Inspection·November 3, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tasks, housekeeping staff does a walk-through of all the residents' rooms. The housekeeping staff then proceeds to pull only over-flowing trash, identify, and fix any spills or debris. Record review of the facility's document titled Rooms Deep Cleaning Schedule dated October 2022 revealed that the last deep clean schedule for room Resident # 586 and Resident # 535 was on October 26th, 2022. Also, it was noted that rooms 136 to 147 need special cleaning (disinfect) every day. Review of the facility's document titled: Housekeeping In-Service 5-Step Daily Washroom Cleaning. The Housekeeping In-Service 7-Step Daily Washroom Cleaning, and Housekeeping Complete Room Cleaning dated 1/1/2000 revealed that the last cleaning training was given to staff on 09/30/22 by Account Manager, Staff G. Moreover, The Complete Room Cleaning schedule ensures that each resident room is discharge-cleaned on a monthly basis. Record review of the Facility's policies and procedures titled Environmental Services Operations Manual revised on 9/05/2017 revealed that It is the policy of this facility to ensure 1. quality service that can only be delivered and maintained through the use of proper environmental services methods, which are outlined herein, 2. Consistency training, communication and orientation of employees is achieved through standardized methods, 3. Standardized infection control procedures are used in thoroughly cleaning and disinfecting the facility, 4. Employees are taught proper cleaning methods and follow proper procedures and protocol in completing job routines. The Environmental Services Operations Manual contains but is not limited to Housekeeping Procedures, Floor Care Procedures, Personal Clothing, and Appendices including Environmental Services Regulations and Mandatory In-services. During an interview on 11/02/22 at 01:27 PM, Account Manager, Staff G revealed that housekeeping staff starts their day by cleaning the offices and public restrooms, then staff goes and assess every room, then they make a determination whether the room needs a 5 or 7-step daily patient room cleaning. During a follow up interview on 11/03/22 at 09:45 AM, Staff G revealed, the facility does not have a log in which housekeeping employees sign after cleaning every room. Staff G noted that the Housekeeping In-Service Form is the only form housekeeping staff signs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 2 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a comprehensive assessment for one (Resident #585) out one resident whose Minimum Data Set (MDS) was reviewed, by not completing the required Resident Assessment Instrument (RAI) within the required 14-days regulatory time frame. The findings included: Record review on 11/01/22 at 01:07 PM revealed that Resident #585's admission 5-day MDS dated [DATE] was in progress. Section B-Hearing, Speech, and Vision was not completed. The Quarterly Prospective Payment System (PPS) was initiated on 11/01/22 and dated 11/07/22 indicated it was in progress. Record review on 11/03/22 08:07 AM of Resident #585 MDS section B-Hearing, Speech, and Vision was completed, finalized, and dated 11/02/22 at 5:01 PM. Interview with Staff H, a Licensed Practical Nurse/MDS Coordinator Assistant on 11/02/22 at 01:40 PM revealed that the MDS staff usually complete the MDS within 14 days of the resident's admission. Staff H stated, we do the resident's care plan and everything else that needs to be assessed. When the surveyor asked Staff H the reason as to why Resident #585's MDS was not completed, Staff H stated, I'm guessing it's because section B needs to be completed by the social worker. When asked about the discrepancy with the Quarterly PPS that initiated on 11/01/22 and dated 11/07/22. Staff I, a Clinical Information Coordinator replied, I canceled it because it didn't follow the schedule, I cancelled it because it's not within the 90 days. Review of the facility's undated policy and procedure titled MDS 3.0 Completion Policies & Procedure on 11/03/22 at 11:49 AM indicated, the facility needs to complete an admission Assessment and Significant Changes in Status Assessment (SCSA) within 14 days. Moreover, 5 Day/Initial Assessment must be completed within 14 days after the ARD (ARD+14 days). If combined with the OBRA assessment, it must be completed by the end of day 14 of admission (admission date +13 days). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 3 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 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 Resident # 485. This deficiency had the potential to affect 85 residents residing in the facility at the time of survey. Residents Affected - Few The findings included: Observation of Resident # 485 on 11/02/22 at 08:42 AM. The resident was having breakfast in his room. On 11/03/22 at 9:05 AM, Resident # 485 was observed lying on his bed with eyes closed showing no sign of distress. Record review of Resident # 485's clinical records revealed the resident was admitted to the facility on [DATE]. Medical diagnoses included but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side; Schizoaffective Disorder, Depressive Type; Anxiety Disorder, Bipolar Disorder. Record review of Resident # 485's PASARR Level I dated 08/27/2020 revealed identification of a mental diagnosis under 1A. Section 1B was not checked for Serious Mental Illness (SMI). Section 4 revealed the individual had no diagnosis or suspicion of serious mental illness (SMI)or intellectual disability (ID) indicated. Level II PASRR evaluation not required. Review of Physician's orders dated 10/18/2022 revealed Resident # 485 was receiving Quetiapine Fumarate Tablet 50 milligrams, 1 tablet by mouth two times a day related to Bipolar Disorder. Record review of Orders dated 10/18/2022 revealed Resident # 485 was receiving Ativan Tablet 0.5 milligrams (Lorazepam) *Controlled Drug* 1 tablet by mouth two times a day related to Anxiety Disorder. Record review of Medication Administration Record (MAR) for the month of October 2022 revealed the resident was receiving Ativan Tablet 0.5 milligrams (Lorazepam). Give 1 tablet by mouth two times a day related to Anxiety Disorder, Unspecified. Started Date 10/19/2022. Review of Resident # 485's Medication Administration Record (MAR) for October 2022 revealed the resident was receiving Quetiapine Fumarate Tablet 50 MG. Give 1 tablet by mouth two times a day related to Bipolar Disorder. Start date 10/19/2022. Record review