Inspection·October 12, 2023

F 0609 resident property; Level of Harm - Minimal harm or potential for actual harm b. Establish policies and procedures to investigate any such allegations. VII. Reporting/Response Residents Affected - Few A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Record review of the facility's AHCA report revealed, on 6/3/2023 at 10:45 AM resident #389's, Staff, C, Certified Nursing Assistant (C N A) reported to Staff B, Registered Nurse (RN) that Resident #389 left thigh was swelling and with abnormal movement. The resident's mother and Advanced Registered Nurse Practitioner were notified and the resident was transferred to a local hospital by ambulance. An X-ray at the hospital revealed, revealed a closed displaced subtrochanteric fracture of the left femur. On 06/13/23 at 3:34 PM, the nursing home adverse incident report was filed by the Director of Nursing with an outcome of fracture or dislocation of bones or joints. Medical Record review of Resident #389 revealed, the resident was admitted on [DATE] with diagnoses of Multiple Sclerosis, quadriplegia, joint derangement, a disorder of muscle, abnormal posture, chronic embolism (blood clots), and thrombosis. Medical record review of resident #389's care plans revealed, Alteration in safety related to the diagnosis of multiple sclerosis, functional quadriplegia, poor trunk control/ no control, noted tremors or shaking of upper extremities, and slightly impaired cognition. Interventions were to use side rails to assist with bed mobility and transfers, instruct how to use/grab it, and assist as needed. Provide care with activities of daily living mobility/transfer. On 10/12/23 at 12:43 PM, resident #389's attending physician was interviewed about Resident #389 and reported, The fracture is not normal. It wasn't a pathological fracture. For someone that is contracted, with immobility of joints, stiffness of bone, even by movement. It can develop. It's not common, but it does happen. There is a possibility, but unintentional. On 10/12/23 at 01:04 PM during an interview with the DON about the filing of the injury of unknown origin report for Resident #389. The DON stated, I created an adverse incident report instead of abuse. For adverse incidents, it's twelve days. The DON provided a statement by the physician dated 6/14/23 that documented, Resident #389 is well known to me and has been my patient here at the facility. The resident is bed-bound and diagnosed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 2 of 10 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 10/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm with debilitating illness, and contractures and receives most of his nutrition via peg [Percutaneous Endoscopic Gastrostomy] tube. Osteopenia is a condition that begins as you lose bone mass and bones get weaker. There is no evidence of falls or any overt incidents. With a diagnostic study that showed osteoarthritic changes to the hip, osteopenia, and contractures. The resident is at risk of fractures. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 3 of 10 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 10/12/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one of of 23 sampled residents (Resident #87) that was discharged home and coded as discharged to the hospital. This deficiency has the potential to affect 79 residents residing in the facility at the time of survey. Residents Affected - Few The finding included: Record review of the admission records for resident #87 revealed, the resident was admitted to the facility on [DATE] and discharged home on [DATE]. Record review of the Medical Diagnoses revealed, the resident's diagnoses included, but were not limited to, Peripheral vascular disease (PVD), Diabetes Mellitus (DM), Major Depressive Disorder, and Alcohol Abuse with Withdrawal. Record review of the Discharge Return Not Anticipated Minimum Data Set (MDS ) dated 08/10/2023, Sections A - Identification Information- Discharge Status was documented as - Acute hospital. Section C revealed, the Brief Interview for Mental Status Summary score was left blank. Section G for Functional Status dated 08/10/2023 revealed the resident needed extensive assistance for Bed mobility, Transfer, Dressing. Extensive Assistance, Eating-Supervision, Toilet Use-Total Dependence. During an interview with the MDS Coordinator on 10/11/23 at 10:51 AM it was reported, The way I read the progress notes I assumed that the resident was going to the hospital and not back home. Record review of resident #87's Care Plan initiated on 06/27/23 revealed, the resident wishes to be discharged to home. Goal: The resident's discharge goals; he will return to the community with his wife after completion of therapy / when medically cleared. Interventions: He will accept assistance with discharge planning. Record review of resident #87's progress notes dated 8/11/2023 at 10:40 revealed, the Residents emergency contact requested to have medications discharged with resident. Medications review with resident. No pain or discomfort noted. Record review of resident #87's progress notes dated 8/10/2023 at 11:18 revealed, the Residents was discharged from the Nursing home on 8/10/23 at 9:24am. Upon leaving the facility the resident had no signs or symptoms of acute distress noted. Vital signs, blood pressure 146/62, heart rate 92, oxygen saturation 99%, temperature 97.0F, respiration 19. He left the facility via Facility transport to go to a local Hospital, and from the hospital he will be going home. Record review of the Social Service Progress Note dated 8/9/2023 at 09:15: revealed, the resident will be discharged to the local hospital on 8-10-2023 to an appointment once the appointment is over the resident will be transported home. Review of the facility Policy and Procedure for MDS 3.0 Completion dated 9/18/2023 revealed: Policy: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 4 of 10 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 10/12/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Discharge Assessment - completed using the discharge date as the Assessment Reference Date, ARD. Must be completed within 14 days of the discharge date /ARD. