Inspection·April 30, 2025

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** Resident # 12 Observations on 04/27/2025 at 8:45 AM, Resident #12 was seated on his bed finishing his breakfast. Residents Affected - Few Observation on 04/28/2025 at 10:30 AM Resident # 12 was watching television and did not answer questions asked. Record review of Resident # 12's clinical records revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include Mood Disturbance, Anxiety; Unspecified Psychosis not Due to a Substance or Known Physiological Condition and Generalized Anxiety disorder. Review of the Admissions MDS (Minimum Data Set) Section A Identification Information dated 03/16/2023 revealed the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition documented- NO Record review of PASRR Level I dated 03/14/2023 revealed identification of a Serious Mental Illness under Section 1A and Section 1B was not checked for Serious Mental Illness (SMI). Section 2, Other Indications for PASRR Screen Decision-Making, no questions were answered no indicating the resident had no behaviors. Section 4 PASRR Screen Completion revealed the resident had Serious Mental Illness and the Level II PASRR is required. Review of Physician Orders and the Medication Administration Records for April 2025 revealed Resident # 12 is receiving Quetiapine Fumarate Tablet 25 milligrams. 1 tablet by mouth at bedtime for psychosis; and monitored for Antipsychotics, Antianxiety, Sedative, Other psychoactive. Record review of Annual Minimum Data Set (MDS) Section C Cognitive Patterns dated 03/12/2025 revealed the Brief Interview for Mental Status (BIMS) summary score was 99 meaning the resident was unable to complete the interview. Review of the Annual MDS Section I Active Diagnosis dated 03/12/2025 include Anxiety Disorder, Psychotic Disorder (other than schizophrenia). Review of the Annual MDS Section N Medications dated 03/12/2025 revealed the resident was taking antipsychotic medication. The Care Plan initiated on 3/15/2023 and the next review date 6/12/2025 documented the resident is on psychotropic drugs and was at risk for drug-related adverse effects from medicine .Psych consult and follow-up as needed. Work with physician/psychiatrist for possible drug reduction. Review of Psychiatrist consultation dated 04/14/2025 revealed the resident with a history of psychosis, major depressive disorder (MDD), and generalized anxiety disorder (GAD) . receive treatment for his psychiatric conditions. Assessment: 1. Unspecified psychosis not due to a substance or known physiological condition: Quetiapine Fumarate Oral Tablet 25 mg. 2. Major depressive disorder, recurrent 3. Generalized anxiety disorder. Interview on 04/30/2025 at 1:45 PM, the Director of Nursing revealed the Social Services Director (SSD) is responsible for completing the Level I PASRR assessments; and if the SSD does not complete the assessments, then she (DON) is responsible to complete the Level I PASRR. Interview on 04/30/2025 at 1:30 PM; the Social Services Director revealed she does not have the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 2 of 8 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 04/30/2025 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 required license to complete the PASRR assessments. Level of Harm - Minimal harm or potential for actual harm Record review of the Policies and Procedures Subject PASRR Pre-admission /Screening and Resident Review, Effective date: 01/2025 I- Purpose: Pre-admission Screening and Resident Review (PASSR) is a federal requirement mandated by the Social Security Act. It is intended to ensure that Medicaid-certified nursing facility applicants and residents with a diagnosis of or suspicion of serious mental illness or intellectual disabilities, or related conditions are identified and admitted or allowed to remain in the nursing facility only if there is a verified need for such services. IV-Policy: The facility ensures that all residents admitted to the facility have PASRR Level I done prior to admission to facility or Level II PASRR as indicated by resident's condition and behavior. The facility ensures that PASRR Level I must reflect current condition and diagnosis or resident. Facility will follow from mandated by AHCA at any given time. Residents Affected - Few Based on record review and interview, the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR)for individuals with a serious mental illness (SMI), or intellectual disability or related conditions (ID)was completed accurately prior to admission and failed to revise the screenings following admission for three (Resident #13, Resident #8 and Resident#12) out of 20 sampled residents. There were 44 residents residing in the facility at the time of the survey. The findings Included: Resident #13 During observations on 04/27/25 at 08:36 AM, Resident #13 is awake in bed. On 04/28/25 at 07:39 AM Resident #13 was observed in room walking around and stated she is ok, just getting around for the day. Observation on 04/29/25 at 10:23 A; Resident #13 was her room sitting on the side of the bed, conversing with roommate and stated, today is a good day. Review of the medical records for Resident #13 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, Major Depressive Disorder recurrent unspecified. Unspecified Psychosis is not due to a substance or known physiological condition. Review of the Physician's Orders Sheet for April 2025 revealed, Resident #13 had orders that included but not limited to: Quetiapine Fumarate Oral Tablet 25 Milligram (MG) -Give one (1) tablet by mouth one time a day for Unspecified Psychosis. Escitalopram Oxalate Oral Tablet 5 MG -Give 1 tablet by mouth one time a day for Depression. Quetiapine Fumarate oral tablet 50 MG -give 1 tablet by mouth at bedtime for unspecified psychosis. Mirtazapine Oral Tablet 7.5 MG -Give 1 tablet by mouth at bedtime for Depression. Record Review of Resident #13's Level I PASRR (Preadmission Screening and Resident Review) documented Section I: PASARR Screen