Health inspection·July 2, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete not supposed to sit on the resident's bed and would have had to go down to the activity room to get a chair. I just felt like standing. Staff I, CNA, confirmed standing most of the time when assisting residents with their meals. 4. On 06/29/25 at 12:25 p.m. five residents were observed in the second-floor activity/dining room waiting for tray delivery. Three of the five residents received trays from the first cart that arrived to the dining room. Two residents who were sitting together, at a separate table from the other residents, were not served their trays. One of the two residents who had not received their meal tray was heard requesting to eat. Trays had not arrived to the dining room before 12:40 p.m. when the surveyor left. During an interview on 06/29/25 at 12:35 p.m. Staff H, CNA stated the second cart for the floor has those residents' trays, the other cart comes later, about 30 minutes or so. The trays are in order of room number only.On 07/01/25 at 11:52 a.m. eight residents were observed in the second-floor activity/dining room. Three residents were seated at a table (table 1), one resident alone at a table (table 2), and another three residents at another table (table 3). Table 1 and 2 were served with their meals and were able to begin the dining experience. Table 3 was not served their meals at this time. During an interview on 07/01/25 at 12:00 p.m. Staff I, CNA stated the second cart for the floor has those three residents' trays on them, their trays come later, in the second cart. The second cart has the other half of the floor's trays, arrives about 30 minutes after the first cart. The trays are in order of the residents' room number only.During an interview on 07/01/25 at 5:00 p.m. Staff G, Licensed Practical Nurse (LPN)/Unit Manager (UM), stated staff should be seated when assisting residents with meals and residents should be served at the same time. During an interview on 07/02/25 at 1:13 p.m. the Director of Nursing (DON) stated the expectation is for residents to be served together and staff should be seated while assisting residents with the meal.Review of the facility's policy and procedure titled Promoting/Maintaining Resident Dignity, dated 01/2025 revealed: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Event ID: Facility ID: 106033 If continuation sheet Page 2 of 55 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 07/02/2025 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure reasonable accommodations were made to ensure three residents (#32, #11, & #2) of three residents reviewed were able to shower. Findings included: On 06/29/25 at 10:17 a.m. Resident #2 was observed in a Geri-chair at the nurses' station with a staff member. Resident #2's hair was not brushed and looked unwashed. Review of the admission Record for Resident #2 revealed an admission on [DATE] with the following diagnosis: dementia with behavioral disturbance, schizophrenia, seizures, major depressive disorder, anxiety disorder, need for assistance with personal care, reduced mobility, drug induced subacute dyskinesia, and other comorbidities. Review of Resident #2's physician visit dated: 05/31/25 revealed: Resident is alert and oriented to self only, able to answer short questions. Review of Resident #2's MDS assessment, dated 04/05/25, revealed: Section GG, Functional Status indicated Resident #2 required total assistance with shower/bathe self, rolling side to side in bed, sit to lying, and for chair/bed to chair transfer. Review of Resident #2's care plan, initiated on 10/13/24, revealed a Focus area of: The resident has an ADL self-care performance deficit. Interventions/Tasks: .Bathing/showering: The resident requires assistance with bathing/showering .On 06/29/25 at 10:49 a.m. and 06/30/25 at 01:00 p.m. Resident #11 was observed in bed, bilateral hand contractures, both hands bent with fingers to the palms. There was a strong yeast like odor, especially strong near the resident. On 06/29/25 at 10:49 a.m. Resident #11 stated a shower would be nice. Review of the admission Record for Resident #11 revealed an admission on [DATE] and re-admitted on [DATE] with the following diagnosis: epilepsy, lymphedema, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), delusional disorders, muscle wasting and atrophy, need for assistance with personal care, other reduced mobility and other comorbidities. Review of Resident #11's Psychiatry Progress Note dated: 06/26/25 revealed: Cognition: Summary: Resident #11 is alert and oriented to self and setting. Thought processes are linear and goal directed. She demonstrates adequate social cognition, though she displays limited insight into her delusional thought content. Judgment and impulse control remain intact during evaluation.Review of Resident #11's MDS assessment, dated 06/27/25, revealed Section GG, Functional Status indicated Resident #11 required total assistance with shower/bathe self, rolling side to side in bed, sit to lying, and for chair/bed to chair transfer. Review of Resident #11's care plan, initiated on 05/20/21, revealed a Focus area of:- Resident #11 has pain symptoms related to: neuropathy, buttock wound, history of fracture of right trochanter, impaired mobility, Resident is able to communicate pain to staff. Interventions/Tasks: . Observe for proper body alignment when in bed/ chair; assist with repositioning as needed.- Resident #11 has a self-care deficit with dressing, grooming, bathing related to (r/t): generalized weakness, limited endurance due to contractures of legs and chronic pain issues. Interventions/Tasks: Utilize mechanical lift with staff assist of two for transfers. Provide hands-on assistance with dressing, grooming, and bathing as needed . Encourage resident to take rest breaks during ADL tasks as needed for SOB (shortness of breath)/fatigue . -Resident #11 has a strength in cognitive function as evidence by (AEB) is oriented to person, place, and time. Short term (ST)/Long Term (LT) memory are intact. Is able to make daily decisions independently.-Resident #11 has an ADL self-care performance deficit r/t musculoskeletal impairment. Interventions/Tasks: .Toileting hygiene: The resident requires (assistance) with toileting hygiene. Bathing/showering: The resident requires (assistance) with bathing/showering. Lying to sitting: Resident requires (assistance) with sitting to lying. Sit to stand: Resident requires (assistance) with sitting to standing. Chair to bed transfer: The resident requires (assistance) with transfers from chair to bed. Toilet transfer: The resident requires (assistance) with Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 3 of 55 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 07/02/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some toilet transfers. Tub/shower transfer: The resident requires (assistance) with transfers in and out of the tub/shower. Transfer: The resident requires mechanical lift with two staff for transfers .During an observation and interview conducted on 06/29/25 at 10:52 a.m. Resident #32 was lying in bed, hair unwashed. Resident #32 stated they never shower me, only bed baths. During an observation and interview conducted on 07/01/25 at 07:58 a.m. Resident #32 was lying in bed, unwashed. Resident #32 confirmed not being offered a shower yet, they have no way to get me up. Review of the admission Record for Resident #32 revealed an admission on [DATE] and re-admitted on [DATE] with the following diagnoses: paraplegia, urinary tract infections, multi-drug resistant, bell's palsy, low back pain, pain, other intervertebral disc displacement, lumbar region, female pelvic inflammatory disease, muscle spasm, need for assistance with personal care, hereditary idiopathic neuropathy, and other co-morbidities. Review of Resident #32's Minimum Data Set (MDS) assessment, dated 04/08/25, revealed Section C Cognitive Patterns, a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was cognitively intact. Section GG, Functional Status indicated Resident #32 required substantial/maximal assistance with shower/bathe self, rolling side to side in bed, sit to lying, and totally dependent on staff for chair/bed to chair transfer. Review of Resident #32's care plan, initiated on 10/12/24, revealed a focus area of: -Resident #32 has an Activities of Daily Living (ADL) self-care performance deficit related to bell's palsy, paraplegia, limited range of motion (ROM) to bilateral ankles. Interventions/Tasks revealed: bathing/showering: The resident requires total assistance with bathing/showering. Roll left to right: The resident requires total assistance to roll left to right; chair to bed transfer: The resident requires total assistance with transfers from chair to bed. Toilet transfer: The resident requires total assistance with toilet transfers. Tub/shower transfer: The resident requires total assistance with transfers in and out of the tub/shower. Transfer: The resident requires a mechanical lift with two staff for transfers. -Resident #32 is at risk for altered level of comfort/pain paraplegia, wound, muscle spasms, neuropathy, endometriosis, bell's palsy, and lumbar pain. Interventions/Tasks revealed: Evaluate the effectiveness of pain interventions, as needed. Review for compliance, alleviating symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Monitor/record/report to Nurse any signs and symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); eyes (wide open/narrow slits/shut, glazed, tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing) body (tense, rigid, rocking, curled up, thrashing). Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. During an interview on 07/01/25 at 04:09 p.m., Staff I, Certified Nursing Assistant (CNA) stated there is a shower schedule in the shower book at the nurses' station. Usually, residents are bathed two times per week unless residents request additional baths. Staff I, CNA stated if a resident is not able or does not want to sit up straight in a shower chair, we just take buckets to them as we only have shower chairs, we do not have a reclining chair or bed. During an interview on 07/01/25 at 04:15 p.m. Staff F, Licensed Practical Nurse (LPN) stated residents are usually showered two times per week, or as residents' request. The CNAs complete the showers; the nurses only receive information from the CNA if the resident has a skin issue. We don't have a shower bed. We utilize a shower chair, or the resident receives a bed bath if they cannot sit up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 4 of 55 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 07/02/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 07/01/25 at 04:33 p.m., Staff G, LPN/Unit Manager (UM) stated the floor has a total lift for residents who cannot sit up in the shower chair. We do not have a shower chair that reclines or a shower bed that would allow the resident to lie back. If a resident refuses, then the nurse should be notified, and documentation of the refusal should be made. Then a bed bath would be offered after the refusal is documented. During an interview on 07/01/25 at 04:42 p.m., Staff K, CNA stated residents who need or want to lie down, don't have a shower bed. We just give bed baths. During an interview on 07/02/25 at 01:13 p.m., the Director of Nursing (DON) stated the expectation is for residents to receive a shower or bath. If the facility does not have a shower bed or reclining chair then we would need to request the Nursing Home Administrator (NHA) for the equipment needed, a bed bath is fine for a short period of time. We would need to meet with therapy to ask for recommendations on assistance and what is safest for the resident. During an interview on 07/02/25 at 12:32 p.m. the Director of Rehabilitation (DOR) stated there are several residents that the shower chair is not an appropriate option for, as it would not be safe for the residents not being able to sit up in the shower chair. Review of the facility's policy and procedure titled Accommodation of Needs dated revised 09/01/23 revealed: Policy: The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered.Policy Explanation and Compliance Guidelines:1. The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom and the common living areas within the facility.2. The facility will ensure that common areas frequented by residents are accommodating physical limitations and enhance their abilities to maintain independence.3. Facility staff shall make efforts to reasonably accommodate the needs and preferences of the resident as they make use of their physical environment.4. Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible. Event ID: Facility ID: 106033 If continuation sheet Page 5 of 55 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 07/02/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings included: 1. During an interview on 06/29/25 at 10:52 AM Resident #32 stated having concerns regarding not receiving medications as ordered by the physician. Review of the admission Record for Resident #32 revealed an admission on [DATE] and re-admitted on [DATE] with the following diagnosis: urinary tract infections (UTI), paraplegia, multi-drug-resistant infection, bell's palsy, low back pain, pain, other intervertebral disc displacement, lumbar region, female pelvic inflammatory disease, muscle spasm, need for assistance with personal care, hereditary idiopathic neuropathy, and other co-morbidities. Review of Resident #32's Minimum Data Set (MDS) assessment, dated 04/08/25, revealed Section C Cognitive Patterns, revealed a score of 14 out 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was cognitively intact. Review of Resident #32's physician order dated to 06/23/2025 at 09:49 AM for INVanz Injection Solution Reconstituted 1 gram (GM) to be given intravenously at bedtime for UTI for 10 days. Review of Resident #32's Medication Administration Record (MAR) revealed: documentation of number 9 indicating Other/See Progress Notes on 06/23, 24, 25, & 29/2025. The progress notes revealed: 6/23/2025 at 21:02 Note Text: INVanz Injection Solution Reconstituted 1 GM, medication not available, called pharmacy. 6/24/2025 at 22:15 Note Text: INVanz Injection Solution Reconstituted 1 GM, on order6/25/2025 no entry found 6/26/2025 at 06:59 Note Text: INVanz Injection Solution Reconstituted 1 GM, this was to be ran on previous shift6/29/2025 at 21:55 Note Text: INVanz Injection Solution Reconstituted 1 GM, Called pharmacy, medication on order.Review of Resident #32's medical record, including assessment/evaluations, progress and physician notes, no documentation was found to show the physician had been notified of the medication not being available/administered. During an interview on 07/01/25 at 04:52 PM Staff F, Licensed Practical Nurse (LPN) stated the process when receiving a new order for medication from the physician is to, input the order into the computer which notifies the pharmacy of the need for delivery. If the medication is available in our emergency medication bank, we can pull the medication from the bank and administer. If the medication is not in the bank, we contact the pharmacy and see when the medication will be delivered, the medication can always be sent STAT (immediately, within 4 hours). We then contact the physician with the information and see if there are new orders to follow. Staff F, LPN confirmed the physician would need to be contacted if the medication is not available or for any reason not administered to the resident. During an interview on 07/01/25 at 05:00 PM with Staff G, LPN/Unit Manager (UM) stated if medication is not available or administered the physician should be notified. Documentation should show notification to the physician and if any new orders were received. During an interview on 07/02/25 at 01:13 PM the Director of Nursing (DON) confirmed Resident #32's medical record did not have documentation of the medication being administered and lacked documentation the physician was notified. The DON stated the expectation is for medication to be administered as the physician orders, if the order cannot be carried out the physician should be notified. During an interview on 07/02/25 at 07:37 PM the physician to Resident #32 stated the facility had not notified him of the medication not being available nor administered. The physician stated, the facility should have contacted me, especially with the resident's issues with infections being resistant to multiple drugs. New orders need to be placed.2. During an interview on 06/30/25 at 03:30 PM the resident representative (RR) to Resident #338 stated the facility left a voice mail, on 01/31/25 at 02:00 PM stating Resident #338 had obtained a scratch on the elbow, nothing serious and a band aid was applied, no need to call back. The next call I received was on 02/01/25 at 2:00 AM when the hospital called and informed us Resident #338 was in the Intensive Care Unit (ICU) and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 6 of 55 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 07/02/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete requested permission to place a central line. Review of the admission Record for Resident #338 revealed an admission on [DATE] with the following diagnosis: hepatic encephalopathy, hypertension, other pancytopenia, need for assistance with personal care and other co-morbidities. Review of Resident #338's progress notes revealed: -01/28/25 at 11:01 PM Interdisciplinary Team (IDT) met to discuss fall on 01/27/25. No other documentation exists regarding 01/27/25 fall including notification to physician or RR. -01/31/25 at 02:59 PM Change of Condition (COC) resident had an increase in confusion. Notifications occurred to the physician and RR. -01/31/25 at 07:33 PM COC resident had a fall. No documentation of notification to physician or RR. -02/01/25 at 03:54 AM the resident was sent to the hospital. No notification to the RR. During an interview on 07/02/25 at 01:13 PM the DON confirmed Resident #338's record did not show notification to the RR for Resident #338's COC on 01/27/25, 01/31/25 at 07:33 PM and the 02/01/25 transfer to the hospital. The DON stated the expectation is for RR be notified of any change in condition of the resident. Review of the facility's policy and procedure titled Notification of Changes, revised 5/2024 revealed: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include:1. Accidentsa. Any accident with or without injury.b. Potential to require physician intervention.