Inspection·March 18, 2021

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appropriately, stated his name. Patient was drowsy but able to take medication and took fluids without difficulty. Usually patient up and about in room and hallway. Enjoys eating and attention from staff. Resident not able to get up of bed (sic) and declined breakfast, poor appetite. The resident was transported to the hospital by emergency services on 02/21/21 at 13:11 with the reason documented as patient has failure to thrive x 2 days. A second Change in Condition report was documented on 2/21/2021 at 13:30 (1:30 p.m.) for altered mental status, food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts.) Vital signs were current for the documentation. The Outcomes of the Physical Assessment were documented as altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse), increased confusion. General weakness, decreased mobility, decreased appetite/fluid intake. Nursing observations, evaluation and recommendations were: Observed abnormal behavior with patient remaining in bed and refusing to eat. Unable to verbalize how he feels. A progress note dated 2/22/2021 at 12:16 a.m. read, called out to (hospital) for admission diagnosis, subdural hemorrhage facial fx (fracture) and UTI (urinary tract infection). The hospital History and Physical dated 02/25/2021 was reviewed. Under History of Physical Illness, the resident was described as a very pleasant [AGE] year old who was sent to the emergency room (ER) after having worsening lethargy and weakness. According to the rehab, the patient hit the bedside table on Friday and developed left peri-orbital bruising. Otherwise there is no history of trauma or falls. patient was found to have chronic appearing subdural hematomas and he was admitted with chronic subdural hematomas. The patient was still lethargic and hypernatremia, the nasal - gastric tube was placed for hydration and nutrition. the family was consulted, and the decision is to transfer the patient with CMO (comfort measures only) to Hospice care. A CT (Computerized Tomography) scan of the head without contrast was performed on 02/21/2021 at 14:46 (2:46 p.m.) which showed mildly displaced fracture anterior wall left maxillary sinus as well as posterior wall left maxillary sinus extending to the orbital floor nondisplaced fracture of the left zygomatic arch as well. The resident was readmitted to the facility on [DATE] with diagnoses of Hospice admission, senile dementia. The resident's level of consciousness was noted as lethargic with orientation to None of the above. The reason for the admission was, end of life care. On 03/09/2021 at 11:12 a.m., a weekly wound note documented, resident's area of discoloration to left peri-orbital area continues with improvement; area is diffuse, fading, intact, green/yellow/purple in color, sclera clear, pupils equal and reactive, no drainage observed. Resident's area to sacrum clarified as sacrococcygeal / bilateral inner buttocks, area is intact, deep purple, non-blanchable, no drainage, no odor, no s/s of infection; surround tissue to area is pink/red, intact and blanchable. Hospital notified for specialty mattress to be delivered. Resident with no expressions of pain or discomfort. Continue with current treatment. On 03/12/2021 at 5:35 a.m. the Progress Note read, at approximately 0510 resident expired. An interview was conducted on 03/18/2021 beginning at 10:28 a.m. with the Corporate Traveler Risk Manager (RM) and the Director of Nurses (DON) about the incident on Friday, 02/19/21 concerning Resident #144. The RM discussed what he remembered from the investigation - the aide had entered the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 2 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's room about 6:00 a.m. and noted a scratch on the inner aspect of his nose and left eye. The aide reported she saw some blood on the pillowcase. She told the nurse who came in and provided first aid to the resident. He said the nurse called the doctor and received no new orders except to monitor. She completed an event report which he reported would not be kept in the resident's medical record. He reported that as the weekend progressed, the area began to discolor and by Sunday the resident was eating poorly, and he was lethargic. The physician was notified, and he ordered the transfer to the ER on [DATE]. He reported at that point they began their investigation into an injury of unknown origin. (Review of the Immediate Report submitted to the state agency revealed a date and time of the incident as 02/21/2021 at 6:00 p.m. with additional comments on the report dated 02/22/2021.) He confirmed that the ER notified the facility of the facial fracture of the left orbit and two small chronic subdural hematomas which was documented by the nurse on 02/22/2021 at 12:16 a.m. In a second interview with the Traveler Risk Manager, on 03/18/2021 beginning at 3:51 p.m., it was confirmed that there had not been an earlier immediate report as the facility didn't feel the incident met the criteria for an injury of unknown origin. The RM reported that the injury had been viewed as possibly the resident's nails were too long and he needed nail care. The DON reported during that interview that on Monday, 02/22/21 interviews with the staff and a review of the resident's environment occurred. Also training on preventing neglect and event reporting began on 02/22/2021. An interview was conducted with Staff U, Registered Nurse (RN), Unit Manager (UM), on 03/15/2021 beginning at 12:30 p.m. She reported that the resident was observed in the morning with a scratch above his left eyebrow which got worse and the X-ray showed bilateral hematomas. She reported that Resident #144 wasn't at risk for falls as he ambulated independently. During an observation of the resident's room with the Unit Manager, she commented that the beds were further apart from each other, which meant Resident #144's bed was closer to the window. Across the bottom of the window was a tiled windowsill approximately two feet from the floor. She confirmed that she never heard what the final decision was, as to how the injury had occurred, but when she saw the resident on the Monday (02/22/2021) the whole eye was black and blue. An interview was conducted with Staff T, Registered Nurse (RN) on 03/18/2021 beginning at 1:40 p.m. She reported that she worked that Saturday, 02/20/2021 although she didn't usually work weekends. She reported that the resident's eye and area around it was black and blue. She reported that the resident was not his usual self, but no one had reported what had happened. She