preference not to have caregivers that are people of color. During an interview on 10/11/2023 at 1:30 p.m. Staff E, LPN/CRS stated the behavior monitoring form listed under CNA tasks in the electronic medical record revealed Resident #11 was exhibiting behaviors for the past 30 days and there was no update to the care plan post the Interdisciplinary Care Team (IDT) meeting held on 9/29/2023. She reviewed the progress notes that revealed Resident #11 was having behaviors of throwing his tray, spiting at staff, refusing meals and medications. Review of the Psychiatric Periodic Evaluation 9/5/2023 completed by the Consultant Psychiatric Nurse Practitioner (NP) revealed: resident was moved to a different hall with a higher concentration of Caucasian nurses. Plan is to continue Haldol and Risperdal, discontinue Invega Susitna as resident refuses, current meds. Staff states there has been at this time some improvement in behaviors. During an interview on 10/12/2023 at 12:34 p.m. the NP stated Resident #11 had behaviors prior to admission, a room change was done where he would have more Caucasian staff to assist in care. She stated per report from staff after the room change his behaviors improved but now, they are escalating again. She also stated staff are aware of his refusal for staff of color to provide his care. She confirmed the resident had behaviors of refusing care, medications, meals, and behaviors of spitting at staff, throwing meal trays on the floor, throwing urinal and feces on the floor. During an interview on 10/12/2023 at 2:00 p.m. with the Assistant Director of Nursing (ADON) and the Social Service Director (SSD) both stated they were not aware Resident #11 was continuing to have behaviors such as spitting at staff, throwing his urinal and feces on the floor, refusing medications, and meals. Both also stated they were aware of the room change but not that it was related to the need to have more Caucasian staff. Review of policy and procedure titled, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, effective March 2017 and revised September 2023, revealed: Policy: 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 wellbeing, in accordance with the comprehensive assessment and plan of care. Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 7 of 24 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 10/12/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm 2. Daily updates to care plans are added by a member of the IDT at the time the change is implemented, the intervention is needed, or other care plan revision is indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting. 3. Dates and documentation on the care plan Residents Affected - Few a. New, revised, or discontinued Problems, Goals or Interventions are dated for the date the documentation is made. b. Problems and Goals have IDT approaches and Interventions to assist the resident in their goal attainment. 5. Comprehensive Plan of Care b. The comprehensive care plan describes or includes: i. The services that are to be furnished and goals that reflect the Resident's wishes, choices and exercise of rights. ii. Any services that would normally be provided, but are not provided due to the resident's exercise of rights including the right o refuse treatment and any alternative means or options to address the problem. iii. The needs, strengths and preferences identified in the comprehensive resident assessment. iv. Prevention of avoidable declines in functioning or functional levels. v. Standards of current professional practice. vi. Adequate information provided to make informed choices regarding treatment. 6. Quarterly Update of the Plan of Care. b. The IDT members make a quarterly care plan review note within the designated disciplines progress notes that includes; i. If goals are met or unmet. ii. If care plan will remain in effect for the resident. 8. Care Plan Meeting g. Nursing i. Review current diagnosis, tests or procedures, treatments (wounds, rashes, etc.), discuss current interventions and risk of further breakdown if applicable, recent or pending referrals, Physician Consults, Restorative, medications, pain management plan, behavioral management plan, special needs, risk of falls and current interventions . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 8 of 24 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 10/12/2023 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 0657 i. Social Services Level of Harm - Minimal harm or potential for actual harm i. Review any changes needed to face sheet information .mental health, recent changes in cognition, behaviors and socialization and approaches .that may need to be addressed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 9 of 24 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 10/12/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to provide care and treatment services in accordance with professional standards of practice as evidenced by not ensuring an acute skin condition was assessed for one resident (#9) of four residents sampled. Residents Affected - Few Findings included: During an interview on 10/9/2023 at 10:00 a.m. Resident #9 said she has been telling her CNAs (certified nursing assistants) and nurses since last week that she has been having pain on her left side near her abdomen and no one has addressed her about it to stop the pain. She said they just continue to ignore her and yell at her when she asks them for assistance. On 10/10/2023 at 10:37 a.m. Resident #9 stated she has been complaining about a sore on her side