Health inspection·May 1, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few psychiatric/mood disorder diagnosis of bipolar disorder. Review of the Annual MDS, dated [DATE], Section I - Active Diagnoses revealed the resident has a Psychiatric/Mood disorder of bipolar disorder. An interview was conducted on 4/30/24 at 2:14 p.m. with the DON and she said social services and herself are responsible for ensuring PASRRs are accurate and complete. She confirmed the facility does not have social service personnel at this time but she will look to see if Resident #13 has a Level II PASRR. An interview was conducted on 4/30/24 at 2:40 p.m. with the DON and she confirmed there was no Level II assessment for Resident #13. She reviewed Resident #13's PASRR, dated 1/20/24, and confirmed the PASRR was not accurate. She said PASRRs are reviewed by social services upon admission for accuracy and she was the back up while the facility did not have social services personnel. Based on record reviews, and interview the facility failed to confirm the accuracy of the Pre-admission Screening and Resident Review (PASRR) Level I and failed to complete a PASRR Level II for three residents (#4, #13, and #29) out of sixteen residents sampled. Findings included: 1. Review of the admission Record revealed Resident #4 was originally admitted on [DATE] and the most current readmission was on 3/18/24. The admission Record revealed the following diagnoses for Resident #4: metabolic encephalopathy (11/10/2023), dementia (10/1/2022), schizoaffective disorder (3/18/2024), obsessive compulsive disorder 9/7/2023), depressive disorder (5/14/2019), obsessional thoughts and acts (12/30/2016), and anxiety (5/12/2015). Review of the physician orders, dated 5/1/2024, for Resident #4 revealed: memantine extended release 28-10 milligram daily for dementia (3/18/2024), sertraline tablet 50 milligram daily for depression (11/10/2023). Review of Minimum Data Set (MDS), dated [DATE], for Resident #4 revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 05 (severe cognitive impairment). Section I - Active Diagnoses showed other neurological conditions, metabolic encephalopathy, depression, other symptoms and signs with cognitive functions and awareness, other symbolic dysfunctions, and obsessive-compulsive personality disorder. Section N - Medications showed antidepressant is taking, and indication noted. Review of the care plan focus, printed 5/1/2024, revealed for Resident #4: behavior related to diagnoses of schizophrenia, anxiety, agitation, and dementia; impaired cognition/communication, behaviors related to vascular dementia, obsessive-compulsive disorder, schizoaffective disorder, anxiety disorder and seizure disorder; at risk for adverse effect due to antidepressive medications; and nutrition management related to dementia. Review of the Level I PASRR, dated 9/9/2013, for Resident #4 revealed: Section IA -Schizoaffective disorder, bipolar disorder Section 1B - serious mental illness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 2 of 14 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 105878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712 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 0644 Section II: Part A - mental illness, yes is identified for Resident #4 she has a diagnosis of serious mental illness. Level of Harm - Minimal harm or potential for actual harm Section III revealed Resident #4 has a primary diagnosis of dementia. Residents Affected - Few No PASRR Level II was present in record. Review of psychiatric diagnostic evaluations for Resident #4 dated 1/29/2024, 12/18/2023, and 11/20/2023, revealed all three contained chief complaint for psychotropic medication response for depression and anxiety, resident has had a past psychiatric admission (dates unknown), current plan of care is to continue medications and monitor nutrition for weight management. Diagnoses listed, anxiety with obsessional features, major depressive disorder, dementia, During an interview on 5/01/24 at 10:39 a.m. the Director of Nursing (DON) stated the current PASRR for Resident #4 was reviewed yesterday and the resident has not had a change in her conditions or a new diagnoses, she has been out of the facility to the hospital related to her seizure disorder, based on the current PASRR there should be a Level II completed. The DON also stated that social services is responsible for the PASRR, however the position is vacant at this time, and she is completing the PASRR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 3 of 14 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 105878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure baseline care plans were developed and accurate for two residents (#105, #205) of 28 sampled residents. Findings included: 1. A review of Resident #105's Clinical Profile revealed he was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, and history of transient ischemic attack. A review of Resident #105's care plan revealed he had a care plan in place to address advance directives which indicated that Advance Directives in place to include (SPECIFY). Review of the interventions