Inspection·February 21, 2024

F 0558 about her wheelchair to the nurses and to therapy. I don't know what they have done about it. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/21/2024 at 10:30 AM., with Staff P, Occupational Therapy Assistant/ Back up therapy manager. She said Resident #77 is not currently receiving therapy but received therapy in the past for strengthening. She was discharged from therapy on 10/31/2023 because she met her goals. The resident had her own personal wheelchair that she was very uncomfortable. We ordered and assessed her for a high back chair. The resident reported that the high back chair was better for, and she felt comfortable in the chair. 'I don't know what happened to the high back chair that we assigned to her but I'm unable to find it. Residents Affected - Few During an interview on 02/21/2024 at 11:30 AM., with the Therapy Director. He said he spoke to the resident a week ago because it was reported to him that she felt uncomfortable in the new chair. I took the chair from her and gave it to another resident. I will have to find her another chair if she wants to get up. Review of the facility policy, titled, Resident Rights, Effective date February 2021 showed Policy: The facility strives to assure that each resident has a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 2 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to act upon a resident grievance related to tracheostomy (trach) care for one resident (#16) out of two residents sampled for grievances. Findings included: Review of a facility document titled, Grievance/Concern log, dated March 2024, revealed Resident #16 had filed a grievance on 3/22/24. The column date resolved was noted as blank. Review of a facility document titled, Grievance/Concern Report, dated 03/22/24, showed Resident #16's family member reported a concern to the facility's Business Office Manager (BOM). The description of the concern using factual terms showed, Resident's [family member] stated, on many occasions the equipment/trach is not working. Trach tube was clogged on 03/20/24 and when he mentions it to the nurse, he gets an attitude. This is the 3pm-11pm nurse. His bed linens/sheets are always dirty, and the floor is dirty. The CNA's (Certified Nursing Assistant) always give me an attitude when he asks them for help. Resident stated that he feels this is racial. [Family member] stated he saw the resident walk to the bathroom alone and asked him why he was walking alone, and the resident stated no one answered his light. A review of the report was conducted on 03/26/24 showing the grievance was assigned to the Nursing Home Administrator (NHA) and the Unit Manager (UM), date assigned 3/22/24. Under what action was taken to resolve the grievance/concern, it was noted Nursing staff will educate staff. The rest of the form was noted as blank. Resident #16 was admitted to the facility on [DATE] with diagnoses to include Respiratory Failure, Unspecified with Hypoxia, Shortness of Breath, Parkinson's Disease Without Dyskinesia, Tracheostomy Status, and Gastrostomy Status. On 3/26/24 at 3:42 p.m. an interview was conducted with the Director of Nursing (DON). She stated she had not been notified of Resident #16's grievance on trach equipment not working. The DON stated the grievance should have been taken care of promptly due to the risk it poses to the resident. She stated the nurse should have fixed the issues and then documented it. The DON stated the grievance was documented as received on Friday (3/22/2024), and the Social Services Director (SSD) was not in the office on Monday (3/25/2024). The DON said, It should have been addressed yesterday. On 03/26/24 at 04:09 p.m., an interview was conducted with the SSD. She stated grievances should be responded to promptly, no more than 72 hours. She stated sometimes it takes longer depending on whether they had further information pending. She stated she had not closed out the grievance because she was waiting for the education to be done. The SSD stated she had notified the Nursing Home Administrator and the Unit Manager on that unit. The SSD stated the grievances were not reviewed the day before, Monday 3/25/24, because I was not here. The SSD stated there should be a process to address timeliness of grievances. She said, I notified the NHA. She says she does not remember being notified. I just asked her. She said it was the end of the day. I don't remember if I notified her. On 03/26/24 at 4:43 p.m. an interview was conducted with the NHA. She stated she was not aware of the grievance filed for Resident #16. She said, I did not know. Not until today when the SSD came to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 3 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few me. We have to find out who the CNA [Certified Nursing Assistant] was. We need to investigate who the nurse was on 3/22/24. The NHA stated the expectation was for trach products to be maintained in a clean manner to prevent infections. She stated if anyone observed the equipment on the floor or not working, they should notify the nurse and the nurse should clean it up immediately. She stated the DON should be notified immediately if there were trach equipment or care concerns. The DON stated she and the DON should have been notified of the grievance immediately. On 03/26/24 at 1:17 p.m. a follow-up was conducted with the SSD. She stated she documented Resident #16's grievance as the BOM was interpreting. She stated after the grievance was filed, I walked into the Administrator's office and told her what was reported. I was told it would be an education. I went to Staff F, Registered Nurse/Unit Manager (RN/UM) and spoke to him and he said he was going to do an education. The SSD stated she made note of that on the form but was waiting for the verification. The SSD confirmed it had been four days since Resident #16's family member reported their concern. She stated the response should not have taken longer than 72 hours. She said, I don't know if it's because State is in the building. The SSD confirmed the facility had not reviewed grievances filed on Friday, Saturday, Sunday, and Monday. She stated they normally review weekend grievances on Mondays, but she was absent. She said, I feel the notification to the NHA is blurry. Managers on the weekend should handle the grievances. Each department should respond to their relative area of the grievance. I was not here. It should have been addressed in a more timely manner. On 03/27/24 at 1:36 p.m., an interview was conducted with Staff F, RN/UM. He confirmed he was notified by the SSD about the grievance regarding trach care for Resident #16. He stated in response they had initiated the trach education. He stated he spoke with the nurse who was on that assignment. It was Staff C, RN. Staff F said, I asked him what happened. He said the family member had complained to him about suctioning him that day. I don't know if he did it or not. I told [Staff C] he had to learn to perform trach care. It was not optional if you work here. On 03/28/24 at 1:48 p.m., an interview was conducted with Resident #16's family member through an interpreter. He confirmed he had reported care concerns to the facility on [DATE]. He stated the first day the resident arrived at the facility they gave him food, he was not supposed to eat. The following day they found him soiled, there was urine on the bed. On a different day the trach machine did not have liquid, they noticed the suction machine was not working, A male nurse, African American turned it off and said if he kept it on, it would catch fire. It was probably the Wednesday after admission. The room was not being cleaned it had a smell of urine. The family member stated there was an African American staff member, a CNA whom if he asked for help, they were rude. He said, Four times, we had concerns with the trach and spoke to the nurse on Tuesday night. We told her he wanted the trach cap to be removed, it smelled bad. The family member told the nurse [Staff D, LPN] that the cap was stuck, and it was smelling, and she ignored. She said, everything is fine. The family member stated no one had responded to his grievance. He confirmed the facility had not reached out to him regarding the grievance. On 03/28/23 at 2:23 p.m., an interview was conducted with the NHA. She said, I have not personally spoken to the [family member]. She stated herself and the SSD screens grievances for abuse and neglect. She stated she saw Resident #16's grievance on Monday after the surveyor brought it to her attention. She said, I am not sure if anyone asked who the 3pm-11 p.m. nurse was. I did not see it as an abuse/neglect concern. The nurse should have assessed the trach equipment. Faulty equipment would have placed the resident at risk. The NHA stated she was not notified that the resident's trach equipment had a problem. She said, We have reviewed the grievances process, the SSD will be providing me a copy, so I have a copy. She stated nursing should have responded to the equipment concerns and done (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 4 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 an assessment. Level of Harm - Minimal harm or potential for actual harm On 3/28/24 at 3.08 p.m. the DON stated she still had not received or reviewed the grievance from Resident #16. She said, I will have to ask nursing staff if they have assessed the equipment to see if it is working. She stated If she would have received the grievance on Friday, she would have investigated to see who the nurse and CNA were. They would have talked about it. She said, I would suspend the staff member if I suspected neglect. Yes, this grievance is critical to his care. I don't know if we have acted timely. The grievance should have been handled differently. Residents Affected - Few Review of a facility policy titled, Grievance/Concern Management, dated February 2021 showed the following: Policy: The residents/representative has the right to present concerns on behalf of themselves and/or others to the staff and/administrator of the facility, to government officials or to any other person. The concern may be filed verbally or in writing and the reporter may request to remain anonymous. Resident representative have the right to recommend changes in policies and services or facility personnel, and to join with other residents or individuals within or outside the facility to work for improvements in resident care, free from restraint interference, coercion, discrimination, or reprisal. These rights include access to ombudsman and advocates and the right to be a member of to be active in and to associate with advocacy or special interest groups. These rights also include the right to prompt efforts by the facility to resolve resident concerns including concerns/grievances with respect to the behavior of other residents. The facility will promptly display a poster that includes the following: A reasonable expected time for completing a review of the concern, the right to obtain a written decision regarding the concern. Residents/resident representative who are unable to complete a written concern will be assisted by staff to prepare and submit the form. The nursing home administrator is responsible for oversight of the concerned process. The social services representative/grievance official in collaboration with the NHA will be responsible for assigning the concern to the appropriate department for investigation. Social services will monitor and document residents/family satisfaction upon completion of the investigation and the summary of findings/conclusion. The facility leadership team will review and discuss concerns in the progress of an investigation and resolution. The department involved will document the concern and record the residents/resident representatives satisfaction with the resolution to the concern. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 5 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 record review and interview, the facility failed to complete and to accurately assess a discharge Minimum Data Set (MDS) on two residents (# 87, 106) out of five residents sampled. Residents Affected - Few Finding Included: 1. Review of an admission Record dated 02/21/2024 showed Resident # 87 was admitted on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus with Unspecified Complications, Acquired Absence of left Above Knee, Major Depressive Disorder, Recurrent Unspecified, Adult Failure to Thrive, Cannabis Abuse, Uncomplicated Review of the admission Minimum Data Set, dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicated cognitively intact. Review of the medical record profiled showed Resident # 87 was discharged on 9/5/2023. Further review of the medical record showed that a discharge Minimum Data Set (MDS) assessment was not completed to show that Resident # 87 physically discharged from the facility. 2. Review of an admission Record dated 02/21/2024 showed Resident # 106 was admitted on [DATE] with diagnoses to include but not limited to paraplegia, unspecified, generalized anxiety disorder, sepsis, unspecified organism, polyneuropathy, unspecified. Review of the medical record profile showed that Resident # 106 was discharged on 12/13/2023. Review of a Minimum Data Set, dated [DATE] Section A2105 Discharge Status showed 04 was coded indicating Resident # 106 was discharged to a Short-Term General Hospital. Facility was asked to provide Resident #106's discharge order and discharge summary but information was not provided. During an interview on 02/21/2024 at 09:08 AM with the Registered Nurse, Clinical Reimbursement Director, RN /CDR. He said he has been working at the facility since June 15th of 2021. I keep a list of all my admission and discharge, and I don't have Resident # 87 listed as a discharge. I have to see where and when she discharged from the facility. I don't have an answer to this resident's discharge. I'm looking at her therapy notes and see that she was discharged from therapy on 9/5/23, it was a Tuesday. I'm sorry I don't know how to answer this discharge. I don't know how we missed this discharge. I know I was out around September around the Labor Holiday. I can't recall this resident's discharge, I don't see any supporting documentation regarding her discharge in the medical record. Typically, if I know someone is being discharged home, I will open the assessment a couple of days ahead and complete it. This MDS discharged assessment was not done. I don't have an answer as to why this was not done. Resident # 106 discharge assessment is incorrect. The resident was discharged to another skilled nursing facility, not to the hospital. I did not complete his assessment. It was completed by a regional traveler because I was out of the facility at the time. The assessment is incorrect. It should have been coded showing that resident # 106 was discharged to a skilled nursing facility. Review of CMS's RAI Version 3.0 Manual, Chapter 2 Assessment for the RAI, dated October 2023 showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 6 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 Affected - Few Discharge refers to the date a resident leaves the facility, or the date the resident's Medicare Part A stay ends but the resident remains in the facility. There are three types of discharges: two are OBRA required- return anticipated and return not anticipated; the third is Medicare required - Part A PPS discharge. A Discharge assessment is required with all three types of discharges. The facility did not have a policy related to the accuracy of the MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 7 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 medical record review, facility file review and staff interviews, the facility failed to ensure Level I Pre admission Screen and Record Reviews (PASRR) were complete and accurate prior to resident admission and failed to ensure Level II PASRRs were completed as required, for fourteen (Residents #5, #49, #10, #35, #64, #67, #75, #13, #92, #69, #48, #54, #83, and #51) of thirty-four sampled residents who were reviewed for PASRR assessments, . Residents Affected - Some Findings included: On 2/18/2024 and 2/22/2024 during medical record review, the following revealed: 1. Review of resident #5's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed Resident #5 had a Power of Attorney to make her medical and financial decisions. Review of the diagnosis sheet revealed diagnoses to include, but not limited to: Anxiety (diagnosed on [DATE]), and Major Depression (diagnosed on [DATE]). Review of the physical medical record kept at the nurse station revealed a Level I PASRR screen. Upon review of the Level I PASRR screen, it revealed it was completed by a Registered Nurse from a hospital on [DATE]. It was determined this Level I PASRR screen was not completed until twenty-six days until after she was admitted to the nursing facility. Further, the Level I PASRR screen indicated in Section I (a) under MI or suspected MI; checked for diagnoses to include Anxiety and Depression Disorder. Section II (1, 2b, 2c, and 3b) were all checked yes. The requirement to have a Level II PASRR completed is to have MI diagnosis checked in Section I, and if any of the questions are answered yes in Section II. There was no evidence that a Level II PASRR screen was ever obtained. On 2/21/2024 at 1:30 p.m. an interview with the Social Service Director confirmed as a result from her review of the resident's Level 1 PASRR screen, it indicated a Level II PASRR screen should have been completed. She also confirmed that a Level 2 PASRR screen was not at all completed and did not know the reason as to why one was not sent out for and completed. 2. Review of Resident #49's medical record revealed he was admitted to the facility on [DATE]. Review of the advance directives revealed Resident #49 had a Health Care Proxy in place to make his medical decisions. Review of the diagnosis sheet revealed diagnosis to include but not limited to: Anxiety (diagnosed on [DATE]), Major Depression (diagnosed on [DATE]) and Schizophrenia (diagnosed on [DATE]). Review of the physical medical record kept at the nurse station revealed a Level I PASRR screen. Upon review of the Level I PASRR screen, it revealed it was completed by a Licensed/Certified Social Worker at a hospital on [DATE], and prior to resident #49's admission to the nursing center. However, review of the Level I PASRR screen section I (a), it did not indicate what MI related diagnosis Resident #49 had, to include; Anxiety, and Major Depression. On 2/21/2024 at 1:30 p.m. an interview with the Social Service Director confirmed the Level 1 PASRR screen was not accurate to reflect MI related diagnoses to include Anxiety and Major Depression. She was not sure why the PASRR was not correct, and confirmed a revised PASRR was never completed. 3. Review of Resident #10 medical record revealed he was admitted to the facility on [DATE] and was readmitted on [DATE]. Review of the advance directives revealed Resident #10 was his own decision (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 8 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 maker. Review of the diagnosis sheet revealed diagnoses to include: Anxiety (diagnosed on [DATE]), and Major Depression (diagnosed on [DATE]). Review of the Level I PASRR screen revealed it was completed 11/29/2017 by a Medical Social Worker from the hospital on [DATE], and prior to his admission at the nursing center. However, review of the Level I PASRR screen section I (a), it did not indicate what MI related diagnosis Resident #10 had, to include: Anxiety and Major Depression. Residents Affected - Some On 2/21/2024 at 1:30 p.m. an interview with the Social Service Director confirmed Resident #10's admission Level 1 PASRR screen was not correct to reveal MI related diagnoses to include Anxiety and Major Depression. She was not sure why those Diagnoses were not reflective in the PASRR, and further confirmed a revised one was not completed. 4. Review of Resident #35's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed Resident #35 had a Health Care Proxy in place to make his medical decisions. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Major Depression (diagnosed on [DATE]). Review of the Level I PASRR screen revealed it was completed by a Medical Doctor from the hospital on 9/18/20217. However, further review of the Level I PASRR screen section 1(a) did not indicate diagnoses to include Major Depression. On 2/21/2024 at 1:30 p.m. an interview with the Social Service Director confirmed the resident's admission Level 1 PASRR screen was not accurate to reflect MI related diagnoses to include Major Depression. She confirmed this PASRR should have been revised to reflect that diagnosis, but a revised one was never completed. 5. Review of Resident #64's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed Resident #64 had a Health Care Proxy to make his medical decisions. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Schizoaffective disorder (diagnosed 8/25/2022), Anxiety (diagnosed on [DATE]), and Major Depression (diagnosed on [DATE]). Review of the Level I PASRR screen revealed it was completed by a Licensed/Certified Social Worker from a hospital on 5/2/2022, prior to Resident #64's last readmission to the nursing center. However, review of the Level I PASRR screen under section I(a), did not indicate MI related diagnoses to include Schizoaffective disorder, Anxiety, and Major Depression. On 2/21/2024 at 1:30 p.m. an interview with the Social Service Director confirmed the resident's admission Level 1 PASSR did not include MI related diagnoses of Anxiety, Major Depression and Schizoaffective Disorder. The Social Service Director did not know why the Level 1 PASRR was not correct, and also confirmed a revised one had never been completed. 6. Review of Resident #67's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed Resident #67 had a Health Care Proxy in place to make her medical decisions. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Anxiety (diagnosed on [DATE]). Review of the Level I PASRR screen revealed it was completed at the hospital on 9/23/2021. However, the Level I PASRR screen section I (a) did not have any MI related diagnoses checked to include Anxiety. On 2/21/2024 at 1:30 p.m. an interview with the Social Service Director confirmed the resident's admission Level 1 PASRR screen was not accurate to reflect MI related diagnoses to include Anxiety. She was not sure why a new Level 1 PASRR screen was not completed to reflect that diagnosis. On 2/21/2024 at 3:25 p.m. an interview with the Social Service Director and the Nursing Home (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 9 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 - Some Administrator revealed the Admissions director is responsible for obtaining competed and accurate Level I PASRR screens prior to the residents' nursing center admission. The Social Service Director revealed a weekend supervisor would be responsible for obtaining a Level I PASRR prior to admission and that Level I PASRR would be given to the admissions director on the next business day. The Social Service Director revealed it was her responsibility to ensure all Level I PASRR screens were accurate and completed prior to the admission and if there were any inconsistencies or need for revision, she would get one completed to reflect an accurate assessment. The Social Services Director further revealed that if the Level I PASRR shows the need to get a Level II PASRR completed, she will send the information out to ensure one is completed. The Social Service Director further revealed that she was employed at the facility prior to the COVID pandemic and came back to the facility on [DATE], where she was supposed to have additional Level I and Level II PASRR inservice/education. She revealed however, that the inservice/education had not been completed yet. 7. Resident #75 was admitted on admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to lack of coordination, brief psychotic disorder, moderate unspecified dementia with other behavioral disturbance, dementia with other behavioral disturbance, dementia with psychotic disturbance, generalized anxiety disorder, mood disorder due to known physiological condition, recurrent major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, all as of 05/25/2023. Review of the Minimum Data Set (MDS) dated [DATE] showed Section C, Brief Interview for Mental Status (BIMS) score of 0 or resident is rarely / never understood. Section I, Active Diagnoses showed non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder (other than schizophrenia). Section N, Medications showed the resident was taking antipsychotics and antidepressants. Review of the physician orders for Resident #75 showed: Risperdal 1 mg (milligrams) twice a day for psychosis Trazodone HCL 75 mg at bedtime for depression Valproic Acid 250 mg / 5 ml (milliliters) , give 10 ml twice a day for schizoaffective behaviors related to unspecified dementia, unspecified severity, with psychotic disturbance: mood disorder due to known physiological condition. Review of Resident #75's care plans showed the resident uses antipsychotic medications related to psychosis, antidepressant to manage depression, antianxiety to manage anxiety, anticonvulsant to manage mood disorder initiated on 05/30/2023. Interventions included but were not limited to monitoring side effects, administering medications as ordered, psychological services per order and as needed, psychiatry services per order. Review of the Preadmission Screening and Resident Review (PASRR) dated 03/03/2023 showed: Section IA, Psychotic disorder. Section III, not a provisional admission Section IV: Individual may not be admitted to a Nursing Facility. Use this from and required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 10 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 Serious Mental Illness (SMI). Level of Harm - Minimal harm or potential for actual harm 8. Resident #13 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to psychosis not due to substance or known physiological condition as of 05/29/2023, recurrent major depressive disorder as of 05/29/2023. Residents Affected - Some Review of the quarterly, MDS dated [DATE] showed Section C, BIMS score of 15 or cognitively intact. Section I, Active Diagnoses showed depression and psychotic disorder (other than schizophrenia. Review of the physician orders showed: Trazodone HCL 50 mg at bedtime for depression Review of Resident #13's care plans showed the resident uses psychotropic medications related to antidepressant to manage depression initiated on 06/23/2023. Interventions included but were not limited to administering medications as ordered, monitoring side effects, psychological services per order and as needed, psychiatry services per order. Review of the Preadmission Screening and Resident Review (PASRR) dated 05/29/2023 showed: Section IA was blank. Section II, all answers were no Section III, not a provisional admission Section IV: No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. 9. Resident #92 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to diffuse traumatic brain injury with loss of consciousness of unspecified duration and schizophrenia both as of 12/12/2023. Review of the admission, MDS dated [DATE] showed Section C, BIMS score of 14 or cognitively intact. Section I, Active Diagnoses showed traumatic brain injury, schizophrenia. Review of the physician orders for Resident #92 showed: Depakote delayed Release 250 mg three times a day for schizophrenia. Review of Resident #92's care plans showed the resident uses psychotropic medications related to anticonvulsant to manage seizures initiated on 12/29/2023. Interventions included but were not limited to administer medications as ordered, monitoring side effects, hypnotic side effect monitoring, psychological services per order and as needed, psychiatry services per order, use of psychotropic medications will be reviewed at least quarterly with the IDT/Md to review continued need for the medications and ensure lowest dose. Review of the Preadmission Screening and Resident Review (PASRR) dated 11/08/2023 showed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 11 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 Section IA, Schizophrenia. Level of Harm - Minimal harm or potential for actual harm Section III, Hospital Discharge Exemption. The Individual is being admitted under the 30-day hospital discharge exemption. If the individual's stay is anticipated to exceed 30 days, the NF must notify the Level I screener on the 25th day of stay and the Level II evaluation must be completed no later than the 40th day of admission, on or before (date): __________ (this was blank). Residents Affected - Some Section IV: Individual may not be admitted to a Nursing Facility. Use this from and required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of Serious Mental Illness (SMI). 10. Review of the admission Record dated 4/4/2020 for Resident #48 revealed the resident was admitted on [DATE] with initial admission on [DATE]. The record included the resident diagnoses of anxiety (onset date 3/30/2021), Alzheimers disease (onset date 12/20/2021), dementia (onset date 1/4/2021), and cognitive deficit (onset date 1/10/2024). Review of Resident #48's Pre-admission Screening and Resident Review (PASRR) , dated 3/30/2020 revealed: a. Under Section I B - Finding is based on (check all that apply) only documented history is checked. b. Under Section II question 2 (A). Interpersonal functioning: the individual has a serious difficulty interacting appropriately and communication effectively with other persons, has a possible history of altercations, evictions, fear of strangers, avoidance of interpersonal relationships, social isolation, or has been dismissed from employment - checked yes. (C). Adaptation to change: The individual has a serious difficulty in adapting to typical changes in circumstances associated with work school, family, or social interactions, manifests agitation, exacerbated signs and symptoms associated with the illness or withdrawal from the situation or requires intervention by the mental health or judicial system - checked yes. c. Under Section II question 3 (B) Due to the mental illness, the individual has experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials - is checked yes. d. Under Section II question 4 - the individual exhibited actions or behaviors that make them a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 12 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 danger to themselves or others - checked yes. Level of Harm - Minimal harm or potential for actual harm e. Residents Affected - Some Under Section II question 5 - Does the individual have a primary diagnosis of : dementia - yes; related neurocognitive disorder (including Alzheimer's disease)? Is checked yes. f. Under Section IV PASRR Screen Completion: Individual may not be admitted to an nursing facility. Use this form and required documentation to request a level II PASRR evaluation because there is a diagnosis or suspicion of serious mental illness is checked. Review of electronic medical record/Minimum Data Set (MDS) dated [DATE] Section C - cognitive patters revealed a Brief Interview for Mental Status (BIMS) 00 as the interview could not be conducted. The residents' record showed no evidence of a Level II PASRR being completed. 11. Review of the admission Record dated 8/1/2019 for Resident #51 revealed the resident was admitted on [DATE]. The record included the resident diagnoses of anxiety (onset date 8/1/2019), major depressive disorder (onset date 8/1/2019), dementia (onset date 10/1/2022), and unspecified psychosis (onset date 8/1/2019), bipolar (onset date 8/1/2019) cognitive deficit (onset date 8/1/2019), and schizophrenia (onset date 8/1/2019). Review of Resident #51's Pre-admission Screening and Resident Review (PASRR) , dated 7/17/2019 revealed: Section I: PASRR Screen Decision-Making (A) Bipolar Disorder, previously received services for mental illness, behavioral observations, and documented history (B) No responses Section II: Other indications for PASRR Scree Decision-Making #1 - is there an indication the individual has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage - answer yes # 2 - does the individual typically have or may have had at least one of the following characteristics on a continuing or intermittent basis? - response yes to all #3 - is there an indication that the individual has received recent treatment for a mental illness with an indication that the individual has experienced at least one of the following? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 13 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 (A) Level of Harm - Minimal harm or potential for actual harm Psychiatric treatment is more intensive than outpatient care (e.g. partial hospitalization or inpatient hospitalization - response - yes. Residents Affected - Some #5 - does the individual have a primary diagnosis of dementia - response yes #6 - Does the individual have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease and the primary diagnosis is an serious mental illness or intellectual disability? Response yes. Section IV: PASRR Screen Completion : Individual may not be admitted to an nursing facility. Use this form and required documentation to request a level II PASRR evaluation because there is a diagnosis or suspicion of serious mental illness is checked. Review of electronic medical record/Minimum Data Set (MDS) dated [DATE] Section C - cognitive patters revealed a Brief Interview for Mental Status (BIMS) 11. The residents' record showed no evidence of a Level II PASRR being completed. 12. Review of the admission Record dated 7/13/2021 for Resident #54 revealed the resident was admitted on [DATE]. The record included the resident diagnoses of anxiety (onset date 8/1/2019), Metabolic encephalopathy (onset date 7/13/2021), dementia (onset date 10/1/2022), unspecified mood disorder (onset date 7/13/2021), and major depressive disorder (onset date 7/13/2021). Review of Resident #54's Pre-admission Screening and Resident Review (PASRR), dated 7/9/2021 revealed: Section I: PASRR Screen Decision-Making (B) Finding is based on - other (specify) - NA Section II: Other indications for PASRR Scree Decision-Making #2 (a) interpersonal functioning: the individual has serious difficulty interacting appropriately and communication effectively with other persons, has a possible history of altercations, evictions, fear of strangers, avoidance of interpersonal relationships, social isolation, or has been dismissed from employment - response - yes #7 Does the individual have validating documentation to support dementia or related neurocognitive disorder including Alzheimer's disease)? - response yes - Other - see notes Section IV: PASRR Screen Completion - Individual may be admitted to an nursing facility (check one of the following - no diagnosis or suspicion of serious mental illness or intellectual disability indicated, Level II PASRR evaluation not required. Review of electronic medical record/Minimum Data Set (MDS) dated [DATE] Section C - cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 14 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 patters revealed a Brief Interview for Mental Status (BIMS) 00 due to resident is rarely/never understood. Level of Harm - Minimal harm or potential for actual harm The residents' record did not reveal any of the documentation identified in the Level I PASRR or a Level II PASRR being completed. Residents Affected - Some 13. Review of the admission Record dated 1/9/2024 revealed the admission date of 1/9/2024 and the initial admission date of 4/4/2023 for Resident #69. The record included the resident diagnoses of dementia (onset date 4/4/2023), mood disorder with depressive features (onset date 4/4/2023), major depressive disorder (onset date 4/4/2023), and anxiety (onset date 4/4/2023). Review of Resident #69's Pre-admission Screening and Resident Review (PASRR) , dated 4/4/2023 revealed: Section I: PASRR Screen Decision-Making (A) Depressive disorder, and other - mood disorder, were checked (B) Services - previously received services for mental illness (MI) Findings based on documented history Section II: Other indications for PASRR Screen Decision-Making #5 Dementia - response yes #7 Does the individual have validating documents to support the dementia or related neurocognitive disorder (including Alzheimer's disease)? Response - yes - comprehensive mental status exam. Section IV: PASRR Screen Completion Individual may be admitted to an nursing facility (check one of the following): - Individual may be admitted to an nursing facility (check one of the following - no diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation not required. Review of electronic medical record/Minimum Data Set (MDS) dated [DATE] Section C - cognitive patters revealed a Brief Interview for Mental Status (BIMS) 00 due to resident is rarely/never understood. The residents' record did not reveal any of the documentation identified in the Level I PASRR or a Level II PASRR being completed. 14. Review of the admission Record dated 1/31/2024 revealed the admission date of 1/31/2024 and the initial admission date of 12/10/2022 for Resident #83. The record included the resident diagnoses of dementia (onset date 12/10/2023), pseudobulbar affect (onset date 7/11/2023), unspecified injury (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 15 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 - Some of the head (onset date 1/31/2024), schizoaffective disorder depressive disorder (onset date 12/10/2022), schizoaffective disorder (onset date 12/10/2022), bipolar (onset date 12/10/2022), major depressive disorder (onset date 12/10/2022), anxiety (onset date 12/10/2022), and cognitive communication deficit (onset date 10/31/2023) Review of Resident #83's Pre-admission Screening and Resident Review (PASRR), dated 7/10/2023 revealed: Section I:PASRR Screen Decision-Making (A) Anxiety disorder, bipolar disorder, depressive disorder, schizoaffective disorder are checked. (B) Finding is based on (check all that apply): documented history and medications Section IV: PASRR Screen Completion Individual may be admitted to an nursing facility (check one of the following): - Individual may be admitted to an nursing facility (check one of the following - no diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation not required. Review of electronic medical record/Minimum Data Set (MDS) dated [DATE] Section C - cognitive patters revealed a Brief Interview for Mental Status (BIMS) 00 due to resident is rarely/never understood. The residents' record did not reveal any documentation identified in the Level I PASRR or a Level II PASRR being completed. During an interview on 02/20/24 at 01:00 PM with Staff E, Social Service Director (SSD) revealed she only obtains the level I PASRR and asked if she should be getting the Level II? Review of Policy & Procedure for Pre-admission Screening and Resident Review (PASRR) Requirements Level I and Level II - Florida dated effective February 2021 for facility social services department revealed: Policy: Pre-admission screening and resident review Preadmission screening for mental illness and intellectual disability is required to be completed prior to a admission to a nursing home. The screening is reviewed by admissions to ensure appropriate placement in the least restrictive environment and to identify any specialized services the applicant may need. PASRR screening applies to all new admissions into a Medicaid certified nursing facility regardless of payer source. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 16 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 I screen is typically done by discharge planners and hospital staff as a step in the discharge process. Level of Harm - Minimal harm or potential for actual harm A resident review must be completed when there has been a significant change in a resident's mental or physical condition. A resident review is also required if a resident is transferred to a hospital for care and the stay lasts longer than 90 consecutive days prior to admission. Residents Affected - Some Procedure PASRR Level I Social services or Registered Nurse (RN) will review to determine if a serious mental illness (SMI) and Intellectual Disability (ID) or both exists while reviewing the PASRR form. The existence of either triggers the requirement for a Level II review and will be provided to the appropriate state agency by the Social Services Director (SSD) upon admission. The SSD/Nursing Administration will review for completion and accuracy during the clinical meeting process. The RN will review the Florida 3008 form for completion of all sections prior to submission of the PASRR level II for review. PASRR Level II 1. Informed consent to evaluate the resident's medical, psychological, and social history is required for level II evaluation and determination. 2. Written notification requirement for level II referral is required once the level I PASRR scree is completed. 3. Level II PASRR must be completed if the below are listed but not limited to: a. Indication of functional limitations b. Primary or secondary diagnosis of dementia or related neurocognitive disorder c. Currently exhibiting interpersonal issues d. