Health inspection·April 9, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to implement the care plans for two of thirty-two sampled residents (Resident #87) related to the use of an adult monitoring device and contractures (Resident #60) out of the sampled thirty-two residents. Findings included: 1. On 04/06/21 at 11:00 a.m., Resident #87 was observed walking down the unit hallway and asking where the restroom was. Staff E, Licensed Practical Nurse (LPN), reported that Resident #87 often wandered, and had an order for an adult monitoring device. On 04/08/21 at 9:26 a.m., Resident #87 was observed sitting in the family lounge room. An adult monitoring device was observed on his left ankle. The admission Record revealed that Resident #87 was admitted into the facility on [DATE] with a primary diagnosis of Dementia without behavioral disturbance. Section C Cognitive Patterns of the admission Minimum Data Set (MDS), dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 04 out of 15, indicating severe impairment. Section P indicated that a wander/elopement alarm was used daily. The Nursing admission Evaluation, with an effective date of 03/04/21, revealed that Resident #87 verbalized a desire to leave the facility. The focus indicated that the resident was noted to wander and required an adult monitoring device. The care plan related to wandering, initiated on 03/04/2, indicated that Resident #87 was noted to wander and required an adult monitoring device. The interventions included, but were not limited to, check adult monitoring device function on 11-7 and check adult monitoring device placement every shift. A review of the current orders (April, 2021) indicated an order for an adult monitoring device and to check placement every shift. There was no order, however, related to checking the functioning of the device. The Treatment Administration Record for March and April 2021 revealed that the placement of the adult monitoring device was checked. There was no documentation, however, related to checking the functioning of the adult monitoring device. On 04/09/21 at 10:52 a.m., Staff B, Certified Nursing Assistant (CNA), reported that she was not responsible for checking the adult monitoring device. On 04/09/21 at 11:05 a.m. Staff C, Registered Nurse (RN), reported that Resident #87 did not have an order in place for checking the functioning of the adult monitoring device. She stated that the night shift was responsible for checking the functioning. Staff C, RN, confirmed that there was no documentation in the resident's medical record related to checking the functioning of the adult monitoring device. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 2 of 6 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 105398 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tierra Pines Center 7380 Ulmerton Rd Largo, FL 33771 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 The policy provided by the facility Wandering Customer, revised 06/29/17, revealed the following: Level of Harm - Minimal harm or potential for actual harm Check daily, usually night shift for proper functioning following manufacturer recommendation. Staff should document proper function on the TAR. Residents Affected - Few 2. On 04/06/21 at 11:53 a.m., Resident #60's family member reported that he was not receiving therapy or services for the left-hand contracture. The family member stated that he contacted the insurance company and had talked to staff about this concern. At this time, the resident was observed not wearing a splint, hip abduction, or the left knee orthotic, per physician orders. The resident's left hand was observed severely contracted. On 04/08/21 at 9:19 a.m., Resident #60 was observed sitting in the wheelchair next to the bed in his room. The resident was dressed for the day. No splints were observed. On 04/08/21 at 11:25 a.m., the resident was observed outside on the patio with the family member. Resident #60 did not have on a splint, hip abduction, or left knee orthotic. The family member reported he bought the resident a splint, but it is in the closet in his room and he had not seen the resident wearing a splint. The family member reported that Resident #60 used to have something for his thighs and he had not seen that either. On 04/08/21 at 3:08 p.m., Resident #60 was observed in bed. A splint was not observed on the left hand. A review of the admission Record for Resident #60 revealed that he was initially admitted into the facility on [DATE] with diagnoses that included, but were not limited to, contracture of unspecified joint and contracture of muscle at multiple sites. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS), dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe impairment. Section O reflected zero no for splint or brace assistance. The care plan related to contractures, initiated on 08/15/19, indicated that the goal was for Resident #60 to tolerate the splint. The interventions reflected that the resident used a left-hand splint, figure 8 splint, and left knee splint. A review of the Order Summary Report with active orders as of 04/09/21 revealed the following order: clarification patient to use hip abduction and left knee orthotic to prevent further contracture and patient to use left hand splint to prevent further contracture, dated 05/15/20. A review of the Treatment Administration Record (TAR) for March and April 2021 found that there was no documentation related to applying the splints or the hip abduction. A review of the Progress Notes for March and April 2021 did not reflect any documentation related to splints and a rationale for why the resident was not wearing the splint or the hip abduction. On 04/09/21 at 11:03 a.m., Staff F, Certified Nursing Assistant CNA, reported that she stopped putting the splint on because of the bruises on Resident #60's hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 3 of 6 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 105398 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tierra Pines Center 7380 Ulmerton Rd Largo, FL 33771 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/09/21 at 11:05 a.m., Staff C, Registered Nurse (RN) reported that they stopped restorative because of COVID. Staff C stated that Resident #60 was not wearing the splint because of the bruising on his hand. On 04/09/21 at 12:23 p.m., the Director of Nursing (DON) reported that the family member reported concerns to her about why Resident #60 was no longer wearing the brace or splint and he wanted her to look into it. On 04/09/21 at 12:25 p.m., the Director of Therapy (DOT) stated that Resident #60 had bruising and the significant other did not want him to have the splint on. He wanted them to hold off on using them. The DON reported that she thinks the splint got sent to laundry and did not come back. The policy provided by the facility Care Plan: Customer, revised 02/08/19, revealed the following: The center must develop and implement a comprehensive, person-centered care plan for each customer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 4 of 6 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 105398 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tierra Pines Center 7380 Ulmerton Rd Largo, FL 33771 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews, the facility did not ensure that 4 vials of Lorazepam 2mg/ML, a Schedule IV medication, were stored in a permanently affixed compartment, separate from other medications in a locked refrigerator for one of two medication storage rooms (First Floor Medication Storage Room). Findings include: On 4/9/21 at 11:00 a.m. an observation in the first-floor medication storage room was conducted with Staff D, Licensed Practical Nurse (LPN). The refrigerator in the room was found to be unlocked and a clear box was observed inside of the refrigerator. The box was not permanently affixed to the refrigerator and was able to be removed for inspection. The box contained Emergency Drug Kit insulin, a resident bag of medications and Emergency Drug Kit with 4 vials of Lorazepam 2mg/milliliter, a Schedule IV medication. Photographic evidence was obtained. An interview was conducted with Staff D, LPN at the time of the observation, she stated the medications are always stored like that. On 4/9/21 at 11:15 a.m. an interview was conducted with the Director of Nursing (DON). She stated the Consulting Pharmacist had just been in the building and had not identified the narcotics being improperly stored. A request for the policy on medication storage was requested. A review of the policy entitled, Medication Storage in the Facility with an effective date of February 2019 indicated the following: ID2: Controlled substance storage Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures: A-The Administrator and/or Director of Nursing, in collaboration with the Consultant Pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. B-Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications or per state regulation. C-Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator in such a manner that prevents its removal for the medication room. On 4/9/21 at 12:04 p.m. a telephone interview was conducted with the Consultant Pharmacist. The Pharmacist stated he had noticed the storage of the Ativan and was aware the medication needed to be in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 5 of 6 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 105398 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tierra Pines Center 7380 Ulmerton Rd Largo, FL 33771 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 a permanently affixed, separate box from other medications in the refrigerator. He stated he had made a note of this during his March rounds and he would work with the facility to correct this issue. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 6 of 6