Health inspection·September 3, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some finished with her lunch. During the observation Staff O, LPN (Licensed Practical Nurse), MDS (Minimum Data Set) said the CNA asked her if she would help feed Resident #19. Staff O, LPN, MDS brought a chair to the doorway, put on a gown and gloves, entered the resident's room, and moved Resident #19 to the left side of the bed and began assisting her with the lunch meal. Resident #15 was admitted to the facility with diagnoses of dementia, protein- calorie malnutrition, and dysphagia, according to the face sheet in the admission record. A review of the MDS assessment dated [DATE] Section C reflected a BIMS score of 0, indicating severe cognitive impairment. Review of Section G, Functional Status of the MDS assessment revealed Resident #15 required extensive assistance of one person for eating. A review of the 9/1/21 Care Plan revealed a nursing diagnosis of at risk for alteration in nutrition and/or hydration r/t [related to]: has a swallowing problem, receives mechanically altered diet, has variable po [by mouth] intake, total dependent on staff. Interventions included provide tray set up; assist as needed and provide hands on assist with eating at meals and as needed. On 9/01/21 at 12:31 p.m. an observation was conducted. Staff N, CNA was standing in front of Resident #15, who was sitting at the bedside in a wheelchair with the lunch meal in front of her. Staff N, CNA was providing feeding assistance to Resident #15. There was not a chair in the room. On 9/01/21 at 12:36 p.m. an interview was conducted with Staff N, CNA after she exited Resident #15's room. Staff M, CNA confirmed there wasn't a chair in the room, so she had to stand to feed Resident #15. On 9/02/21 at 3:39 p.m., an interview was conducted with the Unit Manager for the 400 Hall. The Unit Manager said it's unacceptable for them to be standing. We saw that some of the agency staff needed to be re-educated on that. They are supposed to be eye level with the patient. I would say five to ten minutes max to wait for assistance. Any longer and they need to reorder the tray. The trays should stay on the cart to keep them warm until they are ready to assist. The trays should be served at the same time. You don't want someone to eat while the roommate has to wait. Resident #19 has schizoaffective disorder, and she has outburst moments. There are times where she has outbursts and will refuse. Other times you put the tray in front of her and she will eat right away. If she refuses, we reapproach and try to assist. The tray should not have been left sitting there because obviously after a half an hour the food is cold. We have had her a long time. We know to reapproach her if she refuses. On 9/03/21 at 3:44 p.m., an interview was conducted with the NHA and Staff F, Regional Nurse Consultant. The NHA said a lot of times the residents don't want the chair in their room because the space is limited. We have folding chairs in an alcove that are available. The agency staff will be educated that they are available. A review of the policy, 'Assistance with Meals,' dated July 2017, revealed the following: Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 2 of 20 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 09/03/2021 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 0550 Residents Requiring Full Assistance: Level of Harm - Minimal harm or potential for actual harm 2. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: Residents Affected - Some a. Not standing over residents while assisting them with meals. Based on observations, interviews, and record review, the facility failed to ensure meals were served in a dignified manner related to: 1) Staff standing when assisting residents with a meal for four (#81, #16, #15, and #19) of four residents observed; and 2) waiting for greater than 30 minutes for meal assistance for one resident (#19) of four residents observed. Findings included: During a facility tour on 09/02/21 at 09:12 a.m., an observation was made of Resident #81 being assisted with a breakfast meal. Staff W, CNA (Certified Nursing Assistant) was observed standing by the resident's left side of the bed, while assisting her with meal. On 09/02/21 at 09:19 a.m., an interview was conducted with Staff W, CNA. Staff W stated she works this hall and knows the residents well. Staff W stated when assisting a resident, you don't have to sit. Staff W said, it is staff's preference, you can sit or stand if you like. When asked if she had received training related to assisting residents with meal, Staff W said, yes. I was told it is what I prefer. Staff W stated that she received training a long time ago and could not remember who provided training. A review of Resident #81's admission record revealed admission to the facility on [DATE] with diagnoses to include, hemiplegia and hemiparesis following cerebral infarction affecting right side dominant side, aphasia, legal blindness, generalized anxiety disorder and atherosclerotic heart disease of native coronary artery without angina pectoris. An initial MDS (Minimum Data Set) dated 07/30/21 showed: Section C, cognitive patterns showed unassessed BIMS (Brief Interview for Mental Status) indicating severe impairment; Section G - functional status showed Resident #81 required extensive assistance for ADL's (Activities of Daily Living) including eating, with one-person physical assistance. A care plan for Resident #81 dated 07/29/21 showed Resident #81 was at risk for nutritional and/or hydration and received a mechanically altered diet. Resident #81 has a variable P.O. (by mouth) intake, visual impairment and is nonverbal. Interventions include to provide hands on assistance with eating meals. On 09/02/21 at 09:26 a.m., a tour was conducted of Hall 100. An observation was made of Staff X, CNA assisting Resident #16 with breakfast while standing over her. Staff X was observed standing on the left side of the bed, spooning food into the resident's mouth. In an interview conducted at 09:29 a.m. on 09/02/21, Staff X stated she was agency staff, and it was her first day at this facility. Staff X stated she did not know about this facility's policies. Staff