Inspection·October 5, 2023

F 0561 cell phone that could be utilized for entertainment. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Resident #322 on 10/4/2023 at 5:05 p.m. Resident #322 stated, it is absolutely ridiculous. The facility didn't even discuss the TV issue with me until I had a breakdown. They gave me a word search; you can only do word search for so long. I don't get to leave this room, not even for therapy. I cannot get out of bed until therapy can get me a wheelchair that fits. The only thing I have to take my mind off things is to watch TV. I told them, I don't have a fancy cell phone. I can only make calls on my phone. Too much silence. A radio or something would be nice but has not been offered. The word search was nice but something with noise would be nice. Residents Affected - Few A review of Resident #322's admission Record revealed, resident admitted [DATE], with diagnoses of surgical aftercare following surgery on the digestive system, hypertension, back pain, osteoarthritis, lumbar spondylosis, spinal stenosis, insomnia, and other co-morbidities. A review of the Minimum Data Set (MDS), Section C Cognitive Pattern, dated 10/3/2023 revealed a Brief Interview for Mental Status (BIMS) score of 13/15, which meant the resident was cognitively intact. An interview was conducted with Staff B, LPN on 10/5/2023 at 11:15 a.m. Staff B, LPN stated, [Resident #322] was much better today. I was very worried; it was pitiful yesterday. I have never seen him so upset. Very sad, I'm glad his family came to visit, it gave him something to do. A policy for choices or accommodation of need was requested. No policies were produced at the time of the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105636 If continuation sheet Page 2 of 8 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 105636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belleair Health Care Center 1150 Ponce DE Leon Blvd Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for two (Residents #77, #32) of three residents sampled for PASARR Level II. Findings included: A review of Resident #77's admission record showed the resident was initially admitted to the facility on [DATE]. He was readmitted back to the facility on [DATE] with diagnoses of traumatic brain injury, schizoaffective disorder bipolar type, anxiety disorder, and major depression disorder. A review of Resident #77's Preadmission Screening and Resident Review (PASARR) dated 10/26/20 showed qualifying mental health diagnoses of anxiety disorder, bipolar disorder, and depressive disorder and no PASARR Level II was required. A review of the admission Minimum Data Set (MDS), Section I, Active Diagnoses, with an Assessment Reference Date (ARD) of 9/28/2020, quarterly MDS with ARD of 7/30/23, 1/29/23, 7/31/22, and annual MDS with an ARD of 10/30/2022 revealed medical diagnoses of anxiety disorder, depression, bipolar disorder, schizophrenia, and post-traumatic stress disorder (PTSD). Review of the medical record revealed the resident was not assessed for PASARR Level II. 2. A review of Resident #32's admission record revealed he was admitted to the facility on [DATE] with a medical diagnosis, not limited to, dementia without behavioral disturbances or psychotic disturbances or mood disturbances or anxiety. A review of Resident #32's PASARR dated 2/11/2023 revealed no qualifying mental health diagnosis and no PASARR Level II was required. A review of Resident #32's admission MDS dated [DATE] section I, Active Diagnoses, revealed depression and psychotic disorder. Review of Resident #32's quarterly MDS dated [DATE] and 8/16/23 revealed a diagnosis of depression and psychotic disorder. Review of Resident #32's medical record revealed the resident was not assessed for PASARR Level II. An interview was conducted on 10/4/23 at 3:20 p.m. with the Staff I, Social Services Director. She stated she had been in this position for about a week and half and she handled PASARR's but the facility was working on her getting access to the program. She reviewed Resident #77's PASARR, medical diagnoses, and MDS and said the PASARR should be updated. She also reviewed Resident #32's PASARR, MDS, and medical diagnoses and said maybe he had a diagnosis added from psych, but the PASARR should have been updated. An interview was conducted with the facility's Regional Nurse Consultant on 10/05/23 at 11:38 a.m. she said, we do not have a policy on the PASARR's it's a hospital form and we trust they do it right but they screw us every time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105636 If continuation sheet Page 3 of 8 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 105636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belleair Health Care Center 1150 Ponce DE Leon Blvd Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure one (Resident #34) of thirty-eight sampled residents, who were reviewed for care planning, was care planned with problem areas, goals, and interventions. Findings included: On 10/2/2023 and 10/3/2023 during the 7:00 a.m.