Decision Making: A: Mental Illness (MI) or suspected MI (check all that apply) - No diagnoses checked off. Findings based on documented history were-Section II Other indicators for PASRR screening Decision-Making: All checked - no. Does individuals have validating documentation to support dementia or related Neurocognitive disorder - no. Section III Not a provisional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 3 of 8 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 04/30/2025 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 admission. Section IV. No diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability (ID) indicated. Level II PASRR evaluation not required. PASRR Level I completed by a Social Worker at the hospital on [DATE]. Record review of Resident # 13's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section A 1500 resident is currently considered by the state level II PASRR process to have a SMI or ID or a related condition-Not available. Section C for Cognitive Patterns documented Brief interview for mental status score (BIMS) of 11 on a 0-15 scale indicating the resident is cognitively moderately impaired. Section I for Active diagnosis documented Anxiety disorder, Psychosis and Depression Disorder. Section N indicated that the resident's medications include antidepressants, antipsychotics and anticonvulsant. Record review of Resident #13 's Care Plans Reference Date 03/02/2025 revealed: Resident #13 is on Psychotropic drugs related to Diagnosis of Depression, psychosis, anxiety and is at risk for drug-related adverse effects from medicine. Date Initiated: 12/13/2024 .will benefit from the therapeutic effects of medication and be monitored adverse effects daily through the next review date . Psychological consultation and follow-up as needed. Record Review of Resident #13's Psychological Consultation dated 04/21/25 documented: medications were reviewed and reconciled, the patient was alert and oriented to person and place (x 2). She denied any new or worsening psychiatric or medical symptoms, including changes in mood, emergence of psychotic features, or further cognitive decline . appeared calm and showed no signs of distress . denied suicidal ideation, homicidal ideation, or self-injurious behavior. Patient affect was appropriate to the situation, and her behavior was cooperative and pleasant throughout the session. There were no hallucinations or delusions reported. Ongoing monitoring is in place. Resident # 8 Record Review of Resident # 8's admission records revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE]. Medical Diagnosis revealed Resident #8's diagnoses included, but not limited to, anxiety disorder and Unspecified Psychosis. Review of Resident #8's Physician Order Sheet dated 02/21/2025 revealed Resident #8 is currently receiving Olanzapine Oral Tablet 5 mg (milligrams). Directions: Give 1 tablet by mouth at bedtime related to Unspecified Psychosis. Review of Resident # 8's PASRR Level I dated 09/05/023 revealed no diagnoses checked or identified under 1A. Section 1B for Serious Mental Illness (SMI), Section 2,3 (A/B) and 4 (A/B) were checked. Section II Part A & B were checked. Section IV was completed. Record Review of a Quarterly admission Minimum Data Set (MDS) Section A (identification) dated 12/12/2024 revealed Resident #8 was not considered by the level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I revealed Resident #8 had Anxiety and Psychotic disorder . Record Review of Care Plan dated 03/12/2025 revealed Resident # 8 is at risk for possible adverse side effects of psychotropic medications. Goals: Will benefit from the therapeutic effects of medication and be monitored adverse effects daily through next review date. Interventions: Monitor for mood/behavior and record on behavior sheet. Monitor for drug-related side effects .Work with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 4 of 8 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 04/30/2025 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 MD/Psychiatrist for possible drug reduction. 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 5 of 8 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 04/30/2025 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observations, interview and record review, the facility's Quality Assessment and Assurance (QAA)/QAPI) committee demonstrate effective plan of action were implemented to correct identified quality deficiency in problem areas related to repeated deficient practice for F880-Infection Prevention & Control. As evidenced by: F880 was cited during a Recertification survey ending 12/07/23 when the facility failed to implement infection control procedures. This repeated deficient practice has the potential to affect any of the 44 residents residing in the facility at the time of the survey. The findings included Record review of the facility's survey history revealed, during a recertification conducted on December 04, 2023, through December 07, 2023, F880- Infection Prevention & Control was cited due to the facility's failure to implement infection control procedures related to staff's not changing gloves during tracheostomy care and staff failure to adhere to proper sharps disposal related to used Blood Glucose Monitoring supplies. Review of the facility's policy and procedure titled Quality Assurance and Performance Improvement revision dated/02/25 states: These policies are intended to ensure the facility develops a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. The facility will develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 02/27/2025, 03/27/2025, and 04/24/25 documented the facility had a QAA Committee had meetings monthly. Interview on 04/30/2025 at 3:00 PM Administrator (NHA) stated the QAA Committee meets every month, the last meeting was held on 04/24/2025. The committee consists of the Medical Director, Administrator, Director of Nursing (DON), Infection Preventionist and all interdisciplinary team members. The purpose of QAPI