that has been very painful. On 10/10/2023 at 4:00 p.m. Resident #9 was observed laying down in her bed and she stated she was still having pain on her left side. Review of the admission Record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses to include unspecified open wound to the right lower leg, sequela, and Type 2 diabetes mellitus without complications. Review of the Annual Minimum Data Set, dated [DATE], Section C- Cognitive Patterns revealed the Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. During an interview on 10/11/2023 at 1:28 p.m. Staff Q, CNA said Resident #9 reported to her last week that she was having pain on her left side, and she reported what the resident told her to Staff N, Registered Nurse (RN) last week. Staff Q said, [Resident #9] is always complaining about something. Review of a form titled, Skin Check Weekly & PRN [as needed], with an effective date of 09/28/2023, revealed no new areas of skin impairment. Review of a form titled, Skin Check Weekly & PRN, with an effective date of effective date of 10/05/2023, revealed no new areas of skin impairment. During an interview on 10/12/2023 at 9:11 a.m. Staff N, RN said Resident #9 had recently taken the flu shot, and she had complained to him about soreness in her left arm last week. He offered her a pain pill and said, You just need to work out your arms, but she refused to take the pain pill. Staff N said he did not feel he needed to do a skin assessment or document Resident #9 refusing her pain medication because he knows that her discomfort was from the flu shot. During an interview on 10/12/2023 at 8:55 a.m. the Director of Nursing (DON) said skin assessments are carried out once a week. The DON said a skin assessment and a change of condition should have been carried out as soon as Resident #9 told a nurse that she was experiencing pain and had a sore on her side, and the nurse should have notified the doctor about the resident's condition. The DON said the Nurse Practitioner came yesterday to see Resident #9 but they do not have any documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 10 of 24 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 10/12/2023 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 0684 regarding the visit and the nurse did not document the visit. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/12/2023 at 9:00 a.m. Resident #9 said the Nurse Practitioner conducted an evaluation on her yesterday and told her that she needs to see a dermatologist as soon as possible before the areas on her skin gets infected. Residents Affected - Few Review of the facility policy titled, Weekly and prn Skin Check, effective date October 2021, revealed, The Weekly and PRN Skin Check is used to document skin condition throughout the Resident/Patient's stay in the facility. The nurse will conduct weekly skin check and /or a PRN check when applicable as a proactive measure to identify impairment or suspected impairment timely to reduce the risk of further decline in skin integrity. 1. Once a week and when an area of skin impairment is reported the skin check should be documented on the Weekly & PRN Skin Check documentation tool. If a new area is identified the appropriate skin grid should be initiated within 8 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 11 of 24 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 10/12/2023 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 - Some 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 observations, record reviews, and interviews the facility failed to ensure the urinary drainage bag for one resident (#66) was maintained in a manner that allowed for urine to drain via gravity into the drainage bag and failed to store the urinary catheter tubing and drainage bag in a sanitary manner for one resident (#102) out of four residents with urinary catheters. Findings included: 1. On 10/9/23 at 8:04 a.m. Resident #66 was observed sitting in a wheelchair. The resident's urinary catheter tubing was observed leaving the left leg hole of above-the-knee green shorts. The tubing hung down and then back up to a drainage bag attached to a metal plate located approximately 2 below the wheelchair's armrest. The resident's urine appeared to be thin consistency, milky-colored. On 10/9/23 at 10:41 a.m. Resident #66 was observed sitting in a wheelchair with the urinary drainage bag hanging from the metal plate below the left armrest of the wheelchair, approximately level with the resident's bladder. Resident #66 was observed, on 10/9/23 at 12:09 p.m. sitting in a wheelchair with a urinary drainage bag attached to the metal plate approximately 2 below the left armrest and appeared to be at the same level with the resident's bladder. On 10/10/23 at 1:30 p.m. Resident #66 was observed sitting in a wheelchair with a urinary drainage bag hanging from the left side of the wheelchair on a metal plate directly below the armrest. On 10/11/23 at 9:08 a.m. Resident #66 was observed with a small (leg) urinary drainage bag under the left thigh and appeared to be sitting on it. On 10/11/23 at 11:45 a.m. an observation was made of Resident #66 sitting in a wheelchair with a small urine drainage bag sitting on top of the resident's right leg. An interview was conducted on 10/11/23 at 12:14 p.m. with Staff J, Registered Nurse and the Assistant Director of Nursing (ADON) regarding the appropriate placement of a urinary drainage bag. Staff J stated they change Resident #66's drainage bag to a smaller leg bag while out of bed. The staff members observed the leg