Health inspection·October 6, 2022

F 0584 participated in assessment. Level of Harm - Minimal harm or potential for actual harm Review of Resident #9 's Care Plans with reference date of 2/16/22 revealed: Resident has a Diagnosis of hypertension. Interventions include: Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. Monitor for and document any edema. Notify Physician (MD). Monitor/document/report to MD as needed (PRN)any signs and symptoms of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing (Dyspnea). Monitor/record medication side effects. Report to MD as necessary. Resident use of side rails while in bed to assist staff/resident in repositioning during care, related to impaired mobility, requiring staff assistance for ADL performance. Interventions: Discuss and record with family/guardian the risk and benefits of using side rails. Maintain a safe environment, bed in low position with wheels locked. Monitor for adverse effects with use of side rails, notify nurse. Provide side rails while in bed as indicated. Residents Affected - Few Resident is on diuretic therapy related to: Hypertension, May cause dizziness, postural hypotension, fatigue, and an increased risk for falls. Observe for possible side effects Q-shift. Review of the facility's grievance logs for the last six months did not show any documented grievances filed by Resident #9 in the last 6 months. On 10/05/22 at 08:26 AM, during observation and interview the bedrail was observed behind the resident's bed against the wall. The Assistant Director of Maintenance, (Staff B) came to Resident #9's room and stated via translator (surveyor on the team) that today 10/5/22 is his first day working in the facility. The assistant maintenance director stated that he would work on fixing the resident's bed rail after the resident is finished having breakfast. On 10/05/22 at 08:30 AM, the Director of Maintenance, (Staff C) stated that his first day of work at the facility was yesterday 10/4/22, he will check with his assistant to make sure Resident # 9's bedrail gets fixed as soon as possible. On 10/05/22 at 08:38 AM, the Director of Nursing (DON) was informed of Resident # 9's broken bed rail that has been detached from her bed and being stored behind the bed and furthermore Resident #9 reported that it has been that way for a while and had reported it to several staff members. The DON stated, I will file a grievance for the resident, educate my staff and make sure the bed rail gets fixed today. On 10/5/22, a follow up review of the grievance logs revealed a grievance was filed by the Director of Nursing for Resident #9 about the broken and detached bed rail. On 10/05/22 at 03:03 PM, Resident # 9 was observed out of bed in Geri chair. Resident #9 reported that maintenance brought her a new bed with rails that work correctly, and she is satisfied with the new bed. On 10/05/22 at 03:40 PM the DON provided a copy of the grievance filed on behalf or Resident # 9, dated 10/5/22. Concern-broken bed rail told staff several times. Solution-Bed has been replaced, rails are functioning, resident satisfied with new bed. Review of the undated facility's policy and procedures titled Safe Environment states: The facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 2 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 will maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 3 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 - Few 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 record review and interviews, the facility failed to respond to a grievance for one (Resident #5) out of one resident reviewed for grievances. The facility failed to address a concern after Resident #5's wife established communication with the facility's administrator concerning speaking with the doctor about his care. There were 44 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's policy titled, Grievance Program (dated August 2019) documented the following: Policy: It is the policy of the facility to ensure that individuals are encouraged to discuss comments and concerns which may be positive or negative and when indicated to bring such to a formal grievance status. Right to File Grievances: Residents and visitors have the right to present grievances on behalf of himself or herself or others to the staff or administrator of the facility either verbally or in writing; to receive a written decision related to the grievance filed. Process: Grievances are formal written or verbal complaints made to the facility when prompt or bedside resolution to the satisfaction of the person making the objection was not possible. Review of the Demographic Face Sheet for Resident #5 documented the resident was admitted on [DATE] with diagnoses to include muscle wasting, pressure ulcer of sacral region stage 4, chronic obstructive pulmonary disease, hypertensive heart disease, chronic kidney disease and acute respiratory failure. The responsible party for Resident # 5's his wife. Review of the Minimum Data Set (MDS) admission Assessment for Resident #5 dated 7/20/22 documented the resident's Brief interview for Mental Status (BIMS) Summary Score as 03 out of 15 indicating severe cognitive impairment and the resident was not able to make his needs known. The resident required total dependence with one person to physical assist with ADLs (Activities of Daily Living). During an interview with Resident #5's wife on 10/05/22 at 10:13 AM via telephone. She revealed that she has not received any phone calls from the doctor about his care since he has been at the facility. She has spoken with the Administrator and sent several emails to him concerning the matter and he has not responded to her nor has she received anything. Review of the grievance log dated July 2022 to October 2022 revealed no documented grievance filed on behalf of Resident #5 listed on the grievance log. On 10/06/22 at 9:40 AM, the Administrator stated, I received an email from the daughter that the mother wanted to be contacted by the physician. I contacted the physician and he said that he would contact her. I did not file the concern in the email as a grievance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 4 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to develop written Abuse, Neglect and Exploitation policies and procedures. The facility's