Health inspection·December 8, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a new evaluation psychology report, dated 11/5/21 showed, patient seen today per staff request due to difficulty sleeping. A PTSD assessment showed the patient describes symptoms of PTSD, has a history of experiencing a traumatic event that involved actual or threatened death or serious injury. Afterwards feelings of intense fear and helplessness have been experienced. Patient could not identify the date of the traumatic event. Patient describes symptoms of PTSD including efforts to avoid reminders of the traumatic event, flashbacks, recurrent distressing dreams, hypervigilance, restricted affect, memory issues exclusive to the event. Plan of care to include caregiver education will serve as nonmedical and preventive interventions. Review of a re-evaluation psychology report, dated 12/1/21 showed, . Pt. (patient) still timid, guarded, possible PTSD but does not elaborate on trauma history. Patient has paranoia she states people are telling me, I am an alcoholic and that I have COVID she endorses racing thoughts and anxiety, 7/10. Worried about finances and insurance running out. Psychology plan of care for service dates of 11/16/21 and 12/1/21 showed: Staff to be educated on benefits of implementing the following interventions: Encourage alternative methods of communication with friends and family such as [video conferencing applications] and phone calls, monitor patients for psychosocial changes and observe and report any changes to mental status caused by the situational stress, provide support and allow resident to express feelings fears and concerns, communicate to social service for referral to psychology and psychiatric services providers if needed. Review of Resident #73's care plan, dated 11/1/22, showed: Resident has alteration in mood and psychosocial well-being and behavior related to Parkinson's disease. Pleasant with wandering for short intervals as she prefers to keep busy in her room resident became tearful when she is thinking of something upsetting [family member] in jail she relayed this and she displayed tremors in her arms. When she calmed, the tremors stopped. Goal: Resident will vent feelings regarding life issues and will have psychosocial and spiritual needs met through the next review. Interventions included one-on-one visits for support and promotion of venting feelings, approach in a gentle friendly manner, do not rush decisions or responses, give clear explanation of all care activities prior to, of us like psychology psychiatry services as needed, praise the resident when behavior is appropriate, provide resident with opportunities for choice during care provision, use simple concrete statements Review of Resident #73's care plan with goals initiated and resolved between 10/28/21 and 11/20/22 showed the resident was not care planned related to implementation of a trauma informed care plan related to a PTSD diagnosis. The care plan did not show interventions were in place to identify the history of trauma or interventions to address causes of triggers and traumatization. On 12/07/22 at 12:15 p.m., an interview was conducted with Staff O, Certified Nursing Assistant (CNA). She stated Resident #73 is always crying. Staff O said, An example that happened this morning . she was saying to me; I lied, I know I lied, now they are upset with me. Staff O stated the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 2 of 30 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 12/08/2022 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 repeated this over and over. She stated when this has happened in the past, she tries to reassure the resident. Staff O said, It's just the way she is. Staff O stated when the resident is stuck in things that are not real, we give her space. Staff O stated she thought the resident was nervous when interacting with strangers and sometimes it is in her head. She stated there has been no training on how to deal with that sort of behavior. Staff O stated she uses her instinct as a caregiver, and nursing responses, and just being kind. On 12/07/22 at 12:39 p.m. an interview was conducted with the Assistant Director of Nursing (ADON) and the Regional Clinical Director. The Regional Clinical Director stated the resident has an extensive history of trauma and is seeing psychology. The Regional Clinical Director was notified the care plan did not show any focus or interventions related to PTSD diagnosis. The Regional Clinical said, Most of her symptomatic behaviors are addressed in the mood/ evaluation focus care plan. She stated she would review if Resident #73 should be care planned for PTSD. Review of psychology and psychiatry progress notes from visits conducted on 11/30/22, 11/23/22, 11/16/22, and 10/31/22 showed the resident received on-going CBT (cognitive behavioral) therapy, psychoeducation, and stress management during the treatment sessions. On 12/07/22 at 3:21 p.m., an interview was conducted with the Regional Clinical Director. She stated Resident #73 was here for placement since the [family member's] arrest. The Regional Clinical Director stated the resident was evaluated by psychology and seen by a psychiatrist, was fitted with a wander guard due to wandering behaviors. She stated the resident has a lot of anxiety. She continues to be afraid to get out of her room. She stated psychiatry saw Resident #73 a month ago and reviewed a recent medication change. She stated the resident did not tolerate the medication change, she had increased hallucinations and the Seroquel was reinstated. On 12/08/22 at 8:20 a.m., Resident #73 was observed in her room, her breakfast tray was in front of her. The resident did not eat her breakfast. Resident #73 appeared emotional; eyes noted tearing up. Resident #73 stated she wanted to go downstairs to look at the Christmas tree. Resident #73 stated she was hoping the tree can be decorated before the guests arrive. Resident #73 appeared timid, teary, and withdrawn. On 12/08/22 at 12:49 p.m. an interview was conducted with the ADON and Staff E, Registered Nurse (RN)/Unit Manager. The ADON stated they have behavior monitoring for medication side effects but did not have monitoring related to PTSD/trauma. Staff E stated the resident does not have behaviors on a daily basis, she is quiet, with a private demeanor. Staff E, RN stated Resident #73 was not really showing any psychosis behavior for them to address. The crying, isolation and being withdrawn was her usual self. On 12/08/22 at 1:15 p.m., an interview was conducted with the Social Services Director (SSD). She confirmed Resident #73 was admitted with a diagnosis of PTSD. She stated the staff would know if the resident is being triggered; if they see anxiety increasing, shaking, wandering, rapid thoughts, incoherent, not present conversations. The SSD stated the PTSD was related to the [family member] exploiting her financially and him being arrested. She had gone through the investigation, which is a source of anxiety. If the resident encounters anyone asking her questions, she can be easily triggered. The SSD stated the resident was care planned specifically to mood and depression. She stated they do not have to care plan specific to PTSD diagnosis. The SSD stated they will update the care plan to include behavioral interventions. She stated the treatment interventions should have a way to monitor and report triggering behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 3 of 30 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 12/08/2022 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 An interview was conducted with the MDS Director on 12/08/22 at 1:11 p.m. She confirmed they did not have a care plan for Resident #73 related to PTSD or trauma. She stated they should have a care plan specific to the diagnosis, because it has a significant effect on the resident's day-to-day. She stated Resident #73 should have been assessed upon admission and interventions to manage her behaviors put in place. The MDS Director stated they would review their assessments to cover the history of trauma. The MDS Director stated they are not used to working with residents with the diagnosis of PTSD / Trauma, but that was not a reason not to care plan the resident. During an interview with the Nursing Home Administrator (NHA) on 12/08/22 at 1:57 p.m. She stated they should be care planning PTSD and resident with trauma. She stated Corporate just started the discussion on trauma- based-care. The NHA stated they are working on updating their facility policies and assessments. Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs, is developed and implemented for each resident. (9.) Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. (10.) Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the end point of an interdisciplinary process. (11.) Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making when possible, interventions addressed the underlying sources of the problem area not just addressing only symptoms or triggers. (13.) Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. (14.) The Interdisciplinary Team must review and update the care plan . when the desired outcome is not met. 2. On 12/5/2022 at 1:20 p.m. Resident #58 was observed in the secured/dementia unit and seated in a chair in the hall, across from the secured unit activities room. She was seated with other residents and just watching everything going on around her. She would speak with other residents near her. In an attempt to interview her it was determined she was confused and not interviewable. On 12/6/2022 at 12:04 p.m. Resident #58 was observed in the secured dining room participating in a group activity. Review of Resident #58's medical record revealed she was admitted to the facility on [DATE] and was currently in the facility for long term care services and resided in the secure dementia unit. Review of the current Quarterly MDS assessment, dated 10/7/2022, revealed a BIMS score of 1 out of 15, indicating she had severe cognitive impairment and mood and behaviors were indicated as none. In Section I - Active Diagnosis Post Traumatic Stress Disorder was selected. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 4 of 30 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 12/08/2022 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 Review of the psychological assessment, dated 4/28/2021, revealed Resident #58 was assessed by the psychologist with relation to PTSD/Trauma. The assessment revealed a history and present illness with comments to include: The resident has previously been diagnosed with dementia, anxiety and PTSD. The recommendations revealed: Continue to assess for appropriateness and to continue with psychiatric evaluation for medication management, with an anticipated length of treatment for three months. The treatment plan included: The resident was referred for an evaluation due to symptoms of anxiety. She presented as alert, Ox 2 (times two) with confusion, mildly circumstantial thoughts, elevated and anxious mood, mobile affect, impaired memory. She has previously been diagnosed with PTSD, anxiety and dementia. She has also been diagnosed with a TBI (traumatic brain injury). The resident may benefit from a psychiatric evaluation for medication management. Ongoing assessment to determine if she may benefit from individual psychotherapy. This assessment was completed twenty-six days after the resident was admitted to the facility. On 12/8/2022 at 8:50 a.m. an interview with the Staff G, Registered Nurse/Unit Manager and she revealed Resident #58 was newer to the secured unit and she was normally pleasant and does ambulate throughout the unit and participates in group activities. Staff G revealed at times she (Resident #58) can be resistive to care and with some aggression. Staff G indicated Resident #58 was easily redirected. Staff G was not aware of Resident #58's diagnosis of PTSD/Trauma or behaviors related to the diagnosis. She looked at the electronic medical record under the diagnosis tab and did confirm there was a diagnosis of PTSD/Trauma, but was unaware why the resident had the diagnosis and further confirmed she could not find an assessment or care plan with relation to PTSD/Trauma. On 12/8/2022 at 9:30 a.m. Staff G provided a Social Service Note and indicated she found some information related to Resident #58's trauma. The note revealed: 3/29/2022 12:19 (p.m.) Social Service Note - Resident #58 was involved in a serious car accident years ago that led her into a coma with a TBI, Resident recovered and went back to work as a Licensed Mental Health Tech. Staff G confirmed she was still not knowledgeable of this until just now. She further explained she has worked in the secured/dementia unit for about three months and would not know what type of behaviors to look for related to Resident #58 and her PTSD/Trauma diagnosis. On 12/8/2022 at 9:01 a.m. an interview Staff F, CNA (7:00 a.m. - 3:00 p.m. shift dementia/secured unit) revealed she was aware of Resident #58 and that Resident #58 is usually pleasant and interacts well with staff and other residents. Staff F explained Resident #58 has been on her daily work assignment many times and she interacts with her daily, even if not on her assignment. Staff F confirmed she was not aware of Resident #58 having PTSD/Trauma and has not exhibited with any types of behaviors or observations that would make her believe she had any current or past psychosocial trauma. Staff F further indicated she has not had any specific training and or in-services that would provide her with education on how to handle residents with PTSD/Trauma. On 12/8/2022 at 9:08 a.m. an interview with Staff K, CNA (7:00 a.m. - 3:00 p.m. shift dementia/secured unit) confirmed she has Resident #58 on her assignment routinely and she knows the resident to be pleasant but confused and interacts well with all the residents and staff on the unit. Staff K also confirmed Resident #58 has presented with some refusal of care behaviors and some aggression but has been easily redirected. Staff K confirmed she was not aware Resident #58 had past PTSD/Trauma and would not know what to look for or how to handle a resident who has PTSD/Trauma. On 12/8/2022 at 10:45 a.m. an interview with both the Staff E, LPN and the Assistant Director of Nursing (ADON) was conducted. Staff E was aware Resident #58 had a diagnosis of PTSD/Trauma and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 5 of 30 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 12/08/2022 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 indicated it had been brought to his attention that the resident was involved in a car accident many years ago and was in a coma and had a TBI. He revealed there is no current PTSD/Trauma assessment for Resident #58. The ADON was also involved in this interview and also confirmed she knew about Resident #58's PTSD/Trauma and that related to an accident years ago, but also confirmed there was no assessment to indicate this, other than a social service note and a diagnosis of PTST/Trauma. Staff E and the ADON also confirmed there were no current or past care planning problem areas with interventions related to PTSD/Trauma. On 12/8/2022 at 2:00 p.m. during an interview, the Nursing Home Administrator confirmed Resident #58 was not assessed for PTSD/Trauma upon her admission on [DATE], but was assessed by a psychologist on 4/28/2022, which was twenty-six days after Resident #58's initial admission. The Nursing Home Administrator revealed the resident was not care planned with problem areas and interventions related to the resident's past PTSD/Trauma. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 6 of 30 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 12/08/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to provide respiratory care consistent with professional standards of practice related to not notifying the physician of an episode of respiratory distress and did not following physician oxygen orders for one resident (#95) out of two residents reviewed for oxygen for two out of three observations made of Resident #95. Residents Affected - Few Findings included: Review of Resident #95's admission Record revealed she was admitted from an acute care hospital on 7/13/2022 with diagnoses that included but are not limited to chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, anxiety disorder, major depressive disorder, recurrent, unspecified dementia with other behavioral disturbances. Review of Resident #95's Minimum Data Set Section C Cognitive Patterns, dated August 30, 2022, revealed a Brief Interview for Mental Status summary score of 4 out of 15, indicating severely impaired cognition. On 12/05/22 at 10:06 a.m. Resident #95 was overheard repeatedly yelling from her room Please someone, help me please. Call light was not on. Upon entry into the resident's room, she continued to call out please help me, please help me. Her call light was observed on her bed up by her pillow. The resident had her phone in her hand and was pushing buttons on the phone. She was noted to have her nasal cannula (NC) on, but it was not in her nostrils. She appeared in respiratory distress with an increased respiratory rate. She stated help me; I can't breathe, I can't breathe. The oxygen concentrator was observed to be on 2.5 liters (L) with the nasal cannula not in her nose. This surveyor went and got the nurse, Staff H, Licensed Practical Nurse (LPN), at 10:07 a.m. The nurse went into the room checked the resident's oxygen saturations, placed the NC on her, instructed her to take a few deep breaths in through her nose and out of her mouth and rechecked her oxygen saturations. She reassured the resident she would be just outside of her room and to use her call light for assistance. Immediately after the nurse left the resident's room on 12/05/22 at 10:07a.m. an interview was conducted with Staff H, LPN she stated the resident has COPD, her saturation when I went in was 87% and then came up to 96%. She always pulls her NC out of her nose. She has anxiety so when she pulls her NC out, and her saturations drop she gets confused and anxious. I just gave her an inhaler earlier this morning. Further observation was conducted on 12/06/22 at 11:18 a.m. Resident #95 was observed to be dressed lying in bed, not in any respiratory distress. Resident #95 was observed to have her NC on and in her nose, the oxygen concentrator was set on 3L. Resident #95 stated she was feeling as good as she can feel with her breathing. On 12/08/22 at 8:30 a.m. Resident #95 was observed to be sitting on the side of her bed with increased work of breathing asking where her youngest [family member] was. Staff E, LPN/Unit Manager was next to the resident an observed to put her oxygen cannula back on the resident and telling her to take slow deep breaths. Staff E stated Resident #95 was set on 2L and that she should be on 3L and he adjusted the oxygen. The resident began to relax and her increased work of breathing was better controlled. Staff E was interviewed at this time and he stated when he found the resident she was walking to the nurses station without her oxygen on. He escorted her back to her room placed the nasal cannula back on the resident. He said she will take off her oxygen and she becomes hypoxic and very (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 7 of 30 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 12/08/2022 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confused. We added the order to monitor her oxygen every shift because we had a care plan meeting with the family, and we told them that she has been taking off her oxygen and becoming hypoxic and confused. So, I added that order and told the family because it looked like maybe when she came back from the hospital the order got missed or dropped off. I'm not sure, but it's on there now. She also used to be at the end of the hall, and she would walk up to the nurses' station without her oxygen on and that is not good. It was way too long of a walk for her without her oxygen so we moved her closer to the nurses station. Review of Resident #95's physician orders for December 2022 revealed an order with a start date of 7/18/2022 and a discontinuation date of 12/07/2022 for respiratory-Oxygen: NC (nasal cannula)/mask. Encourage and assess resident to use O2 (oxygen) at 3L (liters) via NC continuous for SOB (shortness of breath) and O2 sat (oxygen saturation) less than 90 every shift for O2 sat less than 90 / SOB. Further review of the physician orders, dated 12/8/22, revealed an order, with a start date of 12/07/2022 with no end date, for Respiratory-Oxygen: NC/mask. Encourage and assess resident to use O2 at 3L via NC continuous for SOB and O2 sat if less than 90% every shift for O2 sat less than 90 / SOB. Review of Resident #95' care plan, revised on 8/15/2022, revealed: Focus: resident is at risk for altered respiratory status/difficulty breathing related to anxiety, COPD/emphysema, and history of acute/chronic respiratory failure. Goal: The resident will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Interventions with an initiation date of 8/15/2022 included but were not limited to: Administer oxygen as ordered. Monitor O2 saturations as ordered/PRN (as needed); Monitor s/sx (signs and symptoms) of respiratory distress and report to MD PRN [Medical Doctor as needed]; Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic Pain; Accessory Muscle usage; Skin color changes to blue/gray. Review of Resident #95's behavior care plan, initiated on 12/6/21 and revised on 8/19/22, did not reveal any indication the resident has behaviors of changing her oxygen settings or removing her nasal cannula. Review of Resident #95's progress notes from 12/01/2022 to 12/08/2022 (survey exit date) did not reveal notification to the physician of an episode of desaturation on 12/5/2022. Review of Resident #95's Treatment Administration Record for December 2022 revealed an order with a start date of 7/18/2022 and a discontinuation date of 12/07/2022 for Respiratory-Oxygen: NC/mask. Encourage and assess resident to use O2 at 3L via NC continuous for SOB and O2 sat less than 90 every shift for O2 sat less than 90 / SOB. On December 5, 2022, it was documented on the 7:00 a.m.to 3:00 p.m. dayshift the oxygen saturation was 98%. Further review of documentation provided by the facility after the survey exit revealed a physician note dated 12/9/2022, Patient with chronic SOB 2/2 COPD/lung nodules, not always compliant with O2, 2/2 dementia. She is known to remove her O2 as well as adjust her settings on her O2 tank PCP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 8 of 30 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 12/08/2022 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 0695 [Primary Care Physician] has been made aware of this, as well as patient's family. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the Nursing Home Administrator on 12/8/2022 at 6:01 p.m. she indicated it would be her expectation the physician should have been notified of hypoxic episodes and the resident should receive the ordered amount of oxygen. Residents Affected - Few Review of the facility's policy titled, Oxygen Administration, revised October 2010, revealed: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. .General Guidelines 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. .b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band place around the resident's head. . Steps in the Procedure 1. Wash and dry your hands thoroughly. 2. Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. 3. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen perfect physician orders. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, revealed: Policy Statement Orders for medication and treatments will be consistent with principles of safe and effective order writing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 9 of 30 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 12/08/2022 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 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #58's medical record revealed she was admitted to the facility on [DATE] and was currently in the facility for long term care services and resided in the secure dementia unit. Review of Resident #58's medical record revealed she was admitted to the facility on [DATE] and was currently in the facility for long term care services and resided in the secure dementia unit. Review of the current Quarterly MDS assessment, dated 10/7/2022, revealed a BIMS score of 1 out of 15, indicating she had severe cognitive impairment and mood and behaviors were indicated as none. In Section I - Active Diagnosis Post Traumatic Stress Disorder was selected. On 12/8/2022 at 9:01 a.m. an interview Staff F, CNA (7:00 a.m. - 3:00 p.m. shift dementia/secured unit) revealed she was aware of Resident #58 and that Resident #58 is usually pleasant and interacts well with staff and other residents. Staff F explained Resident #58 has been on her daily work assignment many times and she interacts with her daily, even if not on her assignment. Staff F confirmed she was not aware of Resident #58 having PTSD/Trauma and has not exhibited with any types of behaviors or observations that would make her believe she had any current or past psychosocial trauma. Staff F further indicated she has not had any specific training and or in-services that would provide her with education on how to handle residents with PTSD/Trauma. She did not remember completing any competencies related to this area. On 12/8/2022 at 9:08 a.m. an interview with Staff K, CNA (7:00 a.m. - 3:00 p.m. shift dementia/secured unit) confirmed she has Resident #58 on her assignment routinely and she knows the resident to be pleasant but confused and interacts well with all the residents and staff on the unit. Staff K also confirmed Resident #58 has presented with some refusal of care behaviors and some aggression but has been easily redirected. Staff K confirmed she was not aware Resident #58 had past PTSD/Trauma and would not know what to look for or how to handle a resident who has PTSD/Trauma. She confirmed she has not received any education and or in-services related to PTSD/Trauma. She did not remember completing any competencies related to this area. On 12/8/2022 at 10:45 a.m. an interview with both the Staff E, LPN and the Assistant Director of Nursing (ADON) was conducted. Staff E was aware Resident #58 had a diagnosis of PTSD/Trauma and indicated it had been brought to his attention that the resident was involved in a car accident many years ago and was in a coma and had a TBI. He revealed there is no current PTSD/Trauma assessment for Resident #58. The ADON was also involved in this interview and also confirmed she knew about Resident #58's PTSD/Trauma and that related to an accident years ago, but also confirmed there was no assessment to indicate this, other than a social service note and a diagnosis of PTST/Trauma. Staff E and the ADON also confirmed there were no current or past care planning problem areas with interventions related to PTSD/Trauma. The ADON and Staff E did not know if there were any specific trauma/PTSD education competencies passed to direct care floor staff. On 12/8/2022 at 2:00 p.m. during an interview, the Nursing Home Administrator confirmed Resident #58 was not assessed for PTSD/Trauma upon her admission on [DATE], but was assessed by a psychologist on 4/28/2022, which was twenty-six days after Resident #58's initial admission. The Nursing Home Administrator revealed the resident was not care planned with problem areas and interventions related to the resident's past PTSD/Trauma. In addition, the NHA could not provide any education to show (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 10 of 30 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 12/08/2022 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 0741 Staff F or K have had competencies related to Trauma/PTSD. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility did not ensure staff were qualified with competencies related to trauma-based care and treatment for Post-Traumatic Stress Disorder (PTSD) diagnosis for two residents ( #73 and #58) of two residents sampled. Residents Affected - Few Findings included: 1. Review of Resident #73's Electronic Medical Record (EMR) showed the resident was admitted to the facility on [DATE] with a diagnosis to include Post Traumatic disorder (PTSD). An annual minimum data set (MDS) dated [DATE], showed under section C the resident has a brief interview for mental status BIMS score of 13, indicating intact cognition. During facility tours on 12/05/22 at 12:43 p.m., 12/06/22 at 9:36 a.m., 12/07/22 at 12:10 p.m., and 12/08/22 at 8:20 a.m. Resident #73 was observed in her room sitting in her wheelchair. Resident #73 was noted withdrawn and avoiding eye contact. The resident was not watching TV or interacting with staff or her roommate. The resident appeared guarded and was hesitant to answer questions. Review of a new evaluation psychology report, dated 11/5/21 showed, patient seen today per staff request due to difficulty sleeping. A PTSD assessment showed the patient describes symptoms of PTSD, has a history of experiencing a traumatic event that involved actual or threatened death or serious injury. Afterwards feelings of intense fear and helplessness have been experienced. Patient could not identify the date of the traumatic event. Patient describes symptoms of PTSD including efforts to avoid reminders of the traumatic event, flashbacks, recurrent distressing dreams, hypervigilance, restricted affect, memory issues exclusive to the event. Plan of care to include caregiver education will serve as nonmedical and preventive interventions. Psychology plan of care for service dates of 11/16/21 and 12/1/21 showed: Staff to be educated on benefits of implementing the following interventions: Encourage alternative methods of communication with friends and family such as [video conferencing applications] and phone calls, monitor patients for psychosocial changes and observe and report any changes to mental status caused by the situational stress, provide support and allow resident to express feelings fears and concerns, communicate to social service for referral to psychology and psychiatric services providers if needed. On 12/07/22 at 12:15 p.m., an interview was conducted with Staff O, Certified Nursing Assistant (CNA). She stated Resident #73 is always crying. Staff O said, An example that happened this morning . she was saying to me; I lied, I know I lied, now they are upset with me. Staff O stated the resident repeated this over and over. She stated when this has happened in the past, she tries to reassure the resident. Staff O said, It's just the way she is. Staff O stated when the resident is stuck in things that are not real, we give her space. Staff O stated she thought the resident was nervous when interacting with strangers and sometimes it is in her head. She stated there has been no training on how to deal with that sort of behavior. Staff O stated she uses her instinct as a caregiver, and nursing responses, and just being kind. On 12/07/22 at 12:39 p.m. an interview was conducted with the Assistant Director of Nursing (ADON) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 11 of 30 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 12/08/2022 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 0741 Level of Harm - Minimal harm or potential for actual harm and the Regional Clinical Director. The Regional Clinical Director stated the resident has an extensive history of trauma and is seeing psychology. The Regional Clinical Director was notified the care plan did not show any focus or interventions related to PTSD diagnosis. The Regional Clinical said, Most of her symptomatic behaviors are addressed in the mood/ evaluation focus care plan. She stated she would review if Resident #73 should be care planned for PTSD. Residents Affected - Few Review of psychology and psychiatry progress notes from visits conducted on 11/30/22, 11/23/22, 11/16/22, and 10/31/22 showed the resident received on-going CBT (cognitive behavioral) therapy, psychoeducation, and stress management during the treatment sessions. The review did not show staff received competencies for trauma informed care. On 12/07/22 at 3:21 p.m., an interview was conducted with the Regional Clinical Director. She stated Resident #73 was here for placement since the [family member's] arrest. The Regional Clinical Director stated the resident was evaluated by psychology and seen by a psychiatrist, was fitted with a wander guard due to wandering behaviors. She stated the resident has a lot of anxiety. She continues to be afraid to get out of her room. She stated psychiatry saw Resident #73 a month ago and reviewed a recent medication change. She stated the resident did not tolerate the medication change, she had increased hallucinations and the Seroquel was reinstated. The Regional Clinical Director did not indicate their plan of care at the facility in assisting the resident to manage the effects of her trauma day-to-day. On 12/08/22 at 8:20 a.m., Resident #73 was observed in her room, her breakfast tray was in front of her. The resident did not eat her breakfast. Resident #73 appeared emotional; eyes noted tearing up. Resident #73 stated she wanted to go downstairs to look at the Christmas tree. Resident #73 stated she was hoping the tree can be decorated before the guests arrive. Resident #73 appeared timid, teary, and withdrawn. An interview was conducted on 12/08/22 at 8:30 a.m., with Staff H, Licensed Practical Nurse (LPN). She stated she works with the resident quite often. She stated the resident is always like that. When asked what like that meant, Staff H said, She is sad, confused, cries