Inspection·January 24, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Review of Resident #3 Electronic Medical Record (EMR) showed no progress notes related to misappropriation or grievance filed in November 2023. A review of the Grievance Log from November 2023 through January 2023 revealed no grievances filed for Resident #3. Residents Affected - Few Review of the Grievance Concern Management provided by the DON on 1/17/2024 with an effective date of February 2021 revealed: Residents/representatives have the right to present concerns on behalf of themselves, and/or others to the staff and/or administrator of the facility, to government officials, or to any other person. The concern may be filed verbally or in writing, and the reporter may request to remain anonymous. The Grievance Procedure Policy was reviewed and showed points 1-13 which included: Point #1, the facility will make resident/resident representative aware of grievance process, location of grievance forms, ombudsman information and location (admission booklet) have all numbers and emails used to addressed grievances. Point #2, The facility will prominently display a poster that includes the following: 1. Contact information of the Grievance Official to include his/her name, business address (mailing and email address), and business phone number. 2. A reasonable expected time for completing a review of the concern. 3. The right to obtain a written decision regarding the concern. 4. Reference to independent entities with whom concerns may be filed. Point #6 The department involved will document the concern and record the resident/resident representative's satisfaction with the resolution to the concern. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 2 of 45 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 01/24/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review the facility failed to protect residents' right to be free from neglect related to not ensuring cardiopulmonary resuscitation (CPR) was provided according to policy and procedure for one resident (#1) out of three reviewed for the CPR process; not performing laboratory tests and not following up on critical lab results for two residents (#11 and #13) out of three reviewed for lab testing and not ensuring treatment and care was in place for one resident (#11) out of three reviewed for an immune deficiency syndrome. These failures created a situation that resulted in a worsened condition and/or the likelihood for serious injury and or death to Residents #1, #11, and #13 and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: 1. Not ensuring cardiopulmonary resuscitation (CPR) was provided: Staff M, Nurse was interviewed at 3:00 pm on [DATE] and stated Staff L, Nurse was performing CPR on Resident #1 during the code on [DATE]. Staff M, Nurse called this surveyor at 3:52 p.m. on [DATE] and said, my conscious got to me. She said she was downstairs and heard the code called. She said she walked fast to get to the 300 unit. She said it was about 5 minutes after the code was called, she got to the unit, and no one was doing compressions on the resident. She said EMS had not yet arrived at the time she got to the room. She said the primary nurse usually starts compressions and other nurses come up and help. Staff M said the resident was lying on the floor with her head towards the foot of the bed and her legs were underneath her. She said it looked like she had been standing and collapsed with her legs under her. She said in that position it would have been difficult to do compressions. Staff M said, I was in shock no one started compressions. She said she didn't know if they were looking for a Do Not Resuscitate (DNR) order or what. Staff M said there were a lot of people in the room, and no one was doing CPR. She said they were just like staring. She said prior to her leaving the room, Staff K, Nurse was getting oxygen for the resident, but she didn't know what that was going to do when she wasn't breathing. She asked the nurses if they needed help and they said no, so she left the room. Technically, there's no formal definition for a code, but doctors often use the term as slang for a cardiopulmonary arrest happening to a patient in a hospital or clinic, requiring a team of providers (sometimes called a code team) to rush to the specific location and begin immediate resuscitative efforts. https://www.webmd.com/a-to-z-guides/code-blue-code-black-what-does-code-mean An interview was conducted on [DATE] at 2:27 p.m. with the Emergency Services Paramedic. She said their unit arrived at the facility first after receiving a 911 call for cardiac arrest. When they arrived at the resident's room, there were two male staff members sitting on the bed, while the patient was lying on the floor. One female staff member was by the crash cart and one by the doorway. The Paramedic said, They were basically watching the resident lying on the floor. She said CPR was not being performed on the resident. The Paramedic said one nurse was messing with the suction on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 3 of 45 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 01/24/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some cart, but nothing was open from that cart. The Paramedic said no one identified themselves as a nurse or a CNA. The Paramedic said no one was doing compressions, suctioning the resident, or providing oxygen to the resident. The Paramedic said, I was mind blown. The Paramedic said she asked staff to do compression while they (emergency services team) set up their equipment and got medications out because there were only two responders on the first unit to arrive. The Paramedic said she had to ask multiple times for staff to help and for someone to do compressions. She said one male started doing compressions and he put his hands in completely wrong placement, hit her chest three times and stood up and looked at them. She told the male she needed him to keep going so he did three more compressions. She said the male was in a hoodie, but she did see him in the nurses' station prior to leaving the facility so she assumed he was staff. The male did three more compressions the Paramedic said she spoke up and asked someone else to do compressions because the male was doing it incorrectly. She said a female said, I ain't doing it, and walked out of the room. She said the second male, a tall white gentleman, had been fumbling with the suction machine. He had the suction tubing but no suction attachment on the end, such as a flexible tubing or yankauer (rigid oral suctioning tool.) The Paramedic said the male was attempting to suction the resident, but it wasn't doing anything since he did not have an attachment on the tubing. The Paramedic said after the female staff member said she wasn't doing compressions, the second EMS (Emergency Medical Services) unit arrived, and they took over. The Paramedic said staff didn't know if the resident had been down a while or not, no one could say. She said EMS responders do compressions and work on the resident until cardiac pads are on and heart rhythm can be verified. The Paramedic said the resident was not obviously deceased when they arrived. An interview was conducted on [DATE] at 12:31 p.m. with an Emergency Medical Technician (EMT). The EMT confirmed she came to the facility on the call for Resident #1 on [DATE]. The EMT said when she walked in the room two male staff were sitting on the bed bending over trying to figure out the suction. She said there was a cart with suction and oxygen and staff were trying to figure that out. The EMT said no one was doing compressions. She said the Paramedic on scene had to ask multiple times for someone to get on the chest. The EMT said one male staff member started compressions, but he wasn't doing it correctly. She said there were only two responders at the time, and they needed the staff to assist while they set up. She said the Paramedic was good at dealing with the staff and wasn't rude, but she was frustrated because she was having to ask multiple times for them to do their job. The EMT said she was trying to get the monitor set up and on the patient. She said when the 911 call was made it came in as CPR in progress and all the staff should know how to do CPR. The EMT said after the male had been asked to do compressions the Paramedic asked for someone to take over, then the second crew arrived, and they took over CPR from staff. An interview was conducted on [DATE] at 5:26 p.m. with an EMS Field Supervisor. He said he received a report from his Paramedic on Monday, [DATE], about the call they received to the facility. He said the Paramedic wrote an incident report regarding arriving at the facility and CPR not being performed on the resident when they arrived. He said he wanted to go talk to management at the facility to see what happened. He said the visit was more of a fact-finding mission. The EMS Field Supervisor said he spoke with the DON on [DATE] and she said she wasn't even aware Resident #1 had a cardiac arrest. He said he told her what happened and what the Paramedic witnessed. He said the DON told him it was probably CNAs in the room, and they are not trained to do CPR and are not allowed to do CPR in the facility. A review of Resident #1's medical record revealed a progress note, dated [DATE] at 5:29 p.m. by Staff I, Nurse, the nurse assigned to the resident. The note showed CNA [Certified Nursing Assistant] notified nurse resident was on floor in room. Nurse observed resident without respirations or pulse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 4 of 45 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 01/24/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Code status verified. Code blue called. CPR initiated and continued until EMS arrival whom took over care. EMS notified. Resident pronounced deceased at 3:10 p.m. Review of admission Records showed Resident #1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, schizoaffective disorder, bipolar type, epilepsy, anxiety disorder, Alzheimer's disease, disease of pancreas, hypothermia, and chronic obstructive pulmonary disease (COPD). Resident #1 expired on [DATE]. Review of an Order Summary Report for Resident #1 revealed an active physician order for Full Resuscitation, order date [DATE]. An interview was conducted on [DATE] at 3:58 p.m. with Staff J, CNA. Staff J, CNA said she was just coming on her shift at about 2:45 p.m. She said she clocked in and got up to the unit just before 3:00. Staff J, CNA said she came up the back stairs and circled the unit before going to the nurses' station and when she came around the corner Staff K, Nurse and Staff I, Nurse were standing at the nurses' station directly across from Resident #1's room and both doors were open. Staff J, CNA said she and another staff member walked up at the same time and the other staff member looked in the room and said a resident had fallen. Staff J, CNA said she quickly set her things down and ran into the room. She said you could see the resident's hair on the floor from the hall. She said the resident was lying on her back and had some vomit/fluid on her face. She said she called out Resident #1's name a few times and the resident didn't respond. Staff J, CNA said she ran out the door and told Staff K, Nurse and Staff I, Nurse the resident was unresponsive and needed help. Staff J, CNA said both nurses looked at me like I was dumb and Staff I, Nurse said are you joking? She said Staff K, Nurse went in Resident #1's room and Staff I, Nurse came two minutes later. Staff J, CNA, said she went into the room to try to help but the nurses told her to leave. She said she did see Staff K, Nurse start CPR but does not know if it continued because she was told to leave. Staff J, CNA said there were 2 male nurses in the room (Staff K, Nurse and Staff L, Nurse) and 3 female Nurses (Staff I, Nurse and two nurses from downstairs.) An interview was conducted on [DATE] at 3:28 p.m. with Staff K, Nurse. He said he was coming in to work on [DATE] for the 3:00 p.m. shift. He said around 2:50 p.m. Staff J, CNA came and said Resident #1 was on her back and didn't look good. He said he went to the room and the resident was lying on her back with her head towards the bathroom door and wasn't breathing at all. He said one of the CNAs grabbed the resident's chart and Staff I, Nurse checked her code status. Staff K, Nurse said a CNA grabbed the emergency cart and he started CPR on the resident. Staff K, Nurse said Resident #1 was still warm. He said he didn't know what happened, but it looked like it just happened to me. He then said Staff I, Nurse brought the emergency cart in with her and used the AMBU bag (a bag valve mask that is used to deliver positive pressure ventilation) to give breaths to the resident and he did compressions. Staff K, Nurse said Staff L, Nurse came in to help and took over the AMBU bag from Staff I, Nurse. Staff K, Nurse said next, he and Staff L, Nurse switched places while Staff I, Nurse did paperwork. He said EMS came quick, but he was disappointed they didn't take over when they showed up. He said the female responder told him to keep doing compressions. He said two more emergency responders came into the room and they told us to continue CPR. Staff K, Nurse said EMS never did chest compressions. He said he was doing compressions when EMS walked in the door and only stopped when they told him to. He said EMS was sticking needles in her and sticking patches on and he thought it was unusual they didn't take over. He said EMS was only there about 5 minutes that's it. She was gone. He said he doesn't remember who all was in the room besides Staff I, Nurse and Staff L, Nurse but he does know the weekend supervisor (Staff N, Nurse) came up at some point. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 5 of 45 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 01/24/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some An interview was conducted on [DATE] at 10:26 a.m. with Staff N, Nurse, the weekend supervisor. She said she was not in the facility when Resident #1 coded. She said she left the facility between 11:00 a.m. and 12:00 p.m. that day. Staff N said there was no supervisor at the facility during the event and staff should have notified the ADON or DON. A follow-up interview was conducted on [DATE] 3:22 p.m. with Staff K, Nurse. Staff K said when the CNA called him to the room Resident #1 was lying on the floor unresponsive. He said he assessed the resident and went out to the nurses' station and got her chart to confirm her code status. He said the CNA stayed in the room while he went to the nurses' station, but the CNA did not do any CPR. He said Staff I, Nurse was sitting at the nurses' station and she called a code blue. Staff K then said he grabbed the emergency cart and took it in the room. He said he did a mouth sweep of the resident and that is when Staff L, Nurse got to the resident's room. He said Staff L, Nurse and himself did CPR on Resident #1. Staff K said Staff L, Nurse got there immediately and the two of them did the whole thing. No other nurse helped out. He said no one else performed compression and if anyone else told you something different that is totally incorrect. When asked who else was in Resident #1's room assisting with the code, Staff K said, I can't tell you. I didn't look around. An interview was conducted on [DATE] at 3:17 p.m. with Staff I, Nurse. Staff I said on [DATE] she worked the 7:00 a.m. to 3:00 p.m. shift. She said Resident #1 coded at shift change. She said she believed it was Staff J, CNA who let her know the resident needed help, but she doesn't remember her exact words. She said Staff K, Nurse checked on the resident while she checked the resident's code status. Staff I confirmed Resident #1 was a full code. She said Staff K, Nurse started CPR and another male nurse was in the room, but she didn't know what that nurse was doing. Staff I said she didn't know if there were any CNAs in the room. Staff I said, I believe he did CPR until EMS arrived. Staff I said she wasn't in the room; she was calling 911 and doing paperwork. She said the other nurses had the emergency cart in the room. Staff I said she did go in the room at some point but doesn't remember when. She said she was doing paperwork and calling 911. She said when EMS arrived, I handed off the paperwork and stepped out. Staff I said EMS did not ask her to assist with CPR. She said they came in and took over. Staff I said the resident was assigned to her that day. She said she saw her just before lunch and the aides said she was in the dining room and lunch ended around 2:00-2:15 p.m. A follow-up interview was conducted on [DATE] at 3:49 p.m. with Staff I, Nurse. She said she confirmed the resident was a full code. She said when she went in the room Staff K, Nurse was doing compressions and Staff L, Nurse was giving the resident breaths, I did not pay any attention to if another nurse was on the floor. I saw [Staff K, Nurse] and [Staff L, Nurse.] Did not see another nurse hands on. When asked who was at the code cart Staff I stated, I was not paying attention to that. When ask if there were just a few people in the room or a lot of staff she said, I don't know how many people were in there. Staff I said she was not documenting and did not know who filled out the Code Blue Worksheet. She said she did not stay in the room. An interview was conducted on [DATE] at 4:29 p.m. with Staff L, Nurse. Staff L said he came in to work on [DATE] for his 3:00 p.m. shift. He said he heard the code called and went upstairs to help on the 300 unit. He said when he arrived Staff K, Nurse was assessing the resident and Staff I, Nurse was prepping the emergency cart. Staff L said he thinks there were some CNAs in the room too. He said Staff K, Nurse started CPR and I think I took the AMBU bag when Staff I, Nurse was taking it off the cart. He said, I might have taken over compressions then switched to the AMBU bag. That's probably what happened. Staff L said Staff K, Nurse was doing CPR on his own while everything was getting set up. He said a lot was going on, but they probably did 6 rounds of 15 compressions and 2 breaths (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 6 of 45 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 01/24/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some before EMS got there. Staff L, Nurse said they were still following through with compressions when EMS got to the room. He said EMS wanted compressions to continue but said the nurse should stop using the AMBU bag. He said he didn't know why and maybe it was some new protocol. He said when the second EMS unit arrived, they took over compressions on Resident #1. Staff L said he does remember the female EMS responder talking about Staff K, Nurse not doing compressions correctly and could we get someone else to do it. He said, I think they were just upset about us doing the AMBU bag. Staff L said Staff I, Nurse was in the room when EMS arrived because he remembers going to stand in the corner with her. He said she was in the room pretty much the whole time. He said CPR was being done during the time I entered the room. I think it continued on until EMS took over. Staff L said they did roll the resident on her side to suction fluids in her mouth. He said he suctioned her once and Staff K, Nurse suctioned her once. Staff L said he and Staff K, Nurse were never just sitting on the bed, but he said he did sit on the bed at some point while he was using the AMBU bag on the resident. He said only he and Staff K, Nurse did compressions on the resident. He said no one else did compressions or helped position the resident. A follow-up interview was conducted on [DATE] at 10:50 a.m. with Staff L, Nurse. Staff L said when he got to Resident #1's room there were people in the room, but he did not know them because he has worked in the facility for less than a month. He said Staff K, Nurse initiated CPR, the resident was being assessed, and Staff K, Nurse was checking her pulse. He said Staff I, Nurse handed him the AMBU bag off the emergency cart. Staff L said he took over chest compressions and he and Staff K, Nurse switched between doing compressions and breaths and there was no one else assisting with CPR. He said at one point he was sitting on the bed while he was suctioning Resident #1. He said when EMS arrived, they told Staff K, Nurse to continue with compressions and Staff L, Nurse said he went and stood in the corner of the room beside Staff I, Nurse. He said one of the responders was rude to the staff and yelled about them not doing things right. He said, She was adamant and making comments like can someone else do this, does anyone know how to do this. I did not think much of it. An interview was conducted on [DATE] at 11:10 a.m. with Staff O, Nurse. She said she worked from 7:00 a.m. to 3:00 p.m. on [DATE] and responded to a code on the 300 unit. Staff O said the code was called three times over the speaker to Resident #1's room. She said when she got upstairs there were already quite a few people that had responded. Staff O, Nurse said when she got to Resident #1's room Staff K, Nurse, Staff L, Nurse, Staff P, Nurse, and Staff M, Nurse were there and Staff I, Nurse was on the phone. Staff O said the resident was lying on the floor and the emergency cart was in the room. She said Staff K, Nurse was on the lower end of the resident, Staff L, Nurse was on the top end of the resident, and Staff P, Nurse was grabbing supplies. Staff O said she grabbed the AMBU bag for Staff L, Nurse and Staff K, Nurse started compressions. She said she got on the floor and helped position the resident and tilt her head to get air. Staff O said Staff I, Nurse came back in the room and confirmed resident was a full code. She said Staff M, Nurse came in and asked if 911 had been called and asked if she could do anything to help. Staff O said at one point she took over compressions on Resident #1 from Staff K, Nurse to give him a break. She said Staff L, Nurse was doing the AMBU bag and Staff P, Nurse was grabbing supplies and paperwork. Staff O said EMS arrived and the staff continued CPR until EMS took over. She said the male responder took over compressions from Staff K, Nurse and a second EMS responder took over the AMBU bag from Staff L, Nurse. She said they were not asked to stop using the AMBU bag, they continued until EMS took it over. She said she was always taught to not stop CPR until EMS arrives and takes over. She said when EMS arrived, they could see that the staff were doing CPR. Staff O said while CPR was being done there was a little mucous/discharge that came to the resident's mouth so Staff I, Nurse grabbed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 7 of 45 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 01/24/2024 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 0600 suction and Staff K, Nurse suctioned the resident only one time. Level of Harm - Immediate jeopardy to resident health or safety A follow-up interview was conducted on [DATE] at 11:25 a.m. with Staff O, Nurse. Staff O said when she heard the code called, she ran to the room, grabbing gloves on her way. She said Staff I, Nurse was standing by the door of the nurses' station calling 911, the emergency cart was already in the room, and Staff K, Nurse, Staff L, Nurse, and Staff P, Nurse were already there. She said the resident was lying on the floor flat on her back. Staff O said Staff P, Nurse grabbed the AMBU bag off the cart and gave it to Staff L, Nurse. Staff O said she got down on the floor and held Resident #1's head in a tilt position, Staff K, Nurse was doing compressions, and Staff L, Nurse was giving breaths with the AMBU bag. Staff O said she yelled out to Staff I, Nurse and asked if EMS was coming because she was used to them responding faster. She said while Staff K, Nurse was doing compressions, she noticed there was some discharge in the resident's mouth and Staff L, Nurse said they needed to suction the resident. Staff P, Nurse was handing us supplies and Staff I, Nurse came back in the room grabbed the suction tubing, placed a yankauer catheter on the tubing and handed it to Staff L, Nurse, who quickly suctioned the resident and gave it back to Staff I, Nurse. Staff O said she switched with Staff K, Nurse and did compressions, but didn't do them for very long and she said she did not ever see Staff L, Nurse do any compressions. Staff O said they did not stop CPR and Staff K, Nurse was doing compressions when the first responders arrived. Staff O said the female medic told them to continue CPR and they didn't take over right away. She said Staff P, Nurse gave the medic the paperwork they needed, and the medic was asking their standard questions like how long the resident had been down. Staff O said a male responder arrived and took over compressions and another took over the AMBU bag. She said the female responder, who seemed to be the lead, was quite rude. Staff K, Nurse said to her, you don't have to be so [expletive] rude. She [the female responder] didn't respond. Residents Affected - Some An interview was conducted on [DATE] at 12:18 p.m. with Staff P, Nurse. Staff P said the code for Resident #1 was called right at the end of her shift, around 3:00 p.m. on [DATE]. She said by the time she arrived in the room; several other nurses were there. Staff P said she asked if they needed anything and did they already do things like check code status, call 911, etc. She said they told her they did not need anything. Staff P said Staff I, Nurse, Staff, K, Nurse and Staff L, Nurse were in the room, but she did not remember if any CNAs were present. She said Staff K, Nurse was doing compressions, she doesn't remember seeing if anyone was giving breaths with the AMBU bag, and Staff I, Nurse was standing there, but Staff P doesn't know what Staff I, Nurse was doing. Staff P, Nurse said she helped get other residents from the hall to the dining room and said she did not help with any paperwork or handing off or gathering equipment. Staff P said she was not near the room when EMS arrived and was not in the room while EMS was there. A follow-up interview was conducted on [DATE] at 12:09 p.m. with Staff P, Nurse. Staff P, Nurse reiterated Staff K, Nurse was doing compressions and Staff L, Nurse and Staff I, Nurse were in Resident #1's room. She said Staff K, Nurse was the only person she knew was physically doing something. She said they all told her they didn't need anything. She confirmed she was not handing equipment or doing paperwork at any point and never went all the way into the resident's room. An interview was conducted on [DATE] at 12:36 p.m. with Staff Q, CNA. Staff Q, CNA said when the code was called on [DATE] for Resident #1 everyone went from the different units. She said CNAs do not perform CPR they just help keep other residents away from the area. She said Staff K, Nurse, Staff L, Nurse and Staff J, CNA were already there. Staff Q, CNA said she grabbed the emergency cart and she and Staff K, Nurse took it to the room. She said she didn't know if Staff K, Nurse had been in to assess the resident or not. She said Staff L, Nurse was next to arrive. Staff Q, CNA said she remembers hearing Staff K, Nurse talking about getting ready to do compressions, but didn't see who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 8 of 45 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 01/24/2024 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 0600 was doing CPR. Level of Harm - Immediate jeopardy to resident health or safety An interview was conducted on [DATE] at 1:24 p.m. with the DON. The DON said she wasn't working the day Resident #1 coded. She said Staff J, CNA found the resident and told Staff I, Nurse and Staff K, Nurse to come to the room because something was wrong with the resident. The DON said the resident wasn't breathing and did not have a pulse so Staff I, Nurse called the code. She said everyone went to the room and Staff K, Nurse started CPR after the code status for Resident #1 was verified. The DON said they continued CPR until EMS arrived and then EMS took over compressions. She said the resident was declared deceased at the facility. The DON said the people involved were Staff J, CNA, Staff K, Nurse, Staff L, Nurse, Staff I, Nurse, Staff O, Nurse, Staff M, Nurse, Staff N, Nurse/weekend supervisor, and two other CNAs (Staff Q, CNA and Staff R, CNA.) The DON said Staff K, Nurse and Staff L, Nurse are the two that did CPR and the rest got items needed for them or helped get other residents out of the hall. The DON said Staff K, Nurse did CPR and Staff L, Nurse assisted, Staff I, Nurse called the code and 911, Staff P, Nurse got items they needed during the code and Staff N, Nurse/weekend supervisor was directing people what to do and who needed to do what. The DON said Staff M, Nurse was helping get people out of the room. When asked when she was informed of Resident #1's cardiac arrest, she said Staff N, Nurse /weekend supervisor called her from the facility while it was occurring or shortly after. The DON was informed Staff N, Nurse/weekend supervisor was not in the facility and she said, She didn't call me? Am I getting people confused? The DON confirmed someone from the fire department came to speak with her the day after the incident and wanted to speak with her about the code for Resident #1. She said EMS had some questions about a female staff member not assisting in the code. The DON said she asked him for a name and the circumstances around what happened, and she said he told her the females that wouldn't help were CNAs. The DON said she told him the CNAs are not trained in CPR and do not do CPR in the facility. She said he understood, and said he did not mention CPR not being done when EMS arrived. Residents Affected - Some An interview was conducted on [DATE] at 3:10 p.m. with the DON. She said for a code blue she would expect there to be a nurse's note in the medical record to say what the scenario was. She said she wouldn't really expect the note to say who was involved or who did what. The DON said they have a Code Blue Worksheet that is filled out and is part of the medical record. At 3:30 p.m. the DON said she wanted to clarify that the Code Blue Worksheet is not part of the medical record. The Code Blue Worksheet for Resident #1 dated [DATE] was reviewed. The information on the sheet was incomplete and the times listed on the worksheet do not line up with the times EMS recorded as having received the 911 call and responded. The DON could not identify who filled out the Code Blue Worksheet provided. 2. Not performing laboratory tests: Review of the admission Records showed Resident #13 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease and epilepsy. Review of medical records showed Resident #13 had a care plan in place for Seizure Disorder, dated [DATE]. Interventions to include Obtain and Monitor lab/diagnostic work as ordered. Report results to doctor and follow up as indicated. Review of Resident #13's physician orders showed the following active orders: -Levetiracetam (Keppra) oral solution 100 milligram (mg) per milliliter (ml) Give 12 ml in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 9 of 45 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 01/24/2024 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 0600 evening for seizure, dated [DATE] Level of Harm - Immediate jeopardy to resident health or safety -Levetiracetam 100mg/ml Give 14 ml one time a day for seizures, dated [DATE], Residents Affected - Some Review of Resident #13's [DATE] Treatment Administration Record (TAR) showed the Keppra level lab was due on [DATE]. It was signed off on the TAR as completed. -Keppra level every 6 months starting on the 5th for 1 day, dated [DATE]. Review of the Facility Lab book that is kept at the nurses' station contained a Lab Monitoring Sheet, dated [DATE], showing Resident #13's Keppra level was to be drawn that day. The lab was not signed off by the phlebotomist as being drawn. There was no documentation on the Lab Monitoring Sheet or progress notes to indicate the resident refused the lab draw. Review of Resident #13's Quarterly Minimum Data Set (MDS,) dated [DATE], Section C, Cognitive Patters, showed he had a Brief Interview for Mental Status (BIMS) score of 3, indicating a severely impaired cognition. He was unable to be interviewed. An interview was conducted on [DATE] at 1:05 p.m. with Staff H, Nurse. Staff H reviewed the Lab Monitoring Sheet for [DATE] out of the lab book. She then logged into the laboratory company's website and confirmed the last lab for Resident #13 was drawn in [DATE]. Staff H reviewed Resident #13's physician orders and confirmed it should have been drawn on [DATE] and it was not completed and there was no documentation as to why. Staff H said this lab was scheduled to be drawn on a Saturday and the missed lab should have been caught when it was reviewed by management on Monday morning. 3. Not following up on critical lab results and not ensuring treatment and care for immune deficiency syndrome: Review of the admission records showed Resident #11 was initially admitted on [DATE] after a hospital stay for pneumonia and with diagnoses including pneumonia, immune deficiency syndrome, thrombocytopenia, and cirrhosis of liver and was re-admitted on [DATE], after a hospitalization for a gastrointestinal bleed. Review of medical records showed a Social Services note, dated [DATE] that said Resident #11 is alert and oriented and can make her needs known. The resident reported to Social Services she lived in shelters, and she would like to improve her health. Review of Resident #11's Psychosocial History and Assessment, dated [DATE], showed the resident was previously homeless, but said she was adjusting and felt safe in the facility. The resident's goals for her stay were to maintain her health and medications. The Assessment also showed the resident reported transportation had kept her from medical appointments or from getting medications. It also noted the resident was cooperative, pleasant, and motivated. According to a National Heart, Lung, and Blood Institute article titled, Thrombocytopenia, dated [DATE], Thrombocytopenia is a condition that occurs when the platelet count in your blood is too low. The article stated this can be life-threatening, especially if the patient had serious bleeding or bleeding in the brain, but early treatment could help avoid serious complications. The article (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 10 of 45 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 01/24/2024 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 0600 explains bleeding causes the main symptoms of thrombocytopenia with signs including bleeding that last a [TRUNCATED] Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 11 of 45 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 01/24/2024 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review the facility failed to ensure an allegations of neglect were reported related to not ensuring cardiopulmonary resuscitation (CPR) was provided according to policy and procedure for one resident (#1) out of three reviewed for the CPR process; not following up on critical lab results for one resident (#11) out of three reviewed for lab testing and not ensuring treatment and care was in place for one resident (#11) out of three reviewed for an immune deficiency syndrome. This failure created a situation that resulted in a worsened condition and/or the likelihood for serious injury and or death and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: On [DATE] at 2:14 p.m. after multiple requests for the facility to provide a list of incidents that had been reported in [DATE], the DON confirmed the facility had no reportable events in [DATE]. An interview was conducted on [DATE] at 2:46 p.m. with the DON. The DON said she did not hear there were any problems with the code for Resident #1 on [DATE]. She said no one reported anything to her. The DON said the fire supervisor came to visit her on [DATE] regarding concerns during the code blue for Resident #1 and he asked about the CNAs and their participation during the code, and she told him they are not certified in CPR and are only there to assist. The DON said he wanted to talk about two staff members not assisting in CPR and he said they were CNAs. When the DON was asked why the fire supervisor would take the time to make a trip to the facility to discuss two CNAs who did not participate in CPR, if there were no concerns with the CPR or care the resident was receiving. The DON said she thought it was odd but didn't think much of it. The DON said she did not ask him if the two staff members could have been nurses. She said, I did not think to ask. I did not think that nurses stopped CPR. No one told me. I guess I could have asked more questions. The DON said she did not interview nurses about not doing CPR. She said she did not think it was a neglect issue and she focused on the CNAs. The DON said she did not document the visit or what was said, and she did not know who the person was that visited their facility or what his title was. The DON said after he left, she did not get staff involved in Resident #1's code blue to write statements. The DON said she did not know how many staff went into Resident #1's room, she did not ask. A phone interview was conducted on [DATE] at 12:08 p.m. with the Nursing Home Administration (NHA) regarding the code blue for Resident #1. The NHA said if there were concerns after a code blue, sometimes an investigation occurs when it is over. The process is to get statements to see if everything went well during a code. The NHA said after every code staff should make sure everything is documented, all staff that were present are interviewed and their role was documented. The NHA said, we do this with every code. The NHA said she was not aware there was a visit from an outsider, she thought it was a phone call. The NHA said the DON told her he called to talk about two CNAs that were standing around during CPR and he asked what their role was. The DON said she clarified the CNAs role to him and he was okay with that. The NHA said she worked on [DATE] but did not know there was a concern. She said she did not think they needed to investigate or report anything. 