-3:00 p.m. shift, Resident #34 was visited several times while in her room. She was observed initially lying in bed and with her legs propped up on a pillow and positioned very close to the edge of the bed. Resident #34 was not presenting with any behaviors, pain or discomfort during each time visited. However, Resident #34's bilateral upper extremities appeared to be somewhat contracted, and/or with movement impairment. She was not wearing braces or splints on her extremities. There were no braces or splints in the room. Resident #34 was interviewable. She was very pleasant and happy to be visited. The resident said she could not move her fingers and at times had pain. She said her fingers had been that way since before she was admitted to the facility. She said she had been in therapy in the past, but not at this time. She confirmed she was not receiving nursing restorative care for her upper extremities. She said prior to her moving to this facility, she was wearing hand splints, and when her daughter moved her belongings from one facility to this one, she must have lost them. She said the splints helped but she did not like to wear them all the time. On 10/3/2023 around 1:00 p.m., during lunch, Resident #34 was noted in her room and seated on the side edge of her bed, with the over the bed table placed in front of her. She was observed eating her meal unassisted and was noted using two types of eating utensils. She had adaptive eating equipment to include a weighted fork and weighted spoon, but she was using a plastic fork to eat with her right hand. She said the weighted spoon and weighted fork were too heavy for her to use and she could not use them. She could not remember if she had spoken to anyone about it but most of the time she received eating utensils that were not weighted. She said she had her own plastic eating ware and had extras that were given to her. She said she would use them when she was accidentally provided with weighted spoons and forks. A review of the meal ticket which was placed on her meal tray, showed she was to use adaptive eating equipment that were built-up but did not indicate if the equipment should be weighted. Resident #34 was observed and interviewed during the 7:00 a.m.-3:00 p.m. shift at least four times during the next couple of days to include 10/4/2023 and 10/5/2023. She was observed during two more meal observations, including a breakfast and lunch observation. During those two meal observations, she received adaptive eating equipment to include a built up spoon and fork. The utensils were not weighted. The resident was observed using the utensils with no concerns. She said she could benefit from wearing some type of splint or brace on both her right and left hand, just not during meal times. On 10/5/2023 at 9:10 a.m., an interview with Staff D, Resident #34's assigned Certified Nursing Assistant (CNA) was conducted. She said Resident #34 did not wear any type of hand splints and did not believe she had any in her room. Staff D confirmed the resident had impaired use of both of her hands. She said there was no current care plan for her to place hand splints or braces on the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105636 If continuation sheet Page 4 of 8 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 105636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belleair Health Care Center 1150 Ponce DE Leon Blvd Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 A review of Resident #34's medical record revealed she was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm A review of the advance directives revealed Resident #34 was her own responsible party with family contacts only. Residents Affected - Few A review of the diagnosis sheet revealed a diagnosis to include but not limited to Age related osteoporosis. A review of the current 10/2023 physician's order sheet (POS) revealed orders to include but not limited to: (a.) Patient to utilize built up utensils with all meals with a start order date of 4/18/2023. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed: Cognition/Brief Interview Mental Score or BIMS score - 15 of 15 which indicated intact cognition; Activities of Daily Living (ADL) - Bed Mobility = Extensive Assistance with one person assistance, Dressing = Extensive Assistance with one person assistance, Eating = Supervision Oversight with one person physical assistance. Review of the daily nurse progress notes and assessments showed the following: 1. Therapy Screen dated 7/18/2023 15:05 (3:05 p.m.) - Screening progress note; Requires assistance with bed mobility. Resident is independent with feeding. Resident requires assistance with toileting. Resident has orders for adaptive equipment. 2. 