a lot, she hallucinates, talks about things that are not real. Staff H, LPN stated she tries to redirect her. She stated she knows how to work with someone with PTSD from schooling, not necessarily from training at the facility. She stated her response is to redirect her and encourage her to get out of her room. Staff H said, I invite her to sit in the hallway so she can watch me pass medications. On 12/08/22 at 8:34 a.m., an interview was conducted with Staff O, CNA who was assigned to Resident #73. She stated the resident was teary again this morning. She was confused. She believes she is at her house and is decorating her house for Christmas. Staff O stated the resident was anxious and has been asking to go outside. Staff O stated if the resident asks to go outside, they redirect her to stay in. Staff O stated the resident is not in reality. Staff O said, I don't know what we can do for her. It is very sad. During an interview on 12/08/22 at 9:30 a.m. with the Assistant Social Services Director (ASD), she stated Resident #73 likes to stay in her room and sometimes she asks to go out. The ASD stated she had not heard from staff that she was confused or experiencing any changes. The ASD stated the resident is at her baseline with anxiety and confusion. The ASD stated if the resident experiences behavioral concerns nursing staff should report to the Unit Manager, who should let social services know. The ASD stated the CNAs should communicate with social services so they can get the resident psych help. She stated she did not know if the facility provided behavioral training, but the CNAs should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 12 of 30 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 12/08/2022 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 0741 let them know if they have training needs. Level of Harm - Minimal harm or potential for actual harm On 12/08/22 at 12:49 p.m. an interview was conducted with the ADON and Staff E, Registered Nurse (RN)/Unit Manager. The ADON stated they have behavior monitoring for medication side effects but did not have monitoring related to PTSD/trauma. Staff E stated the resident does not have behaviors on a daily basis, she is quiet, with a private demeanor. Staff E, RN stated Resident #73 was not really showing any psychosis behavior for them to address. The crying, isolation and being withdrawn was her usual self. Staff E stated he had not been part of any behavioral trainings. He confirmed they had not provided training related to trauma. Residents Affected - Few During an interview with the Nursing Home Administrator (NHA) on 12/08/22 at 1:57 p.m. She stated their annual training covers some trauma informed care. The NHA stated the training is not detailed or specific but, it address some expectations. The NHA presented a document titled, Annual Education, showing the facility's education plan on culturally competent trauma informed care. The NHA said, This does not show the details but, we are working on competencies and will roll them out soon. The NHA stated the ADON has started in-services, but not prior to the survey. Review of an undated document titled, Facility Assessment, showed the nursing facility will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. The purpose of the assessment is to determine what resources are necessary to care for residents completely . Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, psychosocial well-being. The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. Review of Section 1.3 showed under common diagnoses, a list of diagnoses that the facility would commonly accept. PTSD and trauma were not listed. Section 1.4 showed if a resident had a condition not listed in the facility assessment, the facility would review clinical data to ensure the facility is able to care accordingly for the patient, determine if they have or can reasonably obtain staff competencies/resources to meet that patient's needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 13 of 30 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 12/08/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility did not ensure the attending physician provided rationale for disagreeing with the pharmacist recommendations as part of the Drug Regimen Review for two residents (#94 and #43) out of five residents reviewed for unnecessary medication. Findings included: 1. A review of pharmacy recommendations for Resident #94 revealed the following recommendations: * Medication Regimen Review, dated 8/1/2022: Currently receiving Temazepam 15mg (milligrams) at bedtime for insomnia. Long term use not recommended. Please evaluate, consider trial taper to 7.5mg at bedtime, if appropriate. The provider marked disagree with no reason stated. The recommendation was signed on 9/2/22. * Medication Regimen Review, dated 10/3/22: Currently receiving Pantoprazole. Long term use of PPI's (proton pump inhibitors) has been associated with increased risk of pneumonia, c. difficile (clostridioides difficile), hypomagnesemia, fractures, and both B12 and iron deficiency. Please evaluate current need. Consider trial taper to every other day for 14 days then discontinue, if appropriate. The provider marked disagree with no reason stated. The recommendation was signed by ARNP (advanced registered nurse practitioner) as verbally order and not dated. A review of the admission Record indicated Resident #94 was admitted on [DATE] and readmitted on [DATE] with diagnoses including insomnia, gastro-esophageal reflux disease without esophagitis, pneumonitis due to inhalation of food and vomit, and anemia. An interview was conducted with the Regional Nurse on 12/8/22 at 1:50 p.m. She confirmed there was no further documentation in the record noting the provider's rationale for disagreeing with the pharmacy recommendations for Residents #94 and #43. She stated the process is the pharmacy recommendations come to the Director of Nursing (DON.) The DON then divides them up by unit and gives them to the Unit Managers (UMs) The UMs ensure the providers see and complete the forms within two weeks. The forms are returned to the unit managers to verify the orders are in and forms are completed. The Regional Nurse stated the provider should give a reason if they disagree with the recommendation. An interview was conducted with the Assistant Director of Nursing (ADON) on 12/8/22 at 2:10 p.m. The ADON confirmed the process described by the Regional Nurse. She also stated the provider should fill out a reason if they disagree with a recommendation. On 12/8/22 at 3:50 p.m. an interview was conducted with the facility's Consultant Pharmacist. The pharmacist stated medication reviews are completed monthly and her recommendations are sent to the facility. She stated the physician will review the recommendations and it is at their discretion to agree or disagree. The physician will sign and date the recommendation. She stated it is a physician's choice to disagree with the recommendation, but a reason should be notated. She stated the completed forms are in a binder the pharmacist reviews. She stated they use the reason for disagreement noted by the physician to make notes for themselves and to follow up with the DON or physician if needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 14 of 30 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 12/08/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with Staff C, Licensed Practical Nurse (LPN)/Unit Manager (UM) on 12/8/22 at 4:36 p.m. Staff C stated they receive the pharmacy recommendations from the DON and give them to the providers. After the forms are signed by the provider the unit managers verify the orders are updated as needed. Staff C stated most providers put a reason they disagree, but the UM does not check for that. Staff C stated they did not know they were supposed to ensure a reason was listed for disagreement. Staff C stated no one has ever told them a rationale was required and they were not trained on that. Staff C stated now that they know it is needed, they will check that it is done. 2. Resident # 43's admission Record revealed he was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, unspecified, major depressive disorder, anxiety disorder, peripheral vascular disease and type 2 diabetes mellitus with diabetic neuropathy, unspecified. A review of the Medication Regimen, dated 8/1/2022, revealed the pharmacist recommendation was as follows: Currently receiving Diazepam 5mg daily for anxiety. Minimal recent episodes documented in clinical record. Increase risk of respiratory depression with concomitant opioid and gabapentin. Please evaluate continued need, consider trial discontinue if, appropriate. The provider marked disagree with no reason stated. The recommendation was signed on 9/1/22. A review of the Medication Regimen, dated 9/01/2022, revealed the pharmacist recommendation was as follows: Currently receiving Morphine as a standing order. Please evaluate current need. Pain score often recorded as 0. Consider taper to as needed, if appropriate. The recommendation was signed by ARNP (advanced registered nurse practitioner) as verbally order and not dated. A review of the Medication Regimen, dated 11/2/2022, revealed the pharmacist recommendation was as follows: Currently has an active order for Diazepam prn (as needed) without a specified stop date. Please note that CMS (Centers for Medicare and Medicaid Services) guidelines do not allow open ended order for PRN psychotropics. Please evaluate and consider adding stop date or discontinuing the order for Diazepam prn, if appropriate. The provider marked disagree with no reason stated. The recommendation was signed on 11/4/22. A review of the Medication Regimen, dated 10/3/2022, revealed the pharmacist recommendation is as follows: Currently with active order for basal insulin coverage along with routine fingersticks with sliding scale insulin coverage. Fingerstick blood glucose readings are frequently above 200mg/dl (decilitre). Please evaluate and consider increase dose of basal insulin to 12 units daily, if appropriate. The recommendation was signed by ARNP (advanced registered nurse practitioner) as verbally order and not dated. A facility policy titled, Medication Regimen Reviews, dated April 2007, was reviewed. The policy stated the following: 5. The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. A facility policy titled, Drug Regimen Review-Monthly, was reviewed. The policy stated the following: Prescriber/Licensed Designee: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 15 of 30 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 12/08/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm 1. Shall act upon the Drug Regimen Review findings/recommendations in a timely manner of 7-14 days or less. Shall document on the drug regimen review form whether he/she agrees or disagrees with the recommendation and provide a brief clinical rationale if no change is to be made. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 16 of 30 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 12/08/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews and record review, the facility failed to ensure the kitchen was maintained in a sanitary manner as evidence by: 1. the dish washing machine was not receiving sanitizer via the liquid sanitizer delivery system for three wash cycles observed and washing temperatures were not meeting the required temperature; 2. one of one walk in freezers had a large amount of ice buildup; and 3. black bio growth built up on a wall near and behind the dish washing machine, for two days (12/5/2022 and 12/6/2022) of four day observed. Findings included: 1. On 12/5/2022 at 9:20 a.m. the kitchen was toured with the facility's Dietary Manager. Upon entering the kitchen and meeting with the Dietary Manager, he indicated the kitchen utilizes a low temperature dish washing machine, and Staff I, Dietary Aide and Staff J, Dietary Aide were at the time in the process of operating the machine. The Dietary Manager also revealed the dish washing machine's wash temperature cycle was expected to reach at least 120 degrees Fahrenheit (F), and the rinse temperature cycle was to reach at least 120 degrees F. The dish washing machine also delivered a sanitizer via a pump and bucket, through plastic tubing lines. The Dietary Manager confirmed the sanitizer must reach at least 50 - 100 parts per million (PPM) after the wash and rinse cycle. He revealed they have a heating booster and the dish washing machine has to be primed several times before use, in order to get the wash and rinse temperatures per the requirement. He indicated the dish washing machine had already been primed and was operating appropriately. Review of the specification plate on the dish washing machine, revealed the machine is a low temperature machine with the wash temperature at 120 degrees F, and the rinse temperature at 120 degrees F. At this time, Staff I and J were observed to have already run four plastic crates of soiled dishes through the dish washing machine and were ready for drying. Staff I confirmed the machine was a low temp (temperature) dish washing machine. Staff I and J both confirmed the machine was operating appropriately and they had run several crates of dishes through the machine. Staff J also confirmed the machine had been boosted, to ensure the required wash and rinse temperatures were reached. Staff I and J were further interviewed and asked what the required temperatures needed to be with each wash/rinse cycle. Both answered, Wash at 120 degrees F., and rinse at 120 degrees F. Staff I, Staff J and the Dietary Manager were then asked about the sanitizer. Staff I and Staff J both confirmed they had been trained and in serviced on how to test the machine with the sanitizer test strips but did not know exactly what the appropriate test range should be. Staff J then said, 100 parts per million (PPM). Staff J said, I have not tested the sanitizer with the test strips yet. Staff I did confirm she ran four crates of dishes through the machine and did not test the sanitizer. At this time the Dietary Manager took his right hand and flipped a toggle switch labeled Sanitizer several times. He said, It helps the sanitizer not get stuck in the lines. The Dietary Manager flipped the switch approximately seven times and confirmed this should not be the process for each wash cycle. Staff I was asked if she flips the sanitizer switch and she revealed that she did not. At 9:30 a.m. Staff I, Dietary Aide ran a crate of dishes through the machine and the following was observed: The first demonstration indicated the wash temperature reached 115 degrees F and the rinse cycle reached 120 degrees F. After the wash/rinse cycle, the Dietary Manager tested the sanitizer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 17 of 30 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 12/08/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with the test strip in a water pooled section of a plate cover. Once he placed the strip on the plate cover, the white test strip did not change color at all and remained white. (Photographic Evidence Obtained) The Dietary Manager confirmed and indicated there had been some problems with the sanitizer lines and the maintenance company came out and had to replace the lines to ensure sanitizer was de-clogged. He said this happened about two weeks ago. He confirmed the wash temperature did not reach at least 120 degrees and also confirmed that sanitizer was not being delivered from the bucket, through the pump and to the machine. He also confirmed if the sanitizer was working and delivered properly, the test strip would turn a shade of purple indicating at least 50 parts per million (PPM). At 9:32 a.m. the Dietary Manager ran a second demonstration and the dish machine wash temperature reached 118 degrees F and the rinse temperature reached 120 degrees F. The Dietary Manager again tested the sanitizer via a white test strip. He placed the strip on a water pooled section of a dish and the test strip remained white in color and did not change color to indicate a sanitizer level of at least 50 PPM. He again started to flip the sanitizer toggle switch many times to try and unclog the clogged lines. The Dietary Manager then confirmed again that they had been having a clogging problem and the dish machine maintenance company had been out within the past few weeks to correct it. He did not know how long the sanitizer had not been effectively delivered to the machine. The Dietary Manager and Staff I, Dietary Aide both confirmed the sanitizer was not tested with the strip prior to the demonstrations and there had been four crates of dishes run through the dishing washing machine and deemed as cleaned. Staff I and the Dietary Manager also confirmed they did not know the sanitizer was clogged again and did not check it this morning. On 12/7/2022 at approximately 1:45 p.m. the Dietary Manager confirmed he goes by what the dish machine specification plate says; which is affixed to the front of the machine and he goes by what the dish washing machine maintenance company directs. He revealed the dish machine maintenance company suggests operating the machine per the specifications with no adjustment. 2. During the kitchen tours on 12/5/2022 at 9:30 a.m. and again on 12/7/2022 at 1:45 p.m., an observation revealed an approximately two feet wide, and three feet in length section of the wall, behind and to the left side of the dish machine with heavy black bio growth build up. This was confirmed by Staff I, Dietary Aide and the Dietary Manager. (Photographic Evidence Obtained) The Dietary Manager revealed the kitchen is cleaned daily per the schedule and did not know how the wall accrued this black bio growth. Staff I was not aware of the large section of black bio growth. 3. During a kitchen tour on 12/5/2022 at 9:30 a.m. the walk in freezer was observed and the temperature per review of the internal thermometer, was at 0 degrees F. Further observations of the inside of the freezer revealed an internal motor housing hanging from the ceiling at the left side of the freezer. The pipes leading from the motor and down to the back wall revealed a large amount of ice buildup measuring approximately seven inches across and six inches hanging down. (Photographic Evidence Obtained) Interview with the Dietary Manager at this time revealed he chips away at the ice from time to time and the freezer door had been replaced recently, but ice still builds up and he nor the maintenance man are sure why the ice is building up. On 12/8/2022 at 1:25 p.m. the Dietary Manager provided the undated policy titled, PROCEDURES FOR LOW TEMP SANITIZER, for review. The policy revealed if temperatures fall below NSF (National Sanitation Foundation) specifications, to check for 50 ppm available chlorine in final rinse. The procedure further indicated it is recommended emergency chemical sanitizing guidelines: Sanitizer required in final rinse: Minimum 50 ppm available chlorine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 18 of 30 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 12/08/2022 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility did not ensure residents who entered arbitration agreements understood the contract contents for three residents (#363, #362 and #361) of three residents sampled. Residents Affected - Some Findings included: 1. On 12/06/22 at 10:04 a.m., an interview was conducted with the Nursing Home Administrator (NHA). She presented a list of residents who have recently signed arbitration agreements. The NHA stated they have one resident who is currently in the dispute process, their case has not been resolved. The NHA stated all residents review and sign arbitration agreements upon admission. The NHA stated it was optional. Review of the admission Record for Resident #363 revealed an admission date of 11/21/22 with diagnoses to include failure to thrive, and chronic obstructive pulmonary disease. The Responsible Party/Guarantor listed indicated it was not Resident #363. Review of the admission Agreement attachment titled, Attachment K Alternative Dispute Resolution Agreement Between Resident and Facility, was signed by Resident #363 and the Business Office Manager on 11/23/22. On 12/07/22 at 4:15 p.m., an interview was conducted with Resident #363. The resident stated he signed a bunch of papers on admission. He stated he does not know exactly what he signed. He remembers the lady going through all the papers. Resident #363 stated, Yes, I signed all of them. The resident stated he remembers signing some agreement. Resident #363 stated he was not sure what that was or what it means. The resident was shown the copy he signed. Resident #363 stated he does not remember signing that. Resident #363 said, She was talking too fast. I just wanted to rest. Review of an admission Minimum Data Set (MDS) for Resident #363, dated 11/30/22, showed Resident #363 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. 2. Review of the admission Record for Resident #362 revealed an admission date of 11/23/22. Review of an admission Minimum Data Set (MDS), dated [DATE], showed Resident #362 had a BIMS score of 15 out of 15, indicating intact cognition. Review of the admission Agreement attachment titled, Attachment K Alternative Dispute Resolution Agreement Between Resident and Facility, was signed by Resident #362 and the Business Office Manager on 11/28/22. On 12/07/22 at 4:32 p.m., an interview was conducted with Resident #362. The resident reviewed a copy of the agreement she signed. Resident #362 stated, Yes, I signed this. Did I do something wrong? The resident stated she did not know what the agreement meant. Resident #362 said, To be honest, I was foggy that night. I arrived very late in the evening, the lady read through the forms. I was out of it. I don't know what that means. The resident stated she would like someone to explain the form again. Resident #362 stated she would revoke the Arbitration agreement if it didn't affect her stay. The resident stated she just wants to get well and get back home. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 19 of 30 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 12/08/2022 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 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Review of the admission Record for Resident #361 revealed an admission date of 11/29/22. Review of an admission Minimum Data Set (MDS), dated [DATE], showed Resident #361 had a BIMS score of 04 out of 15, indicating severe impairment. Review of the admission Agreement attachment titled, Attachment K Alternative Dispute Resolution Agreement Between Resident and Facility, was signed by Resident #361's Responsible Party (RP) and the Social Work Assistant on 11/30/22. On 12/07/22 at 4:36 p.m. a telephonic interview was conducted with Resident #361's RP. The RP stated he signed the paperwork for the resident. The RP stated he brought the resident to the facility on admission day. The RP stated [Resident #361] was not well at the time. The RP stated the admissions staff went over all the forms. The RP repeatedly said, I don't understand the lingo. This is new to me. I didn't know what I was signing or how it would affect [Resident #361]. He stated he does not remember if he was told it was optional. He said, To be honest, I was just trying to get [Resident #361] into the facility and I'm happy with the care so far. The RP stated he did not anticipate any problems but if they arise, he will deal with it. The RP stated he hoped he did not make a bad decision. The RP said, I didn't understand half of everything I signed. In an interview on 12/08/22 at 10:09 a.m. with the Business Office Manager (BOM), she stated she helps the admission department when they are out marketing or when they are not available. The BOM stated she explains the arbitration agreement to the resident and then asks them to sign. The BOM sated she explains that they are agreeing to settle grievances through mediation instead of the court system. She stated she makes sure they understand. The BOM stated no one asks questions, they just sign. The BOM said, Some of them say they won't be here long, they don't anticipate any problems, and they do not refuse to sign. On 12/08/22 at 10:35 a.m., an interview was conducted with the Admissions Coordinator (AC). The AC stated they have a 72-hour window to meet with the resident, generate the packet and present the arbitration agreement along with admission agreement. The AC stated she tells them it's optional. She stated when they are signing, they are agreeing that they will not go to court and will settle their case through mediation. She stated 90% of the residents don't ask questions. The AC stated sometimes the residents present with confusion, but she has to follow their 72-hour deadline. The AC stated they have them sign acknowledging receipt and review of the agreement. The AC said, There are many residents who do not seem to understand, I do my best to explain it to them. I can see how their cognition and health status can impact decision making. On 12/08/22 at 10:17 a.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated she would expect the residents are given an opportunity to ask questions, and to ensure that they understand they are waiving the right to go to court and instead go through arbitration. The NHA stated they would review their practices to ensure the agreement is explained accordingly and the residents understand they do not have to sign. The timing could impact residents if they are on medications or have just been released from the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 20 of 30 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 12/08/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 12/6/22 at 8:41 a.m. an observation was made of Staff L, Registered Nurse (RN) during medication administration. The nurse was preparing medication for Resident #36. She took the resident's blood pressure, then proceeded to remove six pills from the blister pack directly into her ungloved hand. She then placed the pills from her hand into a medication cup and administered them to Resident #36. Staff L then moved on to prepare medication to be administered to Resident #15. Prior to retrieving the resident's medication Staff L took Resident #15's blood pressure. The nurse used the same blood pressure cuff used on the previous resident without sanitizing it in between uses. Residents Affected - Some On 12/6/22 at 9:03 a.m. an interview was conducted with Staff L, RN. She stated the pills should be popped from the blister back straight into a medication cup and she knows she shouldn't handle them. She also confirmed she did not clean the blood pressure cuff in between resident use. She said she had been trained on sanitizing equipment prior to each use and on medication administration. An interview was conducted with the Regional Nurse on 12/8/22 at 1:50 p.m. She confirmed nurses should not put pills in their hands. She stated the nurse let her know what happened during medication administration and they have begun educating on the proper way to pop pills out of the blister packs into the medication cup. She stated a nurse should not touch the medication. A facility provided policy titled Medication Dispensing System was reviewed. The policy stated the following: All medications will be prepared (blister card, vials, [dose] box) and administered in a manner consistent with the general requirements outlined in this policy. Procedure B.4. Do not touch the medication when opening a bottle or unit dose package. A facility policy titled, Cleaning and Disinfecting of Resident-Care Items and Equipment, dated July 2014, was reviewed. The policy stated the following: 1.d. Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment.) 3. Durable medical equipment must be cleaned and disinfected before reuse by another resident. An interview was conducted with the ADON on 12/8/22 at 2:10 p.m. She said a nurse should not be handling pills for the residents with their hands. She stated they should be put directly in the medication cups. She agreed this is an infection control concern. On 12/5/22 at 9:35 a.m. two clean linen carts were observed outside of room [ROOM NUMBER]. One of the linen carts had partial used skin protectant, perineal cleaner and skin/hair cleaner sitting on the shelf with the clean linen. (Photographic Evidence Obtained) On 12/7/22 at 10:15 a.m. an observation was made of a clean linen cart sitting outside of room [ROOM NUMBER]. The linen cart had barrier cream, a writing pen, and skin check/shower sheets sitting on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 21 of 30 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 12/08/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the shelf with the clean linens. The clean linen cart sitting outside of room [ROOM NUMBER] had a cup of ice water sitting on the shelf with the clean linen. A clean linen cart sitting outside of room [ROOM NUMBER] was observed to have partially used barrier cream, perineal cleaner and hair/skin cleaner on the shelf with clean linen. (Photographic Evidence Obtained) On 12/7/22 at 10:21 a.m. a clean linen cart sitting outside of room [ROOM NUMBER] was observed to have used bottle of fragrance mist, perineal cleaner, and skin cleaner sitting on the shelf with the clean linen. (Photographic Evidence Obtained) On 12/7/22 at 10:29 a.m. a clean linen cart sitting outside of room [ROOM NUMBER] was observed to have a personal zip up sweatshirt and a used hairbrush on the shelf with clean linen. (Photographic Evidence Obtained) On 12/8/22 at 10:30 a.m. an observation was made of a clean linen cart near room [ROOM NUMBER]. The cart had used barrier cream and a hairbrush inside. The linen cart outside of room [ROOM NUMBER] had half a tube of barrier cream on the shelf with the clean linen. An interview was conducted with Staff A, CNA on 12/7/22 at 1:22 p.m. She observed the linen cart with barrier cream inside. She stated some CNAs keep the bottles in their pocket and keep them in the linen cart. She stated the CNAs do take them in resident rooms, use them while cleaning/changing a resident then put them back in the linen cart. She said now that she says that out loud, she can see how that would be an infection control problem. She confirmed she is aware nothing should be kept in the cart with the clean linen. An interview was conducted with Staff B, CNA on 12/8/22 at 10:46 a.m. She stated barrier cream is sometimes in the clean linen cart. She confirmed it does go back and forth between resident room and the cart. She stated items should not be stored in the clean linen carts and there have been in-services about clean linen before. An interview was conducted with Staff C, LPN/Unit Manager on 12/8/22 at 10:49 a.m. She stated nothing should be in the cart with clean linens except clean plastic bags. She stated the CNA made her aware of the concern and she cleaned the carts out herself. On 12/8/22 at 11:12 a.m. an interview was conducted with the Regional Nurse. She stated perineal and skin cleaners should be in drawers in the resident's rooms, not kept in the clean linen carts. She stated there is a break room for staff to keep personal items in. She confirmed the only thing that should be in the cart with clean linen is clean plastic bags that are used to bag up dirty linen. An interview was conducted with Staff D, CNA on 12/8/22 at 11:37 a.m. She said some CNAs do keep items in the linen carts, but nothing should be kept there. She stated We do know better. We have been educated. On 12/8/22 at 11:39 a.m. an interview was conducted with Staff E, LPN/Unit Manager. He stated perineal cleaners and barrier creams should not be in the clean linen carts. As far as those and personal items in the carts he said ,That's a no go, and he will start education. A facility policy titled, Departmental- Laundry and Linen, dated January 2014, was reviewed. The policy stated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 22 of 30 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 12/08/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Washing linen and other soiled items 7. Clean linen will remain hygienically clean through measures designed to protect it from environmental contamination, such as covering linen carts. Based on observations, interviews, record review and review of the Centers for Disease Control and Prevention (CDC) guidelines the facility failed to 1. ensure staff wore wearing well-fitting masks during a COVID-19 outbreak and one staff member's (H) mask was clean and unsoiled on one unit (100 Hall) of four units; 2. ensure one staff member (K) performed hand hygiene during meal service; 3. ensure one staff member (L) sanitized multi use blood pressure cuffs in-between residents (#36 and #15), 4. ensure staff wore appropriate personal protective equipment (PPE) to prevent the spread of COVID-19 while in a COVID-19 positive resident room, 5. ensure staff wore appropriate PPE prior to entering a resident room (Resident #160) with active clostridium difficile colitis (C.Diff) and extended spectrum beta-lactamase (ESBL), 6. ensure 8 of 12 clean linen carts were free of staff belongings and resident hygiene products two floors (1st and 2nd) of two floors, 8. mitigate COVID-19 by ensuring room doors were closed on the COVID-19 unit (200 Hall) which also had five persons under investigation (PUI) residents during a COVID-19 outbreak of 15 residents. Findings included: 1. On 12/5/22 at 10:50 a.m. an observation was conducted of the first floor MISSION MATTERS DIRECT RESIDENT CARE - STAFF ON DUTY board, dated 12/5 shift 7-3, and revealed, Staff Must Wear N95 Mask! (Photographic Evidence Obtained) On 12/05/22 at 10:51 a.m. Staff H, Licensed Practical Nurse (LPN) was observed to