1. Not ensuring cardiopulmonary resuscitation (CPR) was provided: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 12 of 45 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 01/24/2024 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Staff M, Nurse was interviewed at 3:00 pm on [DATE] and stated Staff L, Nurse was performing CPR on Resident #1 during the code on [DATE]. Staff M, Nurse called this surveyor at 3:52 p.m. on [DATE] and said, my conscious got to me. She said she was downstairs and heard the code called. She said she walked fast to get to the 300 unit. She said it was about 5 minutes after the code was called, she got to the unit, and no one was doing compressions on the resident. She said EMS had not yet arrived at the time she got to the room. She said the primary nurse usually starts compressions and other nurses come up and help. Staff M said the resident was lying on the floor with her head towards the foot of the bed and her legs were underneath her. She said it looked like she had been standing and collapsed with her legs under her. She said in that position it would have been difficult to do compressions. Staff M said, I was in shock no one started compressions. She said she didn't know if they were looking for a Do Not Resuscitate (DNR) order or what. Staff M said there were a lot of people in the room, and no one was doing CPR. She said they were just like staring. She said prior to her leaving the room, Staff K, Nurse was getting oxygen for the resident, but she didn't know what that was going to do when she wasn't breathing. She asked the nurses if they needed help and they said no, so she left the room. Technically, there's no formal definition for a code, but doctors often use the term as slang for a cardiopulmonary arrest happening to a patient in a hospital or clinic, requiring a team of providers (sometimes called a code team) to rush to the specific location and begin immediate resuscitative efforts. https://www.webmd.com/a-to-z-guides/code-blue-code-black-what-does-code-mean An interview was conducted on [DATE] at 2:27 p.m. with the Emergency Services Paramedic. She said their unit arrived at the facility first after receiving a 911 call for cardiac arrest. When they arrived at the resident's room, there were two male staff members sitting on the bed, while the patient was lying on the floor. One female staff member was by the crash cart and one by the doorway. The Paramedic said, They were basically watching the resident lying on the floor. She said CPR was not being performed on the resident. The Paramedic said one nurse was messing with the suction on the cart, but nothing was open from that cart. The Paramedic said no one identified themselves as a nurse or a CNA. The Paramedic said no one was doing compressions, suctioning the resident, or providing oxygen to the resident. The Paramedic said, I was mind blown. The Paramedic said she asked staff to do compression while they (emergency services team) set up their equipment and got medications out because there were only two responders on the first unit to arrive. The Paramedic said she had to ask multiple times for staff to help and for someone to do compressions. She said one male started doing compressions and he put his hands in completely wrong placement, hit her chest three times and stood up and looked at them. She told the male she needed him to keep going so he did three more compressions. She said the male was in a hoodie, but she did see him in the nurses' station prior to leaving the facility so she assumed he was staff. The male did three more compressions the Paramedic said she spoke up and asked someone else to do compressions because the male was doing it incorrectly. She said a female said, I ain't doing it, and walked out of the room. She said the second male, a tall white gentleman, had been fumbling with the suction machine. He had the suction tubing but no suction attachment on the end, such as a flexible tubing or yankauer (rigid oral suctioning tool.) The Paramedic said the male was attempting to suction the resident, but it wasn't doing anything since he did not have an attachment on the tubing. The Paramedic said after the female staff member said she wasn't doing compressions, the second EMS (Emergency Medical Services) unit arrived, and they took over. The Paramedic said staff didn't know if the resident had been down a while or not, no one could say. She said EMS responders do compressions and work on the resident until cardiac pads are on and heart rhythm can be verified. The Paramedic said the resident was not obviously (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 13 of 45 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 01/24/2024 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 0609 deceased when they arrived. Level of Harm - Immediate jeopardy to resident health or safety An interview was conducted on [DATE] at 12:31 p.m. with an Emergency Medical Technician (EMT). The EMT confirmed she came to the facility on the call for Resident #1 on [DATE]. The EMT said when she walked in the room two male staff were sitting on the bed bending over trying to figure out the suction. She said there was a cart with suction and oxygen and staff were trying to figure that out. The EMT said no one was doing compressions. She said the Paramedic on scene had to ask multiple times for someone to get on the chest. The EMT said one male staff member started compressions, but he wasn't doing it correctly. She said there were only two responders at the time, and they needed the staff to assist while they set up. She said the Paramedic was good at dealing with the staff and wasn't rude, but she was frustrated because she was having to ask multiple times for them to do their job. The EMT said she was trying to get the monitor set up and on the patient. She said when the 911 call was made it came in as CPR in progress and all the staff should know how to do CPR. The EMT said after the male had been asked to do compressions the Paramedic asked for someone to take over, then the second crew arrived, and they took over CPR from staff. Residents Affected - Some An interview was conducted on [DATE] at 5:26 p.m. with an EMS Field Supervisor. He said he received a report from his Paramedic on Monday, [DATE], about the call they received to the facility. He said the Paramedic wrote an incident report regarding arriving at the facility and CPR not being performed on the resident when they arrived. He said he wanted to go talk to management at the facility to see what happened. He said the visit was more of a fact-finding mission. The EMS Field Supervisor said he spoke with the DON on [DATE] and she said she wasn't even aware Resident #1 had a cardiac arrest. He said he told her what happened and what the Paramedic witnessed. He said the DON told him it was probably CNAs in the room, and they are not trained to do CPR and are not allowed to do CPR in the facility. A review of Resident #1's medical record revealed a progress note, dated [DATE] at 5:29 p.m. by Staff I, Nurse, the nurse assigned to the resident. The note showed CNA [Certified Nursing Assistant] notified nurse resident was on floor in room. Nurse observed resident without respirations or pulse. Code status verified. Code blue called. CPR initiated and continued until EMS arrival whom took over care. EMS notified. Resident pronounced deceased at 3:10 p.m. Review of admission Records showed Resident #1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, schizoaffective disorder, bipolar type, epilepsy, anxiety disorder, Alzheimer's disease, disease of pancreas, hypothermia, and chronic obstructive pulmonary disease (COPD). Resident #1 expired on [DATE]. Review of an Order Summary Report for Resident #1 revealed an active physician order for Full Resuscitation, order date [DATE]. An interview was conducted on [DATE] at 3:58 p.m. with Staff J, CNA. Staff J, CNA said she was just coming on her shift at about 2:45 p.m. She said she clocked in and got up to the unit just before 3:00. Staff J, CNA said she came up the back stairs and circled the unit before going to the nurses' station and when she came around the corner Staff K, Nurse and Staff I, Nurse were standing at the nurses' station directly across from Resident #1's room and both doors were open. Staff J, CNA said she and another staff member walked up at the same time and the other staff member looked in the room and said a resident had fallen. Staff J, CNA said she quickly set her things down and ran into the room. She said you could see the resident's hair on the floor from the hall. She said the resident was lying on her back and had some vomit/fluid on her face. She said she called out Resident #1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 14 of 45 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 01/24/2024 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some name a few times and the resident didn't respond. Staff J, CNA said she ran out the door and told Staff K, Nurse and Staff I, Nurse the resident was unresponsive and needed help. Staff J, CNA said both nurses looked at me like I was dumb and Staff I, Nurse said are you joking? She said Staff K, Nurse went in Resident #1's room and Staff I, Nurse came two minutes later. Staff J, CNA, said she went into the room to try to help but the nurses told her to leave. She said she did see Staff K, Nurse start CPR but does not know if it continued because she was told to leave. Staff J, CNA said there were 2 male nurses in the room (Staff K, Nurse and Staff L, Nurse) and 3 female Nurses (Staff I, Nurse and two nurses from downstairs.) An interview was conducted on [DATE] at 3:28 p.m. with Staff K, Nurse. He said he was coming in to work on [DATE] for the 3:00 p.m. shift. He said around 2:50 p.m. Staff J, CNA came and said Resident #1 was on her back and didn't look good. He said he went to the room and the resident was lying on her back with her head towards the bathroom door and wasn't breathing at all. He said one of the CNAs grabbed the resident's chart and Staff I, Nurse checked her code status. Staff K, Nurse said a CNA grabbed the emergency cart and he started CPR on the resident. Staff K, Nurse said Resident #1 was still warm. He said he didn't know what happened, but it looked like it just happened to me. He then said Staff I, Nurse brought the emergency cart in with her and used the AMBU bag (a bag valve mask that is used to deliver positive pressure ventilation) to give breaths to the resident and he did compressions. Staff K, Nurse said Staff L, Nurse came in to help and took over the AMBU bag from Staff I, Nurse. Staff K, Nurse said next, he and Staff L, Nurse switched places while Staff I, Nurse did paperwork. He said EMS came quick, but he was disappointed they didn't take over when they showed up. He said the female responder told him to keep doing compressions. He said two more emergency responders came into the room and they told us to continue CPR. Staff K, Nurse said EMS never did chest compressions. He said he was doing compressions when EMS walked in the door and only stopped when they told him to. He said EMS was sticking needles in her and sticking patches on and he thought it was unusual they didn't take over. He said EMS was only there about 5 minutes that's it. She was gone. He said he doesn't remember who all was in the room besides Staff I, Nurse and Staff L, Nurse but he does know the weekend supervisor (Staff N, Nurse) came up at some point. An interview was conducted on [DATE] at 10:26 a.m. with Staff N, Nurse, the weekend supervisor. She said she was not in the facility when Resident #1 coded. She said she left the facility between 11:00 a.m. and 12:00 p.m. that day. Staff N said there was no supervisor at the facility during the event and staff should have notified the ADON or DON. A follow-up interview was conducted on [DATE] 3:22 p.m. with Staff K, Nurse. Staff K said when the CNA called him to the room Resident #1 was lying on the floor unresponsive. He said he assessed the resident and went out to the nurses' station and got her chart to confirm her code status. He said the CNA stayed in the room while he went to the nurses' station, but the CNA did not do any CPR. He said Staff I, Nurse was sitting at the nurses' station and she called a code blue. Staff K then said he grabbed the emergency cart and took it in the room. He said he did a mouth sweep of the resident and that is when Staff L, Nurse got to the resident's room. He said Staff L, Nurse and himself did CPR on Resident #1. Staff K said Staff L, Nurse got there immediately and the two of them did the whole thing. No other nurse helped out. He said no one else performed compression and if anyone else told you something different that is totally incorrect. When asked who else was in Resident #1's room assisting with the code, Staff K said, I can't tell you. I didn't look around. An interview was conducted on [DATE] at 3:17 p.m. with Staff I, Nurse. Staff I said on [DATE] she worked the 7:00 a.m. to 3:00 p.m. shift. She said Resident #1 coded at shift change. She said she believed it was Staff J, CNA who let her know the resident needed help, but she doesn't remember her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 15 of 45 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 01/24/2024 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some exact words. She said Staff K, Nurse checked on the resident while she checked the resident's code status. Staff I confirmed Resident #1 was a full code. She said Staff K, Nurse started CPR and another male nurse was in the room, but she didn't know what that nurse was doing. Staff I said she didn't know if there were any CNAs in the room. Staff I said, I believe he did CPR until EMS arrived. Staff I said she wasn't in the room; she was calling 911 and doing paperwork. She said the other nurses had the emergency cart in the room. Staff I said she did go in the room at some point but doesn't remember when. She said she was doing paperwork and calling 911. She said when EMS arrived, I handed off the paperwork and stepped out. Staff I said EMS did not ask her to assist with CPR. She said they came in and took over. Staff I said the resident was assigned to her that day. She said she saw her just before lunch and the aides said she was in the dining room and lunch ended around 2:00-2:15 p.m. A follow-up interview was conducted on [DATE] at 3:49 p.m. with Staff I, Nurse. She said she confirmed the resident was a full code. She said when she went in the room Staff K, Nurse was doing compressions and Staff L, Nurse was giving the resident breaths, I did not pay any attention to if another nurse was on the floor. I saw [Staff K, Nurse] and [Staff L, Nurse.] Did not see another nurse hands on. When asked who was at the code cart Staff I stated, I was not paying attention to that. When ask if there were just a few people in the room or a lot of staff she said, I don't know how many people were in there. Staff I said she was not documenting and did not know who filled out the Code Blue Worksheet. She said she did not stay in the room. An interview was conducted on [DATE] at 4:29 p.m. with Staff L, Nurse. Staff L said he came in to work on [DATE] for his 3:00 p.m. shift. He said he heard the code called and went upstairs to help on the 300 unit. He said when he arrived Staff K, Nurse was assessing the resident and Staff I, Nurse was prepping the emergency cart. Staff L said he thinks there were some CNAs in the room too. He said Staff K, Nurse started CPR and I think I took the AMBU bag when Staff I, Nurse was taking it off the cart. He said, I might have taken over compressions then switched to the AMBU bag. That's probably what happened. Staff L said Staff K, Nurse was doing CPR on his own while everything was getting set up. He said a lot was going on, but they probably did 6 rounds of 15 compressions and 2 breaths before EMS got there. Staff L, Nurse said they were still following through with compressions when EMS got to the room. He said EMS wanted compressions to continue but said the nurse should stop using the AMBU bag. He said he didn't know why and maybe it was some new protocol. He said when the second EMS unit arrived, they took over compressions on Resident #1. Staff L said he does remember the female EMS responder talking about Staff K, Nurse not doing compressions correctly and could we get someone else to do it. He said, I think they were just upset about us doing the AMBU bag. Staff L said Staff I, Nurse was in the room when EMS arrived because he remembers going to stand in the corner with her. He said she was in the room pretty much the whole time. He said CPR was being done during the time I entered the room. I think it continued on until EMS took over. Staff L said they did roll the resident on her side to suction fluids in her mouth. He said he suctioned her once and Staff K, Nurse suctioned her once. Staff L said he and Staff K, Nurse were never just sitting on the bed, but he said he did sit on the bed at some point while he was using the AMBU bag on the resident. He said only he and Staff K, Nurse did compressions on the resident. He said no one else did compressions or helped position the resident. A follow-up interview was conducted on [DATE] at 10:50 a.m. with Staff L, Nurse. Staff L said when he got to Resident #1's room there were people in the room, but he did not know them because he has worked in the facility for less than a month. He said Staff K, Nurse initiated CPR, the resident was being assessed, and Staff K, Nurse was checking her pulse. He said Staff I, Nurse handed him the AMBU bag off the emergency cart. Staff L said he took over chest compressions and he and Staff K, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 16 of 45 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 01/24/2024 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Nurse switched between doing compressions and breaths and there was no one else assisting with CPR. He said at one point he was sitting on the bed while he was suctioning Resident #1. He said when EMS arrived, they told Staff K, Nurse to continue with compressions and Staff L, Nurse said he went and stood in the corner of the room beside Staff I, Nurse. He said one of the responders was rude to the staff and yelled about them not doing things right. He said, She was adamant and making comments like can someone else do this, does anyone know how to do this. I did not think much of it. Residents Affected - Some An interview was conducted on [DATE] at 11:10 a.m. with Staff O, Nurse. She said she worked from 7:00 a.m. to 3:00 p.m. on [DATE] and responded to a code on the 300 unit. Staff O said the code was called three times over the speaker to Resident #1's room. She said when she got upstairs there were already quite a few people that had responded. Staff O, Nurse said when she got to Resident #1's room Staff K, Nurse, Staff L, Nurse, Staff P, Nurse, and Staff M, Nurse were there and Staff I, Nurse was on the phone. Staff O said the resident was lying on the floor and the emergency cart was in the room. She said Staff K, Nurse was on the lower end of the resident, Staff L, Nurse was on the top end of the resident, and Staff P, Nurse was grabbing supplies. Staff O said she grabbed the AMBU bag for Staff L, Nurse and Staff K, Nurse started compressions. She said she got on the floor and helped position the resident and tilt her head to get air. Staff O said Staff I, Nurse came back in the room and confirmed resident was a full code. She said Staff M, Nurse came in and asked if 911 had been called and asked if she could do anything to help. Staff O said at one point she took over compressions on Resident #1 from Staff K, Nurse to give him a break. She said Staff L, Nurse was doing the AMBU bag and Staff P, Nurse was grabbing supplies and paperwork. Staff O said EMS arrived and the staff continued CPR until EMS took over. She said the male responder took over compressions from Staff K, Nurse and a second EMS responder took over the AMBU bag from Staff L, Nurse. She said they were not asked to stop using the AMBU bag, they continued until EMS took it over. She said she was always taught to not stop CPR until EMS arrives and takes over. She said when EMS arrived, they could see that the staff were doing CPR. Staff O said while CPR was being done there was a little mucous/discharge that came to the resident's mouth so Staff I, Nurse grabbed the suction and Staff K, Nurse suctioned the resident only one time. A follow-up interview was conducted on [DATE] at 11:25 a.m. with Staff O, Nurse. Staff O said when she heard the code called, she ran to the room, grabbing gloves on her way. She said Staff I, Nurse was standing by the door of the nurses' station calling 911, the emergency cart was already in the room, and Staff K, Nurse, Staff L, Nurse, and Staff