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include:a. Life-threatening conditions, orb. Clinical complications.3. Circumstances that require a need to alter treatment. This may include:a. New treatment.b. Discontinuation of current treatment due to:i. Adverse consequences.ii. Acute condition.iii. Exacerbation of a chronic condition.4. A transfer or discharge of the resident from the facility Additional considerations:1. Competent individuals:a. The facility must still contact the resident's physician and notify resident's representative, if known.b. A family that wishes to be informed would designate a member to receive calls.c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident. Event ID: Facility ID: 106033 If continuation sheet Page 7 of 55 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 07/02/2025 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to ensure privacy of resident information on one floor (1st) out of two floors in the facility.Findings Included: An observation was conducted on 6/30/25 at 12:27 p.m. in the 100 [NAME] Hall of a medication cart with the computer screen unlocked. A resident's private information was visible to anyone in the hall and there was no staff member present. An interview was conducted on 6/30/25 at 12:29 p.m. with Staff M, Licensed Practical Nurse (LPN). Staff M, LPN returned to her medication cart and confirmed she left the screen unlocked with a resident's medical record displayed. Staff M, LPN said she only walked away to get a blood pressure cuff. She confirmed the screen should have been locked. An observation was conducted on 7/1/25 at 10:15 a.m. of a resident's lab order sitting face up on the upper counter of the first-floor nurses' station. No staff were working at the counter. An observation was conducted on 7/1/25 at 11:51 a.m. of a medication cart on the 100 East Hall with no staff present. There was a piece of paper face up on top of the medication cart that contained multiple residents' private information. An observation was conducted on 7/1/25 at 6:20 p.m. of a medication cart on the 100 East Hall with no staff present. There was an empty medication bubble pack sitting face up on the top with a resident's name and prescription information. An interview was conducted on 7/2/25 at 6:20 p.m. with Staff R. LPN/Unit Manager (UM). Staff R, LPN/UM was brought to the medication cart where she confirmed the medication bubble pack should not have been left sitting on the top of the cart. She said the top of the card with resident information should have been torn off and put in the shred bin. Staff R, LPN/UM stated, It is a HIPPA [Health Insurance Portability and Accountability] problem. Staff R, LPN/UM said the nurse assigned to the cart was on break. Staff R, LPN/UM said staff are educated on the privacy of resident information.An interview was conducted on 7/02/25 08:36 p.m. with the Nursing Home Administrator (NHA). She said resident information should be face down and not visible. The NHA confirmed resident information should not be left on medication carts and on the high counter of the nurse's station when staff aren't present.The facility did not provide the requested policy related to privacy of resident information by the survey exit. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 8 of 55 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 07/02/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to ensure the residents had a clean and homelike environment for two (1st and 2nd floors) of two floors toured.Findings included: 1. On 6/29/25 at 10:01 a.m., a tour of the 2nd floor, east wing was conducted. An observation of room [ROOM NUMBER] revealed the baseboard between the sink and the bathroom door was peeling from the wall. On 6/29/25 at 10:46 a.m., an observation of the bathroom in room [ROOM NUMBER] revealed a section of the floor's surface material was missing a piece about three to four inches in length. Further observations of the bathroom floor revealed multiple cracks that started to open. On 6/29/25 at 11:05 a.m., an observation of room [ROOM NUMBER]'s window area, by the B bed, revealed missing and cracked tile towards the left side. Further observations of the left side of the window had multiple areas of chipped paint and sections where the wall material was missing. On 6/29/25 at 11:15 a.m., an observation of room [ROOM NUMBER], by the D bed, revealed multiple wadded paper towels underneath the air conditioning (a/c) unit. Further observations of room [ROOM NUMBER], by the D bed, revealed the dresser had cloth-like material folded into a square underneath the front right leg. An interview with the resident revealed that area leaks water when it rains which is why he put the paper towels there. He said the dresser is unstable and he put the cloth-like material there to prevent it from wobbling. On 6/30/25 at 9:34 a.m., an observation of room [ROOM NUMBER] revealed the a/c unit had a rolled-up towel underneath. The resident removed the towel which revealed an opening, about 1.5 to 2 inches in width, across the length of the a/c unit. The resident said he put the towel there because when it rains water leaks out from that area. Further observations of the window area revealed the tile on the right corner had missing pieces and was cracked. Further observations of the bathroom in room [ROOM NUMBER] revealed the grab bars connected to the toilet were rusted and oxidized with multiple areas of dark brown and orange stains, particularly around the hinges. Further observations of the grab bars revealed they were loose and unstable. An observation of the soap dispenser in the bathroom revealed it was loose, tilted to the right, and coming off where it was mounted to the wall. On 6/30/25 at 9:42 a.m., an observation of the second-floor nurse's station revealed the right and left corners of the desk had exposed metal pieces, that were slightly sharp and jagged to the touch. On 6/30/25 at 1:12 p.m., a tour of the 1st floor east unit was conducted. An observation of room [ROOM NUMBER] revealed the baseboard was separated from the wall underneath the sink. An observation in the hallway, to the left of room [ROOM NUMBER], the lower part of the wall in the alcove, revealed a piece of wood propped on the baseboard of the wall. On 6/30/25 at 2:01 p.m., an observation of room [ROOM NUMBER] revealed the top drawer of the dresser, by the B bed, was off the plastic tracks and slanted to the left. On 7/1/25 at 10:07 a.m., an observation in the bathroom of room [ROOM NUMBER] revealed a plastic bag tied up sitting in the corner. An uncovered toilet plunger was observed next to the toilet. The over the toilet riser had a dried pink in colored substance on the seat. The tile wall adjacent to the toilet had small, drips of a dried white substance covering the lower portion of the wall, the metal handrail had rust. The ceiling over the toilet was peeling, drooping and had unpainted patches. In the shower behind the faucet was an opening in the tile. The faucet at the top of the shower was capped off, a hand-held sprayer was at waist height. One of the Resident's complained of not being able to stand to shower due to the height of the spicket. The sink in the bathroom had a hole near the piping. A review of completed work orders, from 6/1/25 - 7/1/25, for the 2nd floor east wing revealed the following to include:- . Toilet seat rusting . 210B . Open date 6/30/2025 12:25 PM Closed Date 6/20/2025 1:05 PM .- . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 9 of 55 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 07/02/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Please check dresser [Resident name] reported dresser tipped over . 215DD .Open Date 6/26/2025 9:06 AM Closed Date 6/27/2025 2:40 PM . The plastic clips that stop the drawers from coming off the tracks have broken off. A review of open work orders, from 6/1/25 - 7/1/25, for the 2nd floor east wing revealed the following to include:- .AC Seal needs Checked . 210B . Open Date 6/30/2025 1:28 PM .- . Broken Tile on window seal . 210B . Open Date 6/30/2025 1:29 PM .- . Drain in bathroom not screwed in Check Toilet and Sink areas please . 210B . 6/30/25 1:37 PM .- . Check All AC Seals Residents using towels underneath AC units . Building Wide . 6/30/25 1:29 PM . On 7/2/25 at 3:42 p.m., an interview was conducted with the Environmental Services (EVS) Director. She said bathrooms and bedrooms are cleaned twice a day. Photographic evidence was reviewed with the EVS Director who said the removable toilet observed on 7/1/25 in room [ROOM NUMBER], with pink colored liquid, should have been cleaned by housekeeping staff. She stated, If it's stool then nursing cleans that. The EVS Director said the plunger outside the bag in room [ROOM NUMBER] should not have been like that. She stated, It looks like it was in the bag initially, someone used it and didn't put it back. On 7/2/25 at 3:48 p.m., an interview was conducted with the Director of Maintenance (DOM) and Housekeeping/Maintenance Regional Director. The DOM said he didn't know about the environment concerns in room [ROOM NUMBER] prior to 6/30/25. He said he expected staff to put a work order in when the issues were identified. The DOM said he thinks room [ROOM NUMBER], D bed, received a new dresser on 6/27/25. He said the Maintenance Assistant was supposed to replace the dresser. A review of the work order opened on 6/30/25 regarding building wide a/c units needed to be sealed was conducted with the DOM. He stated, The administrator said residents are saying there are leaks. He said they started on the work orders but have not finished yet. The DOM said the maintenance team just found out about the a/c seal concerns. He stated, If it wasn't in [work order system] we didn't know about it. 2. On 06/29/25 between 09:26 AM and 02:00 PM the following were observed during the initial facility tour: -room [ROOM NUMBER] bathroom - the toilet safety rails were rusted, and a square plastic container sitting on the floor next to the toilet with a toilet bowl brush inside. -room [ROOM NUMBER] bathroom - the toilet safety rails were rusted, and an uncovered toilet plunger was sitting next to the toilet. -room [ROOM NUMBER] closet was not accessible to either resident. -room [ROOM NUMBER] bathroom - the toilet safety rails were rusted, and an uncovered toilet plunger was sitting next to the toilet. The wall next to the toilet including the light switch was soiled with a brown substance.-room [ROOM NUMBER] - the wall adjacent to the footboard of the bed, had two holes above the cove base.-room [ROOM NUMBER] wheelchair armrests were cracked, and leg rest had a beige cloth wrapped around, creating an uncleanable surface. -room [ROOM NUMBER] the upper portion of the wall behind the door had a hole approximately 2 feet wide and 8 height. -room [ROOM NUMBER] bathroom - the toilet safety rails were rusted, and an uncovered toilet plunger was sitting next to the toilet. -room [ROOM NUMBER] bottom drawer of the built in dresser was flakey with a sticky substance-room [ROOM NUMBER] bathroom - call light did not have a pull cord; a cow bell was observed hanging from the safety rail next to the toilet. The shower safety rail has a brown substance running down the tile. The shower head had water continuously dripping. The tub had black bio growth along the tile connecting the wall to the tub. The wheelchair in the bathroom had armrests that were torn exposing foam, and a hole was observed in the seat cushion. -room [ROOM NUMBER] bathroom lacked water faucets to the shower/tub (the facility did not have a communal shower). Resident 110b stated it would be nice not to have to shower in another resident's bathroom. The cove base beneath the sink was separated from the wall. During an interview on 07/02/25 at 03:44 p.m. the EVS Director confirmed the toilet plungers are expected to be covered and toilet brushes should not be left in the bathrooms. During an interview and observation tour on 07/02/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 10 of 55 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 07/02/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete between 04:10 p.m. and 4:50 p.m. with the Maintenance Director and the Regional Environmental Director the following were confirmed: -room [ROOM NUMBER] bathroom - the toilet safety rails were rusted, and a square plastic container sitting on the floor next to the toilet with a toilet bowl brush inside. -room [ROOM NUMBER] bathroom - the toilet safety rails were rusted, and an uncovered toilet plunger was sitting next to the toilet. -room [ROOM NUMBER] closet was not accessible to either resident. -room [ROOM NUMBER] bathroom - the toilet safety rails were rusted, and an uncovered toilet plunger was sitting next to the toilet. The wall next to the toilet including the light switch was soiled with a brown substance.-room [ROOM NUMBER] - the wall adjacent to the footboard of the bed, had two holes above the cove base.-room [ROOM NUMBER] wheelchair armrests were cracked, and leg rest had a beige cloth wrapped around, creating an uncleanable surface. -room [ROOM NUMBER] the upper portion of the wall behind the door had a hole approximately 2 feet wide and 8 height. -room [ROOM NUMBER] bathroom - the toilet safety rails were rusted, and an uncovered toilet plunger was sitting next to the toilet. -room [ROOM NUMBER] bottom drawer of the built in dresser was flakey with a sticky substance-room [ROOM NUMBER] bathroom - call light did not have a pull cord; a cow bell was observed hanging from the safety rail next to the toilet. The shower safety rail has a brown substance running down the tile. The shower head had water continuously dripping. The tub had black bio growth along the tile connected the wall to the tub. The wheelchair in the bathroom had armrests that were torn exposing foam, and a hole was observed in the seat cushion. -room [ROOM NUMBER] bathroom lacked water faucets to the shower/tub (the facility did not have a communal shower). The cove base beneath the sink was separated from the wall. The Maintence Director stated not being aware of the areas and they would need to be corrected. Review of the facility's policy and procedure titled Routine Cleaning and Disinfection, with a revised date of 01/2025 revealed: Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible .Policy Explanation and Compliance Guidelines:1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge .4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to:a. Toilet flush handlesb. Bed railsc. Tray tablesd. Call buttonse. TV remotef. Telephonesg. Toilet seatsh. Monitor control panels, touch screens and cablesi. Resident chairsj. IV polesk. Sinks and faucetsl. Light switches m. Doorknobs and levers .13. Cleaning of walls, blinds and window curtains will be conducted when visibly soiled. Review of the facility's policy titled Preventative Maintenance Program with a revised date of 01/2025 revealed: Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.Policy Explanation and Compliance Guidelines:1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience.3. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them . (Photographic Evidence Obtained) Event ID: Facility ID: 106033 If continuation sheet Page 11 of 55 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 07/02/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure the grievance process was followed for two residents (#4 and #47) out of 21 residents sampled and for the Resident Council members.Findings Included: 1.During an interview on 06/30/2025 at 10:29 a.m., Resident #4 stated she was supposed to have a Cat (CT) scan completed on Friday (06/27/2025) at 8:00 a.m. I spoke with the Administrator on Friday and this morning about it. I was told it would be rescheduled but no one has told me if it has been rescheduled. I’m afraid it will not be completed in time for my appointment with my surgeon on Wednesday. Review of Resident #4's admission record revealed an admission date of 06/04/2025. Resident #4 was admitted to the facility with diagnosis to include unspecified sequelae of cerebral infarction, muscle weakness (generalized), altered mental status, personal history of other venous thrombosis and embolism, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, cerebral infarction, anxiety disorder, and other specified peripheral vascular diseases. Review of Resident #4's admission Minimum Data Set (MDS) dated [DATE] revealed, Section C. Cognitive Patterns, a Brief Interview Mental Status (BIMS) score of 15 out of 15 showing intact cognition. Review of the Grievance Log for June 2025 revealed no grievances for Resident #4. During an interview on 07/02/2025 at 3:03 p.m., the NHA stated I did a grievance on Friday for Resident #4's missed appointment. 2.During an interview on 07/01/2025 at 10:15 a.m., Resident #47 stated he had an issue last night with staff not allowing him to have a private phone call in the dining room. He stated he was on the phone when a staff member came in and told him he was not allowed to be in the dining room at that time. I spoke with a nurse last night about it and was told that my rights were violated. I was not told if it was filed as a grievance. No one has come to speak with me. Review of Resident #47's admission record revealed an admission date of 05/01/2025. Resident #47 was admitted to the facility with diagnosis to include depression, attention-deficit Hyperactivity disorder, and personal history of traumatic brain injury. Review of Resident #47's Medicare 5-day MDS dated [DATE] revealed Section C. Cognitive Patterns, a BIMS score of 14 out of 15 showing intact cognition. During an interview on 07/01/2025 at 10:36 a.m., the Social Services Director (SSD) stated if a staff on the night shift takes a grievance they fill out a form and put it under his or the administrator's door and then they will review them the next day. I did not have any grievances in my office this morning. During an interview on 07/01/2025 at 10:48 a.m., the Nursing Home Administrator (NHA) stated I did not have any grievances left for me this morning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 12 of 55 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 07/02/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 7/01/2025 at 11:14 a.m. Staff M, Licensed Practical Nurse (LPN), stated a grievance is a genuine complaint about a process or something in the facility. Any person or resident can file a grievance. I would try to correct the concern first. If they were not satisfied with the outcome then then I would go to a grievance. To file a grievance there is a form you give to them to fill it out. 3. During a Resident Council (RC) meeting conducted on 06/30/25 at 10:03 a.m. with eight participants, who regularly attend the Resident Council Meetings. The group confirmed ongoing complaints related to the patio doors being broken and pests. The RC stated staff do not complete grievances for them, the resident has to fill out the form. The RC stated this is too hard and does not understand why they could not complete the forms for them. Review of the RC meeting minutes revealed: - On 4/17/25 at 2:00 p.m. revealed: Old Business from the 3/27/25 meeting: Call lights not being answered in March 2025, no hot water, resident garbage cans not emptied routinely. New Business: Nursing: Call lights are still not been answering in a timely manner. Maintenance: Still not getting hot water in the rooms, wheelchairs need washing. - On 5/19/25 at 2:00 p.m. revealed: New Business: pest control service - On 6/19/25 at 2:00 p.m. revealed: New Business: garbage needs emptying often Review of the Grievance Log for April 2025 to June 2025 did not reveal any concerns from RC. During an interview on 06/30/25 at 01:10 p.m. the Life Enrichment Director (LED) confirmed assisting the RC with the meetings, including writing the minutes. The LED stated does not complete a grievance form when issues arise out of RC. During a follow up interview on 06/30/25 at 01:30 p.m. the RC President stated the facility has improved on certain things (call light response) but not on most concerns raised by the group and does not follow up with the group. During an interview on 07/02/25 at 02:21 p.m. the SSD said anyone can complete a grievance. A resident does not have to write the form out. If a resident has a concern that is voiced to a staff member the staff member should complete the form. The form is given to me or the NHA for follow up and tracking. The SSD confirmed there were no grievances from RC for April, May, and June 2025. During an interview on 07/02/25 at 03:15 p.m. the NHA stated not being aware of the RC concerns. If the RC has a concern a grievance form should be completed to ensure follow up. Review of the facility's policy and procedure titled “Resident and Family Grievances” with a review date of 1/2025 revealed: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Definitions: Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 13 of 55 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 07/02/2025 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 0585 working toward resolution of that complaint/grievance. Level of Harm - Minimal harm or potential for actual harm Policy Explanation and Compliance Guidelines: . 