Health inspection·February 16, 2023

F 0609 abuse must report the event immediately. Level of Harm - Minimal harm or potential for actual harm Policy: All events reported as possible abuse will be investigated to determine whether abuse did not take place. The facility will have evidence to demonstrate that a thorough investigation has been completed. Residents Affected - Few Protection: Policy: Patients will be protected from harm during an investigation. Policy: Staff person or persons suspected of abuse will be suspended immediately pending result of investigation. On 2/14/23 at 9:30 a.m. an interview was conducted with Resident #154. The resident stated there was a nurse in the facility that called him a cripple and a cracker. He said the problems with this nurse began when they had a misunderstanding about him wanting his blood sugar checked and getting insulin. The resident stated the day that happened, he felt off and wanted his blood sugar checked. He said he was told his nurse was downstairs, so he went downstairs and had the nurse on the first floor check his blood sugar. He went back upstairs and told Staff L, RN, she then told him she didn't have the keys to the medication cart with his insulin in it. He felt like she wasn't helping him. He said Staff L, RN got angry and went downstairs and yelled at the nurse that took the resident's blood sugar. Resident #154 said since that incident, Staff L, Registered Nurse (RN), has been verbally abusive to him, telling him he will never be anything but a cripple, calling him a cracker and cussing at him. The resident said he reported this to the Nursing Home Administrator (NHA) and the head nurse. Resident #154 stated Staff L, RN turned it around on him and said he was the racist and said he called her the N word. He said the NHA never spoke with him about the alleged verbal abuse he reported to her, but did come up to his room and told him if his behavior continued, he would have to move somewhere else. Resident #154 said he has never used the N word and never would because he is not racist at all. The resident stated he gets along with the other nurses and aides. He added that when Staff L, RN works upstairs, where he resides, he will not leave his room. He added that it makes him very uncomfortable when she is upstairs. The resident stated Staff L, RN has baited him, telling him Come on call me n***** call me n*****. The resident stated he is worried about telling this surveyor about this because he is scared the facility will retaliate and throw him out. He reiterated he is worried about Staff L, RN working on the second floor. Resident #154 said he doesn't think his report to the NHA of verbal abuse was ever looked at. He added that this happened in the last month or two. A review of admission Record indicated Resident #154 was admitted on [DATE] and readmitted on [DATE] with diagnoses including Type II diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction, and hypertension. The resident's Minimum Data Set (MDS,) dated 12/8/22, Section C, Cognitive Patterns, indicated a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident is cognitively intact. A review of Resident #154's electronic medical record revealed a progress note from Staff L, RN on 12/24/22 stating the resident refused to take medication, resident attempted to play one nurse against another. Writer explained to resident, after checking that his blood sugar is 231. She said she would administer insulin once she obtained the keys to the medication cart where the insulin is. The resident went to another nurse and complained of not feeling well and was lightheaded due to his blood sugar. His blood sugar was checked again and was 280. The resident was argumentative with writer, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 2 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 attempts to redirect unsuccessful. Level of Harm - Minimal harm or potential for actual harm An additional progress note was entered on 1/10/23 by Social Services. The note stated the NHA and Social Services Director (SSD) met with the resident at bedside to discuss his concerns as well as concerns expressed by other residents, nursing staff, and a visitor who witnessed the resident using profanity and racial slurs with staff members and even seeking them out and following them using this language in loud tones. Resident stated he does not like the nursing staff on second floor. NHA and SSD offered resident a room change to the first floor with different staff, closer to the Director of Nursing (DON), unit manager, and administration to address his concerns. Resident was belligerent in loud tones and stated, I'm not moving. Resident also refused to do an official grievance for any issues he states he is having with staff. NHA and SSD informed resident that if his behaviors continue, we will have to find him another center, as we do not tolerate these behaviors here and it has become a concern and disturbance to multiple residents and now their family members. Resident verbalized understanding. Residents Affected - Few An interview was conducted with Staff L, RN on 2/14/23 at 3:44 p.m. Staff L, RN denied any verbal abuse towards Resident #154. She stated the resident had inappropriate behavior and did a lot of name calling. Staff L, RN said if Resident #154 wants something and you don't move fast enough, it is a problem for him. An additional note was entered on 1/10/23 stating the resident was being referred to psych (psychological) services for increased behaviors. An interview was conducted with Staff L, RN on 2/14/23 at 3:44 p.m. Staff L, RN denied any verbal abuse towards Resident #154. She stated the resident had inappropriate behavior and did a lot of name calling. Staff L, RN said if Resident #154 wants something and you don't move fast enough, it is a problem for him. An interview was conducted with the NHA and SSD on 2/14/23 at 4:19 p.m. The NHA stated on the same day she and the SSD went to talk to the resident about his behaviors (1/10/23,) the resident had been coming down the hallway towards her office. She stated the resident told her there was a staff member calling him inappropriate names. The NHA said, He likes to stir up drama. The NHA said she told the resident they need to go to social services, and he didn't want to. She stated, It is concerning but he didn't want to file a grievance. The SSD said when she and the NHA went to speak with the resident on 1/10/23, he was not wound up, he was just telling her he didn't say the N word. The NHA stated the resident didn't want to tell her anything. When asked if she went back and tried to speak with Resident #154 about the staff member calling him names, when he was not upset; she stated, Not about this particular situation. The NHA confirmed there was no investigation completed regarding Resident #154's allegation of verbal abuse by a staff member, the staff member was not suspended, and no reports had been filed. The SSD said she was unaware of the resident reporting verbal abuse to the NHA. She said when she and the NHA went to speak with the resident on 1/10/23 she was only aware of the resident's reported behavior. The SSD said if someone had reported to her the staff were calling them names and they were concerned about retaliation she absolutely would have reported it. She stated no one reported anything about this to her. The NHA and SSD confirmed an allegation of verbal abuse should be investigated even without a grievance being filed. A review of facility staffing beginning 1/10/23 to 2/15/23 revealed Staff L, RN had been scheduled to work on the second floor, where the resident resides, 14 times since he reported the verbal abuse to the NHA. Four of those times (1/17/23, 1/19/23, 1/30/23 and 2/5/23), Staff L, RN was directly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 3 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 providing care to Resident #154 and one other time (1/29/23) Staff L, RN was the floor supervisor. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 4 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and policy review the facility failed to ensure a reported allegation of abuse was investigated for one resident (#154) out of 31 one sampled residents. Residents Affected - Few Findings included: On 2/14/23 at 9:30 a.m. an interview was conducted with Resident #154. The resident stated there was a nurse in the facility that called him a cripple and a cracker. He said the problems with this nurse began when they had a misunderstanding about him wanting his blood sugar checked and getting insulin. The resident stated the day that happened, he felt off and wanted his blood sugar checked. He said he was told his nurse was downstairs, so he went downstairs and had the nurse on the first floor check his blood sugar. He went back upstairs and told Staff L, RN, she then told him she didn't have the keys to the medication cart with his insulin in it. He felt like she wasn't helping him. He said Staff L, RN got angry and went downstairs and yelled at the nurse that took the resident's blood sugar. Resident #154 said since that incident, Staff L, Registered Nurse (RN), has been verbally abusive to him, telling him he will never be anything but a cripple, calling him a cracker and cussing at him. The resident said he reported this to the Nursing Home Administrator (NHA) and the head nurse. Resident #154 stated Staff L, RN turned it around on him and said he was the racist and said he called her the N word. He said the NHA never spoke with him about the alleged verbal abuse he reported to her, but did come up to his room and told him if his behavior continued, he would have to move somewhere else. Resident #154 said he has never used the N word and never would because he is not racist at all. The resident stated he gets along with the other nurses and aides. He added that when Staff L, RN works upstairs, where he resides, he will not leave his room. He added that it makes him very uncomfortable when she is upstairs. The resident stated Staff L, RN has baited him, telling him Come on call me n***** call me n*****. The resident stated he is worried about telling this surveyor about this because he is scared the facility will retaliate and throw him out. He reiterated he is worried about Staff L, RN working on the second floor. Resident #154 said he doesn't think his report to the NHA of verbal abuse was ever looked at. He added that this happened in the last month or two. A review of admission Record indicated Resident #154 was admitted on [DATE] and readmitted on [DATE] with diagnoses including Type II diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction, and hypertension. The resident's Minimum Data Set (MDS,) dated 12/8/22, Section C, Cognitive Patterns, indicated a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident is cognitively intact. A review of Resident #154's electronic medical record revealed a progress note from Staff L, RN on 12/24/22 stating the resident refused to take medication, resident attempted to play one nurse against another. Writer explained to resident, after checking that his blood sugar is 231. She said she would administer insulin once she obtained the keys to the medication cart where the insulin is. The resident went to another nurse and complained of not feeling well and was lightheaded due to his blood sugar. His blood sugar was checked again and was 280. The resident was argumentative with writer, attempts to redirect unsuccessful. An additional progress note was entered on 1/10/23 by Social Services. The note stated the NHA and Social Services Director (SSD) met with the resident at bedside to discuss his concerns as well as concerns expressed by other residents, nursing staff, and a visitor who witnessed the resident using (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 5 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few profanity and racial slurs with staff members and even seeking them out and following them using this language in loud tones. Resident stated he does not like the nursing staff on second floor. NHA and SSD offered resident a room change to the first floor with different staff, closer to the Director of Nursing (DON), unit manager, and administration to address his concerns. Resident was belligerent in loud tones and stated, I'm not moving. Resident also refused to do an official grievance for any issues he states he is having with staff. NHA and SSD informed resident that if his behaviors continue, we will have to find him another center, as we do not tolerate these behaviors here and it has become a concern and disturbance to multiple residents and now their family members. Resident verbalized understanding. An additional note was entered on 1/10/23 stating the resident was being referred to psych (psychological) services for increased behaviors. An interview was conducted with the NHA and SSD on 2/14/23 at 4:19 p.m. The NHA stated on the same day she and the SSD went to talk to the resident about his behaviors (1/10/23,) the resident had been coming down the hallway towards her office. She stated the resident told her there was a staff member calling him inappropriate names. The NHA said, He likes to stir up drama. The NHA said she told the resident they need to go to social services, and he didn't want to. She stated, It is concerning but he didn't want to file a grievance. The SSD said when she and the NHA went to speak with the resident on 1/10/23, he was not wound up, he was just telling her he didn't say the N word. The NHA stated the resident didn't want to tell her anything. When asked if she went back and tried to speak with Resident #154 about the staff member calling him names, when he was not upset; she stated, Not about this particular situation. The NHA confirmed there was no investigation completed regarding Resident #154's allegation of verbal abuse by a staff member, the staff member was not suspended, and no reports had been filed. The SSD said she was unaware of the resident reporting verbal abuse to the NHA. She said when she and the NHA went to speak with the resident on 1/10/23 she was only aware of the resident's reported behavior. The SSD said if someone had reported to her the staff were calling them names and they were concerned about retaliation she absolutely would have reported it. She stated no one reported anything about this to her. The NHA and SSD confirmed an allegation of verbal abuse should be investigated even without a grievance being filed. A review of facility staffing beginning 1/10/23 to 2/15/23 revealed Staff L, RN had been scheduled to work on the second floor, where the resident resides, 14 times since he reported the verbal abuse to the NHA. Four of those times (1/17/23, 1/19/23, 1/30/23 and 2/5/23), Staff L, RN was directly providing care to Resident #154 and one other time (1/29/23) Staff L, RN was the floor supervisor. A facility policy titled Abuse Protection and Response Policy, undated, was reviewed. The policy stated the following: Abuse, as hereafter defined, will not be tolerated by anyone, including staff, patients, volunteers, family members, or legal guardians, friends, or any other individuals. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse, holds the highest priority. Verbal Abuse: the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 6 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Identification: Level of Harm - Minimal harm or potential for actual harm Policy: Any resident event that is reported to any staff by patient, family, other staff or any other person will be considered as a possible abuse if it meets any of the following criteria: Residents Affected - Few e. Any complaint of the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance. Procedure: Any and all staff observing or hearing about such events will report the event immediately to the Abuse Hotline at [PHONE NUMBER]. The event will also be reported immediately to the Social Worker, Director of Nursing, or Administrator. Any and all employees are empowered to initiate immediate action as appropriate to protect a resident. Investigation: Policy: Any employee having either direct or indirect knowledge of any event that might constitute abuse must report the event immediately. Policy: All events reported as possible abuse will be investigated to determine whether abuse did not take place. The facility will have evidence to demonstrate that a thorough investigation has been completed. Protection: Policy: Patients will be protected from harm during an investigation. Policy: Staff person or persons suspected of abuse will be suspended immediately pending result of investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 7 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation and staff interviews, the facility failed to ensure the Quarterly Minimum Data Set Assessment (MDS) accurately reflected the resident's status for the use of an opioid received for one resident (#51) of five sampled residents. Residents Affected - Few Findings included: On 02/13/2023 at 11:38 a.m. Resident #51 said she had been at the facility for a short period of time after she had fallen and fractured her shoulder. She confirmed she had pain and rated it as a number 7 out of a total of 10, with 10 rated at the highest level of pain. She stated they had given her Tylenol for pain. She stated they told me they did not get the pain medication in right away. She went on to say they would give it to me in the hospital routine, but here she had to ask for it. She said that some of the nurses will ask her if she has pain and will give me a pain medication. She said the other night it took the nurse eight hours to get one for her. Review of the admission Record indicated Resident #51 had been at the facility for less than two weeks. The diagnoses included unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing. Medical record review of current physician orders for February 2023 showed an order for Hydrocodone-Acetaminophen oral tablet 5-325 mg (milligrams) give 1 tablet by mouth every 6 hours as needed for pain, dated 02/01/2023. Review of the Controlled Drug Disposition forms revealed a makeshift form, a single piece of white paper. This single piece of white paper documented Resident #51's name, the medication name Hydrocodone dated 2/1/23, Total 12. It indicated the amount on hand as 1. On 2/14/23 Staff L, RN was asked about the makeshift form used as a Controlled Drug Disposition record and she stated, the resident was admitted with pain medication from a different pharmacy. That was why there was not a disposition form. She left the cart at that time and returned with a Controlled Drug Disposition form. Staff L then stapled the form on the back of the white piece of paper. Review of the February 2023 Medication Administration Record (MAR) reflected from 02/01/2023 to 02/07/2023 that on one day, 02/05/2023, Resident #51 had received the Hydrocodone-acetaminophen. Further review of the makeshift Control Drug Disposition form from 02/01/2023 to 02/07/2023, reflected Resident #51 had received a total of 5 Hydrocodone (opioid) in five days. Review of the Minimum Data Set (MDS) Assessment ,Reference Date (ARD)/Target date 2023-02-08, showed in Section N - Medications showed: Medication Received: Days: Opioid= 1. The MDS did not accurately reflect the administration according to the makeshift disposition form. On 02/15/2023 at 8:35 a.m. Staff K, RN was observed as she removed an opioid from the medication cart. She documented it on the Controlled Drug Disposition form and then documented in the MAR. She stated, I haven't been a nurse that long. I was trained you have to chart the medication in both places. On 02/16/2023 at 1:47 p.m. an interview was conducted with Staff J, Registered Nurse (RN)/Minimum (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 8 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Data Set (MDS) Coordinator. She said her part of her process was to look at the MAR. She said it was not a part of her process to look at the Controlled Drug Disposition form. Staff J confirmed the one dose of opioid she documented did not reflect accurately on the MDS for Resident #51. Review of the policy titled, MDS Completion and Submission Timeframes, dated July 2017, showed: Policy Statement Our facility will conduct and submit resident assessment in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation 1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS QIES Assessment Submission and Processing (ASAP) system in accordance with federal and state guidelines. Event ID: Facility ID: 106033 If continuation sheet Page 9 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop a comprehensive care plan related to smoking for two residents (#202 and #206) of three residents sampled for smoking. Findings included: 1. Review of the admission Record showed Resident #206 was admitted to the facility on [DATE] with diagnoses to include other psychoactive substance abuse, metabolic encephalopathy. Resident #206 was observed in the smoking area on 2/15/23 at 1:35 p.m. with other residents and two staff members present who were providing smoking materials. Resident #206 was interviewed in his room on 02/16/23 at 12:48 p.m. and said he can go out in his wheelchair to smoke whenever he wants. Staff keep his cigarettes for him, but he has no trouble getting a cigarette when he wants one. Review of Resident #206's medical record showed a Smoking Evaluation was completed on 1/28/23 by Staff K, RN. Results of the smoking evaluation were documented as resident requires supervise/assist while smoking due to poor eyesight, resident must be supervised by staff, volunteer, or family member at all times when smoking, and that resident must request smoking materials from staff. Review of Resident #206's comprehensive care plan, initiated on 10/25/22, indicated a Focus area documented as [Resident #206] is legally blind he enjoys music, going outdoors and reading. Interventions included to offer to take outdoors, and use of clock method to describe where items are located. Further review of Resident #206's care plan did not include a Focus area for smoking nor did it include interventions to ensure the safety of Resident #206 when smoking. Staff I, Certified Nursing Assistant (CNA) was interviewed on 02/16/23 at 12:46 p.m. Staff I said Resident #206 spends most of his time in a wheelchair but he is pretty independent and goes out to smoke by himself. Staff I said residents are supervised when smoking but he was unsure if there are specific instructions for individual residents. During an interview with the Interim Director of Nursing (IDON) on 02/16/23 at 9:17 a.m. she stated that residents who smoke should be care planned for it. 