P, Nurse were already there. She said the resident was lying on the floor flat on her back. Staff O said Staff P, Nurse grabbed the AMBU bag off the cart and gave it to Staff L, Nurse. Staff O said she got down on the floor and held Resident #1's head in a tilt position, Staff K, Nurse was doing compressions, and Staff L, Nurse was giving breaths with the AMBU bag. Staff O said she yelled out to Staff I, Nurse and asked if EMS was coming because she was used to them responding faster. She said while Staff K, Nurse was doing compressions, she noticed there was some discharge in the resident's mouth and Staff L, Nurse said they needed to suction the resident. Staff P, Nurse was handing us supplies and Staff I, Nurse came back in the room grabbed the suction tubing, placed a yankauer catheter on the tubing and handed it to Staff L, Nurse, who quickly suctioned the resident and gave it back to Staff I, Nurse. Staff O said she switched with Staff K, Nurse and did compressions, but didn't do them for very long and she said she did not ever see Staff L, Nurse do any compressions. Staff O said they did not stop CPR and Staff K, Nurse was doing compressions when the first responders arrived. Staff O said the female medic told them to continue CPR and they didn't take over right away. She said Staff P, Nurse gave the medic the paperwork they needed, and the medic was asking their standard questions like (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 17 of 45 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 01/24/2024 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some how long the resident had been down. Staff O said a male responder arrived and took over compressions and another took over the AMBU bag. She said the female responder, who seemed to be the lead, was quite rude. Staff K, Nurse said to her, you don't have to be so [expletive] rude. She [the female responder] didn't respond. An interview was conducted on [DATE] at 12:18 p.m. with Staff P, Nurse. Staff P said the code for Resident #1 was called right at the end of her shift, around 3:00 p.m. on [DATE]. She said by the time she arrived in the room; several other nurses were there. Staff P said she asked if they needed anything and did they already do things like check code status, call 911, etc. She said they told her they did not need anything. Staff P said Staff I, Nurse, Staff, K, Nurse and Staff L, Nurse were in the room, but she did not remember if any CNAs were present. She said Staff K, Nurse was doing compressions, she doesn't remember seeing if anyone was giving breaths with the AMBU bag, and Staff I, Nurse was standing there, but Staff P doesn't know what Staff I, Nurse was doing. Staff P, Nurse said she helped get other residents from the hall to the dining room and said she did not help with any paperwork or handing off or gathering equipment. Staff P said she was not near the room when EMS arrived and was not in the room while EMS was there. A follow-up interview was conducted on [DATE] at 12:09 p.m. with Staff P, Nurse. Staff P, Nurse reiterated Staff K, Nurse was doing compressions and Staff L, Nurse and Staff I, Nurse were in Resident #1's room. She said Staff K, Nurse was the only person she knew was physically doing something. She said they all told her they didn't need anything. She confirmed she was not handing equipment or doing paperwork at any point and never went all the way into the resident's room. An interview was conducted on [DATE] at 12:36 p.m. with Staff Q, CNA. Staff Q, CNA said when the code was called on [DATE] for Resident #1 everyone went from the different units. She said CNAs do not perform CPR they just help keep other residents away from the area. She said Staff K, Nurse, Staff L, Nurse and Staff J, CNA were already there. Staff Q, CNA said she grabbed the emergency cart and she and Staff K, Nurse took it to the room. She said she didn't know if Staff K, Nurse had been in to assess the resident or not. She said Staff L, Nurse was next to arrive. Staff Q, CNA said she remembers hearing Staff K, Nurse talking about getting ready to do compressions, but didn't see who was doing CPR. An interview was conducted on [DATE] at 1:24 p.m. with the DON. The DON said she wasn't working the day Resident #1 coded. She said Staff J, CNA found the resident and told Staff I, Nurse and Staff K, Nurse to come to the room because something was wrong with the resident. The DON said the resident wasn't breathing and did not have a pulse so Staff I, Nurse called the code. She said everyone went to the room and Staff K, Nurse started CPR after the code status for Resident #1 was verified. The DON said they continued CPR until EMS arrived and then EMS took over compressions. She said the resident was declared deceased at the facility. The DON said the people involved were Staff J, CNA, Staff K, Nurse, Staff L, Nurse, Staff I, Nurse, Staff O, Nurse, Staff M, Nurse, Staff N, Nurse/weekend supervisor, and two other CNAs (Staff Q, CNA and Staff R, CNA.) The DON said Staff K, Nurse and Staff L, Nurse are the two that did CPR and the rest got items needed for them or helped get other residents out of the hall. The DON said Staff K, Nurse did CPR and Staff L, Nurse assisted, Staff I, Nurse called the code and 911, Staff P, Nurse got items they needed during the code and Staff N, Nurse/weekend supervisor was directing people what to do and who needed to do what. The DON said Staff M, Nurse was helping get people out of the room. When asked when she was informed of Resident #1's cardiac arrest, she said Staff N, Nurse /weekend supervisor called her from the facility while it was occurring or shortly after. The DON was informed Staff N, Nurse/weekend supervisor was not in the facility and she said, She didn't call me? Am I getting people confused? The DON confirmed someone from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 18 of 45 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 01/24/2024 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 0609 Level of Harm - Immediate jeopardy to resident health or safety the fire department came to speak with her the day after the incident and wanted to speak with her about the code for Resident #1. She said EMS had some questions about a female staff member not assisting in the code. The DON said she asked him for a name and the circumstances around what happened, and she said he told her the females that wouldn't help were CNAs. The DON said she told him the CNAs are not trained in CPR and do not do CPR in the facility. She said he understood, and said he did not mention CPR not being done when EMS arrived. Residents Affected - Some An interview was conducted on [DATE] at 3:10 p.m. with the DON. She said for a code blue she would expect there to be a nurse's note in the medical record to say what the scenario was. She said she wouldn't really expect the note to say who was involved or who did what. The DON said they have a Code Blue Worksheet that is filled out and is part of the medical record. At 3:30 p.m. the DON said she wanted to clarify that the Code Blue Worksheet is not part of the medical record. The Code Blue Worksheet for Resident #1 dated [DATE] was reviewed. The information on the sheet was incomplete and the times listed on the worksheet do not line up with the times EMS recorded as having received the 911 call and responded. The DON could not identify who filled out the Code Blue Worksheet provided. 2. Not following up on critical lab results and not ensuring treatment and care for immune deficiency syndrome: Review of the admission records showed Resident #11 was initially admitted on [DATE] after a hospital stay for pneumonia and with diagnoses including pneumonia, immune deficiency syndrome, thrombocytopenia, and cirrhosis of liver and was re-admitted on [DATE], after a hospitalization for a gastrointestinal bleed. Review of Resident #11's Psychosocial History and Assessment, dated [DATE], showed the resident was previously homeless, but said she was adjusting and felt safe in the facility. The resident's goals for her stay were to maintain her health and medications. The Assessment also showed the resident reported transportation had kept her from medical appointments or from getting medications. It also noted the resident was cooperative, pleasant, and motivated. According to an (IMMUNE DEFICIENCY SYNDROME).gov article titled Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with [IMMUNE DEFICIENCY SYNDROME], dated [DATE], ART is now recommended for all patients with immune deficiency syndrome. In patients who remain untreated for whatever reason, CD4 counts should be monitored every 3-6 months to assess the urgency of ART initiation .[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 19 of 45 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 01/24/2024 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 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review facility failed to ensure an allegations of neglect were investigated related to not ensuring cardiopulmonary resuscitation (CPR) was provided according to policy and procedure for one resident (#1) out of three reviewed for the CPR process; not following up on critical lab results for one resident (#11) out of three reviewed for lab testing and not ensuring treatment and care was in place for one resident (#11) out of three reviewed for an immune deficiency syndrome. Residents Affected - Some This failure created a situation that resulted in a worsened condition and/or the likelihood for serious injury and or death and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: An interview was conducted on [DATE] at 2:46 p.m. with the DON. The DON said she did not hear there were any problems with the code for Resident #1 on [DATE]. She said no one reported anything to her. The DON said the fire supervisor came to visit her on [DATE] regarding concerns during the code blue for Resident #1 and he asked about the CNAs and their participation during the code, and she told him they are not certified in CPR and are only there to assist. The DON said he wanted to talk about two staff members not assisting in CPR and he said they were CNAs. When the DON was asked why the fire supervisor would take the time to make a trip to the facility to discuss two CNAs who did not participate in CPR, if there were no concerns with the CPR or care the resident was receiving. The DON said she thought it was odd but didn't think much of it. The DON said she did not ask him if the two staff members could have been nurses. She said, I did not think to ask. I did not think that nurses stopped CPR. No one told me. I guess I could have asked more questions. The DON said she did not interview nurses about not doing CPR. She said she did not think it was a neglect issue and she focused on the CNAs. The DON said she did not document the visit or what was said, and she did not know who the person was that visited their facility or what his title was. The DON said after he left, she did not get staff involved in Resident #1's code blue to write statements. The DON said she did not know how many staff went into Resident #1's room, she did not ask. A phone interview was conducted on [DATE] at 12:08 p.m. with the Nursing Home Administration (NHA) regarding the code blue for Resident #1. The NHA said if there were concerns after a code blue, sometimes an investigation occurs when it is over. The process is to get statements to see if everything went well during a code. The NHA said after every code staff should make sure everything is documented, all staff that were present are interviewed and their roll was documented. The NHA said, we do this with every code. The NHA said she was not aware there was a visit from an outsider, she thought it was a phone call. The NHA said the DON told her he called to talk about two CNAs that were standing around during CPR and he asked what their roll was. The DON said she clarified the CNAs roll to him and he was okay with that. The NHA said she came in to the facility on [DATE] but did not know there was a concern. She said she did not think they needed to investigate or report anything. 1. Not ensuring cardiopulmonary resuscitation (CPR) was provided: Staff M, Nurse was interviewed at 3:00 pm on [DATE] and stated Staff L, Nurse was performing CPR on Resident #1 during the code on [DATE]. Staff M, Nurse called this surveyor at 3:52 p.m. on [DATE] and said, my conscious got to me. She said she was downstairs and heard the code called. She said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 20 of 45 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 01/24/2024 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some walked fast to get to the 300 unit. She said it was about 5 minutes after the code was called, she got to the unit, and no one was doing compressions on the resident. She said EMS had not yet arrived at the time she got to the room. She said the primary nurse usually starts compressions and other nurses come up and help. Staff M said the resident was lying on the floor with her head towards the foot of the bed and her legs were underneath her. She said it looked like she had been standing and collapsed with her legs under her. She said in that position it would have been difficult to do compressions. Staff M said, I was in shock no one started compressions. She said she didn't know if they were looking for a Do Not Resuscitate (DNR) order or what. Staff M said there were a lot of people in the room, and no one was doing CPR. She said they were just like staring. She said prior to her leaving the room, Staff K, Nurse was getting oxygen for the resident, but she didn't know what that was going to do when she wasn't breathing. She asked the nurses if they needed help and they said no, so she left the room. Technically, there's no formal definition for a code, but doctors often use the term as slang for a cardiopulmonary arrest happening to a patient in a hospital or clinic, requiring a team of providers (sometimes called a code team) to rush to the specific location and begin immediate resuscitative efforts. https://www.webmd.com/a-to-z-guides/code-blue-code-black-what-does-code-mean An interview was conducted on [DATE] at 2:27 p.m. with the Emergency Services Paramedic. She said their unit arrived at the facility first after receiving a 911 call for cardiac arrest. When they arrived at the resident's room, there were two male staff members sitting on the bed, while the patient was lying on the floor. One female staff member was by the crash cart and one by the doorway. The Paramedic said, They were basically watching the resident lying on the floor. She said CPR was not being performed on the resident. The Paramedic said one nurse was messing with the suction on the cart, but nothing was open from that cart. The Paramedic said no one identified themselves as a nurse or a CNA. The Paramedic said no one was doing compressions, suctioning the resident, or providing oxygen to the resident. The Paramedic said, I was mind blown. The Paramedic said she asked staff to do compression while they (emergency services team) set up their equipment and got medications out because there were only two responders on the first unit to arrive. The Paramedic said she had to ask multiple times for staff to help and for someone to do compressions. She said one male started doing compressions and he put his hands in completely wrong placement, hit her chest three times and stood up and looked at them. She told the male she needed him to keep going so he did three more compressions. She said the male was in a hoodie, but she did see him in the nurses' station prior to leaving the facility so she assumed he was staff. The male did three more compressions the Paramedic said she spoke up and asked someone else to do compressions because the male was doing it incorrectly. She said a female said, I ain't doing it, and walked out of the room. She said the second male, a tall white gentleman, had been fumbling with the suction machine. He had the suction tubing but no suction attachment on the end, such as a flexible tubing or yankauer (rigid oral suctioning tool.) The Paramedic said the male was attempting to suction the resident, but it wasn't doing anything since he did not have an attachment on the tubing. The Paramedic said after the female staff member said she wasn't doing compressions, the second EMS (Emergency Medical Services) unit arrived, and they took over. The Paramedic said staff didn't know if the resident had been down a while or not, no one could say. She said EMS responders do compressions and work on the resident until cardiac pads are on and heart rhythm can be verified. The Paramedic said the resident was not obviously deceased when they arrived. An interview was conducted on [DATE] at 12:31 p.m. with an Emergency Medical Technician (EMT). The EMT confirmed she came to the facility on the call for Resident #1 on [DATE]. The EMT said when she walked in the room two male staff were sitting on the bed bending over (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 21 of 45 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 01/24/2024 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some trying to figure out the suction. She said there was a cart with suction and oxygen and staff were trying to figure that out. The EMT said no one was doing compressions. She said the Paramedic on scene had to ask multiple times for someone to get on the chest. The EMT said one male staff member started compressions, but he wasn't doing it correctly. She said there were only two responders at the time, and they needed the staff to assist while they set up. She said the Paramedic was good at dealing with the staff and wasn't rude, but she was frustrated because she was having to ask multiple times for them to do their job. The EMT said she was trying to get the monitor set up and on the patient. She said when the 911 call was made it came in as CPR in progress and all the staff should know how to do CPR. The EMT said after the male had been asked to do compressions the Paramedic asked for someone to take over, then the second crew arrived, and they took over CPR from staff. An interview was conducted on [DATE] at 5:26 p.m. with an EMS Field Supervisor. He said he received a report from his Paramedic on Monday, [DATE], about the call they received to the facility. He said the Paramedic wrote an incident report regarding arriving at the facility and CPR not being performed on the resident when they arrived. He said he wanted to go talk to management at the facility to see what happened. He said the visit was more of a fact-finding mission. The EMS Field Supervisor said he spoke with the DON on [DATE] and she said she wasn't even aware Resident #1 had a cardiac arrest. He said he told her what happened and what the Paramedic witnessed. He said the DON told him it was probably CNAs in the room, and they are not trained to do CPR and are not allowed to do CPR in the facility. A review of Resident #1's medical record revealed a progress note, dated [DATE] at 5:29 p.m. by Staff I, Nurse, the nurse assigned to the resident. The note showed CNA [Certified Nursing Assistant] notified nurse resident was on floor in room. Nurse observed resident without respirations or pulse. Code status verified. Code blue called. CPR initiated and continued until EMS arrival whom took over care. EMS notified. Resident pronounced deceased at 3:10 p.m. Review of admission Records showed Resident #1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, schizoaffective disorder, bipolar type, epilepsy, anxiety disorder, Alzheimer's disease, disease of pancreas, hypothermia, and chronic obstructive pulmonary disease (COPD). Resident #1 expired on [DATE]. Review