Health inspection·February 13, 2025

F 0656 -Therapy screen with a revision date of 02/10/25. Level of Harm - Minimal harm or potential for actual harm -[Resident #2] is to be encouraged to be in activities of choice or in common areas when up with an initiation date of 02/13/25. Residents Affected - Few A review of the active care plans on 02/13/25 at 3:12 p.m. was conducted with the NHA and the Director of Nursing (DON). The DON stated no interventions were put into place after the first fall on 01/15/25. The DON stated they were supposed to put a cushion on her chair. The DON confirmed the care plan should have been updated to reflect fall interventions. He confirmed the care plan was how the staff were able to know the plan of care for the resident. 2. Review of Resident #3's admission Record showed she was admitted to the facility on [DATE] with diagnoses to include hereditary ataxia, cerebral infarction, cerebral palsy, Parkinson's disease, muscle wasting, reduced mobility, dementia and anxiety disorder. Review of Resident #3's medical record revealed the resident had a fall on 01/08/25 and 01/16/25. Review of Resident #3's care plan with a revision date of 09/29/24 revealed [Resident #3] has had actual falls and/or related to injury . The goal revealed Resident will minimize risk of fall related injuries with staff intervention thru the next review date. The interventions revealed the following: -Keep all personal items within reach with a revision date of 02/13/25. -Offer to assist resident to get out of bed . with a revision date of 02/13/25 During an interview with the DON on 02/13/25 at 3:25 p.m., he stated after the fall on 01/08/25 the intervention was for the resident to be up in common area while woke and the intervention for the fall on 01/16/25 was for the resident to be up in common area while woke and to have personal items in reach. No interventions were put in place after each fall on the care plan. They were revised on 2/13/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 2 of 4 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 02/13/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure adequate supervision was provided for two residents (#2, #3) of three residents sampled for fall accidents. Findings include: 1. Review of Resident #2's admission Record showed Resident was admitted to the facility on [DATE] with diagnoses to include senile degeneration of the brain, major depressive disorder, generalized anxiety disorder, heart failure, muscle wasting, weakness and reduced mobility. Review of Resident #2's medical record showed she was discovered to have bruising to her right shoulder and right side of her head on 01/15/25. Resident #2 was sent to the hospital for further evaluation. Further review of the medical record showed the resident was treated in the emergency room on [DATE] and was found to have a right clavicle fracture. During an interview with the Nursing Home Administrator (NHA) on 02/13/25 at 2:11 p.m., she stated through her investigation it was discovered the resident was observed by a staff member on the floor on the side of her bed. She stated the staff member failed to report the fall. Review of Resident #2's fall risk evaluation dated 01/17/25 showed a score of 14 indicating the resident is a high fall risk. Review of Resident #2's medical record showed she had another fall on 02/10/25. A progress note dated 02/10/25 stated Resident during last rounds before shift change was found on the bedside mat with bed in lowest position. Resident assisted back to bed by three staff members . Resident placed into Geri chair at nurses' station . Review of a progress note dated 02/13/25 stated IDT [ interdisciplinary team] team met to discuss resident change of plane on 2/10 where resident was found sitting on floor mats. Resident is to be encouraged to be in activities of choice or in common areas. A review of the active care plans on 02/13/25 at 3:12 p.m. was conducted with the NHA and the Director of Nursing (DON) present. The DON stated no interventions were put into place after the first fall on 01/15/25. The DON stated they were supposed to put a cushion on her chair. The DON confirmed the care plan should have been updated to reflect fall interventions. He confirmed the care plan was how the staff were able to know the plan of care for the resident. 2. An observation of Resident #3 was conducted on 02/13/25 at 09:30 a.m. She was observed in the common area at the end of the hall by herself sitting in a wheelchair watching tv. No staff were present. On 02/13/25 at 12:45 p.m., Resident #3 was observed asleep in her room while sitting in her wheelchair next to her bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 3 of 4 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 02/13/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #3's admission Record showed she was admitted to the facility on [DATE] with diagnoses to include hereditary ataxia, cerebral infarction, cerebral palsy, Parkinson's disease, muscle wasting, reduced mobility, dementia and anxiety disorder. Review of a fall risk evaluation completed after 12/23/24 showed a fall risk score of 11 which indicated a high fall risk. Review of Resident #3's medical record revealed on 01/08/25, she was observed lying on her back next to her bed on the floor. Review of a Progress note dated 01/09/25 stated Resident was observed lying on her back next to her bed on the floor. the incident was unwitnessed. Writer assessed resident assisting staff to transfer resident back to bed writer continued assessing resident no new injuries noted at this time . Review of a progress note dated 01/13/25 stated IDT team met to discuss fall on 1/8/25 to discuss fall with resident. IDT team discuss to get labs on resident, ensure that resident is up in chair in activities / common areas when woke. Review of a progress note dated 01/16/25, stated This writer observed the resident lying on the floor in a prone position next to her bed. When questioned, the resident stated, I was trying to turn off the TV. The resident's left side of her cheek and lip is swollen. The resident can move her mouth and she denies mouth and jaw pain. The resident c/o [complains of] a headache. The new order send the patient to ED was for treatment and evaluation. Review of the hospital physician notes from 01/16/25 showed the resident was admitted to the hospital for a subarachnoid bleed, subdural hematoma and facial trauma. During an interview with the DON on 02/13/25 at 3:25 p.m., he stated after the fall on 01/08/25 the intervention was for the resident to be up in the common area while woke. The intervention for the fall on 01/16/25 was for the resident to be up in the common area while woke and to have personal items in reach. No interventions were put in place after each fall on the care plan. They were revised on 2/13/25. The DON went on to state residents with a high risk score of 8 or higher should be supervised by staff while in common areas. The common area is at the end of the hall. The DON stated Resident #3 was a high fall risk and she should be supervised while not in her bed. He stated it would not be appropriate for Resident #3 to be in the common area unsupervised and it would not be appropriate for Resident #3 to be sitting in her wheelchair next to her bed asleep. A review of policy titled Accidents and Supervision dated September 2023 with a revision date of April 2024 revealed the following: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s).4. Monitoring for effectiveness and modifying interventions when necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 4 of 4