2. Review of the admission Record showed Resident #202 was admitted to this facility on 12/2/22 with diagnoses to include multiple fractures. Resident #202 was observed in the smoking area on 2/15/23 at 1:35 p.m. with other residents and two staff members present who were providing smoking materials. Resident #202 was interviewed on 02/16/23 at 12:33 p.m. and said he can go out to smoke any time he wants until 11:00 p.m. and he enjoys the freedom to go out whenever he wants. Review of Resident #202's comprehensive care plan, initiated 12/5/22, did not include a Focus area for smoking nor did it include interventions to ensure the safety of Resident #202 when smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 10 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff J, RN/Minimum Data Set (MDS) Coordinator was interviewed on 02/16/23 at 4:19 p.m. Staff J stated residents should have smoking in their care plan. If it's not there it should be. She stated that she would review the care plans for Resident #202 and Resident #206 and if it wasn't there she would get those in. Staff J indicated that nursing was supposed to give her a list to update, but it has not happened yet. Review of the policy titled, Care Planning - Interdisciplinary Team, revised December 2016, showed the Policy Statement as, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the policy titled, Resident Smoking Policies, undated, showed under Procedure the following: Residents who smoke will have a plan of care related to this activity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 11 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review the facility failed to follow professional standards of practice for pain management for two residents (#51 and #255) out of 6 residents sampled for pain as evidenced by not reordering a controlled substance in a timely manner. Residents Affected - Few Findings included: 1.On 02/13/2023 at 11:38 a.m. Resident #51 said she had been at the facility for a short period of time after she had fallen and fractured her shoulder. She confirmed she had pain and rated it a number 7 out of a total of 10 ,with 10 rated at the highest level of pain. She stated they had given her Tylenol for pain. She stated they told me they did not get the pain medication in right away. She went on to say they would give it to me in the hospital routine, but here she had to ask for it. Resident #51 stated, The other night it took the nurse eight hours to get me one. I don't know why I am having to wait extended periods of time for pain medication. She stated just this past Friday (02/10/2023), around lunch time, she asked the nurse for a pain medication. She said she didn't see the nurse the rest of the day. She stated, I called the front desk and left a message. I called the Director of Nursing's office and was told she had just left the facility and that was at 4:00 p.m. Resident #51 stated, Finally an aide came in my room after 4:00 p.m. to answer my call light, that I had on for hours it seemed. I told her I needed something for pain. That was when I was finally given something. Resident #51 said that only some of the nurses will ask her if she has pain. On 02/13/2023 at 12:00 p.m. an interview was conducted with Staff L, Registered Nurse (RN). When informed Resident #51 was having pain she stated, She didn't tell me. Review of the admission Record indicated Resident #51 had been at the facility for less than two weeks. The diagnoses included unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing, and personal history of malignant of breast. The admission Record indicated she was admitted for short term rehabilitation. Medical record review of current physician orders for February 2023 showed an order for Hydrocodone-Acetaminophen oral tablet 5-325 mg (milligrams) give 1 tablet by mouth every 6 hours as needed for pain, dated 02/01/2023. Review of Minimum Data Set (MDS), dated [DATE], indicated in Section C-Cognitive Patterns the Brief Interview for Mental Status (BIMS) score for Resident #51 was a total score of 14, which indicates the resident was cognitively intact. On 02/14/2023 at 1:15 p.m. Resident #51 was sitting in her bed and smiled when approached. When asked about her pain she stated, They gave me Tylenol this morning. The nurse told me they ran out of the strong one. I would rather have had the stronger one then the Tylenol. She stated the Tylenol helped a bit. Resident #51 said the strong one lasts almost the day. She rated her pain at a number 7 out of a total of 10. She said when she was going through her breast cancer, she was told not to take Tylenol, but I can take it now only if I have to for pain. Resident #51 went on to say that her [family member's] stomach bled from taking too much Tylenol, and said, I don't want the same thing to happen to me. On 02/14/2023 at 1:20 p.m. an interview was conducted with Staff L, RN. She stated that they are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 12 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm still waiting for [Resident #51's] narcotic (controlled substance). She said the pharmacy has two runs a day, and if they were completely out, we can pull it out of the EDK (emergency drug kit). She went on to say Resident #51 was a new resident, and she doesn't think she (Resident #51) has been seen by the pain MD (doctor) yet. Staff L said she gave her Tylenol this morning and it usually helps her and she had no further complaints. Residents Affected - Few On 02/15/2023 at 1:15 p.m. Resident #51 was sitting up in her bed holding her right arm. She stated she had not had a pain pill today. She stated, I'm supposed to ask for it. She stated her pain level was a 6 right now and if the pain medication was available, she would take it. She added, I don't think it's here yet. Resident #51 denied the nurse asked her if she was having any pain. On 02/15/2023 at 1:20 p.m. Staff M, Licensed Practical Nurse (LPN) stated the resident did not tell me she had pain. When informed Resident #51 reported a pain level of 6, at that time, Staff M reviewed the Medication Administration Record (MAR) and confirmed Resident #51 had a current order for Hydrocodone, but the medication was not in the medication cart. When asked about the process of ordering narcotics, Staff M stated, when a resident runs out you notify, they pharmacy. She said if there are no current refills you call the MD. Staff L, RN said it did not look like there was a stop date for the medication. She said if it was re-ordered yesterday, it should be here by now. Further medical record review from 02/13/2023 to 02/16/2023 indicated the pharmacy, and the physician had not been contacted for a refill. On 02/16/2023 at 12:52 p.m. a phone interview was conducted with Resident #51's Physician, who confirmed he knew the resident was at the facility for short term rehabilitation. He confirmed she needed her prescribed pain medication and the facility should have them available for her. He indicated this was not acceptable practice and stated, They should have called me. On 02/16/2023 at 1:35 p.m. a phone interview was conducted with the Interim Director of Nursing (IDON) who indicated she was unaware of Resident #51's unrelieved pain and the delay in reordering the Hydrocodone. She confirmed narcotics should be reordered timely. On 02/16/2023 at 4:25 p.m. a phone interview was conducted with the Consulting Pharmacist, who indicated she was not aware that the pharmacy was not providing pain medications to the facility in a timely manner. She stated, Usually when the facility calls; the pharmacy gets the meds