of Resident # 485's admission Minimum Data Set (MDS) Section A (A1500) dated 10/05/2022 documentation indicated: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No. Section C dated 10/05/2022 revealed the Brief Interview for Mental Status (BIMS) Summary Score was left blank. Review of Care Plan initiated on 09/28/2022 and revised on 10/25/2022 documented, the resident had a diagnosis of Schizoaffective Disorder, Bipolar Disorder and Anxiety. As per resident's daughter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 4 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 the resident can become anxious and demonstrate agitation if he is asked too many questions. Resident demonstrates yelling / making noise behavior. He also demonstrated restlessness behavior attempting to get out of bed and wheelchair without assistance. Goal: The resident will decrease yelling / making noise behavior, anxiousness behavior, and restlessness behavior by next review date as evidenced by staff observation. Interventions: Allow resident ample time to express himself. Allow resident to continue to be involved in her plan of care. Always explain to resident care being given prior to initiating care. Always talk to resident in a soft soothing voice, with tactile and verbal prompts and cues throughout task. Encourage regular visits from family. Document and inform Social Worker and Nurse of any behaviors / change in mood. Monitor and assess for stressors in the environment that trigger inappropriate behaviors. One to one visit with Social Services as needed. Praise for tasks accomplished or achieved. Re-enforce appropriate behavior while discouraging inappropriate behavior as observed. Remove resident to a quiet setting and allow time to calm down. Allow quiet calm environment during acute phase. Identify/inform resident when care/treatment is to be provided. Involve family in plan of care. Psyche re-evaluation as needed. Re-direct resident as needed / take resident outside to calm down as needed When the resident is agitated attempt to calm the resident down if unable to calm the resident reproached later. Review of Psychiatrist Consultation dated 10/27/2022 revealed the resident was seen. Treatment Plan: Resident was currently stable on the current medications. Monitor for changes in mood or behaviors. Will follow up in 4-6 weeks or sooner if needed. During an interview Staff N Registered Nurse (RN) on 11/03/22 at 08:53 AM stated, the resident was agitated most of the time and was alert and oriented to person and the resident is not able to use the call light for assistance. On 11/03/22 at 09:38 AM, the Social Services Director reported that the resident was admitted with the Level I PASRR from another facility. The Social Services Director stated that she did not realize the resident had behaviors and diagnosis of mental illness and she will request the Level II PASRR right now. Record review of Policies and Procedures for Coordination with PASARR Program dated June 6, 2007, revealed Policies: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1-a) PASARR Level I -initial pre-screening that is completed prior to admission. Interview with Social Services Director on 11/03/22 10:45 AM She stated the Level II PASRR for resident # 485 was requested. Record review of Policies and Procedures for Coordination with PASARR Program dated June 6, 2007, revealed Policies: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1-a) PASARR Level I -initial pre-screening that is completed prior to admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 5 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 - Few 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 observations, record review and interviews, the facility failed to follow and implement nursing care plan intervention for one (Resident #535) out one resident whose care plans were reviewed. As evidence by The facility's staff failed to offload the heels as ordered for Resident #535. The findings included: In an observation conducted on 10/31/22 at 09:18 AM resident #535 was observed lying in bed. Observation revealed the resident had a dressing to the right foot and a dressing on the ankle of the left foot. There was a pillow underneath the resident's left knee and calf. The foot of the bed was elevated but the resident's heels were not offloaded with an offloading device such as the pillows. On 10/31/22 at 03:30 PM, Resident # 535 was observed in bed with eyes closed and laying semi-Fowler_position (lying on back with the head and torso raised). There was a pillow underneath the resident's calf, but his heels were not offloaded. On 11/02/22 at 09:35 AM Resident #535 was awake and observed with right ankle dressing dated 11/1/22. The resident's feet were on a pillow, but the heels were not offloaded. Record revie revealed Resident #535 was originally admitted to the facility on [DATE] and readmitted on [DATE].Resident #535 diagnoses include but not limited to Pressure Ulcer and Pressure Injury (PU & PI), open wound, left foot, Transient Ischemic Attack, Cerebral Infarction, disorder of electrolyte and fluid balance, aphasia, gastrostomy status, hemiplegia and hemiparesis following cerebral infarction affecting left non- dominant, convulsions, Parkinson's disease. Review of the physician's orders dated 10/21/2022 indicated: offload heels as tolerated while in bed every shift. Review of the Physician Wound treatment orders dated 11/03/2022 for Resident #535 indicated Betadine to the right heel every day shift every other day for Unstageable cleanse heel with normal saline. Other active order dated 11/3/2022 documented Betadine to left ankle every day shift every other day for Unstageable DTI. Review of care plan-initiated date of 10/06/2022 indicated Resident #535 is at risk for skin breakdown secondary to non-ambulatory, requiring total care from staff, 2 persons assistance from staff with transfers. #535 has severe dryness to bilateral lower extremities and discoloration to bilateral feet. #535 present with stage 2 pressure ulcer to sacrum, and deep tissue injury to right heel, right ear skin opening. 10/21/22: readmitted : Right 5th toe discoloration, Left ankle discoloration, Left heel deep tissue injury history. Interventions indicated offload heels when in bed. Pressure reducing device to bed/chair. Record review of Resident # 533's Minimum Data Set (MDS) with entry dated 11/02/2022 indicated in Section C for cognitive Pattern in the Brief Interview for Mental Status (BIMS) documented No (resident rarely/ never understood). Section G for functional status indicated the resident is dependent on staff for activities of daily living. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 6 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 - Few Observation on 11/03/22 at 10:03 AM, revealed the resident in bed and the feet covered with blankets. Further observation revealed the heels were not offloaded. Observation on 11/3/22 at 10:47 AM, revealed when the surveyors and the Charge Nurse entered Resident #535's room, the resident was receiving a bed bath, and the Certified Nursing Assistant changed the bed linen afterwards. During this observation it was noted that the wound dressings on the heels were coming off and the resident's heels were not being offloaded as ordered. The Charge Nurse acknowledged the findings and adjusted the pillows to offload the resident's heels. On 11/03/22 at 12:43 PM, the Director Of Nursing (DON) was informed of the concerns and findings related to the resident's heels not being offloaded. Record review of the facility's policy and procedure titled Pressure Injury Prevention and Management Date Implemented: 1/2020 Date Reviewed/ Revised: 1/2022, under Policy Explanation and Compliance Guidelines (4) (c) Evidence based interventions for prevention will be implemented for all residents who are assess at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: (i) Redistribute pressure (such as repositioning, protecting and / or offloading heels, etc). Review of the facility's policy and procedure titled Comprehensive Care Plans Date Implemented: 1/2021 Date Reviewed Revised 1/2022. It states It is the policy of this facility to develop and implement a comprehensive person-centered car plan for each resident .Under Policy Explanation and Compliance Guidelines: (8) Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out interventions, initially and when changed are made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 7 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, record review and interview, the facility failed ensure appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion was provided as ordered for one (Resident #27) out of one resident reviewed. This practice has the potential to increase the risk of negative resident outcome for residents residing in the facility require services related to range of motion. The findings included: Review of Resident #27's face sheet showed the initial admission date 08/06/16, with diagnoses that include but not limited to, Parkinson's Disease, Multiple Sclerosis, Dementia, Psychotic Disturbance, bed confinement status and contracture. Observation of Resident #27 on 10/31/22 at 11:53 AM revealed, the resident was observed lying in bed, her right hand fingers noted to be contracted. Record review of quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) dated 08/15/2022 Section C for cognitive status revealed the resident Brief Interview for Mental Status (BIMS) summary score was not marked, Section G for functional status documented for bed mobility, transfer, locomotion, dressing, eating, toileting, and personal hygiene Resident # 27 is total dependent, including fasteners. Section I for active diagnoses revealed the resident has Multiple Sclerosis, Parkinson's Disease. Section O special treatments indicated the resident was receiving therapy the start date recorded the most recent therapy regimen (since most recent entry) started on 11/18/2020 and ended on 11/23/2020. Review of progress notes dated 07/20/22, documented Resident #27 with history of Multiple Sclerosis and Parkinson's screened today by Occupational Therapy (OT). Patient appears to be functioning at max potential, dependent on floor staff for all levels of care. Patient sits in a [wheelchair brand] chair when out of bed and wears left and right palm protectors during the day up to 8 hours to help maintain skin integrity of palms of hand. Patient's palm protectors replaced with new ones. OT services are not deemed necessary at this time. Review of Resident # 27's Care Plans dated 08/15/2022; Focus indicates Resident #27 has contractures of right upper extremity and has potential for further contractures related to Multiple Sclerosis, impaired mobility, Goal: Resident will not develop any further contracture through next review date. Intervention: Active/passive range of motion to extremities during care and as needed. Adaptive equipment: Bilateral Upper Extremity Resting hand splints on in am, off at bedtime (HS) as tolerated; may remove for hygiene and Range of Motion (ROM) with checks for skin integrity .equipment, [] positioning chair with pummel cushion to decrease tone and muscle spasms. Assist and encourage resident to participate in range of motion exercises. Policy and procedures review revealed the facility must endure that the resident receives the services, care, and equipment to assure that; a resident maintains, and/or improve to his/her higher level of range of motion (ROM) and mobility, unless a reduction is clinically unavoidable; and a resident with limiter range of motion and mobility maintains or improves function unless reduced range of motion/mobility is unavoidable based on the resident's clinical condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 8 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 0688 Level of Harm - Minimal harm or potential for actual harm During an interview the Rehab Director on 11/02/22 at 11:59 AM, stated that the order for the splint was on 01/26/22 to 02/15/22. The resident has had palm protector cushions for every 12 hours since then. Interview with Staff F a Registered Nurse (RN) on 11/02/22 at 12:15 PM revealed that since she has been taking care of Resident #27, she has not had an order for hand palm protector cushions for every 12 hours. Residents Affected - Few On 11/02/22 at 12:44 PM, interview with the Occupational Therapist (Staff E) revealed the resident has had the order for palm protector, but the resident does not like to use them, and tries to take them off. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 9 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide adequate supervision to ensure the safety of a vulnerable resident (Resident #185) who was newly admitted to the facility, as evidenced by Resident #185 left the facility through an exit door undetected, approximately four (4) minutes after being admitted to the facility. There were 86 residents residing in the facility at the time of this survey. The findings included: Review of Resident #185's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Encephalopathy, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety Disorder, history of falling, Essential Primary Hypertension and Mood Affective Disorder. Resident #185 was discharged on 6/16/22 to an Assisted Living Facility (ALF) Review of the Physician's Orders Sheet (POS) for November 2022 revealed Resident #185 had orders that included but not limited to: Order received by Medical Doctor (MD) for the resident to be discharged to Assisted Living Facility (ALF) on 06/16/22 as per the resident's son request, 6/10/22-Adaptive equipment check wander guard battery for optimal working condition every Friday 7:00 AM to 3:00 PM day shift, 6/9/22-Psychological Consultation, 6/9/22 wander guard to right foot. Medications included: Seroquel Tablet 25 Milligram (MG) (Quetiapine Fumarate)-Give 25 MG by mouth two times a day for Agitation related to Unspecified Mood Affective Disorder, Buspirone HCl Tablet 10 MG-Give 10 mg by mouth in the morning for Agitation related to Unspecified Mood Affective Disorder, Divalproex Sodium Tablet Delayed Release 250 MG-Give 1 tablet by mouth at bedtime related to Unspecified Mood Affective Disorder, Amlodipine Besylate Tablet 10 MG-Give 1 tablet by mouth in the morning related to Essential Primary Hypertension. Review of the nursing Progress Notes dated 6/8/2022 timestamped 21:00 late entry by Licensed Practical Nurse (LPN) Staff B documented: Resident transferred from the hospital. The CNA went to get extra linen and on return to the room she realized that the resident was not in the room. She immediately told the nurse that the resident is not in the bed nor in the bathroom. The nurses and the staff coordinated and searched the rest of the facility including all the rooms, bathrooms, the kitchen, laundry, the patios, and the facility grounds and on the roads immediate around the facility. The Director of Nursing (DON), Administrator and Director of Social Services were called and informed of what was occurring. 911 was called and also her son, who was notified that his mother had just arrived at the facility and left out immediately. He was informed that the staff was actively looking for her and that the police and the Administration staff was notified and on their way. I and other staff members drove around on the surrounding roadways to look for her. When the police came I and the police went around the back of the building to look in the bushes for her. The police got a brief description of her, but I could not say what clothing she had on a she had just come into the facility covered with a blanket. I explained to the police that the resident had just came into the facility. The son also arrived at the facility and was able to give a description as well. The police said they would get a search dogs and helicopter to assist us. As I was going outside to find out what was going to be done next, when I heard someone shouted, We got her. and she was coming inside in a wheelchair, and I went and got her from the lobby. A visual inspection was done of her and placed in front of the nursing station for closer supervision and talking with her son. She got something to eat as well while she sat and spoke with her son. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 10 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nursing progress notes dated 6/8/2022 timestamped 22:33 documented: Resident demonstrates wandering behavior wandering outside attempted to leave Hospital emergency room as per documentation. Wander guard placed on resident. Son in facility and aware. Review of the admission summary progress notes dated 6/9/2022 timestamped 00:57 documented: admitted resident from the Hospital to nursing facility .resident is awake, alert and confused at time. Respiration even and unlabored, skin warm and dry to touch. Mucous membrane pink and moist. Resident is under care of MD (Medical Doctor) multiple diagnosis: Dementia, Hypertension. Lung sounds clear to auscultation. Bowel sounds present in all 4 quadrants. Abdomen soft no distended. Resident is unable to let staff knows her need, therefore staff assisted her regularly for ADLs (Activities of Daily Living). Vital signs stable at this present time. Call light placed in easy reach. Resident was educated and instructed how to use call light to call staff if she needed. Bed in lowest position. Safety and comfort maintained Review of elopement screen assessment conducted by Licensed Practical Nurse (LPN) (Staff A) dated 6/9/22 documented: Resident is a Wanderer/High Risk Potential Score: 5.0. Review of the admission summary progress notes dated 6/9/2022, timestamped 16:05 documented: The resident was admitted from the Hospital. She is verbal and able to make her needs known. The resident primary language is English . the resident does not demonstrate any mood nor behavior indicators. She denies having any feelings of sadness at this time. The resident states that she does not smoke and denies substance/alcohol abuse .the resident denies mouth/dental pain/discomfort. The resident reported that prior to being admitted to the hospital she was ambulating independently. The resident appears to be accepting towards current placement. She reports that she plans to return home with her son. She states she lives in a house with her son. The resident declined information regarding returning to the community. Review of the nursing progress notes dated 6/9/2022 timestamped 06:38 documented: Resident did not want to stay in bed, trying all night to get out of the room, staff redirected her. Resident: stated I want to go home to my son. Residents awake, alert confused at time. respiration even and unlabored. skin warm and dry to touch. Staff frequently monitored her. A staff member is rotated to sit 1 to 1 with her every 20 minutes with the nurse overseeing. ADLs (Activities of Daily Living) and comfortable care maintained. Call light within reach. Bed at lowest position. Resident instructed and demonstrated how to use call light if needed help, wander guard in working order and on her foot. Safety and comfort maintained. Review of the Resident's Psychiatric Evaluation completed on 6//11/22 documented: assessment plan, follow up as needed. Record review of Resident # 185's Care Plans Reference date 6/9/22 revealed Resident wanders, at times resident attempts to wander outside. Interventions include: Administer medications as ordered for severe agitation and assess effectiveness, assist with repositioning, avoid pressure points, attempt to