Health inspection·December 20, 2019

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concern, he puts it on a form. He showed the surveyor a form titled, Resident Council Issues to be Addressed. The Activities Director also said he writes the issue, the date, the disciplines, plus the date of the meeting on the form. Then he puts the form in the appropriate department head's mail. The form is labeled with nursing, dietary, or whatever department is responsible for the concern. He said there were no issues in November. When the surveyor inquired about the alternate meals, residents reported they had not been receiving, the Activities Director said, No, I did not write a concern for the Resident Council. He said he did speak to the department head, and it says in there what she was going to do. He said dietary services reported there was a breakdown between the receptionist who takes the orders, and the kitchen. He had a form filled out with the dietary concern dated 10/22/19. The resolution was to have discussion with the receptionist because she was not turning in the alternate sheet. The resolution date had to be by 10/25/19. The Activities Director said he went back to the CDM who said she would meet with the receptionist. She said it was resolved. An interview was conducted with the Nursing Home Administrator (NHA) on 12/20/19 at 10:18 a.m. She was asked if a concern reported by Resident Council members should be documented on the grievance log. She said it depends if it rises to the level of the grievance. The Director of Nursing (DON), who was present during the interview, said a grievance is usually handed out to the department head. At that point, we come up with a resolution. He said a grievance should have been generated. The NHA said generally yes, a grievance would be initiated. The facility will do whatever means they need; to resolve the issue. She added, the facility does not always generate a form. It depends on the issue. She was not aware a concern form had not been filled out for the concern in November 2019. The DON said it wasn't resolved the first time, so it was something that should have been addressed immediately. He said it should have been brought to us so we could address it. Review of the facility policy titled, Grievance Policy and Procedure, undated, reflected the following information: The resident/representatives has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination of reprisal and without the fear of discrimination or reprisal. The resident/resident representative has the right to and the facility must make prompt efforts to resolve grievances the resident/resident representative may have. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their long-term care stay. These may be expressed any time, both verbally and in writing. Staff have been trained on the policy and instructed on how to assist residents and resident representatives to write or complete a grievance form. A grievance may be presented anonymously if so chosen by the resident/resident representative. Residents or representatives are encouraged to report grievances as a positive step in arriving at a satisfactory resolution and outcome. A grievance form is provided for use, although a grievance may be expressed in any written or verbal format. These grievance forms may be found on each nursing unit or in a box on the wall outside of the social service office. The social worker has been given the authority of the grievance official. The grievance official is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion; leading necessary investigations by the facility: maintaining confidentiality of all information associated with grievances, issuing written grievance decisions to the resident/resident representative, and coordinating with state and federal agencies as necessary in light of specific allegations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 2 of 8 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 105978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782 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 0585 Level of Harm - Minimal harm or potential for actual harm Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. Residents Affected - Few All grievances will be dated when received, filed in a grievance log and assigned to the appropriate department within 24 working hours. The director of the involved department will personally investigate the expressed issue or assign investigation to inform staff member for investigation. This person will speak with all necessary personnel in the complaining party to obtain details and make every attempt to reach a resolution that is satisfactory to the person who expresses the grievance. The department director or his/her designee will document his/her actions, the resolution, sign and date the form and return the form to the grievance official within 5-10 days of having received it. The grievance official will follow up with the resident/representative to ensure that the concern is fully resolved. The complainant has the right to receive a written response containing the results of any investigation and any corrective actions to be put in place. Should resolution not be reachable the concern party will be advised of his/her right to file a grievance with one or all of the following advocacy agencies. Grievances will be reported to the QAPI committee. Any patterns or trends will be investigated and systems identified that require corrective action will be reviewed and appropriate changes and updates will be made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 3 of 8 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 105978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan for one resident (#305) of twenty-nine residents sampled related to