said she watched him all shift, and then when she worked on Sunday, he wasn't much better. She said she decided to call the doctor then and have him sent out. She commented that any time there was a mark on a resident, and no one saw it happen, it was an injury of unknown origin and a report and investigation must be conducted immediately. She commented that there had been a change in condition completed at 11:30 a.m. which was four hours after the incident. An interview was conducted with Staff Q, Certified Nursing Assistant (CNA) on 03/17/2021 at 8:23 a.m. He reported that his usual assignment was on the secured unit and the day shift. He confirmed he knew Resident #144 well. He reported that he came in one morning to work and saw that the resident had a cut across his forehead. He reported that the night shift had not said anything about the cut or what had happened. He said he commented to the other aide that was working and she confirmed that she had heard nothing about the incident. He reported that the resident was ambulatory and could be seen walking around the unit exercising his arms by rolling them in front of his chest and reaching up to the ceiling. He described the resident as being a good sleeper and a good eater. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 3 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with Staff R, CNA on 03/18/21 beginning at 1:55 p.m. She reported that she remembered coming into work and meeting up with the usual aides on the unit. She reported that one of the aides called to her to come look at Resident #144's eye. She hadn't heard anything from the prior shift about the resident's eye. She said she wasn't sure what had happened, but the area around the eye was black and blue. She confirmed that the staff that worked on the prior Friday, Saturday and Sunday were not the usual staff who knew the residents. She reported that no staff were 'owning up' to anything. When asked if she had been told what new intervention was added, to prevent a similar incident from occurring again, she said no, she had heard of nothing new. An interview was conducted with Staff S, CNA on 03/18/2021 beginning at 3:50 p.m. He confirmed he worked the 3:00 p.m. - 11:00 p.m. shift consistently and knew the residents on the secured unit well. He confirmed he had worked until 11:00 p.m. the night before (referring to 02/18/2021) and there was nothing wrong with Resident #144's eye. Then when he came in the next afternoon, the resident had a big black eye. He confirmed he had not been told anything about the injury and had not been told of any new intervention to prevent the injury from occurring again. A review was conducted of the facility's policy on Abuse, Neglect, Exploitation, Mistreatment of Resident/Patient, or Misappropriation of Resident/Patient Property, effective date 2012, which revealed no reference to investigating injuries of unknown origin. A second policy was provided which reviewed event reporting for any occurrence outside the routine operational expectation of the facility. This policy included investigating an injury of unknown origin, including bruising. A definition of an injury of unknown source/origin was provided: source (cause) of injury cannot be explained by resident and was not witnessed/ observed when it occurred. AND the location of the injury is suspicious because of the extent of the injury or the number of injuries observed at one time, or the incident of injuries over time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 4 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to assess to accurately reflect the resident's status and document discoloration of skin for two (Residents #76 and #245) of three residents observed. Residents Affected - Few Findings Included: 1. Observation of Resident #76 on 3/15/21 at 9:57 a.m. revealed the resident lying in bed with a purple colored rectangular area to the left center of forearm and right hand. Resident #76 stated she had no idea where she got the marks and called them bruises. She stated her memory was not great but was happy they did not hurt. Observation on 3/16/21 at 12:59 p.m. revealed a rectangular left forearm discoloration and a right hand purple discoloration. Resident #76 was unsure how she obtained the marks. During a interview with Staff O, Licensed Practical Nurse (LPN) on 3/16/21 at 4:21 p.m., she stated the residents' skin evaluations were completed on admission and weekly. She stated she had not noticed any bruising or discoloration on the resident and would check during medication administration. Staff O confirmed the discolored areas and said she would notify the manager, doctor and Power of Attorney (POA) of the bruising. An interview on 3/17/21 at 3:02 p.m. with Staff O revealed that the resident had a lab draw on 3/11/21. Staff O said, since the resident could not remember how she got the bruises, she [Staff O] completed her part and turned in the documents for management to investigate. She said the resident toilets herself and could have hit the door. Review of nursing progress notes revealed on 3/16/21 at 10:34 p.m., the patient was noted with a bruise to the left forearm and the right hand. Patient also noted with red bump like area on the right upper buttock, and a dark scab crust like area between the 4th and 5th digit. No new orders were given and staff would continue to monitor. Review of the skin check weekly dated 2/23/21 revealed no new areas of skin impairment. Review of the skin check weekly dated 3/2/21 revealed no new areas of skin impairment. Review of the skin check weekly dated 3/9/21 revealed no new areas of skin impairment. Review of the skin check weekly dated 3/16/21 revealed new areas of skin impairment found on the right hand, back of hand, bruising and Left forearm bruising. Review of the care plan revealed the resident with skin integrity: bruising to left forearm and right back of hand dated 3/18/21. Interventions to observe bruising to ensure areas do not open initiated on 3/18/21. Review of the skin grid for all other skin problems dated 3/17/21 revealed right hand yellow wound bed measuring 4 cm x 4.5 cm x 0 intact. Review of the skin grid for all other skin problems dated 3/17/21 revealed left forearm yellow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 5 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 wound bed measuring 5 cm x 4 cm x 0 intact. Level of Harm - Minimal harm or potential for actual harm An interview on 3/18/21 at 12:56 p.m. with Staff P, RN revealed the nurse should have measured and documented the bruises and marks on the resident. Staff P confirmed the resident was able