determine situations and environment that creates inappropriate behavior, follow up with psychiatric consult as needed for evaluation of medications and effectiveness, and to maintain in minimum dose for behavior modification, and quality of life, monitor resident and place in a supervised area, observe for dizziness; excessive fatigue, observe for signs of generalized weakness or fainting, staff to anticipate and meet needs promptly, use safety devices/ wander guard as ordered, and wander guard in place on resident to alert staff as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 11 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident # 185's Discharge Return Not anticipated Minimum Data Set (MDS) dated [DATE] documented: Section C for Cognitive Patterns indicated -Brief Interview for Mental Status (BIMS) Score 06 out of 15 indicating the resident is cognitively impaired. Section E for Behavior indicated the resident has no potential indicators of psychosis, wandering occurred daily. Section G for Functional Status indicated resident needs supervision for Activities of Daily Living (ADLs). Section H for Bladder and Bowel indicated resident is occasionally incontinent of bowel and bladder. Section N for Medications indicated resident received antipsychotic and antianxiety medications in the last 7 days. Review of the progress notes dated 6/15/2022 timestamped 18:50 documented: Resident's son request the resident to be discharge to ALF on 06/16/22. Resident's son is aware of the resident's cognitive status and wandering behavior. ALF also aware of the above information and reports that they are able to care for the resident. Review of the discharge summary progress notes dated 6/16/2022 timestamped 11:17 documented: Resident escorted out of the facility by staff along with son. The discharge documents were signed by the resident's son and discharged education given. Resident escorted to the car. Resident is able to stand up and help herself with assistance to the car. Resident skin intact and morning medication administered. All safety measures maintained. Interview on 11/03/22 at 09:30 AM Maintenance Director revealed; the exit door by room [], once you open it the alarm goes off and it keeps going off until a staff member resets it with a key. All the nurses have keys to reset the alarm. I check the door alarms weekly and I have a maintenance log of when I check the doors, all the alarms are in working order, the alarms are battery operated and when the battery is low it starts beeping so we know they need to be changed. The battery usually lasts approximately 2-3 months. The surveyor was provided with a demonstration of how the exit door at the north station alarm works. Demonstration revealed the alarm sounds very loud when the exit door is opened and the light flashes red continuously and required a key to be placed in the lock and turned twice to be turned off. On 11/03/22 at 09:39 AM, the Director of Nursing (DON) reported that the incident happened on 6/8/22 at 8:50 PM, the resident came to the facility from a local hospital, the ambulance dropped her off, the resident was placed in wheelchair in the room and was assigned to room [], Certified Nursing Assistant (CNA) assigned to resident went to get some linen for the resident's bed and on returning to the room the resident was not in the room, the CNA looked for the resident and could not find her, the CNA told the charge nurse that the resident was missing, the charge nurse organized a facility search, and called the Administrator, DON and Social Services Director. The resident's doctor was notified. The Administrator and Social Services Director came to the facility immediately. The Charge Nurse called the police department, Administrator and police officer looked at the video and determine that the resident left through the north exit door approximately 4 minutes after she arrived, the police officer and administrator started searching for the resident outside of the facility and the resident was found in the parking lot of the apartment building right across the street from the facility. The DON was not aware of the time the resident was found, but indicated it was about 9:50 PM when the resident was back in the facility, a complete skin check and assessment was done on the resident, no problems were noted with her skin and her vitals were ok, but she could not answer any questions correctly, she expressed she wanted to go home with her son. The resident's son came to the facility to be with his mother, the resident's doctor gave orders for a wander guard and a psychiatric consult. The resident was placed on 1 to 1 observation until the psychiatric evaluation, wander guard was applied, son was informed of the benefits of the wander guard, resident was seen by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 12 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few psychiatric services on 6/9/22. During the duration of her stay the resident walked around and responded well to redirection. On 6/16/22 resident was transferred to and ALF. On 6/8/22 when the Administrator came to the facility after the resident was found, the Administrator checked all the exit doors and found all the door alarms to be in working order. The administrator established a system that the doors are going to be checked weekly, routinely. An elopement in-service was done in June 2022 for all the staff, last week we had an elopement drill for all staff, we hid a resident and alerted the staff that the resident was missing and had the staff perform the entire elopement procedure they learned at their in-service- calling the appropriate personnel, establishing the search criteria etc. We have several emergency preparedness books that are accessible to all staff that includes a quick reference of what to do if a patient elopes. On 11/03/22 at 10:17 AM, during a telephone interview, Licensed Practical Nurse (LPN) Staff B stated: I don't really remember the events of that night; the patient's name does not even sound familiar to me. The Director of Nursing (DON) reminded the nurse about the incident, Staff B then stated oh ok what I remember this was a brand new patient to the facility, the CAN (Certified Nursing Assistant) told me she could not find the resident, we started searching for the resident room by room, we could not find her we looked outside, we call the police and continued to look for the patient, while we were looking for the resident, the police found her and brought her back to the facility. I apologize