revealed DNR [do not resuscitate] with an initiated date of 4/25/24. Review of the resident's physician orders revealed the resident was a full code under Code Status and an actual physician order dated 4/24/24 for Full Code. During a review of the Hospital History and Physical with a print date of 4/16/24 indicated the resident was a Full Code status on Page 2 of 36, and Page 23 of 36. During an interview with Resident #105's family member on 04/30/24 at 9:09 a.m. she reported the resident was a Do Not Resuscitate (DNR), and the facility has the paperwork. During an interview on 4/30/24 at 10:47 a.m. with the Director of Nursing (DON), she revealed that she updated the care plan today after speaking to the POA (power of attorney) this morning. She confirmed the resident has a living will and does not have a DNR and if that is what they want then DNR paperwork has to be signed for the DNR to be valid. During an interview on 4/30/24 at 10:56 a.m. Staff E, Minimum Data Set (MDS) Coordinator/Registered Nurse (RN), revealed between the DON and herself they were responsible for making sure the care plan is accurate. She reported that she has not looked at Resident #105 yet for his code status. She reported the nurses create the baseline care plan and she goes back and reviews it. She reported that she is doing it now because his ARD date is tomorrow, and that is when she makes sure the care plan is accurate. 2. Review of Resident #205's admission Record revealed he was admitted to the facility on [DATE] with diagnoses of cardiac arrest, cardiac arrest due to other underlying condition, malignant neoplasm of prostate, type 2 diabetes mellitus without complications, end stage renal disease, and dependence on renal dialysis. Review of Resident #205's physician order with an order date of 4/24/24 and no end date revealed Full Code. Review of the medical record was conducted on 4/29/24 at 12:05 p.m. and did not reveal an advanced directive care plan was in place. An interview was conducted on 4/30/24 at 2:10 p.m. with Resident #205. He said he would want life (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 4 of 14 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 105878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712 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 0655 Level of Harm - Minimal harm or potential for actual harm saving measures if anything were to happen to him and he has not had a care plan meeting since he has been here. A review of the medical record was conducted on 4/30/24 10:59 a.m. and revealed an advanced directive care plan with a creation date of 4/30/24 for Resident #205. Residents Affected - Few An interview was conducted on 4/24/24 at 10:30 a.m. with the Director of Nursing (DON) and she said baseline care plans are created based on the information from the admission data set. She said she doesn't think baseline care plans include advanced directives. She said advanced directives are determined upon admission and a physician's order is put in. She reviewed Resident #205's care plan and confirmed it was created on 4/30/24. Review of the facility's Baseline (Interim/Initial/IPOC) Plan of Care policy, revised on 8/2023, revealed: Policy The center will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The baseline care plan will be developed within 48 hours of a resident's admission. Fundamental Information (F655) Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increased resident safety, and safeguard against adverse events that are most likely to occur right after admission; if applicable; are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. (F655, N0072). A Comprehensive care plan can be developed in the place of the Baseline Care Plan . The Baseline Care Plan includes the minimum healthcare information necessary to properly care for a resident including, but not limited to: Information received from the referring center, .physician's orders, .social services orders, . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 5 of 14 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 105878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 04/29/24 at 10:52 a.m. Resident #39 was observed sitting outside making facial expressions as if she was crying. On 04/30/24 at 2:15 p.m. the resident was observed sitting in the common area next to the couch in her wheelchair. Her face was red, and she was moaning. A review of the admission Record showed the resident was initially admitted on [DATE] with diagnoses to include anxiety disorder, major depressive disorder, dementia, pseudobulbar affect, and Alzheimer's disease. A review of the Order Summary Report with active orders as of 04/30/24 revealed the following: buspirone HCl oral tablet 10 MG- Give 1 tablet by mouth two times a day for anxiety (04/19/24), desvenlafaxine oral tablet extended release 24-hour 50 MG (01/17/24)- Give 1 tablet by mouth one time a day related to major depressive disorder, rexulti oral tablet (02/04/24)- Give 2 mg by mouth one time a day for dementia and associated agitation and psychosis, tamoxifen citrate oral tablet 20 MG (01/23/24)- Give 1 tablet by mouth one