8/14/2023 11:38 a.m. Therapy Screen - Resident is currently utilizing side rail x 2. Therapy screen for side rail indicated. Side rail x 2. Rational recommendation pt refuses participation with physical therapy. Skilled PT eval not indicated at this time. Review of the current care plans with next review date 9/19/2023 showed the following: (a.) Resident #34 has an ADL self care performance deficit related to fractured left tibia, impaired mobility with interventions to include but not limited to: Built up utensils with all meals. There were no interventions related to orthotics/splint use (b.) Resident #34 at risk for alteration in nutrition/hydration, with interventions in place. There were no interventions related to orthotics/splint use. (c.) ADL self care deficit performance deficit r/t fracture left tibia impaired mobility with interventions in place to included but not limited to: built up eating utensils. There were no interventions related to orthotics/splint use. Review of the Occupational Therapy Evaluation and Plan of Treatment with a certification period of 3/28/2023 - 5/11/2023 revealed the following information: (1.) The goals mentioned included but not limited to: Patient will complete self feeding tasks with set-up using AE PRN (may benefit from built up utensils), in order to ensure proper nutrition and hydration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105636 If continuation sheet Page 5 of 8 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 105636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belleair Health Care Center 1150 Ponce DE Leon Blvd Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (2.) The initial assessment with current referral notes revealed; Reason for referral to include but not limited to: Increased need for assistance from others, limited and painful movement and pain, with diagnoses of Osteoporosis. (3.) The Musculoskeletal System Assessment section revealed; a. Upper Extremity Range of Motion = Right Upper Extremity impaired; Left Upper Extremity impaired; b. Right Upper Extremity Hand = impaired, Thumb = impaired, Index finger = impaired, Middle finger = impaired, Ring finger = impaired, Little finger = impaired; c. Left Upper Extremity Hand = impaired, Thumb = impaired, Index finger = impaired, Middle finger = impaired, Ring finger = impaired, Little finger = impaired. (5.) The Reason for Therapy section of the assessment summary revealed; Use adaptive equipment for performance during ADL and facilitate follow-through with techniques and strategies. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for to include but not limited to: Decreased participation with functional tasks, immobility, increased dependency upon caregivers, limited out-of-bed activity and muscle atrophy. A review of the Occupational Therapy Discharge summary dated [DATE] showed; Short term goals = Patient will complete self feeding tasks with set-up using AE PRN (may benefit from built up utensils), in order to ensure proper nutrition and hydration; Discharge Reason = discharged per Physician or Case Manager; Skilled Interventions = Use of assistive devices in order to achieve optimal level of functioning and discharge site with least amount of assistance required safely; Test/UE Strength - Right Arm Curl Test = Not Tested; Left Arm Curl Test = Not Tested; Right Hand Grip Strength = Not Tested; Left Hand Grip Strength = Not Tested; Discharge Recommendations = Patient to remain here at the facility; Restorative Programs = Not indicated at this time. On 10/5/2023 at 11:45 a.m. an interview with Staff H, Rehabilitation Manager, revealed she was familiar with Resident #34 and did have her on Occupational Therapy (OT), and Physical Therapy (PT) case load during the certification period of 3/28/2023 - 5/11/2023. She said Resident #34's services for PT and OT ended with a Discharge summary dated on 4/25/2023, as she had plateaued and met her goals. Staff H revealed Resident #34 had several PT and OT screens since being discharged from therapy on 4/25/2023, which were conducted on 7/18/2023, 8/14/2023 (resident refused), and 9/24/2023 with no indications of contractures or impairment with Right and Left upper extremities. She revealed that during those screens, her and her team did not find Resident #34 had any contractures, but did find Resident #34 had Right Upper Extremity, and Left Upper Extremity limitations. Staff H revealed this was due to Arthritis and Osteoporosis, but there were not any contractures per their assessment. Staff H clarified the OT assessment related to Right Upper Extremity impaired; Left Upper Extremity impaired; b. Right Upper Extremity Hand = impaired, Thumb = impaired, Index finger = impaired, Middle finger = impaired, Ring finger = impaired, Little finger = impaired; c. Left Upper Extremity Hand = impaired, Thumb = impaired, Index finger = impaired, Middle finger = impaired, Ring finger = impaired, Little finger = impaired. She said this meant Resident #34 had upper right and left extremities (hands), that were impaired and with decreased movement. She said that it did not necessarily mean her hands were contracted, but they would do a new PT and OT screen to assess for contractures or increased further impairment. On 10/5/2023 at 9:40 a.m. an interview was conducted with the Staff F, Licensed Practical Nurse (LPN),400 Unit Manager. She said she