X stated that it did not matter if she stood over the resident when providing feeding assistance. Staff X further stated, I guess I could get a chair if you want me to. Staff X was asked if she had received training related to assisting a resident meal. Staff X stated, I don't work here. A review of Resident #16's admission record revealed admission to the facility on [DATE] with diagnoses to include unspecified Dementia with behavioral disturbance, unspecified protein-calorie malnutrition, chronic obstructive pulmonary disease with acute exacerbation, anemia, vitamin deficiency, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 3 of 20 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 09/03/2021 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some schizoaffective disorder, idiopathic progressive neuropathy and adult failure to thrive. An initial MDS dated [DATE] showed: Section C, cognitive patterns showed unassessed BIMS score indicating severe impairment; Section G - functional status showed Resident #16 was totally dependent and requires extensive assistance for ADL's including eating, with one-person physical assistance. A care plan for Resident #16 with a quarterly review date 08/26/21 showed Resident #16 was at risk for nutritional and/or hydration and has a swallowing problem. Resident #16 received a mechanically altered diet. Interventions included to provide hands on assistance with eating meals. An interview was conducted with Staff Y, LPN (Licenses Practical Nurse) on 09/02/21 at 09:29 a.m. Staff Y stated that staff should not be standing over residents during meal assistance. Staff Y said, They are supposed to be eye level, comfort for the resident. Staff Y said she was agency staff, and she knows this from her training. On 09/02/21 at 09:32 a.m., an interview was conducted with Staff L, CNA. Staff L stated that they [CNA's] had been trained on meal supervision expectations. Staff L said, we should not be standing. It is overpowering the resident. Staff L stated they were trained that staff should sit at bedside and have eye contact with the resident. A follow up interview was conducted with Staff H, LPN/Unit Manager on 09/02/21 at 09:41 a.m. Staff H stated the expectation related to meal assistance is to bring a chair to the resident's room and sit. Staff H said, We encourage them to sit unless there is specified resident's preference. Staff H stated there are residents who prefer staff stand when assisting with meal. When asked which residents had expressed that staff should stand during meal assistance, Staff H said, I don't have anyone in mind. I can't remember. Staff H stated that it was not a staff's preference if they should sit or stand during meal assistance. Staff H confirmed that neither Residents #81 nor #16 had made that choice. Staff H further said that Resident # 81 was non-verbal and did not have the ability to make such a choice. Staff H said that if a resident wanted a staff to stand during meal assistance, it would be indicated in the care plan. Staff H stated, this as a dignity concern. An interview was conducted with the Nursing Home Administrator (NHA) on 09/02/21 at 02:54 p.m. The NHA stated staff should sit, preferably at eye level during meal assistance. The NHA said, the expectation is for staff not to be standing over a resident. The NHA stated that they have folded chairs in the nurse's station for them [staff] to grab if there is no chair in the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 4 of 20 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 09/03/2021 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record reviews, interviews, and a review of the policy and procedure Resident Mistreatment, Neglect and Abuse Prohibition Guidelines, the facility failed to ensure an alleged allegation related to abuse for one resident (Resident #32) out of the sampled twenty-nine residents was reported immediately to the governing agency in accordance with the State law. Findings included: A review of the admission Record for Resident #32 revealed that he was admitted into the facility on [DATE] with a primary diagnosis of osteomyelitis. Other diagnosis included but was not limited to generalized anxiety disorder. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #32 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating that he was cognitively intact. On 09/01/21 at 9:05 a.m., Resident #32 was observed in his room sitting in the wheelchair next to the bed. Resident #32 reported about a week and a half ago, Staff T, Certified Nursing Assistant (CNA), pushed his room door while he was standing behind the door and slammed him against the cabinet behind the door. He stated Staff T then started arguing with him and said that the door had to be opened. Resident #32 stated he went to close the door, but Staff T did not want the door closed and knocked him into the cabinet with the door. He stated he was trying to close the door because he did not want to disrobe in the front of staff in the hallway. Resident #32 stated that the Social Services Director (SSD) told him to write everything on paper, but never came back to get his statement. A review of the Grievance /Concern Report dated 08/14/21 indicated that the resident reported that the staff did not want him to close the door as he changed his shirt. The Resolution section of the report indicated that the writer spoke with staff regarding recent concern. The Follow-Up section indicated that the writer spoke with resident and explained the reason why the door had to be open. A review of the Abuse/Exploitation/Neglect Tracking for August 21 did not reveal an allegation related to this incident. On 09/01/21 at 12:02 p.m., the SSD reported that Resident #32 reported that he wanted the door closed to his room to change his shirt. He did not want to leave the door open, and females were around. Staff were passing trays during breakfast and the CNA explained to him that he needed to leave the door open because he needed to check on the roommate while he was eating his breakfast. Staff T wanted him to go into the restroom and Resident #32 got upset and started screaming. The SSD reported that during her investigation process she