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 17 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 Difficulty maintaining concentration, persistence, and pace Level of Harm - Minimal harm or potential for actual harm e. Difficulty with adaptation to change Residents Affected - Some Florida Specific Guidelines If the preadmission screening requires a level II evaluation submit all required documents to Coronavirus Act, Relief, and Economic Security (CARES) timely, so that a level II can be completed within the required time frames/ FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 18 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assess and develop care plan interventions related to communication for Non-English speaking residents for three residents (#16, #17 and #20) out of four residents sampled. Findings included: During a facility tour on 3/26/24 at 9:49 a.m., an observation was made of Resident #16 in bed, he summoned surveyor pointing to his suction equipment. The resident stated he spoke Spanish. He pointed to the cup on his bed side table. He nodded yes to needing water. On 3/27/24 at 09:04 a. m., Resident #16 was observed in his room. He was pointing to the cup at his bedside. An interview was attempted with the resident. When asked if he understood English, he said, No English. The resident was observed making attempts to communicate with the surveyor. The resident's room did not have any indication on the plan for communicating with the resident. On 3/27/24 at 9:09 a.m., an interview was conducted with Staff H, Certified Nursing Assistant (CNA) assigned to Resident #16. She stated she did not speak Spanish. She said, I don't know what he needs. I don't understand him. She stated she had notified the nurse that the resident needed something. Resident #16 was admitted to the facility on [DATE] with diagnoses to include Respiratory Failure, Unspecified with Hypoxia, Shortness of Breath, Parkinson's Disease Without Dyskinesia, Tracheostomy Status, and Gastrostomy Status. Resident #16's admission assessment showed under primary language the form was left blank. Review of Resident #16's Form 3008, Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form, dated 3/15/24 showed under patient information, under language, the resident spoke Spanish. Review of Resident #16's care plan on 3/26/24 revealed the resident care plan did not have a focus on communication. Review of Resident #16's care plan on 3/27/24 revealed a communication focus indicating the resident had a problem with communication, Spanish speaking. Interventions included, when possible, face directly and establish eye contact , allow ample time to respond, minimize distractions, speak clearly and distinctly, and ask simple yes/no questions. Review of Resident #17's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include encounter for surgical aftercare following surgery. Review of the admission assessment did not indicate a language barrier. An admission progress note, dated 03/15/24, showed, Resident speaks mainly Spanish. Review of Resident #17's care plan showed there was no focus related to language barrier interventions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 19 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 On 3/27/24 at 11:09 a.m., an interview was attempted with Resident #17. The interview was unsuccessful due to the resident's spoken language. Review of Resident #20's medical record revealed he was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. Residents Affected - Some An admission assessment dated [DATE] indicated the resident's primary language was Spanish. A care plan for Resident #20, dated 05/27/23, revealed the resident had a problem with communication related to primary language other than English. Interventions included reporting to nurse changes in ability to communicate. When possible, Face directly and establish eye contact, allow ample time to respond, minimize distractions, speak clearly and distinctly, ask simple yes/no questions, anticipate, and meet needs per physical/non-verbal indicators of discomfort/distress and follow up as needed, reduce background noise ( TV, Radio etc.) to improve communication as needed and repeat, rephrase as needed. Report to MD changes ability to communicate. On 3/28/23 at 2:11 p.m., an interview was conducted with Staff I, CNA. He stated the resident did not speak English and he had worked with him. He stated, I try to make out what he is saying. I don't know if there is a number to call. He stated if he could not understand a resident, he could ask some staff who speak Spanish. During an observation and interview conducted with Staff F, RN/UM on 3/27/24 at 9:11 a.m., Staff F was observed trying to communicate with the Resident #16 regarding his trach equipment. Language barrier was noted as a concern. The resident was speaking to Staff F in Spanish. Staff F stated he did not speak the language. Resident #16 was observed getting frustrated, raising his voice, and increasing hand gestures trying to identify what the problem was. When asked if there was an interpreter, Staff F stated the BOM (Business Office Manager) was one of the interpreters. The BOM came to the room and the resident stated he could not eliminate the phlegm. During the interview, the resident stated through an interpreter there was a nurse that does not respond to him when he calls. He stated the 3 pm-11 p.m. nurse did not care for him. Resident #16 stated the nurse says she does not understand him. On 3/27/24 at 2:38 p.m., an interview was conducted with Staff F, RN/UM, Staff C, RN and Staff G, LPN. They stated they had five residents whose primary language was not English. Staff F stated for non-English speakers if I don't understand them, I get someone who does. They stated the resident's care plan should reflect this. On 03/28/24 at 2:47 p.m., an interview was conducted with the Minimum Data Set (MDS)/RN. The MDS RN stated ensuring communication was a team effort with a goal to ensure a comprehensive care plan was in place. He stated residents whose primary language was not English should have a communication care plan. He stated for Resident #16, he had 14 days to do the MDS and 7 days to lock it in. In the meantime, I think staff might be able to understand him. They should have tools to communicate with residents who speak other languages. The MDS/RN stated he believed the resident needed a communication focus in his care plan and the resident did not have it in the place in the beginning. The MDS/RN said, I just put it in. If the nursing staff are unable to communicate with him, I would suggest using [phone app name] translate or get someone who speaks the language. I know it is not indicated in the care plan. I don't know if the facility has a practice. The MDS reviewed the care plans for the three residents and stated, I see how these interventions might not be clear. Annunciating another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 20 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some language does not mean the other person understood what was being said. He stated he would revise the care plans. He confirmed if anyone did not speak English as a primary language, there should be specific interventions to make sure the resident is understood, and their needs are met. On 3/28/24 at 3:18 p.m., an interview was conducted with the Director of Nursing. The DON stated staff should use the language line if they do not understand the resident. She stated they should call and get the interpreter on the line. DON stated she would find out if the care plans should reflect this. She said, There should be a number to call. The staff should have it. In a follow up on 03/28/24 at 4:04 p.m., The DON stated the administration stated staff should use [phone app name] translate. She stated the facility had a tablet for staff to use. She stated all staff should be made aware of this plan. She stated they did not have a specific policy. On 03/28/24 at 4 .36 p.m., The Regional Nurse Consultant (RNC -1) stated care plans should include the accommodation of other languages. She stated staff should know what to do to communicate with each specific resident. Review of a facility policy titled, Care-plan Interdisciplinary Plan of Care from interim meeting, dated February 2024, showed the following: Policy:The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents to include but may not be limited to monitoring resident condition and responding with appropriate interventions. The overall care plan should be oriented towards (a.) addressing ways to try to preserve and build upon a resident's strengths, needs, personal and cultural preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 21 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide care and services related to performing weekly skin checks for 2 of 2 sampled residents (#75 and #39). Residents Affected - Few Findings included: 1. Resident #75 was admitted on admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to lack of coordination, brief psychotic disorder, moderate unspecified dementia with other behavioral disturbance, dementia with other behavioral disturbance, dementia with psychotic disturbance, generalized anxiety disorder, mood disorder due to known physiological condition, recurrent major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, all as of 05/25/2023. Review of the Minimum Data Set (MDS) dated [DATE] showed Section C, Brief Interview for Mental Status (BIMS) score of 0 or resident is rarely / never understood. Review of the physician orders for Resident #75 showed: -No weekly skin checks were ordered. Review of Resident #75 care plans showed he did not have a care plan related to monitoring of his skin weekly. Review of Weekly Skin Checks from January and February 2024 showed only the following: -On 01/03/2024, no new areas of skin impairment were found. -On 01/03/2024, new areas of skin impairment were found, redness to left elbow. 2. Resident #39 was admitted on [DATE]. Review of the admission Record showed the diagnoses included but were not limited to Parkinson's, Chronic Obstructive Pulmonary Disease, schizophrenia, anxiety, viral hepatitis C, depression, seizures, spinal stenosis, paresthesia of skin (numbness or tingling), weakness, and adult failure to thrive. Review of the physician orders for Resident #39 showed: -No weekly skin checks were ordered. Review of Weekly Skin checks for January and February 2023 showed only the following: -On 01/17/2023, no new areas of skin impairment. Review of Resident #39's care plans showed he does not have a care plan related to monitoring of skin weekly. During an interview on 02/21/2024 at 9:08 a.m. the Director of Nursing (DON), Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM) and Nursing Home Administrator (NHA) verified that the skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 22 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete checks were to be performed weekly. The negative outcome for not observing the skin could be a skin integrity impairment, skin breakdown or wounds. The DON verified both Resident #75 and Resident #39 did not have orders for weekly skin checks, and they were not being performed. Review of the Wound Prevention and Treatment Overview, effective October 2021 showed the facility strives to ensure that a Resident entering the facility without Ulcers does not develop them unless the individual's clinical condition demonstrates that were unavoidable. Procedure: 7. Review skin integrity on a weekly basis as a proactive approach enabling the facility staff to identify possible changes in skin integrity / condition. Event ID: Facility ID: 105274 If continuation sheet Page 23 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide respiratory care and services for tracheostomy dependent residents according to professional standards of practice for four residents (#14, #15, #16, and #19) out of five residents with a tracheostomy. Residents Affected - Some On [DATE] a grievance was filed by Resident #16's family related to tracheostomy care and suctioning. The grievance process was not followed through by the facility to a resolution for the resident. On [DATE] Resident #15 requested his tracheostomy to be suctioned. The certified nursing assistant (CNA) notified the nurse. By the time the nurse got to the room, Resident #15 was unresponsive. A code was called, Cardiopulmonary Resuscitation (CPR) was initiated with no evidence the airway was cleared prior to providing breaths, the resident was transported to the hospital where he expired. During the survey, two residents (#14 & #16) were observed in the facility needing tracheostomy suctioning whom staff had not responded to their requests. There was inaccurate and incomplete documentation related to tracheostomy care. Staff expressed lack of confidence and access to supplies related to care and services to residents with tracheostomies. A tracheostomy (also called a tracheotomy/trach) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. The person with a tracheotomy (trach) breathes through the tracheostomy tube (trach tube) rather than through the nose and mouth. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/tracheostomy accessed on [DATE]. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #14, #15, #16, and #19 and resulted in the determination of Immediate Jeopardy starting on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the scope and severity was reduced to an E. Findings included: Review of a progress note written by Staff B, Licensed Practical Nurse (LPN), dated [DATE] at 11:44 p.m., showed, Around 11:30pm this writer was attending to another resident when a CNA informed me that [Resident #15] wants to be suctioned. This writer then proceeds to [Resident #15's room] and observed resident to be non-responsive after calling out his name and gentle chest rub on the chest. No pulse, no respiration, pale looking, warm to touch, O2 [oxygen] sat [saturation] reading 76%, full code status, code blue paged, CPR initiated while another nurse called 911. EMS [Emergency Medical Services] arrived in the facility around 11:38 pm and took over. Resident was taken to [Hospital] around 12:05am. MD [Medical Doctor], [name of family member], and DON [Director of Nursing] notified. A code blue is called if a patient goes into cardiac arrest, respiratory arrest, has respiratory issues, or experiences another medical emergency. Oxygen saturation is a measure of how well the lungs are working based on oxygen levels in the blood vessels. Review of the admission Record showed Resident #15 was admitted on [DATE] with diagnoses to include lack of coordination, chronic respiratory failure, tracheostomy, gastrostomy, dysphagia, major depressive disorder, ventricular premature depolarization, and myasthenia gravis with acute exacerbation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 24 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #15's admission Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed he had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. Section O - Special Treatments, Procedures, and Programs showed he needed continuous oxygen, suctioning, and tracheostomy care. A review of Resident #15's physician orders showed the following: Residents Affected - Some -Maintain suction set up at bedside. Date [DATE]. -Trach: Suction trach post. Record amount of secretions, characteristics of secretions (color, odor, viscosity), lung sounds, heart rate, respirations, and tolerance. Every shift for preventative measure. Date [DATE]. -Change suction canister every 72 hours and/or when ¾ full. Date [DATE]. -Change small tubing between canister and suction machine monthly. Starting on the 15th. Date [DATE]. -Full Resuscitation. Date [DATE]. -Humidified Oxygen per trach continuous 4 Liters (L) 28%. Date [DATE]. -Maintain ambu bag at bedside and replacement trach of equal size and one size down maintained at bedside. Date [DATE]. -Tracheostomy type: Shiley size 6. Trach care daily and as needed. Clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Every shift. Date [DATE]. Review of Resident #15's [DATE] Treatment Administration Record (TAR) showed no documentation that the resident was suctioned on [DATE] evening shift and [DATE] day shift. It showed there was no documentation that the ambu bag and replacement trach was at the bedside or suction was set up at the bedside on [DATE] evening shift and [DATE] day shift. Review of Resident #15's hospital History and Physical, showed he had his tracheostomy procedure on [DATE] and he was decannulated (trach was removed) on [DATE]. The resident's chief complaint was respiratory failure and he had to have a repeat tracheostomy on [DATE]. Review of Resident #15's Respiratory Notes, dated [DATE], showed the resident was tolerating a speaking valve on his trach and was in no respiratory distress. It showed the resident had yellow drainage and nursing was made aware. The Respiratory Note, dated [DATE], showed the resident was alert and pleasant, sitting in his wheelchair. He had no signs or symptoms and denied any distress. He had a moderate amount of thick white/pale yellow secretions. Trach care was done with inner cannula and tie changed. An interview was conducted on [DATE] at 9:44 a.m. with Staff A, CNA. She said she took care of Resident #15 starting at 11:00 p.m. on [DATE]. She said right around change of shift she was walking down the hall checking on each resident like she did every shift change. Staff A said she saw Resident #15 had his light on, so she went to check on him. She said the resident told her he needed his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 25 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some trach suctioned. She said he didn't seem distressed. She said she did notice his feet looked different, they were uncovered and were very pale. She told the resident it was the middle of shift change but she would let the nurse know and the resident told her thank you. Staff A said when she left Resident #15's room the nurse, Staff B, Licensed Practical Nurse (LPN) was in the hall. She said Staff B was checking her resident rooms since the shift just started. Staff A, CNA told Staff B, LPN the resident needed to be suctioned and Staff B went to the room and came right back out. Staff A said Staff B went to the nurses' station and Staff A assumed the nurse was getting supplies. Staff A said it was about 10 minutes later when Staff B, LPN went back to Resident #15's room and found him unresponsive, and a code blue was called. An interview was conducted on [DATE] at 3:46 p.m. with Staff B, LPN. She said she worked from 11:00 p.m. on [DATE] to 7:00 a.m. on [DATE] and was assigned to care for Resident #15. She said she got report from the nurse who was leaving then did her rounds. Staff B said she went to check on another resident and was suctioning that resident when Staff A, CNA came and told her Resident #15 needed suctioning. She said she finished up with the other resident and went to Resident #15's room. She said it was only 1-2 minutes. She said she went to Resident #15's room around 11:30 p.m. Staff B said when she got to his room, called his name, and rubbed his chest when he didn't respond. She said Resident #15 was not breathing and she yelled for another nurse to call a code blue. Staff B said she took out the inner cannula of his trach and everyone else arrived and they attached the bag to his trach. She said the resident was not suctioned prior to or during CPR. Staff B said she had cared for Resident #15 previously and was familiar with him. She said when he asked to be suctioned, she would go do it. She said he would let staff know if he needed suctioning. Staff B said sometimes he would want to be suctioned before he went to bed around midnight and sometimes he didn't get suctioned at all during her 11:00 p.m. to 7:00 a.m. shift. She said when she suctioned him on previous shifts he was mucousy and wanted to clear his throat. She said sometimes his secretions were a little thick. Staff B said Resident #15 couldn't really cough. A follow-up interview was conducted on [DATE] at 4:56 p.m. with Staff A, CNA. She confirmed when she checked on Resident #15 and came out of his room and Staff B, LPN was in the hall walking behind me going to rooms and stuff. She said Staff B was not in another resident room. She said Staff B walked in the room, talked to the resident for a minute then came back out and went to nurses' station. Staff A said she continued to check on her residents, finishing her last rooms. She said she then came out and started fixing ice water cups for residents that may want them. Staff A said she had fixed a few cups when Staff B went into Resident #15's room, and the code was called. She said it was about 10 minutes after she told the nurse the resident needed suctioning. An interview was conducted on [DATE] at 10:56 a.m. with the facility's Respiratory Therapist (RT). She said she comes to the facility once a month to do full trach changes on the residents with tracheostomies. She said each trach resident had a supply bag at their bedside for emergencies that contained a suction catheter, inner cannula, lubricant, trach cleaning kit and trach ties. The RT said if a resident asked to be suctioned, they should be suctioned right then. She said no resident wants to be suctioned, it is not comfortable, so if they are asking for it, they need it. She said the suctioning should be done right when the resident asks. The RT said Resident #15 had been doing really good. She said when she came in, the resident always needed a deep suctioning, and he needed continuous oxygen. She said he needed to be checked because even when his oxygen saturation was in the 80's he did not report shortness of breath. She said he did not have a good cough and couldn't get anything up, even part of the way. She said for him it would not have been okay to wait 10 minutes if he said he needed suctioning. The RT said if Resident #15 was not suctioned quickly, it would cause distress for him. She said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 26 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some practiced coughing with him, and he just did not have a good cough. She said the resident had thick secretions. The RT said if he asked for suctioning and it took 10 minutes for someone to do it, it could have caused respiratory arrest. The RT said in her training with the nurses she taught them if the inner cannula is not open that is the easiest way to code a patient. On [DATE] at 4:03 p.m. an interview was conducted with the Director of Nursing (DON) regarding Resident #15. The DON stated Resident #15 was a trach patient. She stated she was notified the resident had notified a CNA he needed to be suctioned and by the time the nurse got to him, he had coded. The DON stated she was shocked. She said, I had seen him earlier. He was just fine. The only question I had in my mind was how long he had been waiting to be suctioned and how soon did our staff respond. She stated she had not had a chance to review the record or interview the CNA and nurse on their timeline. She stated it was something in the back of her mind. She said, It is hard to tell what really happened. A follow-up interview was conducted on [DATE] at 11:54 a.m. with the DON. She said when she called the hospital, she found out Resident #15 had passed away. She said she hadn't talked to the nurse or CNA about the situation or what happened. She said there are emergency supplies in each trach resident's room, but routine suctioning supplies are not necessarily in the room. She said some nurses keep supplies in the drawer of the room, but they are in the supply closet that isn't far away. She said, I feel like when a resident needs suctioning that needs to be done right away. Suctioning should be immediate you don't know if it is stopped their airway. It is very important they are suctioned right away. Within 2 minutes. If right outside door, less than a sec[second]. When asked if she felt like nurses responded to the resident's need for trach suctioning timely, she responded, I am going to plead the fifth on that one. It is a work in progress. The DON said the process needs structure and No, they don't respond. They don't respond quick enough for me. The DON said, I think it is more they need more training and more confidence. Some nurses have just graduated out of school. She said that is why she had the RT do training last week. The DON said during training the nurses didn't do return demonstration or competencies. They just went over the information on trach care. The DON said management, or the Respiratory Therapist had not watched nurses do trach care to ensure they knew what they were doing. She said she is going to start that. She said not 100% of their nurses were comfortable doing trach care and some of the newer nurses needed more training. The DON agreed a resident was placed at risk if their trach was clogged and said if a resident asked to be suctioned a nurse should respond immediately. She added, That patient is in danger. They could be where they can't breathe. The DON read the grievance filed on [DATE]. She said she was not made aware of the grievance and had not addressed it. She said if a person did not receive trach care and suctioning, it was a lack of care and services, and I think that is neglect. The DON said Monday, [DATE] at approximately 10:00 a.m., management had a morning clinical meeting where they looked back at what happened the past 72 hours. She said she saw the note about Resident #15 and her first question was why. She said her thought when she read the progress note was how long did it take that nurse to get in that room. Where was the nurse? The DON said, I was shocked. I literally was shocked. I talked to him on Friday. He was sitting in the dining room. An interview was conducted on [DATE] at 2:38 p.m. with Staff C, Registered Nurse (RN). He said he knew Resident #15 and was surprised when he heard he passed away. Staff C stated Resident #15 was pleasant and sometimes asked to be suctioned or have his trach inner cannula changed. Staff C said Resident #15 was not the type that asked all the time. So, if he asked for suctioning, then he really needed it. A John Hopkins Medical article titled, Living with a Tracheostomy Tube and Soma, accessed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 27 of 64 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 105274 B. Wing (X3) DATE SURVEY COMPLETED A. Building 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some [DATE], showed, The upper airway warms, cleans, and moistens the air we breathe. The trach tube bypasses these mechanisms so that the air moving through the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus. Suctioning clears mucus from the tracheostomy tube and is essential for proper breathing. Also, secretions left in the tube could become contaminated and a chest infection could develop. Avoid suctioning too frequently as this could lead to more secretion buildup. The article also informed readers that suctioning a tracheostomy is important to prevent a mucus plug from blocking the tube and stopping the patient's breathing. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/living-with-a-tracheostomy-tube-and-stoma#:~:text= A review of the admission Record showed Resident #19 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include cerebral palsy, other specified diseases of the jaw, chronic obstructive pulmonary disease (COPD), epilepsy, dementia, respiratory failure, tracheostomy, and gastrostomy. Review of Resident #19's Discharge MDS, dated [DATE], showed his BIMS was unable to be conducted. Review of Resident #19's physician orders showed the following: -Change small tubing between canister and suction machine monthly starting on the 15th. Date [DATE]. -Tracheostomy Type: Shiley Size 4. Trach care daily and as needed. Clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Date: [DATE]. -Trach: Suction trach post. Record amount of secretions, characteristics of secretions (color, odor, viscosity), lung sounds, heart rate, respirations, and tolerance. Every shift for preventative measure. Date [DATE]. -Maintain suction set up at bedside, every shift and as needed. Date [DATE]. -Change suction canister every 72 hours and/or when 3/4 full. Every 72 hours and as needed. Date [DATE]. -Change trach collar, mask and oxygen weekly as well as PRN. Every Sunday for preventative. Date [DATE]. -Humidified oxygen per trach continuously 28 L every shift for Shortness of Breath. Date [DATE]. Review of Resident #19's [DATE] TAR showed no documentation for trach care on 3/5, 3/6, and [DATE]. It showed no documentation for continuous humidified oxygen at 28 L or trach suctioning on [DATE] evening shift, [DATE] day shift, [DATE] day and evening shift, [DATE] day and evening shift, [DATE] night shift, and [DATE] evening shift. Review of Resident #19's [DATE] Medication Administration Record (MAR) showed the resident was taking the antibiotic, Ciprofloxacin 500 milligram (mg) for a trach site infection from [DATE] to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 28 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0695 [DATE]. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #19's Change in Condition Evaluation, dated [DATE], showed the resident was observed bleeding from his mouth and trach. He was transferred to a higher level of care. Residents Affected - Some Review of Resident #19's Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form (3008), dated [DATE], showed the resident's primary diagnosis was tracheostomy issue. Review of Resident #19's Respiratory Notes, dated [DATE], showed the resident was slightly tachypneic (rapid shallow breathing) with oxygen saturation at 88% on room air. Resident was placed on oxygen via trach mask at 2L with oxygen saturation increasing to 95%. The Respiratory Therapist's recommendations were monitor symptoms (tachypnea and low sats [oxygen saturation.] A Respiratory Note, dated [DATE], showed his breath sounds were course with mild expiratory wheeze, sputum sample obtained related to a moderate amount of yellowish green sputum with a foul odor. Review of Resident #19's Weights and Vitals showed the resident's oxygen saturation was not documented on 2/10, 2/11, [DATE] and only once on [DATE] at 2:03 p.m. During the interview with the RT on [DATE] at 10:56 a.m. the RT said Resident #19 was currently on antibiotics due to a trach site infection. She said the resident had pneumonia, but she felt like it started as a trach site infection then progressed to his lungs. When asked how the staff were with the resident's trach care she said she was not in the facility on a consistent basis, but sometimes when she came It may not be like I would like it. The RT said, I am not sure how good they do. With the newer staff I am not sure how comfortable with trach stuff they are. Review of the facility's Grievance Log for March of 2024 revealed a grievance filed on [DATE] by the family of Resident #16. They wrote that on many occasions the resident's equipment and trach were not working and his tracheostomy tube was clogged on [DATE] when they came to visit. The family wrote the evening nurse got an attitude when they mentioned the tracheostomy tube being clogged. The grievance showed the Nursing Home Administrator (NHA) and Unit Manager (UM) were designated to take action for this grievance. It was assigned on [DATE] showing the action to resolve the grievance was Nursing will educate staff. During a facility tour on [DATE] at 9:49 a.m., an observation was made of Resident #16 in bed, he summoned this surveyor pointing to his suction equipment. The suctioning hose and mask were observed on the floor. The resident's suctioning piece was in his hand. The resident only spoke Spanish. He pointed to the cup on his bedside table. He nodded yes to needing water. This Surveyor exited the room and could not locate the CNA assigned to this hall. When the nurse had finished administering meds in the room adjacent to Resident #16, surveyor notified the nurse (Staff G, LPN) that Resident #16 needed water. The nurse said, Hang on. I'll get with him. After approximately 5 minutes, she entered the room to respond to the resident. Review of the admission Record showed Resident #16 was admitted on [DATE] with diagnoses to include respiratory failure, unspecified with hypoxia, shortness of breath, Parkinson's disease without dyskinesia, without mention of fluctuations, tracheostomy status, gastrostomy status, personal history of pneumonia (Recurrent), iron deficiency anemia, unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, essential (Primary) hypertension, hyperglycemia, unspecified, elevated white blood cell count, Unspecified, and paralysis of vocal cords and larynx, unspecified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 29 of 64 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 105274 B. Wing (X3) DATE SURVEY COMPLETED A. Building 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident #16's MDS admission assessment, dated [DATE], revealed a BIMS in Section C Cognitive Patterns: he was not assessed due to being rarely/never understood related to his diagnosis of paralysis of vocal cords and larynx. Review of Resident #16's physician orders showed the following: -Tracheostomy Type: Cuffless Size: 6XL Tracheostomy change or replace as needed if displaced or dislodged. every 24 hours as needed. Date [DATE]. -Tracheostomy Type: Cuffless Size: 6XL Trach care daily and as needed. Cleanse tracheostomy site with normal saline, pat dry. Change inner cannula. Cover with drain sponge daily and as needed. every day shift AND as needed. Date [DATE]. -Maintain suction set up at bedside, every shift and as needed. Date [DATE]. -Change suction canister every 72 hours and/or when 3/4 full. Every 72 hours and as needed. Date [DATE]. Resident #16 did not have any tracheostomy cleaning or change orders prior to the start of the survey on [DATE]. Review of Resident #16's [DATE] TAR revealed missing documentation showing suction was set up at the bedside and an ambu bag and replacement trach was at the bedside on 3/18, 3/21, 3/25, and [DATE]. During a tour of hall 200 on [DATE] at 9:54 a.m., an observation was made of Resident #14. The resident was non-verbal and pointed to her trach site. The resident was asked if she needed to be suctioned. She nodded her head up and down indicating, yes. A nurse or CNA could not be located in the hall, the NHA was notified the resident needed care. The NHA went to the resident's room and notified Resident #14 she would let the nurse know. An observation was conducted on [DATE] at 12:45 p.m. Two call lights were observed on. Staff C, RN was observed sitting at the nurses' station on the phone. Staff C was asked what the beeping noise was, and he stated it was because a resident had turned on a call light. Staff H, CNA was observed responding to the call light in Resident #14's room. Staff H stepped out of the room and stated Resident #14 needed something to do with her trach and she was letting the nurse know. Staff C, RN overheard the CNA speaking to surveyor. He said to the surveyor, I'm on break, am I not entitled to my break? The nurse was observed remaining seated at the nurse's desk. A tour with the DON was conducted on [DATE] at 3:46 p.m. of Resident #14's room. The resident was again observed pointing to her trach site. The DON asked the resident if she needed to be suctioned. The resident nodded yes. The DON notified Staff G, LPN. An observation was made with the DON on [DATE] at 3:54 p.m. Resident #16 was observed in his room. The resident's yankauer (a ridged oral suctioning tool) was observed on the resident's bedside table, exposed to the elements. The hose was observed to have some dust and crusted matter on it from being on the floor earlier in the day. The resident spoke Spanish. The DON stated the equipment should be maintained in a sanitary manner. She stated anything that goes into a resident should be bagged and dated. She stated she had noted there was need for training related to trach care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 30 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some A follow-up interview was conducted on [DATE] at 5:03 p.m. with the DON. She stated the nurse told her Resident #14's trach was cleaned and changed by the Staff F, RN/UM at approximately 4:45 p.m. The DON stated there was no documentation that the resident had received trach care. The DON stated if it was not documented it did not happen. An interview was conducted on [DATE] at 5:18 p.m. with Staff E, RN, who was the 7:00 a.m. to 3:00 p.m. Unit Manager (UM) on the 300/400 hall. She stated she went to Resident #16's room with Staff D, LPN about an hour earlier. She stated they replaced the hose and the suction catheter. She said, Sometime after 4 p.m. [Staff D] came to me. She was looking for the right hose, suction catheter, and connecting hose. She was not sure what size he needed. She asked me for help. I went in, made sure we changed the hose, told the resident to make sure he is not setting it on the table, and told him to keep it clean. Staff E said she wasn't sure what staff were doing previously for him to keep the suction catheter clean, but they are now giving him the bag the suction catheter comes in and encouraging him to place it in the bag when he isn't using it. An observation was conducted on [DATE] at 5:22 p.m. of Resident #14 with mucous coming out of her trach site. The resident had her call light on and was observed pointing to her trach site. The nurse and the CNA assigned to this hall could not immediately be found. The surveyor notified the NHA Resident #14 had a call light on, and she was pointing to her trach site. On [DATE] at 5.24 p.m. the DON confirmed there was no documentation in Resident #14's medical record to show she was suctioned at 4:45 p.m. The DON was notified of the observation of Resident #14's trach site at 5:22 p.m. She had the nurse and the unit manager go suction the resident at that time and said she would make sure they documented. An interview was conducted on [DATE] at 2:38 p.m. with Staff F, RN/UM, Staff C, RN and Staff G, LPN. Staff F said there were concerns about getting sterile gloves, need for the trach suctioning procedure, for both himself, Staff C, and three other male nurses. He said they did not have access to XL (extra large) sterile gloves. Staff C said he did not provide trach care with the inner cannula of the trach because he didn't have gloves. He said he will get another nurse to do the care that fits in the sterile gloves. He said he documented the care because he is in the room when it is done. Staff C said on [DATE] he worked from 7:00 a.m. to around 2: 45 p.m. He said he did not provide trach care to Resident #14. He said he had a problem with supplies and couldn't find stuff. He said he is new here and sometimes provides his own supplies. Staff F, RN/UM stated the expectations is for the facility to provide the supplies needed to care for residents. He said to ensure the product was sanitary, staff needed to use only facility provided supplies. Staff C, RN said, You need the sterile gloves when you do the deep suctioning. We don't have them. I have never received sterile gloves from the facility. It makes it hard to do my job. Staff F said on [DATE] around 2:25 p.m. he suctioned and cleaned Resident #14. He said she was not junky and didn't cough anything out. He confirmed he did not document anything related to this care stating, It is not documented it did not happen. Staff F said prior to this time, he was not aware Resident #14 needed trach care or suctioning. Staff G said she was assigned to Resident #14 on [DATE]. Staff G said Staff F suctioned Resident #14 before he left and a couple hours later the resident kept pointing to her trach site. Staff G said she suctioned her and applied new gauze. She said Resident #14 is always asking to be suctioned because she felt like something was stuck in her throat. Staff G, LPN and Staff C, RN both said they attended a class with the RT the previous week and Staff F, RN/UM said he attended two weeks ago. They said the RT went over the specific cannula sizes for each resident and where the emergency replacements are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 31 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some located. They said other than that, the RT did general trach teaching and did not give specifics that pertain to the residents at the facility. All three staff members said they were not sure about the RT's documentation and had never seen any notes or documentation from respiratory about the trach residents. Staff F, RN/UM reviewed the missing documentation from the residents with trachs and said it looks like it was not done. He said if care was completed, it should be documented. If it is not documented, it did not happen. Staff F said, I don't know if anyone audits documentation. I am not aware of who is in charge of reviewing files for completeness or accuracy. An interview was conducted on [DATE] at 9:11 a.m. with Staff F, RN/UM. He stated he had been notified by the nurse Resident #16's trach equipment was not working. He stated that was why he came in the room with the canister. He said he needed to figure out what happened. Staff F said the nurse assigned to the resident had not worked with trach patients before and was still learning. Staff F was observed trying to communicate with Resident #16 but there was a language barrier. When asked if there was an interpreter, Staff F, RN/UM stated the Business Office Manager (BOM) could interpret. The BOM came to the room and the resident stated he could not eliminate the phlegm in his throat. Staff F stated he had just figured out the equipment was turned off and he did not know how long it had been off. He stated if the machine was off the resident could not suction himself. Staff F then exited the room. During the continued interview the resident stated through an interpreter there was a nurse that does not respond to him when he calls. He stated the 3:00 p.m.-11:00 p.m. nurse (Staff D, LPN) does not care for him and does not understand him. The resident said, through an interpreter, When I ask her for help, she gives me an attitude. She does not want to help me. Resident #16 reported he was currently having shortness of breath and was observed trying to clear his throat. He said to the interpreter, I am not okay. The interpreter left the room to get a nurse. At 9:23 a.m. Staff F, RN/UM responded with a pulse oximeter to check the resident's oxygen saturation. The resident's oxygen saturation was 96% and 98% upon recheck. The resident stated, through an interpreter, he was having anxiety and he needed to be repositioned to clear his air way. A follow-up interview was conducted on [DATE] at 1:05 p.m. with Staff F, RN/UM. He said if Resident #16 is trying to disrupt equipment and his own care, it should be care planned. He said that morning, [DATE], when he went to the resident's room there was a bag over the motor part of the suction machine and the resident could not remove it from where he was sitting due to it being behind him. He said the resident could not see the switch to turn it on/off. He said Resident #16 shuts the suction machine off, but it can shut off if the canister is full. He said the nurses should know that. Staff F said Resident #16 is not care planned for that behavior and if he had behaviors, it should be in the care plan. An interview was conducted on [DATE] at 9:35 a.m. with Staff G, LPN. She stated she had last seen Resident #16 shortly before[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 32 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. On Sunday, 2/18/2024 at 9:05 a.m., a tour of the building to include 100/200 halls was conducted. The nursing assignment board to include both the 100/200 halls revealed the current date of 2/18/2024 and the current 7-3 shift. The board also revealed the resident census for the 100/200 halls at forty-nine. Further review of the assignment board for the 100/200 halls revealed Staff A assigned to the 100 hall and with Staff I in training, and with Staff C assigned to the 100 hall. The aides that were assigned to share between both 100/200 halls were CNAs Staff J, K, and L. All staff that were listed on the assignment board were verified and on working on the floor. However, at 10:48 a.m. the 100/200 Nursing board was observed changed and updated. The board now reflected Staff A assigned as the nurse on the 100 hall, and Staff C assigned as the nurse on the 200 hall. It was noted that the nurse Staff I, who was originally assigned to train with Staff A, was now assigned to work as a CNA. The CNAs that were now assigned to work between the 100/200 halls were Staff I, J, K, and L. At 10:49 a.m. on 02/18/2024 an interview with the 100/200 Unit Manager, Staff A, confirmed prior to the surveyor's arrival, Staff I was assigned to work as a nurse in training with him. He revealed the 100/200 hall still had three assigned CNAs to support the resident census of forty-nine. Staff A was asked why they made the change to take Staff I from nurse in training, and then put her on the CNA assignment. He revealed that he was told to make those changes when the Director of Nursing came into the building. On 2/21/2024 at 11:00 a.m. an interview with the Staffing Coordinator and the Nursing Home Administrator revealed they were aware of the staff changes that occurred on the 100/200 halls on Sunday, 2/18/2024, during the 7-3 shift. The Staffing Coordinator and Nursing Home Administrator both revealed though they were appropriately staffed to meet the needs for forty-nine residents, and had three CNAs assigned already, they went ahead and just took the nurse in training, Staff I off the training schedule and placed her on CNA duties as a result of the State survey visit. Review of the facility's Staffing policy with an effective date of April 2015 revealed the following: Policy Each nursing center has sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident, as required by the federal law, and sufficient staff to meet applicable state law requirements (Including minimum staffing rations). The projected staffing plans are re-evaluated on an on-going basis in response to changes in the facility, resident population or other circumstances. Staffing is monitored on an ongoing basis through a combination of offsite and onsite facility reviews conducted by Facility, Consulting and Compliance staff. The facility Administrator and/or Director of Nursing should evaluate staffing on a daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 33 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0725 basis. Level of Harm - Minimal harm or potential for actual harm Procedure Establish Facility Projected Staffing Levels Residents Affected - Some 1. Monitor the census and resident special care needs daily. 2. 11-7 is the first shift of the day. 3. Adjust staffing throughout the day based on census and resident special care needs changes. 4. Develop daily staffing patterns that allocate positions per unit per shift. 