bag sitting on top of the resident's right leg. The ADON confirmed the drainage bag should be in a lower position to allow for drainage. Staff J, RN lowered the drainage bag to below the resident's right knee. Review of Resident #66's admission Record identified the resident was admitted on [DATE] with a diagnosis of flaccid neuropathic bladder not elsewhere classified. Resident #66's Quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status score of 9, indicative of moderate cognitive impairment. A review of the resident's care plan, revised on 3/7/23, identified a urinary catheter was used with risk for infection and/or complications. The interventions related to this focus revealed nursing staff were to keep the catheter tubing free of kinks and keep drainage bag below level of bladder. On 10/12/23 at 3:40 p.m. the Director of Nursing (DON) stated the urinary drainage bag should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 12 of 24 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 10/12/2023 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 below waist level. Level of Harm - Minimal harm or potential for actual harm 2. On 10/10/23 at 6:22 a.m. Resident #102's urinary catheter tubing was observed lying on the floor next to the resident's bed, the drainage bag with a privacy bag was hanging from the bedframe. Staff M, Certified Nursing Assistant (CNA) stated, at the time of the observation, the resident's bed was in a low position because the resident rolled (demonstrated). Staff M stated it (bag and tubing) should be in a basin. (Photographic Evidence Obtained) Residents Affected - Some Review of Resident #102's admission Record revealed an admission date of 6/14/23 and 10/5/23. The admission Record included a diagnoses not limited to unspecified neuromuscular dysfunction of bladder. A review of Resident #102's Order Summary Report for October 2023 instructed nursing staff to Drain urinary catheter bag every shift and PRN (as needed). On 10/12/23 at approximately 4:00 p.m. the Nursing Home Administrator (NHA) stated the facility did not have a policy for indwelling catheters (as requested) and used the competency titled, Perineal Care/Catheter Care as the policy. Review of the Perineal Care/Catheter Care Competency did not identify the position of the drainage bag or if the catheter tubing should be lying on the floor. The Cleveland Clinic, located at https://my.clevelandclinic.org/health/articles/14832-urine-drainage-bag-and-leg-bag-care, revealed The urinary (name brand) catheter is placed into the bladder through the urethra, the opening through which urine passes. The catheter is held in place in the bladder by a small, water-filled balloon. In order to collect the urine that drains through the catheter, the catheter is connected to a bag. It is either a regular (large bag) drainage bag or a small leg bag. The guidance identified Arrange the catheter tubing so that it does not twist or loop. When you are getting into bed, hang the urine bag beside the bed. You can sleep in any position as long as the bedside bag is below your bladder. Do not place the urine bag on the floor. Always keep your urine bag below your bladder, which is at the level of your waist. This will prevent urine from flowing back into your bladder from the tubing and urine bag, which could cause an infection. Also, do not go to bed or take a long nap while wearing the leg bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 13 of 24 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 10/12/2023 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 observations, interviews, and record reviews the facility failed to maintain one resident's (#102) tracheotomy in a clean, sanitary manner of one sampled resident with a tracheotomy. Residents Affected - Few Findings included: On 10/10/23 at 10:00 a.m. an observation of Resident #102's tracheostomy's (trach) revealed the inner cannula had a dried brown/tan colored substance around the entire rim of it, the oxygen trach mask was located toward the resident's shoulder and had brown/tan colored smudges, the green elastic mask tie had the same colored dried substance on it, and the padded trach collar was discolored with a tan and darkish brown substance on it. The resident's skin around the whitish colored split gauze under the trach appeared to be reddened. The suction canister, located on the nearby dresser had approximately 2 of an opaque white watery liquid in it. The Assistant Director of Nursing (ADON) viewed the resident, attempted to move the trach mask, and the resident began swinging their arms. The ADON confirmed the trach collar and cannula was dirty and the resident was not a heavy suctioner. A white bordered, undated dressing was observed on Resident #102's left upper arm, which the ADON stated looked like an old IV (intravenous) site. The resident's oral cavity was observed dry and with light tan patches on tongue. During an interview on 10/10/23 at 10:22 a.m. Staff R, Registered Nurse/Unit Manager (RN/UM) reported speaking with the ADON regarding Resident #102's trach site and how she had attempted to clean it a little bit this morning but the resident had resisted. Staff R confirmed the trach had not been changed last night by the looks of it and stated, No it wasn't. On 10/10/23 at 2:22 p.m. an observation was conducted with the Respiratory Therapist (RT), ADON, and Staff N, RN of Resident #102. The resident appeared to be agitated, saying ah, ah, ah and swinging arms while observed from the hallway. The ADON reported the resident had been