Inspection·July 1, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the process for putting ordered items on meal trays prior to 07/01/21 had been that one aide called out items on the meal ticket and another aide was responsible for putting items like supplements on the tray. She said the morning of 07/01/21, she had started a new process which was that the CDM would check every tray with the meal ticket before it went into the delivery cart. She said, I don't know how they (nutritional supplements) got missed [for Resident #63] .I think the girls were nervous and tried to make everything perfect and faltered. Review of facility policy titled, Comprehensive Care Plans, last revised 07/19/18 revealed that a person-centered comprehensive care plan to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. The policy revealed that care plans were ongoing and revised as information about the resident and their condition changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106103 If continuation sheet Page 2 of 7 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 106103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707 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, interview, and policy review, the facility failed to post Nursing Staffing information that included all the required elements on three of three days observed. Residents Affected - Some Findings included: Posted Staffing Data was observed on 06/28/21 at 11:42 A.M. in the lobby of the facility. The posting was dated 06/27/21; numbers of staff by discipline and shift were posted however the column titled 'actual hours' was blank. Posted Staffing Data was observed on 06/29/21 at 10:33 A.M. in the lobby of the facility. The posting was dated 06/28/21; numbers of staff by discipline and shift were posted however the column titled 'actual hours' was blank. Photographic evidence was obtained. Posted Staffing Data was observed on 06/30/21 at 9:33 A.M. in the lobby of the facility. The posting was dated 06/29/21; numbers of staff by discipline and shift were posted however the column titled 'actual hours' was blank. Photographic evidence was obtained. During an interview conducted with the Nursing Home Administrator (NHA) on 06/30/21 at 12:01 P.M., the NHA stated staffing numbers are completed by the Staffing Coordinator and posted in the front lobby daily. The posting was reviewed with the NHA, and she confirmed no data was entered or posted relating to actual hours worked. She said she was not aware that the actual staffing hours needed to be completed and posted. The NHA also confirmed all staffing data should be posted for the current date. Review of a facility-provided policy titled 'Posting of Nurse Staffing' and dated 6/28/18 revealed: Skilled Nursing Facilities and Nursing Facilities are required to post, on a daily basis, the actual hours and total number of hours worked by licensed and unlicensed nursing staff who are directly responsible for resident care on each shift in the facility. 1. On a daily basis, at the beginning of the shift, the facility must have posted or available for review the following data: -the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: a. Registered Nurses b. Licensed Practical Nurses or Licensed Vocational Nurses c. Certified Nurse Aides FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106103 If continuation sheet Page 3 of 7 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 106103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review, interview, and policy review, the facility failed to ensure that PRN (as needed) psychotropic medications were limited to 14 days of use unless otherwise directed by the prescribing physician for one (Resident #63) of five residents sampled for unnecessary medications. Findings included: Record review of Resident #63 revealed an initial admission date of 10/06/20. Diagnoses included vascular dementia with behavioral disturbance, Alzheimer's disease, generalized anxiety, and major depressive disorder A review of Resident #63's active physician orders revealed a start date of 06/03/21 for Lorazepam-Schedule IV tab 0.5 mg (milligram) to be given PRN for anxiety, with an open-ended end date. A review of the Minimum Data Set (MDS) assessment, dated 06/08/21, revealed a Brief Interview of Mental Status (BIMS) score of 04, indicating Resident #63 had severe cognitive impairment. A review of the pharmacist interim medication regimen reviews (MRR) dated 04/15/21 and 05/18/21 revealed that there were no recommendations made by the consultant pharmacist. A review of the MRR dated 06/15/21, revealed that the consultant pharmacist recommended the medication Lorazepam be discontinued on 06/15/21. On 07/01/21 at 4:20 p.m., an interview with the Director of Nursing (DON) was conducted. She confirmed that she received and reviewed the recommendation from the consultant pharmacist. She stated that she intended to make the changes, but she must have forgot to click the button, due to being summoned elsewhere. She confirmed that there was a 14-day maximum use of PRN psychotropic medication and that was the expectation at the facility. She said she was currently in the process of putting together a plan that would ensure that MRR recommendations were followed. An attempt was made to reach the consulting pharmacist by telephone on 07/02/21 with no response received. A review of the facility policy titled, Psychotropic Medications, last revised 09/05/18, revealed the pharmacist and/or consulting pharmacist monitored psychotropic drug use in the facility to ensure the medications were not used in excessive doses or for excessive duration. The policy revealed the pharmacist was to document a separate report of irregularities and notify the attending physician, medical director, and the DON. The policy also revealed that the pharmacist performed a monthly drug regimen review and participated in the Interdisciplinary quarterly review of residents on psychotropic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106103 If continuation sheet Page 4 of 7 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 106103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707 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, staff interviews, facility policy and record review, the facility failed to maintain the kitchen in a safe and sanitary manner as evidence by 1. Failure to ensure that staff personal items were stored away from the food preparation area, 2. Failed to ensure one of one reach-in refrigerator and one of one reach-in freezer had an inside temperature gauge to monitor for accurate temperatures, 3. Failure to ensure water was not pooling on dishware prior to lunch service, 4. Failure to ensure one of one dish machine was operating in accordance with manufacturer standards for washing and rinsing temperatures, and 5. Failure to ensure dietary staff wore gloves while handling food in the tray line. Findings included: On 6/28/2021 at 09:33 a.m., an initial tour of the kitchen was conducted with Staff A, Facility Cook. She indicated that the Certified Dietary Manager (CDM) was on vacation and that she oversaw the kitchen, when the CDM was not around. The findings were as follows. 