spoke to Resident #32, the nurse, and the CNA. She stated Resident #32 did not turn in his written statement. On 09/01/21 at 12:36 p.m., the SSD reported that the incident happened on 08/14. The SSD reported that there was another CNA in the hallway during the time of the incident, but she did not have a statement from her. The SSD reported that when she went to follow up with Resident #32, he stated that he did not have a concern. He was only concerned that he could not close his door. The SSD presented a statement from staff T that revealed that Resident #32 accused him and another CNA of verbally (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 5 of 20 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 09/03/2021 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 0609 assaulting him. Level of Harm - Minimal harm or potential for actual harm On 09/01/21 at 4:13 p.m., Staff T stated that he did not remember the day the incident happened. He was asked to write a statement. Resident #32 kept closing the door to the room. The resident in bed B needed assistance with his meal due to aspiration and choking risk, so the door needed to be open to observe him. He always closes the door and he's been told multiple times that they needed clear sight to B bed stated Staff T. While getting ready to take in bed B's tray, Resident #32 was behind the door. The resident said he was changing and asked if he could come back. Staff T stated he told him to pull the curtain or go to the bathroom. Resident #32 went off on a rant that the door hit him which it didn't stated Staff T. He said he was going to report to the cops about the abuse and two other coworkers were immediately outside of the door. Both coworkers Staff V, CNA, and Staff U, CNA, chimed in because Resident #32 gets loud fast. They reiterated to Resident #32 to go to the bathroom or change behind the curtain. The resident was recording with his phone, and he stated to him that's ok that you're recording but we need access to bed B. Resident #32 proceeded to use racist words. The SSD asked him to write a statement about the incident. Staff T asked, Why is it happening now? Why are they doing the investigation now and this happened weeks ago, asked Staff T. Staff T reported that he was never suspended. He was just told this evening that he had to leave while the investigation was going on. Stated he asked the Administrator why he was just now getting suspended. Staff T stated he was never educated after the incident happened. He stated he was assigned to Resident #32 on that day of the incident and had worked with him whenever he was assigned to work. Residents Affected - Few On 09/03/21 at 2:07 p.m., Staff U, CNA, stated on the day of the incident she heard words and raised voices, asked them to keep it down. A staff member was talking to another staff member, and he said he didn't have a right to close his door. They were talking at the same time. Another staff member was telling Resident #32 the same thing. She did not know what happened during or after the incident. Resident #32 stated he was known to snap necks. On 09/03/21 at 10:19 a.m., Staff V, CNA, was contacted. A voicemail was left for a return call. On 09/03/21 at 12:15 p.m., in an interview with the Administrator and the SSD, the SSD reported that the resident only complained that he wanted the door closed because he was changing his shirt, but the CNA wanted the door opened to watch the roommate. After that she went to the nurses' station and asked the staff what was going on. Spoke with the nurse and Staff T. The nurse said they explained to the resident that the door had to be opened. Staff T stated that the resident was very mean to him and started yelling. The SSD reported that she had Staff T to write a statement. Another resident came to her office and said she heard Resident #32 in the hall and Resident #32 was not very nice. The SSD stated that Resident #32 never mentioned that he was verbally assaulted and that he only wanted to close the door. The SSD reported confirmed that Staff T's statement read that the resident stated he was verbally assaulted, but she did not report the allegation as abuse because the resident stated he did not have a concern when she went to talk to him. When you get an allegation of abuse, it should be reported and investigate stated the Administrator. The policy provided by the facility, Resident Mistreatment, Neglect and Abuse Prohibition Guidelines dated August 2018 revealed the following: Purpose All allegations of abuse, neglect, injuries of unknown origin and misappropriation or mistreatment of resident property are to be reported immediately and investigated per state and federal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 6 of 20 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 09/03/2021 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 0609 regulations. Level of Harm - Minimal harm or potential for actual harm Reporting/Response Residents Affected - Few Regulations require employees that provide services to elderly persons or dependent adults (mandated reporters) to report instances of abuse, neglect, or misappropriation/exploitation of resident property to the state survey agency (AHCA), Department of Children and Families (DCF) and local law enforcement agency within 2 hours if the alleged violation involves abuse or results in serious bodily injury or as soon as practically possible within 24 hours of detection if the alleged violation does not involve abuse and does not result in serious bodily injury. All employees are required to promptly report the facts of known or suspected instances of abuse to their direct supervisor on duty, Abuse Coordinator, Administrator, and/or Director of Nursing (either directly or anonymously), so that facility responsibilities to protect residents and promptly investigate occurrences may be met. The facility administration is required to report to the State licensing authority any knowledge of actions by a court of law which would indicate an employee is unfit for services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 7 of 20 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 09/03/2021 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to take the appropriate actions in response to an alleged violation related to abuse inflicted by direct care staff such as thoroughly investigate the alleged violations to prevent further abuse, neglect, and mistreatment from occurring for one resident (Resident #32) out of the sampled twenty-nine residents. Residents Affected - Few Findings included: A review of the admission Record for Resident #32 revealed that he was admitted into the facility on [DATE] with a primary diagnosis of osteomyelitis. Other diagnosis included but was not limited to generalized anxiety disorder. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #32 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating that he was cognitively intact. On 09/01/21 at 9:05 a.m., Resident #32 was observed in his room sitting in the wheelchair next to the bed. Resident #32 reported about a week and a half ago, Staff T, Certified Nursing Assistant (CNA), pushed his room door while he was standing behind the door and slammed him against the cabinet behind the door. He stated Staff T then started arguing with him and said that the door had to be opened. Resident #32 stated he went to close the door, but Staff T did not want the door closed and knocked him into the cabinet with the door. He stated he was trying to close the door because he did not want to disrobe in the front of staff in the hallway. Resident #32 stated that the Social Services Director (SSD) told him to write everything on paper, but never came back to get his statement. A review of the Grievance /Concern Report dated 08/14/21 indicated that the resident reported the staff did not want him to close the door as he changed his shirt. The Resolution section of the report indicated that the writer spoke with staff regarding recent concern. The Follow-Up section indicated that the writer spoke with resident and explained the reason why the door had to be open. A review of the Abuse/Exploitation/Neglect Tracking for August 21 did not reveal an allegation related to this incident. On 09/01/21 at 12:02 p.m., the SSD reported that Resident #32 reported that he wanted the door closed to his room to change his shirt. He did not want to leave the door open, and females were around. Staff were passing trays during breakfast and the CNA explained to him he needed to leave the door open because he needed to check on the roommate while he was eating his breakfast. Staff T wanted him to go into the restroom and Resident #32 got upset and started screaming. The SSD reported that during her investigation process she spoke to Resident #32, the nurse, and the CNA. She stated Resident #32 did not turn in his written statement. On 09/01/21 at 12:36 p.m., the SSD reported the incident happened on 08/14/21. The SSD reported there was another CNA in the hallway during the time of the incident, but she did not have a statement from her. The SSD reported when she went to follow up with Resident #32, he stated that he did not have a concern. He was only concerned that he could not close his door. The SSD presented a statement from Staff T that revealed that Resident #32 accused him and another CNA of verbally assaulting him. On 09/01/21 at 4:13 p.m., Staff T stated he did not remember the day the incident happened. He was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 8 of 20 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 09/03/2021 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few asked to write a statement. Resident #32 kept closing the door to the room. The resident in bed B needed assistance with his meal due to aspiration and choking risk, so the door needed to be open to observe him. He always closes the door and he's been told multiple times that they needed clear sight to B bed stated Staff T. While getting ready to take in bed B's tray, Resident #32 was behind the door. The resident said he was changing and asked if he could come back. Staff T stated he told him to pull the curtain or go to the bathroom. Resident #32 went off on a rant that the door hit him which it didn't stated Staff T. He said he was going to report to the cops about the abuse and two other coworkers were immediately outside of the door. Both coworkers Staff V, CNA, and Staff U, CNA, interjected because Resident #32 gets loud fast. They reiterated to Resident #32 to go to the bathroom or change behind the curtain. The resident was recording with his phone, and he stated to him that's ok that you're recording but we need access to bed B. Resident #32 proceeded to use racist words. The SSD asked him to write a statement about the incident. Staff T asked, Why is it happening now? Why are they doing the investigation now and this happened weeks ago, asked Staff T. Staff T reported that he was never suspended. He was just told this evening that he had to leave while the investigation was going on. Stated he asked the Administrator why he was just now getting suspended. Staff T stated he was never educated after the incident happened. He stated he was assigned to Resident #32 on that day of the incident and had worked with him whenever he was assigned to work. On 09/03/21 at 2:07 p.m., Staff U, CNA, stated on the day of the incident she heard words and raised voices, asked them to keep it down. A staff member was talking to another staff member, and he said he didn't have a right to close his door. They were talking at the same time. Another staff member was telling Resident #32 the same thing. She did not know what happened during or after the incident. Resident #32 stated he was known to snap necks. On 09/03/21 at 10:19 a.m., Staff V, CNA, was contacted. A voicemail was left for a return call. On 09/03/21 at 12:15 p.m., in an interview with the Administrator and the SSD, the SSD reported that the resident only complained that he wanted the door closed because he was changing his shirt, but the CNA wanted the door opened to watch the roommate. After that she went to the nurses' station and asked the staff what was going on. Spoke with the nurse and Staff T. The nurse said they explained to the resident that the door had to be opened. Staff T stated the resident was very mean to him and started yelling. The SSD reported