a change in the level of cognitive status and the ability to smoke independently, and keep smoking supplies of a lighter with him at all times. Findings included: A review of facility policy titled, Care Planning-Interdisciplinary Team, with a revision date of September 2013, Page 03 of 03 read as follows under the section of Policy Interpretation and Implementation: 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The care plan, with an initiated date of 12/16/19 and a target date of 3/16/2020, for Resident #305 included a focus area which read, [Resident #305] desires to smoke. Resident has been assessed as able to smoke: independently. Interventions/Tasks included, Maintain smoking materials on self safely. Review of the clinical record revealed Resident #305's most recent smoking evaluation was dated 12/3/19 an indicated the resident was a safe smoker. An Unsupervised/Independent Smoker could retain smoking materials on his person per the facility policy titled, Smoking Policy, revised on June 2015. Further record review revealed that on 12/8/19, Resident #305 was found to be an elopement risk and read, A. (5) Alert and Continuous Confusion and D. (5) Actively Exit Seeking. The elopement risk score was 14, which on a scale of 0-14 scale, indicated he was to wear an electronic alarm device with a picture placed in the facility's elopement book. On 12/17/19 at 12:56 p.m. a random observation of Resident #305 was conducted. The resident had a lighter, and cigarettes in his hand, and utilized a cane. He was in the hall wandering and appeared confused. An unidentified staff member was observed to approach the resident and told the resident to wait where he was, he would go get him help. The Director of Nursing (DON) went over to the resident and saw that he wanted to smoke and accompanied him to the 300 Hall. The DON left the resident on the smoking patio On 12/17/19 at 2:48 p.m., an observation and interview was conducted with Resident #305. He indicated that he kept his own cigarettes, he kept his lighter in his pocket, and at night put it in a drawer in the bedside table, and that he sometimes takes his oxygen off. Interview with Staff C, Certified Nursing Assistant (CNA) for Resident #305 was conducted on 12/20/19 at 9:00 a.m. During the interview Staff C was asked about the resident's level of cognition and oxygen usage. Staff C stated, He usually is confused. He packs his stuff up forgets he is not leaving and says good morning to me multiple times. She revealed that Resident #305 had been using and wearing oxygen since he was admitted to the facility (12/3/19). Record review for Resident #305 indicated he was admitted to the facility on [DATE] with multiple diagnoses that included chronic obstructive pulmonary exacerbation, disorder of urea cycle disease, schizoaffective disorder, bipolar type major depressive disorder, generalized anxiety disorder, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 4 of 8 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 105978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 alcohol abuse and unspecified dementia without behavioral disturbance. Level of Harm - Minimal harm or potential for actual harm Review of laboratory results revealed that Resident #305 had a high ammonia level results on a reference scale range of 9-35 mcmol/L (micromoles per liter). Resident #305's ammonia level on 12/10/19 was high at 91 mcmol/L. Subsequent laboratory ammonia levels were drawn, and they were as follows: 12/11/19 was high at 138 mcmol/L, 12/16/19 was high at 101 mcmol/L, and 12/19/19 was high at 50 mcmol/L. Residents Affected - Few During an interview conducted with the (DON) on 12/20/19 at 11:00 a.m. The DON revealed that the resident is sometimes confused with moderate cognitive impairment. He confirmed the resident should not have smoking supplies, of a lighter on him until the confusion resolves. The DON also confirmed the care plan should have been updated to reflect the resident's change in level of cognitive status, and another smoking evaluation should be initiated by Staff A, Unit Manager. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 5 of 8 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 105978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, it was determined the facility failed to provide appropriate supervision related to oxygen usage and failure to limit the accessibility of smoking supplies for one resident (#305) with a decrease in cognitive status of four residents sampled. Findings included: On 12/17/19 at 10:00 a.m., an observation was conducted of Resident #305's room. The resident was not in the room at the time. It was observed that an oxygen converter set at 2.5 Liters was running and the nasal cannula was on the resident's bed. Further observation on 12/17/19 at 10:45 a.m. revealed Resident #305 to be sitting on his bed with the nasal cannula on, looking out of the room into the hall. A follow-up observation later in the day, at 2:00 p.m., of Resident #305's room revealed that he was not in the room, and the oxygen converter was running while the nasal cannula was left on the resident's bed. There was no indication of any signage posted inside the room, or on the outside of the room for oxygen in use, do not smoke while oxygen is in use, similar too other residents who used oxygen in the facility. On 12/17/19 at 12:56 p.m. a random observation of Resident #305 was conducted. The resident had a lighter, and cigarettes in his hand, and utilized a cane. He was in the hall wandering and appeared confused. An unidentified staff member was observed to approach the resident and told the resident to wait where he was, he would go get him help. The Director of Nursing (DON) went over to the resident and saw that he wanted to smoke, and accompanied him too