time a day for mood disorder, and valproic acid oral solution 250 MG/5ML (01/17/24)- Give 5 ml by mouth three times a day for mood disorder. The Medication Administration Record (MAR) for February 2024, March 2024, and April 2024 showed no behavior monitoring for tamoxifen. The MAR for February 2024, March 2024, and April 2024 revealed no side effect monitoring for buspirone HCl oral tablet 10 MG, desvenlafaxine oral tablet extended release 24-hour 50 MG, rexulti oral tablet, tamoxifen citrate oral tablet 20 MG, and valproic acid oral solution 250 MG/5ML. Review of the care plan related to antidepressants, initiated on 07/07/21, revealed the following intervention: monitor ongoing signs and symptoms of depression unaltered by antidepressant medications: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body, functions, anxiety, and constant reassurance. On 04/30/24 at 2:05 p.m. the Director of Nursing (DON) stated she would expect to see behavior monitoring for tamoxifen. For side effects, staff chart by exception. She would expect to see the observation of crying documented. The policy provided titled, Psychotropic Medication Assessment & Monitoring, revised 08/2023, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 6 of 14 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 105878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712 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 0758 revealed the following: Level of Harm - Minimal harm or potential for actual harm c. The Interdisciplinary Team assesses the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via the MDS [minimum data set] process. Residents Affected - Few d. Monitoring of residents receiving antipsychotic medication will be completed by a licensed nurse as per acceptable standards of practice using the behavior monitoring record. Based on observations, interviews and record reviews, the facility did not ensure side effect monitoring of psychotropic medications was in place for two residents (#33 and #39) of seven sampled residents reviewed for unnecessary medication. Findings included: 1. On 04/29/24 at 10:51 a.m. an interview was conducted with Resident #33. She said she felt drowsy and tired. Resident #33 stated she felt the feeling is related to Parkinson's medication she is prescribed. Resident #33 was observed drooling during the interview. Staff A, Licensed Practical Nurse (LPN) was seen outside the resident's room and when asked about the drooling, she confirmed that Resident #33 drools. A review of the admission Record showed the resident was initially admitted on [DATE] with a readmission on [DATE]. A review of active physician orders as of 05/01/24 revealed the following: Venlafaxine HCl ER Tablet Extended Release 24 Hour 75 MG (milligrams). Give 1 tablet one time a day for depression. Start date 02/23/24. QUEtiapine Fumarate Oral Tablet. Give 75 mg at bedtime related to unspecified psychosis not due to a substance or known physiological condition. Start date 02/24/24. KlonoPIN Oral Tablet 1 MG (Clonazepam). Give 0.5 tablet in the morning for Anxiety, give 0.5 tablet in the afternoon for Anxiety, and give 1 tablet at bedtime for Anxiety. Start dates 03/05/24, 03/06/24. Carbidopa-Levodopa Tablet 25-100 MG. Give 1 tablet every 12 hours as needed for Parkinson. Start date 04/10/24. Sinemet Oral Tablet 25-100 MG (Carbidopa-Levodopa). Give 1 tablet two times a day for Parkinson's Disease. Start date 04/10/24. Amantadine HCl Oral Capsule 100 MG (Amantadine HCl). Give 1 capsule by mouth in the afternoon for Parkinson's Disease. Start date 04/17/24. Neupro Transdermal Patch 24 Hour 4 MG/24HR (Rotigotine). Apply 1 patch one time a day for Parkinson's. Start date 04/19/24. Stalevo 150 Oral Tablet 37.5-150-200 MG (Carbidopa-Levodopa-Entacapone). Give 1 tablet five times a day for Parkinson's disease. Start date 04/19/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 7 of 14 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 105878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #33's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 (intact cognition). Review of Resident #33's care plan, initiated on 11/19/22 and revised on 01/26/23, revealed a focus for [Resident #33] uses Psychotropic Medication Therapy r/t [related to] anxiety, depression, insomnia. The goals included: Resident will reduce the use of psychotropic medication through the review date, Resident will show decreased episodes through the review date, and Resident will be free from discomfort or adverse reactions related to psychotropic therapy through the review date. Interventions included: Educate family/caregivers about risks, benefits and the side effects of medications. Further review of Resident 33's care plan initiated on 11/28/22 and revised on 03/07/24, revealed a focus for [Resident #33] has impaired cognitive function/impaired thought process r/t Disease Process, Psychotropic drug use and BIMS evaluation. Interventions included: Monitor any changes in cognitive function, specifically changes in: decision making, memory recall, general awareness, level of consciousness, mental status and/or difficulty expressing