to the facility. I will have to call the pharmacy to see what is wrong. The Consulting Pharmacist said if a prescription runs out call a doctor first for new a prescription refill. If I am in the facility and notified of it, I will call the pharmacy to make sure of what is going on . She confirmed it was her expectation they (facility) should just call the pharmacy for a refill. The pharmacy will then direct them on what to do next. She stated, The pharmacy is open 24 hours a day and would be able to alleviate all delays. Review of the facility policy titled, Pain-Clinical Protocol, dated March 2018, showed: Assessment and Recognition 1. The Physician and staff will identify individuals who have pain or who are at risk for having pain a. This includes reviewing known diagnosis and conditions that commonly cause pain. Treatment/Management 1. With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment. 2. The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. Monitoring 1. The staff will reassess the individual's pain and related consequences at regular intervals, at least every shift for acute pain or significant changes in level of chronic pain and at least weekly in stable conditions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 13 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. During an interview on 02/13/2023 at 12:56 p.m. Resident #255 stated that a couple weeks ago the facility got Resident #255's prescription pain medication and put them in the Unit Manager's office. Resident #255 stated then the Unit Manager was not present in the facility over the weekend and they could not get the pain medications because the medication was locked up in the office. A review of Resident #255's admission Record showed a diagnosis of chronic pain. A review of the February 2023 physician orders revealed an order, dated 08/01/22, as, Oxycodone-APAP 10-325MG (milligram) Give 1 tablet orally every 6 hours as needed for pain. Review of a care plan showed a Focus of chronic back pain and leg pain, revised on 2/21/18. Interventions included to consult per physician orders. In review of the Medication Administration Record (MAR) for January 2023, Oxycodone was not administered to Resident #255 for the days of 01/26/2023, 01/27/2023, 01/28/2023 and 01/29/2023. The January 2023 MAR also showed that Resident #255 was administered Oxycodone at least once a day until that four day period when it was not administered. An additional physician order, dated 06/24/2020, showed, Evaluate Resident for pain by using appropriate scale: 0 -no pain, 1-3 mild, 4-6 moderate, 7-10 severe. Record location if noted every shift. The January 2023 MAR showed on 01/28/23 and 01/29/2023 there was no pain assessment conducted to evaluate Resident #255's pain levels. Review of the Medicare Five Day Minimum Data Set (MDS), dated [DATE], showed in Section C Cognitive Patterns that Resident #255 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. It showed in Section N Medications that Resident #255 received seven days of opioids during the look back and was on a pain regimen. A pain evaluation, dated 07/30/2022, showed Resident #255 had aching in the lower extremities with rest and pain medication to alleviate pain. During an interview on 02/15/2023 at 3:45 p.m., Staff C Licensed Practical Nurse (LPN) stated that narcotics are always kept in the medication cart locked in the narcotics box. Staff C, LPN stated the facility did not store narcotics in offices. Staff C, LPN stated that if anything; a written script could be in an office but never the medication. Staff C, LPN stated no recollection of a script being found or held in an office for Resident #255. Staff C, LPN reviewed Resident #255's January MAR and confirmed that Resident #255 did not receive Oxycodone for the dates of 01/26/2023, 01/27/2023, 01/28/2023 and 01/29/2023. During an interview on 02/15/2023 at 3:48 p.m., Staff G Registered Nurse (RN) stated the incident where Resident #255 did not get her pain medication for a four day period may have been a pharmacy issue. Staff G, RN stated the facility had issues with the pharmacy getting the medications to the facility. Staff G, RN stated that pharmacy issues occurred, Many, many times. Staff G, RN stated that every time an RN calls to see where the medication was the pharmacy always stated the medication would be on the next delivery and then the medication never arrived. During an interview on 02/16/2023 at 9:40 a.m., Staff A, LPN stated Resident #255 always asked for her pain medications. Staff A, LPN stated if Resident #255 didn't get the pain medication it was probably because of pharmacy delays. Staff A, LPN stated that multiple nurses can call on a medication and each time the nurses are told the medication would be on the next run but then the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 14 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 would not be. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/16/2023 at 10:30 a.m. Interim Director of Nursing (IDON) stated if Resident #255 received an Oxycodone on any day between 01/26/2023 through 01/29/2023 then the medication should have been documented when given. The IDON confirmed the order stated, Evaluate resident for pain by using the appropriate scale: 0: No pain; 1-3: Mild Pain; 4-6: Moderate pain; 7-10: Severe pain. Record location if noted & intervene PRN (as needed). every shift. The IDON confirmed Oxycodone was not administered to Resident #255 and acknowledged that Resident #255 was administered Oxycodone every day before and after the four day absence. Interim DON also confirmed staff did not assess Resident #255 for pain as the physician order stated during the morning shift on the dates of 01/28/23 and 01/29/23. Residents Affected - Few During an interview on 02/16/2023 at 4:25 p.m. the Consulting Pharmacist stated there should be no reason why Resident #255 should have to go for four days without a pain medication. The Consulting Pharmacist stated that medications should be received by the pharmacy and given in a timely manner. The Consulting Pharmacist stated that staff at the facility can always reach out to the Consulting Pharmacist, an assigned representative and even the pharmacy if there were medication delivery problems. The Consulting Pharmacist stated that she was not aware any residents were not receiving their medications in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 15 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure shared communication between the facility and the dialysis facility for three residents (#203, #208 and #209) of three residents sampled for dialysis care. Residents Affected - Some Findings included: 1. The admission Record showed Resident #203 was admitted to the facility on [DATE]. The Dialysis Communication binder for Resident #203 was reviewed on 02/15/23 at 1:04 p.m. Review of dialysis communication forms for the dates of 2/11/23 and 2/14/23 showed the post dialysis portion of the form, Section 3 To be completed on return from dialysis, was not completed. 2. Review of Resident #208's Dialysis Communication binder revealed the resident had dialysis appointments on 2/15, 2/13, 2/10, 2/8, 2/6, 2/3, and 2/1. The Dialysis Communication forms Sections 2 To be filled out by Dialysis Center and post dialysis Section 3 were not completed on any of the dialysis days listed above. 