the smoking patio and left him. It was observed that the resident lit his cigarette and began to smoke independently with no facility staff present. On 12/17/19 at 2:48 p.m., an observation and interview was conducted with Resident #305. He indicated that he kept his own cigarettes, he kept his lighter in his pocket, and at night put it in a drawer in the bedside table, and that he sometimes takes his oxygen off. On 12/17/19 at 3:20 p.m. an interview was conducted with Staff A, Unit Manager (UM), Licensed Practical Nurse (LPN). She was informed of the observations for Resident #305 and asked specifically what the facility policy was regarding both lighters in a resident's room while the resident was using oxygen. She indicated that she did not know where the resident got the oxygen concentrator because Resident #305 did not have an active physician order to use oxygen. Review of the physician orders for December 2019 for Resident #305 did not reveal an active physician order for oxygen. Review of facility policy titled, Oxygen Administration, Level III with a revision date of 2010, Pages 1 and 2 of 3 pages, read as follows: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Steps in the procedure: .2. Place an Oxygen in use sign on the outside of the room entrance door.4. Remove all potentially flammable items (e.g. lotions, oils, smoking articles, etc.) from the immediate area where the oxygen is to be administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 6 of 8 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 105978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review for Resident #305 indicated he was admitted to the facility on [DATE] with multiple diagnoses that included chronic obstructive pulmonary exacerbation, disorder of urea cycle disease, schizoaffective disorder, bipolar type major depressive disorder, generalized anxiety disorder, and alcohol abuse and unspecified dementia without behavioral disturbance. Review of the admission Minimum Data Set (MDS) dated [DATE], identified in Section C for Cognitive Patterns, that Resident #305's Brief Interview for Mental Status (BIMS) score was 11, which indicated moderate cognitive impairment. Section O for Special Treatments, Procedures, Programs, showed the resident was not receiving oxygen therapy. The care plan, with an initiated date of 12/16/19 and a target date of 3/16/2020, for Resident #305 included a focus area which read, [Resident #305] desires to smoke. Resident has been assessed as able to smoke: independently. Interventions/Tasks included, Maintain smoking materials on self safely. The care plan, with an initiated date of 12/16/19 included a focus area which read, [Resident #305] has a potential for complications of respiratory distress r/t (related to) dx (diagnosis) of: COPD. Interventions/Tasks included, Administer medications as ordered; observe for effectiveness . Review of the clinical record revealed Resident #305's most recent smoking evaluation was dated 12/3/19 an indicated the resident was a safe smoker. An Unsupervised/Independent Smoker could retain smoking materials on his person per the facility policy titled, Smoking Policy, revised on June 2015. Further record review revealed that on 12/8/19, Resident #305 was found to be an elopement risk and read, A. (5) Alert and Continuous Confusion and D. (5) Actively Exit Seeking. The elopement risk score was 14, which on a scale of 0-14 scale, indicated he was to wear an electronic alarm device with a picture placed in the facility's elopement book. Review of laboratory results revealed that Resident #305 had a high ammonia level results on a reference scale range of 9-35 mcmol/L (micromoles per liter). Resident #305's ammonia level on 12/10/19 was high at 91 mcmol/L. Subsequent laboratory ammonia levels were drawn, and they were as follows: 12/11/19 was high at 138 mcmol/L, 12/16/19 was high at 101 mcmol/L, and 12/19/19 was high at 50 mcmol/L. A review of the provider progress notes revealed a clinical psychologist consult was conducted on 12/18/19 and read, The resident does not have the capacity to make medical decisions for himself with intermittent confusion. Also, Resident #305 was noted to have moderate cognitive impairment. An interview was conducted with Staff B, LPN, on 12/18/19 at 8:55 a.m., regarding Resident #305 using oxygen and the converter observed running in his room. Staff B, LPN stated, The other day, I removed it when you noticed it, I was told by the UM (LPN) and DON to do so. I don't recall seeing it previously. Interview with Staff C, Certified Nursing Assistant (CNA) for Resident #305 was conducted on 12/20/19 at 9:00 a.m. During the interview Staff C was asked about the resident's level of cognition and oxygen usage. Staff C stated, He usually is confused. He packs his stuff up forgets he is not leaving and says good morning to me multiple times. She revealed that Resident #305 had been using and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 7 of 8 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 105978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782 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 0689 wearing oxygen since he was admitted to the facility (12/3/19). Level of Harm - Minimal harm or potential for actual harm During an interview conducted with the (DON) on 12/20/19 at 11:00 a.m. The DON revealed that the resident is sometimes confused with moderate cognitive impairment. He confirmed the resident should not have smoking supplies, of a lighter on him until the confusion resolves. The DON also confirmed the care plan should have been updated to reflect the resident's change in level of cognitive status, and another smoking evaluation should be initiated by Staff A, UM. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 8 of 8