5. The daily staffing patterns should be focused on permanent consistent assignments. 6. Monitor to insure minimum State staffing levels are always maintained. .Other: 1. Post the daily staffing hours . Based on observations, interviews, and record review, the facility failed to provide sufficient staff to meet the needs for five residents (#72, #80, #44, and #210) on three of four units. Findings included: An interview was conducted with Staff A, Unit Manager, Licensed Practical Nurse (LPN) on 2/19/24 at 10: 25 AM. He said all the medications due at 9:00 a.m. on the 400 hall are late. Staff A, UM, LPN said the day shift nurse never showed up for her shift and if they would have notified me at 7:00 a.m. when she didn't come, I would have been able to get on the cart and start the medication pass but they didn't notify me until 10:00 a.m. that she didn't show up. The night shift nurse stayed over but she didn't start medication pass because she was busy catching up on emergency's that happened last night. He confirmed he has 15 residents with late medications. On 02/19/24 at 10:30 AM a medication administration observation was conducted with Staff A, Unit Manager (UM), Licensed Practical Nurse (LPN) for Resident #72. Resident #72's electronic medication administration record (MAR) was highlighted in red. Staff A, UM, LPN confirmed the following medications were late and scheduled to be given at 9:00 a.m. Staff A, UM, LPN dispensed the following late medications: -Aspirin low dose, Extended Release 81 milligram (MG) tablet -Depakote sprinkles delayed release 125MG capsule -Lisinopril 5MG tablet Review of Resident #72's February MAR revealed all 3 of the administered medications were scheduled to be given at 9:00 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 34 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0725 Level of Harm - Minimal harm or potential for actual harm On 02/19/24 at 10:36 AM a medication administration observation was conducted with Staff A, UM, LPN for Resident #80. Resident #80's electronic MAR was highlighted red. Staff A, UM, LPN confirmed the following medications were late and scheduled to be given at 9:00 a.m. Staff A, LPN dispensed the following late medications: Residents Affected - Some -Folic Acid 1MG tablet -Magnesium 400MG tablet -Multivitamin 1 tablet -Thiamine 100MG tablet Staff A, UM, LPN said the resident needs medpass supplement drink, but he did not have any medpass on his medication cart, and he would give it to him later. He gave Resident #80 his medications and came back to the computer and signed the medication off as administered and did not provide Resident #80 with the med pass supplement drink. Review of Resident #80's Med Admin Audit Report revealed 90mls of medpass was administered on 2/19/24 at 10:49 a.m. Review of Resident #80's February MAR revealed all 4 of the medications and the nutritional supplement were scheduled to be administered at 9:00 a.m. An interview was conducted on 2/19/24 at 10:58 AM with Staff B, LPN she said this is her second shift back at the facility and she is still getting to know the residents and confirmed she has A few residents with late medications On 02/19/24 at 11:00 AM a medication administration observation was conducted with Staff B, LPN for Resident #44. Resident #44's electronic MAR was highlighted red. Staff B, LPN confirmed the following medications were late and scheduled to be given at 9:00 a.m. Staff B, LPN dispensed the following late medications: -Ibuprofen 800mg -Aspirin 81MG chewable tablet -Eliquis 5MG tablet -Finasteride 5MG tablet -Gabapentin 300MG capsule -Januvia 25MG tablet -Pioglitazone 45MG tablet -Flomax 0.4MG capsule (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 35 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0725 -5 tablets of Vitamin D-3 1000 units each. Level of Harm - Minimal harm or potential for actual harm -Cyclobenzaprine HCL (hydrochloride) 10MG tablet. Staff B, LPN said she did not have the medication in her medication cart. She said she did not have a code to get into the Electronic Emergency Drug Kit (EDK) so she asked Staff A, UM, LPN who was administering medications on the 400 hall to enter into the electronic EDK to obtain 10MG of Cyclobenzaprine. They both confirmed the medication was not in the Electronic EDK. Staff B, LPN said she would have to contact the pharmacy to have them deliver the medication. Residents Affected - Some Review of Resident #44's physician order with a start date of 2/20/24 and no end date for Vitamin D3 Capsule 50,000 UNIT (Cholecalciferol) give 1 capsule by mouth one time a day every 7 day(s) for Deficiency OTC [over the counter] . An interview was conducted on 2/19/24 at 11:25 AM with Staff A, LPN she confirmed she administered 5,000 units of Vitamin D3. She reviewed Resident #44's physician order and confirmed the order says 50,000 units of Vitamin D3, not 5,000 units. She confirmed she made a medication error. An interview was conducted on 2/19/24 at 10:35 AM with Staff C, LPN. She said she had 22 residents with one resident in the hospital. She said she had a busy resident set and as long as she doesn't have any emergencies then she can meet the resident's needs. She said she has a couple of residents with behaviors that require her to spend over 20 minutes with them to try and calm them down and that will set her behind. But, as long as the behaviors are under control and there are not emergent situations, she can meet the resident needs in a timely manner. During the interview one resident was yelling out and Staff C, LPN said that is one of the resident behaviors that can take a while to deescalate. She excused herself from the interview to answer a call light in the room where the resident was yelling out. An interview was conducted on 02/19/24 at 11:00 AM with Resident #210 she said I have been waiting two and a half hours for ice water and I still have not gotten any. Staff B, LPN overheard the interview with the resident and said, I can get you some water just let me finish what I am doing. An observation was conducted on 2/19/24 at 11:30 AM of housekeeping bringing Staff B, LPN Resident #210's water cup to her and the housekeeper asked if Staff B, LPN could get Resident #210 some water she is asking for some. Staff B, LPN said I have a new water cup for her right here and provided the cup to Resident #210. An interview was conducted on 2/21/24 at 11:08 a.m. with Staff D, Staffing Coordinator. She said she will try to overstaff each shift with nurses and CNA's, and she will look at the census and most of the time it works out pretty good. She said she will over staff however, at the point of shift and before each shift, they have been getting more call offs. She will try to staff certain high acuity halls with more staff than non high acuity residents. She did confirm there has been a staffing concern as of late. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 36 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the nursing staff was competent to provide appropriate tracheostomy care, respond to resident's request for tracheostomy suctioning, and document tracheostomy care for four residents (#14, #15, #16, and #19) out of five residents reviewed for tracheostomy care. On 3/22/24 a grievance was filed by Resident #16's family related to tracheostomy care and suctioning. On 3/24/24 Resident #15 requested his tracheostomy to be suctioned. The CNA notified the nurse. By the time the nurse got to the room, Resident #15 was unresponsive. A code was called, CPR initiated with no evidence the airway was cleared prior to providing breathes, the resident was transported to the hospital where he expired. Two residents (#14 and #16) were observed in the facility needing tracheostomy suctioning whom staff had not responded to their requests. There was inaccurate and incomplete documentation related to tracheostomy care. Staff expressed lack of confidence and access to supplies during the survey related to care and services to residents with tracheostomies. A tracheostomy (also called a tracheotomy/trach) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. The person with a tracheotomy breathes through the tracheostomy tube (trach tube) rather than through the nose and mouth. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/tracheostomy accessed on 4/1/24. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #14, #15, #16, #19 and resulted in the determination of Immediate Jeopardy starting on 3/22/24. The findings of Immediate Jeopardy were determined to be removed on 3/29/24 and the severity and scope was reduced to an E. Findings included: Review of a progress note written by Staff B, Licensed Practical Nurse (LPN), dated 3/24/24 at 11:44 p.m., showed, Around 11:30pm this writer was attending to another resident when a CNA informed me that [Resident #15] wants to be suctioned. This writer then proceeds to [Resident #15's room] and observed resident to be non-responsive after calling out his name and gentle chest rub on the chest. No pulse, no respiration, pale looking, warm to touch, O2 [oxygen] sat [saturation] reading 76%, full code status, code blue paged, CPR initiated while another nurse called 911. EMS [Emergency Medical Services] arrived in the facility around 11:38 pm and took over. Resident was taken to [Hospital] around 12:05am. MD [Medical Doctor], [name of family member], and DON [Director of Nursing] notified. Review of the admission Record showed Resident #15 was admitted on [DATE] with diagnoses to include lack of coordination, chronic respiratory failure, tracheostomy, gastrostomy, dysphagia, major depressive disorder, ventricular premature depolarization, and myasthenia gravis with acute exacerbation. Review of Resident #15's admission Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed he had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. Section O - Special Treatments, Procedures, and Programs showed he needed continuous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 37 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0726 oxygen, suctioning, and tracheostomy care. Level of Harm - Immediate jeopardy to resident health or safety A review of Resident #15's physician orders showed the following: Residents Affected - Some -Trach: Suction trach post. Record amount of secretions, characteristics of secretions (color, odor, viscosity), lung sounds, heart rate, respirations, and tolerance. Every shift for preventative measure. Date 3/12/24. -Maintain suction set up at bedside. Date 3/12/24. -Change suction canister every 72 hours and/or when ¾ full. Date 3/12/24. -Change small tubing between canister and suction machine monthly. Starting on the 15th. Date 3/12/24. -Full Resuscitation. Date 3/12/24. -Humidified Oxygen per trach continuous 4 Liters (L) 28%. Date 3/12/24. -Maintain ambu bag at bedside and replacement trach of equal size and one size down maintained at bedside. Date 3/12/24. -Tracheostomy type: Shiley size 6. Trach care daily and as needed. Clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Every shift. Date 3/12/24. Review of Resident #15's March 2024 Treatment Administration Record (TAR) showed no documentation that the resident was suctioned on 3/17/24 evening shift and 3/20/24 day shift. It showed there was no documentation that the ambu bag and replacement trach was at the bedside or suction was set up at the bedside on 3/17/24 evening shift and 3/20/24 day shift. Review of Resident #15's Respiratory Notes, dated 3/20/24, showed the resident was tolerating a speaking valve on his trach and was in no respiratory distress. It showed the resident had yellow drainage and nursing was made aware. The Respiratory Note, dated 3/22/24, showed the resident was alert. He had a moderate amount of thick white/pale yellow secretions. Trach care was done with inner cannula and tie changed. An interview was conducted on 3/27/24 at 9:44 a.m. with Staff A, CNA. She said she took care of Resident #15 starting at 11:00 p.m. on 3/24/24. She said right around change of shift she was walking down the hall checking on each resident like she did every shift change. Staff A said she saw Resident #15 had his light on, so she went to check on him. She said the resident told her he needed his trach suctioned. She said he didn't seem distressed. She said she did notice his feet looked different, they were uncovered and were very pale. She told the resident it was the middle of shift change but she would let the nurse know and the resident told her thank you. Staff A said when she left Resident #15's room the nurse, Staff B, Licensed Practical Nurse (LPN) was in the hall. She said Staff B was checking her resident rooms since the shift just started. Staff A, CNA told Staff B, LPN the resident needed to be suctioned and Staff B went to the room and came right back out. Staff A said Staff B went to the nurses' station and Staff A assumed the nurse was getting supplies. Staff A said it was about 10 minutes later when Staff B, LPN went back to Resident #15's room and found him (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 38 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0726 unresponsive, and a code blue was called. Level of Harm - Immediate jeopardy to resident health or safety An interview was conducted on 3/27/24 at 3:46 p.m. with Staff B, LPN. She said she worked from 11:00 p.m. on 3/24/24 to 7:00 a.m. on 3/25/24 and was assigned to care for Resident #15. She said she got report from the nurse who was leaving then did her rounds. Staff B said she went to check on another resident and was suctioning that resident when Staff A, CNA came and told her Resident #15 needed suctioning. She said she finished up with the other resident and went to Resident #15's room. She said it was only 1-2 minutes. She said she went to Resident #15's room around 11:30 p.m. Staff B said when she got to his room, called his name, and rubbed his chest when he didn't respond. She said Resident #15 was not breathing and she yelled for another nurse to call a code blue. Staff B said she took out the inner cannula of his trach and everyone else arrived and they attached the bag to his trach. She said the resident was not suctioned prior to or during CPR. Staff B said she had cared for Resident #15 previously and was familiar with him. She said when he asked to be suctioned, she would go do it. She said he would let staff know if he needed suctioning. Staff B said sometimes he would want to be suctioned before he went to bed around midnight and sometimes he didn't get suctioned at all during her 11:00 p.m. to 7:00 a.m. shift. She said when she suctioned him on previous shifts he was mucousy and wanted to clear his throat. She said sometimes his secretions were a little thick. Staff B said Resident #15 couldn't really cough. Residents Affected - Some A follow-up interview was conducted on 3/27/24 at 4:56 p.m. with Staff A, CNA. She confirmed when she checked on Resident #15 and came out of his room and Staff B, LPN was in the hall walking behind me going to rooms and stuff. She said Staff B was not in another resident room. She said Staff B walked in the room, talked to the resident for a minute then came back out and went to nurses' station. Staff A said she continued to check on her residents, finishing her last rooms. She said she then came out and started fixing ice water cups for residents that may want them. Staff A said she had fixed a few cups when Staff B went into Resident #15's room, and the code was called. She said it was about 10 minutes after she told the nurse the resident needed suctioning. An interview was conducted on 3/27/24 at 10:56 a.m. with the facility's Respiratory Therapist (RT). She said she comes to the facility once a month to do full trach changes on the residents with tracheostomies. She said each trach resident had a supply bag at their bedside for emergencies that contained a suction catheter, inner cannula, lubricant, trach cleaning kit and trach ties. The RT said if a resident asked to be suctioned, they should be suctioned right then. She said no resident wants to be suctioned, it is not comfortable, so if they are asking for it, they need it. She said the suctioning should be done right when the resident asks. The RT said Resident #15 had been doing really good. She said when she came in, the resident always needed a deep suctioning, and he needed continuous oxygen. She said he needed to be checked because even when his oxygen saturation was in the 80's he did not report shortness of breath. She said he did not have a good cough and couldn't get anything up, even part of the way. She said for him it would not have been okay to wait 10 minutes if he said he needed suctioning. The RT said if Resident #15 was not suctioned quickly, it would cause distress for him. She said she practiced coughing with him, and he just did not have a good cough. She said the resident had thick secretions. The RT said if he asked for suctioning and it took 10 minutes for someone to do it, it could have caused respiratory arrest. The RT said in her training with the nurses she taught them if the inner cannula is not open that is the easiest way to code a patient. On 3/26/24 at 4:03 p.m. an interview was conducted with the Director of Nursing (DON) regarding Resident #15. The DON stated Resident #15 was a trach patient. She stated she was notified the resident had notified a CNA he needed to be suctioned and by the time the nurse got to him, he had coded. The DON stated she was shocked. She said, I had seen him earlier. He was just fine. The only question (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 39 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some I had in my mind was how long he had been waiting to be suctioned and how soon did our staff respond. She stated she had not had a chance to review the record or interview the CNA and nurse on their timeline. She stated it was something in the back of her mind. She said, It is hard to tell what really happened. An interview was conducted on 3/27/24 at 2:38 p.m. with Staff C, Registered Nurse (RN). He said he knew Resident #15 and was surprised when he heard he passed away. Staff C stated Resident #15 was pleasant and sometimes asked to be suctioned or have his trach inner cannula changed. Staff C said Resident #15 was not the type that asked all the time. So, if he asked for suctioning, then he really needed it. A John Hopkins Medical article titled, Living with a Tracheostomy Tube and Soma, accessed on 4/1/24, showed, The upper airway warms, cleans, and moistens the air we breathe. The trach tube bypasses these mechanisms so that the air moving through the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus. Suctioning clears mucus from the tracheostomy tube and is essential for proper breathing. Also, secretions left in the tube could become contaminated and a chest infection could develop. Avoid suctioning too frequently as this could lead to more secretion buildup. The article also informed readers that suctioning a tracheostomy is important to prevent a mucus plug from blocking the tube and stopping the patient's breathing. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/living-with-a-tracheostomy-tube-and-stoma#:~:text= A review of the admission Record showed Resident #19 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include cerebral palsy, other specified diseases of the jaw, chronic obstructive pulmonary disease (COPD), epilepsy, dementia, respiratory failure, tracheostomy, and gastrostomy. Review of Resident #19's physician orders showed the following: -Change small tubing between canister and suction machine monthly starting on the 15th. Date 1/31/24. -Tracheostomy Type: Shiley Size 4. Trach care daily and as needed. Clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Date: 1/31/24. -Trach: Suction trach post. Record amount of secretions, characteristics of secretions (color, odor, viscosity), lung sounds, heart rate, respirations, and tolerance. Every shift for preventative measure. Date 1/31/24. -Maintain suction set up at bedside, every shift and as needed. Date 1/31/24. -Change suction canister every 72 hours and/or when 3/4 full. Every 72 hours and as needed. Date 1/31/24. -Change trach collar, mask, and oxygen weekly as well as PRN. Every Sunday for preventative. Date 1/31/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 40 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0726 -Humidified oxygen per trach continuously 28 L every shift for Shortness of Breath. Date 1/31/24. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #19's March 2024 TAR showed no documentation for trach care on 3/5, 3/6, and 3/7/24. It showed no documentation for continuous humidified oxygen at 28 L or trach suctioning on 3/2/24 evening shift, 3/5/24 day shift, 3/6/24 day and evening shift, 3/7/24 day and evening shift, 3/12/24 night shift, and 3/21/24 evening shift. Residents Affected - Some Review of Resident #19's March 2024 Medication Administration Record (MAR) showed the resident was taking the antibiotic, Ciprofloxacin 500 milligram (mg) for a trach site infection from 3/20/24 to 3/26/24. Review of Resident #19's Change in Condition Evaluation, dated 1/24/24, showed the resident was observed bleeding from his mouth and trach. He was transferred to a higher level of care. Review of Resident #19's Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form (3008), dated 1/28/24, showed the resident's primary diagnosis was tracheostomy issue. Review of Resident #19's Respiratory Notes, dated 2/9/24, showed the resident was slightly tachypneic (rapid shallow breathing) with oxygen saturation at 88% on room air. Resident was placed on oxygen via trach mask at 2 L with oxygen saturation increasing to 95%. The Respiratory Therapist's recommendations were monitor symptoms (tachypnea and low sats [oxygen saturation.] A Respiratory Note, dated 3/15/24, showed his breath sounds were course with mild expiratory wheeze, sputum sample obtained related to a moderate amount of yellowish green sputum with a foul odor. Review of Resident #19's Weights and Vitals showed the resident's oxygen saturation was not documented on 2/10, 2/11, 2/12/24 and only once on 2/13/24 at 2:03 p.m. During the interview with the RT on 3/27/24 at 10:56 a.m. the RT said Resident #19 was currently on antibiotics due to a trach site infection. She said the resident had pneumonia, but she felt like it started as a trach site infection then progressed to his lungs. When asked how the staff were with the resident's trach care she said she was not in the facility on a consistent basis, but sometimes when she came It may not be like I would like it. The RT said, I am not sure how good they do. With the newer staff I am not sure how comfortable with trach stuff they are. Review of the facility's Grievance Log for March of 2024 revealed a grievance filed on 3/22/24 by the family of Resident #16. They wrote that on many occasions the resident's equipment and trach were not working and his tracheostomy tube was clogged on 3/20/24 when they came to visit. The family wrote the evening nurse got an attitude when they mentioned the tracheostomy tube being clogged. It was assigned on 3/22/24 showing the action to resolve the grievance was Nursing will educate staff. During a facility tour on 3/26/24 at 9:49 a.m., an observation was made of Resident #16 in bed, he summoned this surveyor pointing to his suction equipment. The suctioning hose and mask were observed on the floor. The resident's suctioning piece was in his hand. The resident only spoke Spanish. He pointed to the cup on his bedside table. He nodded yes to needing water. This surveyor exited the room and could not locate the CNA assigned to this hall. When the nurse had finished administering meds in the room adjacent to Resident #16, surveyor notified the nurse (Staff G, LPN) that Resident #16 needed water. The nurse said, Hang on. I'll get with him. After approximately 5 minutes, she entered the room to respond to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 41 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Review of the admission Record showed Resident #16 was admitted on [DATE] with diagnoses to include respiratory failure, unspecified with hypoxia, shortness of breath, Parkinson's disease without dyskinesia, without mention of fluctuations, tracheostomy status, gastrostomy status, personal history of pneumonia (Recurrent), iron deficiency anemia, unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, essential (Primary) hypertension, hyperglycemia, unspecified, elevated white blood cell count, Unspecified, and paralysis of vocal cords and larynx, unspecified. Residents Affected - Some Review of Resident #16's MDS admission assessment, dated 3/18/2024, revealed a BIMS in Section C Cognitive Patterns: he was not assessed related to his diagnosis of paralysis of vocal cords and larynx. Review of Resident #16's physician orders showed the following: -Tracheostomy Type: Cuffless Size: 6XL Tracheostomy change or replace as needed if displaced or dislodged. every 24 hours as needed. Date 3/27/24. -Tracheostomy Type: Cuffless Size: 6XL Trach care daily and as needed. Cleanse tracheostomy site with normal saline, pat dry. Change inner cannula. Cover with drain sponge daily and as needed. every day shift AND as needed. Date 3/27/24. -Maintain suction set up at bedside, every shift and as needed. Date 3/16/24. -Change suction canister every 72 hours and/or when 3/4 full. Every 72 hours and as needed. Date 3/16/24. Resident #16 did not have any tracheostomy cleaning or change orders prior to the start of the survey on 3/26/2024. Review of Resident #16's March 2024 TAR revealed missing documentation showing suction was set up at the bedside and an ambu bag and replacement trach was at the bedside on 3/18, 3/21, 3/25, and 3/26/24. During a tour of hall 200 on 3/26/24 at 9:54 a.m., an observation was made of Resident #14. The resident was non-verbal and pointed to her trach site. The resident was asked if she needed to be suctioned. She nodded her head up and down indicating, yes. A nurse or CNA could not be located in the hall, the NHA was notified the resident needed care. The NHA went to the resident's room and notified Resident #14 that she would let the nurse know. An observation was conducted on 3/26/24 at 12:45 p.m. Two call lights were observed on. Staff C, RN was observed sitting at the nurses' station on the phone. Staff C was asked what the beeping noise was, and he stated it was because a resident had turned on a call light. Staff H, CNA was observed responding to the call light in Resident #14's room. Staff H stepped out of the room and stated Resident #14 needed something to do with her trach and she was letting the nurse know. Staff C, RN overheard the CNA speaking to surveyor. He said to the surveyor, I'm on break, am I not entitled to my break? The nurse was observed remaining seated at the nurse's desk. A tour with the DON was conducted on 3/26/24 at 3:46 p.m. of Resident #14's room. The resident was again observed pointing to her trach site. The DON asked the resident if she needed to be suctioned. The resident nodded yes. The DON notified Staff G, LPN. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 42 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0726 Level of Harm - Immediate jeopardy to resident health or safety An observation was made with the DON on 3/26/24 at 3:54 p.m. Resident #16 was observed in his room. The resident's Yankauer (a ridged oral suctioning tool) was observed on the resident's bedside table, exposed to the elements. The hose was observed to have some dust and crusted matter on it from being on the floor earlier in the day. The resident spoke Spanish. The DON stated the equipment should be maintained in a sanitary manner. She stated anything that goes into a resident should be bagged and dated. She stated she had noted there was need for training related to trach care. Residents Affected - Some A follow-up interview was conducted on 3/26/24 at 5:03 p.m. with the DON. She stated the nurse told her Resident #14's trach was cleaned and changed by the Staff F, RN/UM at approximately 4:45 p.m. The DON stated there was no documentation that the resident had received trach care. The DON stated if it was not documented it did not happen. An interview was conducted on 3/26/24 at 5:18 p.m. with Staff E, RN, who was the 7:00 a.m. to 3:00 p.m. Unit Manager (UM) on the 300/400 hall. She stated she went to Resident #16's room with Staff D, LPN about an hour earlier. She stated they replaced the hose and the suction catheter. She said, Sometime after 4 p.m. [Staff D] came to me. She was looking for the right hose, suction catheter, and connecting hose. She was not sure what size he needed. She asked me for help. I went in, made sure we changed the hose, told the resident to make sure he is not setting it on the table, and told him to keep it clean. Staff E said she wasn't sure what staff were doing previously for him to keep the suction catheter clean, but they are now giving him the bag the suction catheter comes in and encouraging him to place it in the bag when he isn't using it. An observation was conducted on 3/26/24 at 5:22 p.m. of Resident #14 with mucous coming out of her trach site. The resident had her call light on and was observed pointing to her trach site. The nurse and the CNA assigned to this hall could not immediately be found. The surveyor notified the NHA Resident #14 had a call light on, and she was pointing to her trach site. On 3/26/24 at 5.24 p.m. the DON confirmed there was no documentation in Resident #14's medical record to show she was suctioned at 4:45 p.m. The DON was notified of the observation of Resident #14's trach site at 5:22 p.m. She had the nurse and the unit manager suction the resident at that time and said she would make sure they documented. An interview was conducted on 3/27/24 at 2:38 p.m. with Staff F, RN/UM, Staff C, RN and Staff G, LPN. Staff F said there were concerns about getting sterile gloves, need for the trach suctioning procedure, for both himself, Staff C, and three other male nurses. He said they did not have access to XL (extra-large) sterile gloves. Staff C said he did not provide trach care with the inner cannula of the trach because he didn't have gloves. He said he will get another nurse to do the care that fits in the sterile gloves. He said he documented the care because he is in the room when it is done. Staff C said on 3/26/24 he worked from 7:00 a.m. to around 2: 45 p.m. He said he did not provide trach care to Resident #14. He said he had a problem with supplies and couldn't find stuff. He said he is new here and sometimes provides his own supplies. Staff F, RN/UM stated the expectations is for the facility to provide the supplies needed to care for residents. He said to ensure the product was sanitary, staff needed to use only facility provided supplies. Staff C, RN said, You need the sterile gloves when you do the deep suctioning. We don't have them. I have never received sterile gloves from the facility. It makes it hard to do my job. Staff F said on 3/26/24 around 2:25 p.m. he suctioned and cleaned Resident #14. He said she was not junky and didn't cough anything out. He confirmed he did not document anything related to this care stating, It is not documented it did not happen. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 43 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some F said prior to this time, he was not aware Resident #14 needed trach care or suctioning. Staff G said she was assigned to Resident #14 on 3/26/24. Staff G said Staff F suctioned Resident #14 before he left and a couple hours later the resident kept pointing to her trach site. Staff G said she suctioned her and applied new gauze. She said Resident #14 is always asking to be suctioned because she felt like something was stuck in her throat. Staff G, LPN and Staff C, RN both said they attended a class with the RT the previous week and Staff F, RN/UM said he attended two weeks ago. They said the RT went over the specific cannula sizes for each resident and where the emergency replacements are located. They said other than that, the RT did general trach teaching and did not give specifics that pertain to the residents at the facility. All three staff members said they were not sure about the RT's documentation and had never seen any notes or documentation from respiratory about the trach residents. Staff F, RN/UM reviewed the missing documentation from the residents with trachs and said it looks like it was not done. He said if care was completed, it should be documented. If it is not documented, it did not happen. Staff F said, I don't know if anyone audits documentation. I am not aware of who is in charge of reviewing files for completeness or accuracy. An interview was conducted on 3/27/24 at 9:11 a.m. with Staff F, RN/UM. He stated he had been notified by the nurse Resident #16's trach equipment was not working. He stated that was why he came in the room with the canister. He said he needed to figure out what happened. Staff F said the nurse assigned to the resident had not worked with trach patients before and was still learning. Staff F was observed trying to communicate with Resident #16 but there was a language barrier. When asked, Staff F, RN/UM said the Business Office Manager (BOM) could interpret. The BOM came to the room and the resident stated he could not eliminate the phlegm in his throat. Staff F stated he had just figured out the equipment was turned off and he did not know how long it had been off. He stated if the machine was off the resident could not suction himself. Staff F then exited the room. During the continued interview the resident stated through an interpreter there was a nurse that does not respond to him when he calls. He stated the 3:00 p.m.-11:00 p.m. nurse (Staff D, LPN) does not care for him and does not understand him. The resident said, through an interpreter, When I ask her for help, she gives me an attitude. She does not want to help me. Resident #16 reported he was currently having shortness of breath and was observed trying to clear his throat. He said to the interpreter, I am not okay. The interpreter left the room to get a nurse. At 9:23 a.m. Staff F, RN/UM responded with a pulse oximeter to check the resident's oxygen saturation. The resident's oxygen saturation was 96% and 98% upon recheck. The resident stated, through an interpreter, he was having anxiety and he needed to be repositioned to clear his air way. A follow-up interview was conducted on 3/27/24 at 1:05 p.m. with Staff F, RN/UM. He said if Resident #16 is trying to disrupt equipment and his own care, it should be care planned. He said that morning, 3/27/24, when he went to the resident's room there was a bag over the motor part of the suction machine and the resident could not remove it from where he was sitting due to it being behind him. He said the resident could not see the switch to turn it on/off. He said Resident #16 shuts the suction machine off, but it can shut off if the canister is full. He said the nurses should know that. Staff F said Resident #16 is not care planned for that behavior and if he had behaviors, it should be in the care plan. An interview was conducted on 3/27/24 at 9:35 a.m. with Staff G, LPN. She stated she had last seen Resident #16 shortly before 8:00 a.m., during medication administration. She stated she had cleaned his equipment and covered it after she was done. She said, I did not check if it was working. I did not notice anything. He did not say anything at that time. He was not using it at the time. An interview was conducted on 3/27/24 at 11:21 a.m. with the RT. She stated Resident #14 should not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 44 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some have waited all day on 3/26/24 to receive the care she needed. The RT confirmed Resident #14 can clearly articulate her needs by yes/no by nodding. She said if the resident said she needed suctioning it should have been done and there was no excuse for it not to be. The RT said Resident #14 was assigned to the male nurse, Staff C, RN, who did not have access to sterile gloves. She said he is not able to provide the care he needs because he needs sterile gloves that fit him, and the facility doesn't have any. The RT said she notified the previous administration and just notified the current administration. She said the trach care kits only come with very small sterile gloves that do not fit larger hands. The RT said she did not know what the facility's plan was. An interview was conducted using an interpreter on 3/28/24 1:48 p.m. with Resident #16's family member regarding care. He stated the resident had the trach for one month, so it was new to the family. The first day he arrived at the facility, a food tray was delivered to him, and a staff was started to feed the resident, when he was not supposed to eat anything by mouth. The following day the family found Resident #16 soiled with urine on the bed. The family member said on another day the trach machine did not have liquid and they noticed the suction machine was not working. The resident told his family that a male nurse turned the suction machine off around 9:00 p.m. saying if he kept it on, it would catch fire. He said on four different occasions the family had concerns with Resident #16's trach, he and another family member spoke to the nurse. He said they told her the resident wanted the trach cap to be removed because it smelled bad. He said the other family member told Staff D, LPN the cap was stuck, and it was smelling. He said Staff D told them everything was fine and ignored their concerns. The family member said Resident #16 was readmitted to the hospital on [DATE] for an unrelated issue but the doctor told them the resident was having problems breathing because he was not being suctioned at the facility. He confirmed he filed a grievance on 3/22/24 and complained about the resident having trouble breathing because the trach tube was clogged. He said one of the nurses told the family he could not suction the resident because he didn't have gloves. An interview was conducted on 03/28/24 at 5.20 p.m. with the second family member of Resident #16. She said three days ago, on a Tuesday, she asked Staff D, LPN how often they clean the resident's trach site and change the dressing because in the hospital it was done daily. She said Staff D told her, I don't know about that, that is a question for the respiratory person. She said she would ask the nurses when the resident had been cleaned because he smelled, and they couldn't ever tell her. The family member said she never saw staff clean the trach site. She said the past couple of days the resident tried to remove the trach cap so he can speak, but it had accumulated phlegm and wouldn't come off. She said the resident complained to the family about the one female staff member being mean and the nurses dismissing their concerns. The family member said Resident #16 was in the hospital and she called and spoke the respiratory therapist in the hospital. She said the therapist told her they had checked and cleaned the resident's trach site and it was dirty. She said at [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 45 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for three of four shifts reviewed. Residents Affected - Many Findings included: An observation was conducted on 02/18/24 at 12:08 PM. The posted nurse staffing was dated 2/17/24 and only the 11:00 p.m.-7:00 p.m. staffing was completed. 7:00a.m.-3:00p.m. and 3:00p.m.-11:00 p.m. staffing information was not completed. (Photographic evidence obtained) An interview was conducted on 2/18/24 at 12:09 PM with Staff D, Staffing Coordinator, at the time of the observation, and she said she was updating the posting now. Usually, the 11:00 p.m. to 7:00 a.m. staff updates the posting, and she updates the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 p.m. shift posting. An interview was conducted on 2/21/24 at 11:08 a.m. with Staff D, Staffing Coordinator and the Nursing Home Administrator (NHA). The NHA and Staff D, Staffing Coordinator confirmed the Federal nurse staffing posting was not up to date to reflect 2/18/2024, upon the start of the day on 2/18/2024. Review of the facility's Staffing policy with an effective date of April 2015 revealed the following: Policy Each nursing center has sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident, as required by the federal law, and sufficient staff to meet applicable state law requirements (including minimum staffing rations). .Other: 1. Post the daily staffing hours . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 46 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed, and nineteen errors were identified for four residents (#72, #80, #44, #10) out of four residents observed. These errors constituted a 63.33% medication error rate. Residents Affected - Some Findings included: On 02/19/24 at 10:30 AM a medication administration observation was conducted with Staff A, Unit Manager (UM), Licensed Practical Nurse (LPN) for Resident #72. Resident #72's electronic medication administration record (MAR) was highlighted in red. Staff A, UM, LPN confirmed the following medications were late and scheduled to be given at 9:00 a.m. Staff A, UM, LPN dispensed the following late medications: -Aspirin low dose, Extended Release 81 milligram (MG) tablet -Depakote sprinkles delayed release 125MG capsule -Lisinopril 5MG tablet Review of Resident #72's February MAR revealed all 3 of the administered medications were scheduled to be given at 9:00 AM. On 02/19/24 at 10:36 AM a medication administration observation was conducted with Staff A, UM, LPN for Resident #80. Resident #80's electronic MAR was highlighted red. Staff A, UM, LPN confirmed the following medications were late and scheduled to be given at 9:00 a.m. Staff A, UM, LPN dispensed the following late medications: -Folic Acid 1MG tablet -Magnesium 400MG tablet -Multivitamin 1 tablet -Thiamine 100MG tablet [NAME] A, UM, LPN said the resident needs medpass supplement drink, but he did not have any medpass on his medication cart, and he would give it to him later. He gave Resident #80 his medications and came back to the computer and signed the medication off as administered and did not provide Resident #80 with the med pass supplement drink. Review of Resident #80's Med Admin Audit Report revealed 90mls of medpass was administered on 2/19/24 at 10:49 a.m. Review of Resident #80's February MAR revealed all 4 of the medications and the nutritional supplement were scheduled to be administered at 9:00 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 47 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0759 Level of Harm - Minimal harm or potential for actual harm On 02/19/24 at 11:00 AM a medication administration observation was conducted with Staff B, LPN for Resident #44. Resident #44's electronic MAR was highlighted red. Staff B, LPN confirmed the following medications were late and scheduled to be given at 9:00 a.m. Staff B, LPN dispensed the following late medications: Residents Affected - Some -Ibuprofen 800mg -Aspirin 81MG chewable tablet -Eliquis 5MG tablet -Finasteride 5MG tablet -Gabapentin 300MG capsule -Januvia 25MG tablet -Pioglitazone 45MG tablet -Flomax 0.4MG capsule -5 tablets of Vitamin D-3 1000 units each. -Cyclobenzaprine HCL (hydrochloride) 10MG tablet. Staff B, LPN said she did not have the medication in her medication cart. She said she did not have a code to get into the Electronic Emergency Drug Kit (EDK), so she asked Staff A, UM, LPN who was administering medications on the 400 hall to enter into the electronic EDK to obtain 10MG of Cyclobenzaprine. They both confirmed the medication was not in the Electronic EDK. Staff B, LPN said she would have to contact the pharmacy to have them deliver the medication. Review of Resident #44's physician order with a start date of 2/20/24 and no end date for Vitamin D3 Capsule 50,000 UNIT (Cholecalciferol) give 1 capsule by mouth one time a day every 7 day(s) for Deficiency OTC [over the counter] . An interview was conducted on 2/19/24 at 11:25 AM with Staff B, LPN she confirmed she administered 5,000 units of Vitamin D3. She reviewed Resident #44's physician order and confirmed the order says 50,000 units of Vitamin D3, not 5,000 units. She confirmed she made a medication error. Review of Resident #44's February MAR revealed all the administered medications were scheduled to be administered at 9:00 a.m. On 02/19/24 at 11:18 AM a medication administration observation was conducted with Staff B, LPN for Resident #10. Staff B, LPN dispensed the following medication: -Percocet 10MG-325MG tablet for Resident #10's pain score of 7 out of 10. Review of the electronic MAR revealed the last administration of the medication was given on 2/19/24 at 5:25 AM. Staff B, LPN removed the medication from the narcotic lock box, documented the removal of the medication the narcotic log. She administered the medication to Resident #10. She then documented the administration of the medication in the electronic MAR, an alert came up on the computer screen and Staff B, LPN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 48 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0759 said Oh it's three minutes early that's fine. She signed off the medication as administered. Level of Harm - Minimal harm or potential for actual harm Review of Resident #10's physician orders revealed an order with a start date of 11/13/23 and no end date for Percocet Oral Tablet 10-325MG 1 tablet every 6 hours as needed for pain. Residents Affected - Some Review of Resident #10's February MAR revealed Percocet 10-325MG, 1 tablet every 6 hours as needed for pain was administered on 2/19/24 at 5:25 a.m. and again on 2/19/24 at 11:19 a.m. by Staff B, LPN. During an interview on 02/21/2024 at 2:29 p.m. the Director of Nursing (DON) stated she expected the nurses to administer the medications 30 minutes before and 30 minutes after their scheduled times. Related to when to administer as needed narcotics scheduled every 6 hours, she stated the nurses were to wait until it was available every 6 hours, they were not to override the alert on the electronic medication administration record (e-mar) to give it early. The DON stated the nurses were to give the physician ordered doses of medications. They were to take the medication card out and match it to the e-mar and double check it and follow the physician orders for correct dosage. She stated that the nurses should have access to the EDK prior to their shift. If they do not have access, they should contact her (DON) or the pharmacy. Review of the facility's Medication Administration General Guidelines policy dated 09/2018 revealed the following: Policy Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administered mediations do so only after they have familiarized themselves with the medication. Procedures Medication Preparation: .3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the residence MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in direction, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to label if directions have changed from the current label. .Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber .9. Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart b. When dose is prepared (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 49 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0759 c. Before dose is administered Level of Harm - Minimal harm or potential for actual harm .14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 50 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident related to residents with a tracheostomy not being cared for in a safe and sanitary manner for four residents (#14, #15, #16, and #19) out of five residents sampled. Residents Affected - Some On [DATE] a grievance was filed by Resident #16's family related to tracheostomy care and suctioning. The grievance process was not followed through by the facility to a resolution for the resident. On [DATE] Resident #15 requested for his tracheostomy to be suctioned. The CNA notified the nurse. By the time the nurse got to the room, Resident #15 was unresponsive. A code was called, CPR initiated with no evidence airway was cleared prior to providing breathes, resident was transported to hospital where he expired. During the survey, two residents (314 and #16) were observed in the facility needing tracheostomy suctioning whom staff had not responded to their requests. There was inaccurate and incomplete documentation related to tracheostomy care. Staff expressed lack of confidence and access to supplies during the survey related to care and services to residents with tracheostomies. A tracheostomy (also called a tracheotomy/trach) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. The person with a tracheotomy breathes through the tracheostomy tube (trach tube) rather than through the nose and mouth. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/tracheostomy accessed on [DATE]. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #14, #15, #16, and #19 and resulted in the determination of Immediate Jeopardy starting on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the scope and severity was reduced to an E. Cross reference to F695 and F726. Please see F695 and F726 for additional infomation related to Residents #14, #15, #16, and #19. Findings included: Review of a progress note written by Staff B, Licensed Practical Nurse (LPN), dated [DATE] at 11:44 p.m., showed, Around 11:30pm this writer was attending to another resident when a CNA informed me that [Resident #15] wants to be suctioned. This writer then proceeds to [Resident #15's room] and observed resident to be non-responsive after calling out his name and gentle chest rub on the chest. No pulse, no respiration, pale looking, warm to touch, O2 [oxygen] sat [saturation] reading 76%, full code status, code blue paged, CPR initiated while another nurse called 911. EMS [Emergency Medical Services] arrived in the facility around 11:38 pm and took over. Resident was taken to [Hospital] around 12:05am. MD [Medical Doctor], [name of family member], and DON [Director of Nursing] notified. Review of the admission Record showed Resident #15 was admitted on [DATE] with diagnoses to include lack of coordination, chronic respiratory failure, tracheostomy, gastrostomy, dysphagia, major depressive disorder, ventricular premature depolarization, and myasthenia gravis with acute exacerbation. Review of Resident #15's admission Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed he had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 51 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0835 Level of Harm - Immediate jeopardy to resident health or safety cognitively intact. Section O - Special Treatments, Procedures, and Programs showed he needed continuous oxygen, suctioning, and tracheostomy care. A review of Resident #15's physician orders showed the following: -Maintain suction set up at bedside. Date [DATE]. Residents Affected - Some -Trach: Suction trach post. Record amount of secretions, characteristics of secretions (color, odor, viscosity), lung sounds, heart rate, respirations, and tolerance. Every shift for preventative measure. Date [DATE]. -Change suction canister every 72 hours and/or when ¾ full. Date [DATE]. -Change small tubing between canister and suction machine monthly. Starting on the 15th. Date [DATE]. -Full Resuscitation. Date [DATE]. -Humidified Oxygen per trach continuous 4 Liters (L) 28%. Date [DATE]. -Maintain ambu bag at bedside and replacement trach of equal size and one size down maintained at bedside. Date [DATE]. -Tracheostomy type: Shiley size 6. Trach care daily and as needed. Clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Every shift. Date [DATE]. Review of Resident #15's [DATE] Treatment Administration Record (TAR) showed no documentation that the resident was suctioned on [DATE] evening shift and [DATE] day shift. It showed there was no documentation that the ambu bag and replacement trach was at the bedside or suction was set up at the bedside on [DATE] evening shift and [DATE] day shift. Review of Resident #15's hospital History and Physical, showed he had his tracheostomy procedure on [DATE] and he was decannulated (trach was removed) on [DATE]. The resident's chief complaint was respiratory failure and he had to have a repeat tracheostomy on [DATE]. Review of Resident #15's Respiratory Notes, dated [DATE], showed the resident was tolerating a speaking valve on his trach and was in no respiratory distress. It showed the resident had yellow drainage and nursing was made aware. The Respiratory Note, dated [DATE], showed the resident was alert and pleasant, sitting in his wheelchair. He had no signs or symptoms and denied any distress. He had a moderate amount of thick white/pale yellow secretions. Trach care was done with inner cannula and tie changed. An interview was conducted on [DATE] at 9:44 a.m. with Staff A, CNA. She said she took care of Resident #15 starting at 11:00 p.m. on [DATE]. She said right around change of shift she was walking down the hall checking on each resident like she did every shift change. Staff A said she saw Resident #15 had his light on, so she went to check on him. She said the resident told her he needed his trach suctioned. She said he didn't seem distressed. She said she did notice his feet looked different, they were uncovered and were very pale. She told the resident it was the middle of shift change but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 52 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0835 Level of Harm - Immediate jeopardy to resident health or safety she would let the nurse know and the resident told her thank you. Staff A said when she left Resident #15's room the nurse, Staff B, Licensed Practical Nurse (LPN) was in the hall. She said Staff B was checking her resident rooms also since the shift just started. Staff A, CNA told Staff B, LPN the resident needed to be suctioned and Staff B went to the room and came right back out. Staff A said Staff B went to the nurses' station and Staff A assumed the nurse was getting supplies. Staff A said it was about 10 minutes later when Staff B, LPN went back to Resident #15's room and found him unresponsive, and a code blue was called. Residents Affected - Some An interview was conducted on [DATE] at 3:46 p.m. with Staff B, LPN. She said she worked from 11:00 p.m. on [DATE] to 7:00 a.m. on [DATE] and was assigned to care for Resident #15. She said she got report from the nurse who was leaving then did her rounds. Staff B said she went to check on another resident and was suctioning that resident when Staff A, CNA came and told her Resident #15 needed suctioning. She said she finished up with the other resident and went to Resident #15's room. She said it was only 1-2 minutes. She said she went to Resident #15's room around 11:30 p.m. Staff B said when she got to his room, called his name, and rubbed his chest when he didn't respond. She said Resident #15 was not breathing and she yelled for another nurse to call a code blue. Staff B said she took out the inner cannula of his trach and everyone else arrived and they attached the bag to his trach. She said the resident was not suctioned prior to or during CPR. Staff B said she had cared for Resident #15 previously and was familiar with him. She said when he asked to be suctioned, she would go do it. She said he would let staff know if he needed suctioning. Staff B said sometimes he would want to be suctioned before he went to bed around midnight and sometimes he didn't get suctioned at all during her 11:00 p.m. to 7:00 a.m. shift. She said when she suctioned him on previous shifts he was mucousy and wanted to clear his throat. She said sometimes his secretions were a little thick. Staff B said Resident #15 couldn't really cough. A follow-up interview was conducted on [DATE] at 4:56 p.m. with Staff A, CNA. She confirmed when she checked on Resident #15 and came out of his room and Staff B, LPN was in the hall walking behind me going to rooms and stuff. She said Staff B was not in another resident room. She said Staff B walked in the room, talked to the resident for a minute then came back out and went to nurses' station. Staff A said she continued to check on her residents, finishing her last rooms. She said she then came out and started fixing ice water cups for residents that may want them. Staff A said she had fixed a few cups when Staff B went into Resident #15's room, and the code was called. She said it was about 10 minutes after she told the nurse the resident needed suctioning. An interview was conducted on [DATE] at 10:56 a.m. with the facility's Respiratory Therapist (RT). She said she comes to the facility once a month to do full trach changes on the residents with tracheostomies. She said each trach resident had a supply bag at their bedside for emergencies that contained a suction catheter, inner cannula, lubricant, trach cleaning kit and trach ties. The RT said if a resident asked to be suctioned, they should be suctioned right then. She said no resident wants to be suctioned, it is not comfortable, so if they are asking for it, they need it. She said the suctioning should be done right when the resident asks. The RT said Resident #15 had been doing really good. She said when she came in, the resident always needed a deep suctioning, and he needed continuous oxygen. She said he needed to be checked because even when his oxygen saturation was in the 80's he did not report shortness of breath. She said he did not have a good cough and couldn't get anything up, even part of the way. She said for him it would not have been okay to wait 10 minutes if he said he needed suctioning. The RT said if Resident #15 was not suctioned quickly, it would cause distress for him. She said she practiced coughing with him, and he just did not have a good cough. She said the resident had thick secretions. The RT said if he asked for suctioning and it took 10 minutes for someone to do it, it could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 53 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some have caused respiratory arrest. The RT said in her training with the nurses she taught them if the inner cannula is not open that is the easiest way to code a patient. On [DATE] at 4:03 p.m. an interview was conducted with the Director of Nursing (DON) regarding Resident #15. The DON stated Resident #15 was a trach patient. She stated she was notified the resident had notified a CNA he needed to be suctioned and by the time the nurse got to him, he had coded. The DON stated she was shocked. She said, I had seen him earlier. He was just fine. The only question I had in my mind was how long he had been waiting to be suctioned and how soon did our staff respond. She stated she had not had a chance to review the record or interview the CNA and nurse on their timeline. She stated it was something in the back of her mind. She said, It is hard to tell what really happened. A follow-up interview was conducted on [DATE] at 11:54 a.m. with the DON. She said when she called the hospital, she found out Resident #15 had passed away. She said she hadn't talked to the nurse or CNA about the situation or what happened. She said there are emergency supplies in each trach resident's room, but routine suctioning supplies are not necessarily in the room. She said some nurses keep supplies in the drawer of the room, but they are in the supply closet that isn't far away. She said, I feel like when a resident needs suctioning that needs to be done right away. Suctioning should be immediate you don't know if it is stopped their airway. It is very important they are suctioned right away. Within 2 minutes. If right outside door, less than a sec[second]. When asked if she felt like nurses responded to the resident's need for trach suctioning timely, she responded, I am going to plead the fifth on that one. It is a work in progress. The DON said the process needs structure and No, they don't respond. They don't respond quick enough for me. The DON said, I think it is more they need more training and more confidence. Some nurses have just graduated out of school. She said that is why she had the RT do training last week. The DON said during training the nurses didn't do return demonstration or competencies. They just went over the information on trach care. The DON said management, or the Respiratory Therapist had not watched nurses do trach care to ensure they knew what they were doing. She said she is going to start that. She said not 100% of their nurses were comfortable doing trach care and some of the newer nurses needed more training. The DON agreed a resident was placed at risk if their trach was clogged and said if a resident asked to be suctioned a nurse should respond immediately. She added, That patient is in danger. They could be where they can't breathe. The DON read the grievance filed on [DATE]. She said she was not made aware of the grievance and had not addressed it. She said if a person did not receive trach care and suctioning, it was a lack of care and services, and I think that is neglect. The DON said Monday, [DATE] at approximately 10:00 a.m., management had a morning clinical meeting where they looked back at what happened the past 72 hours. She said she saw the note about Resident #15 and her first question was why. She said her thought when she read the progress note was how long did it take that nurse to get in that room. Where was the nurse? The DON said, I was shocked. I literally was shocked. I talked to him on Friday. He was sitting in the dining room. An interview was conducted on [DATE] at 2:38 p.m. with Staff C, Registered Nurse (RN). He said he knew Resident #15 and was surprised when he heard he passed away. Staff C stated Resident #15 was pleasant and sometimes asked to be suctioned or have his trach inner cannula changed. Staff C said Resident #15 was not the type that asked all the time. So, if he asked for suctioning, then he really needed it. A review of the admission Record showed Resident #19 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include cerebral palsy, other specified diseases of the jaw, chronic obstructive pulmonary disease (COPD), epilepsy, dementia, respiratory failure, tracheostomy, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 54 of 64 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 105274 B. Wing (X3) DATE SURVEY COMPLETED A. Building 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0835 and gastrostomy. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #19's Discharge MDS, dated [DATE], showed his BIMS was unable to be conducted. Residents Affected - Some -Change small tubing between canister and suction machine monthly starting on the 15th. Date [DATE]. Review of Resident #19's physician orders showed the following: -Tracheostomy Type: Shiley Size 4. Trach care daily and as needed. Clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Date: [DATE]. -Trach: Suction trach post. Record amount of secretions, characteristics of secretions (color, odor, viscosity), lung sounds, heart rate, respirations, and tolerance. Every shift for preventative measure. Date [DATE]. -Maintain suction set up at bedside, every shift and as needed. Date [DATE]. -Change suction canister every 72 hours and/or when 3/4 full. Every 72 hours and as needed. Date [DATE]. -Change trach collar, mask, and oxygen weekly as well as PRN. Every Sunday for preventative. Date [DATE]. -Humidified oxygen per trach continuously 28 L every shift for Shortness of Breath. Date [DATE]. Review of Resident #19's [DATE] TAR showed no documentation for trach care on 3/5, 3/6, and [DATE]. It also showed no documentation for continuous humidified oxygen at 28 L or trach suctioning on [DATE] evening shift, [DATE] day shift, [DATE] day and evening shift, [DATE] day and evening shift, [DATE] night shift, and [DATE] evening shift. Review of Resident #19's [DATE] Medication Administration Record (MAR) showed the resident was taking the antibiotic, Ciprofloxacin 500 milligram (mg) for a trach site infection from [DATE] to [DATE]. Review of Resident #19's Change in Condition Evaluation, dated [DATE], showed the resident was observed bleeding from his mouth and trach. He was transferred to a higher level of care. Review of Resident #19's Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form (3008), dated [DATE], showed the resident's primary diagnosis was tracheostomy issue. Review of Resident #19's Respiratory Notes, dated [DATE], showed the resident was slightly tachypneic (rapid shallow breathing) with oxygen saturation at 88% on room air. Resident was placed on oxygen via trach mask at 2 L with oxygen saturation increasing to 95%. The Respiratory Therapist's recommendations were monitor symptoms (tachypnea and low sats [oxygen saturation.] A Respiratory Note, dated [DATE], showed his breath sounds were course with mild expiratory wheeze, sputum sample obtained related to a moderate amount of yellowish green sputum with a foul odor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 55 of 64 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 105274 B. Wing (X3) DATE SURVEY COMPLETED A. Building 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident #19's Weights and Vitals showed the resident's oxygen saturation was not documented on 2/10, 2/11, [DATE] and only once on [DATE] at 2:03 p.m. During the interview with the RT on [DATE] at 10:56 a.m. the RT said Resident #19 was currently on antibiotics due to a trach site infection. She said the resident also had pneumonia, but she felt like it started as a trach site infection then progressed to his lungs. When asked how the staff were with the resident's trach care she said she was not in the facility on a consistent basis, but sometimes when she came It may not be like I would like it. The RT said, I am not sure how good they do. With the newer staff I am not sure how comfortable with trach stuff they are. Review of the facility's Grievance Log for March of 2024 revealed a grievance filed on [DATE] by the family of Resident #16. They wrote that on many occasions the resident's equipment and trach were not working and his tracheostomy tube was clogged on [DATE] when they came to visit. The family wrote the evening nurse got an attitude when they mentioned the tracheostomy tube being clogged. The grievance showed the Nursing Home Administrator (NHA) and Unit