I do not remember everything that happened at that time. During an interview on 11/03/22 at 10:22 AM, the Social Services Director (SSD) stated: On 6/8/22 at night I received a call from the DON, we had just received a new resident in the building and the staff was unable to locate her, I came to the facility, the police was actively looking for the patient, the NHA (Nursing Home Administrator) and I reviewed the cameras and noted that the patient left out the north station exit door, we saw her walking, the camera noted the time but I don't know what the time it was off the top of my head, as soon as we saw the time that she left, the police came walking in with the patient, they stated they found her across the street in the apartment complex. The son was previously called and about 5 minutes later after the police came with the resident her son showed up to the facility. This patient was brand new to the facility, so no one really knew her, the resident son stated that she had severe dementia, and she caught the house on fire. I informed the resident's son that we are not a locked unit, and we will assess her and see if we can meet her needs in this facility. The son verbalized that he understood. I was involved in redirecting the resident during her stay at the facility, she did not give us any problems when instructed to do something. I assisted in coordinating with the placement agency, an Assisted Living Facility (ALF) for the resident. On 6/16/22 the resident was transferred to an ALF. On 11/03/22 at 02:17 PM, during an interview the Nursing Home Administrator (NHA) when asked about the incident that occurred on 6/8/22 at the facility stated: Once I got to the facility, the police was already here, I met with the police and the nurse managers to find out what is going on, we reviewed the video tapes to see when the resident left the facility, we saw when the resident came to the facility, when the ambulance that brought her left, it was approximately 3-4 minutes from the time she was dropped off by the ambulance to the time she left the facility out of the side door. I checked the alarm on the door that she went out to make sure it was working; it was in good working order. The employees stated that they did not hear the alarm go off, it was around 8:50 PM when the resident went out the door soon after, the police got a call from one of the neighbors across the street from the facility stating that there was a woman knocking on the door, the police went and picked the resident up and brought her back to the facility around approximately 9:50 PM. The resident's son was at the facility, I checked all the doors in the facility, the resident was placed on 1 to 1 supervision. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 13 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident was only in the building for 4 minutes, we really did not know much about this resident, she was placed on 1 to 1 observation, she had a psychiatric consultation two days later, we provided necessary care during her stay here and she was discharged on 6/16/22 to an ALF. A wander guard was place on the resident that night after she returned. We did an in-service for all staff on 6/30/22 on elopement and listening out and not ignoring audible alarms and last week we did a live drill on elopement in the afternoon around 3 O' clock to have both shifts involved. We learned about the areas of our drill that we need to improve on, we will be doing the live drill again maybe after the first of the year and we will continue to do in-services. We are not a locked facility, but we have a wander guard system. We take the necessary precautions to avoid elopements, we have a book at the front desk of pictures and information of our elopement risk residents. This is for our receptionist to be familiar with residents who have wander guards on and look out for them. we have an emergency preparedness book that include elopement procedures quick reference at each nursing station and at the front desk for staff to reference. We now have established a code silver announcement for resident elopement that all staff have been trained on and are aware of the code silver meaning and what to do when they hear this announcement. On 11/03/22 at 02:38 PM, the 3:00 PM to 11:00 PM Nursing Supervisor, Licensed Practical Nurse (LPN) (Staff C) stated: The resident came to the facility, she was not in the facility for long, when the nurse and the CNA went to the room to do the assessment the resident was not there, so the LPN Staff B let all the staff know that a resident is missing, we checked the whole facility, I called the DON and the Administrator and called the police, we kept searching, the police came to the facility, we gave them the information from the hospital. we did not have a picture because she just came, the police began to search for her, I called the resident's son, we kept searching for her, after a short while the police came back with the resident, and stated they found the resident in the building across the street, she was knocking on someone's door and that person called the police, I'm not sure of what time the police brought the resident back to the facility, it was not a long time, the nurse assessed the resident after she came back and the resident was placed on 1 to 1 observation, I was working at the north station on 6/8/22 and this incident all happened I believe between 9:00 PM to 10:00 PM, I did not hear the alarm go off, the other staff in the area stated they did not hear the alarm. On 6/8/22 I was not the nursing supervisor, there was a patient in room [] that was positive for Covid-19 that I was assigned to take care of, I was the nurse and the CNA for that resident. Again, I did not hear the alarm go off and I did not turn the alarm off. Interview on 11/03/22 at 03:22 PM Certified Nursing assistant (CNA) (Staff D), stated .6/8/22 I worked 3-11 shift that night, the patient was in the room, I went to get linens to make the patient bed and when I came back to the room the patient was not there, I checked the bathroom and then then I told LPN (Staff C) I cannot find the patient, and I went back to help another resident, Staff C alerted the other staff and started the search of the facility and did whatever they have to when there is an elopement, I helped with the search after I finished helping my other resident, I was not involved in whatever happened after the resident was found, I finished my work and I left the facility at 11:30 PM that night. I did not here the alarm