Abuse, Neglect and Exploitation policy and procedure didn't include components for the investigation, protection and reporting/response. This affected 1 (Resident #15) out of 20 sampled residents. This had the potential to affect all 44 residents admitted to the facility. Residents Affected - Few The findings included: Observation of Resident #15 on 10/3/2022 at 8:58AM revealed, the resident sitting up at her bedside, the resident had a bruised bump on her head, another wound on her forehead and a small wound to her nose. The resident reported, she was walking into her room, and a former resident (Resident #10) pushed her, she fell and hit her head on the bottom of her bed. Resident #15 reports, she went to hospital and she feels awful since the fall. The resident reported, Resident #10 no longer resided at the facility. On 10/03/2022 at 9:30AM, Resident #15 was observed in the hallway and walking to the shower room. On 10/03/2022 at 01:17 PM, Resident #15 was observed in the dining room eating lunch at a table with her roommate. The resident ate approximately 50% of her lunch, and she reported, the lunch was good. Resident #15 was observed to be fully dressed and had wrapped bandages on her legs. On 10/04/2022 at 08:30 AM, Resident #15 was observed in the hallway without shoes on and had bandages wrapped around both feet and ankles, and had on hospital gowns. The wounds to her face continued as before, and sutures to the left forehead wound were observed. On 10/04/22 at approximately 9:00 AM, the Nursing Home Administrator (NHA) presented the Abuse investigation for the resident to resident altercation between Resident #15 and Resident #10 that occurred on 09/21/2022. The administrator presented the facility's Abuse, Neglect, Exploitation Policy and Procedure dated as revised on 11/2019. The NHA presented sign in sheets for training on the facility's Abuse Policy completed on 8/29/22, 8/30/22, 8/31/22. The NHA reported, he was the Abuse Coordinator. A review of the Resident to Resident Abuse investigation revealed a Nursing Home Federal Immediate Report dated 9/21/2022 and timed 5:00 AM. The investigation included information about facility Registered Nurse, Staff E, observed Resident #10 push Resident #15 after an altercation between the residents. Resident #15 had sustained a 2 inch laceration to the forehead, and a slight scratch to her left wrist. The incident occurred on 09/21/2022 at approximately 5:00 PM. Both residents were sent to a local hospital. The Abuse Registry and Resident representative were notified on 09/21/2022. A Nursing Home Federal Reporting Five Day Report was included in the investigation which included documentation of the facility findings that Resident #15 returned to the facility on 9/23/2022. The report documented, the resident had received stitches, had a Computed Tomography (CT) Scan. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 5 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #15 sustained a fractured midline left paramedian outer table left frontal bone. The resident had a hematoma to her frontal scalp. The Five Day report, documented Resident #15 on her own volition contacted the police on 9/24/2022. Police Officers came to the facility on [DATE]. The Five Day report documented, Due to the fact this was a resident to resident altercation beyond any facility control, no measures identified to be taken at this time. Facility staff had been previously in-serviced on what to do in both probable and unforeseen resident altercations. The Abuse investigation included the local hospitals discharge documentation which included Resident #15 diagnoses as Facial Laceration, Fracture of Frontal Bone, and a Subdural Hematoma. During the review of Resident #15's medical record, it was noted the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Encephalopathy, Chronic Obstructive Pulmonary Disease, Malignant Neoplasm, Osteoarthritis of the left and right shoulder, Hypertensive Heart Disease and a history of falling. The facility's Nursing Progress Notes revealed on 9/23/2022 at 17:15 - Resident returned to facility from [ ] medical center via medical transportation this evening at 5:00 PM. Resident is alert and oriented X3 (time 3). Resident complains of some head pain and discomfort at stitches site. Resident vital signs stable BP (Blood Pressure) 132/82 pulse 82 temp 97.8 RR (Respiratory rate) 18 oxygen 99 on room air. Resident has stitches on left and right side of forehead covered with gauze. Resident has bruising down the front of her face under bilateral eyes. Bruising on the front of Bilateral thigh area. Resident has some swelling to face. [ ] was called this evening and asked to send over the medication list via fax I writer was assured it would be sent over as soon as possible. Resident is ambulating at baseline and continues on regular consistency diet. Neuro checks done and WNL (Within normal limits). Will continue to monitor. During the review of the facility's Abuse, Neglect, Exploitation Policy and Procedure dated as revised on 11/2019, it was noted the policy and procedure included 4 components instead of the required 7 components to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property. The facility's Abuse policy included, Definitions, Purpose, Procedures for Screening, Training, Prevention and Identification. The policy did not include components for Abuse, Neglect, and Exploitation Investigation, Protection and Reporting/Response. On 10/06/2022 at 03:30 PM, the NHA, Director of Nurses and owner were interviewed about the facility's Abuse Policy missing components. They weren't aware components of the policy were missing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 6 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 0608 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to 1. Include in their written Abuse, Neglect and Exploitation policies and procedures the requirement to report crimes occurring in long term care facility, reporting suspicion of crimes to law enforcement immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 2. The facility failed to report a suspicion of a crime that resulted in serious bodily harm to 1 (Resident #15) out of 20 sampled residents. This had the potential to affect all 44 residents admitted to the facility. The findings included: Observation of Resident #15 on 10/3/2022 at 8:58 AM revealed, the resident sitting up at her bedside, the resident had a bruised bump on her head, another wound on her forehead and a small wound to her nose. The resident reported, she was walking into her room, and a former resident (Resident #10) pushed her, she fell and hit her head on the bottom of her bed. Resident #15 reports, she went to hospital and she feels awful since the fall. The resident reported, Resident #10 no longer resided at the facility. On 10/03/2022 at 9:30 AM, Resident #15 was observed up in the hallway and walking to the shower room. On 10/03/2022 at 01:17 PM, Resident #15 was observed in the dining room eating lunch at a table with her roommate. The resident ate approximately 50% of her lunch, and she reported, the lunch was good. Resident #15 was observed to be fully dressed and had wrapped bandages on her legs. On 10/04/2022 at 08:30 AM, Resident #15 was observed in the hallway without shoes on and had bandages wrapped around both feet and ankles, and had on hospital gowns. The wounds to her face continued as before, and sutures to the left forehead wound were observed. On 10/04/22 at approximately 9:00 AM, the Nursing Home Administrator (NHA) presented the Abuse investigation for the resident to resident altercation between Resident #15 and Resident #10 that occurred on 09/21/2022. The administrator presented the facility's Abuse, Neglect, Exploitation Policy and Procedure dated as revised on 11/2019. The NHA presented sign in sheets for training on the facility's Abuse Policy completed on 8/29/22, 8/30/22, 8/31/22. The NHA reported, he was the Abuse Coordinator. A review of the Resident to Resident Abuse investigation revealed a Nursing Home Federal Immediate Report dated 9/21/2022 and timed 5:00 AM. The investigation included information about facility Registered Nurse, Staff E, observed Resident #10 push Resident #15 after an altercation between the residents. Resident #15 had sustained a 2 inch laceration to the forehead, and a slight scratch to her left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 7 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 0608 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wrist. The incident occurred on 09/21/2022 at approximately 5:00PM. Both residents were sent to a local hospital. The Abuse Registry and Resident representative were notified on 09/21/2022. A Nursing Home Federal Reporting Five Day Report was included in the investigation which included documentation of the facility findings that Resident #15 returned to the facility on 9/23/2022. The report documented, the resident had received stitches, had a Computed Tomography (CT) Scan. Resident #15 sustained a fractured midline left paramedian outer table left frontal bone. The resident had a hematoma to her frontal scalp. The Five Day report, documented Resident #15 on her own volition contacted the police on 9/24/2022. Police Officers came to the facility on [DATE]. The Five Day report documented, Due to the fact this was a resident to resident altercation beyond any facility control, no measures identified to be taken at this time. Facility staff had been previously in-serviced on what to do in both probable and unforeseen resident altercations. The Abuse investigation included the local hospitals discharge documentation which included Resident #15 diagnoses as Facial Laceration, Fracture of Frontal Bone, and a Subdural Hematoma. During the review of Resident #15's medical record, it was noted that the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Encephalopathy, Chronic Obstructive Pulmonary Disease, Malignant Neoplasm, Osteoarthritis of the left and right shoulder, Hypertensive Heart Disease and a history of falling. The facility's Nursing Progress Notes revealed on 9/23/2022 at 17:15 - Resident returned to facility from [ ] medical center via medical transportation this evening at 5:00 PM. Resident is alert and oriented X3. Resident complains of some head pain and discomfort at stitches site. Resident vital signs stable BP 132/82 pulse 82 temp 97.8 RR 18 oxygen 99 on room air. Resident has stitches on left and right side of forehead covered with gauze. Resident has bruising down the front of her face under bilateral eyes. Bruising on the front of Bilateral thigh area. Resident has some swelling to face. [ ] was called this evening and asked to send over the medication list via fax I writer was assured it would be sent over as soon as possible. Resident is ambulating at baseline and continues on regular consistency diet. Neuro checks done and WNL (Within normal limits). Will continue to monitor. During the review of the facility's Abuse, Neglect, Exploitation Policy and Procedure dated as revised on 11/2019, it was noted the policy and procedure included 4 components instead of the required 7 components to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property. The facility's Abuse policy included, Definitions, Purpose, Procedures for Screening, Training, Prevention and Identification. The policy did not include components for Abuse, Neglect, and Exploitation Investigation, Protection and Reporting/Response. The policy did not include ensuring reporting of crimes occurring in federally-funded long-term care facilities, Annually notifying covered staff of their obligation to comply with the following reporting requirements, Each covered staff shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility, Each covered staff shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 8 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 0608 Level of Harm - Minimal harm or potential for actual harm On 10/06/2022 at 03:30 PM, the NHA, Director of Nurses and owner were interviewed about the facility's Abuse Policy missing components. They weren't aware the policy was missing components. They were reminded that they did not report Resident #15's suspicion of a crime to law enforcement after their staff saw the residents serious injuries on 9/21/2022. Resident #15 was potentially assaulted and facility staff did not report the incident. Residents Affected - Few Resident #15 had to notify law enforcement on 9/24/2022 after being discharged from the hospital on 9/23/2022. This was 3 days after the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 9 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for