of an Order Summary Report for Resident #1 revealed an active physician order for Full Resuscitation, order date [DATE]. An interview was conducted on [DATE] at 3:58 p.m. with Staff J, CNA. Staff J, CNA said she was just coming on her shift at about 2:45 p.m. She said she clocked in and got up to the unit just before 3:00. Staff J, CNA said she came up the back stairs and circled the unit before going to the nurses' station and when she came around the corner Staff K, Nurse and Staff I, Nurse were standing at the nurses' station directly across from Resident #1's room and both doors were open. Staff J, CNA said she and another staff member walked up at the same time and the other staff member looked in the room and said a resident had fallen. Staff J, CNA said she quickly set her things down and ran into the room. She said you could see the resident's hair on the floor from the hall. She said the resident was lying on her back and had some vomit/fluid on her face. She said she called out Resident #1's name a few times and the resident didn't respond. Staff J, CNA said she ran out the door and told Staff K, Nurse and Staff I, Nurse the resident was unresponsive and needed help. Staff J, CNA said both nurses looked at me like I was dumb and Staff I, Nurse said are you joking? She said Staff K, Nurse went in Resident #1's room and Staff I, Nurse came two minutes later. Staff J, CNA, said she went into the room to try to help but the nurses told her to leave. She said she did see Staff K, Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 22 of 45 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 01/24/2024 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some start CPR but does not know if it continued because she was told to leave. Staff J, CNA said there were 2 male nurses in the room (Staff K, Nurse and Staff L, Nurse) and 3 female Nurses (Staff I, Nurse and two nurses from downstairs.) An interview was conducted on [DATE] at 3:28 p.m. with Staff K, Nurse. He said he was coming in to work on [DATE] for the 3:00 p.m. shift. He said around 2:50 p.m. Staff J, CNA came and said Resident #1 was on her back and didn't look good. He said he went to the room and the resident was lying on her back with her head towards the bathroom door and wasn't breathing at all. He said one of the CNAs grabbed the resident's chart and Staff I, Nurse checked her code status. Staff K, Nurse said a CNA grabbed the emergency cart and he started CPR on the resident. Staff K, Nurse said Resident #1 was still warm. He said he didn't know what happened, but it looked like it just happened to me. He then said Staff I, Nurse brought the emergency cart in with her and used the AMBU bag (a bag valve mask that is used to deliver positive pressure ventilation) to give breaths to the resident and he did compressions. Staff K, Nurse said Staff L, Nurse came in to help and took over the AMBU bag from Staff I, Nurse. Staff K, Nurse said next, he and Staff L, Nurse switched places while Staff I, Nurse did paperwork. He said EMS came quick, but he was disappointed they didn't take over when they showed up. He said the female responder told him to keep doing compressions. He said two more emergency responders came into the room and they told us to continue CPR. Staff K, Nurse said EMS never did chest compressions. He said he was doing compressions when EMS walked in the door and only stopped when they told him to. He said EMS was sticking needles in her and sticking patches on and he thought it was unusual they didn't take over. He said EMS was only there about 5 minutes that's it. She was gone. He said he doesn't remember who all was in the room besides Staff I, Nurse and Staff L, Nurse but he does know the weekend supervisor (Staff N, Nurse) came up at some point. An interview was conducted on [DATE] at 10:26 a.m. with Staff N, Nurse, the weekend supervisor. She said she was not in the facility when Resident #1 coded. She said she left the facility between 11:00 a.m. and 12:00 p.m. that day. Staff N said there was no supervisor at the facility during the event and staff should have notified the ADON or DON. A follow-up interview was conducted on [DATE] 3:22 p.m. with Staff K, Nurse. Staff K said when the CNA called him to the room Resident #1 was lying on the floor unresponsive. He said he assessed the resident and went out to the nurses' station and got her chart to confirm her code status. He said the CNA stayed in the room while he went to the nurses' station, but the CNA did not do any CPR. He said Staff I, Nurse was sitting at the nurses' station and she called a code blue. Staff K then said he grabbed the emergency cart and took it in the room. He said he did a mouth sweep of the resident and that is when Staff L, Nurse got to the resident's room. He said Staff L, Nurse and himself did CPR on Resident #1. Staff K said Staff L, Nurse got there immediately and the two of them did the whole thing. No other nurse helped out. He said no one else performed compression and if anyone else told you something different that is totally incorrect. When asked who else was in Resident #1's room assisting with the code, Staff K said, I can't tell you. I didn't look around. An interview was conducted on [DATE] at 3:17 p.m. with Staff I, Nurse. Staff I said on [DATE] she worked the 7:00 a.m. to 3:00 p.m. shift. She said Resident #1 coded at shift change. She said she believed it was Staff J, CNA who let her know the resident needed help, but she doesn't remember her exact words. She said Staff K, Nurse checked on the resident while she checked the resident's code status. Staff I confirmed Resident #1 was a full code. She said Staff K, Nurse started CPR and another male nurse was in the room, but she didn't know what that nurse was doing. Staff I said she didn't know if there were any CNAs in the room. Staff I said, I believe he did CPR until EMS arrived. Staff I said she wasn't in the room; she was calling 911 and doing paperwork. She said the other nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 23 of 45 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 01/24/2024 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some had the emergency cart in the room. Staff I said she did go in the room at some point but doesn't remember when. She said she was doing paperwork and calling 911. She said when EMS arrived, I handed off the paperwork and stepped out. Staff I said EMS did not ask her to assist with CPR. She said they came in and took over. Staff I said the resident was assigned to her that day. She said she saw her just before lunch and the aides said she was in the dining room and lunch ended around 2:00-2:15 p.m. A follow-up interview was conducted on [DATE] at 3:49 p.m. with Staff I, Nurse. She said she confirmed the resident was a full code. She said when she went in the room Staff K, Nurse was doing compressions and Staff L, Nurse was giving the resident breaths, I did not pay any attention to if another nurse was on the floor. I saw [Staff K, Nurse] and [Staff L, Nurse.] Did not see another nurse hands on. When asked who was at the code cart Staff I stated, I was not paying attention to that. When ask if there were just a few people in the room or a lot of staff she said, I don't know how many people were in there. Staff I said she was not documenting and did not know who filled out the Code Blue Worksheet. She said she did not stay in the room. An interview was conducted on [DATE] at 4:29 p.m. with Staff L, Nurse. Staff L said he came in to work on [DATE] for his 3:00 p.m. shift. He said he heard the code called and went upstairs to help on the 300 unit. He said when he arrived Staff K, Nurse was assessing the resident and Staff I, Nurse was prepping the emergency cart. Staff L said he thinks there were some CNAs in the room too. He said Staff K, Nurse started CPR and I think I took the AMBU bag when Staff I, Nurse was taking it off the cart. He said, I might have taken over compressions then switched to the AMBU bag. That's probably what happened. Staff L said Staff K, Nurse was doing CPR on his own while everything was getting set up. He said a lot was going on, but they probably did 6 rounds of 15 compressions and 2 breaths before EMS got there. Staff L, Nurse said they were still following through with compressions when EMS got to the room. He said EMS wanted compressions to continue but said the nurse should stop using the AMBU bag. He said he didn't know why and maybe it was some new protocol. He said when the second EMS unit arrived, they took over compressions on Resident #1. Staff L said he does remember the female EMS responder talking about Staff K, Nurse not doing compressions correctly and could we get someone else to do it. He said, I think they were just upset about us doing the AMBU bag. Staff L said Staff I, Nurse was in the room when EMS arrived because he remembers going to stand in the corner with her. He said she was in the room pretty much the whole time. He said CPR was being done during the time I entered the room. I think it continued on until EMS took over. Staff L said they did roll the resident on her side to suction fluids in her mouth. He said he suctioned her once and Staff K, Nurse suctioned her once. Staff L said he and Staff K, Nurse were never just sitting on the bed, but he said he did sit on the bed at some point while he was using the AMBU bag on the resident. He said only he and Staff K, Nurse did compressions on the resident. He said no one else did compressions or helped position the resident. A follow-up interview was conducted on [DATE] at 10:50 a.m. with Staff L, Nurse. Staff L said when he got to Resident #1's room there were people in the room, but he did not know them because he has worked in the facility for less than a month. He said Staff K, Nurse initiated CPR, the resident was being assessed, and Staff K, Nurse was checking her pulse. He said Staff I, Nurse handed him the AMBU bag off the emergency cart. Staff L said he took over chest compressions and he and Staff K, Nurse switched between doing compressions and breaths and there was no one else assisting with CPR. He said at one point he was sitting on the bed while he was suctioning Resident #1. He said when EMS arrived, they told Staff K, Nurse to continue with compressions and Staff L, Nurse said he went and stood in the corner of the room beside Staff I, Nurse. He said one of the responders was rude to the staff and yelled about them not doing things right. He said, She was adamant and making comments like (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 24 of 45 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 01/24/2024 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 0610 can someone else do this, does anyone know how to do this. I did not think much of it. Level of Harm - Immediate jeopardy to resident health or safety An interview was conducted on [DATE] at 11:10 a.m. with Staff O, Nurse. She said she worked from 7:00 a.m. to 3:00 p.m. on [DATE] and responded to a code on the 300 unit. Staff O said the code was called three times over the speaker to Resident #1's room. She said when she got upstairs there were already quite a few people that had responded. Staff O, Nurse said when she got to Resident #1's room Staff K, Nurse, Staff L, Nurse, Staff P, Nurse, and Staff M, Nurse were there and Staff I, Nurse was on the phone. Staff O said the resident was lying on the floor and the emergency cart was in the room. She said Staff K, Nurse was on the lower end of the resident, Staff L, Nurse was on the top end of the resident, and Staff P, Nurse was grabbing supplies. Staff O said she grabbed the AMBU bag for Staff L, Nurse and Staff K, Nurse started compressions. She said she got on the floor and helped position the resident and tilt her head to get air. Staff O said Staff I, Nurse came back in the room and confirmed resident was a full code. She said Staff M, Nurse came in and asked if 911 had been called and asked if she could do anything to help. Staff O said at one point she took over compressions on Resident #1 from Staff K, Nurse to give him a break. She said Staff L, Nurse was doing the AMBU bag and Staff P, Nurse was grabbing supplies and paperwork. Staff O said EMS arrived and the staff continued CPR until EMS took over. She said the male responder took over compressions from Staff K, Nurse and a second EMS responder took over the AMBU bag from Staff L, Nurse. She said they were not asked to stop using the AMBU bag, they continued until EMS took it over. She said she was always taught to not stop CPR until EMS arrives and takes over. She said when EMS arrived, they could see that the staff were doing CPR. Staff O said while CPR was being done there was a little mucous/discharge that came to the resident's mouth so Staff I, Nurse grabbed the suction and Staff K, Nurse suctioned the resident only one time. Residents Affected - Some A follow-up interview was conducted on [DATE] at 11:25 a.m. with Staff O, Nurse. Staff O said when she heard the code called, she ran to the room, grabbing gloves on her way. She said Staff I, Nurse was standing by the door of the nurses' station calling 911, the emergency cart was already in the room, and Staff K, Nurse, Staff L, Nurse, and Staff P, Nurse were already there. She said the resident was lying on the floor flat on her back. Staff O said Staff P, Nurse grabbed the AMBU bag off the cart and gave it to Staff L, Nurse. Staff O said she got down on the floor and held Resident #1's head in a tilt position, Staff K, Nurse was doing compressions, and Staff L, Nurse was giving breaths with the AMBU bag. Staff O said she yelled out to Staff I, Nurse and asked if EMS was coming because she was used to them responding faster. She said while Staff K, Nurse was doing compressions, she noticed there was some discharge in the resident's mouth and Staff L, Nurse said they needed to suction the resident. Staff P, Nurse was handing us supplies and Staff I, Nurse came back in the room grabbed the suction tubing, placed a yankauer catheter on the tubing and handed it to Staff L, Nurse, who quickly suctioned the resident and gave it back to Staff I, Nurse. Staff O said she switched with Staff K, Nurse and did compressions, but didn't do them for very long and she said she did not ever see Staff L, Nurse do any compressions. Staff O said they did not stop CPR and Staff K, Nurse was doing compressions when the first responders arrived. Staff O said the female medic told them to continue CPR and they didn't take over right away. She said Staff P, Nurse gave the medic the paperwork they needed, and the medic was asking their standard questions like how long the resident had been down. Staff O said a male responder arrived and took over compressions and another took over the AMBU bag. She said the female responder, who seemed to be the lead, was quite rude. Staff K, Nurse said to her, you don't have to be so [expletive] rude. She [the female responder] didn't respond. An interview was conducted on [DATE] at 12:18 p.m. with Staff P, Nurse. Staff P said the code for Resident #1 was called right at the end of her shift, around 3:00 p.m. on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 25 of 45 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 01/24/2024 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some [DATE]. She said by the time she arrived in the room; several other nurses were there. Staff P said she asked if they needed anything and did they already do things like check code status, call 911, etc. She said they told her they did not need anything. Staff P said Staff I, Nurse, Staff, K, Nurse and Staff L, Nurse were in the room, but she did not remember if any CNAs were present. She said Staff K, Nurse was doing compressions, she doesn't remember seeing if anyone was giving breaths with the AMBU bag, and Staff I, Nurse was standing there, but Staff P doesn't know what Staff I, Nurse was doing. Staff P, Nurse said she helped get other residents from the hall to the dining room and said she did not help with any paperwork or handing off or gathering equipment. Staff P said she was not near the room when EMS arrived and was not in the room while EMS was there. A follow-up interview was conducted on [DATE] at 12:09 p.m. with Staff P, Nurse. Staff P, Nurse reiterated Staff K, Nurse was doing compressions and Staff L, Nurse and Staff I, Nurse were in Resident #1's room. She said Staff K, Nurse was the only person she knew was physically doing something. She said they all told her they didn't need anything. She confirmed she was not handing equipment or doing paperwork at any point and never went all the way into the resident's room. An interview was conducted on [DATE] at 12:36 p.m. with Staff Q, CNA. Staff Q, CNA said when the code was called on [DATE] for Resident #1 everyone went from the different units. She said CNAs do not perform CPR they just help keep other residents away from the area. She said Staff K, Nurse, Staff L, Nurse and Staff J, CNA were already there. Staff Q, CNA said she grabbed the emergency cart and she and Staff K, Nurse took it to the room. She said she didn't know if Staff K, Nurse had been in to assess the resident or not. She said Staff L, Nurse was next to arrive. Staff Q, CNA said she remembers hearing Staff K, Nurse talking about getting ready to do compressions, but didn't see who was doing CPR. An interview was conducted on [DATE] at 1:24 p.m. with the DON. The DON said she wasn't working the day Resident #1 coded. She said Staff J, CNA found the resident and told Staff I, Nurse and Staff K, Nurse to come to the room because something was wrong with the resident. The DON said the resident wasn't breathing and did not have a pulse so Staff I, Nurse called the code. She said everyone went to the room and Staff K, Nurse started CPR after the code status for Resident #1 was verified. The DON said they continued CPR until EMS arrived and then EMS took over compressions. She said the resident was declared deceased at the facility. The DON said the people involved were Staff J, CNA, Staff K, Nurse, Staff L, Nurse, Staff I, Nurse, Staff O, Nurse, Staff M, Nurse, Staff N, Nurse/weekend supervisor, and two other CNAs (Staff Q, CNA and Staff R, CNA.) The DON said Staff K, Nurse and Staff L, Nurse are the two that did CPR and the rest got items needed for them or helped get other residents out of the hall. The DON said Staff K, Nurse did CPR and Staff L, Nurse assisted, Staff I, Nurse called the code and 911, Staff P, Nurse got items they needed during the code and Staff N, Nurse/weekend supervisor was directing people what to do and who needed to do what. The DON said Staff M, Nurse was helping get people out of the room. When asked when she was informed of Resident #1's cardiac arrest, she said Staff N, Nurse /weekend supervisor called her from the facility while it was occurring or shortly after. The DON was informed Staff N, Nurse/weekend supervisor was not in the facility and she said, She didn't call me? Am I getting people confused? The DON confirmed someone from the fire department came to speak with her the day after the incident and wanted to speak with her about the code for Resident #1. She said EMS had some questions about a female staff member not assisting in the code. The DON said she asked him for a name and the circumstances around what happened, and she said he told her the females that wouldn't help were CNAs. The DON said she told him the CNAs are not trained in CPR and do not do CPR in the facility. She said he understood, and said he did not mention CPR not being done when EMS arrived. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 26 of 45 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 01/24/2024 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some An interview was conducted on [DATE] at 3:10 p.m. with the DON. She said for a code blue she would expect there to be a nurse's note in the medical record to say what the scenario was. She said she wouldn't really expect the note to say who was involved or who did what. The DON said they have a Code Blue Worksheet that is filled out and is part of the medical record. At 3:30 p.m. the DON said she wanted to clarify that the Code Blue Worksheet is not part of the medical record. The Code Blue Worksheet for Resident #1 dated [DATE] was reviewed. The information on the sheet was incomplete and the times listed on the worksheet do not line up with the times EMS recorded as having received the 911 call and responded. The DON could not identify who filled out the Code Blue Worksheet provided. 2. Not following up on critical lab results and not ensuring treatment and care for immune deficiency syndrome: Review of the admission records showed Resident #11 was initially admitted on [DATE] after a hospital stay for pneumonia and with diagnoses including pneumonia, immune deficiency syndrome, thrombocytopenia, and cirrhosis of liver and was re-admitted on [DATE], after a hospitalization for a gastrointestinal bleed. Review of medical records showed a Social Services note, dated [DATE] that said Resident #11 is alert and oriented and can make her needs known. Review of Resident #11's Psychosocial History and Assessment, dated [DATE], showed the resident was previously homeless, but said she was adjusting and felt safe in the facility. The resident's goals for her stay were to maintain her health and medications. The Assessment also showed the resident reported transportation had kept her from medical appointments or from getting medications. Review of medical records for Resident #11 showed a progress note, dated [DATE], saying the resident reported to the nurse she was vomiting on the floor inside her room. When nurse arrived in resident's room, she noticed a huge amount of coffee brown and red blood on the floor. The resident denied any pain, discomfort, or shortness of breath. This nurse immediately called the doctor and received orders to send the resident to the hospital for evaluation and treatment. Review of Resident #11's hospital History and Physical, dated [DATE], noted [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 27 of 45 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 01/24/2024 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, facility failed to ensure Cardiopulmonary Resuscitation (CPR) was performed according to professional standards on one resident (#1) out of three reviewed for CPR, the facility failed to ensure three out of five emergency carts were stocked correctly and ready to be utilized in a code blue, and failed to ensure six out of thirty-two nurses had hands-on and in person skills assessment training with their CPR certification. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: 1. Not ensuring cardiopulmonary resuscitation (CPR) was provided: Staff M, Nurse was interviewed at 3:00 pm on [DATE] and stated Staff L, Nurse was performing CPR on Resident #1 during the code on [DATE]. Staff M, Nurse called this surveyor at 3:52 p.m. on [DATE] and said, my conscious got to me. She said she was downstairs and heard the code called. She said she walked fast to get to the 300 unit. She said it was about 5 minutes after the code was called, she got to the unit, and no one was doing compressions on the resident. She said EMS had not yet arrived at the time she got to the room. She said the primary nurse usually starts compressions and other nurses come up and help. Staff M said the resident was lying on the floor with her head towards the foot of the bed and her legs were underneath her. She said it looked like she had been standing and collapsed with her legs under her. She said in that position it would have been difficult to do compressions. Staff M said, I was in shock no one started compressions. She said she didn't know if they were looking for a Do Not Resuscitate (DNR) order or what. Staff M said there were a lot of people in the room, and no one was doing CPR. She said they were just like staring. She said prior to her leaving the room, Staff K, Nurse was getting oxygen for the resident, but she didn't know what that was going to do when she wasn't breathing. She asked the nurses if they needed help and they said no, so she left the room. Technically, there's no formal definition for a code, but doctors often use the term as slang for a cardiopulmonary arrest happening to a patient in a hospital or clinic, requiring a team of providers (sometimes called a code team) to rush to the specific location and begin immediate resuscitative efforts. https://www.webmd.com/a-to-z-guides/code-blue-code-black-what-does-code-mean An interview was conducted on [DATE] at 2:27 p.m. with the Emergency Services Paramedic. She said their unit arrived at the facility first after receiving a 911 call for cardiac arrest. When they arrived at the resident's room, there were two male staff members sitting on the bed, while the patient was lying on the floor. One female staff member was by the crash cart and one by the doorway. The Paramedic said, They were basically watching the resident lying on the floor. She said CPR was not being performed on the resident. The Paramedic said one nurse was messing with the suction on the cart, but nothing was open from that cart. The Paramedic said no one identified themselves as a nurse or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 28 of 45 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 01/24/2024 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some a CNA. The Paramedic said no one was doing compressions, suctioning the resident, or providing oxygen to the resident. The Paramedic said, I was mind blown. The Paramedic said she asked staff to do compression while they (emergency services team) set up their equipment and got medications out because there were only two responders on the first unit to arrive. The Paramedic said she had to ask multiple times for staff to help and for someone to do compressions. She said one male started doing compressions and he put his hands in completely wrong placement, hit her chest three times and stood up and looked at them. She told the male she needed him to keep going so he did three more compressions. She said the male was in a hoodie, but she did see him in the nurses' station prior to leaving the facility so she assumed he was staff. The male did three more compressions the Paramedic said she spoke up and asked someone else to do compressions because the male was doing it incorrectly. She said a female said, I ain't doing it, and walked out of the room. She said the second male, a tall white gentleman, had been fumbling with the suction machine. He had the suction tubing but no suction attachment on the end, such as a flexible tubing or yankauer (rigid oral suctioning tool.) The Paramedic said the male was attempting to suction the resident, but it wasn't doing anything since he did not have an attachment on the tubing. The Paramedic said after the female staff member said she wasn't doing compressions, the second EMS (Emergency Medical Services) unit arrived, and they took over. The Paramedic said staff didn't know if the resident had been down a while or not, no one could say. She said EMS responders do compressions and work on the resident until cardiac pads are on and heart rhythm can be verified. The Paramedic said the resident was not obviously deceased when they arrived. An interview was conducted on [DATE] at 12:31 p.m. with an Emergency Medical Technician (EMT). The EMT confirmed she came to the facility on the call for Resident #1 on [DATE]. The EMT said when she walked in the room two male staff were sitting on the bed bending over trying to figure out the suction. She said there was a cart with suction and oxygen and staff were trying to figure that out. The EMT said no one was doing compressions. She said the Paramedic on scene had to ask multiple times for someone to get on the chest. The EMT said one male staff member started compressions, but he wasn't doing it correctly. She said there were only two responders at the time, and they needed the staff to assist while they set up. She said the Paramedic was good at dealing with the staff and wasn't rude, but she was frustrated because she was having to ask multiple times for them to do their job. The EMT said she was trying to get the monitor set up and on the patient. She said when the 911 call was made it came in as CPR in progress and all the staff should know how to do CPR. The EMT said after the male had been asked to do compressions the Paramedic asked for someone to take over, then the second crew arrived, and they took over CPR from staff. An interview was conducted on [DATE] at 5:26 p.m. with an EMS Field Supervisor. He said he received a report from his Paramedic on Monday, [DATE], about the call they received to the facility. He said the Paramedic wrote an incident report regarding arriving at the facility and CPR not being performed on the resident when they arrived. He said he wanted to go talk to management at the facility to see what happened. He said the visit was more of a fact-finding mission. The EMS Field Supervisor said he spoke with the DON on [DATE] and she said she wasn't even aware Resident #1 had a cardiac arrest. He said he told her what happened and what the Paramedic witnessed. He said the DON told him it was probably CNAs in the room, and they are not trained to do CPR and are not allowed to do CPR in the facility. A review of Resident #1's medical record revealed a progress note, dated [DATE] at 5:29 p.m. by Staff I, Nurse, the nurse assigned to the resident. The note showed CNA [Certified Nursing Assistant] notified nurse resident was on floor in room. Nurse observed resident without respirations or pulse. Code status verified. Code blue called. CPR initiated and continued until EMS arrival whom took over (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 29 of 45 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 01/24/2024 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 0678 care. EMS notified. Resident pronounced deceased at 3:10 p.m. Level of Harm - Immediate jeopardy to resident health or safety Review of admission Records showed Resident #1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, schizoaffective disorder, bipolar type, epilepsy, anxiety disorder, Alzheimer's disease, disease of pancreas, hypothermia, and chronic obstructive pulmonary disease (COPD). Resident #1 expired on [DATE]. Residents Affected - Some Review of an Order Summary Report for Residet #1 revealed an active physician order for Full Resuscitation, order date [DATE]. An interview was conducted on [DATE] at 3:58 p.m. with Staff J, CNA. Staff J, CNA said she was just coming on her shift at about 2:45 p.m. She said she clocked in and got up to the unit just before 3:00. Staff J, CNA said she came up the back stairs and circled the unit before going to the nurses' station and when she came around the corner Staff K, Nurse and Staff I, Nurse were standing at the nurses' station directly across from Resident #1's room and both doors were open. Staff J, CNA said she and another staff member walked up at the same time and the other staff member looked in the room and said a resident had fallen. Staff J, CNA said she quickly set her things down and ran into the room. She said you could see the resident's hair on the floor from the hall. She said the resident was lying on her back and had some vomit/fluid on her face. She said she called out Resident #1's name a few times and the resident didn't respond. Staff J, CNA said she ran out the door and told Staff K, Nurse and Staff I, Nurse the resident was unresponsive and needed help. Staff J, CNA said both nurses looked at me like I was dumb and Staff I, Nurse said are you joking? She said Staff K, Nurse went in Resident #1's room and Staff I, Nurse came two minutes later. Staff J, CNA, said she went into the room to try to help but the nurses told her to leave. She said she did see Staff K, Nurse start CPR but does not know if it continued because she was told to leave. Staff J, CNA said there were 2 male nurses in the room (Staff K, Nurse and Staff L, Nurse) and 3 female Nurses (Staff I, Nurse and two nurses from downstairs.) An interview was conducted on [DATE] at 3:28 p.m. with Staff K, Nurse. He said he was coming in to work on [DATE] for the 3:00 p.m. shift. He said around 2:50 p.m. Staff J, CNA came and said Resident #1 was on her back and didn't look good. He said he went to the room and the resident was lying on her back with her head towards the bathroom door and wasn't breathing at all. He said one of the CNAs grabbed the resident's chart and Staff I, Nurse checked her code status. Staff K, Nurse said a CNA grabbed the emergency cart and he started CPR on the resident. Staff K, Nurse said Resident #1 was still warm. He said he didn't know what happened, but it looked like it just happened to me. He then said Staff I, Nurse brought the emergency cart in with her and used the AMBU bag (a bag valve mask that is used to deliver positive pressure ventilation) to give breaths to the resident and he did compressions. Staff K, Nurse said Staff L, Nurse came in to help and took over the AMBU bag from Staff I, Nurse. Staff K, Nurse said next, he and Staff L, Nurse switched places while Staff I, Nurse did paperwork. He said EMS came quick, but he was disappointed they didn't take over when they showed up. He said the female responder told him to keep doing compressions. He said two more emergency responders came into the room and they told us to continue CPR. Staff K, Nurse said EMS never did chest compressions. He said he was doing compressions when EMS walked in the door and only stopped when they told him to. He said EMS was sticking needles in her and sticking patches on and he thought it was unusual they didn't take over. He said EMS was only there about 5 minutes that's it. She was gone. He said he doesn't remember who all was in the room besides Staff I, Nurse and Staff L, Nurse but he does know the weekend supervisor (Staff N, Nurse) came up at some point. An interview was conducted on [DATE] at 10:26 a.m. with Staff N, Nurse, the weekend supervisor. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 30 of 45 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 01/24/2024 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some said she was not in the facility when Resident #1 coded. She said she left the facility between 11:00 a.m. and 12:00 p.m. that day. Staff N said there was no supervisor at the facility during the event and staff should have notified the ADON or DON. A follow-up interview was conducted on [DATE] 3:22 p.m. with Staff K, Nurse. Staff K said when the CNA called him to the room Resident #1 was lying on the floor unresponsive. He said he assessed the resident and went out to the nurses' station and got her chart to confirm her code status. He said the CNA stayed in the room while he went to the nurses' station, but the CNA did not do any CPR. He said Staff I, Nurse was sitting at the nurses' station and she called a code blue. Staff K then said he grabbed the emergency cart and took it in the room. He said he did a mouth sweep of the resident and that is when Staff L, Nurse got to the resident's room. He said Staff L, Nurse and himself did CPR on Resident #1. Staff K said Staff L, Nurse got there immediately and the two of them did the whole thing. No other nurse helped out. He said no one else performed compression and if anyone else told you something different that is totally incorrect. When asked who else was in Resident #1's room assisting with the code, Staff K said, I can't tell you. I didn't look around. An interview was conducted on [DATE] at 3:17 p.m. with Staff I, Nurse. Staff I said on [DATE] she worked the 7:00 a.m. to 3:00 p.m. shift. She said Resident #1 coded at shift change. She said she believed it was Staff J, CNA who let her know the resident needed help, but she doesn't remember her exact words. She said Staff K, Nurse checked on the resident while she checked the resident's code status. Staff I confirmed Resident #1 was a full code. She said Staff K, Nurse started CPR and another male nurse was in the room, but she didn't know what that nurse was doing. Staff I said she didn't know if there were any CNAs in the room. Staff I said, I believe he did CPR until EMS arrived. Staff I said she wasn't in the room; she was calling 911 and doing paperwork. She said the other nurses had the emergency cart in the room. Staff I said she did go in the room at some point but doesn't remember when. She said she was doing paperwork and calling 911. She said when EMS arrived, I handed off the paperwork and stepped out. Staff I said EMS did not ask her to assist with CPR. She said they came in and took over. Staff I said the resident was assigned to her that day. She said she saw her just before lunch and the aides said she was in the dining room and lunch ended around 2:00-2:15 p.m. A follow-up interview was conducted on [DATE] at 3:49 p.m. with Staff I, Nurse. She said she confirmed the resident was a full code. She said when she went in the room Staff K, Nurse was doing compressions and Staff L, Nurse was giving the resident breaths, I did not pay any attention to if another nurse was on the floor. I saw [Staff K, Nurse] and [Staff L, Nurse.] Did not see another nurse hands on. When asked who was at the code cart Staff I stated, I was not paying attention to that. When ask if there were just a few people in the room or a lot of staff she said, I don't know how many people were in there. Staff I said she was not documenting and did not know who filled out the Code Blue Worksheet. She said she did not stay in the room. An interview was conducted on [DATE] at 4:29 p.m. with Staff L, Nurse. Staff L said he came in to work on [DATE] for his 3:00 p.m. shift. He said he heard the code called and went upstairs to help on the 300 unit. He said when he arrived Staff K, Nurse was assessing the resident and Staff I, Nurse was prepping the emergency cart. Staff L said he thinks there were some CNAs in the room too. He said Staff K, Nurse started CPR and I think I took the AMBU bag when Staff I, Nurse was taking it off the cart. He said, I might have taken over compressions then switched to the AMBU bag. That's probably what happened. Staff L said Staff K, Nurse was doing CPR on his own while everything was getting set up. He said a lot was going on, but they probably did 6 rounds of 15 compressions and 2 breaths before EMS got there. Staff L, Nurse said they were still following through with compressions when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 31 of 45 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 01/24/2024 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some EMS got to the room. He said EMS wanted compressions to continue but said the nurse should stop using the AMBU bag. He said he didn't know why and maybe it was some new protocol. He said when the second EMS unit arrived, they took over compressions on Resident #1. Staff L said he does remember the female EMS responder talking about Staff K, Nurse not doing compressions correctly and could we get someone else to do it. He said, I think they were just upset about us doing the AMBU bag. Staff L said Staff I, Nurse was in the room when EMS arrived because he remembers going to stand in the corner with her. He said she was in the room pretty much the whole time. He said CPR was being done during the time I entered the room. I think it continued on until EMS took over. Staff L