to tell him that she had no idea how she got the bruises but stated she was happy with staff. Staff P confirmed the resident had a Brief interview of Mental Status (BIMS) of 8 to indicate moderate cognitive impairment. Staff P confirmed he was happy with her response although she could not remember, since the bruises were not in any of the abuse hot spots, he confirmed he did not further investigate the marks. Residents Affected - Few 2. Observation and interview on 3/15/21 at 4:32 p.m. revealed Resident #245 lying in bed without a shirt. The resident was observed with a large yellow to purple area on his abdomen about the size of a dessert plate. The resident stated he did not know how he got it but most likely happened when he fell out of bed and stated it did not hurt. On 3/16/21 at 8:46 a.m., an observation of the resident lying in bed without a shirt revealed a large yellowish purple discoloration around the size of a dessert plate. During an interview on 3/17/21 at 3:00 p.m. with Staff O, LPN, she confirmed she completed a skin assessment on the resident and stated he did have a bruise in varying stages from yellow-green to purple in color and asked the resident why he did not say anything. She said the resident told her it was from his fall and did not see it. Staff O confirmed it had been there for a while and should have been documented. Review of the progress notes dated 3/7/21 at 11:50 p.m. revealed the resident was found on his knees trying to get back in bed. Bed was in low position. Resident stated he was sleeping and rolled out of bed. No complaint of pain. Review of the progress notes dated 3/10/21 at midnight revealed a skin check was completed and no redness, swelling, bruising or other concern noted. Review of the progress notes dated 3/16/21 at 10:22 p.m. revealed a skin check was completed and a bruise to the left abdomen was observed. The resident stated it was from a previous fall. Review of the 3/11/21 weekly skin check revealed no new areas of skin impairment. Review of the 3/16/21 weekly skin check revealed new areas of skin impairment on left iliac crest (front) bruising. Review of the skin grid for all other skin problems dated 3/17/21 revealed abdomen (left) green in color measuring 18 cm x 25 cm x 0. Review of the resident's BIMS (Brief Interview for Mental Status) score dated 3/6/21 revealed a score of 15 to indicate his cognition was intact. Review of the care plan, initiated on 3/18/21, revealed a focus area of skin integrity risk as the resident has actual impairment to skin integrity related to bruises to left lateral abdomen. Interventions to observe for signs and symptoms swelling, discoloration or pain initiated on 3/18/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 6 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/17/21 at 4:56 p.m. with the Nursing Home Administrator, she stated her expectation was for staff to document any bruising on a resident and if the resident could not remember how they got the bruise an investigation would be started. An interview on 3/18/21 at 12:58 p.m. with Staff P, RN revealed the nurse should have measured the bruises. Staff P confirmed the resident was able to tell him that he had a fall and that must have been where the bruise came from. Staff P confirmed the resident was alert and oriented so he did not investigate further. Review of the policy and procedure effective 2/21, two pages, revealed: The weekly and as needed skin check is used to document skin condition throughout the resident stay in the facility. If a new area of impairment is identified during or between scheduled checks, it should be documented on the weekly and as needed skin check and the appropriate skin grid initiated depending on the cause. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 7 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice as evidence by 1. Failure to ensure a wound vac (vacuum assisted closure) was on and in working order for one (Resident #66) of three residents with wound vacs and 2. Failure to follow up on the Registered Dietitian's (RD) recommendations for one (Resident #145) of one resident reviewed. Residents Affected - Few 1 -An observation of Resident #66 was conducted on 3/15/21 at 11:11 a.m. She was lying in bed, dressed, and a wound vac was observed on the left side of resident's bed. Resident #66 stated, My wound vac has not been working all morning, and I have been calling for assistance and no one has responded to assist in reconnecting or fixing the wound vac. Observation of the resident at that time, revealed a clear transparent dressing to Resident #66's right knee with tubing attached. The tubing attached to the knee dressing was not connected to the wound vac. An interview was conducted with the Certified Nursing Assistant (CNA), Staff C, on 03/15/21 at 11:15 a.m. Staff C stated that she had told the charge nurse that Resident #66's wound vac was not working, or needed to be connected, but the nurse has not yet respond. An interview was conducted with the Charge Nurse, License Practical Nurse (LPN), Staff A, on 3/15/21 at 11:20 a.m. Staff A confirmed that the wound vac was disconnected and stated that it was disconnected by another staff when Resident #66 was assisted to the bath room. Staff A stated, I will connect the wound vac when I do treatment later today. She then exited the room. Record review of Resident #66 medical records revealed that she was admitted to the facility on [DATE], with diagnoses that included Aftercare following joint replacement surgery, presence of right artificial knee joint, spinal stenosis, lumbar region without neurogenic claudication, arthrodesis status, and multiple fracture of pelvis without disruption of pelvic ring. Review of her Minimum Data Set (MDS) assessment dated [DATE], section C revealed a Brief Interview for Mental Status (BIMS) Score of 15, which indicated she had no cognitive impairment. Review of physician's orders dated 2/11/21 revealed an order for wound vac dressing changed three times per week on Monday, Wednesday, and Friday to right lower extremity (RLE), .attach wound vac at wound site, cover with transparent dressing. Check placement, seal, and vac setting every shift. Review of Resident #66 care plan dated 2/11/21, revealed she had actual skin impairment related to a surgical wound to top of right knee. Intervention included: Notify physician of new/increase discoloration, pain, regime/intervention not effective. Follow facility protocol for treatment. During a follow observation on 3/18/21 at 12:00 p.m., the wound vac was observed on bedside table. In an interview with Resident #66, she stated that the wound vac was beeping, and no one came in to tend to it. On 3/18/21 at 12:05 p.m., during an interview with Staff B, Licensed Practical Nurse, (LPN), she went into Resident #66's room and asked permission to check her wound vac and tubing. Staff B confirmed that the wound vac was not working or functioning. She stated that the secretions or drainage should have been observed in a moving motion in the tubing. Staff B stated that she was not too familiar (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 8 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 with fixing the wound vac, but she would get someone who was able to. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the DON (Director of Nurses) on 3/18/21 at 1:42 p.m. During the interview the DON went to Resident #66's room and examined the wound vac. She confirmed that the wound vac was not functioning and stated that she would get a nurse to fix it. Residents Affected - Few In a follow up interview with the DON, on 03/18/21 at 4:00 p.m, a policy and procedure (P&P) related to use of the wound vac and treatment were requested. Later that day at approximately 5:00 p.m., the DON returned to say that there was not a P&P on the use of a wound vac. 2 - On 3/17/2021 Resident #145's record was reviewed. Resident #145 was admitted in the facility on 5/11/2016. Resident # 145 was transferred to the acute hospital on 2/23/2021 for a critical high BUN (Blood Urea Nitrogen - laboratory test for kidney function) of 109 mg/dL (normal level is 7 to 25 mg/dL) and dehydration. Further review of Resident #145's record indicated a comprehensive nutritional evaluation conducted by the facility Registered Dietitian (RD) dated 1/13/2021. The evaluation indicated .17.5% weight loss in 90 days, 16.1 loss in 180 days .67 Y/O female. Has had weight loss .Also recommending BMP labs (basic metabolic panel group of eight tests including BUN that provides information on blood sugar level, the balance of electrolytes and fluids, and the health of the kidneys). There was no documented evidence in the resident's record that the recommended BMP laboratory tests were obtained. On 3/17/2021 at 2:21 p.m., Resident #145's record was reviewed with the RD. The RD stated she completed the nutritional evaluation for the resident on 1/13/2021 because the resident was losing weight. The RD stated she recommended BMP labs but could not find evidence in the resident's record that the recommendation was carried out. The RD stated she followed up on the resident on 2/3/2021 and found that the resident .lost more weight since I last saw her . On 3/18/2021 at 9:53 a.m. the DON (Director of Nurses) was interviewed. The DON stated she and the RD had a meeting to follow up on Resident #145's status on 1/27/2021 and 2/3/2021. The DON stated at both times they missed following up on the BMP recommendations made by the RD. The DON stated the results would have helped in assessing Resident #145's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 9 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions, including adequate supervision, consistent with the resident's needs, goals, and care plan in order to eliminate or reduce the risk of accidents and injuries for one (Resident #44) of five residents sampled for accidents. Resident #44 was admitted to the facility in September of 2020 with a diagnosis of repeated falls. Resident #44 sustained five falls since admission between 10/8/20 and 2/27/21 with no documented evidence of analysis of hazards and risks to prevent further accidents. Resident #44 was placed on 15 minute checks on 1/20/21 with no documentation of safety checks maintained. On 3/10/2021 scans revealed Resident #44 had bilateral fractures in the hip area thought to be associated with the fall on 2/27/21. Observations and interviews with staff during the survey revealed staff continued to be unaware of Resident #44's hip fractures and interventions to prevent further injuries from occurring. Findings included: During a tour of the facility conducted on 3/15/2021 at approximately 10:00 a.m., Resident #44 was observed in her room, in bed, awake, and responsive. The resident's bed was in the high position and a floor mat was on the left side of the resident's bed. On 3/16/2021 at 3:24 p.m., Resident #44 was observed in the dining room sitting up in a geri-chair wearing rubber soled shoes. A review of the Facility's Incident Log from 10/1/2020 through 3/16/2021 indicated Resident #44 fell on [DATE], 12/17/2020, 1/2/2021, 1/16/2021, and 2/27/2021. A review of Resident #44's record was conducted. Resident # 44 was admitted in the facility on 9/2/2020 with diagnoses that included repeated falls. The admission Minimum Data Set (MDS - an assessment tool) dated 9/8/2020 indicated a BIMS (Brief Interview for Mental Status), an evaluation of cognition, score of 7 (0-7 severe cognitive impairment). The assessment also indicated the following: - supervision for eating -one person limited assistance with bed mobility, transfers and dressing -one person extensive assistance with toilet use and personal hygiene -dependent on one staff for bathing -no functional limitation or impairment in both upper and lower extremity range of motion Review of Resident #44's progress notes indicated: 3/10/2021, Resident returned from (name of hospital) via stretcher resident had CT (Computerized Tomography) scans showing bilateral fractures of symphysis pubis (joint between the left and right pubis of the hip bones, located in front of and below the urinary bladder) on the left extending to the anterior aspect of the acetabulum on the right and fracture of the left inferior pubic ramus (bones). Resident is no weight bearing on the LLE (left lower extremity) and may toe touch weight bear as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 10 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave 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 0689 tolerated on the RLE (right lower extremity) . Level of Harm - Actual harm There was no other documentation in the resident's record addressing the change in Resident #44's weight bearing status. Residents Affected - Few There was no documentary evidence in the physician's orders or Resident #44's care plans addressing the resident's hip fractures and new weight bearing status. 