she had Staff T write a statement. Another resident came to her office and said she heard Resident #32 in the hall and Resident #32 was not very nice. The SSD stated that Resident #32 never mentioned that he was verbally assaulted and that he only wanted to close the door. The SSD reported confirmed that Staff T's statement read that the resident stated he was verbally assaulted, but she did not report the allegation as abuse because the resident stated he did not have a concern when she went to talk to him. When you get an allegation of abuse, it should be reported and investigate stated the Administrator. The policy provided by the facility, Resident Mistreatment, Neglect and Abuse Prohibition Guidelines dated August 2018 revealed the following: Purpose All allegations of abuse, neglect, injuries of unknown origin and misappropriation or mistreatment of resident property are to be reported immediately and investigated per state and federal regulations. Reporting/Response (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 9 of 20 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 09/03/2021 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regulations require employees that provide services to elderly persons or dependent adults (mandated reporters) to report instances of abuse, neglect, or misappropriation/exploitation of resident property to the state survey agency (AHCA), Department of Children and Families (DCF) and local law enforcement agency within 2 hours if the alleged violation involves abuse or results in serious bodily injury or as soon as practically possible within 24 hours of detection if the alleged violation does not involve abuse and does not result in serious bodily injury. All employees are required to promptly report the facts of known or suspected instances of abuse to their direct supervisor on duty, Abuse Coordinator, Administrator, and/or Director of Nursing (either directly or anonymously), so that facility responsibilities to protect residents and promptly investigate occurrences may be met. The facility administration is required to report to the State licensing authority any knowledge of actions by a court of law which would indicate an employee is unfit for services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 10 of 20 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 09/03/2021 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the medication error rate was below 5.00%. A total of twenty-five medications were observed administered and two errors were identified for two (Resident #81 and #258) of five residents observed. These errors constituted a medication error rate of 8.00 percent. Residents Affected - Few Findings included: On 09/02/2021 at 8:45 a.m., an observation was conducted of Staff A, Licensed Practical Nurses (LPN) administering medication to Resident #81. During the observation Staff A, LPN was observed administering Metoprolol Succinate ER (Extended-Release) 24 Hour 50 milligrams (MG) Give one (1) Tablet by one time a day for Diagnosis of Hypertension. The medication had on the pharmacy label Do not Crush. Staff A, LPN was observed to place the tablet in a clear packet and crushed the medication, and then placed them in apple sauce in a clear medication cup with other 9:00 a.m. medications and administered them to Resident #81. An immediate interview was conducted with Staff A, LPN, who revealed that she did realize they were Extended-Release medications and should not be crushed. She stated, I didn't see that. On 08/11/2021 at 10:07 a.m., an observation was conducted of Staff B, LPN, on the 300 Hall, administering medications to Resident #258. Staff B, LPN was observed administering Humalog Kwik-Pen Solution Pen Injector 100 Unit/milliliter (ML) (Insulin Lispro 1 Unit) Dial Inject 12 Units Subcutaneously with meals for Diabetes Mellitus (DM). Record review of active Physician Orders and the Medication Administration Record (MAR) for Resident #258, revealed that the medications administered to the resident were given late, and scheduled to be administered at 8:00 a.m. On 09/02/2021 at 12:05 p.m. an interview was conducted with the Staff C, LPN, Unit Manager (UM) for the 100-300 Halls. Staff C, UM was informed of the observations made of Staff B, LPN administering insulin late and stated, The staff that work here know the importance of giving insulin on time, because it can mess everything up. An interview was conducted on 09/02/2021 at 12:13 p.m. with the Regional Nurse Consultant, she was informed of observations made during medication administration for Resident #81 and #258. She stated, the physician was in just now, and he reviewed all the medications for Resident #81, because ER should not be crushed. She further indicated the physician changed all the of Resident #81's medications to be crushed. The Regional Nurse Consultant stated, For Resident #258 the insulin medication was late, and that is an error. On 09/03/2021 at 12:52 p.m., a telephone interview was conducted with the facility's Pharmacy Consultant. He was informed of observations made of Staff A, LPN and Staff B, LPN administering medications late and crushing an Extended-Release medication, both of which were not administered according to the Physician orders. He stated Did she (Staff A) not read the label on the card of crushing the Extended-Release medication? That is bad, and the insulin was given incorrectly not at the correct time, they are both medication errors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 11 of 20 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 09/03/2021 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 0759 Level of Harm - Minimal harm or potential for actual harm A facility provided policy titled, Administering Medications, revision date April 2019, Page 01 of Page 03 reads under Policy and Procedure, Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: Residents Affected - Few 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 10. The individual administering medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) before giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 12 of 20 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 09/03/2021 