said they did roll the resident on her side to suction fluids in her mouth. He said he suctioned her once and Staff K, Nurse suctioned her once. Staff L said he and Staff K, Nurse were never just sitting on the bed, but he said he did sit on the bed at some point while he was using the AMBU bag on the resident. He said only he and Staff K, Nurse did compressions on the resident. He said no one else did compressions or helped position the resident. A follow-up interview was conducted on [DATE] at 10:50 a.m. with Staff L, Nurse. Staff L said when he got to Resident #1's room there were people in the room, but he did not know them because he has worked in the facility for less than a month. He said Staff K, Nurse initiated CPR, the resident was being assessed, and Staff K, Nurse was checking her pulse. He said Staff I, Nurse handed him the AMBU bag off the emergency cart. Staff L said he took over chest compressions and he and Staff K, Nurse switched between doing compressions and breaths and there was no one else assisting with CPR. He said at one point he was sitting on the bed while he was suctioning Resident #1. He said when EMS arrived, they told Staff K, Nurse to continue with compressions and Staff L, Nurse said he went and stood in the corner of the room beside Staff I, Nurse. He said one of the responders was rude to the staff and yelled about them not doing things right. He said, She was adamant and making comments like can someone else do this, does anyone know how to do this. I did not think much of it. An interview was conducted on [DATE] at 11:10 a.m. with Staff O, Nurse. She said she worked from 7:00 a.m. to 3:00 p.m. on [DATE] and responded to a code on the 300 unit. Staff O said the code was called three times over the speaker to Resident #1's room. She said when she got upstairs there were already quite a few people that had responded. Staff O, Nurse said when she got to Resident #1's room Staff K, Nurse, Staff L, Nurse, Staff P, Nurse, and Staff M, Nurse were there and Staff I, Nurse was on the phone. Staff O said the resident was lying on the floor and the emergency cart was in the room. She said Staff K, Nurse was on the lower end of the resident, Staff L, Nurse was on the top end of the resident, and Staff P, Nurse was grabbing supplies. Staff O said she grabbed the AMBU bag for Staff L, Nurse and Staff K, Nurse started compressions. She said she got on the floor and helped position the resident and tilt her head to get air. Staff O said Staff I, Nurse came back in the room and confirmed resident was a full code. She said Staff M, Nurse came in and asked if 911 had been called and asked if she could do anything to help. Staff O said at one point she took over compressions on Resident #1 from Staff K, Nurse to give him a break. She said Staff L, Nurse was doing the AMBU bag and Staff P, Nurse was grabbing supplies and paperwork. Staff O said EMS arrived and the staff continued CPR until EMS took over. She said the male responder took over compressions from Staff K, Nurse and a second EMS responder took over the AMBU bag from Staff L, Nurse. She said they were not asked to stop using the AMBU bag, they continued until EMS took it over. She said she was always taught to not stop CPR until EMS arrives and takes over. She said when EMS arrived, they could see that the staff were doing CPR. Staff O said while CPR was being done there was a little mucous/discharge that came to the resident's mouth so Staff I, Nurse grabbed the suction and Staff K, Nurse suctioned the resident only one time. A follow-up interview was conducted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 32 of 45 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 01/24/2024 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some on [DATE] at 11:25 a.m. with Staff O, Nurse. Staff O said when she heard the code called, she ran to the room, grabbing gloves on her way. She said Staff I, Nurse was standing by the door of the nurses' station calling 911, the emergency cart was already in the room, and Staff K, Nurse, Staff L, Nurse, and Staff P, Nurse were already there. She said the resident was lying on the floor flat on her back. Staff O said Staff P, Nurse grabbed the AMBU bag off the cart and gave it to Staff L, Nurse. Staff O said she got down on the floor and held Resident #1's head in a tilt position, Staff K, Nurse was doing compressions, and Staff L, Nurse was giving breaths with the AMBU bag. Staff O said she yelled out to Staff I, Nurse and asked if EMS was coming because she was used to them responding faster. She said while Staff K, Nurse was doing compressions, she noticed there was some discharge in the resident's mouth and Staff L, Nurse said they needed to suction the resident. Staff P, Nurse was handing us supplies and Staff I, Nurse came back in the room grabbed the suction tubing, placed a yankauer catheter on the tubing and handed it to Staff L, Nurse, who quickly suctioned the resident and gave it back to Staff I, Nurse. Staff O said she switched with Staff K, Nurse and did compressions, but didn't do them for very long and she said she did not ever see Staff L, Nurse do any compressions. Staff O said they did not stop CPR and Staff K, Nurse was doing compressions when the first responders arrived. Staff O said the female medic told them to continue CPR and they didn't take over right away. She said Staff P, Nurse gave the medic the paperwork they needed, and the medic was asking their standard questions like how long the resident had been down. Staff O said a male responder arrived and took over compressions and another took over the AMBU bag. She said the female responder, who seemed to be the lead, was quite rude. Staff K, Nurse said to her, you don't have to be so [expletive] rude. She [the female responder] didn't respond. An interview was conducted on [DATE] at 12:18 p.m. with Staff P, Nurse. Staff P said the code for Resident #1 was called right at the end of her shift, around 3:00 p.m. on [DATE]. She said by the time she arrived in the room; several other nurses were there. Staff P said she asked if they needed anything and did they already do things like check code status, call 911, etc. She said they told her they did not need anything. Staff P said Staff I, Nurse, Staff, K, Nurse and Staff L, Nurse were in the room, but she did not remember if any CNAs were present. She said Staff K, Nurse was doing compressions, she doesn't remember seeing if anyone was giving breaths with the AMBU bag, and Staff I, Nurse was standing there, but Staff P doesn't know what Staff I, Nurse was doing. Staff P, Nurse said she helped get other residents from the hall to the dining room and said she did not help with any paperwork or handing off or gathering equipment. Staff P said she was not near the room when EMS arrived and was not in the room while EMS was there. A follow-up interview was conducted on [DATE] at 12:09 p.m. with Staff P, Nurse. Staff P, Nurse reiterated Staff K, Nurse was doing compressions and Staff L, Nurse and Staff I, Nurse were in Resident #1's room. She said Staff K, Nurse was the only person she knew was physically doing something. She said they all told her they didn't need anything. She confirmed she was not handing equipment or doing paperwork at any point and never went all the way into the resident's room. An interview was conducted on [DATE] at 12:36 p.m. with Staff Q, CNA. Staff Q, CNA said when the code was called on [DATE] for Resident #1 everyone went from the different units. She said CNAs do not perform CPR they just help keep other residents away from the area. She said Staff K, Nurse, Staff L, Nurse and Staff J, CNA were already there. Staff Q, CNA said she grabbed the emergency cart and she and Staff K, Nurse took it to the room. She said she didn't know if Staff K, Nurse had been in to assess the resident or not. She said Staff L, Nurse was next to arrive. Staff Q, CNA said she remembers hearing Staff K, Nurse talking about getting ready to do compressions, but didn't see who was doing CPR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 33 of 45 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 01/24/2024 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some An interview was conducted on [DATE] at 1:24 p.m. with the DON. The DON said she wasn't working the day Resident #1 coded. She said Staff J, CNA found the resident and told Staff I, Nurse and Staff K, Nurse to come to the room because something was wrong with the resident. The DON said the resident wasn't breathing and did not have a pulse so Staff I, Nurse called the code. She said everyone went to the room and Staff K, Nurse started CPR after the code status for Resident #1 was verified. The DON said they continued CPR until EMS arrived and then EMS took over compressions. She said the resident was declared deceased at the facility. The DON said the people involved were Staff J, CNA, Staff K, Nurse, Staff L, Nurse, Staff I, Nurse, Staff O, Nurse, Staff M, Nurse, Staff N, Nurse/weekend supervisor, and two other CNAs (Staff Q, CNA and Staff R, CNA.) The DON said Staff K, Nurse and Staff L, Nurse are the two that did CPR and the rest got items needed for them or helped get other residents out of the hall. The DON said Staff K, Nurse did CPR and Staff L, Nurse assisted, Staff I, Nurse called the code and 911, Staff P, Nurse got items they needed during the code and Staff N, Nurse/weekend supervisor was directing people what to do and who needed to do what. The DON said Staff M, Nurse was helping get people out of the room. When asked when she was informed of Resident #1's cardiac arrest, she said Staff N, Nurse /weekend supervisor called her from the facility while it was occurring or shortly after. The DON was informed Staff N, Nurse/weekend supervisor was not in the facility and she said, She didn't call me? Am I getting people confused? The DON confirmed someone from the fire department came to speak with her the day after the incident and wanted to speak with her about the code for Resident #1. She said EMS had some questions about a female staff member not assisting in the code. The DON said she asked him for a name and the circumstances around what happened, and she said he told her the females that wouldn't help were CNAs. The DON said she told him the CNAs are not trained in CPR and do not do CPR in the facility. She said he understood, and said he did not mention CPR not being done when EMS arrived. An interview was conducted on [DATE] at 3:10 p.m. with the DON. She said for a code blue she would expect there to be a nurse's note in the medical record to say what the scenario was. She said she wouldn't really expect the note to say who was involved or who did what. The DON said they have a Code Blue Worksheet that is filled out and is part of the medical record. At 3:30 p.m. the DON said she wanted to clarify that the Code Blue Worksheet is not part of the medical record. The Code Blue Worksheet for Resident #1 dated [DATE] was reviewed. The information on the sheet was incomplete and the times listed on the worksheet do not line up with the times EMS recorded as having received the 911 call and responded. The DON could not identify who filled out the Code Blue Worksheet provided. 2. Emergency Carts An observation was conducted on [DATE] at 9:44 a.m. of the 100 high hall emergency cart. The emergency cart was sitting in the hall directly across from the nurses' station. The oxygen tank meter on the cart showed the tank was only ¼ full and the needle was pointing to where the red and yellow line met. (The yellow line indicated the oxygen tank was running low and the red indicated the tank was empty.) The cart contained an Emergency Cart Inventory Check List showing the following items should be in the cart: 1-Mobile Emergency Cart 2-Gloves 3-CPR backboard 4-AMBU bag (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 34 of 45 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 01/24/2024 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 0678 5-Charged Oxygen tank Level of Harm - Immediate jeopardy to resident health or safety 6-Oxygen tubing Residents Affected - Some 8-Oxygen Mask simple 7-Nasal Cannula 9-Oxygne Mask non-rebreather 10-Suction machine (set up with cannister and connection tubing ready to operate 11-Suction catheter (Yankauer) 12-Suction catheter (flexible) 13-Blood pressure cuff (large and small) 14-Stethoscope 15-Code Documentation form/Pad on clipboard 16-Pen Black ink (2) The 100 high hall emergency cart did not have a CPR backboard (#3) or a yankauer suction catheter (#11). The top of the cart was also soiled with dried liquid and debris. The Emergency Cart Inventory sheet showed the cart was signed off by a staff member daily from [DATE] to [DATE] as being verified that each item listed in the inventory was present and available for immediate use. (Photographic evidence obtained.) On [DATE] at 9:50 a.m. the cart remained with an oxygen tank only ¼ full, with no backboard and no yankauer suction catheter. The Emergency Cart Inventory had been signed off as verified on [DATE]. (Photographic evidence obtained.) An observation was conducted on [DATE] at 9:51 a.m. of the main dining room emergency cart. The cart did not contain a small blood pressure cuff (#13), it contained two large cuffs. The Emergency Cart Inventory was signed off as verified on 1/1 to [DATE] and 1/15 to [DATE]. The cart had not been checked on [DATE] and [DATE]/24. (Photographic evidence obtained.) An observation was conducted on [DATE] at 1:35 p.m. of the 300 hall emergency cart. The cart was in the nurses' station behind a locked door, and it was being blocked by a cart with a drink cooler on it. The suction canister that was attached to the suction machine on the cart had been used and contained dried fluids. The cart did not contain a small blood pressure cuff (#13; it contained two large cuffs. Staff V, Nurse, came over and looked at the suction canister. She said it was disgusting and there is no reason for that. Staff V, Nurse, said the night shift staff checks the carts and makes sure they are stocked and clean. She said she doesn't know why this cart was signed off everyday with the used suction canister. Staff V, Nurse said she believed [DATE] was the last time the cart was used but she would have to check with the DON. (Photographic evidence obtained.) An interview was conducted on [DATE] at 1:24 p.m. with the DON. The DON confirmed the 300 hall emergency cart was last used on [DATE]. The DON confirmed on [DATE], two codes were called on the 300 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 35 of 45 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 01/24/2024 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some hall: one around 7:00 a.m. and one around 3:00 p.m. When asked if the cart had been restocked and cleaned after the morning code she stated, I can't say that it was. The DON said the cart should be restocked with whatever was utilized during the code, ideally right after the code is completed. She said the emergency carts were checked by the night shift and they should check to make sure all items on the inventory are on the cart and available for use. When asked what level the oxygen tank should be, the DON said there is no policy to show when to change it. When asked if ¼ of a tank of oxygen is sufficient she said, it is just supposed to be functional for use. She said if it turns on and works it is fine and if it ran out in a code someone would get another oxygen tank. Regarding the 300 hall suction canister being soiled, the DON said she doesn't know what happened with it sitting there. An interview was conducted on [DATE] at 9:47 a.[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 36 of 45 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 01/24/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the facility failed to perform ordered laboratory (lab) testing, failed to inform the provider of critical lab results and/or failed to carry out provider orders in response to critical lab results for two resident (#11 and #13) out of three residents reviewed for labs. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #11, and #13 and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Finding included: 1. Resident #11 Review of the admission records showed Resident #11 was initially admitted on [DATE] after a hospital stay for pneumonia and with diagnoses including pneumonia, immune deficiency syndrome, thrombocytopenia, and cirrhosis of liver and was re-admitted on [DATE], after a hospitalization for a gastrointestinal bleed. According to a National Heart, Lung, and Blood Institute article titled, Thrombocytopenia, dated [DATE], Thrombocytopenia is a condition that occurs when the platelet count in your blood is too low. The article stated this can be life-threatening, especially if the patient had serious bleeding or bleeding in the brain, but early treatment could help avoid serious complications. The article explains bleeding causes the main symptoms of thrombocytopenia with signs including bleeding that last a long time, even from small injuries, petechia (small, flat red spots under the skin from blood leaking out of blood vessels), purpura (bleeding in your skin that can cause red, purple, or brownish-yellow spots) nosebleeds or bleeding from gums, or blood in urine or stool. (Accessed on [DATE] at https://www.nhlbi.nih.gov/health/thrombocytopenia) Review of medical records for Resident #11 showed a progress note, dated [DATE], saying the resident reported to the nurse she was vomiting on the floor inside her room. When nurse arrived in resident's room, she noticed a huge amount of coffee brown and red blood on the floor. The resident denied any pain, discomfort, or shortness of breath. This nurse immediately called the doctor and received orders to send the resident to the hospital for evaluation and treatment. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 3008), dated [DATE], showed Resident #11 was diagnosed with an upper gastrointestinal (GI) bleed and needed to have Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) labs drawn in 2-3 days. Discharge instructions noted the resident had a transfusion of 2 units of packed red blood cells (PRBC) on [DATE]. The plan was to follow-up with the primary care provider in 3-5 days, follow-up with a Gastroenterology physician in 2 weeks and follow-up with a cardiology physician. Review of labs drawn at the facility on [DATE] for Resident #11 had the following results. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 37 of 45 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 01/24/2024 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 (WBC) Level of Harm - Immediate jeopardy to resident health or safety 1.1 Residents Affected - Some Critical Low ref range 3.8-10.8 Red Blood Cell (RBC) 2.84 ref range 3.90-5.20 Low Hemoglobin (Hgb) 8.9 ref range 12.0-15.6 Low Hematocrit (Hct) 25.8 ref range 35.0-46.0 Low Platelets (PLT) 34 ref range 130-400 Critical Low Review of Resident #11's medical record did not show any documentation a provider was notified, or any new orders were put in place related to the critical lab results from [DATE]. The Director of Nursing (DON) provided a copy of the lab results showing they were faxed from the lab to the facility on [DATE] at 12:35 p.m. and Resident #11's primary care provider signed the results as being reviewed by him on [DATE]. At that time, he put in a stat (immediate) order to repeat the labs. Review of labs drawn on [DATE] for Resident #11 had the following results: WBC (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 38 of 45 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 01/24/2024 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 1.1 Level of Harm - Immediate jeopardy to resident health or safety ref range 3.8-10.8 Residents Affected - Some RBC Critical Low 2.81 ref range 3.90-5.20 Low Hgb 8.8 ref range 12.0-15.6 Low Hct 25.5 ref range 35.0-46.0 Low PLT 23. ref range 130-400 Critical Low Review of medical records for Resident #11 revealed a progress note on [DATE] showing On Call MD [doctor] for [primary care provider (PCP)] notified regarding resident CBC critical lab result. Order received for Hematologist consult. Review of physician orders revealed an order dated [DATE] for a Hematologist consult for critical WBC 1.1, Platelet count 34 every day shift for Critical lab result. This order was a verbal order given by the on-call provider notified on [DATE] of critical lab values. Review of physician orders from [DATE]-[DATE] revealed no orders for the resident to follow-up with a gastroenterologist within two weeks of hospital discharge (by [DATE]) or for a cardiology consult per hospital discharge instructions. The orders did not show any antiretroviral therapy (ART) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 39 of 45 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 01/24/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Some treatment in place for the resident and no lab orders to check the resident's immune deficiency syndrome status. Review of Resident #11's [DATE] Medication Administration Record (MAR) showed the order for Hematologist consult was signed off as completed by the nurse daily from [DATE] to [DATE]. However, there were no progress notes indicating a hematologist had been consulted, no appointment scheduled for the resident to see a hematologist, and no doctor notes showing a hematologist had seen the resident. Review of Resident #11's medical record did not show any interventions or orders in place to monitor the resident for signs and symptoms of bleeding related to the critically low platelet counts. Review of Resident #11's medical records showed a progress note, dated [DATE] 3:00 p.m., revealing the resident was found unresponsive without pulse or respirations in her room at approximately 2:16 p.m. on [DATE]. A code blue was called, CPR was initiated after code status was verified. Emergency Medical Services (EMS) arrived and took over care and continued with CPR. EMS pronounced the resident expired at 2:48 p.m. Review of medical records showed a Social Services note, dated [DATE] that said Resident #11 is alert and oriented and can make her needs known. The resident reported to Social Services she lived in shelters, and she would like to improve her health. Review of Resident #11's Psychosocial History and Assessment, dated [DATE], showed the resident was previously homeless, but said she was adjusting and felt safe in the facility. The resident's goals for her stay were to maintain her health and medications. The Assessment also showed the resident reported transportation had kept her from medical appointments or from getting medications. It also noted the resident was cooperative, pleasant, and motivated. An interview was conducted on [DATE] at 4:28 p.m. with the Social Services Director (SSD). The SSD stated she remembered Resident #11. She said the resident mostly kept to herself but was starting to engage a little more. She said the resident came in as a homeless person and it seemed like she had a difficult life but was happy to be here. The SSD said she knew the resident had an immune deficiency syndrome but did not discuss it with her. The SSD said, I know she wanted to get stronger. She was not resistive to care. She said she was not aware of the resident ever refusing medications, She wanted to live. She just wanted to get better. An interview was conducted on [DATE] at 12:04 p.m. with Staff G, Nurse Staff G said she completed the initial admission assessment for Resident #11. Staff G said Resident #11 would walk around like normal, she was very nice and didn't refuse medication or care. She said the resident had been homeless and was super thankful to be here. An interview was conducted on [DATE] at 5:34 p.m. with the Assistant Director of Nursing (ADON). The ADON said for critical lab results, the nurse is expected to call the resident's provider right away. She said the nurse should notify the provider of all labs, but critical labs require an immediate response. The ADON said the nurse assigned to the resident should also contact the doctor for follow-up. The ADON said she was not aware of any concerns related to Resident #11's labs. An interview was conducted on [DATE] at 10:52 a.m. with a lab technician (tech), who worked for the laboratory (lab) processing the facility's lab orders. The lab tech said when lab results are critical, the nurse caring for the resident is called and if they cannot reach the nurse caring for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 40 of 45 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 01/24/2024 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 - Immediate jeopardy to resident health or safety resident, they ask for the Director of Nursing (DON.) If the DON is not reachable, they call the receptionist and ask for a nurse. He said if they still get no response, they fax the facility and ask for them to call the lab. He said the lab results are also faxed to the facility, even when a call is made. The lab tech reviewed Resident #11's lab work and said on [DATE] the resident had critical results and Staff F, Nurse was notified on [DATE] at 1:40 p.m. The lab tech also confirmed Resident #11 did not have any labs drawn related to her immune deficiency syndrome, she only had a CBC and CMP. Residents Affected - Some An interview was conducted on [DATE] at 3:47 p.m. with Staff F, Nurse. Staff F said Resident #11 was a very pleasant, very nice lady and was very mobile and cooperative with care. She said on [DATE] she was not notified of Resident #11's critical lab results. Staff F said on [DATE] she saw critical lab results for Resident #11 and her primary care provider was in the building, so she had him review and sign the results. Staff F said I got so busy, I always put a note in. I forgot to put the note in the computer. Staff F said it is difficult because Unit Mangers follow up on labs but get put on the medication cart to work and someone else is supposed to take care of those duties. She said there needs to be a better process in place for the Unit Manger job duties for when unit managers are working on the medication cart. Regarding Resident #11 she said, We failed her. An interview was conducted on [DATE] at 1:10 p.m. with Staff E, Nurse. She stated Resident #11 was calm, compliant, and cognitively aware. She said the resident could walk around the facility independently but did like being in her room. Staff E, Nurse said when a resident had critical lab results, the lab would call the nurse and fax the results. She said the nurse then calls the provider's office immediately, even if it is after hours. Staff E, Nurse said after Resident #11 had critical lab results on [DATE] she saw a hematology consult was ordered, but she said on her screen it only showed a consult is needed, it did not show her it was related to critical lab values. Staff E, Nurse said she believed the consultation was a follow-up. Staff E, Nurse reviewed the order in the resident's electronic medical record and confirmed the order showed the consultation was for critical labs, she reiterated it does not show up like that on the nurses' screen, it only shows a consult is needed and does not provide the order details. She said she reached out to a couple of hematology offices and was waiting to hear back. She said she didn't document anything because there wasn't an appointment scheduled. Staff E, Nurse said if she had known the consultation was for critical labs, she would have made more attempts, documented, and reached out to the primary care provider to let them know there wasn't an appointment yet. Staff E, Nurse confirmed there was no monitoring in place related to signs and symptoms of bleeding for Resident #11. Staff E, Nurse said on [DATE] Resident #11 mentioned she wasn't feeling good. The facility had some residents with COVID-19, so they did a COVID test around 1:30 p.m. and it was negative. Staff E, Nurse said she called the doctor, and a chest x-ray was ordered. When the x-ray technician showed up, they found the resident unresponsive in bed. An interview was conducted on [DATE] at 10:10 a.m. with the DON. The DON reviewed Resident #11's electronic medical record regarding critical lab results. The DON said, I don't see anything written, related to the critical lab values on [DATE]. She said she thinks Staff F, Nurse talked to the provider, but she confirmed nothing was documented. The DON said for critical lab values, they receive a call and a fax from the lab. She said the fax goes directly to the nurses' station and the nurses know to check for faxes. The DON said the doctor should be notified immediately. She said management does look at results and if there are orders they follow up to ensure those were completed. The DON said I think that is why the Unit Manager, Staff F, Nurse, spoke to the nurse practitioner about the labs, I just don't see a note. Regarding the hematology consult for Resident #11, the DON said she believed one of the nurses was working on getting an appointment, but I don't see it documented. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 41 of 45 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 01/24/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Some confirmed the lack of action for the critical labs was a problem. The DON said with these critical lab values she would have expected monitoring for signs and symptoms of bleeding to have been in place. She reviewed the medical record and confirmed the monitoring was not in place for Resident #11. An interview was conducted on [DATE] at 2:41 p.m. with Resident #11's PCP. The PCP said he was aware of the resident, but he believed his nurse practitioner saw her. Regarding Resident #11's critical lab results on [DATE], the PCP said he was not notified of the critical lab results when they came in. He said a week or so after that (he said he didn't remember the date), he saw the results. He said when he first saw the lab results, he wanted to send Resident #11 to the hospital, but the results were so old, so he ordered repeat labs. The PCP said he didn't hear anything back and when he went to check on the resident's labs again, he was notified she died. An interview was conducted on [DATE] at 5:00 p.m. with Resident #11's PCP's Advanced Registered Nurse Practitioner (ARNP.) The ARNP said she saw Resident #11 last on [DATE] and she was not in any distress. She said the resident was cooperative with care and there had not been any non-compliance reported. The ARNP said she was not notified of Resident #11's critical lab results on [DATE]. She said if something was abnormal, she would expect to have been notified. The ARNP said she receives notifications from facilities on an application program (app) her practice uses or on her text messages. She reviewed her provider app and text messages and confirmed she had no notifications related to Resident #11's critical labs on [DATE]. She said, I rely on staff to let me know if anything needs a STAT response. They have my number. I know she was at high risk with such low numbers. That was kind of missed. It is unfortunate. The ARNP confirmed she was working on [DATE] and would have been available if staff contacted her. As for the critical lab results on [DATE] for Resident #11, she said she did not see those labs, but the response for the resident to see a hematologist should have been STAT. The ARNP said she would have personally sent the resident to the hospital with her platelet count below 40. 2.Resident #13 Review of the admission Records showed Resident #13 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease and epilepsy. Review of medical records showed Resident #13 had a care plan in place for Seizure Disorder, dated [DATE]. Interventions to include Obtain and Monitor lab/diagnostic work as ordered. Report results to doctor and follow up as indicated. Review of Resident #13's physician orders showed the following active orders: -Levetiracetam (Keppra) oral solution 100 milligram (mg) per milliliter (ml) Give 12 ml in the evening for seizure, dated [DATE] -Levetiracetam 100mg/ml Give 14 ml one time a day for seizures, dated [DATE], -Keppra level every 6 months starting on the 5th for 1 day, dated [DATE]. Review of Resident #13's [DATE] Treatment Administration Record (TAR) showed the Keppra level lab was due on [DATE]. It was signed off on the TAR as completed. Review of the Facility Lab book that is kept at the nurses' station contained a Lab Monitoring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 42 of 45 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 01/24/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Sheet, dated [DATE], showing Resident #13's Keppra level was to be drawn that day. The lab was not signed off by the phlebotomist as being drawn. There was no documentation on the Lab Monitoring Sheet or progress notes to indicate the resident refused the lab draw. Review of Resident #13's Quarterly Minimum Data Set (MDS,) dated [DATE], Section C, Cognitive Patters, showed he had a Brief Interview for Mental Status (BIMS) score of 3, indicating a severely impaired cognition. He was unable to be interviewed. An interview was conducted on [DATE] at 1:05 p.m. with Staff H, Nurse. Staff H reviewed the Lab Monitoring Sheet for [DATE] out of the lab book. She then logged into the laboratory company's website and confirmed the last lab for Resident #13 was drawn in [DATE]. Staff H reviewed Resident #13's physician orders and confirmed it should have been drawn on [DATE] and it was not completed and there was no documentation as to why. Staff H said this lab was scheduled to be drawn on a Saturday and the missed lab should have been caught when it was reviewed by management on Monday morning. An interview was conducted on [DATE] at 1:38 p.m. with the DON. The DON said each unit had a lab book where lab orders were listed. She said the lab tech draws the lab and signed it off in the book each day on the Lab Monitoring Sheet. The unit managers then took the daily lab monitoring sheet out of the book and made a copy of it. The original daily lab monitoring sheet was returned to the book and the unit managers used the copy to check off each section of the lab sheet (i.e. results, doctor notified, results in chart, orders received, noted in chart, and comments) as it was completed. The DON confirmed the copied daily lab monitoring sheet was not reconciled with the lab monitoring sheet in the lab book. She said the unit managers brought the copied sheet to the morning meetings where the management team reviewed labs. The completed sheets were given to the DON. She agreed a nurse would not be able to see if all the steps were completed if they checked the daily lab book. The Regional Nurse Consultant (RNC) pulled up Resident #13's medical record and confirmed his lab had not been completed as ordered. The DON said she didn't know how that happened and why it wasn't reviewed and caught. An interview was conducted on [DATE] at 3:05 p.m. with the facility's Medical Director. The Medical Director stated he would expect critical lab values to be responded to the day the facility receives them. He said the nurse should reach out to the resident's provider and if they do not get a response, they should call him. The Medical Director said for critical lab values, staff can always call him, and the resident could be sent to the emergency department for acute care. He said if staff had concerns or did not get an appropriate response from the resident's doctor, they should let me know. He said he would expect there to be documentation in a resident's record anytime a provider was contacted, or an attempt was made. The Medical Director said he would be addressing these concerns with the facility. Review of a facility policy titled Laboratory Services, effective [DATE], showed the following: Policy: The facility will provide or obtain laboratory services to meet the needs of its residents/patients. The facility will be responsible for the quality and timeliness of services whether provided by the facility or an outside agency. The laboratory selected to perform the tests will be Medicare approved. Procedure 1. Assure laboratory tests or[sic] completed and results provided to the facility within timeframes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 43 of 45 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 01/24/2024 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 normal for appropriate intervention. Level of Harm - Immediate jeopardy to resident health or safety 2. Provide or obtain laboratory services only when ordered by a physician. Residents Affected - Some 4. Assist the resident/patient in making transportation arrangements to and from the laboratory if specimen is unable to be obtained at the facility and if the resident/patient needs assistance. 3. Assure Nursing notifies the physician promptly of the findings. 5. Assure the laboratory reports submitted by the laboratory and filed in the resident/patient's clinical record contain at least the following: a. Date b. Resident/patient name c. Name and address of the testing laboratory 6. Monitor services, timelines, and quality through the Quality Assurance Committee. Facility immediate actions to remove the Immediate jeopardy included: 1.Regional Nurse Consultant completed education on the lab monitoring process with the facility Administrator, Director of Nursing, and Assistant Director of Nursing. 2.Director of Nursing and Assistant Director of Nursing completed education with licensed staff related to the daily lab monitoring process on [DATE]. Education included the lab monitoring process. Lab requisitions are listed on the monitoring form by the licensed nurse, the phlebotomist signs the entry when lab is drawn, the facility nurse upon receipt of the lab results notifies medical provider of any critical results. The nurse then completes the lab monitoring form which includes documentation of the notification in the medical record. The lab monitoring binder which contains the daily forms is brought to the clinical meeting and reviewed for completion by nursing leadership. 91% of Licensed Staff were educated regarding the lab monitoring process. The remaining 3 licensed nurses will receive the education prior to starting of their next shift. 3.This was completed on [DATE]. Verification of the facility's removal plan was conducted by the survey team on [DATE]. An interview was conducted on [DATE] at 3:50 p.m. with the DON, Regional [NAME] President (RVP), and Regional Nurse Consultant (RNC.) Copies of all education provided to staff were reviewed. They confirmed all nurses were educated on the process of ensuring labs were completed as ordered, reporting critical lab values, and following up on physician orders. The RNC confirmed they educated the Nursing Home Administrator and the DON. The RVP stated the facility was not correctly following the lab process. Interviews were conducted and education confirmed for 34 out of 34 nurses. Nurses signed in-service education and/or were able to state that they had been trained and were knowledgeable about the policies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 44 of 45 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 01/24/2024 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 Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of E. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105749 If continuation sheet Page 45 of 45