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 5 of 10 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 10/12/2023 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 observation, interview and record review, the facility failed to develop and implement a comprehensive care plan related to skilled services for one out of 23 sampled residents. (Resident #289) The findings included: Observation of resident #289 on 10/09/23 at 11:29 AM revealed, the resident was lying on his bed. The resident stated he is tired, he just got to the room from rehabilitation. He was not so happy with the therapy. Observation of resident #289 on 10/11/23 at 08:14 AM revealed, the resident was sitting on his bed, having breakfast. The resident reportedd the breakfast was very good and he was enjoyed it. Record review revealed resident #289 was admitted to the facility on [DATE], with diagnoses that include, but were not limited to alcohol dependence with withdrawal delirium; supraventricular tachycardia, unspecified; neuralgia and neuritis, unspecified; poisoning by other opioids, accidental (unintentional), initial encounter; chronic obstructive pulmonary disease, unspecified. Review of the physician orders revealed, an order dated 09/21/2023 for physical therapy 6x times per week for 4 weeks that included: Bed Mobility, Transfers, Therapuetic Exercise, Gait/Ambulation Training and patient education as needed one time a day every Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday for 32 Days. Review of the physicians orders revealed an order for 09/21/2023 for an Occupational Therapy (OT) evaluation and treat. An OT clarification order included, Patient to be seen 5 times (x)/week for 30 days to include therapeutic exercises, therapeutic activities, activities of daily living (ADLs), retraining, hot pack/cold pack/biofreeze as need, patient/caregiver education, and [discharge planning] d/c planning. One time a day every Monday, Tuesday, Wednesday, Thursday, Friday for 30 Days. A review of the Minimum Data Set (MDS) dated [DATE] revealed, Section C Brief Interview of Mental Status (BIMS) summary score was 14 out of 15 indicating the resident was cognitively intact. Section G revealed, the resident needed extensive assistance with one person physical assistance for bed mobility, transfer, dressing, and toilet use. The resident needed limited assistance with one person physical for locomotion and personal hygiene. The resident needed supervision with set up only for eating. Section O documented, the resident was receiving physical and occupational therapy. The resident Care Plan initiated on 9/22/2023 with the next review date of 10/10/2023 did not include these physician order. Interview with MDS/Care Planning Coordinator on10/12/23 at 10:13 AM, revealed, she reported the resident had a baseline care for therapy. She reported, the resident had fall care plan where one of the interventions is [Physical Therapy} PT evaluation. She reported, the ADL care plan was not developed and she made a mistake. Then she provided a copy of the new ADL care plan with the PT and OT interventions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 6 of 10 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 10/12/2023 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Interview of the Rehabilitation Director on 10/12/23 at 11:41 AM revealed, resident #289 was evaluated on 9/21/2023 and started physical and occupational therapy the same date. Review of the facility's Policy and Procedures dated 09/18/2023 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines. 2- The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Event ID: Facility ID: 105153 If continuation sheet Page 7 of 10 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 10/12/2023 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure they were free of a significant medication error for one out of 23 sampled residents as evidenced by during the medication administration observation Registered Nurse (Staff A) drew insulin from the insulin pen with an insulin syringe for administration to resident #16 and demonstrated the incorrect procedure for administering insulin to resident #16. Residents Affected - Few The findings included: In an observation on 10/10/23 at 11:40 AM, Resident #16 blood sugar level was 387. Eight units of insulin were to be given per sliding scale and injected subcutaneously (under the skin). Staff A RN (Registered Nurse) went to the central supply room to retrieve a box of one-milliliter insulin syringes. Staff A, pulled the plunger back to draw air and inserted the needle into the rubber seal of the insulin pen to retrieve the insulin. The nurse prepped her supplies, sanitized hands, and locked the cart. The Surveyor confirmed with Nurse, Is this the dose that you will giving to the resident? Staff A reported, yes and proceeded to the resident's room. The surveyor stopped Staff A RN at the resident #16's door. In an interview with Staff A, RN. Staff A was asked How do you use the insulin pen? Staff A, stated, There is too much air in the pen. It will take too much time to remove it. I don't want to waste a new pen. I decided to get the insulin from the pen with the syringe. The Director of Nursing (DON) and Pharmacist Consultant