when it was going off. Review of the facility's policy and procedures titled, Elopement and Wandering Residents dated 12/10/2018 states: The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 14 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure enteral feeding was administered as ordered for 1 resident (Resident # 535) out of 1 resident reviewed for tube feedings out of the 10 residents residing in the facility receiving nutrition and hydration via tube feeding at the time of this survey. Residents Affected - Few The findings included: In an observation conducted on 10/31/22 at 09:18 AM, Resident # 535 was observed with Glucerna ® 1.2 (formulary type) running at 65 ml(milliliter) and 30 ml water flush per hour via feeding pump. (photographic evidence), On 11/01/22 at 08:19 AM, observation revealed feeding running, with Glucerna ® 1.2 at 65 ml per hour and water flush at 30 ml per hour. On 11/02/22 at 09:35 AM, Resident # 535 was observed awake in bed. The feeding pump was off. On 11/03/22 at 10:03 AM, observation revealed Resident #535 in bed, the feeding pump was on and the Glucerna ® 1.2 formula was running at 65 ml per hour and water flush at 30 ml per hour. Review of Resident # 535's clinical records revealed Resident #535 was admitted to the facility on [DATE]. The resident was discharged to the hospital due to seizures on 10/11/2022 and readmitted . Clinical diagnoses include but not limited to Transient Ischemic Attack, Cerebral Infarction, disorders of electrolyte and fluid balance, aphasia, gastrostomy status. Review of Resident # 535's physician's orders showed physician order with documented start date of 10/28/2022 every shift Glucerna ® 1.2 at 75 ml per hour for 23 hours via G-tube (gastronomy tube) . (providing 1725 ml/2070 (kcal) kilocalories /20.7_units every 24 hours indefinitely .Order dated 10/21/2022 18 indicated Auto-Flush Enteral Tube with water at 30 ml per hour for 23 hour and may have medications crushed and administered with apple sauce or water if appropriate. Review of the admission Minimum Data Set indicated the resident's cognitive skills for daily decision making to be severely impaired. No sign and symptoms of delirium, inattention. Total dependence on eating. Feeding tube by abdominal Percutaneous Endoscopic Gastrostomy (PEG). Review of Resident # 535's care plan, noted the resident is dependent with tube feeding and water flushes. See MD (Medical Doctor) orders for current feeding orders. Date initiated 10/06/2022. Revision on 11/2/2022. Review of Resident #535's weekly weights, revealed that on 10/06/2022, the resident weighed 139.6 pounds. On 11/02/2022, the resident weighed 127 pounds which is a 9.03 % weight loss. Review of Resident # 535's progress notes Nutrition/Dietary Note dated 10/28/2022 indicated weekly weight; 126 pounds today, 6 pounds weight loss since readmission. Current TF (tube feeding) regimen is well tolerated. No report of s/s (signs or symptoms) of intolerance . Wounds are showing improvement . Noted that accuchecks are very high up to 500 despite disease specific formula . Poorly controlled glycemia could cause weight loss. Plan: Recommend increase Glucerna® 1.2 to 75 ml per hour (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 15 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 0692 Level of Harm - Minimal harm or potential for actual harm for 23 hours, continue with water flush at 30 ml per hour for 23 hours to provide; 2070 kcal or 36 kcal per Kg/ BW (kilograms per body weight), 104 grams protein or 1.8 grams kilograms per body weight and 2100 ml free water or 37 ml/kg/ BW. MD (Medical Doctor) to medically manage glycemia. Continue to monitor closely. For nutritional interventions, 1 packet of Juven® packet enterally two times a day for healing was ordered 10/25/2022. Residents Affected - Few During an interview on 11/03/22 at 12:43 PM, the Director of Nursing was informed of the findings related to the enteral feeding not running at the ordered rate of 75 ml per hour. On 11/03/22 at 03:03 PM, observation of Resident #535 revealed the tube feeding formula Glucerna ®1.2 was running at 75 ml per hour and water flush at 30 ml per hour. Review of facility's policy and procedure titled Care and Treatment of Feeding tube, with implemented date 1/2021 and Reviewed/ Revised dated 1/2022; documented under Policy Explanation and Compliance Guidelines: item 9 (e) Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner' s orders and (10) (c) Periodic evaluation of the amount of feeding being administered for consistency with practitioner's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 16 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide appropriate storage of medications/Pharmaceuticals and medical supplies. As evidenced by expired medical supplies in one (South Station medication storage room) out of two of the facility's medication storage rooms and unidentified pills found in medication carts. This had the potential to affect 86 residents residing in the at the time of this survey. The findings included: During observation on [DATE] at 2:48 PM of the facility's South Station medication storage room with Licensed Practical Nurse (LPN) (Staff E) revealed: Four (4) medical specimen collection swab kits found were expired as follows: One (1) kit expired on [DATE], 1kit expired on [DATE], two (2) kits expired on [DATE]. Nine (9) enteral feeding pump spike sets found were expired as follows: Two (2) kits expired on [DATE], Seven (7) kits expired on [DATE]. During an interview on [DATE] at 03:00 PM, Licensed Practical Nurse, Staff E stated that the nurses check the Medication Storage Rooms once a week and pharmacy checks the medication rooms every month. We check for expiration dates and damage items. During an interview on [DATE] at 03:13 PM, the Director of Nursing (DON) revealed, the nurses and the central supply staff check the medication rooms weekly and pharmacy checks monthly. Moving forward myself and the charge nurses will be checking the medication storage on a weekly basis for any expired medical supplies or medication. Observation on [DATE] at 3:25 pm, Cart 4 North was checked with Staff L, Registered Nurse (RN), 4 1/2 unidentified pills were found in the medication drawers. Observation on [DATE] at 03:47 PM, Cart 3 North was checked with Staff M, Licensed Practical Nurse (LPN) 6 unidentified pills were found in the medication drawers. Review of the facility's policy and procedures titled, Storage of Medications dated 07/2015 states: Medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 17 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 record review and interview, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F689 Free of Accident Hazards/Supervision/Devices. There were 86 residents residing in the facility at the time of this survey. Review of the facility's survey history revealed the facility was cited F689 Free of Accident Hazards/Supervision/Devices during the survey with exit date of 03/05/2020 related to a resident having a cigarette lighter in their possession. During this survey with exit date of 11/03/2022 the facility was cited

