Health inspection·October 31, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm 9. Resident room [ROOM NUMBER] (door bed) was observed with the Right wheelchair armrest cracked and torn. It was noted the resident utilized the wheelchair. 10. Resident room [ROOM NUMBER] (window bed) was observed with the Left wheelchair armrest cracked and torn. Residents Affected - Some 11. Resident room [ROOM NUMBER] (door bed) was observed with the Left wheelchair armrest cracked and torn. 12. Resident room [ROOM NUMBER] (window bed) was observed with both the Right and Left wheelchair armrests cracked and torn. It was noted the resident had utilized the wheelchair. Photographic evidence obtained. 2. On 10/30/2023 at 9:45 a.m., 1:00 p.m., and again on 10/31/2023 at 7:55 a.m., and 10:00 a.m. the following resident rooms were observed and revealed: 13. Resident room [ROOM NUMBER] (door bed) was observed with an over the bed table that had plastic surfaces peeling and peeled, leaving sharp edges, as well as a non cleanable surface. The span of the peeled surface reached from one side of the table to the other. There was a resident who resided in that room bed at the time of the observation. 14. Resident room [ROOM NUMBER] (window bed) was observed with a wooden surfaced over the bed table with plastic/rubber molding peeled up and off the table leaving a non cleanable surface. The surface of the table could no longer be level and with one side of the table pointed downward approximately ten to fifteen degrees. 15. Resident room [ROOM NUMBER] (door bed) was observed with a wooden surfaced over the bed table with plastic/rubber molding peeled up and off the table leaving a non cleanable surface. The surface of the table could no longer be level and with one side of the table pointed downward approximately ten to fifteen degrees. Photographic evidence obtained. 3. On 10/30/2023 at 9:45 a.m., 1:00 p.m., and again on 10/31/2023 at 7:55 a.m., and 10:00 a.m. the following resident rooms were observed and revealed: 16. Resident room [ROOM NUMBER] (door bed) was observed with the bedside and door side wall with heavy water saturation and water staining which covered approximately three feet up from the floor and approximately three quarters of the length of the wall. Further, the plastic/rubber baseboard was observed peeled slightly from the water saturated area and with black biogrowth spanning three quarters of the length of the wall. Also, the ceiling area directly above this water saturated wall was observed with water staining and some water saturation. The area on the ceiling measured approximately two feet across by one foot wide. There was a resident who resided in the door bed at the time of the observation but was not able to give an interview. Photographic evidence obtained. On 10/31/2023 at 9:00 a.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 2 of 4 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 10/31/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some provided the maintenance work order report for the month of 10/2023. The report identified the room number, date of job open, the closed date and status. The following was revealed to include but not limited to: 1. Work order 9850 - room [ROOM NUMBER] Open date 10/4/2023, Closed date 10/5/2023. The report also revealed; wall needs attention the high wall needs attention. It is discolored, wall adjoining wall. Report work order status was reviewed as closed. 2. Work order 9860 - The Bathroom room [ROOM NUMBER] Open date 10/4/2023, Closed date 10/5/2023. The report also revealed; the wall behind the toilet is discolored mush-like both doors need to be painted. Report work order status was reviewed as closed. 3. Work order 9862 - room [ROOM NUMBER] Open date 10/4/2023, Closed date 10/5/2023. The report also revealed; Hole in the wall to left of A/C. Report work order status was reviewed as closed. 4. Work order 9863 - room [ROOM NUMBER] Open date 10/4/2023, Closed date 10/5/2023. The report also revealed; Touch up paint needed to right of A/C. Report work order status was reviewed as closed. On 10/31/2023 at 11:30 a.m., an interview was conducted with the Maintenance Director. He revealed there were guardian angel rounds conducted by specific employees for each room. If there were things identified that needed repair, staff would put in a work order through the [electronic work order system], and the Maintenance Director would follow up with those concerns based on a priority status. The Maintenance Director confirmed the four job orders related to room [ROOM NUMBER], which included job orders 9850, 9860, 9862, and 9863. He revealed the jobs were completed by his staff and marked as status complete, as of 10/5/2023, which was twenty-six days ago from today, 10/31/2023. The Maintenance Director did not remember exactly what the job orders for that room entailed. He could not speak to the wall and baseboard saturation and biogrowth, nor could he speak to a ceiling leak and water stained ceiling. The Maintenance Director reviewed the work order sheet and confirmed none of the work orders were related to the current observations in the room with saturated walls, biogrowth, and a leaky ceiling. The Maintenance Director confirmed it had not rained in the area for over a week and confirmed the areas of concern in room [ROOM NUMBER] should have been brought to his attention by the guardian angel staff, so he could have taken care of it immediately. On 10/31/2023 at 1:20 p.m., the Regional Nurse Consultant, by way of the Nursing Home Administrator, provided the Maintenance Service policy and procedure dated 2001. The policy stated; Maintenance service shall be provided to all areas of the building, grounds, and equipment. The policy interpretation and implementation section revealed; 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but not limited to; (a.) Maintaining the building in compliance with current federal, state, and local laws, regulation and guidelines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 3 of 4 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 10/31/2023 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 0584 (b.) Maintaining the building in good repair and free from hazards. Level of Harm - Minimal harm or potential for actual harm (c.) Establishing priorities in providing repair service. (d.) Providing routinely scheduled maintenance service to all areas. Residents Affected - Some (e.) Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105398 If continuation sheet Page 4 of 4