previously medicated and was waiting for it kick in. The RT reported only changing the trach, staff changed the cannulas and tubing. An observation of the oxygen equipment was made with the ADON and showed the humidifying bottle had a scant amount of water in it. Staff N was holding the trach mask to cannula while the RT received an oxygen saturation of 91%. The RT stated the substance (attached to inner cannula and ties) looks like secretions and the resident has had a variable amount of secretions. The RT changed the trach, inner cannula and tie, washing the resident's chest resulting in a heightened reddened area. The RT observed the removed inner cannula and admitted it did not look like it got changed last night. The inner cannula tube had a yellowish-cream substance in it. The RT reported the resident has been prone to pneumonia in the past. An observation was conducted on 10/11/23 at 6:00 a.m. of Staff T, Licensed Practical Nurse (LPN) completing trach care for Resident #102 while assisted by Staff N, RN and the Director of Nursing (DON). Staff T, LPN confirmed the resident was receiving 6 liters per minute (lpm) of oxygen. The observation identified the split gauze under the resident's trach was colored with brownish/cream-colored substance and the end of the inner cannula was stained with the same colored substance. During the treatment the resident became agitated. The DON reported to the ADON, who had arrived, the resident was having heavy secretions. Staff T, LPN cleaned the area around the trach with sweetened gauze, placed new ties, and applied a split gauze under trach. The suction container on the resident's dresser held approximately 200 mL (milliliters) of a creamy non-frothy liquid. The resident coughed and frothy cream-colored liquid was observed in the inner cannula. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 14 of 24 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 10/12/2023 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 The Regional Nurse Consultant (RNC) reported on 10/11/23 at 7:54 a.m., of observing Resident #102's tracheostomy yesterday (10/10/23). The RNC stated education had begun on trach care. A review of Resident #102's admission Record revealed the resident was readmitted on [DATE]. The record included diagnoses not limited to unspecified respiratory failure unspecified whether with hypoxia or hypercapnia, unspecified chronic obstructive pulmonary disease, and unspecified encephalopathy. A review of the October 2023 Order Summary Report for Resident #102 included the following physician orders: - Change suction canister every 72 hours and/or when three quarter full as needed (start date,10/5/23). - Change suction canister every 72 hours and/or when three quarter full, every night shift every three days (start date, 10/5/23). - Change trach collar, mask, and oxygen weekly as well as needed (PRN). (start date 10/6/23) - Change trach collar, mask, and oxygen weekly as well as PRN every night shift every Friday (Fri), Sunday (Sun) for a preventive measure. (start date, 10/6/23) - Humidified oxygen per trach continuously 4 liters every shift for shortness of breath (start date, 10/10/23). -Trach: Suction trach, post record amount of secretions characteristics of secretion: (Color, Odor, Viscosity), Lung sounds, heart rate (HR), respirations, and tolerance as needed for preventive measure (start date, 10/5/23). - Tracheostomy Type: [name brand] size 8 Trach care daily and as needed. Cleanse tracheotomy site with normal saline (and) pat dry. Change inner cannula, cover with drain sponge daily, and as needed for trach care (start date, 10/6/23). - Tracheostomy Type: [NAME] size 8 Trach care daily and as needed. Cleanse tracheotomy site with normal saline (and) pat dry. Change inner cannula, cover with drain sponge daily, and as needed, every night shift for trach care (start date, 10/6/23). A review of Resident #102's Treatment Administration Record (TAR) for October 2023 revealed the resident's inner cannula and drain sponge was changed on the night shift of 10/6, 10/7, 10/8, and 10/9/23. The TAR did not identify the resident's trach collar or mask had been changed as needed despite the observed soiling on 10/10/23. The TAR did not reveal Resident #102's inner cannula had been changed or the area had been cleaned as needed and did not identify the resident had received suctioning with record of the characteristics of the secretions prior to the observation of the resident on 10/10/23. The care plan for Resident #102 included a focus identifying the resident had a Tracheostomy with a history of respiratory failure, hypoxia, and pneumonia. The resident's goal was documented as the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 15 of 24 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 10/12/2023 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 resident would have no signs/symptoms (s/sx) of infection through the review date and would have no abnormal drainage around trach site through the review date of 12/11/23. The interventions instructed staff to monitor/document restlessness, agitation, confusion, increased heart rate (Tachycardia), and bradycardia. The request for the facility's policy for Tracheostomy care resulted in receiving a copy of Tracheostomy Suctioning Competency Skills Checklist and Tracheostomy Care Competency Skills Checklist. The Skills checklist instructed staff: - If applicable due to soiling replace trach ties before using flanges, one side at a time keeping the trach secure. Ties should be no more than one to