3. Review of Resident #209's Dialysis Communication binder revealed the resident had dialysis appointments on 2/15, 2/13, 2/10, 2/8, 2/6, 1/16, 1/13 and 1/11 of 2023. The Dialysis Communication form, Section 3, was not completed on any of the forms for the dates listed above. Staff A, Licensed Practical Nurse (LPN) was interviewed on 02/15/23 at 11:16 a.m. Staff A, LPN was shown the Dialysis Binder for Resident #208 and she stated she only works days and residents don't return from dialysis appointments during her shift. Staff A said residents come back in the evening and she is not sure what is supposed to happen when residents return from dialysis. Staff B, Assistant Director of Nursing was asked about the missing information on the communication forms in Resident #208's Dialysis Binder on 02/15/23 at 11:45 a.m. Staff B stated the form is supposed to be completed when residents return from dialysis. Staff B took the binder to consult with the Director of Nursing. She returned and stated the information was available in the electronic medical record. The electronic medical record was reviewed and no post dialysis progress notes were identified related to the dialysis days of 2/15, 2/13, 2/10, 2/8, 2/6, 2/3, and 2/1 of 2023. Resident progress notes for Residents #208 and #209 were reviewed with Staff C, LPN/Unit Manager on 02/16/23 at 2:56 p.m. Staff C stated when residents return from dialysis they are supposed to have their vital signs documented in the electronic medical record. After reviewing the nursing progress notes, Staff C confirmed that post dialysis notes were not consistently documented for Residents #208 and #209. Review of the policy titled, Hemodialysis Access Care, revised September 2010, did not provide procedures for post dialysis assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 16 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, medical record review, and review of the policy for Drug Diversion, the facility failed to ensure the disposition of controlled medications reflected accurate accounting and record keeping for three residents (#52, #59, and #51) out of six residents sampled for pain. Findings included: 1.On 2/13/2023 at 11:30 a.m. Resident # 52 was in the hallway asking if she could have a pain medication. Staff L, Registered Nurse (RN) stated she already had one this morning. Staff L was asked why Resident #52's Controlled Drug Disposition Form for the Hydrocodone APAP 5-325 mg (milligram) reflected her last dosage was given on 02/12/2023 at 10:00 a.m. Staff L looked at the form, and then changed the number 2 to a number 3, indicating three doses had been given. On 2/14/2023 at 12:33 p.m. a review was conducted of the Control Drug Disposition book that revealed an empty bubble card for Resident #52. The card read for Hydrocodone APAP 5-325 mg and was then compared to the Controlled Drug Disposition form that reflected the amount remaining count as 1. On 2/14/2023 at 12:35 p.m. an interview was conducted with Staff L, RN and she stated, I just finished signing the log. She confirmed the medication was administered on 2/14/2023 at 8:29 a.m. and she failed to sign the out the dosage on the Control Drug Disposition form. 2. On 2/14/2023 at 1:09 p.m. a medication observation pass was conducted alongside Staff L, RN as she prepared Resident #59's medications. She removed one oxycodone IR 5 mg from the bubble card and proceeded to document the medication on the Control Drug Disposition form. She was observed signing out an 8:30 a.m. dosage and a 1:09 p.m. dosage at that same time. When asked, she confirmed she signed out both doses at that same time. Review of Resident #59's physician orders for February 2023 showed an order for Oxycodone HCI tablet 5 mg give one table by mouth every 4 hours as needed for severe pain 7-10, dated 10/07/2022. Review of the Control Drug Disposition form and the February 2023 Medication Administration Record (MAR) did not match. The MAR reflected omitted documentation on 02/06 of one administration and the Control Drug Disposition showed one administration; on 02/07 three separate administrations were omitted on the MAR and shown on the Control Drug Disposition; on 02/09 four separate administrations were omitted on the MAR and shown on the Control Drug Disposition; on 02/10 two of the three administrations were omitted on the MAR and shown on the Control Drug Disposition; on 02/12 two of the four administrations were omitted on the MAR, on 02/13 two of the three administrations were omitted on the MAR, and on 02/14 two of three administrations were omitted on the MAR. 3. Medical record review of Resident #51's February 2023 physician orders showed an order, dated 02/01/2023, for Hydrocodone-Acetaminophen oral tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain. Review of the Controlled Drug Disposition form revealed a makeshift form of a single piece of white paper. The paper documented Resident #51's name, the medication name hydrocodone dated 2/1/23, Total 12. It indicated the amount on hand as 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 17 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Control Drug Disposition form revealed on 02/02/2023 at 8:45 p.m. one dosage of hydrocodone was administered, it was omitted of a signature of the person who gave the pill, and on 02/03/23 at 9:45 a.m. one tablet was administered with an omitted signature. Further review of the Control Drug Disposition form reflected the administration on 02/05 at 9:00 a.m. and at 9:00 p.m., on 02/06 at 9:00 a.m. and at 8:00 p.m., on 02/07 at 9:00 a.m., 0n 02/08 at 4:20 p.m., on 02/09 at 9:00 a.m., on 02/10 at 9:00 a.m., on and on 02/12 at 3:00 p.m. Review of the February 2023 MAR showed Hydrocodone-Acetaminophen oral tablet 5-325 mg was administered on 02/05 at 8:45 a.m. (0845) and at 8:45 p.m. (2056), on 02/08 at 4:19 p.m. (1619) and on 02/12 at 2:46 p.m. (1446). Which indicated the MAR was omitted of seven documented doses. On 02/15/2023 at 2:13 p.m. Interim Director of Nursing confirmed there was a discrepancy in the narcotic documentation and counts and an investigation was started along with suspending staff. The Interim Director of Nursing confirmed the MAR and the Controlled Drug Disposition forms should match. She indicated education would be immediately provided to the licensed staff members. On 02/16/2023 at 4:25 p.m. a phone interview was conducted with the Consulting Pharmacist who confirmed she performs audits of the control medications when at the facility. She indicated she was not aware that the Controlled Drug Disposition form did not match what was documented in the MAR. The Pharmacist stated, They should match. She said they need to additionally document in the MAR. She said she does not match the Disposition form with the MAR. The Consulting Pharmacist stated, That nurse should sign the narcotics out right when they give it. Review of the policy titled, Controlled Substance Prescription, dated 09-2018, showed: Policy medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations. The Director of Nursing and the contracted consultant pharmacist maintain the facility's compliance with the federal and state laws and regulations in the handling of controlled medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 18 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, policy review and photographic evidence the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items in both the walk in freezer and dry storage area. The facility failed to ensure the refrigerator and freezer temperature logs were completed. The facility failed to ensure the dishwasher temperature gauges were in good working order in one of one kitchen with the potential to affect 73 out of a census of 75 residents. Findings included: An observation on 02/13/23 at 10:40 a.m. showed both