3/2/2021, Resident is wincing in pain and moaning when rolling from side to side, when asked where her pain was she motioned towards her left leg .new orders for pelvis, left hip and left femur x-rays. 2/27/2021, Writer came out into hallway from another room and Resident was in hallway lying on right side directly in front of wheelchair. head to toe assessment completed. No injuries observed. Right side forehead with pink/red, dime sized non raised area. AROM (active range of motion) WNL's (within normal level) to BUE/BLE's (bilateral upper extremity/bilateral lower extremity). resident with no expressions of pain or discomfort. Denies pain .Shoes only half on with heels hanging out backside of shoes . 1/16/2021, .CNA (certified nurse assistant) pushing resident in wheelchair. While in motion resident attempted to stand up by placing feet to floor .she fell forward on face front height of chair to floor .large hematoma covering left side of forehead and eyebrow .EMS called . Review of Resident #44's fall care plan indicated: 9/2/2020, The resident is at risk for falls or fall related injury because of history of falls, Goal: Will minimize the risk for fall. -initiated 2/27/2021, Resident to wear non-skid socks at all times. -initiated 1/20/2021, q (every) 15 min safety checks -initiated 9/9/2020. Ensure Non-Skid socks/shoes in place at all times Review of other care plans initiated for of Resident #44 indicated: -2/8/2021, CANCELED:TRANSFER -- decline in ability -2/8/2021, CANCELED:DRESSING & GROOMING -- decline in ability On 3/16/2021 at 3:30 p.m., the Unit Manager (UM) was interviewed regarding Resident #44's fall incidents. The UM stated, All the other Unit Managers are all gone .were suppose to have three, now it's only me, the education person is also gone the DON has been working on the floor too . The UM stated, We have had to work the floor because we have insufficient staff. The UM stated As unit manager my responsibility is auditing orders for medication, new treatments, follow up on labs, x-ray .there's no oversight because we have been working the floor. On 3/16/2021 at 4:37 p.m., the MDS Nurse was interviewed. The MDS nurse stated she complete a significant change in status MDS on 2/2/2021 for Resident #44 because She had so many falls .with all of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 11 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave 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 0689 her falls her functional status has really declined including her cognition. Level of Harm - Actual harm On 3/16/21 at 5:12 p.m. Resident #44's record was reviewed with the Director of Nursing (DON). The DON stated fall risk was assessed on admission and reassessed by the Interdisciplinary Team after fall incidents and then the care plan was updated. The DON reviewed Resident #44's fall incidents: Residents Affected - Few -10/8/2020 - witnessed, slipped from her wheelchair and fell backwards, hit her head -12/17/2020 - unwitnessed fall, complained of left wrist pain -1/2/2021 - unwitnessed, found sitting on the floor in the dining room, bump on left side of the head -1/16/2021 - witnessed, attempted to stand up while being wheeled by CNA, subdural hematoma -2/27/2021 - found in the hallway lying on her right side Review of the IDT notes provided by the DON indicated the following: -10/9/2020, IDT review of fall 10/8. Resident fell in her room. Psych services to assess resident and medication review sent to pharmacy. -12/22/2020, IDT review of fall on 12/17. resident reported fall in the night, unwitnessed. Reports pain in her thumb .Medication review sent over to pharmacy. -1/6/2021, IDT review of fall on 1/2. Labs UA (urinalysis) to r/o (rule out) medical concerns for fall. -3/1/2021, IDT review of fall on 2/27. Resident not wearing shoes correctly. the back of her heels were hanging out of her shoes. resident states she doesn't know what happened. She states she was tired .Labs and UA obtained .UA still pending -There was no documentary evidence in Resident #44's record of the IDT evaluation and analysis of hazards and risks to prevent further accidents. - There was no documentary evidence in Resident #44's record of implementation, monitoring for effectiveness and modification of interventions from the IDT. During the 3/16/21 5:12 p.m. record review and interview with the DON, she indicated that there was no documented evidence in the resident's record addressing the cause of Resident #44's recent fractures and, there was no documented evidence the resident's treatment and care plans were updated to reflect the recent fractures and new weight bearing status. The DON stated they surmised the fractures were related to the resident's fall incident on 2/27/2021. The DON also confirmed there was no documentary evidence to indicate that the every 15 minutes safety checks were conducted for Resident #44. On 3/16/2021 at 6:06 p.m., Staff F was interviewed. Staff F was the CNA assigned to the resident. Staff F stated she was an agency nurse and this was first time she was assigned to Resident #44. Staff F stated she did not know about the resident's fracture and weight bearing status. Staff F stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 12 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave 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 0689 Usually around this time there are only agency nurses .I just try to figure it out .I only look at the shower book . Level of Harm - Actual harm Residents Affected - Few On 3/16/2021 at 6:17 p.m. Staff G was interviewed. Staff G was the nurse assigned to the resident. Staff G stated the CNA would not know about the resident's fracture and weight bearing status because It's not there (in the [NAME]) there is no instructions for transfers. On 3/17/2021 at 4:04 p.m., the significant change in status MDS dated [DATE] was reviewed with the MDS nurse. The MDS nurse stated Resident #44's functional status has declined as evidenced by the following assessed changes: -Cognition BIMS from 7 to 2 -Eating from supervision with one person assist to limited assistance with two persons assisting -One person limited assistance with bed mobility, transfers and dressing to extensive assistance with two person assist -One person extensive assistance with toilet use and personal hygiene to extensive assistance with two person assist -Bathing from total dependence one person assist to dependence with two persons assist -Balance During Transition and Walking from not steady able to stabilize with staff assistance to activity did not occur, stated the resident was not able to perform the task anymore -Functional limitation in Upper Extremity Range of Motion from no limitation to impairment on one side Review of the hospital Emergency Department Documents for Resident #44 dated 3/10/2021 indicated: -History of Present Illness: Hip Injury-Pain. The patient presents with bilateral hip pain. The onset was one week ago . -Diagnosis: Mechanical Fall, Acute closed bilateral pubic rami fractures with extension into the left acetabulum. -Plan: .non weight bearing on the left lower extremity. May toe touch weight bear as tolerated on the right lower extremity . On 3/30/2021 at 3:56 p.m., a telephone interview was conducted with Advance Practice Registered Nurse (APRN) who was following Resident #44. The APRN stated he was not informed of the resident's status upon returning from the hospital to the facility on 3/10/2021. The APRN stated the multiple falls the resident has had in the facility contributed to her significant functional and cognitive decline. Review of the facility policy and procedure, Fall and Injury Reduction Policy, effective February (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 13 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 2021 indicated The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Falls and Injury Reduction Policy. Resident data is collected to identify fall risk factors. The interdisciplinary team works with the resident and family to identify and implement appropriate interventions to reduce the risk for falls or injuries while maximizing dignity and independence .4. Implement plan of care based on individual needs. 5. Communicate interventions during shift report, daily clinical rounds and/or entry on electronic care communication tool to the care giving team. 6. Provide training to staff as needed. 7. Review and revise the plan of care as needed to reflect the resident's current needs . Event ID: Facility ID: 105690 If continuation sheet Page 14 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation of the resident, interview with the resident's nurse and Director of Nurses (DON), and review of the resident's medical record and facility documents, the facility failed to ensure one (Resident #54) of eight residents with indwelling urinary catheters, was provided care to aid in the prevention of an infection related to his urinary catheter bag observed out of the privacy bag, laying on the floor, under the front left wheel of his wheelchair. Findings included: Resident #54 was a long term resident of the facility with diagnoses that included Chronic Kidney Disease, Retention of Urine, Urinary Tract Infection, and Obstructive and Reflux Uropathy for which he had an indwelling urinary catheter. A consult with the Urologist was noted for the concern of hematuria on 02/22/2021. Review of the resident's care plans revealed a care plan initiated on 11/27/2020 for the Indwelling Catheter with the Focus as Resident uses a Urinary Catheter with risk for infection and/or complications related to Obstructive Uropathy. Interventions included: change drainage bag routinely and as needed; provide catheter care daily and as needed; change catheter prn (as needed). On 03/16/2021 at 12:25 p.m., the resident was observed sitting in his wheelchair at a dining table in the common room eating his lunch. The front left wheel of his wheelchair was noted to be resting on the drainage bag of his indwelling catheter, which had come out of the privacy bag and was lying flat on the ground. There was yellow liquid on the floor around the catheter drainage bag. Staff A, Licensed Practical Nurse (LPN) was notified of the drainage bag under the wheelchair wheel and she spent several minutes trying to get the wheel off of the drainage bag and then the drainage bag back into the privacy bag which was attached to the back of the resident's wheelchair. On 03/18/2021 at 11:10 a.m., the Director of Nurses was made aware of the observation of the resident's wheelchair wheel resting on the resident's catheter drainage bag on the floor. She confirmed that the nurse should have written a note about the incident and should have changed the bag as it had been on the common room/dining room floor and under the wheel of the wheelchair. A review of the nurse's notes, after speaking with the Director of Nurses, revealed there was no note detailing the incident including nothing about changing the bag and tubing as it had been on the floor under the wheel. A review of the Treatment Administration Record also did not include documentation that the bag and tubing had been changed. A policy for the care of an Indwelling Urinary Catheter was requested on 03/18/2021 at approximately 4:30 p.m. The Consultant Nurse reported at approximately 5:30 p.m. on 03/18/2021 that there was not a policy for the care of the Indwelling Catheter and the nursing staff would follow the general Infection Control Policy for care of an Indwelling Catheter as well as the facility Infection Control Process Surveillance Checklist. A review was conducted of the facility policy, Infection Prevention and Control Program. The Goals for the Infection Prevention and Control Program are to provide a safe, sanitary and comfortable environment, decrease the risk of infection and communicable disease development and transmission, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 15 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete identify and correct problems relating to infection control and prevention practices, and focus on activities to optimize the treatment of infections, while reducing the potential for the occurrence of adverse events associated with antibiotic use. The Infection Control Process Surveillance Checklist included under the Surveillance Area of [urinary] Catheters, Bag is below the bladder and off of the floor. Event ID: Facility ID: 105690 If continuation sheet Page 16 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure enteral feeding pumps and the pump settings were accurately calibrated to provide the rate and volume consistent with the care plan for two (Resident #68 and Resident #41) out of two sampled residents. Findings included: 1. On 3/15/2021 at 9:30 a.m., a tour of the facility was conducted. Resident #68 was observed in bed. Resident #68 was observed to be connected to an enteral feeding pump with the formula running at 67 milliliters/hour (ml/hr), dose limit (total volume to be infused) 1770. On 3/15/2021 at 9:32 a.m., Resident #68's record was reviewed. Resident #68 was admitted in the facility on 2/6/2021 with diagnoses that included tracheostomy (an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube) and gastrostomy (external opening into the stomach for nutritional support). The resident's physician's orders dated 2/17/2021 indicated, Glucerna 1.2 Cal (tube feeding formula) Liter Continuous via G-tube to infuse at a rate of 67 mL/hr per 24 hours. Total volume to infuse is 1.608 ml/24 hr . On 03/16/21 9:43 a.m., Staff D, Licensed Practical Nurse (LPN) was