two finger space (s) between tie and the residence neck. - Document procedure and all observations. On 10/12/23 at 3:44 p.m. the Director of Nursing (DON) stated the expectation (for trach care) was if visually dirty for staff to change it out. The DON reported sometimes the facility has residents who have a large amount of sputum but for staff to clean the area and the facility encourages residents to cough instead of suctioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 16 of 24 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 10/12/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed and two errors were identified for two residents (#59 and #14) of six residents observed. These errors constituted a 7.14% medication error rate. Residents Affected - Few Findings included: 1. On 10/10/23 at 8:15 a.m., an observation of medication administration with Staff K, Licensed Practical Nurse (LPN) was conducted with Resident #59. Staff K dispensed the following medications: - Metformin 1000 milligram (mg) tablet - Buspirone 10 mg tablet - Fludrocortisone 0.1 mg tablet - Lisinopril 20 mg tablet - Celecoxib 100 mg capsule - Potassium Chloride Extended Release 20 milliequivalent tablet - Zoloft 50 mg tablet. Immediately following the dispensing of the medications and prior to entering the resident room to administer them Staff K confirmed seven tablets/capsules had been dispensed. A review of Resident #59's Medication Administration Record (MAR) for October 2023 identified the resident was to receive Pristiq 100 mg Extended Release tablet at 9:00 a.m., the same scheduled time as the above medications. The MAR revealed Staff K documented the resident had received the scheduled 9:00 a.m. dose of Pristiq. The Medication Administration Audit Report identified Staff K documented Pristiq was administered at 8:24 a.m. and documented at 8:31 a.m., along with the observed medications. 2. On 10/10/23 at 8:25 a.m. an observation of medication administration with Staff R, Registered Nurse/Unit Manager (RN/UM) was conducted with Resident #14. The staff member dispensed the following medications: - Aspirin chewable 81 mg tablet over-the counter (otc) - Divalproex Sodium Delayed Release 500 mg tablet - Cymbalta 20 mg DR capsule - Ferrous Sulfate 325 mg tablet otc - Fludrocortisone 0.1 mg tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 17 of 24 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 10/12/2023 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 0759 - Levetiracetam 1000 mg tablet Level of Harm - Minimal harm or potential for actual harm - Memantine Hydrochloride 10 mg tablet - Lactulose 10 gram/ 15 milliliter (gm/mL) - 30 mL liquid Residents Affected - Few - Acetaminophen 325 mg tablet otc. Immediately following the dispensing and prior to entering Resident #14's room, Staff R confirmed eight tablets/capsules and one liquid (medication) had been dispensed. The staff member entered the resident's room and administered the medications. A review of Resident #14's Medication Administration Record (MAR) for October 2023 revealed a physician order for Acetaminophen 325 mg - Give 2 tablets by mouth every 6 hours as needed for pain. The MAR identified Staff R dispensed Acetaminophen 2 tablets for the resident at 8:30 a.m. on 10/10/23. The observation identified Staff R, RN dispensed 1 tablet of Acetaminophen. The policy titled, Medication Administration General Guidelines, dated 09/18, showed Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices, and only by the persons legally authorized to do so. Personnel authorized to administer medications do so only after they are familiarized themselves with the medication. The Medication Administration and Documentation procedures included: - Medications are administered in accordance with written orders of the prescriber. - The individual who administers the medication dose, records the administration on the residents MAR immediately following the medication being given. On 10/12/23 at 3:29 p.m. the Director of Nursing stated the expectation was that medications be given as ordered by the provider. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 18 of 24 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 10/12/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure one resident (#92) of thirty four sampled residents received a breakfast meal tray as ordered to meet nutritional needs during one meal (10/10/2023) of three meals observed. Findings included: Resident #92 resides in the dementia unit of the facility and requires continual supervision. On 10/10/2023 at 8:00 a.m. Resident #92 was observed in her room, seated in a chair, and had just received her breakfast meal tray from Staff D, Certified Nursing Assistant (CNA). Staff D placed the tray on the over the bed table and set it up for Resident #92 to start eating. Staff D, CNA sat down next to the resident and attempted to assist with her meal. Resident #92 got up and began to ambulate around the room. Staff D attempted to coerce Resident #92 to sit and eat but the resident continued to walk away. An interview was conducted with Staff D, CNA on 10/10/2023 at 8:00 a.m. Staff D provided the meal ticket for review which and revealed the following: 10/10/2023 Breakfast - Regular Diet, Regular Texture, Large Portions to include: 1 Hard Boiled Egg, 2 oz. (ounces) Ham, 6 oz. Fortified Oatmeal, 1 Blueberry Muffin, 4 oz. Juice, 8 oz. coffee, 8 oz. 2% milk. Observation of the meal tray showed the following: 1 Hard Boiled egg, 1small slice of breakfast ham, 1 blueberry muffin, 6 oz. Fortified