4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (Long Term Care) facility stay. 7. Grievances may be voiced in the following forums: Residents Affected - Some a. Verbal complaint to a staff member or Grievance Officer. b. Written complaint to a staff member or Grievance Officer. c. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings. e. Via the company toll free Compliance Line (if applicable). 10. Procedure: a. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. i. Take any immediate actions needed to prevent further potential violations of any resident right. ii. Report any allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator and follow procedures for those allegations. b. Forward the grievance form to the Grievance Officer as soon as practicable. c. The Grievance Officer will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. i. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. ii. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Officer. Prompt efforts include acknowledgment of complaint/grievances and actively working toward a resolution of that complaint/grievance. iii. All staff involved in the grievance investigation or resolution will take steps to preserve the confidentiality of files and records relating to grievances, and will share them only with those who have a need to know. d. The Grievance Officer, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. 12. The facility will make prompt efforts to resolve grievances…14. The facility will make prompt efforts to resolve grievances. 15. When resolving a grievance, Department Managers/Social (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 14 of 55 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 07/02/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Services/Designee should consider the following approaches when contacting a Resident/Responsible Party: a. Thank the resident/responsible party for bringing the grievance to your attention. Treat the customer with empathy, courtesy, patience, honesty and fairness. b. Speak to the Resident/Responsible Party in person if possible c. Show the Resident/Responsible Party that you clearly understand their grievance by listening and taking notes and ask questions to clarify the situation. d. Do not jump to conclusions, apportion blame, or become defensive. e. Summarize back to the Resident/Responsible Party your understanding of the problem. f. Respond to the problem quickly, tell the Resident/Responsible Party how the grievance will be handled and tell them when they can expect a response. g. Speak to the Resident/Responsible Party regarding the centers resolution and politely ask if they are satisfied with the results. h. Social Services/Designee/Department managers should document all contacts, follow up actions until grievance is resolved.17. All Grievances should be documented on the Grievance Log and maintained per retention policy… Event ID: Facility ID: 106033 If continuation sheet Page 15 of 55 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 07/02/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility did not ensure Preadmission Screening and Resident Review (PASRR) Level I screens were updated and/or Level II's were submitted for seven residents (#37, #14, #11, #2, #63, #69, #47) out of seven reviewed for PASRRs to ensure they were appropriate to admit to the facility. Residents Affected - Many Findings included: 1. Review of admission Records showed Resident #37 was admitted on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia, mood disorder due to known physiological condition, generalized anxiety disorder, cocaine abuse, irritability and anger, and personal history of other mental and behavioral disorders. Review of Resident #37's PASRR Level I Screen, dated 10/31/23, Section A. MI (Mental Illness) or suspected MI showed schizophrenia and substance abuse. Services: Did not indicate resident was currently or had previously received services for MI. Question #1 in Section II, Is there an indication the individual has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's development stage? was documented as No. Section IV, PASRR Screen Completion, showed No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. An updated Level I Screen, dated 1/9/25, in Section A. MI (Mental Illness) or suspected MI anxiety disorder was added. Services: now showed Currently receiving services for MI. Section IV, PASRR Screen Completion, showed No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Review of Resident #37's medical records did not reveal a Level II PASRR. Review of Resident #37's Order Summary Report showed: -Lithium Carbonate Oral Tablet. Give 150 mg (milligram) by mouth one time a day for bipolar disorder. Dated 5/8/25. -Seroquel XR (extended release) Oral Tablet Extended Release 24 Hour 300 mg. Give 1 tablet by mouth two times a day related to schizophrenia, unspecified. Dated 2/5/25. -Valproic Acid Oral Capsule 250 mg. Give 1 capsule by mouth two times a day for Schizophrenia. Dated 11/3/23. Review of Resident #37's Psychological Services Psychosocial Evaluation, dated 4/22/25, showed -Does patient's condition result in significant impairment in social functioning? Yes -Does patient's condition result in significant impairment in psychological functioning? Yes -Does patient's condition result in significant impairment in emotional functioning? Yes -Comprehensive Trauma Screening noted unable/unwilling to answer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 16 of 55 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 07/02/2025 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 0645 -Session Summary noted Declined therapy services. Level of Harm - Minimal harm or potential for actual harm Review of Resident #37's progress notes showed: Residents Affected - Many -2/2/25 CNAs [Certified Nursing Assistant] told Writer that resident had just pulled a switchblade on a resident. They explained another resident was not moving fast enough out of his way and the resident pulled out his switchblade and said, 'I'll cut your throat you don't know who you are messing with x [times] 2. CNA separated them and they went their separate ways. The resident then came back to the nures's [sic] station and said 'see' while showing the knife to the CNAs and then to [sic] went to his room. Writer came around the corner and was told about the incident. Writer then went with another nurse to resident's room. Writer spoke to resident and then asked him for the switchblade. Resident had no issues giving Writer the knife. Resident then began telling Writer his criminal history while getting agitated, breathing heavy, and telling Writer how he could kill a man with a pen. Writer told him to stay away from other resident so he won't make any impulsive decisions. He said ok and that he doesn't want the knife back, but he will talk to the DON about it. Writer notified Administrator and was told to call the police. Psych was called and notified of the situation. When the police arrived this Writer explained what happened and the police explained due to resident's illness and long-term status that hemore [sic] that likely will not be prosecuted. The police went to the room to speak with him, and he became a bit aggressive with his speech and was all over the place not answering their questions about the incident that had just happened. Police came out ofthe [sic] room and said he needs to go and if psych was involved. Writer called the Psych APRN [Advanced Practice Registered Nurse] and received order for resident to be [involuntarily hospitalization]. Writer notified [family member]. Review of Resident #37's Certificate of Professional Initiating Involuntary Examination, dated 2/2/25 showed The patient presents with psychosis, significant agitation, he is aggressive, threatening staff and other residents. He pulled out a switch blade on another resident and threatened to kill him. It is noted that this patient has a hx [history] of violent offenses. The patient presents as a danger to others within the facility, he is requiring a higher level of care for safety. Review of Resident #37's medical records did not reveal a Level II PASRR after the involuntarily hospitalization on 2/2/25. Further Review of Resident #37's progress notes showed: -5/30/25 Writer walking hall down to end of 1 East. Res. [resident] had a plate of bbq ribs, uncovered sitting in the left side of the hall, directly opposite of his chair across the hall. Writer bent down to pick up plate for resident, as she thought it had been dropped. Resident began yelling profanities at writer, shaking his fist in writer's face, relaying to not touch his food that was blocking the hall path. Fellow staff came to the incident and were able to redirect and calm resident down. Writer walked away backto [sic] 1 West, her scheduled hall. An observation was conducted on 7/2/25 at approximately 10:30 a.m. Resident #37 was at the front desk of the facility cussing and yelling about his check not being at the facility. Staff escorted him back toward his room and he could be heard yelling as he went down the hall. 2. Review of admission Records showed Resident #14 was admitted on [DATE] with diagnoses including major depressive disorder, generalized anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, adjustment disorder with anxiety, other psychoactive substance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 17 of 55 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 07/02/2025 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 0645 abuse, and epilepsy. Level of Harm - Minimal harm or potential for actual harm Review of Resident #14's PASRR Level I Screen, dated 2/24/25, Section A. MI (Mental Illness) or suspected MI, showed only depressive disorder and substance abuse. Under related conditions, epilepsy was not indicated. The services section indicated Resident #14 was currently receiving services for MI. Question #1 in Section II, Is there an indication the individual has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's development stage? was documented as No. Section IV, PASRR Screen Completion, showed No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Residents Affected - Many Review of Resident #14's medical records did not reveal a Level II PASRR. Review of Resident #14's Order Summary Report showed: -Bupropion HCl (Hydrochloride) oral tablet 75 mg. Give 2 tablets by mouth two times a day for depression. Dated 6/11/2025. -Levetiracetam oral tablet 500 mg. Give 3 tablets by mouth every 12 hours for seizures. Dated 6/9/25. -Paroxetine HCL oral tablet 40 mg. Give 1 tablet by mouth one time a day for depression. Dated 6/9/25. -Trazadone HCL oral tablet 100 mg. Give 150 mg by mouth at bedtime for insomnia. Dated 6/28/25. -Zolpidem Tartrate 5 mg. Give 5 mg by mouth at bedtime for insomnia. Dated 6/10/25. Review of Resident #14's Psychological Services Psychosocial Evaluation, dated 4/22/25, showed -Does patient's condition result in significant impairment in social functioning? Yes -Does patient's condition result in significant impairment in psychological functioning? Yes -Does patient's condition result in significant impairment in emotional functioning? Yes -Will patient's condition deteriorate if patient does not participate in psychotherapy or if treatment discontinues? Yes Review of Resident #14's Psychological Services Progress note, dated 5/8/25, showed: Stressors/changes in mental status: recurrent trauma memories are resurfacing. Stabilization of Symptoms- Objectives worked on during this session diet/exercise/health and depression. Disposition/Rationale for continued treatment: Symptoms require more attention Goal- Decrease symptoms of depression that are being triggered by memories of past traumas. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 18 of 55 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 07/02/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm Interventions- Patient was able to practice redirecting negative-intrusive thought patterns during the session. Response- Patient was able to identify that he was feeling better by talking about his concerns. 'I'm glad I have decided to talk about the things that have been bothering me. I guess I can use this to help me.' Residents Affected - Many Review of Resident #14's Psychological [NAME] Progress note, dated 5/27/25, showed: Stressors/changes in mental status: Recent hospitalization for seizure. Stabilization of Symptoms- Objectives worked on during this session sleep patterns, diet/exercise/health, depression, anxiety. Disposition/Rationale for continued treatment: Symptoms require more attention Goal- Continue to address symptoms of depression & anxiety. Intervention- Coping skills-supportive therapy. Response- Patient reported, 'I'm dressed.' 'I can't sleep.' Responded well to therapy session. Review of Resident #14's medical record did not show any progress notes from Psychological Services after 5/27/25. Review of Resident #14's Progress notes showed: -6/7/25 2:30 p.m. It was reported to this writer that this resident was in the front lobby anxious and agitated and told the receptionist that he was leaving even if he has to smash the glass on the front entry door to get out. Office personnel was able to calm this resident down and get him to come back to the unit but instead this resident went out to the court yard and placed left arm over the fence and was attempting to climb across the fence Writer was informed this resident had his left arm across in an attempt to climb across the fence but was stopped by the nursing staff that was out in the court yard. This resident was escort[sic] with no difficulty back to the unit to this writer. Resident stated, 'he was leaving, even if it means climbing over the fence.' Body check was done with noted dry red abrasion area 3cm [centimeters] x 3cm to this anterior forearm. Resident denies pain. Writer was able to talk with this resident and calm him down. 1:1 [one on one] monitoring initiated. Psych, DON and resident family to be made awar [sic]. -6/8/25 3:20 a.m. Resident started taking lithium 150 mg 7-6-25 resident is having nightmares and screaming out. Resident also stated that his step father is here and was trying to lock him in a closet. Reassured resident that the stepfather was not here and he was safe and in no danger. Resident is in bed resting at this time with call light in reach. -6/8/25 3:04 p.m. Resident was wanting to sign LOA [Leave of Absence] with another resident's friend. Informed the resident that this writer would need to speak to the resident's friend prior to him leaving to review the LOA process. Resident's friend did not want to accept responsibility for the resident upon arrival. Resident became angry threatening to leave AMA [against medical advice]. Informed psych and physician who felt resident was not able to leave AMA safely and determined (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 19 of 55 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 07/02/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm [involuntarily hospitalization] was appropriate. 911 and Police were called as resident continued to be aggressive about leaving the building. Resident signed bed hold policy and transfer form and was transferred to the hospital for evaluation. Resident stated he did not want to return to any facility that he just wanted to live on his own. Residents Affected - Many -6/9/25 6:57 p.m. Resident arrived to facility via [transportation company] . Review of Resident #14's medical records did not reveal a Level II PASRR after the involuntarily hospitalization on 6/8/25. Further Review of Resident #14's progress notes showed: -6/16/25 Resident in to speak regarding recent med changes for psych mgmt. [Management] States his mood is currently stable however, would like to see psych regarding dreams that awaken him during the night. Current medication regimen reviewed and agreed on by resident. Psych notified to see resident on next visit-resident okay with time frame. -6/18/25 9:57 a.m. Spoke with psych after his meeting with resident. Discuss psychosocial changes within the last few weeks. Resident mood status range from helplessness and hopelessness to manic to aggressive ness [sic] and agitation. Resident mood today is calm, however, noted to have confabulation and fabricating stories that are verified not true. Psych services in and adjusted mediations prior. NP [nurse practitioner] states resident has anxiety and depression, PTSD [post-traumatic stress disorder], TBI [traumatic brain injury], along with personality disorder with unspecified psychosis. PoC [plan of care] conts [continues] at this time. Recent change to Wellbutrin as resident requested this is previous effective dose. POC conts. -6/19/25 12:59 p.m. Resident approached writer requesting anxiety medication. Call placed to [name] psych ARNP [Advanced Registered Nurse Practitioner], per NP [Nurse Practitioner] medication list is in review. No medication changes at this time, resident notified. No s/s [signs/symptoms] of anxiety noted at this time. Mood is stable. Review of Resident #14's Care Plan showed a focus area of The resident has tendencies to not use w/c [wheelchair] and use walker; [Resident #14] has tendencies to fabricate stores. Becomes verbally agitated and expresses his desire to leave the facility when personal requests are not immediately met. Date initiated; 6/20/25. Interventions included anticipate and meet the resident's needs and assist the resident to develop more appropriate methods of coping and interacting (when agitation occurs). Encourage the resident to express feelings appropriately. An interview was conducted on 7/2/25 at 5:45 p.m. with Resident #14. He said it had helped him to have therapy and have someone to talk to. He said it was hard for him to trust someone, and he had been talking to the Licensed Mental Health Counselor (LMHC) and telling her things no one knew but his brother. Resident #14 said he needed someone to talk to, and he felt like his anxiety had got worse, and he wasn't sleeping as well since therapy stopped. Resident #14 said he hoped someone would come to talk to him soon. An interview was conducted on 7/2/25 at 8:02 p.m. with the Director of Nursing (DON). The DON said with Resident #14 she saw more of an agitation with him wanting to maintain his independence. She stated, what I see is outbursts and agitation. The DON said the resident's outbursts and agitation weren't frequent but weren't far between either. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 20 of 55 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 07/02/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many An interview was conducted on 7/2/25 at 3:12 p.m. with the Nursing Home Administrator (NHA). The NHA said Resident #14 had not seen psychology for therapy since the end of May. She said she had anticipated the new psychology company to start in June because they had done credentialing, but then things changed. The NHA said psychology had not been in the building since May to see residents. An interview was conducted on 7/2/25 at 5:25 p.m. with the Licensed Mental Health Counselor (LMHC) that had been seeing residents at the facility prior to June 2025. The LMHC said Resident #14 would participate in therapy apart from a couple of visits he said he was fine. The LMHC said it is the resident's choice to do therapy or not. She said Resident #14 was consistently doing psychotherapy in May 2025. The LMHC said it is difficult to know if missing therapy would have set Resident #14 back, but like a lot of clients at the facility the more access they have to counseling the better. She said Resident #14 is definitely someone that could use all the help he can get. The LMHC said she had completed an evaluation on Resident #37, but he did not participate in psychotherapy. An interview was conducted on 7/2/25 at 1:06 p.m. with the NHA. She said in the morning clinical meetings all new admissions are reviewed as well as anyone that had a change, such as a recent involuntary hospitalizations, new diagnosis, or return to hospital. The NHA said if a resident needed a PASRR Level II the DON and MDS (Minimum Data Set) Coordinator would assist with those requests. The NHA said on 6/17/25 during a QAPI meeting they talked about problems with PASRRs but there had been no audits completed and the process to correct the problems had not been started. The NHA said when PASRR Level I screens are reviewed in clinical meetings, they look at the diagnoses that are marked, the answers to the questions in Section II, and if it is a provisional admission. The NHA said pretty much anyone with a diagnosis on the PASRR Level I screen should be screened for a Level II, for example if a resident had schizophrenia or had an inpatient hospitalization (involuntary hospitalization). She said for a resident already in the facility, new diagnosis, or if something happened that affected the resident's daily life would potentially trigger a PASRR Level II. The NHA said she believed the DON had access to the PASRR system to do any updates. She said the facility Social Services Director (SSD) is not a licensed social worker so he cannot do the PASRRs. The NHA reviewed Resident #37's PASRR and said she thought he had a involuntary hospitalization in February 2025 and the fact he didn't have a Level II PASRR would have been caught when they started their audits. An interview was conducted on 7/2/25 at 1:50 a.m. with the DON. The DON said she did not have access to the PASRR system to do updates or request Level II PASRRs. The DON said the Assistant Director of Nursing (ADON) was the only person with access to the system. The DON had the ADON join the interview. The ADON said she had not done PASRR updates in two years and no longer had access to update them or request Level II PASRRs. The DON and ADON both stated during clinical meetings they only review PASRR Level I screens to ensure the residents had them and they are not a provisional admission. The DON said they did not check the Level I PASRRs for accuracy; we literally just look to see it is there and not provisional. The DON then stated no one in the facility had access to the PASRR system to update Level I screens or request Level 3. Review of the admission Record for Resident #11 revealed an admission on [DATE] and re-admitted on [DATE] with the following diagnosis: epilepsy, delusional disorders, major depressive disorder, anxiety, muscle wasting and atrophy, lymphedema, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), need for assistance with personal care, other reduced mobility and other co-morbidities. Review of Resident #11's MDS assessment, dated 06/27/25, revealed resident did not have a Level II PASRR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 21 of 55 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 07/02/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of Resident #11's PASRR Level I Assessment, dated 05/11/16 did not reveal a qualifying mental health diagnosis marked in section I A. A level II PASRR should be completed due to the qualifying diagnoses. Nor was a PASRR completed for re-admission on [DATE]. 4. Review of the admission Record for Resident #2 revealed an admission on [DATE] with the following diagnosis: Dementia with behavioral disturbance, Schizophrenia, Seizures, Major Depressive Disorder, Anxiety Disorder, Need for Assistance with personal Care, Reduced Mobility, drug induced subacute dyskinesia, and other co-morbidities. Review of Resident #2's MDS assessment, dated 01/04/24, revealed: Level 2 PASRR was not marked. Review of Resident #2’s PASRR Level I assessment dated [DATE] revealed a qualifying mental health diagnosis marked in section I A. and yes was marked in Section II. A level II PASRR should be completed due to the qualifying diagnoses. A Level 2 PASRR was not revealed in the record for this time frame. Nor was a PASRR completed for re-admission on [DATE]. Review of Resident #2's Level 2 Florida PASRR/MI Level II Determination Summary dated 07/10/13 revealed resident is in need of services. It is recommended a new Level II request be submitted again if there are any significant change in mood or behavior. Review of Resident #2's nurse note dated 04/16/25 revealed resident having significant behavior changes. Durning an interview on 07/02/25 at 01:27 p.m. the NHA stated Resident #11 & #2 should have had new Level II PASRR submitted. 5. A review of Resident #63's admission record revealed an original admission date of 2/1/23, and a re-admission date of 9/29/24. Further review of the admission record revealed diagnoses to include schizoaffective disorder, bipolar type, other specified depressive episodes, major depressive disorder, recurrent, unspecified, bipolar disorder, current episode depressed, mild, generalized anxiety disorder. A review of Resident #63's physician's orders revealed the following to include: - bupropion hydrochloride (HCI) extended release (ER) oral tablet 150 milligrams (mg), give 150 mg by mouth one time a day for depression. - Klonopin oral tablet 0.5 mg (clonazepam), give 1 tablet by mouth two times a day for anxiety. A review of Resident #63's care plan revealed the following to include: - [Resident name] has the potential for adverse side effects related to the use of psychotropic medications: antianxiety for tx [treatment] of anxiety and antidepressant for depression. - The resident uses antidepressant medication r/t [related to] diagnosis of bipolar depression. - The resident uses anti-anxiety medications r/t anxiety. - The resident has a mood problem r/t recent hospitalizations, deconditioning, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 22 of 55 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 07/02/2025 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 0645 medical decline, bipolar disorder and anxiety disorder. Level of Harm - Minimal harm or potential for actual harm - The resident has depression r/t diagnosis of bipolar depression, history of negative interactions with son, recent hospitalizations with medical decline. Residents Affected - Many A review of Resident #63's PASRR, level I screen, dated 1/30/23, revealed the following diagnoses were marked under section A, bipolar disorder and alcohol (ETOH). No other diagnoses are indicated on the PASRR, Level 1. A review of Resident #63's medical record revealed no documentation of a PASRR, Level II submission or results. 6. A review of Resident #69's admission record revealed an original admission date of 8/7/23, and a re-admission date of 10/12/24. Further review of the admission record revealed diagnoses to include unspecified dementia, unspecified severity, with other behavioral disturbance (primary diagnosis), brief psychotic disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other Alzheimer's disease, and dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of Resident #69's physician's orders revealed the following to include: - Aricept oral tablet 10 mg (donepezil hydrochloride), give 1 tablet by mouth at bedtime related to unspecified dementia, unspecified severity, with other behavioral disturbance. - Depakote oral tablet delayed release 250 MG (Divalproex Sodium), give 1 tablet by mouth two times a day for mood disorder. -Zyprexa oral tablet 5 mg (olanzapine), give 5 mg by mouth at bedtime related to brief psychotic disorder. A review of Resident #69's care plan revealed the following to include: - [Resident name] has a potential for alteration in thought process r/t: dx [diagnoses] of dementia. - The resident has impaired cognitive function/dementia or impaired thought processes r/t non-Alzheimer's dementia with behaviors. - The resident has a mood problem r/t dementia with behavioral symptoms. receives anticonvulsant for mood disorder. A review of Resident #69's PASRR, Level I screen, dated 8/6/23, revealed no diagnoses were marked under section A. Under section II, question 5, the answer no, is marked as dementia not being a primary diagnosis. No other diagnoses are indicated on the PASRR, Level 1. A review of Resident #69's medical record revealed no documentation of a PASRR, Level II submission or results. On 7/2/25 at 1:06 p.m., an interview was conducted with the NHA. The NHA confirmed Residents #63 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 23 of 55 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 07/02/2025 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 0645 and #69 do not have a PASRR, Level II submission initiated by the facility. Level of Harm - Minimal harm or potential for actual harm 7. Review of Resident 47's admission record revealed an admission date of 05/01/2025. Resident #47 was admitted to the facility with diagnosis to include Depression, Attention-Deficit Hyperactivity Disorder, and Personal History of Traumatic Brain Injury. Residents Affected - Many Review of Resident #47's PASRR Level 1 dated 05/01/2025 revealed it was blank. During an interview on 07/02/2025 at 12:03 p.m., the Social Services Director (SSD) stated he has been here for a month and has not done any PASRR's. I don’t have any PASRR's in here. During an interview on 07/02/2025 at 1:15 p.m., the Nursing Home Administrator (NHA) stated they review newly admitted residents PASRR's during the morning meetings. She stated Resident #47's PASRR should have his diagnoses listed on it. Review of the facility policy dated 9/1/2023, titled Resident Assessment-Coordination with PASRR program revealed, Policy: This facility coordinates assessments with the pre admission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 24 of 55 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 07/02/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure quality care and services were provided to one resident (#33) out of thirty-six residents reviewed related to physician orders for intravenous (IV) site dressing changes. Findings included:On 6/29/25 at 10:06 a.m., an observation of Resident #33 revealed he was sitting up in bed with the television on and looking at his personal cell phone. Further observation of the resident revealed a central line IV site on his right chest with the dressing dated 6/18/25. Further observation of the dressing revealed an initial that appeared to be, AN. Photographic evidence obtained with the permission of Resident #33.On 6/30/25 at 10:21 a.m., an observation of Resident #33 revealed the central line IV site on his right chest dressing was still dated 6/18/25.On 6/30/25 at 10:23 a.m., an interview was conducted with Staff F, Licensed Practical Nurse (LPN). She said Resident #33 declined for staff to remove the central IV line. Staff F, LPN said he wanted to go to his doctor outside the facility to remove the central IV line. She stated, He handles his own affairs and transportation. She said the floor nurse's do the flushes. She stated, That's on the orders. Staff L, LPN stated, I have not been here, but I got verbal report, about Resident #33 refusing to let nursing staff change the dressing or remove the central IV line. She said she had not documented that, but it should be documented in Resident #33's progress notes by other staff.A review of Resident #33's admission record revealed an original admission date of 4/11/25 and re-admission date of 5/29/25. Further review of the admission record revealed diagnoses to include muscle wasting and atrophy, not elsewhere classified, multiple sites, muscle weakness (generalized), severe sepsis with septic shock, adjustment disorder with mixed anxiety and depressed mood, other malaise, and dependence on wheelchair. A review of Resident #33's Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, cognitively intact.A review of Resident #33's physician's orders revealed the following:- Change midline IV dressing 24 hours post insertion, then every (q) week and as needed (PRN) for IV site care use securement device with each dressing change. Start date 6/3/25 and no end date.- Change midline IV dressing 24 hours post insertion, then q week and PRN one time a day every 7 days for IV site care use securement device with each dressing change. Start date 6/4/25 and no end date.A review of Resident #33's progress notes revealed the following to include:- 6/18/25, Changed right chest central line dressing w/o [without] diff [different] Primary nurse at BS [bedside]. No s/s [signs and symptoms] of infection. Pt [patient] tol [tolerate] well. Pt friend at BS. Call bell in reach.-6/23/25, Pt sitting up in bed visitor at bs. Right chest central line IV drsg [dressing] clean, dry & intact. No c/o [complaint] pain or s/s of distress. Call bell in reach.-6/28/25, The Change In Condition/s [CIC] reported on this CIC Evaluation are/were: Fever . Nursing observations, evaluation, and recommendations are: CNA [certified nursing assistant] summoned this writer to [room number].Pt laying in bed. Flushed face & pt stated i feel hot inside my body but cold outside my body . Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ER [emergency room] for r/o [rule out] sepsis and remove Central line .-6/28/25, Resident returned from ER with no new orders . Right central line drsg CDI [clean, dry, and intact], no redness nor warmth noted.A review of progress notes revealed no documentation from 6/18/25 to 6/30/25 of Resident #33 refusing the central line IV dressing changes or care.A review of Resident #33's June medication administration record (MAR) and treatment administration record (TAR) revealed the orders for changing the midline IV dressing was marked as completed on 6/4/25, 6/11/25, 6/18/25, and 6/25/25.On 7/1/25 at 4:39 p.m., an interview with Staff G, LPN/Unit Manager (UM) was conducted. She said the 3:00 p.m. - 11:00 p.m. Registered Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 25 of 55 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 07/02/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Nurse (RN) supervisor was completing all the dressings, changing foley bags, and overseeing infection control. Staff G, LPN/UM said Resident #33's central IV dressing was supposed to be changed every 7 days. She stated, From my understanding it was being done. Staff G, LPN/UM said she knows the dressing changes were completed because of the documentation and the RN supervisor told her. She said she was not aware the central line IV dressing had not been changed since 6/18/15. Staff G, LPN/UM said she should have been made aware and there should be documentation. She stated, I wouldn't know any other way.On 7/1/25 at 5:13 p.m., a phone interview was conducted with the 3:00 p.m. - 11:00 p.m. RN supervisor. She said she previously was the infection preventionist (IP). The RN supervisor said Resident #33 didn't want the central line taken out by any of the nurses. She stated she did not document refusals and, I just heard about it. She said the Advanced Registered Nurse Practitioner (ARNP) removed the central line. She stated, The doctors and everyone knew, that he did not want the central IV line to be taken out. She said the last time she changed his dressing was when she was the IP. The RN supervisor said that it was most likely the beginning of June 2025. She confirmed the physician order was for the dressing change to be completed every 7-10 days. She stated she could not confirm when the last time she completed the dressing change was but, I always put my initial. She said Resident #33 always let her change the dressing. She stated, It should not have been more than 7-10 days to change it.On 7/02/25 at 11:33 a.m., an interview was conducted with the Director of Nursing (DON). She said the assigned nurse is responsible for completing the care and dressing change of the central IV line. She said if Resident #33's MAR and TAR were checked off as completed, she expected it would have been done. The DON said Resident #33 does refuse care and dressing changes. She stated, He only wants the MD [Medical Doctor] or NP [Nurse Practitioner] to touch the dressing. The DON said she expected there to be documented refusals about not wanting anyone except for the MD and the NP to change the central line IV dressing. She reviewed the progress notes and confirmed she didn't see any documentation.A policy on following physician orders was requested but not provided by the facility by the survey exit. Event ID: Facility ID: 106033 If continuation sheet Page 26 of 55 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 07/02/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide appropriate bathing equipment for three residents (#32, #11, & #2) out of three sampled residents.Findings included: On 06/29/25 at 10:17 a.m. Resident #2 was observed in a Geri-chair at the nurses' station with a staff member. Resident #2's hair was not brushed and looked unwashed. Review of the admission Record for Resident #2 revealed an admission on [DATE] with the following diagnosis: dementia with behavioral disturbance, schizophrenia, seizures, major depressive disorder, anxiety disorder, need for assistance with personal care, reduced mobility, drug induced subacute dyskinesia, and other co-morbidities. Review of Resident #2's physician visit dated: 05/31/25 revealed: Resident is alert and oriented to self only, able to answer short questions. Review of Resident #2's MDS assessment, dated 04/05/25, revealed: Section GG, Functional Status indicated Resident #2 required total assistance with shower/bathe self, rolling side to side in bed, sit to lying, and for chair/bed to chair transfer. Review of Resident #2's care plan, initiated on 10/13/24, revealed a Focus area of:The resident has an ADL self-care performance deficit. Interventions/Tasks: .Bathing/showering: The resident requires assistance with bathing/showering . On 06/29/25 at 10:49 a.m. and 06/30/25 at 01:00 p.m. Resident #11 was observed in bed, bilateral hand contractures, both hands bent with fingers to the palms. There was a strong yeast like odor, especially strong near the resident. On 06/29/25 at 10:49 a.m. Resident #11 stated a shower would be nice. Review of the admission Record for Resident #11 revealed an admission on [DATE] and re-admitted on [DATE] with the following diagnosis: epilepsy, lymphedema, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), delusional disorders, muscle wasting and atrophy, need for assistance with personal care, other reduced mobility and other co-morbidities. Review of Resident #11's Psychiatry Progress Note dated: 06/26/25 revealed: Cognition: Summary: Resident #11 is alert and oriented to self and setting. Thought processes are linear and goal directed. She demonstrates adequate social cognition, though she displays limited insight into her delusional thought content. Judgment and impulse control remain intact during evaluation. Review of Resident #11's MDS assessment, dated 06/27/25, revealed Section GG, Functional Status indicated Resident #11 required total assistance with shower/bathe self, rolling side to side in bed, sit to lying, and for chair/bed to chair transfer. Review of Resident #11's care plan, initiated on 05/20/21, revealed a Focus area of:- Resident #11 has pain symptoms related to: neuropathy, buttock wound, history of fracture of right trochanter, impaired mobility, Resident is able to communicate pain to staff. Interventions/Tasks: . Observe for proper body alignment when in bed/ chair; assist with repositioning as needed.