1. An observation of the food preparation table revealed one large purple coffee cup, an open can of ginger ale, a sharpie permanent marker, two used towels, a pair of blue oven safety gloves, a cardboard box, spices, a dirty spoon, bread in a wrapper, spray oil, and frozen Frankfurters that were taken out to thaw on the table. (Photographic Evidence obtained.) Staff A said that the personal items were hers. She further stated, I have not had time to throw the can away. Staff A took the open ginger ale can and threw it in a nearby garbage receptacle. She removed her personal coffee cup off the preparation table and placed it in the CDM's empty office. 2. At 10:00 a.m., an observation was conducted of the reach-in refrigerator and revealed that there was no temperature gauge located inside the refrigerator to take accurate temperatures. Next to the refrigerator was the reach-in freezer which stored ice cream and frozen desserts. The reach in freezer did not have a temperature gauge located inside of it to take accurate temperatures. An observation of the temperature logs outside the reach-in refrigerator and reach-in freezer revealed that for the month of June 2021, the temperature logs for both had not been completed for the morning shift since 6/22/21 and the afternoon shift had not been completed since 6/25/2021. In an interview with Staff A, she indicated she did not know why there were no temperature gauges in both the refrigerator or the freezer and could not answer why the temperature logs were incomplete. Facility policy 019, Revised 9/2017, Page 01 of 01, titled Food Storage, under Procedures read: 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. 3. An observation was conducted of the dishware placed on four wheeled carts in the kitchen and revealed wet nesting between all dishes that were stacked on top of each other and not dried completely. Staff C was shown the dishware and confirmed there was water located on the dishware. Photographic evidence obtained. 4. An observation was conducted of the low temperature dish machine, with chemical sanitizer. During the observation, Staff C, Dietary Aide filled a dish tray with kitchen utensils and empty food containers then ran it through the dish machine. The temperature gauge on the bottom of the machine did not move from 115 degrees. Staff C indicated that the dish machine had to be run three times for it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106103 If continuation sheet Page 5 of 7 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 106103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707 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 to work. Staff C then confirmed after the third time that the temperature gauge was not moving and could not provide further information because she said she was new to the facility. The manufacturer specifications on the side of the machine revealed that for [model number], the minimum wash and rinse temperatures were to be at 120 degrees Fahrenheit. An interview was conducted on 06/28/2021 at 10:32 a.m., with the Nursing Home Administrator (NHA). During the interview she was informed that the dish machine, with chemical sanitizer was not operating according to the manufacturer's specifications. The NHA indicated that she understood that the safety of the facility residents was important and that she would cease all kitchen staff from using the kitchen dish machine. She stated, I'm finding the Maintenance Director to see if it is a hot water heater problem, and we have paper plates to use if we need to. During a later interview with the NHA at 11:02 a.m., she revealed that the Maintenance Director adjusted the hot water heater, and that the facility called [name of the dish machine company] to come out to the facility to service the equipment. The NHA also revealed that the facility would serve all meals using disposable plates, utensils and cups until the dish machine was fixed. An interview was conducted with the Operations Consultant and the District Manager on 06/28/2021 at 12:55 p.m. Both confirmed that the dish machine was not operating correctly. The Operations Consultant stated I told the staff not to do any ware washing in the dishwasher till we get it repaired. The facility provided a policy titled, Ware Washing Policy 022, Revised 9/2017, Page 01 of 01 under Procedures it read as follows. 1. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. 2. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. 3. Temperature and/or sanitizer concentration logs will be completed, as appropriate. 4. All dishware will be air dried and properly stored. The Operations Consultant in a subsequent interview on 6/30/2021 at 11:23 a.m., indicated that the [name of the dish machine company] service representative was on site and confirmed that the temperature was not within minimum standards, it was at 118 degrees, of 120 degrees for washing and rinsing. The Operations Consultant revealed that the dish machine water must be manually drained before kitchen staff use it. A schedule for using the dish machine only and not running other water sources in the kitchen was made. The three compartment sink also had a schedule for use. He further indicated that either a separate stand-alone heater needed to be purchased since the dish machine did not have an internal heating source, or the facility would find an alternative solution to heat the dish machine as well as maintain hot water sources throughout the kitchen. 5. During the comprehensive kitchen assessment conducted on 6/30/2021 at 11:41 a.m., it was observed that Staff B, while working on the food line, did not have on gloves. During the observation, Staff B's long fingernails were observed to be touching the mash potatoes on a plate, and several other food items numerous times. The Operations Department Consultant was overseeing the line and was informed of the observations. He confirmed the non-gloved hands of Staff B whose nails touched plates (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106103 If continuation sheet Page 6 of 7 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 106103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707 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 and food. He stated, Yes I do now notice it, and it aggravates me. He then told Staff B to put gloves on. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106103 If continuation sheet Page 7 of 7