Oatmeal, 1 ice cream cup, and 8 oz. carton of whole milk. Resident #92 did not receive the large portioned meal, or the 2% milk. Photographic evidence was taken. Staff D confirmed the resident had not received a large portion of meat and received whole milk instead of 2% milk. She stated she would notify the kitchen of the error. She stated she should have reviewed the slip better when setting up the tray for Resident #92. On 10/10/2023 at 8:16 a.m. the Dietary Manager (DM) arrived on the 300 unit and presented a new breakfast tray for Resident #92. He stated the tray was just brought up from the kitchen with the correct diet order for Resident #92. He stated Resident #92 should not have received whole milk and she should have received large portions for breakfast which included two hard boiled eggs not one. The tray consisted of a large portion of scrambled eggs, a slice of ham, and a 2% carton of milk. The DM stated it is the cook and the line aide's responsibility to review the tickets prior to plating and both should have ensured the resident received the appropriate diet order. He stated it was his responsibility to routinely audit the meal tickets to ensure residents are receiving the right order and receiving their preferences. The DM stated staff on the 300 hall should also check the meal tickets when taking the tray out from the tray cart. On 10/11/2023 at 11:00 a.m. an interview with the 300 Unit Manager revealed she normally reviews all the meal tickets when the tray cart arrives on the floor, and she does not let the aides take the trays unless the trays are checked against the meal ticket. She revealed she was not available (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 19 of 24 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 10/12/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few during the breakfast meal service on 10/10/2023 and did not know if there was a nurse supervisor reviewing the meal tickets. She stated all floor staff are trained and in-serviced to make sure they review the meal tickets and ensure the meal trays reflect what is on the tickets. A review of Resident #92's medical record revealed she was admitted to the facility on [DATE], with a diagnoses to include but not limited to: Encephalopathy, Convulsions, Anemia, Altered Mental Status, Schizophrenia, Major Depression, and Dementia. A review of the Advance Directives revealed the resident had a Power of Attorney to make her medical and financial decisions. A review of the weight log for Resident #92 revealed she had recent weight loss to from 7/6/2023 at 80 lbs. to 8/7/2023 at 74 lbs. Resident #92 had a history of losing weight, and a history of poor eating consumption. A review of the current Physician's Order Sheet for the month of 10/2023, revealed the following: 1. Medpass QID (four times a day) 1 carton PO (by mouth) as supplement. 2. Regular Diet, Regular texture, Regular thin liquid - Fortified Foods, large entrees with meals. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the following: Section C: Cognition-Brief Interview Mental Score (BIMS) score - 1 of 15, which indicated severe cognitive impairment. Section G: Functional Abilities-Activities of Daily Living (ADL) - EATING = Extensive Assistance with one-person physical assistance; Nutrition - Has had 5% or 10% wt. loss last 6 months. A review of the Nutritional Risk Evaluation, dated 8/22/2023, revealed the following; Regular Diet, Regular texture, thin liquid, large entrees. Supplement to include Fortified foods with meals, magic cup, mighty shake with meals, med pass 1 carton QID. A review of the Nutritional Risk Evaluation, dated 9/19/2023, revealed the following: Regular Diet, Regular texture, thin liquid, large entrees. Supplement to include Fortified foods with meals, magic cup, mighty shake with meals, med pass 1 carton QID. A review of the comprehensive care plan, next review date 1/30/2024, revealed the following problem areas: (a.) Has a nutritional problem or potential nutrition problem related to diagnoses Altered Mental Status, Dementia, Catatonic disorder, Increased activity level due to excessive ambulation, History of significant weight changes, BMI underweight category with interventions in place to include: Assist with meals as need, Fortified Foods, Weights as indicated, Allow adequate time to eat, Diet as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 20 of 24 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 10/12/2023 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 0803 ordered, Fluids as ordered, Offer substitutes if refusal. Level of Harm - Minimal harm or potential for actual harm (b.) ADL - Resident has an ADL self-care performance deficit Assist for thoroughness, weakness, may require more assistance than allowing staff to render, with interventions in place to include EATING = Supervision, EATING = Assist of 1 as need. Residents Affected - Few On 10/11/2023 at 1:40 p.m. an interview with the Registered Dietician (RD) and the Dietary Manager revealed Resident #92 had a current diet order to include Regular Diet, Regular consistency texture, and Regular thin liquids. They stated the resident was to receive a fortified diet to include large portions/entrees for all three meals. The Dietician stated Resident #92 has been ordered and receiving several other dietary supplements to include a magic up, Medpass, and other types of snacks to help increase her weight. The Dietician revealed Resident #92 had slowly been increasing her weight but has found its hard to keep the resident seated for a