F689 again related to the elopement of a newly admitted resident. The facility's Quality Assurance and Performance Improvement (QAPI) Plan provided by the facility revealed: At Pinecrest Rehabilitation Center, we proclaim the value of life and the beauty of dignity of old age and will strive to maintain a leadership role in the shaping and delivery of services and programs of care for the elderly. On 10/20/22 at 3:55 PM, the Director of Nursing (DON) revealed the QAPI committee meets monthly on the third Thursday of the month. The committee consist of the Administrator, Director of Nursing, Pharmacist, Social Service, Medical Director, Activities, Admissions Director, admission Assistance, Marketer, Dietitian, food service supervisor, Minimum Data Set (MDS) Coordinator and MDS coordinator assistance. The facility's QAPI plan will guide the facility's performance improvement efforts. The committee discussed the progress of all the issues brought to the meeting the prior month. The goals in place that the facility is currently working on include reducing the risk of transmission of infectious agents by increasing compliance with hand hygiene and infection control practice .Elopement in service and drills to make sure that residents do not elope. During the daily meeting to keep discussing this for the safety of the resident. Review of the sign in sheets revealed the last QAPI meeting was held on 09/21/2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 18 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 observations, record review and interviews, the facility failed to implement infection prevention and control precautions for a resident on contact precaution Resident #59 and Resident #78 whose room was next to Resident #59 and they shared a bathroom while Resident #59 was on Contact Precautions. This affected 2 of 21 sampled residents. Residents Affected - Few The findings included: 1) During the initial tour on 10/31/2022 at 8:57 AM, Resident #59 was observed to have a Personal Protective Equipment (PPE) door caddy hanging on the door. The PPE caddy had gowns, gloves and red garbage bags, but there was no isolation sign on the door. On 10/31/22 at 09:02 AM, Staff B a Licensed Practical Nurse (LPN) was asked what type of precautions Resident #59 was on and she reported the resident was on Contact Precautions due to Herpes Zoster (Shingles). Observation on 10/31/22 at 01:00 PM, Resident #59 was visited after putting on PPE, the resident now had a sign on the door for Droplet Precautions. Resident #59 held up his right arm and it was observed to be reddened and swollen from his upper arm to his lower arm. Staff B, put on PPE to take Resident #59 his lunch on a disposable tray. During the observation, Staff B went into Resident #59's bathroom to wash her hands and Resident #78 came to the bathroom door to speak to Staff B using the bathroom door to his adjoining room. Resident #59 and Resident #78 were observed to be capable of ambulating to the bathroom and the bathroom adjoined the rooms. Staff B was asked whether the residents should be sharing a bathroom. Staff B, reported they weren't sharing a bathroom. She reported, there was 2 commodes and two sinks in the bathroom. Staff B was preparing to show there were separate commodes and sinks and then she realized, there was one sink and one commode being used by both residents. This caused Resident #78 to exposed to Resident #59's Herpes Zoster/Shingles. On 10/31/22 at 01:10 PM, Staff B removed her PPE and reported she needed to report the shared bathroom to the Director of Nurses (DON). On 10/31/22 at 01:20 PM, Staff B was asked whether Resident #59 is on contact or droplet precautions. Staff B reported, the resident is on contact precautions. Staff B was informed, Resident #59 had a sign on the door for droplet precautions. Staff B reported, she would check on the sign and it should be contact precautions. On 11/01/2022 at 12:11 PM, it was observed that resident #59 had been moved across to a room across the hall and the resident room located next to the resident was observed to be empty. During record review it was noted that Resident #59 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Zoster without complication, Major Depression, Type 2 Diabetes Mellitus and Hypertension. Review of the residents physicians order dated 10/30/2022, for CONTACT ISOLATION FOR 7 DAYS (HERPES ZOSTER), every shift for 7 Days, starting 10/30/2022 to 11/06/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 19 of 20 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 105153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinecrest Center for Rehabilitation and Healing 13650 NE 3rd Court North 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 During record review, it was noted Resident #59 had a care plan initiated on 10/30/2022 for Contact Isolation X (times) 7 days until 11/6/2022 r/t (Related To) Dx (Diagnosis) of Herpes Zoster. The goal was for the infection to be resolved. The interventions included, but were not limited to, place in private room with contact isolation precautions. During record review, it was noted Resident #78 was admitted on [DATE] with diagnoses that included but were not limited to, End Stage Renal Disease, Seizures and Altered Mental Status. Review of the facility's policy and procedure on Isolation - Categories of Transmission-Based Precautions revised October 2018 included a Policy Statement - Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection: arrives for admission with symptoms of an infection; or has a laboratory confirmed infection and is at risk of transmitting the infection to other residents. The policy Interpretation and Implementation included but were not limited to, 2. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. Contact Precautions 1. Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the residents environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 20 of 20