three residents (Residents # 2, Resident # 45 and Resident # 46) out of three resident's MDS assessments reviewed at the time of survey. This deficient practice has the potential to affect 44 residents residing in the facility at the time of survey. The findings included: Record Review of Resident # 2 's admission record revealed Resident # 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Medical diagnoses included but were not limited to, encounter for other orthopedic aftercare; fracture of Unspecified part of neck . and unspecified sequelae of cerebral infarction. Review of the Transfer and Discharge records revealed Resident # 2 was discharged from the facility on 05/04/2022 and 05/13/2022. Review of Resident # 2' Minimum Data Set (MDS) dated [DATE] documented : Return not Anticipated and revealed the resident was discharged . The MDS documentation indicated : Discharge Return not Anticipated for the resident's discharge on [DATE] was not filed. Record review of admission Record for Resident # 45 revealed the resident was admitted to the facility on [DATE] and discharged to an acute hospital on [DATE]. Resident # 45 clinical records documented clinical diagnoses include but not limited to other Idiopathic Peripheral Autonomic Neuropathy, Acute Neurological; Hypertensive Heart Disease Without Heart Failure; Diabetes Mellitus Without Complications; Acute Respiratory Failure with Hypoxia and End Stage Renal Disease. Review of Resident # 45's Minimum Data Set (MDS) Section A dated 08/20/2022 documented Discharge-Return Anticipated. Further review of the MDS documentation revealed the resident was discharged to the community. Review of Resident #45's Nursing Notes dated 08/20/2022 revealed Resident # 45 was transferred to the hospital. Record review of admission Record revealed the Resident # 46 was admitted to the facility on [DATE] and discharged on 08/08/2022 to an Assisted Living Facility (ALF). Clinical diagnoses documented in the medical records included, but were not limited to, Type 2 Diabetes Mellitus Without Complications; Venous Insufficiency (Chronic)(Peripheral) and Other Abnormalities of Gait and Mobility. Review of Nursing Notes for Resident # 46 dated 07/08/2022 revealed the resident was at the facility for short-term care. Record review of the Minimum Data Set (MDS) Section A dated 08/08/2022 documented Discharge-Return not Anticipated. Further review of the MDS revealed the resident was discharged to an acute hospital. Review of the Nursing Home Transfer and Discharge Notice dated 08/08/2022 revealed Resident #46 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 10 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 discharged to an Assisted Living Facility. Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Nursing on 10/06/2022 at 8:45 AM. The DON revealed she is in charge for MDS. Residents Affected - Few Resident # 2's MDS was not filed when the resident was discharged . Resident # 45, was discharged to the hospital and a mistake was made for the discharge status on Section A of the MDS that documented the resident was discharged to the community. For Resident # 46, the DON revealed the resident was discharged to an Assisted Living Facility not to a hospital. and stated this was a mistake in Section A of the MDS that documented the resident was discharged to a hospital. The DON acknowledged the discrepancies. Review of the facility's undated policy and procedures for Resident Assessment revealed: Intent: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development. Completion of the Minimum Data Set: 6) the assessments will accurately reflect the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 11 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 observation, record review, and interview the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately prior to admission and failed to revise the screening following admission for one( Resident #35) out of one resident PASRR reviewed. This had the potential to affect the 44 residents residing in the facility at the time of the survey. Residents Affected - Few The Findings Included: On 10/03/22 at 08:58 AM, Resident # 35 was observed in room in chair by bed. On 10/04/22 at 10:14 AM Resident #35 was observed in activities during bingo. On 10/05/22 at 02:45 PM Resident #35 was observed standing at the nurse's station conversing with staff, wander alert device noted on left forearm. Review of Resident # 35's Level I PASRR (Preadmission Screening and Resident Review) dated 9/01/22 under Section I: Section I: PASRR Screen Decision Making: A: Mental Illness (MI) or suspected MI (check all that apply) - no diagnosis checked (Anxiety Disorder, Depressive Disorder, and Psychotic Disorder not checked). Findings based on documented history. Section II Other indicators for PASRR screening Decision-Making: All checked no. Does individual have validating documentation to support dementia or related Neurocognitive disorder - no. Section III Not a provisional admission. Section IV No diagnosis or suspicion of MI or Intellectual Disability (ID) indicated. Level II PASRR evaluation not required. PASRR Level I completed by a Social Worker (MSW) at the Hospital, no diagnosis included on PASRR Review of the medical records for Resident #35 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Unspecified Dementia with Behavioral Disturbances, Other Specified Depressive Episodes, Anxiety Disorder and Unspecified Psychosis not due to a substance or unknown Physiological Condition. Review of the Physician's Orders Sheet for October 2022 revealed Resident #35 had orders that included but not limited to: Memantine HCI tablet 10 Milligram (MG)-Give 1 tablet by mouth two times a day for dementia, Aricept 5 MG tablet-Give 5 MG by mouth at bedtime for dementia, Risperidone 0.5 MG Tablet-Give 0.5 MG by mouth at bedtime for bipolar disorder. Escitalopram Oxalate 0.5 MG tablet- Give 1 tablet by mouth one time a day for depression, Lorazepam 1 MG tablet-Give 1 MG by mouth every 8 hours as needed for anxiety and Haldol Solution 5 MG/ML-inject 2.5 MG intramuscularly every 6 hours as needed for behavioral, get patient consent prior to administration. Record review of Resident #35 's admission Minimum Data Set (MDS) dated [DATE] revealed: Section A 1500 identification information for