period of time to eat her meals as she is constantly up and walking around. The Dietician confirmed direct care staff are to assist her with her meals and to ensure she is consuming most to all of her meals. The Dietician and the Dietary Manager confirmed Resident #92 had received the wrong meal after viewing the photographic evidence. The Dietician stated the diet order/meal ticket is to include the type of diet, consistency of the food items, list of food items to receive, and if large portions or not, and any other pertinent information so the cook and dietary aides can ensure the resident receives the appropriate diet and food items. The Dietician confirmed both the line cook and the dietary aide plating should be reviewing each diet/meal ticket to ensure all residents receive what is ordered. The Dietary Manager confirmed when the tray cart arrives on the floor or in the dining room, there should be supervisory staff to review each tray and meal ticket to make sure the residents receive the correct meal. On 10/12/2023 at 3:00 p.m. the Nursing Home Administrator (NHA) provided the facility's policy titled Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, revision date September 2023, which revealed the following: Policy: 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. The overall care plan should be oriented towards: Addressing ways to try to preserve and build upon a resident's strengths, needs, personal and cultural preferences. Applying current standards of practice in the care planning process. Evaluating treatment of measurable objectives, timetables and outcomes of care, Involving the resident to have a role in care planning even if adjudged incompetent, and the resident's family and/or other resident representatives as appropriate to participate in the development and implementation of his/her person-centered plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 21 of 24 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 10/12/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to ensure clean and sanitary equipment in the one of one kitchen related to 1) the dishwashing machine not reaching optimum wash and rinse temperatures, and 2) the sanitizer solution not reaching the dishwashing machine by way of pump and tubing properly. Findings included: On 10/9/2023 at 9:30 a.m. a general tour of the kitchen was conducted with the Dietary Manager (DM) and the Registered Dietician (RD). The DM stated the kitchen had a Low temperature dish washing machine. He stated the staff run the machine three times a day, once after the breakfast meal, once after the lunch meal, and once after the dinner meal. He stated the machine has been running appropriately and has not had any recent repairs, other than routine maintenance provided by an outside contract company. The dish machine log was reviewed for 10/2023 and revealed daily wash and rinse temperatures as well as sanitizer Parts Per Million (PPM) logged each day with each meal service. The log revealed temperatures ranging over 120 degrees Fahrenheit (F) and 50 ppm of sanitizer. At 9:34 a.m. the dish machine room was observed with staff running crates of dishes, cups, and eating utensils through the machine. Staff A, Dietary Aide (DA) was observed running the crates of dishes through the machine. She stated the dishwashing machine was a Low temperature machine with wash temperatures to reach at least 120 degrees F., and the rinse temperatures to reach at least 120 degrees F. She stated once after each meal they test the machine for temperatures as well as the sanitizer range. She stated she uses a litmus paper test strip after running a crate of dishes through the machine and places the litmus test strip on water drops on the dishes. She stated the litmus paper test strip must turn color and meet the 50 -100 PPM range. An observations of the right side of the machine and below the assembly unit revealed the specifications plate, which indicated the machine was a LOW temperature machine with wash 120 degrees F., rinse 120 degrees F., and Sanitizer to be 50 - 100 ppm. At 9:37 a.m. Staff A was asked to run a crate of dishes through the machine to demonstrate how it was operating, with the DM and RD present. The demonstration revealed the following: Wash cycle reached no more than 115 degrees F., after the wash cycle the machine clicked and the rinse cycle began. The rinse cycle only reached 119 degrees F. Since the machine did not reach it's optimal and required wash and rinse temperatures, the sanitizer test strip was not demonstrated. A second demonstration was conducted at 9:38 a.m. and revealed the following: Wash cycle reached no more than 119 degrees F., and the rinse cycle reached barely 120 degrees F. Staff A, DA took a sanitizer litmus paper test strip and placed it on the cleaned dishes. The paper stayed a color of white and did not change to meet the color requirement, revealing the sanitizer did not reach 50 - 100 ppm. Photographic evidence was obtained. Staff A, DA and the DM confirmed the machine did not reach required temperatures and the sanitizer must not have reached the machine properly, leaving the litmus test strip white in color. An interview with Staff A was conducted and she stated she had already ran about five crates of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 22 of 24 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 10/12/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many dishes through the machine prior to doing the demonstration. Staff A stated the machine had already been heat primed