go into Resident #95's room located on the first floor to assess her respiratory status prior to walking into the room she was noted to have a surgical mask on and there was a vertical stain on the mask from below the nose midway down the mask. On 12/05/22 beginning at 11:30 a.m. multiple observations were made of Staff H wearing a surgical mask on the resident care unit. Staff H was observed repeatedly removing her mask to blow her nose, discarding her soiled tissues in a receptacle on her medication cart, not performing hand hygiene after blowing her nose before continuing on with her tasks including contact with items on her medication cart. On 12/05/22 at 12:17 p.m. an interview was conducted with Staff H, LPN. She was observed to be at her medication cart with a blue surgical mask on, with a stain on the mask that appeared just below her nose and ran midway down the mask. During the interview she continued to cough and sniffle. She said, I woke up at 3:00 a.m. this morning coughing and a runny nose. I took Mucinex, Sudafed and even Loratadine, but I can't get my nose to stop running. It's so moist in this mask. She was asked if that was a stain on her mask? She said, Oh is it stained? She removed her mask and confirmed her mask was stained and she did not know. She threw the surgical mask away and put on a new surgical mask. Staff H, LPN stated, A while ago I was getting bad headaches from whatever they spray in the N95 masks. My doctor said they aren't all sprayed with stuff but it's so hard to find a mask that isn't sprayed on the inside. So, I just wear this [indicating her surgical mask]. Staff H, LPN continued to say I spoke with the DON [Director of Nursing] and she wanted me to write something saying I can't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 23 of 30 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 12/08/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wear the N95s but I'm not going to lie. I haven't gotten around to that yet. But, when I came in we do the questions and the temperature and I got a COVID test this morning and it was negative or else I wouldn't be here I'm in compliance with my surgical mask, I think, I'm not around the COVID residents and if I do I have this N95 mask here on my medication cart and I would just put it over my surgical mask. On 12/8/22 at 3:30 p.m. an interview was conducted with the facility's Assistant Director of Nursing (ADON), who was also the Infection Preventionist. She indicated the facility had 15 residents in the building positive for COVID-19. She further indicated, dirty masks should be discarded and a new one should be put on immediately when soiled and the staff have been educated on that The expectation is to wear a gown, N95 mask, gloves, face shield or goggles with a closed eye. The ADON stated it was not appropriate to store personal items on the clean linen cart. She stated I have already provided education before on storage of personal items. The staff have been educated on what PPEs to wear. As soon as they see that yellow bag hanging on the door that is an alarm to them to wear your PPEs. She stated [Staff H, LPN] told me that she has some medical condition related to an allergy. She is supposed to have documentation excusing her from wearing N95s but I don't have documentation of that. My expectation is the staff wear N95 masks right now during our COVID outbreak. She stated the staff are expected to clean blood pressure cuffs in-between residents and they have previously been educated on that. Staff should clean hands after wiping their nose. It is my expectation the doors should be closed while on COVID isolation. Unless the resident is a fall risk then the curtain should be pulled closed. Review of the CDC Infection Control Guidance, updated on September 23, 2022, revealed Patient Placement Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). . Implementing Source Control Measures Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing . When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through . Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) | CDC. Review of the facility's policy, Infection Prevention and Control Program, revised October 2018, revealed: Policy Statement An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. .11. Prevention of Infection Important facets of infection prevention include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 24 of 30 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 12/08/2022 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 0880 (1) identifying possible infections or potential complications of existing infections; Level of Harm - Minimal harm or potential for actual harm (2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures; Residents Affected - Some (4) Communicating the importance of standard precautions and cough etiquette to visitors and family members; (5) enhancing screening for possible significant pathogens; . (7) implementing appropriate isolation precautions when necessary; and (8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). Review of the facility's policy, COVID-19 Facility Testing/Isolation Guidelines/Exposure/Return to Work Processes, revised 10/10/2022, revealed .PPE (Personal Protective Equipment) COVID UNIT- if the facility has an active COVID Unit, then facility staff and visitors on the unit should wear full PPE including N95 mask and eye wear. PUI UNIT (new admission/outbreak testing)- If the facility has a PUI (Persons Under Investigation) Unit then staff and visitors on the PUI Unit should wear source control. 2. On 12/5/2022 at 10:20 a.m. Resident #160's room door was open and was observed with hanging Personal Protective Equipment (PPE) and a sign that indicated to Stop and not enter and to see a nurse before entering. Interviews with Staff F, Certified Nursing Assistant (CNA), and Staff G, Registered Nurse (RN) both revealed Resident #160 has an infection to include C-Diff and ESBL in the urine and is on contact isolation precautions and is receiving antibiotic therapy. Observed from the hallway, Resident #160 was noted in her room and lying in bed. On 12/6/2022 at 8:00 a.m. while standing in the hallway in between resident rooms [ROOM NUMBERS], Staff F, CNA and Staff K, CNA were observed going in and out from resident rooms, removing finished breakfast meal trays. Staff K was observed to come out from resident room [ROOM NUMBER] with a tray, put it in the tray cart and then proceeded to walk into Resident #160's room, which was a room on isolation precautions. The door was observed with hanging PPE to include gowns, masks, and gloves. The door had a large sign that had a picture of a red and white STOP sign and read, please see nurse before entering this room. At 8:01 a.m. Staff K, CNA walked into Resident #160's room and did not gown up and only went in the room with PPE to include a N95 mask. She went to Resident #160's bed and picked up the breakfast meal tray and then walked out of the room, opened the tray cart with her right ungloved hand and then placed the tray in the cart and then closed the cart door with her ungloved right hand. Immediately following the observation Staff K was interviewed about isolation precautions in Resident #160's room. Staff K confirmed Resident #160's room was on isolation precautions an explained that she was aware the room was on isolation precautions and the reason she did not gown up or wear additional PPE was because she just went in the room to grab the meal tray. She replied, It's my first day in this hall and I should have gowned up with a gown, gloves, eye protection, but did not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 25 of 30 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 12/08/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some After the interview was completed on 12/6/22 at 8:04 a.m. Staff K, CNA proceeded to walk down the hall and went into Resident room [ROOM NUMBER] and picked up a used meal cart and brought it to the tray cart and open and closed the door with her ungloved right hand, she then went to Resident room [ROOM NUMBER] and did the same. It was observed that Staff K did not wash or sanitize her hands after leaving Resident #160's isolation room, nor did she wash and or sanitize her hands prior to entering and leaving Resident rooms [ROOM NUMBERS], which were not on isolation precautions. At 8:06 a.m. Staff K was asked when she normally washes and or sanitizes her hands. She explained after she leaves each room and after use of resident equipment and resident contact. She was asked if she washed and or sanitized her hands after leaving Resident #160's isolation room and in between and after leaving resident rooms [ROOM NUMBERS]. Staff K replied, I don't remember if I did, but I am supposed to. On 12/7/2022 at 8:30 a.m. an interview with the Staff G, RN confirmed there was one room in the secured unit on isolation precautions. She revealed Resident #160 currently had ESBL in the urine and C-Diff. She confirmed the resident was on contact precautions and anyone who goes in the room are to follow the infection control procedure, as listed on the resident's door. She revealed all staff and visitors must wear PPE upon entering the room and in this case PPE includes a N95 mask, gown, and gloves must be donned. She further revealed staff are to doff the PPE while in the room and then wash their hands prior to leaving. Staff G revealed it is her responsibility to monitor staff throughout the shift and to ensure when someone goes in an isolation room, they don the appropriate PPE. She indicated she also ensures all other departmental staff who come on the unit and go in an isolation room are knowledgeable of the PPE requirements before entering the room. Staff G further indicated she, and all other staff are educated and in-serviced on the importance of PPE, and when to use PPE, especially in rooms that are on infection isolation precautions. Staff G confirmed Resident #160's room had a sign on the door that read; Stop, report to nurse before entering, and also confirmed there was a hanging sleeve on the door with all the required PPE. She revealed Staff K should have donned gown, gloves, had N95 on prior to entering the room and then doffed and washed hands prior to leaving the room, even if only picking up a meal tray. Staff G further explained there should have been another staff member to take the tray, prior to Staff K leaving the room, and prior to her washing her hands. On 12/6/2022 at 2:04 p.m. Resident #160 was not in her room. The room was still observed on infection precautions per the signage on the door and with the PPE hanging on the door. Upon observing down the hall of this secured/dementia unit, Resident #160 was observed standing up in the activity room doorway with Staff F, CNA talking with her. She was observed to re direct the resident and walked her to her room. Resident #160 was not interviewable. On 12/6/2022 at 2:20 p.m. Resident #160 was noted back out from her room and seated at a table with a couple of other residents and participating in a group activity. The activities staff member was in the room. Also, Staff F, CNA was in the room and she did not re direct Resident #160 back to her room. On 12/7/2022 at 8:32 a.m. Resident #160 was observed sitting