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interviews and record review the facility failed to ensure medications were secured appropriately, as evidenced by: 1) an unsecured and unattended box of medications on top of one (300 hall) of three medication carts observed; 2) loose and unidentified medications in two (100 hall and 300 hall) of three medication carts observed; and 3) staff personal items stored in one (100 hall) of three medication carts observed. Findings included: On 09/02/2021 at 9:45 a.m., Staff J, Certified Nursing Assistant (CNA)/Central Supply Technician was observed placing a box of Nicotine Transdermal System Step One Patches on top of the 100-hall medication cart and walking away. There were no staff nearby or in the vicinity of the medication cart. Several residents were observed to be self-propelling in wheelchairs nearby the medication cart which was located in a high traffic area on the 300 Hall. The surveyor was observed by Staff F, Regional Nurse Consultant and went over to the cart, and removed the medication from the top of the medication cart. In an immediate interview during the observation, she said the medication should not be left out. On 09/03/2021 at 10:30 a.m., observation of the medication cart on 300 Hall included in the second draw from the top of the medication cart, 1 ½ a loose tablets. Staff D Registered Nurse (RN) confirmed the presence of the unsecured white tablets On 9/03/2021 at 11:15 a.m., an observation was conducted of the 100 Hall medication cart. During the observation a loose yellow capsule was observed in the third draw from the top of the medication cart, and a bottle of Fuji water was observed in the fourth draw. Staff E, Licensed Practical Nurse (LPN) confirmed the presence of the loose capsule, and the water bottle. She stated, That's my water, I put it there because I was thirsty. On 09/03/2021 at 11:58 p.m. an interview was conducted with Staff J, related to leaving the medication out on top of the 300-medication cart. Staff J stated I know I am not supposed to put the nicotine patches on the cart, I thought she (Staff B, LPN) was coming to get the patches, and she did not, I should have looked to see if she was getting them. Normally I give it to them, and they put it in the draw. On 09/03/2021 at 12:52 p.m., a telephone interview was conducted with the facility's Pharmacy Consultant. He was informed of the observations made and stated, there should be no loose medications in the medications carts, no medications should be left out, and there should not be any personal items of the nursing staff, left in the medication carts. On 09/03/2021 at 2:00 p.m. a subsequent interview was conducted with Staff F. She was made aware of further observations made of the 100 and 300 Hall medication carts. Staff F stated The Bubble Packs are paper thin. The pharmacy consultant was here the other day, and there should be no loose pills, or water or personal items in the medication carts. She further revealed that no medications should be left out on top of the medication carts too. A facility provided policy titled, Storage of Medications, with Revision Date November 2020, was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 13 of 20 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 09/03/2021 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed and read under Policy Heading The Facility stores all drugs and biologicals in a safe secure and orderly manner. Policy Interpretation and Implementation: 2. Drugs and biologicals are stored in the packaging containers or dispensing systems in which they are received. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 14 of 20 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 09/03/2021 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, record review, and staff interviews, the facility failed to ensure the kitchen was maintained in a sanitary manner, and food was stored appropriately related to maintenance of the ice machine, maintenance of the microwave, maintenance of the dish machine, and dating opened foods in the walk-in cooler. Findings included: On 08/31/21 at 9:35 a.m., an initial tour of the kitchen was conducted with the Kitchen Manager. During the tour, the inside of the ice machine was observed to have brown stains on both sides of the ice machine (photographic evidence obtained). The inside of the microwave was observed with a splattered brown substance (photographic evidence obtained). The policy provided by the facility Ice dated October 2019 revealed the following: Policy Statement It is the center policy that ice is prepared and distributed in a safe and sanitary manner. 2. The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed, or according to manufacturer guidelines. 4. The Dining Services Director will ensure that the ice bins are cleaned monthly and as needed. The policy provided by the facility Equipment dated October 2019 revealed the following: Policy Statement It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order. Action Steps 1. The Dining Services Director will ensure that all equipment is routinely cleaned and maintained in accordance to manufacturer directions and training materials. 2. The Dining Service Director will ensure that all staff members are properly trained in the cleaning and maintenance of all equipment. 