the refrigerator and freezer temperature logs were hanging up on the wall outside of the walk in refrigerator and walk in freezer. The freezer temperature log showed no temperature for the morning of 02/09/23 and no additional freezer temperatures documented for 02/10/23 to 02/13/23. The refrigerator temperature log showed no refrigerator temperatures documented for days of 02/10/23 and 02/12/23. There was no evening refrigerator temperatures documented for the day 02/11/23. (Photographic Evidence Obtained) An immediate interview on 02/13/23 at 10:40 a.m. was conducted with the Dietary Manager (DM) who stated, Those should have been done. An observation on 02/13/23 at 10:45 a.m., showed the walk in freezer contained four packages of frozen meat not labeled or dated. In addition, a frozen bag of diced green peppers bag was not dated. (Photographic Evidence Obtained) During an immediate interview, on 02/13/23 at 10:45 a.m. the DM identified one bag of diced up ham and stated that all meats should be labeled and dated when taken out of the manufacturer's box. The DM stated all food items should have been labeled and dated. An observation on 02/13/23 10:50 a.m. showed a plastic bin in the dry storage area that contained two bags of yellow rice cereal and an additional half of a bag that was opened and not labeled or dated. (Photographic Evidence Obtained) During an immediate interview on 02/13/23 at 10:50 a.m. the DM identified the cereal and did not know when the cereal would be out of date. The DM stated the bin should have been labeled and dated to know this information. Multiple observations on 02/13/23 at 10:52 a.m., 10:55 a.m. and at 11:02 a.m. showed the dishwasher temperature gauges did not move when the dishwasher ran. The wash cycle gauge showed at 120 degrees and did not move during any of the three observed wash cycles. The rinse gauge during the rinse cycle never moved off the temperature of 104 degrees during both the rinse cycle and when not in use. The rinse cycle temperature gauge appeared to be loose and wobbly. (Photographic Evidence Obtained) During an immediate interview on 02/13/23 at 11:02 a.m. the DM stated the wash cycle gauge should have moved above 120 degrees and did not. The DM stated, the rinse cycle gauge was not working properly because the gauge is very loose and not working. The DM stated the dishwasher maintenance company was coming to the facility today. The DM stated the dishwasher gauges work and sometimes they do not, but the dishwasher maintenance will look at it and fix it. The DM confirmed the dishwasher gauges (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 19 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 did not work properly during the three observations. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy titled, Food Storage- Dry Goods, with a revision date of October 2019, showed, The Dining Services Director or designee ensures that the storage will be neat, arranged for easy identification and date marked as appropriate. Residents Affected - Many A review of the facility's policy titled, Food Storage: Cold, with a revision date of October 2019, showed, The Dining Services Director/Cook insures all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. A review of the facility's policy titled, Ware Washing, with a revision date of October 2019 showed, The Dining Services Director insures that all the dish machine water temperatures are maintained in accordance with manufacture recommendations for high temperature or low temperature machines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 20 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on observation, interview, and medical record review the facility failed to ensure that outside services were collaborated for one resident (#56) out of one resident receiving hospice services. Residents Affected - Few Findings included: On 02/13/2023 at 12:12 p.m. Resident #56 was sitting on the side of her bed and verbalized a concern about not being able to leave the facility on her own like her roommate. Resident noted with cognitive deficit at that time stating, To just leave for a while. She said she knew she was receiving hospice services but could not recall the last time someone visited her. Review of Resident #56's admission Record form indicated her last admission was two months ago with the primary payer as Hospice. The Hospice Face Sheet showed diagnoses of malignant neoplasm of unspecified (unsp.) part of unspecified bronchus or lung, secondary and unspecified malignant neoplasm of lymph node. On 02/16/2023 at 1:12 p.m. an interview was conducted with Staff N, Licensed Practical Nurse (LPN)/Unit Manager (UM). She stated, The hospice nurse and aide come one day a week. She was unsure what day of the week. She went on to say Resident #56 was transferred from the lower unit two weeks ago. Staff N stated, she had not talked to the hospice nurse. On 02/16/2023 at 1:35 p.m. an interview was conducted with the Director of Nursing (DON) she said the facility was in the process of going paper free. She stated, The hospice notes and care plan would be in the electronic medical record (EMR) under miscellaneous. Review of the miscellaneous section in Resident #56's EMR did not reflect a hospice note nor plan of care. On 02/16/2023 at 2:00 p.m. and interview was conducted with Staff J, Registered Nurse (RN)/MDS Coordinator (Minimum Data Set). She stated, The resident's first admission assessment was performed on 12/22/2022. At that time, she was unable locate the Interdisciplinary Plan of Care to identify who had attended the meeting. She indicted one was always done. Staff J was observed going through a stack of Interdisciplinary Plan of Care sign in sheets without locating one. She additionally checked the EMR without success. Staff J confirmed she was the one who sets up the dates of the care plan meetings, and she contacts any outside services of the pending meetings. She said she did remember the meeting and that hospice did not attend. She then added she was not sure why hospice did not attend. Staff J was asked for a copy of the facility plan of care for Resident #56 that would reflect current hospice services. Staff J was not able to find one and stated, I must have for forgot to start one. Staff J confirmed she was the one responsible for the care plan. On 02/16/2023 at 2:48 p.m. Staff J provided a copy of Resident #56's Interdisciplinary Care Plan Review form sign in sheet. She confirmed the form contained her name, the unit manager and the resident. Staff J stated, I did not call hospice and notify them of the meeting. They will notify me of a care plan meeting, that has been the past process. I don't know how they were doing it before I got here. She went on to say the prior MDS nurse was gone before she started. She indicated she was not aware when hospice visits the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 21 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm On 02/16/2023 at 2:55 p.m. an interview was conducted with Staff C, LPN UM. She confirmed Resident #56 had resided on her unit before she was transferred. Staff C said hospice was coming in weekly to see the resident, but then it changed to every other week because they were having staffing issues. Staff C said she had talked with the hospice nurse about the resident's plan of care. She confirmed she did not document in the resident's medical record that would reflect the coordination of services. Residents Affected - Few On 02/16/2023 at 3:15 p.m. the DON stated, I reached out to hospice, they have sent their care plan. She said the resident has only been here for two months, and confirmed an initial care plan meeting was held. She went on to state, Hospice did not need to be involved with the initial care plan. The facility provided a copy of a Hospice Registered Nurse note, dated 02/08/2023. The note indicated a visit was conducted for Resident #56. The noted was omitted of any care or coordination of services with the facility staff. Review of the facility's policy titled, Hospice Program, revised July 2017, showed the Policy Statement as: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation. 