were present. The surveyor informed both of the observation findings. The DON stated, I will immediately have an in-service and Staff A RN will give the insulin. The pharmacist Consultant stated, I'm going to replace the pen. It's not good practice to remove insulin from the pen. In an observation on 10/10/23 at 12:08 p.m. Staff A, received a new insulin pen, wiped the rubber seal with an alcohol pad, primed the insulin pen with 2 units of insulin, and pressed the dose button. Staff A, replaced the needle and selected eight units on the pen. Staff A, locked the cart went into the resident room, placed supplies on the table, and washed her hands. Staff A wiped the residents left deltoid area with alcohol and proceeded to draw the pen near the deltoid area. The surveyor stopped the nurse from injecting insulin into the deltoid. In an interview with Staff A, about Which sites can you inject insulin? Staff A stated, the Deltoid, back of arm, abdomen, and thigh. On 10/10/23 at 12:20 PM, the DON was informed of the incorrect administration of medication for Resident #16 and the DON reported, they would speak with Staff A. During an interview on 10/11/23 at 11:59 AM with the Director of Nursing, Nursing Consultant for the Pharmacy and the Pharmacist Consultant, the Director of Nursing stated, When the nurse drew insulin up. I stopped the nurse and we immediately in-serviced her. We got a new insulin pen and told the nurse to administer the insulin dose to the resident. Staff A, demonstrated how to use the pen to me and the Pharmacist. Staff A, knew what to do. When you came in again and told us of Staff A, was going to administer the insulin into the deltoid. We got another nurse to administer the insulin to the resident in my presence correctly. Again, Staff A was in-serviced, on insulin injection sites. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 8 of 10 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 10/12/2023 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 0760 Level of Harm - Minimal harm or potential for actual harm The DON stated the process to administer insulin, Prime with safety needle, prime with two units, and prime dose. When asked, If there is air in an insulin pen. What can a nurse do to remove it? The DON stated, It's normal to have a little amount of air. The nurse will prime 2 units to remove the air. When asked, Can a nurse remove insulin from an insulin pen with a syringe? The Pharmacist Consultant stated, It's not recommended to remove insulin from an insulin pen with an insulin syringe. Residents Affected - Few When asked, What areas of the body can insulin be injected into? The Pharmacist Consultant stated, The upper arm, abdomen and thigh. The DON stated, We showed her the areas where insulin can be administered subcutaneously. When asked, What injection route is insulin administered into? The Consultant Pharmacist stated, subcutaneous (under the skin) Record review for Resident #16 revealed an admission date of 10/13/22. Medical diagnoses included but were not limited to, Type 2 Diabetes. Resident #289 had a physician order dated 10/11/23 for insulin to be injected subcutaneously after meals and at bedtime related to Type 2 Diabetes per sliding scale: 201-250=2 units 251-300=4 units 301-350=6 units 351-400=8 units Review of the facility's Policies and Procedures titled, Specific Medication Administration Procedures Dated May 2022 revealed, The purpose was to administer medications via subcutaneous, intradermal, and intramuscular routes in a safe, accurate, and effective manner. In the section titled, Sites for Administration. Under subcutaneous was the abdomen, upper arm - fatty tissue over triceps, top of thigh - fatty tissue over anterolateral thigh. Under Intramuscular, was the deltoid (arms). In the section titled, Procedure, inject a volume of air equal to the volume of the dose into the vial and withdraw the medication except on pen devices and pre-filled syringes. Pen devices: dial dose as instructed by the pen manufacturer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 9 of 10 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 10/12/2023 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 F656, Develop and Implementation of Comprehensive Residents Centered Care Plans related to the development of the resident's Activities of Daily Living care plan for one out of 23 sampled residents (Resident # 289). The finding included: Review of the facility's survey history revealed, the facility was cited at F656 Development and Implementation of Comprehensive Resident-Centered Care Plan during the survey with an exit date of November 3, 2022, related to interventions for one resident whose care plan was reviewed, as evidenced by the facility's staff failed to offload the heels as ordered for Resident # 535. During this survey with an exit date of 10/12/2023 the facility was cited F656 again related to the development and Implementation of Comprehensive Residents Centered Care Plan for a newly admitted resident. On 10/12/2023 at 12:21 PM, the Director of Nursing (DON) revealed the Quality Assurance Performance Improvement (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 assistant. 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 included, reducing the risk of not practicing infection control standard practices, antibiotic use, and staff influenza vaccination. During the daily meeting to keep discussing the issues. Review of the sign in sheets revealed the last QAPI meeting was held on 09/21/2023. The facility's Quality Assurance and Performance Improvement (QAPI) Plan provided by the facility revealed: At [ ], 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105153 If continuation sheet Page 10 of 10