4. The Dining Services Director ensures that all non-food contact equipment is clean. The temperature for the dish machine was observed at 114 degrees Fahrenheit for wash. The dietary aid ran the dish machine three times and the temperature gauge for wash did not move. This was confirmed by the Kitchen Manager, and he stated that he would contact the chemical company. The policy provided by the facility Ware washing dated October 2019 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 15 of 20 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 09/03/2021 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 0812 2. The Dining Services Director ensures that all the dish machine water temperatures are maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. Level of Harm - Minimal harm or potential for actual harm An opened package of hotdogs and diced ham was observed without a date in the walk-in cooler. Residents Affected - Some The policy provided by the facility Food Storage: Cold dated October 2019 revealed the following: Policy Statement It is the center policy to ensure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code. 5. The Dining Services Director/ Cook(s) ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. On 08/31/21 at 2:07 p.m., the Certified Dietary Manager (CDM) reported that the dish machine was up and running. She stated the relay switch on the dish machine was out. On 09/02/21 at 12:20 p.m., the CDM reported that an outside company comes to break down the ice machine for cleaning. The kitchen staff were responsible for the general cleaning of the ice machine. She stated the ice machine should be cleaned every day or every other day. The CDM stated the microwave should be cleaned daily. The microwave was used to heat up sauce that morning it was not cleaned after it was used. She reported that the dish machine was a low temperature machine, and the temperature should be at 140 degrees Fahrenheit for wash. The staff member that sets the machine up and doing the washing was responsible for documenting the temperature and making sure it was running appropriately. The CDM stated all staff was responsible for making sure foods in the walk-in cooler were labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 16 of 20 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 09/03/2021 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 09/01/21 at 09:22 a.m., a tour of hall 100 was conducted. An observation was made of Staff Z, CNA going room to room picking up breakfast trays from 09:22 a.m. to 09:32 a.m. Staff Z, was observed without wearing a gown in rooms noted with droplet precautions posted on the doors. Staff Z, went to room [ROOM NUMBER] walked out without tray, went to room [ROOM NUMBER] and grabbed a tray, then room [ROOM NUMBER], 105 and 107, grabbing trays. Staff Z then went back to room [ROOM NUMBER] and was there for 5 minutes and walked out with a tray. Staff Z was observed without a gown during the entire process and did not change gloves or use ABHR between room to room encounters. Residents Affected - Few An interview was conducted with Staff Z on 09/01/21 at 09:32 a.m. Staff Z stated that she was going in to pick up trays and assist the residents who are finishing up with breakfast. Staff Z stated that she was an agency staff. When asked what the PPE expectation was, Staff Z said, I am supposed to put on a new gown and change gloves between each room. Staff Z said, I was in a hurry trying to get to all these people, my bad. I should have changed gloves. Staff Z said she forgot to wear the right PPE. Review of a pink sign posted on all the doors in rooms 101, 105, 106, 107 and 108 showed droplet precautions STOP attention please carefully review the instructions below Everyone clean their hands, including before entering and when leaving the room with ABHR [alcohol-based hand rub] PPE requirement: Gown and gloves, face shield or goggles. N95 mask or higher-level respirator must be worn at all times while in patient room. Photographic evidence was obtained. An interview was conducted on 09/01/21 at 10:30 a.m., with Staff L, CNA. Staff L stated they had been trained to wear full PPE, change gowns and gloves between rooms and use sanitizer. On 09/03/21 at 10:02 a.m., an interview was conducted with Staff R, RN, IP. Staff R stated that his expectation would be that staff will don new PPE before going into each room and doff before they exit. Staff R said, They [staff] should not go room to room wearing the same PPE. They should not go into a droplet precautions room without a gown. Staff R stated they have educated all staff and are giving the agency staff training materials right at the door. Staff R said, they know. Based on observations, interviews, policy review, photographic evidence, and CDC (Centers for Disease Control) guidelines the facility failed to ensure appropriate infection control standards were followed related to: 1) PPE (Personal Protective Equipment) use and storage for five staff members (Staff L, N, P, Q, and Z) on two of four days observed and; 2) appropriate storage of personal items in one of one laundry rooms observed. Findings included: On 9/01/21 at 12:36 p.m. an observation was conducted. Staff N, CNA (Certified Nursing Assistant) exited room [ROOM NUMBER] wearing a gown, mask, and eye protection; she was carrying a lunch tray. Staff N, CNA walked down the 400 hall with the tray and brought it to the dining cart that was located outside room [ROOM NUMBER]. Staff N, CNA placed the lunch tray on the dining cart. Staff O, LPN (Licensed Practical Nurse) told Staff N she had to take the gown off in the room. In an interview with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 17 of 20 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 09/03/2021 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff N, CNA conducted during the observation, she said she was supposed to take the gown off in the room, but she didn't know how she could take the tray out if she took the gown off. On 9/01/21 at 9:32 a.m. an observation was conducted in the staff break room. Staff P, Floor Technician was observed in the staff break room removing a lunch bag from the refrigerator. On a table nearby was a KN95 mask and a pair of goggles. Staff P put the lunch bag on the table. An interview was conducted during the observation. Staff P said he can clean the goggles. Staff P said there isn't anywhere to put the mask and goggles. He can throw the mask away. They either clean them or throw them away. Staff P removed a mask from his pocket and disposed of the mask that was on the table in the trash receptacle nearby. On 9/01/21 at 9:33 a.m. an observation was conducted in the staff break room. Staff Q, Housekeeper entered the breakroom with an N-95 mask on top of her head. Staff Q placed her face shield on a table. An interview was conducted during the observation through translation by Staff P, Floor Technician. Staff Q said there isn't a designated area to place the mask or face shield. Staff Q also said she was not aware that putting the mask on top of her head