self/understanding others. Review of Resident #33's medical record revealed there was no side effects monitoring. On 04/30/24 at 12:37 p.m. an interview was conducted with the Director of Nursing (DON) regarding side effect monitoring. The DON stated staff monitors side effects by exception. The DON stated if the resident does not have side effects to medications, then staff do not document anything. She said if the resident does have side effects, then the staff documents. The DON stated the side effect documentation would be found in the progress notes. Review of Resident #33's progress notes from 04/03/24 - 4/26/24, did not reveal any documentation of symptoms and/or side effects related to drowsiness, tiredness, and drooling. A review of a nurse progress note dated 04/15/24, revealed the family member was notified of Resident #33's off state. No specific side effects or symptoms were documented. On 04/30/24 at 2:01 p.m. an interview was conducted with the DON. The DON stated she spoke to the nurse for Resident #33. She stated on 4/15/24 a barium swallow study was ordered due to drooling related to Parkinson's. She said, The Parkinson's medications were adjusted because at one point the resident was receiving 5 times a day PRN [as needed]. Further review of the progress note revealed that on 4/15/24 a nurse's progress note showed .new orders received for Barium swallow study. No specific side effects or symptoms were documented. On 05/01/24 at 1:19 p.m. a phone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated she reviews the admissions on Monday, Wednesday, and Friday. She said she conducts full reviews monthly for every resident. The Pharmacy Consultant stated she utilizes the Gradual Dose Reduction (GDR) tracker and makes recommendations. She stated side effect monitoring for psychotropic medications is important to ensure no new side effects are occurring on a regular basis. She said for residents who are established she will just spot check for the behaviors and side effects, meaning she will select more than a few residents to ensure they have behavior and side effect monitoring. She said certain medications have side effects, such as drooling, but that every resident is different. She said the importance for monitoring side effects for residents on psychotropic medications is because of the risk of tardive dyskinesia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 8 of 14 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 105878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interview and record review the facility failed to maintain the dish machine in a clean manner. Residents Affected - Some Findings included: An observation on 04/29/24 at 9:15 a.m. of the facility's dish machine revealed a soiled white rag stored on top of the machine. Closer observation of the dish machine revealed the top of the dish machine was covered with crumbs and debris. An interview at this time with Staff D, Dietary Aide revealed the top of the dish machine should not be dirty and the rag should not be on top of the machine. Another interview at this time with the Certified Dietary Manager confirmed the top of the dish machine was dirty and she reported it was cleaned on Saturday (4/27/24). (Photographic Evidence Obtained) Review of the facility policy titled, Food and Nutrition-Kitchen Sanitation, with a revised date of 03/26/2019, revealed the following: Proper cleaning and sanitation of equipment ensures removal of residual food, chemicals, and bacteria. The Food and Nutrition staff shall maintain the sanitation of the kitchen through compliance with written, comprehensive cleaning schedules developed by the Food and Nutrition manager or designee. Sanitizing cloths should be placed in sanitizing buckets when not in use. These buckets need to be changed every two (2) hours or more frequently, as needed and must be at the proper concentrations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 9 of 14 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 105878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that three residents (#29, #33, #41) of three residents sampled for binding arbitration agreements acknowledged that they understood the agreement prior to signing the document. Residents Affected - Some Findings included: 1. Review of Resident #29's clinical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Minimum Data Set (MDS), dated [DATE], showed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Review of Resident #29's medical record revealed that she signed a binding arbitration form on 9/11/23. There was no acknowledgement from the resident that she understood the agreement prior to signing it. During an interview on 05/01/24 at 12:38 p.m. with Resident #29 she revealed that no one explained the binding arbitration agreement to her and that no one explained that she did not have to sign the agreement. 