in the hall outside of activity room next to other unit residents. She was sitting quietly but observed shivering. A resident sitting next to Resident #160 verbalized she was cold and it was making her neck hurt. The resident sitting next to Resident #160 was noted touching her hands and the back of her neck area. On 12/8/2022 at 10:00 a.m. interviews with Staff G, RN, Staff F, CNA and Staff K, CNA all revealed it was hard to keep residents in one place, to include Resident #160, while in the secured/dementia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 26 of 30 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 12/08/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unit. Staff F, CNA revealed she tries to redirect Resident #160 back to her isolation precaution room when she is out of it, but she is confused and leaves her room after being successfully redirected. Staff G, F and K all confirmed Resident #160 is on contact isolation and should stay in her room and not have contact with other residents. They all said, however, Resident #160 continually leaves her room and goes out to the main hallway and into the dining/activity room. Staff G, F and K confirmed Resident #160 was the only resident who was on isolation precautions in the unit. Further interview with Staff G, RN on 12/7/2022 at 10:05 a.m. Staff G revealed if a resident room is placed on isolation precautions and there is PPE to wear prior to entering, staff are to don the required PPE and then doff the PPE prior to exiting the room. She further indicated the Assistant Director of Nursing (ADON), who is also the infection control nurse, is responsible for placing the PPE and signage on the door to each room that is on isolation precautions. Staff G indicated the ADON trains all staff and educates all staff with relation to infection control, COVID mitigation, how to identify and follow isolation precautions and PPE training. Staff G further revealed as a floor nurse, she will continually audit staff as they go into isolation rooms and at this point they only have one resident (#160), who is on isolation precautions. Staff G explained the resident (#160) resides in the secured/dementia unit and she does not listen to staff when asked to remain in room. She does ambulate and walk and leave her room, and staff try to re direct as possible, but there is no way they can keep her in the room, and of course they are not allowed to secure the resident in that room. They try to ensure the resident does not have any close activity and not in close proximation to other residents but again in this unit, residents who have dementia, they cannot redirect all the time. There are no other active dx. of infections in this unit. Staff are continually educated on re directing. Staff G revealed Resident #160 is on contact isolation only and has ESBL and C-DIFF. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 27 of 30 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 12/08/2022 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/6/2022 at 9:20 a.m. an observation was made in room [ROOM NUMBER]. The A bed's call light was observed missing from the call light system attached to the wall inside room [ROOM NUMBER]. Residents Affected - Some On 11/6/2022 at 9:30 a.m. an interview was conducted with the resident in the A bed. The Resident said she never had a call light in her room and she is independent, so she really doesn't need assistance from the staff. The Resident in the B bed overheard the conversation and said she would usually put the call light on if [Resident A bed] needed assistance from the staff. On 12/6/2022 at 10:00 a.m. an interview was conducted with Staff A, CNA. Staff A said room [ROOM NUMBER] has always had one call light in the room. Staff A said there was a padded call light in the room at first and then they changed that call light out for the regular call light that is in the room now. Staff A confirmed there should be two call lights in the room and said yes if there are two residents in the room both residents should have a call light. Staff A said [Resident in A bed] did not need a call light because she is independent. Based on observations, interviews, and record review the facility failed to ensure a functioning communication system was in place for residents to call for staff assistance from bedside and from toilet facilities on three units (2 South, 2 North, 1 North) out of four units surveyed to include resident rooms room [ROOM NUMBER] A bed and B bed, room [ROOM NUMBER] A bed, room [ROOM NUMBER] and the shared bathroom for resident rooms [ROOM NUMBERS]. Findings included: 1. A tour was conducted of facility unit 2 South on 12/07/2022 beginning at 9:26 a.m. Staff Q, Certified Nursing Assistant (CNA) assisted with testing of resident bedside call light function for room [ROOM NUMBER] & provided witness the call lights for A bed and B bed did not work. When the call button was pressed, the small light on the box on the wall lit up, however the light in the hallway above the room door did not light up. Manual bells were observed at bedside for bed A and bed B. During this observation, Staff C, Licensed Practical Nurse (LPN)/Unit Manger (UM) arrived at the room and stated it had been known since 12/06/2022 the call lights in room [ROOM NUMBER] were not working and had been reported to the facility maintenance team. She stated an audit of call light function for all the rooms in the facility was conducted on 12/06/2022. She said the problem with the call light function in room [ROOM NUMBER] had been ongoing. On 12/07/2022 at 9:58 a.m. Staff C followed up and provided documentation of the call light audit completed on 12/06/2022. Regarding why the audit was done on 12/06/2022, she stated the nurse for room [ROOM NUMBER] bed A had brought to her attention on 12/06/2022 there was no call light for that resident and stated the audit was done because of that report. Review of the audit documents revealed: 228-B Needs New, 226A/B call light stays on & can't be seen on outside of room, next to room [ROOM NUMBER]A was written Bell [electronic work order] notification, next to rooms 118A and 118B was written Call light box needs to be fixed (still working). On 12/07/2022 at 11:40 a.m., the resident in bed B in room [ROOM NUMBER] was heard from outside the hallway yelling, Nurse please help, nurse help. The resident was noted to be in bed and continued to repeatedly call for help and also ring a hand-held manual bell. During this time, six staff members were observed in the nursing station area at the end of hall. It was noted that no one could hear (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 28 of 30 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 12/08/2022 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the resident as he continued to ring his bell and call for help. Two CNAs came by the resident's door with a lunch cart. The CNA dropped off the cart and left as the resident continued calling for help. The two CNAs were talking to each other and did not respond to the hand-held manual call bell. The resident continued ringing the handheld bell for approximately15 minutes. On 12/07/2022 at 12:07 p.m. an interview was conducted with Staff Q, CNA and Staff B, CNA. They stated they did not hear the resident calling for help, or him ringing his hand-held manual call bell. They stated sometimes it is loud in the halls and that was why they could not hear the resident in room [ROOM NUMBER] calling for help. They confirmed the hand-held manual bells were not loud enough. On 12/07/22 at 12:03 p.m. Staff R, Licensed Practical Nurse (LPN) heard the resident calling as he walked past the door and responded to the resident's call. Staff R confirmed the room's call light had issues, and the Unit Manager was aware, stating that was why she gave the residents the hand-held manual call bells. Staff R stated he would let the Unit Manager know the hand-held call bells were not loud enough for staff to hear from down the hall. An interview was conducted with the Nursing Home Administrator (NHA), the Director of Facilities Management (DFM)/Maintenance Director, and a facility corporation Regional [NAME] President (RVP) on 12/08/2022 at 9:30 a.m. All parties confirmed they were aware of findings during the survey of the call light system malfunctions. The DFM stated problems with the system function were known and had been ongoing. He stated the system was old, the whole system was scheduled to be replaced, and planning for that had begun a year ago to install a wireless system but it turned out that was not compatible with the facility. So, currently an alternate replacement system was being planned and replacement should be completed within the year. The DFM stated he became aware of problems on the first floor last month and said room [ROOM NUMBER] only became an issue late last week. He stated replacement parts had been ordered for these areas but were found on 12/05/2022 to be incompatible. All parties confirmed that until replacement parts could be secured and until the entire call light system was replaced, those areas identified as not working would continue to not work, additional areas could malfunction, and a temporary solution that met the needs of the residents by ensuring staff could hear and respond quickly would need to be established given the findings of staff not hearing and not responding to use of the manual hand-held bell in room [ROOM NUMBER]. 3. On 12/5/2022 at 10:08 a.m., 12/6/2022 at 7:50 a.m., 12/7/2022 at 7:50 a.m., and on 12/8/2022 at 2:55 p.m. the following was observed: - Resident room [ROOM NUMBER] bed (A) upon attempt to press the call button, while placed on the top of the bed, it did not work. The green, small light on the box on the wall lit up. However, the light in the hallway, above the door did not light up. There was no enunciator as well during the observation. It was also noted through attempt to trigger, the bed (B) call light that it did not work appropriately. The outside of the room light above the door did not light up. At 9:08 a.m. Staff G, Registered Nurse (RN) was interviewed and she, along with Staff K, CNA tested the call lights on bed (B) and bed (A) and found the light above the door in the hall did not light up. They indicated they would notify maintenance immediately. Staff G indicated all call lights are expected to work and even if the residents in the room do not use the call light. - Resident rooms 128/126 shared bathroom was observed with a missing call light system. The wall next to the toilet was only observed with several loose wires hanging out from it. (Photographic Evidence Obtained) It was observed also on 12/7/2022 at 9:02 a.m. the call light system in the bathroom was still missing and only with wires hanging from the wall. Interview with Staff G, and the DFM were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 29 of 30 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 12/08/2022 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 0919 not aware of the missing call light system box in the bathroom and would get it fixed. The DFM had no further information with regards to monitoring and checking call lights in resident rooms and bathrooms. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 30 of 30