was not sure if Resident #34 had contractures, had ever been seen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105636 If continuation sheet Page 6 of 8 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 105636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belleair Health Care Center 1150 Ponce DE Leon Blvd Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few by PT OT for contractures or contracture management, and did not know if she was care planned for contractures and or contracture management. On 10/5/2023 at 11:04 a.m. a second interview with Staff F revealed she followed up with record review and did not find anything related to contracture or contracture management related to Resident #34. She revealed that the resident did utilize adaptive eating utensils when eating and had been screened by therapy a number of times but the assessments did not indicate any contractures. Staff F also indicated that she spoke with Resident #34 today (10/5/2023) about the use of splints or braces while eating meals. The resident told her she did not want splints/braces on during meals because when using her hands with a brace on, she would have hand pain. On 10/5/2023 at 10:55 a.m. during an interview with the Staff E, LPN, 400 Unit E who had routinely had Resident #34 on her assignment, said she was aware Resident #34 had Arthritis and Osteoporosis and used built up adaptive equipment during meals. She explained that PT and OT did not assess the Resident #34 as having contractures on her upper extremities and felt the resident could complete her eating tasks fine with the equipment. Staff E confirmed Resident #34 could not open her hands and spread her fingers open completely, nor move her fingers in a manner to do range of motion. She said Resident #34 could benefit from the use of some sort of extremity orthotic. On 10/5/2023 at 9:45 a.m. an interview with the MDS Coordinator Staff G revealed she was knowledgeable of Resident #34 and her care needs. She was not aware nor remembered if Resident #34 had upper extremities contractures and did not remember if she was on any type of contracture management plan. Staff G revealed she would need to look a her record and clarify. Staff G said Resident #34 had a diagnosis of Rheumatoid Arthritis and Osteoporosis and was care planned for Osteoporosis under a Tibia fracture and pain management problem. However Staff G confirmed by reviewing the current care plans, there were no problem areas with goals and interventions related to contractures and contracture management. Staff G confirmed there was no specific care plan problem area with goals and interventions related to Left and Right Upper Extremity impairment. On 10/5/2023 at 1:15 p.m. the Nursing Home Administrator provided the facility's Baseline, Resident Centered Comprehensive Care Plans, and Care Plan Summary Policy and Procedure, with no effective or last revision date, for review. The Purpose section of the policy revealed: Implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for deliver of care and services by receiving a written summary. The Procedure section of the policy revealed the following but not limited to: 1. The Baseline Care Plan must be initiated within the first 48 hours of admission and must include the healthcare information necessary to properly care for each resident immediately upon their admission. 2. Baseline Care Plan areas will trigger from questions answered on the Nursing admission Evaluation (Make edits to any items that require personalization or require changes.) 3. Within the first 48 hours of admission the facility staff must implement interventions to assist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105636 If continuation sheet Page 7 of 8 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 105636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belleair Health Care Center 1150 Ponce DE Leon Blvd Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 the resident to achieve care plan goals and objectives. Level of Harm - Minimal harm or potential for actual harm 4. The Baseline Care Plan must be updated to reflect changes to approaches, as necessary, resulting from significant changes in condition or needs occurring prior to development of the comprehensive Care Plan. Residents Affected - Few 5. The Care Plan Summary will be initiated by the MDS coordinator and completed by IDT: Must include (Initial goals for the resident, Services and Treatments to be administered by the facility.) 6. Comprehensive Care Plans must be developed within 7 days after completion of the comprehensive assessment (Admission, Annual or Significant Change in Status) and review and revise the care plan after each assessment. 7. If the Comprehensive assessment and comprehensive care plan identified change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes must be incorporated in to an updated summary provided it the resident and his or her representative, if applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105636 If continuation sheet Page 8 of 8