Manager (UM) were designated to take action for this grievance. It was assigned on [DATE] showing the action to resolve the grievance was Nursing will educate staff. During a facility tour on [DATE] at 9:49 a.m., an observation was made of Resident #16 in bed, he summoned this surveyor pointing to his suction equipment. The suctioning hose and mask were observed on the floor. The resident's suctioning piece was in his hand. The resident only spoke Spanish. He pointed to the cup on his bedside table. He nodded yes to needing water. This Surveyor exited the room and could not locate the CNA assigned to this hall. When the nurse had finished administering meds in the room adjacent to Resident #16, surveyor notified the nurse (Staff G, LPN) that Resident #16 needed water. The nurse said, Hang on. I'll get with him. After approximately 5 minutes, she entered the room to respond to the resident. Review of the admission Record showed Resident #16 was admitted on [DATE] with diagnoses to include respiratory failure, unspecified with hypoxia, shortness of breath, Parkinson's disease without dyskinesia, without mention of fluctuations, tracheostomy status, gastrostomy status, personal history of pneumonia (Recurrent), iron deficiency anemia, unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, essential (Primary) hypertension, hyperglycemia, unspecified, elevated white blood cell count, Unspecified, and paralysis of vocal cords and larynx, unspecified. Review of Resident #16's MDS admission assessment, dated [DATE], revealed a BIMS in Section C Cognitive Patterns: he was not assessed due to his diagnosis of paralysis of vocal cords and larynx. Review of Resident #16's physician orders showed the following: -Tracheostomy Type: Cuffless Size: 6XL Tracheostomy change or replace as needed if displaced or dislodged. every 24 hours as needed. Date [DATE]. -Tracheostomy Type: Cuffless Size: 6XL Trach care daily and as needed. Cleanse tracheostomy site with normal saline, pat dry. Change inner cannula. Cover with drain sponge daily and as needed. every day shift AND as needed. Date [DATE]. -Maintain suction set up at bedside, every shift and as needed. Date [DATE]. -Change suction canister every 72 hours and/or when 3/4 full. Every 72 hours and as needed. Date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 56 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0835 [DATE]. Level of Harm - Immediate jeopardy to resident health or safety Resident #16 did not have any tracheostomy cleaning or change orders prior to the start of the survey on [DATE]. Residents Affected - Some Review of Resident #16's [DATE] TAR revealed missing documentation showing suction was set up at the bedside and an ambu bag and replacement trach was at the bedside on 3/18, 3/21, 3/25, and [DATE]. During a tour of hall 200 on [DATE] at 9:54 a.m., an observation was made of Resident #14. The resident was non-verbal and pointed to her trach site. The resident was asked if she needed to be suctioned. She nodded her head up and down indicating, yes. A nurse or CNA could not be located in the hall, the NHA was notified the resident needed care. The NHA went to the resident's room and notified Resident #14 that she would let the nurse know. An observation was conducted on [DATE] at 12:45 p.m. Two call lights were observed on. Staff C, RN was observed sitting at the nurses' station on the phone. Staff C was asked what the beeping noise was, and he stated it was because a resident had turned on a call light. Staff H, CNA was observed responding to the call light in Resident #14's room. Staff H stepped out of the room and stated Resident #14 needed something to do with her trach and she was letting the nurse know. Staff C, RN overheard the CNA speaking to surveyor. He said to the surveyor, I'm on break, am I not entitled to my break? The nurse was observed remaining seated at the nurse's desk. A tour with the DON was conducted on [DATE] at 3:46 p.m. of Resident #14's room. The resident was again observed pointing to her trach site. The DON asked the resident if she needed to be suctioned. The resident nodded yes. The DON notified Staff G, LPN. An observation was made with the DON on [DATE] at 3:54 p.m. Resident #16 was observed in his room. The resident's Yankauer (a ridged oral suctioning tool) was observed on the resident's bedside table, exposed to the elements. The hose was observed to have some dust and crusted matter on it from being on the floor earlier in the day. The resident spoke Spanish. The DON stated the equipment should be maintained in a sanitary manner. She stated anything that goes into a resident should be bagged and dated. She stated she had noted there was need for training related to trach care. A follow-up interview was conducted on [DATE] at 5:03 p.m. with the DON. She stated the nurse told her Resident #14's trach was cleaned and changed by the Staff F, RN/UM at approximately 4:45 p.m. The DON stated there was no documentation that the resident had received trach care. The DON stated if it was not documented it did not happen. An interview was conducted on [DATE] at 5:18 p.m. with Staff E, RN, who was the 7:00 a.m. to 3:00 p.m. Unit Manager (UM) on the 300/400 hall. She stated she went to Resident #16's room with Staff D, LPN about an hour earlier. She stated they replaced the hose and the suction catheter. She said, Sometime after 4 p.m. [Staff D] came to me. She was looking for the right hose, suction catheter, and connecting hose. She was not sure what size he needed. She asked me for help. I went in, made sure we changed the hose, told the resident to make sure he is not setting it on the table, and told him to keep it clean. Staff E said she wasn't sure what staff were doing previously for him to keep the suction catheter clean, but they are now giving him the bag the suction catheter comes in and encouraging him to place it in the bag when he isn't using it. An observation was conducted on [DATE] at 5:22 p.m. of Resident #14 with mucous coming out of her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 57 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some trach site. The resident had her call light on and was observed pointing to her trach site. The nurse and the CNA assigned to this hall could not immediately be found. The surveyor notified the NHA Resident #14 had a call light on, and she was pointing to her trach site. On [DATE] at 5.24 p.m. the DON confirmed there was no documentation in Resident #14's medical record to show she was suctioned at 4:45 p.m. The DON was notified of the observation of Resident #14's trach site at 5:22 p.m. She had the nurse and the unit manager suction the resident at that time and said she would make sure they documented. An interview was conducted on [DATE] at 2:38 p.m. with Staff F, RN/UM, Staff C, RN and Staff G, LPN. Staff F said there were concerns about getting sterile gloves, need for the trach suctioning procedure, for both himself, Staff C, and three other male nurses. He said they did not have access to XL (extra-large) sterile gloves. Staff C said he did not provide trach care with the inner cannula of the trach because he didn't have gloves. He said he will get another nurse to do the care that fits in the sterile gloves. He said he documented the care because he is in the room when it is done. Staff C said on [DATE] he worked from 7:00 a.m. to around 2: 45 p.m. He said he did not provide trach care to Resident #14. He said he had a problem with supplies and couldn't find stuff. He said he is new here and sometimes provides his own supplies. Staff F, RN/UM stated the expectations is for the facility to provide the supplies needed to care for residents. He said to ensure the product was sanitary, staff needed to use only facility provided supplies. Staff C, RN said, You need the sterile gloves when you do the deep suctioning. We don't have them. I have never received sterile gloves from the facility. It makes it hard to do my job. Staff F said on [DATE] around 2:25 p.m. he suctioned and cleaned Resident #14. He said she was not junky and didn't cough anything out. He confirmed he did not document anything related to this care stating, It is not documented it did not happen. Staff F said prior to this time, he was not aware Resident #14 needed trach care or suctioning. Staff G said she was assigned to Resident #14 on [DATE]. Staff G said Staff F suctioned Resident #14 before he left and a couple hours later the resident kept pointing to her trach site. Staff G said she suctioned her and applied new gauze. She said Resident #14 is always asking to be suctioned because she felt like something was stuck in her throat. Staff G, LPN and Staff C, RN both said they attended a class with the RT the previous week and Staff F, RN/UM said he attended two weeks ago. They said the RT went over the specific cannula sizes for each resident and where the emergency replacements are located. They said other than that, the RT did general trach teaching and did not give specifics that pertain to the residents at the facility. All three staff members said they were not sure about the RT's documentation and had never seen any notes or documentation from respiratory about the trach residents. Staff F, RN/UM reviewed the missing documentation from the residents with trachs and said it looks like it was not done. He said if care was completed, it should be documented. If it is not documented, it did not happen. Staff F said, I don't know if anyone audits documentation. I am not aware of who is in charge of reviewing files for completeness or accuracy. An interview was conducted on [DATE] at 9:11 a.m. with Staff F, RN/UM. He stated he had been notified by the nurse Resident #16's trach equipment was not working. He stated that was why he came in the room with the canister. He said he needed to figure out what happened. Staff F said the nurse assigned to the resident had not worked with trach patients before and was still learning. Staff F was observed trying to communicate with Resident #16 but there was a language barrier. The surveyor asked the Staff F, RN/UM if there was an interpreter, and he said the Business Office Manager (BOM) could interpret. The BOM came to the room and the resident stated he could not eliminate the phlegm in his throat. Staff F stated he had just figured out the equipment was turned off and he did not know (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 58 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some how long it had been off. He stated if the machine was off the resident could not suction himself. Staff F then exited the room. During the continued interview the resident stated through an interpreter there was a nurse that does not respond to him when he calls. He stated the 3:00 p.m.-11:00 p.m. nurse (Staff D, LPN) does not care for him and does not understand him. The resident said, through an interpreter, When I ask her for help, she gives me an attitude. She does not want to help me. Resident #16 reported he was currently having shortness of breath and was observed trying to clear his throat. He said to the interpreter, I am not okay. The interpreter left the room to get a nurse. At 9:23 a.m. Staff F, RN/UM responded with a pulse oximeter to check the resident's oxygen saturation. The resident's oxygen saturation was 96% and 98% upon recheck. The resident stated, through an interpreter, he was having anxiety and he needed to be repositioned to clear his air way. A follow-up interview was conducted on [DATE] at 1:05 p.m. with Staff F, RN/UM. He said if Resident #16 is trying to disrupt equipment and his own care, it should be care planned. He said that morning, [DATE], when he went to the resident's room there was a bag over the motor part of the suction machine and the resident could not remove it from where he was sitting due to it being behind him. He said the resident could not see the switch to turn it on/off. He said Resident #16 shuts the suction machine off, but it can shut off if the canister is full. He said the nurses should know that. Staff F said Resident #16 is not care planned for that behavior and if he had behaviors, it should be in the care plan. An interview was conducted on [DATE] at 9:35 a.m. with Staff G, LPN. She stated she had last seen Resident #16 shortly before 8:00 a.m., during medication administration. She stated she had cleaned his equipment and covered it after she was done. She said, I did not check if it was working. I did not notice anything. He did not say anything at that time. He was not using it at the time. An interview was conducted on [DATE] at 11:21 a.m. with the RT. She stated Resident #14 should not have waited all day on [DATE] to receive the care she needed. The RT confirmed Resident #14 can clearly articulate her needs by yes/no by nodding. She said if the resident said she needed suctioning it should have been done and there was no excuse for it not to be. The RT said Resident #14 was assigned to the male nurse, Staff C, RN, who did not have access to sterile gloves. She said he is not able to provide the care he needs because he needs sterile gloves that fit him, and the facility doesn't have any. The RT said she notified the previous administration and just notified the current administration. She said the trach care kits only come with very small sterile gloves that do not fit larger hands.[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 59 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 2. On 02/20/2024 at 8:55 a.m. Staff N, Licensed Practical Nurse (LPN) was observed administering medications to Resident #72. After administering medications Staff N left the residents room and took medication to the medication room to be discarded. She did not hand sanitize after administering the medications and leaving the resident's room. It was also noted she had painted long, pointy, acrylic fingernails. Residents Affected - Many On 02/20/2024 at 9:05 a.m. Staff M, LPN, was observed administering medications to Resident #3. Staff M left the resident's room without hand sanitizing after the resident refused her medications and requested something for nausea. Staff M went down the hall to the nursing station and used the computer and phone without hand sanitizing. During an interview on 02/21/2024 at 2:29 p.m. the Director of Nursing (DON) stated she the nurses were expected to perform hand sanitizing prior to pulling the medications from the cart, they were to place the medications into the medication cup and hand sanitize again as well as before they entered the resident's room. They were to hand sanitize and or wash their hands after administering medications. The nurse should not go down the hall before hand sanitizing their hands. The nurse should not have long or acrylic nails due to infection control issues and the possibility of injuring a resident. If the nails were polished, the polish may chip which is another infection control issue. Review of the Facility Policy and Procedure for the Infection Control Program, effective October 2021 from the Infection Control Manual revealed: Policy: The infection prevention and control program is comprehensive program that addresses detection, prevention and control of infections and communicable disease among residents, visitors, those individuals providing services under contractual agreement, and personnel. The infection prevention and control program, in addition, will facilitate activities to improve antibiotic use to reduce adverse events, prevent emergence of antibiotic resistance, and promote better outcomes for residents. Procedure: The major activities of the program are: a. Surveillance of infections and communicable disease b. Antibiotic Stewardship c. Implementation of infection control and prevention measures d. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 60 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 Prevention and Communicable Diseases Level of Harm - Minimal harm or potential for actual harm Division of Responsibilities for infection prevention activities: The facility administrator is ultimately responsible for the infection prevention and control program. Residents Affected - Many Infection prevention and control coordination has the responsibility to carry out the daily functions. Reporting goes to the Quality Assurance Committee and provides education and feedback to with guidance to staff, residents and other departments as needed. The infection prevention and control plan will be reviewed annually, and as needed by the quality assurance committee. Minutes of the infection prevention and control committee meetings are maintained with the quality assurance and performance improvement monthly meeting minutes. Review of the facility Policy and Procedure for Medication Administration - General Guidelines, effective September 2018 from the Nursing Care Center Pharmacy Policy, and Procedure Manual, reveled: Policy: Medications are administered as prescribed in accordance with the manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedure: Medication Administration: 11. Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy. Note: Soap and water should always be used after contact with resident with Clostridium difficile (c. diff) as antimicrobial sanitizer does not kill the spores produced by c. diff, which may result in the spread of the infection. Based on record reviews, staff interviews and observations, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the year 2023 for 99 of 99 residents in the facility during survey, and failed to ensure hand sanitizing was performed by two staff (N and M) during medication pass observation Findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 61 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 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 - Many FORM CMS-2567 (02/99) Previous Versions Obsolete 1. During an interview on 02/21/2024 at 11:32 a.m. with the Director of Nursing (DON) and Regional Nurse, the Regional Nurse revealed the current DON has been in the position since approximately February 2024. She stated the DON will be the Infection control preventionist until the Assistant Director of Nursing position is filled. Prior to February 2024 the previous DON held the position of Infection Control Preventionist. The current DON could not provide evidence of Infection Control Preventionist training. The DON nor the Regional Nurse were able to provide any infection control/prevention data for the year 2023. There was no verification of surveillance of infections and communicable disease, antibiotic stewardship, implementation of infection control and prevention measures, and prevention of infection and communicable disease. The DON revealed that the previous DON maintained all infection control records. The Regional Nurse revealed that she saw the information and admitted that she was unable to locate the binders with all the information, which included but not limited to, surveillance, minutes, program plan for 2024, line listing of antibiotics, employee vaccinations, etc. Event ID: Facility ID: 105274 If continuation sheet Page 62 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record reviews, staff interviews and observations, the facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use for 2023 for 99 of 99 residents in the facility during survey. Residents Affected - Many Findings revealed: Review of the Facility Policy and Procedure for the Infection Control Program, effective October 2021 from the Infection Control Manual revealed: Policy: The infection prevention and control program is comprehensive program that addresses detection, prevention and control of infections and communicable disease among residents, visitors, those individuals providing services under contractual agreement, and personnel. The infection prevention and control program, in addition, will facilitate activities to improve antibiotic use to reduce adverse events, prevent emergence of antibiotic resistance, and promote better outcomes for residents. Procedure: One of the major activities of the program: Antibiotic Stewardship Ongoing tracking of antibiotic prescribing, antibiotic use, and developing antibiotic resistance patterns with documentation and education. Tracking of antibiotics will include; antifungals, antivirals, and all formulation of the antibiotics used. Division of Responsibilities for infection prevention activities: The facility administrator is ultimately responsible for the infection prevention and control program. Infection prevention and control coordination has the responsibility to carry out the daily functions. Reporting goes to the Quality Assurance Committee and provides education and feedback to with guidance to staff, residents and other departments as needed. The infection prevention and control plan will be reviewed annually, and as needed by the quality assurance committee. Minutes of the infection prevention and control committee meetings are maintained with the quality assurance and performance improvement monthly meeting minutes. During an interview on 02/21/2024 at 11:32 a.m. with the Director of Nursing (DON) and Regional Nurse, the Regional Nurse revealed the current DON has been in the position since approximately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 63 of 64 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete February 2024. She stated the DON will be the Infection control preventionist until the Assistant Director of Nursing position is filled. Prior to February 2024 the previous DON held the position of Infection Control Preventionist. The current DON could not provide evidence of Infection Control Preventionist training. The DON nor the Regional Nurse were not able to provide any data for antibiotic surveillance for the year 2023. The DON was not able to provide the antibiotic utilization rate for 2023. The DON revealed that the previous DON maintained all of the tracking for antibiotic stewardship records. The Regional Nurse revealed that she saw the information and admitted that she was unable to locate the binder that contained the information related to antibiotic tracking for 2023. Event ID: Facility ID: 105274 If continuation sheet Page 64 of 64