interviewed. Staff D who was the nurse for Resident #68 stated she was a registry nurse and it was her first day in the facility. Staff D stated when she arrived in the facility, The 11-7 nurse reported to me the resident's GT was turned off at six. Staff D stated she had not restarted the resident's tube feeding. Staff D stated she did not understand 1.608 ml/24 hrs and .the order did not state a specific start or stop time just 24 hours continuously. On 03/16/21 9:48 a.m., Resident #68's enteral feeding pump was observed with Staff E, LPN, who was the resident's nurse the previous day. Staff E stated the pump indicated a dose limit of 1770. On 03/16/21 9:50 a.m., Resident # 68's physician orders were reviewed with the Unit Manager (UM). She stated, 1.608 ml/24 hrs should be 1608 ml/24 hrs and the enteral feeding pump dose limit should indicate 1608. Review of Resident #68's care plan initiated 2/6/2021 indicated, .dependent on enteral feeding and flushes for nutrition and hydration needs .Administration of enteral nutrition as ordered (Refer to MD orders) . On 3/17/2021 at 2:36 p.m., the facility's Registered Dietitian (RD) was interviewed. The RD reviewed Resident #68's physician's orders and stated the dose limit should have been clarified to indicate the correct dose limit of 1608 mls/day. The RD stated the enteral feeding orders were calculated based on the specific resident needs and therefore, If tube feeding orders are not administered as ordered the result may not meet the resident's nutritional needs. The RD stated the tube feeding orders should be calibrated to match the orders. 2. On 3/16/2021 at 10:55 a.m., Resident # 41's record was reviewed. Resident #41 was admitted in the facility on 1/27/2021 with diagnoses that included tracheostomy and gastrostomy. The physician's order dated 3/4/2021 indicated, Glucerna 1.2 Cal Liter Continuous via peg tube to infuse at a rate of 67 mL/hr per 21 hours. Total volume to infuse is 1407 ml/24 hr 6 am, down at 3 am (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 17 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/16/21 at 11:00 a.m., Resident #41 was observed with Staff E, LPN. Resident # 41's tube feeding pump was connected to the resident but was turned off. Staff E stated she did not know why the resident's tube feeding pump was off. Staff E turned on the tube feeding pump and the pump indicated a of rate 69 and a dose limit of 1450. On 03/16/21 at 11:05 a.m., Staff D, who was the assigned nurse for the resident, was interviewed. Staff D stated she was not the one who turned off resident #41's tube feeding pump. Staff D stated she did not know how long it had been off. On 03/16/21 at 11:10 a.m., Resident #41's tube feeding pump was observed with the UM. The UM stated the rate should be at 67 ml/hr and the dose limit should be 1407 and not 1450. The UM while attempting to correct the dose limit on the pump stated, The nurses do not usually use the dose limit .the pump cannot be even set to 1407. The UM further stated, The pump should not have been turned off, it should be running. Review of Resident #41's care plan initiated 1/27/2021 indicated, .dependent on enteral feeding and flushes for nutritional and hydration needs .Enteral formula and flushes as ordered . Review of the facility policy and procedure, Medication Administration Enteral Tubes dated 2007 indicated The nursing care center assures the safe and effective administration of enteral formulas and medications .Enteral formulas, equipment, route of administration, and rate of flow are selected based on an assessment of the resident's condition and needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 18 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide sufficient qualified nursing staff at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for one (Resident #44) of five sampled residents related to falls and one (Resident #66) of four residents related to a wound vac (vacuum assisted closure). Findings: 1. During a tour of the facility conducted on 3/15/2021 at approximately 10:00 a.m., Resident #44 was observed in her room in bed, awake, and responsive. The resident's bed was in the high position and a floor mat was on the left side of the resident's bed. On 3/16/2021 at 3:24 p.m., Resident #44 was observed in the dining room sitting up in a geri-chair chair. A review of the Facility's Incident Log from 10/1/2020 through 3/16/2021 revealed Resident #44 fell on [DATE], 12/17/2020, 1/2/2021, 1/16/2021, and 2/27/2021. A review of Resident #44's record was conducted. Resident # 44 was admitted to the facility on [DATE] with diagnoses that included repeated falls. Review of Resident #44's progress notes indicated: 3/10/2021, Resident returned from (name of hospital) via stretcher resident had CT (Computerized Tomography) scans showing bilateral fractures of symphysis pubis (joint between the left and right pubis of the hip bones, located in front of and below the urinary bladder) on the left extending to the anterior aspect of the acetabulum on the right and fracture of the left inferior pubic ramus (bones). Resident is no weight bearing on the LLE (left lower extremity) and may toe touch weight bear as tolerated on the RLE (right lower extremity) . There was no other documentation in the resident's record addressing the change in Resident #44's weight bearing status. There was no documentary evidence in the physician's orders or Resident #44's care plans addressing the resident's hip fractures and new weight bearing status. On 3/16/2021 at 3:30 p.m., the Unit Manager (UM) was interviewed regarding Resident #44's recent fracture and fall incidents. The UM stated, All the other Unit Managers are all gone .we're suppose to have three, now it's only me, the education person is also gone .the DON has been working on the floor too . The UM stated, We have had to work the floor because we have insufficient staff. The UM stated, As unit manager my responsibility is auditing orders for medication, new treatments, follow up .there's no oversight because we have been working the floor. On 3/16/2021 at 6:06 p.m., the Certified Nursing Assistant (CNA), Staff F was interviewed. Staff F was the CNA assigned to the resident. Staff F stated she was an agency CNA and this is the first (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 19 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few time she was assigned to Resident #44. Staff F stated she did not know about the resident's fracture and weight bearing status. Staff F stated Usually around this time there's no one who knows .I just try to figure it out .I only look at the shower book . On 3/16/2021 at 6:17 p.m., Staff G was interviewed. Staff G was the LPN assigned to the resident. Staff G stated she worked full time in the facility. She stated that the CNA would not know about the resident's fracture and weight bearing status because It's not there (in the [NAME]) there is no instructions for transfers. 