cognitive patterns indicated resident is currently considered by the state level II PASRR process to have a SMI or ID or a related condition-No. Section C for cognitive patterns indicated Brief Interview for Mental Status Score (BIMS) 3 out of 15 indicating the resident is severely impaired cognitively. Section D for mood indicated the resident has trouble concentrating, slowly moving, and speaking. Section E for behavior indicated resident has no behavior indicators and no potential indicators of psychosis. Section G for functional status indicated supervision needed for eating, transfer, and bed mobility. Extensive assistance needed for toilet use. Section I for active diagnosis indicated resident has hypertension, diabetes mellitus, wound infection, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 12 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 - Few non-Alzheimer's dementia, anxiety, depression, psychotic disorder, and Section J for health conditions indicated resident received no scheduled or as needed pain medications had no shortness of breath and no falls. Record review of Resident #35 's Care Plans dated 9/9/2022 revealed: Resident has scored 0 on the BIMS assessment and has a short- and long-term care memory impairment with severely impaired cognition regarding task of daily living. Mental function varies over the course of the day related to current medical conditions. Resident sometimes understands and is sometimes understood. Interventions include avoid a hurried judgmental attitude with each interaction with resident. Provide activities that do not involve overly demanding tasks and stress. Staff to address resident by name daily at each interaction. Resident is displaying mood/behavior or symptoms such as periods of restlessness and wandering behavior, possibly attributed to diagnosis of anxiety and depression. Interventions include approach in a calm manner. Establish a trust relationship. Explain importance of complying with care and treatments. Follow up psychiatrist consult as needed. Give positive feedback for cooperating and efforts made. Inquire why resident is experiencing an episode. Make family/representative aware of the behavior problem, any changes in care and treatments. Monitor, report, and document behavior. Provide resident opportunities to discuss problems and attempt to resolve it. Resident has impaired cognitive function/dementia or impaired thought processes related to Dementia. Interventions include Administer meds as ordered. Monitor/document /report to Physician (MD) any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others. Resident receives psychotropic medications (Haldol, Risperidone) related to behavior management, disease process of dementia. Interventions include, administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, Physician (MD) to consider dosage reduction when clinically appropriate. Discuss with MD, family re ongoing need for use of medication. Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Monitor/record/report to MD as needed (PRN) side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Resident receives an antidepressant medication related to depression. Interventions include, give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness- dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. Monitor/document/report to MD PRN ongoing signs and symptoms (s/sx.) of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations ., mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Resident receives anti-anxiety medications (Ativan) related to anxiety disorder. Interventions include, give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness: Drowsiness, lack of energy, Clumsiness, slow reflexes, slurred speech, confusion, and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Paradoxical side effects: Mania, hostility, and rage, aggressive or impulsive behavior, hallucinations. Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Review of Resident # 35's psychiatric consult dated 9/2/22, completed by the Physician (MD) documented: Diagnosis: Agitation, psychiatric (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 13 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 - Few medication: Celexa, denies any substance abuse, appearance, and behavior: calm, cooperative, fair hygiene, prescribed: Risperidone 0.5 MG 1 tablet at by mouth at bedtime. On 10/05/22 at 02:47 PM, Registered Nurse (Staff A) was asked about Resident #35's behavior. Staff A stated: this resident is very compliant with taking his medications and when we redirect him to his room our towards an activity he usually cooperates with the staff. I know that this resident takes medication for depression, anxiety, and other mental illness, I have not witnessed the resident with any physical side effects of the medication he takes, he is usually very pleasant on my shift. On 10/06/22 at 11:45 AM, the Director of Nursing (DON) was asked about the PASRR process. The DON stated: On admission of residents to the facility, I review the admission documents to ensure the resident have a PASRR Level I, review the diagnosis, review if the PASRR is provisional one and if they require a level II. If they have a PASRR level I, I make sure that they are safe to be here in the facility. The surveyor showed the DON Resident #35's PASRR in the system with no diagnosis listed; the DON stated that she would have to do a correction on this resident and assess the resident to make sure he is safe to be in the facility and schedule a psychological consult if the resident has not already had one. Review of the facility's undated policy and procedure titled Coordination-Pre-admission Screening and Resident Review (PASRR) program states: It is the policy of the facility to assure that all residents admitted to the facility receive a Preadmission Screening and resident Review in accordance with state and Federal Regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 14 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a discharge care plan for one (Resident # 46 ) out of three resident reviewed for discharge care plan at the time of the survey. This deficient practice has the potential to affect 44 residents residing in the facility at the time of survey. The findings included: Review of Resident # 46's admission records revealed