12. Our facility has designated (name - omitted) (title - omitted) to coordinate care provided to the resident by the facility staff and the hospice staff. a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for resident receiving these services. b. Communicating with the hospice representatives and other healthcare providers participating in the provision of care. 13. Coordinated care plans for resident receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility. Review of the Hospice- Nursing Facility Services Agreement, dated 5/1/2019, showed: Agreements In consideration of the Recitals and mutual agreements that follow, the parties agree to the following terms and conditions. 1. Definitions. (e) Hospice Plan of Care means a written care plan established, maintained, reviewed and modified, if necessary at intervals identified by the Hospice, Hospice Interdisciplinary Group (IDG) in coordination with Facility and each Hospice Patient's attending physician, if any. The Hospice Plan of Care must reflect goals of each Hospice Patient and his or her family and interventions based on the problems identified in each Hospice Patients assessments. The Hospice Plan of care will reflect the participation of the Hospice, Facility, a Hospice Patient and his or her family to the extent possible. Specifically, the Hospice Plan of Care includes: (i) identification of the Hospice Services, including interventions. (ii) a statement of the cope and frequency of such Hospice Services and Facility Services. (iii) measurable outcomes anticipated from implanting and coordinating the Hospice Plan of care. (e) Coordination of Care (page 5 of 19) (i) General. Facility shall participate in any meetings, when requested by Hospice for the coordination of services provided to Hospice Patients. Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure needs of Hospice Patients are met 24 hours per day. (ii) Design of Hospice Plan of care. In accordance with applicable federal and state laws and regulations, Facility shall coordinate with the Hospice in developing a Hospice Plan of Care for each patient that is consistent with the hospice philosophy and is responsive to the unique of each Hospice Patient and his or her expressed desire for hospice care. Facility will notify Hospice of all scheduled care plan meetings, including date and time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 22 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and policy review the facility failed to ensure the call bell system was working and available on two of two floors for a census of 75 residents. Residents Affected - Many Findings included: During an observation on 02/15/23 at 12:45 p.m., Resident #200 was in the door of his room. He stated he had been trying to get someone to come to his room, but his call bell wasn't working. He wasn't sure how long he had been trying to get assistance. Resident #200's call bell was tested as well as call bells in the rooms around his. It was discovered that no call bells were working on the second floor (both East and [NAME] wings). During an interview on 02/15/23 at 12:55 p.m., Staff D, Licensed Practical Nurse (LPN) stated that none of the call lights are working on the second floor. Staff D, LPN stated that she was just told the call bell system wasn't working by another staff member about five minutes ago. Staff D, LPN pointed out the maintenance staff down the hallway and stated, They are working on it now. During an interview on 02/15/23 at 1:02 p.m., Staff E, Maintenance Supervisor stated the maintenance staff were not aware the call bell system was not working and thanked the survey team for bringing the issue to their attention. During an observation on 02/15/23 at 1:04 p.m. Resident #257 was seen at the nurses' station informing a nurse that the call bell in their room was not working and no staff came to the room when the call bell was pushed about a half an hour ago. During an interview on 02/15/23 at 1:05 p.m., Staff D, LPN stated she assumed maintenance was on the second floor to fix the call bell system. Staff D, LPN stated that she was made aware of the call bell system malfunction by the Staff G, Registered Nurse (RN) on the floor and assumed the Maintenance Department knew of the call bell issue. An observation on 02/15/23 at 1:20 p.m., Second Floor, East had no staff present with no working call bell system. There were no staff present on Second Floor East until 1:26 p.m. when Staff G, Registered Nurse (RN) went room to room and delivered hand bells. At this time, due to the fire system also malfunctioning, the fire doors were closed, completely separating this unit from the nurses' station. During an interview on 02/15/23 at 1:40 p.m. Resident #257 stated that he mashed the call light and waited. Resident #257 stated after waiting a little while he pushed the call light button again and went to look outside the room door to see if the light was on. Resident #257 stated that as he looked to see if the light was on the outside of the door Staff E, Maintenance Supervisor walked by so Resident #257 informed Staff E that the call light was not working. Resident #257 stated Staff E responded, I will get to it in a little bit. Resident #257 stated he informed maintenance that the call bell was not working approximately around 12:30 p.m. Resident #257 stated he waited about a half an hour and then went to the nurses' station to let them know the call bell was not working. On 2/15/23 starting at 1:00 p.m. an interview was conducted with the Interim Director of Nursing (IDON). The IDON was asked what back-up plan the facility had in place due to the call light system was not functioning. The DON was surprised and stated she was not aware the system wasn't working, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 23 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Level of Harm - Minimal harm or potential for actual harm no one had told her, there had been an issue. The DON immediately went to the 1st floor and then the 2nd floor to investigate. The DON confirmed both floors did not have a functioning call bell system at that time. An interview was conducted with Resident #190 on 2/15/23 at 1:10 p.m. Resident #190 stated she had been hitting her call bell for 45 to 60 minutes and no one had come. Residents Affected - Many On 2/15/23 at 1:50 p.m. the residents on 2 [NAME] were given manual bells to ring in place of the call bell system. This was 50 minutes after the facility was notified the call bell system was not functioning. A facility policy titled, Call Light Maintenance, undated, was reviewed. The policy stated the following: Purpose: To maintain call light system in working order to respond to resident's requests and needs. Procedure: 1. Staff to report any malfunction to Administrator, DON and Maintenance immediately. 2. If call light is not in working order, place bell in room by bedside as well as bathroom until call light is fixed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 24 of 24