is to meet with the IDT ( interdisciplinary team) staff to make improvements for the residents, measure results, determine what issues to be worked on and need to be corrected. Make improvements and have interventions in place to have better patient/resident outcomes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 6 of 8 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 04/30/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement infection control procedures for two Residents (Resident 23 and Resident #34), out of 20 sampled residents. As evidenced by staff failed to dispose used Blood Glucose Monitoring supplies in the sharps container, failed to clean the insulin vial before extracting medications via needle syringe and failed to wear Personal protective equipment (PPE) during catheter care for one ( Resident # 34)out of one resident reviewed indwelling urinary catheter. There were 44 residents residing in the facility at the time of the survey. Residents Affected - Few The findings Included: During a Blood Glucose Monitoring observation on 04/27/25 at 11:08 AM for Resident #34 with Staff A, Licensed Practical Nurse. Staff A prepared the supplies, entered the resident's room, identified the resident, explained treatment, washed hands, donned gloves, cleaned the residents right index finger with an alcohol pad, checked the Blood Glucose (BG), the results was 326. Staff A, cleaned the resident's right index finger again with an alcohol pad, discarded lancet, blood glucose test strips and used alcohol pads in the garbage can in the resident's room. Staff A exited room, cleaned blood glucose machine with micro kill-wipes, let dry, returned the unused supplies to the medication cart, checked resident's sliding scale orders-Eight (8) units of insulin required. Staff A extracted eight (8) units of insulin from the insulin vial using a needle syringe, Staff A did not clean the top of insulin vial with an alcohol pad before inserting the needle syringe into the vial. Interview on 04/27/25 at 11:32 AM, Staff A revealed she forgot to wipe the top of insulin vial with an alcohol pad before inserting the syringe needle into the insulin vial to withdraw the 8 units of insulin needed for administration to Resident #34 and was not sure if she was allowed to put any unused supplies taken into a resident's room back in the cart and she placed all the used supplies into her gloves and disposed it in the garbage can in the resident's room; and thought that was ok because the used supplies were wrapped in the gloves. Interview on 04/30/25 at 08:36 AM, the Director of Nursing (DON) was informed of the concerns mentioned above related to infection control procedures and care for the residents. Review of the facility policy and procedure titled Infection Control revision date 10/2019 states: The facility will develop and maintain an effective infection control program that protects residents, families, visitors and staff by preventing and controlling infections and communicable diseases as an integral part of the quality assessment performance improvement program. The infection control program will be in accordance with States and Federal Regulations. and national guidelines. The Infection Preventionist will ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection. On 04/30/2025 at 10:24 AM during Resident #23's indwelling urinary catheter care observation being performed by Licensed Practical Nurse (Staff C) The nurse performed hygiene care gathered catheter supplies and entered Resident #23's room identified the resident explained procedure and provided privacy. Staff C did not put on a gown, Staff C performed hand hygiene, perineal care and catheter care, discarded used supplies in a biohazard bag washed hands exited the resident's room and placed the bag in the biohazard bin (located outside). Review of medical records for Resident #23 revealed, the resident was initially admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 7 of 8 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 04/30/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include Paraplegia and Neurogenic Dysfunction of Bladder. Review of the Physician Orders Sheet for October 2024 revealed, Resident #23 had orders that included but were not limited to: [] indwelling catheter Care every shift. For April 2025, revealed, Resident #23 had orders that included but were not limited to: Enhanced Barrier Precautions (EBP) for risk of infection related to indwelling medical device every shift. Review of Resident #23's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Resident # 23 is cognitively intact; needs substantial or maximal assistance for toileting hygiene and care and has an indwelling catheter. Record Review of Resident #23's Care Plan reference date 04/11/2025 revealed: Resident #23 is at risk for urinary tract infections due to indwelling catheter use. Interventions included but not limited to: Change catheter, tubing, and drainage bag as ordered, catheter care daily and as needed, and monitor amount, character, color, odor of urine output, note for recurring urinary tract infections. Interview on 04/30/2025 at 11:08 AM, Staff C revealed, Resident #23's catheter care is done daily and as needed, and handwashing is the number one priority. Infection control practices we implement for a patient with a [indwelling catheter] is always following Enhanced Barrier Precautions (EBP) by using Personal Protective Equipment (PPE) and handwashing. PPE includes using gloves, gown, mask, and eye protection (if needed). PPE helps prevent infection. During an interview on 04/20/2025 at 11:30 AM Staff D, Registered Nurse Supervisor revealed: when a patient is on EBP, there would be PPE inside the patient's room and the nurse should always wear PPE when taking care of patients on EBP. Nurses will know if a patient is on EBP when they receive report at the beginning of shift and the nursing supervisor always tries to reinforce it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 8 of 8