the resident was admitted to the facility on [DATE] and discharged to an Assisted Living Facility on 08/08/2022. Record review of Resident # 46's medical records revealed the resident's diagnoses included, but not limited to, Type 2 Diabetes Mellitus without Complications; Venous Insufficiency (Chronic) (Peripheral); Other abnormalities of Gait and Mobility. Review of the Social Services Notes dated 07/08/2022 revealed Resident #46 was admitted to the facility on [DATE] via ambulance stretcher accompanied by attendants, with Diagnosis of Type 2 Diabetes Mellitus without Complications. Resident was a Full Code. Resident was verbal most of the time. He had moderately impaired cognitive skills for daily decision making. Staff will be helped to anticipate his needs. Resident had voiced satisfaction with the care and looks forward to adjusting to the facility. Resident was here for short term care, planning discharge. He requires 24-hour nursing supervision. Social Services will provide support and assistance. Review of Resident # 46's Discharge Care Plan revealed the facility did not develop a Discharge Care Plan for the resident. Review of Resident #46's Minimum Data Set (MDS) Section A dated 08/08/2022, documented Discharge-Return not Anticipated. Further review of the MDS indicated in Section A 2100 for Discharge status documented the resident was discharged to an acute hospital. Review of the Nursing Home Transfer and Discharge Notice dated 08/08/2022 revealed the resident was discharged to an Assisted Living Facility. Review of the Nurses Notes dated 08/08/2022 Late Entry: Note Text documented: Patient was transferred to an Assisted Living Facility (ALF) by a local transportation company. Vital signs were stable at time of transfer and no complain of pain of discomfort. On 10/05/22 at 01:33 PM, the Social Services Consultant revealed she is not in charge of the Nursing Home Transfer and Discharges. During an interview with Director of Nursing on 10/06/22 08:10 AM. The Director of Nursing reported that Resident #46 was discharged to an ALF and then he went to the hospital. She stated it was an error not to develop a Discharge Care Plan for the resident, that was a short-term care resident that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 15 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 came for Rehabilitation and was planning return to his Assisted Living Facility. Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated Comprehensive Care Plan policies and Procedures revealed: Intent:-It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service, and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. Updating Care Plans: 10) Discharge planning concerns will be identified by all disciplines through ongoing assessment. The licensed nurse will make appropriate referrals to interdisciplinary team members, as necessary. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 16 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide care and services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being, related to dialysis services for one (Resident #32) out of one resident reviewed and two residents receiving in-house dialysis services. Written documentation was not available in the medical records. Services provided by the Dialysis nurse were not coordinated and communicated in written documentation. This practice has the potential to increase the risk of negative resident outcomes and to affect all two in-house dialysis residents residing in the facility at the time of this survey. Residents Affected - Few The findings included: Record review of the Dialysis Contract revealed a local Dialysis Company entered into a written agreement with this facility effective on May 23, 2022. The Provider will perform dialysis treatments for residents upon the request and written orders. All requested treatments will be delivered by trained and experienced personnel. Provider will use a Method of billing for provision of supplies and equipment in providing home dialysis treatments and assumes responsibility for all aspects of care and compliance including but not limited to: 14) Maintain accessible, properly documented and organized medical records for easy retrieval of information. Observation of Resident #32 on 10/06/22 at 7:32 AM revealed the resident sitting in a recliner in the dialysis room, receiving dialysis services. Review of the Demographic Face Sheet for Resident #32 documented the resident was admitted on [DATE] with diagnoses to include muscle wasting, end stage renal disease, anemia, schizophrenia and hypertensive heart disease. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #32 dated 8/25/22 documented the resident's Brief interview of Mental Status (BIMS) Summary Score as 06 out of 15 indicating cognitive impairment and the resident was not able to make his needs known. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living). Review of the Physician's Order Sheet (POS) for September 2022 and October 2022 documented Resident #32 received in-house dialysis on Tuesday, Thursday and Saturday. The resident started receiving in-house dialysis on 9/18/22. Review of the End Stage Renal Disease/Dialysis care plan (written 8/21/22) documented the resident was receiving dialysis services. Review of the electronic medical record for Resident #32 revealed no written documentation was available in the medical chart from the local Dialysis Company. No documentation noted of communication from the dialysis personnel. Interview with the Dialysis Registered Nurse on 10/06/22 at 7:33 AM, revealed the resident receives dialysis on Tuesday, Thursday and Saturday. The resident tolerates dialysis well and that the DON (Director of Nursing) had the binder with the dialysis communication forms. Interview with the Director of Nursing (DON) on 10/06/22 at 7:40 AM, requesting the dialysis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 17 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few communication forms. The DON revealed that she does not have a binder with the dialysis communication forms and she would contact the dialysis nurse supervisor concerning the dialysis communication forms. The DON stated, The dialysis communication forms should stay here in the facility and not leave here. Subsequent interview with the DON on 10/06/22 at 9:21 AM, with a second request for the dialysis communication forms. The DON revealed that she contacted the dialysis supervisor concerning the dialysis communication and they will fax the dialysis communication forms. Interview with the Consultant Registered Dietitian on 10/06/22 at 12:45 PM revealed the resident received dialysis services. Interview with the DON on 10/06/22 at 2:11 PM revealed dialysis communication forms for Resident #32 dated 7/21/22 to 10/04/22. Interview with Staff E, Licensed Practical Nurse (LPN) on 10/06/22 at 2:23 PM. Staff E stated: The resident goes to dialysis three times a week on Tuesdays, Thursdays and Saturdays in-house. He tolerates dialysis well. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 18 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility failed to provide pharmacy services according to the requirements and according to the facility's policy and procedure. This failure had the potential to affect all 44 residents admitted to the facility. The findings included: 1. On [DATE] at 8:40 AM, during observation of the medication administration on Cart B with Staff E, a Registered Nurse (RN). Staff E took a Retacrit 10,000IU/ml (International unit/Milliliter) vial to Resident #27's bedside to administer 10,000 units subcutaneously. Staff E was observed to draw the Retacrit into a syringe with a 1½ inch, 22 gauge needle. Prior to giving the injection, Staff E was asked whether this was the correct needle size to use for a subcutaneous injection and she reported, yes and gave Resident #27 the Retacrit in his left abdomen. The needle size was observed to be the size used for an intramuscular injection. 2. During the observation of the facility's one Medication Storage storage room on [DATE] at 11:21AM with Staff D, RN Charge Nurse. The medication refrigerator was observed locked, an Emergency kit inside the refrigerator was observed to be open with an open multidose Ativan 20 mg/10cc (milligrams/cubic centimeters) vial inside. The Ativan vial was not dated when it was opened. The red plastic lock was observed inside the open emergency kit container. Inside the open emergency kit, there were 8 emergency drug kit slips that included, 1 slip for [DATE], 3 slips for [DATE], 1 slip for [DATE] and 2 slips for [DATE]. The multidose Ativan vial was observed to be almost empty, but was still inside the open emergency drug kit. The Emergency Drug Kit Slips accounted for 8 cc of Ativan administered. Photo obtained. 3. On [DATE] at approximately 11:30 AM, during continued observation inside the medication room a metal cabinet was observed on the wall. Staff D reported, the Director of Nurses (DON) was the only one with a key to the cabinet. The DON came to the medication storage room and opened the double locked cabinet, the cabinet was full of over 30 narcotic Bingo cards that included Temazepam, Ativan, Clonazepam, and Ultram, the narcotic sign out sheets were wrapped around the bingo cards. Some of the observed narcotic sheets were signed out as last used in April, May, and [DATE]. Photo obtained. The DON reported these were narcotics that needed to be returned to the pharmacy. The facility's Pharmacy policies were requested. The DON reported, the pharmacist had been there about a month and a half ago, but she needed to confirm the date. 4. Observation on [DATE] at 11:50 AM of Cart A, with Staff A, Registered Nurse the following was observed, 12 and 1/2 unidentified tablets with loose pieces of paper were observed in the bottom of the 2nd and 3rd drawers of the cart. Medications for 3 discharged residents were found in the cart to include Dexamethasone 3 tabs, Ventolin Inhaler, Symbicort Inhaler, Azithromycin, 4 boxes of Lidocaine Patches, with 5 patches in each box, Antifungal foot powder and (1) open Pink Bismuth bottle found in the bottom drawer that was expired on 6/2022. On [DATE] at 10:47 AM, Staff D was interviewed about the size of the needle the facility uses for subcutaneous injections, and she presented a 29 G x 1/2 inch needle syringe. Staff D was informed a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 19 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 22 G, 1 1/2 inch needle was used on Resident #27 for a subcutaneous Retacrit injection. She reported, the 22 gauge, 1 1/2 inch needle was the wrong sized needle for a subcutaneous injection. Staff D informed Staff E about the correct sized needle to use for subcutaneous injections. On [DATE] at 11:17 AM, Staff D was asked who is the facility's Consultant Pharmacist and she did not know the Consultant Pharmacist name. Staff D was asked, how often the Consultant Pharmacist comes to the facility and she did not know, but said, the DON would know since the pharmacist meets with her. Staff D was asked to request this information from the DON. The name of the Consultant Pharmacist was obtained, but the last time the Pharmacist was at the facility was not provided. During the review of the facility's Pharmacy Policies and Procedures, it was determined the policies were not followed regarding the observations. The facility's Pharmacy Services Policy and Procedure was reviewed. The policy was not dated. The intent section documented, It is the policy of the facility to provide Pharmacy Services in accordance to State and Federal regulations. The procedures section documented, 1. The facility will employ or obtain the services of a licensed pharmacist who: a. Provides consultation on all aspects of the provision of pharmacy services in the facility. b. Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and c. Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. 5. The facility will provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing and administration of all drugs and biologicals to meet the needs of each resident. 8. The facility will maintain an Emergency Medication kit, .The kit will be readily available and will be kept sealed If the seal is broken, the kit will be resealed the next business day after use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 20 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 - Few 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 interview, the facility failed to have the pharmacy consultant conduct medication regimen review at least monthly. This practice has the potential to increase the risk of negative resident outcomes and to affect all twenty-four residents receiving psychoactive medications residing in the facility at the time of this survey. The findings included: Record review of the Demographic Face Sheet for Resident #32 documented the resident was admitted on [DATE] with diagnoses to include muscle wasting, end stage renal disease, anemia, schizophrenia and hypertensive heart disease. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #32 dated 8/25/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 06 out of 15 indicating cognitive impairment and the resident was not able to make his needs known. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living). The resident received the following medications: Antipsychotic 2 days, Antidepressant 7 days, Hypnotic 3 days and Diuretic 1 day. Review of the Physician's Order Sheet (POS) for September 2022 and October 2022 documented Resident #32 received the following medications: Restoril 30 mg (milligrams) cap (capsule) 30 mg PO (by mouth) HS (at bedtime) for insomnia, Alprazolam 0.5 mg 1 tab (tablet) PO every 6 hours PRN (as needed) for anxiety for 60 days (Start 8/26/22, End 10/25/22), Zyprexa 2.5 mg tab 1 tab PO BID (twice a day) for psychosis and Fluoxetine HCL 10 mg tab 10 mg PO one time a day for antidepressant. Review of the medication regimen review for Resident #32 documented the review of the medication by the Consultant Pharmacist. The drug regimen review was not dated with the month and not signed by the consultant pharmacist nor the physician. Recommendations were made by the Consultant Pharmacist: Evaluate resident for iron/B-12/Folate supplementation; Medications reviewed: Zyprexa 2.5 mg QD on 7/22/22 (schizophrenia on file), Prozac 10 mg QD on 8/22/22, Alprazolam 0.5 mg Q 6 H PRN on 8/22/22 (stop date 10/26/22), Temazepam 15 mg HS on 8/22/22 (stop date 9/25/22). Interview with the DON (Director of Nursing) on 10/06/22 to 4:14 PM revealed the following: The Consultant Pharmacist comes to the facility, every few months; He last visited the facility, about a month and half ago; When asked do you have any documentation for this visit, she answered that she will look for the documentation and When asked why are there so few medication reviews in the Medication Regimen Review book, she reported that's what was sent to her. She was told some of the information is dated and she answered, she's aware of this. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 21 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to establish a complete infection control program, as evidenced by no monthly infection surveillance and antibiotic stewardship documentation being available to review electronically or in print. This had the potential to affect the 44 residents residing in the facility at the time of the survey. Residents Affected - Few The Findings Included: Review on 10/4/22 at approximately 4:00 PM with the Director of Nursing (DON) who is also the Infection Control Preventionist (ICP) of a list of Infection Control documentation that would be needed for the infection control interview on the last day of survey. On 10/5/22 infection control documents were requested twice during the time surveyor was at the facility, some documents received. On 10/6/22 the DON wrote down the list of documents needed. The DON was informed to provide the surveyor with the infection control documents as they became available. On 10/6/22 several times during the survey at the facility with the last request at 6:30 PM, the infection control documentation was requested from the DON and not all requested documents were received. During an interview on 10/06/22 at 07:00 PM the DON stated: all our Infection Control Surveillance and Antibiotic Stewardship information is on Point Click Care (PCC) and it is no longer populating on the computer screen, everything is blank on the screen, a ticket was sent to PCC help desk to fix the information. Documentation of the ticket sent to PCC help desk and blank copies of the facility Infection Surveillance and Antibiotic Stewardship reports were given to surveyor. The PCC help desk documentation revealed: no time stamp of help desk ticket that consisted of DON's personal info and case description that stated, I am not able to pull my infection surveillance report that was generated. The DON stated : The facility surveillance we use here tracks and trends the different infections that are treated and the amount to ensure and to prevent an outbreak, I map the infections by units, If I find a cluster of infections in one area, I investigate the staff that work in that area for tracks and trends, education and training is done for the staff on infection control and anything related to the particular infection. For the Antibiotic Stewardship program, I track and trend to ensure the antibiotic is working for the specific infection and monitor for signs and symptoms to ensure the infection is relieved by that treatment. I do not keep physical copies of my Infection Surveillance and Antibiotic Stewardship report on file, everything is kept electronically. When asked how the facility's infection control surveillance and Antibiotic stewardship information is shared with the staff. The DON did provide a direct response to the question but stated: My head is in a blur right now, I can't think straight right now, I can't believe this happened to me. The DON stated she would be following up with the help desk in the morning to see how they could correct the issue. Review of the undated facility's policy and procedure titled Infection prevention and Control and Surveillance Program states: The facility will establish and maintain an infection prevention and control program under which it: a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 22 of 23 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevents, identifies, reports, investigates, and control the spread of infections and communicable disease in the facility. b. Conducts surveillance for early detection of infections, clusters/outbreaks, and reportable diseases and to track and trend surveillance data. c. Decides when and how isolation should be apples to a resident. d. Maintains a record of incidents and corrective actions related to infection prevention and control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 23 of 23