was unsanitary. On 9/02/21 at 3:39 p.m. an interview was conducted with the unit manager. The unit manager said the gown has to be taken off inside the room. On 9/03/21 at 9:56 a.m. an observation was conducted in the laundry room. Staff P, Floor Technician and Staff Q, Housekeeper were in the clean laundry folding room with the Social Services Director (SSD), a Laundry Attendant, and Staff AA, Housekeeper. The room was approximately 8x10 feet. Staff P and Staff Q were not wearing a mask or eye protection. There were clean linens and resident personal clothing on carts, bins and a folding table in the room that were uncovered. Staff F, Regional Nurse Consultant was present during the observation and confirmed the observation. She instructed Staff P and Staff Q that they must wear their PPE. Staff AA, Housekeeper stated she was the supervisor. Staff AA said the last Covid education was about two weeks ago. Further observation of the clean folding room revealed a lunch bag and two beverages sitting on one of the clean folding tables; photographic evidence was obtained. Staff AA, Housekeeper confirmed they should not be there. On 9/03/21 at 10:50 a.m. an interview was conducted with Staff R, RN (Registered Nurse), the Infection Preventionist (IP), and the Regional Director of Clinical Services (Staff F). They stated the agency staff are educated prior to coming into the facility and when they arrive in the building, they are provided a document to read and sign specifically related to infection control. They are informed the facility is on droplet precautions, and the PPE requirement. Staff R, RN said he monitors throughout the day also, and stated, We sent the one walking around in the gown from room-to-room home. He further said, every shift is educated, and there are signs on every door. Staff R, RN said he thinks they are using the brown paper bags for PPE storage. He also said he asked the staff in the laundry room about the observations, and they didn't have an answer. On 9/03/21 at 3:58 PM an interview was conducted with the NHA (Nursing Home Administrator) and Staff F, Regional Nurse Consultant. The NHA said Staff P, Floor Technician is not usually in the laundry room. The SSD was in there looking for a resident's belongings because she was being discharged in an hour. Staff P, Floor Technician and Staff Q, Housekeeper were getting ready to go to lunch and the SSD asked for their help. They set their things on the table and began helping her get the resident's things together. The NHA stated staff can throw the masks and eyewear away. We have plenty of masks and eye protection. They are everywhere. They don't have to keep the same mask. They can bag it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 18 of 20 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 09/03/2021 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 0880 or throw it away during their break. Level of Harm - Minimal harm or potential for actual harm Review of the policy, Coronavirus Disease (Covid-19)-Infection Prevention and Control Measures, updated October 2020, revealed the following information: Residents Affected - Few Policy Statement This facility follows recommended standard and transmission-based precautions, environmental cleaning, and social distancing practices to prevent the transmission of Covid-19 within the facility, Policy Interpretation and Implementation 1. This policy is based on current recommendations for standard and transmission-based precautions, environmental cleaning, and social distancing for Covid-19. 2. While in the building personnel are required to strictly adhere to established infection prevention and control policies, including: Hand hygiene; Appropriate use of PPE; Transmission-based precautions where indicated; Laundry Practices 3. To address asymptomatic and pre-symptomatic transmission, universal source control is being implemented. Anyone entering the facility is required to wear face covering regardless of symptoms. 1. Cloth face coverings for source control are not considered PPE. Staff and visitors should wear a facemask at all times when in the facility. Upon review of the policy, Isolation-Categories of Transmission-Based Precautions, revised October 2018, the following information was discovered: Policy Statement Transmission based precautions are initiated when the resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection and is at risk of transmitting the infection to other residents. Contact precautions 1. Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental services or resident care items in the resident's environment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 19 of 20 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 09/03/2021 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 0880 Level of Harm - Minimal harm or potential for actual harm 5. Staff and visitors well wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. The following CDC guidelines were found on 9/7/21 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#ppe: Residents Affected - Few Source Control and Distancing Measures Implement Source Control Measures HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. Personal Protective Equipment Ensure Proper Use and Handling of Personal Protective Equipment Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Implement Universal Use of Personal Protective Equipment Transmission from asymptomatic or pre-symptomatic residents with SARS-CoV-2 infection can occur in healthcare settings, particularly in geographic areas with moderate to substantial community transmission. One of the following should be worn by HCP while in the facility and for protection during resident care encounters: A well-fitting facemask (e.g., selection of a facemask with a nose wire to help the facemask conform to the face; selection of a facemask with ties rather than ear loops; use of a mask fitter; tying the facemask ' s ear loops and tucking in the side pleats; fastening the facemask ' s ear loops behind the wear ' s head; use of a cloth mask over the facemask to help it conform to the wearer's face) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105978 If continuation sheet Page 20 of 20