- Resident #11 has a self-care deficit with dressing, grooming, bathing related to (r/t): generalized weakness, limited endurance due to contractures of legs and chronic pain issues. Interventions/Tasks: Utilize mechanical lift with staff assist of two for transfers. Provide hands-on assistance with dressing, grooming, and bathing as needed . Encourage resident to take rest breaks during ADL tasks as needed for SOB (shortness of breath)/fatigue .-Resident #11 has a strength in cognitive function as evidence by (AEB) is oriented to person, place, and time. Short term (ST)/Long Term (LT) memory are intact. Is able to make daily decisions independently.-Resident #11 has an ADL self-care performance deficit r/t musculoskeletal impairment. Interventions/Tasks: .Toileting hygiene: The resident requires (assistance) with toileting hygiene. Bathing/showering: The resident requires (assistance) with bathing/showering. Lying to sitting: Resident requires (assistance) with sitting to lying. Sit to stand: Resident requires (assistance) with sitting to standing. Chair to bed transfer: The resident requires (assistance) with transfers from chair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 27 of 55 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 07/02/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to bed. Toilet transfer: The resident requires (assistance) with toilet transfers. Tub/shower transfer: The resident requires (assistance) with transfers in and out of the tub/shower. Transfer: The resident requires mechanical lift with two staff for transfers . 3. During an observation and interview conducted on 06/29/25 at 10:52 a.m. Resident #32 was lying in bed, hair unwashed. Resident #32 stated they never shower me, only bed baths. During an observation and interview conducted on 07/01/25 at 07:58 a.m. Resident #32 was lying in bed, unwashed. Resident #32 confirmed not being offered a shower yet, they have no way to get me up. Review of the admission Record for Resident #32 revealed an admission on [DATE] and re-admitted on [DATE] with the following diagnoses: paraplegia, urinary tract infections, multi-drug resistant, bell's palsy, low back pain, pain, other intervertebral disc displacement, lumbar region, female pelvic inflammatory disease, muscle spasm, need for assistance with personal care, hereditary idiopathic neuropathy, and other co-morbidities. Review of Resident #32's Minimum Data Set (MDS) assessment, dated 04/08/25, revealed Section C Cognitive Patterns, a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was cognitively intact. Section GG, Functional Status indicated Resident #32 required substantial/maximal assistance with shower/bathe self, rolling side to side in bed, sit to lying, and totally dependent on staff for chair/bed to chair transfer. Review of Resident #32's care plan, initiated on 10/12/24, revealed a focus area of:-Resident #32 has an Activities of Daily Living (ADL) self-care performance deficit related to bell's palsy, paraplegia, limited range of motion (ROM) to bilateral ankles. Interventions/Tasks revealed: bathing/showering: The resident requires total assistance with bathing/showering. Roll left to right: The resident requires total assistance to roll left to right; chair to bed transfer: The resident requires total assistance with transfers from chair to bed. Toilet transfer: The resident requires total assistance with toilet transfers. Tub/shower transfer: The resident requires total assistance with transfers in and out of the tub/shower. Transfer: The resident requires a mechanical lift with two staff for transfers.-Resident #32 is at risk for altered level of comfort/pain paraplegia, wound, muscle spasms, neuropathy, endometriosis, bell's palsy, and lumbar pain. Interventions/Tasks revealed: Evaluate the effectiveness of pain interventions, as needed. Review for compliance, alleviating symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Monitor/record/report to Nurse any signs and symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); eyes (wide open/narrow slits/shut, glazed, tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing) body (tense, rigid, rocking, curled up, thrashing). Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. During an interview on 07/01/25 at 04:09 p.m., Staff I, Certified Nursing Assistant (CNA) stated there is a shower schedule in the shower book at the nurses' station. Usually, residents are bathed two times per week unless residents request additional baths. Staff I, CNA stated if a resident is not able or does not want to sit up straight in a shower chair, we just take buckets to them as we only have shower chairs, we do not have a reclining chair or bed. During an interview on 07/01/25 at 04:15 p.m. Staff F, Licensed Practical Nurse (LPN) stated residents are usually showered two times per week, or as residents' request. The CNAs complete the showers; the nurses only receive information from the CNA if the resident has a skin issue. We don't have a shower bed. We utilize a shower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 28 of 55 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 07/02/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete chair, or the resident receives a bed bath if they cannot sit up. During an interview on 07/01/25 at 04:33 p.m., Staff G, LPN/Unit Manager (UM) stated the floor has a total lift for residents who cannot sit up in the shower chair. We do not have a shower chair that reclines or a shower bed that would allow the resident to lie back. If a resident refuses, then the nurse should be notified, and documentation of the refusal should be made. Then a bed bath would be offered after the refusal is documented. During an interview on 07/01/25 at 04:42 p.m., Staff K, CNA stated residents who need or want to lie down, don't have a shower bed. We just give bed baths. During an interview on 07/02/25 at 01:13 p.m., the Director of Nursing (DON) stated the expectation is for residents to receive a shower or bath. If the facility does not have a shower bed or reclining chair then we would need to request the Nursing Home Administrator (NHA) for the equipment needed, a bed bath is fine for a short period of time. We would need to meet with therapy to ask for recommendations on assistance and what is safest for the resident. During an interview on 07/02/25 at 12:32 p.m. the Director of Rehabilitation (DOR) stated there are several residents that the shower chair is not an appropriate option for, as it would not be safe for the residents not being able to sit up in the shower chair. Review of the facility's policy and procedure titled Accommodation of Needs dated revised 09/01/23 revealed: Policy: The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered.Policy Explanation and Compliance Guidelines:1. The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom and the common living areas within the facility.2. The facility will ensure that common areas frequented by residents are accommodating physical limitations and enhance their abilities to maintain independence.3. Facility staff shall make efforts to reasonably accommodate the needs and preferences of the resident as they make use of their physical environment.4. Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible. Event ID: Facility ID: 106033 If continuation sheet Page 29 of 55 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 07/02/2025 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations and interviews the facility did not ensure one courtyard out of one was free from accident hazards.Findings included: Residents Affected - Some An observation was conducted on 7/1/25 at 8:45 a.m. of an open side gate that goes from the maintenance and housekeeping areas to the road. The gate had a sign directed to keep the gate closed. There were no staff in sight. An observation was conducted on 7/1/25 at 12:00 p.m. in the courtyard of the facility. There were no staff in the courtyard and the side gate was open. Upon walking through the side gate, it was discovered there was a small house, unlocked. The small house was observed to contain chemicals and equipment for cleaning. There was also a maintenance shed with an open door that contained tools, equipment, and boxes. The grassy area outside the small house and maintenance shed had miscellaneous carts and equipment. The side gate going from the small house and maintenance shed to the road on the side of the facility was also propped open. The gate had a red sign that read Keep gate closed. Both gates being opened allowed any residents in the courtyard access to the road. No staff were observed in the small house or maintenance area. Upon returning to the courtyard through the open gate, two residents were observed sitting outside in wheelchairs with no staff present. There was a cart sitting by a table under an umbrella that was observed to be unlocked. The cart was observed to contain cigarettes, lighters, and other miscellaneous items. An interview was conducted on 7/1/25 at 12:04 p.m. with the Activities Director (AD) who walked outside to the courtyard. The AD said the staff member that was responsible for the smoking cart was on their break. She said she did not think the cart should have been unlocked, but she didn't really know. She said she wouldn't leave it unlocked. The AD said she is not responsible for the cart, and she did not have anything to do with smoking apart from bringing residents outside. The AD was then observed walking away from the area, leaving the cart unlocked and returning into the facility. An observation and interview were conducted on 7/1/25 at 12:06 p.m. with the Nursing Home Administrator (NHA) and the Assistant NHA (ANHA). The NHA and ANHA exited the facility into the courtyard and walked up to the smoking cart. The NHA confirmed the cart was unlocked and the expectation is for the cart to be locked when a staff member is not present. The NHA stated she was not aware if the gate from the courtyard to the small house and maintenance area was able to lock or not. At 12:10 p.m. the ANHA was observed going to the open gate in the courtyard. She stated the gate is able to latch but not lock and confirmed the gate was difficult to latch. She said the staff must lift the gate into the latch. The ANHA confirmed all the doors to the small house and maintenance shed were open and unlocked with chemicals and other equipment. The ANHA stated the area should be restricted to staff only and would immediately begin staff education. The ANHA also stated the gate from that area to the road should remain closed and always locked. During an observation on 06/30/2025 at 12:10 p.m., one resident was observed sitting in the courtyard. No staff were observed in the area. During an observation on 06/30/2025 at 5:30 p.m., four residents were observed in the courtyard area. No staff were observed in the area. During an observation on 06/30/2025 at 2:55 p.m., Multiple residents were observed pushing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 30 of 55 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 07/02/2025 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 handicap button in the hallway to the door leading to the courtyard. The door did not open. Level of Harm - Minimal harm or potential for actual harm During an observation on 06/30/2025 at 2:57 p.m., An unidentified staff member was observed pushing the handicap button under the covered outside walkway and the door did not open. Residents Affected - Some During an interview on 06/30/2025 at 2:55 p.m., Staff N, Certified Nursing Assistant (CNA) stated the door has been like that for a while. During an interview on 07/02/2025 at 11:30 a.m., Staff O, CNA stated the courtyard closes during mealtimes and after 11 p.m. Residents can come to the outside area with a responsible party. The outside area is closed if there is lightning, thunder and rain. She was not sure about them closing the area if it is too hot or who monitors it for being too hot outside for residents. The buttons on the doors work but the doors get stuck. The doors have been like that for a few months. During an interview on 07/02/2025 at 11:20 a.m., the Director of Nursing stated the outside area is closed during meals. Residents are not allowed to smoke during these times. Residents can go out to the area and do not need to be accompanied by anyone. She was not if anyone monitors the temperatures outside to determine if it is too hot for residents to be in the courtyard. She was not aware of any concerns with the doors leading to or from the patio not working. During an interview on 07/02/2025 at 3:46 p.m., the Maintenance Director stated We know the doors leading to and from the patio are not working. The door is expensive, and the company wants two quotes to fix it. Both doors open if you push the button, the switch might have been turned off and that is why the button was not working. Review of the facility policy dated 9/1/2023, titled Accidents and Supervision revealed 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 31 of 55 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 07/02/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility did not ensure monitoring and interventions were put in place related to a significant weight loss for one resident (#44) out of three residents reviewed for nutrition.Findings included: Review of admission Records showed Resident #44 was admitted on [DATE] with diagnoses including end stage renal disease and unspecified protein-calorie malnutrition. Review of Resident #44's weights showed the resident had a post-dialysis weight of 163.9 pounds (lbs.) on 5/21/25 and a post-dialysis weight of 149.6 lbs. on 6/16/25, showing an 8.72% weight loss in less than 30 days. Review of Resident #44's Mini Nutritional Assessment, dated 5/20/25, showed the resident had not had any weight loss in the previous 3 months. The assessment also indicated the resident was at risk of malnutrition. Review of Resident #44's Progress Notes did not show any dietary notes since the nutrition assessment on 5/20/25. An interview was conducted on 7/1/25 at 2:45 p.m. with the Registered Dietician (RD) that sees Resident #44 at the dialysis center. The RD said Resident #44 had a pretty significant weight loss in the past month. The RD said they provided what nutrition support they can at the dialysis center, but the facility should have been tracking the resident's weight loss and put interventions in place. The RD said the weight loss Resident #44 had was not due to normal dialysis fluctuations. The RD at the dialysis center said she attempted to reach Staff S, RD at the facility on 6/16/25 and did not receive a return call. She said she reached back out to Staff S, RD on 6/22/25 and was able to speak with her about the resident's weight loss. The RD from the dialysis center said her records showed Resident #44 had a weight of 162.5 lbs. on 6/6/25 and a weight of 149.6 on 6/30/25, showing a 7.94% weight loss in 24 days. An interview was conducted on 7/2/25 at 11:04 a.m. with Staff T, RD and the Regional Dietician. Staff T said typically when a resident had weight loss it triggered in the electronic medical record and was linked to the progress notes. The Regional Dietician reviewed Resident #44's medical record confirmed there had been no documentation the resident was being followed for weight loss. She said she would have expected to see a note from Staff S, RD, especially if the dialysis center reached out to her about weight concerns for the resident. Review of a facility policy titled Weight Monitoring, revised 1/2025, showed:Policy:Based on the resident's comprehensive assessment, the facility will ensure that the highest level of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise.Compliance Guidelines:Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended weight loss over a period of time) may indicate a nutritional problem.1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes:a. Identifying and assessing each resident's nutritional status and risk factors.b. Evaluating/analyzing the assessment informationc. Developing and consistently implementing pertinent approaches.d. Monitoring the effectiveness of interventions and revising them as necessary 8. Documentation:a. The physician and family or responsible party should be informed of a significant change in weight.b. The physician may order nutritional interventions and should be encouraged to document the diagnosis or clinical condition that may be contributing to the weight loss.c. The Registered Dietician or Dietary Manger should be consulted to assist with interventions; actions are recorded in the nutrition progress notes.d. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate.e. The interdisciplinary plan of care communicates care instructions to staff. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 32 of 55 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 07/02/2025 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interviews, the facility failed to post the Daily Nursing Staffing form appropriately for four out of four days. Findings Included: During multiple observations from 06/29/2025 thru 07/02/2025 revealed the Daily Nursing Staffing form was not posted on the 2nd floor. During an observation on 06/29/2025 at 9:15 a.m., the Daily Nursing Staffing form for Day Registered Nurse (RN) total Number and Actual Hours was blank. The Daily Staff Form for Evening Licensed Practical Nurse (LPN) was blank for total number and actual hours. (Photographic evidence obtained) During an observation on 07/01/2025 at 8:52 a.m., the Daily Nursing Staffing form for Evening Licensed Practical Nurse (LPN) was blank for total number and actual hours. During an interview on 07/02/2025 at 4:50 p.m., the Staffing Coordinator stated nurses work 12 hours, and the nurses for the evening hours are included in the night and day hours. Before I leave on Friday, I do a rough estimate of the form to reflect what is scheduled. If there are any call outs over the weekends, I update the form on Mondays because there is no one else on the weekends to update it. I never thought about having the form posted on the second floor. I was always told to post it on the first floor. Review of the facility policy titled Nurse Staffing Posting Information, Dated 3/1/2025 revealed, Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time . D. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift i. Registered nurses; ii. Licensed practical nurses/licensed vocational nurses; iii. Certified nurse aides 4. A copy of the schedule will be available to all supervisors to ensure the information posted is up to date and current. A. The information shall reflect staff absences on that shift due to call outs and illness. After the start of each shift, actual hours will be updated to reflect such. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 33 of 55 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 07/02/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure medication reviews and recommendations from the pharmacy consultant were addressed and side effect/behavior monitoring was not in place for three residents (#3, #47 and #14) of five residents reviewed for unnecessary medications. Findings included: 1. A review of Resident #3's admission record revealed an original admission date of 1/4/02, initial admission date of 9/1/22, and a re-admission date of 5/7/25. Further review of the admission record revealed diagnoses to include generalized anxiety disorder, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, other Alzheimer's disease, major depressive disorder, recurrent, moderate, anxiety disorder, unspecified convulsions, and unspecified psychosis not due to a substance or known physiological condition. A review of Resident #3's physician orders revealed the following to include: - levetiracetam oral tablet, give 500 milligrams (mg) by mouth two times a day related to unspecified convulsions, with a start date of 6/27/25. - abilify oral tablet 10 mg (aripiprazole) give 1 tablet by mouth at bedtime for unspecified psychosis, with a start date of 5/14/25. - carbamazepine 200mg tablet (tab) give 1 tablet orally two times a day related to conversion disorder with seizures or convulsions, with a start date of 5/8/25. - Nuedexta 20-10mg cap give 1 capsule orally two times a day related to pseudobulbar affect, with a start date of 5/8/25. - lorazepam 0.5mg tab give 1 tablet orally two times a day related to adjustment disorder with anxiety, with a start date of 5/8/25. Further review of physician's orders revealed no behavior or side effect monitoring orders were put in place until 6/30/25. A review of Resident #3's care plan revealed the following to include: - [Resident #3] has hx [history] of behavior problems, such as becoming verbally abusive and even physically combative at times. Res.[resident]is known to use derogatory names/racial slurs towards staff at times. He often uses profanity and may curse at staff and at roommates when he is angry. Date initiated: 10/12/2013 Revision on 04/25/2018, with interventions that included the following, Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date initiated 10/12/2013 . - [Resident #3] is at risk for alteration in Mood State r/t [related to] hx of depression and anxiety. Res.[Resident] has hx of becoming aggressive at times. He will try to grab your hand and then squeeze it very hard. Date Initiated: 10/12/20 . with interventions that include the following, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 34 of 55 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 07/02/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 10/12/2013 Revision on: 09/14/2016 . Monitor/record/report to MD [medical doctor] prn [as needed] mood patterns s/sx [signs and symptoms] of depression, anxiety, sad mood as per facility behavior monitoring protocols. Date Initiated: 10/12/2013 Revision on: 09/14/2016 . A review of the pharmacist medication regimen review (MRR) recommendations, dated 5/9/25 and 6/9/25, revealed the following, Nurse recommendation: Please consider adding an AIMS [abnormal involuntary movement scale] assessment and antipsychotic medication behavior and side effect monitoring orders; Abilify . Further review of the pharmacist MRR recommendations on 5/9/25 and 6/9/25 revealed the following response from the Assistant Director of Nursing (ADON) dated 6/30/25, Agree: Please write order. On 7/1/25 at 2:08 p.m., an interview was conducted with the [NAME] President (VP) of Clinical Services. She confirmed Resident #3 was started on an antipsychotic medication on 5/14/25. She stated on 6/30/25 she identified that behavior monitoring wasn't present for Resident #3 and completed, A house audit. The VP of Clinical Services said there were 18 residents identified that did not have side effect and/or behavior monitoring. On 7/1/25 at 2:34 p.m., a phone interview was conducted with the consulting pharmacist. He stated, Antipsychotic medications need behavior and side effect monitoring. He said he expected the pharmacist recommendations to be completed within 30 days or less. On 7/2/25 at 11:47 a.m., an interview with the Director of Nursing (DON) was conducted regarding Resident #3's physician orders for side effect and behavior monitoring started on 6/30/25. She stated, I can't explain why the order wasn't placed. She stated the facility completed an audit on 6/30/25, To fix and create baseline of everything. She stated the order, Should have been added. She said during morning meetings, they add side effect and behavior monitoring for residents that require it. She stated, We are developing a process, but we didn't get to do it the way we wanted to. The DON said they have educated the nurses on what to do if they get an order for medications that require side effect and behavior monitoring. She stated, The nurses need to do behavior monitoring because they are the ones putting in orders. The DON stated, It should be standard of care. 2. Review of Resident #14’s admission record showed Resident #14 was admitted on [DATE] with diagnoses including depression and seizures. Review of Resident #14's Consultant Pharmacist Medication Regiment Review showed the following recommendations: - 3/10/25. Please consider adding antidepressant/anxiolytic medication behavior monitoring orders: Librax/Trazadone. This recommendation was not signed as acknowledged until 6/30/25, after the information was requested from the facility. No behavior monitoring was put in place until 5/31/25. - 3/28/25. Please consider adding antidepressant medication behavior monitoring orders: Paxil This recommendation was signed on 6/30/25, after the information was requested. No behavior monitoring was put in place until 5/31/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 35 of 55 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 (X3) DATE SURVEY COMPLETED A. Building 07/02/2025 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 0756 - 5/6/25. Divalproex sodium oral tablet DR [delayed release] 500 mg. Give 1 tablet by mouth 2 x day for seizures. Level of Harm - Minimal harm or potential for actual harm consider ammonia and valproic acid level. Residents Affected - Some This recommendation was not addressed until 6/30/25, after the information was requested from the facility. - 5/17/25. Resident has a duplicate order for Fioricet capsule 50-300-40 mg. This recommendation was not addressed until 6/30/25, after the information was requested from the facility. An interview was conducted 7/2/25 5:52 p.m. with the DON and the Assistant Director of Nursing (ADON). They stated they realized pharmacy recommendations were not being completed and requested them from the pharmacy. The DON said pharmacy recommendations are sent to her. The ADON and DON said they are establishing a process to complete the recommendations. They confirmed the recommendations that were requested were not completed and signed until after the request was made. The DON said they found a lot of pharmacy recommendations that were not addressed. The DON said once the recommendations are received from the pharmacy, she would like them to be completed within a week. An interview was conducted on 7/2/25 at 7:37 p.m. with the facility's Medical Director. He was not aware the pharmacist recommendations were not being followed up on and he would expect the recommendations to have been sent to the providers to be addressed. Review of Resident #47's admission record revealed an admission date of 05/01/2025. Resident #47 was admitted to the facility with diagnosis to include Depression, Attention-Deficit Hyperactivity Disorder, and personal history of traumatic brain injury, and personal history of venous thrombosis and embolism. Review of Resident #47's Medicare 5-day Minimum Data Set (MDS) dated [DATE] revealed Section N. Medications Anticoagulant. Review of Resident #47's orders revealed: Start Date: 05/01/2025 Xarelto Oral Tablet 2.5 milligrams MG (Rivaroxaban) Give 1 tablet by mouth one time a day for anticoagulant. No orders for side effect monitoring for anticoagulant medication were found. Review of Resident #47's Care Plan Dated 05/02/2025 revealed: Focus: The resident is on anticoagulant therapy related to deep vein thrombosis (DVT)/history of DVT. Interventions: Administer medications as ordered by physician; Monitor for side effects and effectiveness every shift; Labs as ordered. Report abnormal lab results to the physician. Review of Resident #47's Medication Regimen Review (MRR) dated 05/17/2025 revealed, Physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 36 of 55 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 07/02/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Recommendation: Xarelto Oral Tablet 2.5 MG (Rivaroxaban) Give 1 tablet by mouth one time a day for anticoagulant; please evaluate 2.5 mg every day dose for DVT Prophylaxis, 2.5 mg dose is usually dosed twice a day, and recommended DVT Prophylaxis dose is 10 mg daily. The other box was checked, response (handwritten note) continue Xarelto Oral Tablet 2.5 MG once a day left lower extremity DVT status post inferior vena cava (IVC) filter. The pharmacist recommendation was not signed by Assistant Director of Nursing (ADON) until 06/30/2025. Review of Resident #47's progress notes revealed no documentation related to the MRR dated 05/17/2025. During an interview on 07/02/2025 at 2:35 p.m., the Consultant Pharmacist stated anticoagulants require side effect monitoring. MRR's are labeled for who they are intended for such as Nursing or the Physician. During an interview on 07/02/2025 at 6:23 p.m., the DON and ADON stated Resident #47 should have side effect monitoring for his anticoagulant. ADON stated she is the one who wrote the MRR response for Resident #47. I usually document how I was notified by the physician for the response. She reviewed Resident #47's MRR dated 05/17/2025 and stated it does not state if this was a phone or verbal response from the physician and should. She reviewed Resident #47's progress notes and stated, there is no note in there either. Review of the facility policy dated 09/2023, titled Pharmacy Services, revealed Policy: It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. 1. The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to [NAME] the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice .4. The licensed pharmacist will collaborate with facility leadership and staff to coordinate pharmaceutical services within the facility, guide development and evaluation of pharmaceutical services procedures, and help the facility identify comma evaluate comma and resolve pharmaceutical concerns which affect residents care, medical care, or quality of life such as the: a. Provision of consultative services by a licensed pharmacist as necessary; and b. Coordination of the pharmaceutical services if multiple pharmaceutical service providers are utilized .7. The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' health care needs, goals and quality of life that are consistent with current standards of practice and meet the state and federal requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 37 of 55 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 07/02/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for two residents (#85 and #27) out of five residents sampled for medication administration. This resulted in five errors out of 26 medication administration opportunities for a medication error rate of 19.23%.Findings Included: An observation was conducted on 6/29/25 at 9:16 a.m. of medication administration with Staff V, Licensed Practical Nurse (LPN). Staff V was observed preparing and administering the following medications for Resident #85:1-Pregabalin 50 mg (milligrams) one capsule2-Hydralazine 100 mg one tablet3-Metoprolol Tartrate 25 mg one tablet4-Amlodipine 10 mg one tablet5-Vitamin C 500 mg one tablet6-Saccharomyces probiotic one capsule7-Aspirin 81 mg one tablet8-Sodium Bicarb 5g (gram) (325mg) two tablets9-Lantus pen 100 u/ml (units per milliliter), five units Reconciliation of Resident #85's physician orders showed the following orders:-Polysaccharide Iron Complex Capsule 150 mg. Give 1 capsule by mouth one time a day. Start date 6/18/25.-Lantus SoloStar 100 unit/ml pen injection. Inject 8 units subcutaneously two times a day related to diabetes mellitus. Hold for blood glucose less than 100. Start date 6/20/25.-No order was found for saccharomyces probiotic During the medication administration Staff V, LPN did not administer polysaccharide iron complex and did administer Saccharomyces probiotic, which there was no order for. Staff V was observed turning the dial on the Lantus pen injector to seven units. Staff V said she should administer five units but dialed the pen to seven units then pushes a little out to prime it and she then administered the injection to the resident. An observation was conducted on 7/2/25 at 9:15 a.m. of a medication administration with Staff R, Licensed Practical Nurse (LPN). Staff R was observed preparing and administering the following medications for Resident #27:1-Metformin 500 mg one tablet2-Sertraline 100 mg one tablet3-Gabapentin 100 mg two capsules Reconciliation of Resident #27's physician orders showed the following orders:-Metformin HCL 500 mg. Give 1 tablet via g-tube one time a day for diabetes mellitus. Start date 6/12/25.-Sertraline HCL 100 mg. Give 1 tablet via g-tube one time a day for depression. Start date 6/12/25. During the medication administration Staff R, LPN was observed crushing the metformin and sertraline separately and putting each in a cup with water. The medications were not stirred well and did not dissolve in the water. After completion of the medication administration the two cups that contained metformin and sertraline were observed to have a significant amount of medication remaining in the bottom of the cup. The cups were disposed of upon completion of medication administration with significant amount of medication left in each cup. Staff R said sometimes there is residual left in the bottom of the cups, and it looked like it was the skin of the metformin remaining. I could have added more water and given the medication. (Photographic evidence obtained) An interview was conducted on 7/2/25 at 8:18 p.m. with the Director of Nursing (DON). The DON reviewed Resident #85's medical record and confirmed he did not have an order for a probiotic and should have been administered the ordered iron. The DON also confirmed nurses are not educated to prime the insulin pen by dialing up two extra units and then pushing a little out then administering. The DON confirmed Resident #85's order was for eight units of Lantus. The DON reviewed pictures of the medication cups that contained metformin and sertraline for Resident #27. She said the nurse should have added more water, stirred the medication and administered it. The DON confirmed Resident #27 did not receive the full dose of metformin and sertraline that had been ordered. Review of a facility policy titled Medication Administration, revised 1/2025, showed:Policy:Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Policy Explanation and Compliance Guidelines:10. Review MAR [Medication Administration Record] to identify Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 38 of 55 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 07/02/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm medication to be administered.11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time .14. Administer medication as ordered in accordance with manufacturer specifications. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 39 of 55 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 07/02/2025 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 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure a Calcium Tomography Angiography (CTA) was competed for one (Resident #4) out of 21 residents sampled.Findings Included: During an interview on 06/30/2025 at 10:29 a.m., Resident #4 stated she was supposed to have a cat (CT) scan completed on Friday (06/27/2025) at 8:00 a.m. When I asked transportation about the appointment on Friday, I was told he cannot just take me to appointments. The CT is supposed to be done before I see my Vascular Surgeon on Wednesday (07/01/2025) so that he can review it and schedule my surgery. Now I am afraid the CT is not going to be scheduled in time for my appointment on Wednesday. I was told it would be rescheduled but no one has told me if it has been rescheduled. Review of Resident #4's admission record revealed an admission date of 06/04/2025. Resident #4 was admitted to the facility with diagnosis to include unspecified sequelae of cerebral infarction, muscle weakness (generalized), altered mental status, personal history of other venous thrombosis and embolism, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, cerebral infarction, anxiety disorder, and other specified peripheral vascular diseases. Review of Resident #4's admission Minimum Data Set (MDS) dated [DATE] revealed, Section C. Cognitive Patterns, a Brief Interview Mental Status (BIMS) score of 15 out of 15 showing intact cognition. Review of Resident #4's Orders Revealed:-Start Date: 06/17/2025 Discontinued 06/26/2025Appointment at Bayfront [NAME] Imaging for the CTA with contrast on June 27th at 8:30 a.m. but must arrive at 8:00 a.m. must have nothing by mouth (NPO) after midnight drink plenty of water the day before. Make sure Resident #4 comes with a medication list and script for the CTA every night shift for procedure until 06/27/2025 23:59 do paperwork and make sure up and ready for pick up.-Start Date: 06/17/2025 Discontinued: 06/30/2025Follow up with the vascular surgeon office. To go over the CTA results with the resident. During an interview on 06/30/2025 at 10:40 a.m., the Nursing Home Administrator (NHA) stated there was a miscommunication with the new transportation person on Friday. They spoke with Resident #4 on Friday and told her they would reschedule the appointment as soon as possible. I was not made aware of the missed appointment until 4:00 p.m., on Friday and it was too late for us to reschedule it. During an interview on 07/02/2025 at 3:03 p.m., the NHA stated I did a grievance on Friday for Resident #4's missed appointment. Her appointment has been rescheduled for tomorrow (07/03/2025) and transportation is aware. The vascular surgeon appointment had to be rescheduled because she missed the CT appointment. The facility was asked to provide a policy related to radiology and diagnostic services and transportation and it was not provided by the end of survey. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 40 of 55 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 07/02/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure menus were provided to one resident (#53) out of eight residents sampled. Findings included: During an interview on 06/29/2025 at 2:23 p.m., Resident #53 stated they used to bring me an alternative menu to order from, but they stopped doing that. They give me entirely too much chicken. During an observation on 06/29/2025 at 2:23 p.m., hanging on Resident #53's wall was an activity calendar. No food menu was observed in Resident #53's rooms. Review of Resident #53's admission record revealed an admission date of 01/03/2025. Resident #53 was admitted with diagnosis to include complete traumatic amputation at level between right hip and knee, generalized anxiety disorder, acquired absence of left leg above knee, unspecified complications of amputation stump, acquired absence of right leg above knee, and paraplegia. Review of Resident #53's Annual Minimum Data Set (MDS) dated [DATE], Section C. Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15 out of 15 showing intact cognition. Review of Resident #53's orders revealed:Consistent Carbohydrate Diet (CCHO) diet regular texture, thin consistency, and large portions. During an interview on 06/30/2025 at 3:47 p.m., Staff P, Certified Nurse Assistant (CNA), stated we have regular residents who get an alternate meal. If a resident wants an alternate meal, they have to ask the CNA and they can fill out the form. Menu items are posted in the hallway. During an interview on 06/30/2025 at 4:00 p.m., Certified Dietary Manager (CDM), stated they have an always available menu residents can request when there is something on the menu they do not want. The resident can fill out a form and it is submitted to the kitchen. Menu items are posted in the hallway. Menu items are not posted in individual residents' rooms. During an interview on 07/02/2025 at 3:03 p.m., the Nursing Home Administrator (NHA), stated she was not sure if anyone passes out menus to residents in their rooms. The residents can ask the CNA what is on the menu. If a resident wants something else to eat, they can request an alternate meal. The CNA fills out the form and then gives it to the kitchen. No policy was provided by the facility relating to this cite. Event ID: Facility ID: 106033 If continuation sheet Page 41 of 55 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 07/02/2025 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to offer a snack to residents who want to eat at non-traditional times or outside scheduled meal service times for one resident (#439) out of 8 residents sampled for dining and the Resident Council.Findings included: During the Resident Council (RC) meeting on 06/30/25 at 10:03 a.m. with eight regularly attending oriented residents, they stated not receiving or being offered snacks. The RC continued to state sometimes the first floor has some sandwiches, but it is not always available, or the facility runs out. The facility recently has not had them available. During an interview on 06/29/25 at 10:00 a.m., Resident #439 said he is supposed to get snacks like a sandwich and some fruit in between meals but they do not give it to him. He stated if he asks for a snack they bring a couple packs of cookies. Review of Resident #439's admission record revealed an admission date of 06/23/2025. Resident #439 was admitted to the facility with diagnoses to include muscle wasting and atrophy, not elsewhere classified, multiple Sites, immune deficiency syndrome, unspecified cirrhosis of liver, and unspecified protein-calorie malnutrition. Review of Resident #439's 5-Day Medicare Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 14 out 15 showing intact cognition. Review of Resident #439's orders revealed: No Added Salt (NAS) diet mechanical soft texture, thin consistency. During an interview on 06/30/2025 at 3:47 p.m., Staff P, Certified Nurse Assistant (CNA) stated they have snacks in the nourishment room. They have half peanut butter and jelly sandwiches, crackers, and cookies. Residents are given snacks when they ask for them. The kitchen closes at 7:00 p.m., they give us half sandwiches, and they go quickly. We run out of snacks a few times a week. When we run out of snacks I go and buy the resident something to eat from the store with my personal money. During an interview on 06/30/2025 at 3:50 p.m., the Dietary Director stated they provide snacks at 10:00 a.m., 2:00 p.m., and at the end of the dietary shifts. They provide peanut butter and jelly sandwiches (PBJ), cookies, crackers, puddings, milk and juices. Those are kept in the nourishment rooms. They make 15 sandwiches cut in half for each floor. She is aware of only a couple of times when there were concerns about not having enough snacks. There is one resident who eats all the sandwiches on her own. The kitchen closes at 7:00 p.m., but there is a key on site, where staff can go into the kitchen to get snacks for the residents. During an interview on 06/30/2025 at 4:00 p.m., the [NAME] Dietician stated, snacks are provided at 10:00 a.m., 2:00 p.m., and bedtime. The dietary staff prepares the snacks and keeps them at a par level. She was not sure what the par level was. She is not aware of any issues with snacks being available. I don't know why there wouldn't be snacks available for residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 42 of 55 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 07/02/2025 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy dated to 2/2024 titled Offering/Serving Snacks revealed, Policy: The facility is committed to supporting the nutritional well-being and preferences of all residents by offering nourishing and appropriate snacks at designated times throughout the day. Snacks are considered an essential part of resident care and are offered consistently to ensure adequate caloric intake, accommodate medical needs, and enhance resident satisfaction.1. Selection: snacks will be appropriate to each resident's dietary needs, including therapeutic diets, textures, allergies, and preferences. A variety of snack options will be rotated regularly and include both sweet and savory items, as well as beverages when appropriate. 2. Distribution: snacks will be offered to residents in their rooms or served in common areas depending on facility activities and individual preferences. Bedtime snacks may be distributed directly by dietary or nursing staff, depending on availability and staffing coordination . Staff responsibilities: Dietary Aides: Responsible for preparing and delivering snacks at scheduled times. Nursing staff: may assist in distributing bedtime snacks and ensuring residents on special diets receive appropriate items. Registered Dietitian: Overseas the appropriateness of snack offerings in accordance with residents nutrition care plans. Resident rights: residents have the right to refuse snacks and to request alternative snack items that meet their preferences and dietary needs. Efforts should be made to honor reasonable requests within the scope of the facilities capabilities. Event ID: Facility ID: 106033 If continuation sheet Page 43 of 55 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 07/02/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, record review, and interviews, the facility did not follow professional standards for food service safety in the kitchen as evidenced by: a) staff did not add sanitizer solution to the three-compartment sink; b) refrigerator and freezer temperatures were not recorded; c) hand hygiene was not performed during a change of tasks; and d) fruits and vegetables were not maintained to prevent spoilage.Findings included: On 6/29/25 at 9:15 a.m., an initial tour of the kitchen was conducted with Staff A, Cook. The Certified Dietary Manager (CDM) was not present for the initial tour. On 6/29/25 at 9:23 a.m., an observation of the refrigerator and freezer temperature logs revealed the afternoon temperatures were not documented on 6/26/25, 6/27/25, and 6/28/25. On 6/29/25 at 9:25 a.m., an observation of the walk-in refrigerator revealed a clear bag of shredded lettuce, on a rack, that appeared wilted, soggy and with moisture build-up. Further observations of the refrigerator revealed a box of tomatoes that appeared soft and mushy, with visible dents. Several of the tomatoes had spots with a white, fuzzy outline and dark gray centers. Another observation of a rack in the refrigerator had an open crate with eight cucumbers, one had been used as evidenced by a plastic covering at the end of it, that had multiple white and dark gray spores. On 6/29/25 at 9:28 a.m., an observation of the walk-in freezer, to the right of the freezer's fan unit, revealed a white rectangular bin that had ice buildup covering the bottom. On 6/29/25 at 9:31 a.m., an observation revealed Staff B, Dietary Assistant, was at the three-compartment sink. There were kitchen items and cookware in the first sink. At 9:33 a.m. Staff A, [NAME] checked the sanitizing solution in the last sink with a test strip. The color on the test strip indicated a reading of zero parts per million (PPM). At 9:42 a.m., Staff A, [NAME] attempted to check the sanitizing solution again, but the test strip indicated the same reading observed at 9:33 a.m. Staff A, [NAME] stated, It's supposed to be 200. On 6/29/25 at 12:32 p.m., an interview was conducted with the CDM. She said the walk-in freezer had condensation, causing water to drip, therefore she put a pan three weeks ago to prevent the water from leaking on the food. The CDM said the unit fan is working properly. She stated, It's the condensation that is causing the build-up. The CDM said there is a work order for the freezer. Regarding the three-compartment sink, she stated, It works but the solution doesn't dispense well. She said the staff needed to manually add the solution. The CDM said she educated them today on how to do that. On 7/1/25 at 11:27 a.m., Staff A, [NAME] was observed putting food from the tray line into foam takeout containers. She was observed stopping that task to take food temperatures for lunch. Staff A, [NAME] was not observed performing hand hygiene before taking food temperatures. A review of open work orders, with a date of 6/29/25 at 1:24 p.m., revealed the following description, Walking freezer ice built up. Further review of open work orders, with a date of 6/30/25 at 8:00 a.m., revealed the following description, Freezer Door. On 7/2/25 at 10:16 a.m., follow-up interviews were conducted with the CDM and the Regional Registered Dietitian (RD) present. She said the cook is responsible for recording refrigerator and freezer temperatures. On the days observed with no documentation of the refrigerator and freezer temperatures, the CDM said the afternoon cook was responsible for that. She stated, They know they have to do that because it's in their job description. She said she reviewed the temperature logs every day, with the exception of weekends she is not working. The CDM said if she's not working on weekends, the cook is considered the supervisor and expected to check and review the temperature logs. The CDM said there is a designated staff member who completed the stocking task every Tuesday. She said she received a delivery every Tuesday and Friday. She stated, On Friday's leading into the weekend I make sure it's done. She said she reviewed the walk-in refrigerator Monday through Friday, and the cook is responsible on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 44 of 55 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 07/02/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the weekends. The CDM said she rejects the food if it doesn't look good and gives it back to the vendor. She stated, When I checked them on Friday, they were not like that. The Regional RD stated the produce can, Turn that quickly from Friday to Sunday because of the heat and humidity, they don't last long. They both said the breaking down process of the produce could have started on the delivery truck to the facility's kitchen. Regarding the work order for the walk-in freezer opened on 6/30/25, she stated, The heating strip around freezer door has gone bad. The issue is with the door. She said the maintenance staff thinks the freezer door is potentially causing condensation and water to drip. The CDM said the dietary staff receive education and in-service on the three-compartment sink as a new hire. She said the cook should have manually dispensed the sanitizer in the third sink. She stated, If it's reading zero, it means there's no chemical in it. The CDM said she expected dietary staff should be performing hand hygiene between each task. She said when touching ready to eat food, the staff should be washing their hands and using gloves. She confirmed Staff A, [NAME] should have washed her hands prior to taking the meal temperatures. Photographic evidence obtained. A review of the facility's policy titled, Hand Hygiene, revealed the following, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Further review of the policy under, Policy Explanation and Compliance Guidelines, revealed the following, 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . A review of the facility's policy titled, Food Safety Requirements, with an implemented date of 3/25 and a revised date of 9/25 revealed the following, . Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Further review of the policy under, Policy Explanation and Compliance Guidelines, revealed the following, 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: .b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. f. Employee hygienic practices. 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. c. Refrigerated storage - . Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of refrigeration equipment daily and at routine intervals during all hours of operation; .7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. a. Staff shall wash hands according to facility procedures. A review of the facility's policy titled, Handwashing Guidelines for Dietary Employees, with an implemented date of 3/1/25 and a revised date of 9/1/25, revealed the following under compliance guidelines, . Frequency of Handwashing: Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: . f. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks . A review of the facility's policy titled, Date Marking for Food Safety, revealed the following under policy explanation and compliance guidelines, . 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed. Event ID: Facility ID: 106033 If continuation sheet Page 45 of 55 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 07/02/2025 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility did not follow requirements for food service safety in two of two dumpsters as evidenced by garbage was not properly contained and the area was not maintained in a sanitary condition.Findings included: On 6/29/25 at 9:38 a.m., an observation of the dumpster area, conducted with Staff A, Cook, revealed the lids were not closed on two of two dumpsters. An observation of the dumpster, specifically for cardboard boxes, revealed boxes protruding out of the top and not broken down as indicated on the signage. An observation of the second dumpster revealed the two doors were not covering the exposed bags containing refuse. The two dumpsters observed were located on top of dirt, leaves, and gravel rather than a non-porous surface. On 7/2/25 at 10:53 a.m., an interview was conducted with the Certified Dietary Manager (CDM). She said the lids of the dumpsters should be closed. A review of photographic evidence obtained on 6/29/25 of the dumpsters and the surrounding area was conducted with the CDM. The CDM stated, It's an issue. She said all staff members are responsible for maintaining the cleanliness of the dumpster area and properly storing the garbage. The CDM said she is ultimately responsible. She stated, Staff should be checking the dumpster lids. Photographic Evidence Obtained. A review of the facility's policy titled, Disposal of Garbage and Refuse, with an implemented date of 3/25 and a revised date of 9/1/25, revealed the following under policy explanation and compliance guidelines, .3. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 46 of 55 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 07/02/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility did not ensure medical records were accurate, related to the location of a wound, for one resident (#33) of thirty-six residents reviewed.Findings included: On 6/29/25 at 10:06 a.m., an observation of Resident #33 revealed he was sitting up in bed, with the television on, and looking at his personal phone. He had a sheet over his legs, however, both feet were exposed. Observations of Resident #33's feet revealed he had a wound on his left great toe. Resident #33's toe wound seemed to be healed as evidenced by dry, scabbing skin. A review of Resident #33's admission record revealed an original admission date of 4/11/25 and re-admission date of 5/29/25. Further review of the admission record revealed diagnoses to include muscle wasting and atrophy, not elsewhere classified, multiple sites, unspecified protein-calorie malnutrition, muscle weakness (generalized), adjustment disorder with mixed anxiety and depressed mood, other malaise, and dependence on wheelchair. A review of Resident #33's Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 14, cognitively intact. A review of Resident #33's progress notes revealed the following to include:5/8/25, Resident made facility aware that while on unsupervised LOA [leave of absence] during bus ride, the bus stopped and resident in wc [wheelchair] fell forward to the floor. Resident stated he was being transferred to [hospital name]. Bed hold and ACHA [Agency for Healthcare Administration] form completed and sent to [hospital name] via fax, along with resident face sheet and necessary medical papers for transfer. Nurse to nurse completed with ER [emergency room] nurse. Emergency contact notified and updated on resident status.-5/8/25, Resident returned from the hospital at 21.55 [9:55 p.m.] and laceration of right grate toe without nail damage. skin assessments done.-5/9/25, Resident on anti-biotics sulfamethoxazole-trimethoprim twice a day for 14 day or until infection completed. for prevent infection right grate toe infection.-5/10/25, Resident continues to be on ABT [antibiotic] prophylactically for infection in his right great toe. ABT tolerates well. Resident continues to be monitored.-5/11/25, .Resident Observation & [and] Intervention: . Right toe wound. ABT prophylaxis,-5/19/25, Order received from APRN [Advanced Practice Registered Nurse] [Provider name] to remove resident's stitches from R [right] great toe. A review of Resident #33's assessments revealed the following:- Nursing - Skin Check Weekly Head to Toe . Effective Date: 5/9/25 . New Skin Impairment . Does the resident have new skin impairment 1. Yes . Site 51) Right toe(s) Description stiches on L [left] toe .- Nursing - Daily Skilled Note . Effective Date: 5/11/25 . 13. Resident Response to Treatments & [and] Additional Comments A. Record Resident Response to Treatment & Additional Comments: Right toe wound. ABT prophylaxis . On 7/1/25 at 4:39 p.m., an interview was conducted with Staff G, Licensed Practical Nurse (LPN)/Unit Manager (UM). She said Resident #33 sustained a toe injury when he went on a leave of absence (LOA). Staff G, LPN/UM said she thinks he fell in the transport, went to the hospital, and was treated. She said the treatment was continued at the facility. Staff G, LPN/UM said she wasn't aware the documentation in Resident #33's medical record is about the right great toe, and not the left. She said he's only had one toe wound, so it had to be the left one. On 7/1/25 at 4:44 p.m., a follow-up interview and observation was conducted with Resident #33. He said his right great toe has never had a wound. Resident #33 gave permission to take photographic evidence of the healed great toe wound on his left foot. On 7/2/25 at 11:42 a.m., an interview was conducted with the Director of Nursing (DON). She said she saw Resident #33's toe wound yesterday, and it has healed. She confirmed he sustained the toe injury on LOA while on the bus. She confirmed the wound was on his left great toe, not his right. The DON said Resident #33 hasn't had any injuries or wounds on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 47 of 55 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 07/02/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete his right toe. A review of the facility's policy titled, Documentation in Medical Record, with an implemented date of 3/24 and a revised date of 1/25 revealed the following, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Further review of the policy under policy explanation and compliance guidelines revealed the following, .3. Principles of documentation include but are not limited to: .b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. (Photographic Evidence Obtained.) Event ID: Facility ID: 106033 If continuation sheet Page 48 of 55 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 07/02/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to follow infection control practices related to staff with artificial nails, an ice scoop in the ice not in the holder, hand hygiene during medication distribution and transmission-based precautions were followed for Resident #82.Based on observation, record review and interviews, the facility failed to follow infection control practices related to staff with artificial nails, an ice scoop in the ice not in the holder, hand hygiene during medication distribution and transmission-based precautions were followed for Resident #82. Residents Affected - Some Findings Included: During an observation on 06/29/2025 at 12:11 p.m., Staff Q, Certified Nurse Assistant (CNA) was observed with artificial nails protruding past the tips of her fingers. 