2. Review of Resident #33's admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Minimum Data Set (MDS), dated [DATE], showed in Section C - Cognitive Patterns a BIMS score of 14 (cognitively intact). Review of Resident #33's medical record revealed that she signed a binding arbitration form on 11/19/22. There was no acknowledgement from the resident that she understood the agreement prior to signing it. During an interview on 05/01/24 at 12:42 p.m. with Resident #33 she revealed that she does not remember signing the binding arbitration agreement document and could not be sure if it was explained to her that she did not have to sign the agreement. 3. Review of Resident #41's admission Record revealed she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS), dated [DATE], showed in Section C - Cognitive Patterns a BIMS score of 12 (moderately impaired cognition). Review of Resident #41's medical record revealed that she signed a binding arbitration form on 2/8/23. There was no acknowledgement from the resident that she understood the agreement prior to signing it. During an interview on 05/01/24 at 12:40 p.m. with Resident #41 she revealed that no one explained the binding arbitration agreement to her and that no one explained that she did not have to sign the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 10 of 14 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 105878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712 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 0847 agreement. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/01/24 at 12:32 p.m. with Staff F, Administrative Assistant and the Nursing Home Administrator (NHA), Staff F reported that she verbally explains to the resident about going into the arbitration agreement, and she gives them the option to sign it verbally. Residents Affected - Some During an interview on 05/01/24 at 12:44 p.m. with the NHA he reported the binding arbitration agreement itself indicates that the resident has a choice to sign the document. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 11 of 14 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 105878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview the facility failed to maintain a safe and sanitary environment for one of one resident laundry room and one of one resident adaptive equipment storage room. Residents Affected - Some Findings included: A tour of the laundry room was conducted on 5/1/24 at 12:00 p.m. with the Environmental Services Director (EVS). The laundry room was in a building separate from the nursing home but still on the same grounds as the facility. The washing and drying area were separated by a wall and door. There were three washing machines and three dryers. A laundry aide was observed to be in the drying area, wearing a gown, hanging residents' personal clothing onto a rack. The EVS Director said one dryer door did not stay closed while running, if there was a large load in it. Directly behind the washing machine was broken sheet rock with a large hole and debris on the ground. On the other side of the large hole, behind the washing machine, was deteriorated sheet rock and the debris on the ground behind the washing machine was visible from the other side of the wall through the deteriorated sheet rock. Directly next to the washing machine was more deteriorated sheet rock with rust colored edging on the bottom of the wall. An interview was conducted with the EVS Director at the time of the observation and he said the wall has been that way for about seven to eight months. He stated the Maintenance Director was made aware of it and has not fixed it because they said we were going to get an industrial washing machine. During the observation, the Nursing Home Administrator (NHA) arrived in the laundry room and was interviewed. He said the wall damage must have been from when the washing machines broke and there was a flood. He said the wall has been that way since before he started in June of 2023. Also, in the building housing the laundry room was a storage room with resident wheelchairs, positioning devices, walkers, and shower chairs. The walls of the storage room were not secured to the wall frames leaving large open areas to the outside. The walls were also deteriorated leaving large holes and an opening to the outside towards the floor of the building. During this observation an interview was conducted with the Director of Rehabilitation, and she said the equipment is used by residents when they need it, and this is where they store the equipment. An interview was conducted on 5/1/24 at 12:38 p.m. with the Maintenance Director. He said the only thing he knows about the laundry room was there is money set aside to tear it down and rebuild but he does not know when that is going to happen. An interview was conducted on 5/1/24 at 1:20 p.m. with the Maintenance Director. He said, there is a budget on the laundry room building to tear down, but they are looking at financing at this point and they do not have a hard start date. A safe, and clean environment policy was requested and the facility did not have one to provide. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 12 of 14 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 105878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to maintain an effective pest control program for two residents (#7 and #44) and two facility wings (East and West) of three facility wings and one of one emergency supply shed. Residents Affected - Some Findings included: 1. A review of the admission Record showed Resident #7 was initially admitted to the facility 06/15/23 with a primary diagnosis to include acute and chronic respiratory failure with hypercapnia. Section C- Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] showed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating cognitively intact. On 04/29/24 at 10:21 a.m., Resident #7 stated fruit flies were bad in her room. Two fruit flies were observed on a napkin on the over the bed table next to a meal tray (Photographic Evidence Obtained). Two more fruit flies were observed flying around. An orange round container that showed 960 Fruit Fly was observed on the bedside table. Resident #7 stated the container was given to her by maintenance. She stated her family member brought in a light to plug in the wall for bugs (Photographic Evidence Obtained). Resident #7 reported that she saw roaches in the room also and her roommate confirmed. The resident reported she sees a person from pest control in the facility, but they have never sprayed her room. A review of the Pest Sighting/Evidence Log only showed two pest issues since December 2023 to present. No issues with fruit flies were documented. On 04/30/24 at 3:26 p.m. the Maintenance Director reported pest control comes out monthly on the 2nd or 3rd Monday. He had noticed a couple of fruit flies but not extreme. There had been a resident or two that say they have fruit flies and when he walks in the room, he does not see anything. The Maintenance Director reported he did not recognize the container that stated 960 Fruit Fly. He stated staff should be logging pest sightings. There is a pest control book on the south hall near the nursing station. When they had an employee meeting, he brought up a concern related to the pest control book because staff were not documenting in the book. Pest control checks the pest control book and initials off on concerns documented by the staff. 2. On 04/29/24 at 10:09 a.m. Resident #44 was observed sitting in his room on his bed, flies and fruit flies were noted throughout the room. On 04/30/24 at 8:30 a.m. during medication pass observation on the East Wing fruit flies were noted throughout the hallway. On 04/30/24 at 12:30 p.m. during a medication pass observation, on the East Wing, of Staff A, Licensed Practical Nurse (LPN) as she went to empty her ice bin, fruit flies and flies were observed in the container. On 04/30/24 at 12:50 p.m. during an interview with the Director of Nursing (DON) she verified there are fruit flies and flies throughout the building. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 13 of 14 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 105878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712 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 0925 On 05/01/24 at 12:15 p.m. fruit flies were observed around the reception desk. Level of Harm - Minimal harm or potential for actual harm 3. An observation on 04/29/24 at 9:45 a.m. of the emergency supply shed which contained the facility's emergency food supply revealed black oblong droppings with a white tip on top of boxes which contained plastic portion cups. (Photographic Evidence Obtained). A combination of similar droppings and all black oblong droppings were observed on the floor, beside and in front of boxes of insulated containers (Photographic Evidence Obtained). Further observations revealed a combination of similar droppings and all black oblong droppings on the floor below a rack where food cans were stored, and on the left side/corner upon entering the shed (Photographic Evidence Obtained). An interview was conducted with the Certified Dietary Manager (CDM), at this time and she confirmed she is the one who oversees the emergency food supply and should have reported the droppings, but she has not. Residents Affected - Some During an interview conducted on 04/29/24 at 11:27 a.m. the Maintenance Director stated [vendor name] services the facility and comes once a month. The Maintenance Director reported he thinks the droppings are from lizards. Review of the Pest Sighting/Evidence Log on 4/29/2024 revealed no documentation of droppings in the emergency food shed prior to 4/29/2024. On 4/29/24 at 11:30 a.m. the Maintenance Director documented lizards on the pest sighting log and indicated the location was in the emergency supply shed. Service date invoices were reviewed for the dates of 1/2024 to 4/2024 which all revealed, no findings noted during the service. Materials were applied to the interior and exterior areas of the facility; however, the serviced locations did not include the emergency food supply shed. Review of the facility's policy titled, Pest Control, with a revised date of 8/2023, revealed the following: Keep all food storage and preparation areas clean. For documentation, the policy revealed the facility should Maintain a written record of pest sightings and remedial actions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105878 If continuation sheet Page 14 of 14