prior to running the crates of dishes through. A third demonstration was conducted at 9:41 a.m. and revealed the following: Wash cycle reached no higher than 117 degrees F., and the rinse cycle reached barely 120 degrees F. Staff A placed a sanitizer test strip on the crate of dishes and the test strip remained white in color. The DM confirmed the observation. A fourth demonstration was conducted at 9:50 a.m. and revealed the following: Wash cycle reached no higher than 105 degrees F., and the rinse cycle barely reached 120 degrees F. Staff A placed a sanitizer test strip on the crate of dishes and the test strip remained white in color. The DM confirmed the observation. The RD stated she believed a switch button labeled fill on the top of the machine needs to be pressed a few times in order to cycle the hot water through. The DM agreed and he pressed the button several times and then ran the machine which revealed the following: Wash temperature barely reached 120 degrees F., and the rinse cycle barely reached 120 degrees F. The DM placed a sanitizer test strip on the crate of dishes and the test strip remained white in color. The DM confirmed the observation. The DM and RD stated they did not know how many times staff needed to press the fill button during washing. Staff A, DA stated she did not know how to press the button to cycle hot water through. The DM stated the dish machine was maintained from an outside sourced company who was in several weeks ago and no problems were identified. On 10/11/2023 at 11:40 a.m. the DM stated the maintenance company had been out to service the dishwashing machine in the afternoon of 10/9/2023. A demonstration of the dish washing machine was conducted on 10/11/2023 at 1:36 p.m., and revealed the following: Staff B, DA and C, DA ran a load of dishes through the machine. Wash temperature reached 115 - 118 degrees F., and the rinse temperature reached over 120 degrees F. The DM pushed the button switch on the top of the dish machine that read Fill, and he stated the button resets and brings more hot water to the machine. An interview with the Staff B and Staff C was conducted. The DA's stated they did not press this button and felt the machine was operating properly just minutes before the surveyor came into the kitchen. At 1:41 p.m. another observation was conducted and revealed the following: Wash temperature revealed 118 - 119 degrees F., and the rinse cycle temperature reached just over 120 degrees F. The DM pressed the fill switch/button several times and ran the crate of dishes again. At 1:43 p.m. the Wash temperature reached now at 120 degrees F., and the Rinse cycle reached over 120 degrees F. A sanitizer test strip was demonstrated to have sanitizer Parts Per Million (PPM) reading between 50 and 100. On 10/12/2023 at 10:00 a.m. the Nursing Home Administrator provided the dish washing machine's operation manual for review. The manual revealed the machine was an ES = Door type, Chemical Sanitizing 2000 = Single rack dish machine and 4000 = Dual rack dish machine. Section 1: Specification Information, page 2, revealed; Wash pump capacity at 61 gallons per minute, Wash temperature to be 120 degrees F. minimum and Rinse temperature to be 120 degrees F. minimum. The water requirements revealed 50 Parts Per Million (PPM) were required for minimum chlorine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 23 of 24 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 10/12/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 10/12/2023 at 10:00 a.m. the Nursing Home Administrator provided the policy titled Dish Machine Temperature Log, effective date of January 2021, which revealed the following: Policy: To Monitor dish machine temperatures and chemical saturation (parts per million [PPM] for both high and low temperature machines at each meal prior to dishwashing to assure proper cleaning and sanitizing of dishes. Procedures: 1. Record month and year at the top of the form; 2. Send an empty dish rack through the dish machine prior to recording the temperature, a. This allows the water to reach appropriate temperatures, b. May take 3-4 times; 3. Record wash and rinse temperatures under appropriate meal column and initial; 4. Record chemical saturation level by indicating PPM using the appropriate litmus; 5. Report discrepancies from standard temperatures and chemical saturation to the Food Service Manager. On 10/12/2023 at 10:00 a.m. the Nursing Home Administrator provided the policy titled Cleaning and Sanitation, effective September 2021, which revealed the following: Policy: The facility promotes a clean and sanitary environment for its employees, residents, and visitors. The entire Food and Nutrition Services team maintains clean and sanitary kitchen facilities and equipment. Walls, floors, ceiling, equipment and utensils are clean, sanitized and in good working order. Local, State and Federal regulations are followed to assure a safe and sanitary Nutrition Services Department. Procedures: 7 Follow appropriate procedures for washing and sanitizing kitchen equipment; #8 Wash dishes in: (c.) Low Temperature dish machine per manufacturer guideline plate or at 120 degrees F. wash and rinse while maintaining the appropriate chemical saturation of 50 ppm (parts per million) or dish surface in final rinse (or in accordance with State regulation); #9 Record dish machine temperatures and chemical saturation ppm three times daily using the Dish Machine Temperature Log to ensure dishes are sanitized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 24 of 24