06/30/2025 at 10:50 a.m., the Assistant Director of Nursing (ADON) and Infection Preventionist (IP) was observed with artificial nails protruding past the tips of her fingers During an interview on 7/2/25 at 6:49 p.m., the Director of Nursing (DON) stated nails should be cut short, length should not be over the fingernail tip. Nails was not a high focus area yet. We will educate staff on this. Review of the undated facility policy titled Suitable Work Clothes/Personal Grooming revealed Employees providing direct patient care must abide by the following guidelines to ensure personal and resident safety .No acrylic nails are permitted for direct caregivers and nails should not be over fingertip length as evidenced by the back of the hand. 2. On 6/29/25 at 10:50 a.m., an observation of room [ROOM NUMBER] revealed a contact precaution sign on the door with no personal protective equipment (PPE) on the door or in the hallway. Further observation of room [ROOM NUMBER] revealed a housekeeping staff member went into the room without putting PPE on. On 6/29/25 at 10:51 a.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN). She said Resident #82 is on contact precautions. On 6/29/25 at 10:55 a.m., an interview was conducted with Staff E, Housekeeping Assistant. She confirmed she did not put PPE on when she entered room [ROOM NUMBER]. Staff E, Housekeeping Assistant said she did not need to put PPE on because none of the residents in that room required it. She said the residents leave that room all the time. Staff E, Housekeeping Assistant stated, I think it's an old sign because a resident previously in that room was very sick. On 6/30/25 at 10:22 a.m., an observation of room [ROOM NUMBER] revealed a contact precaution sign on the door with PPE hanging next to it. An interview was conducted with Staff F, LPN and she confirmed Resident #82 was on contact precautions. He was not in his room at the time of the observation. Staff F, LPN said he is in the common area participating in an activity. A review of Resident #82's admission record revealed an admission date of 4/23/25. Further review of the admission record revealed diagnoses to include muscle wasting and atrophy, not elsewhere classified, multiple sites, respiratory conditions due to other specified external agents, emphysema, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 49 of 55 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 07/02/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm unspecified, unsteadiness on feet, cognitive communication deficit, need for assistance with personal care, pneumonia, unspecified organism, and unspecified dementia, unspecified severity, with other behavioral disturbance. A review of Resident #82's physician's orders revealed the following to include: Residents Affected - Some - human papillomavirus (HPV) contact precautions every shift for HPV, with a start date of 6/12/25. - imiquimod external cream 5% apply to groin topically at bedtime every Monday, Thursday, Saturday for HPV for 7 days leave on for 8 hours then wash with soap and water, with a start date of 6/28/25 and end date of 7/5/25. A review of Resident #82's progress notes revealed the following: - 6/12/25, . Chief Complaint / Nature of Presenting Problem: Skin lesion of groin area, low back pain post med [medication] addition . History Of Present Illness: Pt [patient] seen today with nurse for Skin lesion of groin area, low back pain post med addition. Pt was started on doxycycline and bacitracin for groin abscess and is seen for follow-up. Nurse today reports minimal change. Plan: Skin lesion: appears to be HPV wart. d/c [discontinue] doxycycline and bacitracin add podofilox 0.5% gel q [every] 12hr [hours] x [for] 3days. hold off for 4 days, then repeat again for 3 more days . - 6/14/25, . Using enhanced barrier precautions. Resident is OOB [out of bed] walking around the unit with no exit seeking/elopement behaviors. - 6/15/25, . Using enhanced barrier precautions. Resident is OOB walking around the unit with no exit seeking/elopement behaviors. - 6/15/25, . Using enhanced barrier precautions. - 6/19/25, . Chief Complaint / Nature of Presenting Problem: F/u [follow-up] HPV wart . He was started on imiquimod cream for HPV wart and is seen for follow-up. Plan: HPV wart: improving podofilox order changed to imiquimod due to cost concerns. Cont. (continue) imiquimod 5% cream, to be applied at hs [bedtime] to wart for 8 hours and then rinsed off daily, stop 7/4/25. -6/23/25, . History Of Present Illness: . He also has a HPV wart on his groin area that has been treated topically. Facility staff states that the area has improved and wound care is following. Patient seen and examined in his room sit up in bed no acute distress patient denies complaints although he is a poor historian. On 7/2/25 at 11:52 a.m., an interview was conducted with the Director of Nursing (DON). She said for contact precautions PPE should be worn by all staff. The DON said they recently started education, about 3-4 weeks ago, on topics to include PPE training, enhanced barrier precautions, transmission-based precautions, and donning and doffing demonstrations/competencies. She said it's on-going training that's included in weekly and monthly education. The DON said they started the education because of new staff and management. She confirmed that it is okay for Resident #82 to leave the room and walk around. She stated, If it is something contained they can walk around. She said because of the location of the warts, it is considered contained. The DON confirmed all staff should be wearing PPE (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 50 of 55 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 07/02/2025 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 0880 when entering the room because Resident #82 is on contact precautions. Level of Harm - Minimal harm or potential for actual harm 3. An observation was conducted on 6/30/25 at 12:27 p.m. of a cart with an ice chest in the 100 [NAME] hall. The ice chest was observed to contain ice and had an ice scoop sitting down in the ice. The cover for the scoop was on the second shelf of the cart. Residents Affected - Some An observation was made on 6/30/25 at 12:34 p.m. of a resident walking up to the ice chest and opening the lid. A staff member came to assist him and told him he needed a new cup. The staff member retrieved a new cup, used the scoop from inside the ice chest to fill the cup, then placed the scoop in the holder on the second shelf of the cart. An interview was conducted on 7/2/25 at 6:28 p.m. with the facility's Infection Preventionist (IP). The IP said an ice scoop should not be stored in the ice; it should be in a cover outside of the ice chest. She said if the scoop was in the ice chest the ice was contaminated. 3. An observation was made on 7/2/25 at 9:15 a.m. of medication administration with Staff R, LPN/UM (Licensed Practical Nurse/Unit Manager). Staff R was observed pulling medication out of the medication cart, crushing the medication, entering the resident rooms, prepping the g-tube, checking for residual, and administering medications without performing hand hygiene. An interview was conducted on 7/2/25 at 10:20 a.m. with Staff R, LPN/UM. When asked about not performing hand hygiene prior to administering medications in the g-tube, she said normally she did hand hygiene before starting the medication process, then she gathers medication, goes to the room, does everything with the resident, then does hand hygiene at the end. An interview was conducted on 7/2/25 at 6:28 p.m. with the facility's Infection Preventionist (IP). The IP said hand hygiene should be performed by nurses before and after medications are administered and should be completed after prepping medication and prior to a nurse giving medications in a resident's g-tube. Review of a facility policy titled Transmission-Based (Isolation) Precautions, implemented 3/1/25, showed: Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. For training and quick referencing purposes, a summary of precautions is contained at the end of this policy. Policy Explanation and Compliance Guidelines: 8. Contact Precautionsa. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. . c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 51 of 55 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 07/02/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. VRE, C. difficile, noroviruses and other intestinal tract pathogens, RSV). Review of a facility policy titled Hand Hygiene, revised 1/2025 showed: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Review of a facility policy titled Medication Administration, revised 1/2025, showed: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 4. Wash hands or ABR prior to administering medication per facility protocol and product. Review of a facility policy titled Infection Prevention and Control Program, revised 1/2025, showed: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 52 of 55 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 07/02/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to ensure equipment was functioning and timely follow-up and submission of work orders related to the automatic patio door, dish machine, walk-in freezer, and first floor nourishment room refrigerator.Findings included: 1. During multiple observations from 06/29/2025 thru 07/02/2025, the glass doors leading to and from the outside patio were observed to be stuck open or not functioning to open. During an observation on 06/30/2025 at 2:55 p.m., multiple residents were observed pushing the handicap button in the hallway to the door leading to the courtyard. The door did not open. During an observation on 06/30/2025 at 2:57 p.m., an unidentified staff member was observed pushing the handicap button under the covered outside walkway and the door did not open. During an interview on 06/30/2025 at 2:55 p.m., Staff N, Certified Nursing Assistant (CNA) stated the door has been like that for a while. During an interview on 07/02/2025 at 11:30 a.m., Staff O, CNA stated the buttons on the doors work but the doors get stuck. The doors have been like that for a few months. During an interview on 07/02/2025 at 3:46 p.m., the Maintenance Director stated We know the doors leading to and from the patio are not working. The door is expensive, and the company wants two quotes to fix it. Both doors open if you push the button, the switch might have been turned off and that is why the button was not working. During the Resident Council (RC) meeting on 06/30/25 at 10:03 a.m. with eight regularly attending, oriented residents, they stated the doors exiting the facility onto the courtyard have been broken for months now. The doors being broken make it difficult to get back into the facility from the courtyard. 2. On 6/29/25 at 9:16 a.m., an initial tour of the kitchen was conducted with Staff A, Cook. An observation of the dish machine revealed it was not in use. Staff A, [NAME] said it had not been working for two weeks. She said they are serving food on foam take out boxes, foam cups for beverages, and residents are provided with plastic utensils. On 6/29/25 at 11:53 a.m., an observation of the dining room for the lunch meal revealed food was served in foam boxes and bowls, beverages in foam cups, and residents had plastic utensils. On 6/29/25 at 12:04 p.m., an interview was conducted with Staff C, Certified Nursing Assistant (CNA). She said she normally assisted in the dining room. Staff C, CNA said residents have been receiving food in foam boxes for the last 2-3 days. She said there is an issue with the dish machine. On 7/2/25 at 2:05 PM the CDM provided e-mail communication about the dish machine. A review of the electronic communication, dated 7/2/25, revealed the following, .Just wanted to recap our service on 6/24 there was an issue with the Motor overload system failing in the machine. Due to not having the part on hand I was not able to execute the repair. This part controls the electrical conductivity that powers the whole system, which I was not able to get up and running or override . The facility did not provide the requested invoice or documentation from the vendor on 6/24/25, which is when the CDM said it was identified the dish machine was not functioning. 3. On 6/29/25 at 9:28 a.m., an observation of the walk-in freezer, to the right of the freezer's fan unit, revealed a white rectangular bin that had ice buildup covering the bottom. On 6/29/25 at 12:32 p.m., an interview was conducted with the Certified Dietary Manager (CDM). She said the walk-in freezer had condensation, causing water to drip, therefore she put a pan three weeks ago to prevent the water from leaking on the food. The CDM said the unit fan is working properly. She stated, It's the condensation that is causing the build-up. The CDM said there is a work order for the freezer. 4. On 6/29/25 at 12:43 p.m., an observation of the first-floor nourishment room was conducted with the CDM. She said the refrigerator had not been working since 6/27/25. The CDM stated, There is a work order for that. A review of open work orders revealed the following to include:- walking freezer ice built up . Status InProgress . open date 6/29/25 1:24 PM .- Freezer Door . Status InProgress . open date 6/30/25 8:00 AM .Dish Machine Not Working . Status Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 53 of 55 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 07/02/2025 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete InProgress . open date 6/29/25 1:04 PM . On 7/2/25 at 10:36 a.m., an interview was conducted with the CDM regarding the work order for the walk-in freezer opened on 6/30/25. She stated, The heating strip around the freezer door has gone bad. The issue is with the door. She said the maintenance staff thinks the freezer door is potentially causing condensation and water to drip. She said on 6/24/25 she was aware the dish machine was not working. The CDM said she and the maintenance staff called the vendor and spoke with the local representative. The CDM said the representative came out on the same day, 6/24/25, and determined it was an electrical issue. She said the vendor's representative spoke with the nursing home administrator (NHA) who said it is a rental and cannot be fixed. The CDM confirmed the vendor picked up the dish machine on 7/1/25. A review of work orders with the CDM revealed there is no documentation related to the first floor nourishment room refrigerator. Review of the facility's policy and procedure titled Preventative Maintenance Program dated 9/1/2025 revealed: Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them. 4. The Maintenance Director shall develop a calendar to assist with keeping track of all tasks. 5. Documentation shall be completed for all tasks and kept in the Maintenance Director's office for at least three years. Event ID: Facility ID: 106033 If continuation sheet Page 54 of 55 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 07/02/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility did not maintain an effective pest control program to prevent pests on one floor (1st) out of two floors in the facility.Findings included: An observation was conducted on 6/29/25 at 11:13 a.m. in room [ROOM NUMBER] of three flies on a resident's bed. There were also gnats observed to be flying around the room. The residents in the room stated the flies and gnats have been an ongoing problem. An observation was conducted on 6/29/25 at 11:20 a.m. in room [ROOM NUMBER] of ants crawling on two tables, in the trash can, and on the wall by the window. The resident in the room stated the ants had been there a few days and he had notified staff members, including Staff U, Certified Nursing Assistant (CNA). An observation was conducted on 6/29/25 at 12:25 p.m. in room [ROOM NUMBER] of gnats flying around the residents' over bed tray tables. The resident in 115 bed C said the gnats had been a problem and you cannot eat without them flying around your food and mouth. An observation was conducted on 7/2/25 at 10:58 a.m. of the bathroom between rooms [ROOM NUMBERS] had webs with bugs in them along the ceiling/wall joint over the window. Throughout the survey, gnats were observed daily in the first-floor halls, resident rooms, conference rooms, and nurses' station. Throughout the survey there were daily observations of the door from the first-floor main corridor to the outside courtyard being propped open, allowing pests to enter. Vegetation outside the building was also observed to be overgrown. During a Resident Council Meeting on 6/30/25 at 10:03 a.m., the resident council members had concerns of continuing pests in the facility. An interview was conducted on 6/30/25 at 1:05 p.m. with the Maintenance Director. He was asked for the pest control service reports, and he did not know what that was. He provided a logbook that had initials and a date showing pest control came. He said he would have to ask if there were service reports. An interview was conducted on 6/30/25 at 1:16 p.m. with Staff U, CNA. Staff U said if a staff member saw bugs or a resident told them there were bugs, she thought it was maybe put in the [Vendor] Maintenance System, but she really wasn't sure what to do. The maintenance director provided the pest control service reports for review. A [Pest Control Company] Service Report, dated 6/25/25, for a standard, semi-monthly service showed:Open Actions from Previous Service-Fly light not working. Location: kitchen. Recommendation: Replace unit. Date entered 5/12/25.-Door open when not in use. Location: Common Area Hallway. Recommendation: Close doors. Date entered 4/30/25.-Door gap. Location: Patient Care Areas. Recommendation: Add/replace weather stripping. Date entered 3/31/25.A [Pest Control Company] Service Report, dated 6/26/25, mosquito-monthly service showed:-Overgrown vegetation. Location: Exterior. Recommendation: Cut vegetation. Date entered 3/29/25. An interview was conducted on 7/2/25 at 3:45 p.m. with the Maintenance Director. He stated he had not seen the [Pest Control Company] Service Reports because they are not given to him. The Maintenance Director stated he did not know they put recommendations in the reports, and he had not seen the recommendations or completed them. The Maintenance Director said the door in the first-floor main corridor, going to the courtyard, is broken and that did not help with the fly problem. He said they did not have any interventions in place to try to prevent flies from coming in until the door is fixed. He said they only ask staff to close the door. When asked if the fly lights were on in the facility, the Maintenance Director said I cannot say yes, cannot say no.The Pest Control Policy was requested and had not been provided prior to survey ending. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106033 If continuation sheet Page 55 of 55