2. An observation of Resident #66 was conducted on 3/15/21 at 11:11 a.m. She was lying in bed, dressed, with a wound vac (negative pressure wound therapy), a therapeutic technique using a suction pump, tubing and a dressing to remove excess exudate (fluid), was observed on the left side of resident's bed. Resident #66 stated, My wound vac has not been working all morning, and I have been calling for assistance and no one has responded to assist in reconnecting or fixing the wound vac. Observation of the resident at that time, revealed a clear transparent dressing to Resident #66's right knee with tubing attached. The tubing attached to the knee dressing was not connected to the wound vac. An interview was conducted with the Certified Nursing Assistant (CNA), Staff C, on 03/15/21 at 11:15 a.m. Staff C stated that she had told the charge nurse that Resident #66's wound vac was not working, or needed to be connected, but the nurse had not responded. An interview was conducted with the Charge Nurse, License Practical Nurse (LPN), Staff A, on 3/15/21 at 11:20 a.m. Staff A confirmed that the wound vac was disconnected and stated that it was disconnected by another staff when Resident #66 was assisted to the bath room. Staff A stated, I will connect the wound vac when I do treatment later today. She then exited the room. On 3/16/21 9:30 a.m., a follow up interview was conducted with Resident #66. The resident stated that she fell two times last evening, because no one would assist her to the bathroom. She was told by the staff that she could go to the bathroom by herself. On 3/18/21 at 12:00 p.m., Resident # 66 was observed with the wound vac on bedside table. In an interview with Resident #66 she stated that the wound vac was beeping, and no one came in to fix it. Record review of Resident #66's medical records revealed that she was admitted to the facility on [DATE], with diagnoses that included: Aftercare following joint replacement surgery and multiple fractures of pelvis. Review of her Minimum Data Set (MDS) assessment dated [DATE], section C revealed a Brief Interview for Mental Status (BIMS) Score of 15, which indicated she had no cognitive impairment. 3 Review of the Resident Census and Conditions of Residents (CMS-672) and the Matrix For Providers (CMS-802) submitted by the facility during the survey indicated the facility had 96 total number of residents. The document further indicated the following number of residents requiring special care: - 4 residents requiring Intravenous therapy (IV) including IV nutrition (TPN - total parenteral nutrition, method of feeding that bypasses the gastrointestinal tract, fluids are given into a vein to provide the nutrients the body needs); - 4 residents requiring Tracheostomy (an opening surgically created through the neck into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 20 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 (windpipe) to provide an airway and to remove secretions from the lungs) care and suctioning; Level of Harm - Minimal harm or potential for actual harm - 4 residents on Negative Pressure Wound Therapy (wound vac - a therapeutic technique using a suction pump, tubing and a dressing to remove excess exudate and promote wound healing, and; Residents Affected - Few - 7 residents requiring Tube feedings (tube inserted into the stomach through the abdomen used to provide nutrition). On 3/18/21 at 11:13 a.m., Staff I was interviewed. Staff I stated she was a CNA and she was the central supply and staffing coordinator for the facility. Staff I stated she had been doing the monthly schedules, staffing calculations and during the week, If there's a call off I have to find the replacement. Staff I stated she determined the number of licensed nurses and nurse aids to be scheduled depending on the census and number of admissions. Staff I stated she did not factor in resident needs such traches, wound vacs or IVs. Staff I stated she did not know which nurses were trained with wound vacs, and for IVs. She stated, I do not know which Licensed Practical Nurses (LPN) have certification. The staffing assignments from 3/14/2021 - 3/16/2021 was reviewed with Staff I. The review indicated there was no Registered Nurse (RN) during the 3/15/201 11:00 p.m. to 3/16/2021 7:00 a.m. shift. Staff I stated only three LPNs worked the shift. Staff I stated she did not know if the LPNs on the shift were IV certified or if they have had wound vac training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 21 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure effective infection prevention measures were in place to reduce the spread of COVID-19 and prevent the development of infections by failing to ensure staff donned Personal Protective Equipment during a COVID-19 nasal test for one (Resident #67) of one observed while the nurse performed a nasal swab, for failing to don Personal Protective Equipment (PPE) while obtaining vital signs in one of one rooms on contact precautions for clostridium difficile (C-diff), for failing to don gloves while holding and cleaning a recently used glucometer, and for failing to disinfect a face shield prior to replacing in a clear plastic bag for reuse. Residents Affected - Few Findings Included: During an interview with the Director of Nursing (DON) on 3/17/21 at 10:00 a.m. she stated the facility performed COVID-19 testing with the oral swab in the cheek and the person was able to swab themselves without donning all of the PPE to perform the test. An observation was made of Resident #67 during a COVID-19 testing on 3/17/21 at 10:20 a.m. by Staff L, Licensed Practical Nurse (LPN). Staff L spoke to the resident and asked her to go back in her room and explained she needed to complete the COVID - 19 test. Resident #67 said she needed the test for a procedure at the end of the week. Staff L wearing prescription glasses, a KN95 mask, and gloves opened the swab and placed it in Resident #67's left nostril then in the vial. Staff L stated she forgot to bring a biohazard bag to place the sample in and used a glove to drop the vial into then placed the nasal swab sample into her left front shirt pocket. Staff L went into the bathroom, washed her hands, and exited the resident's room without anything in her hands. When asked where she placed the sample. Staff L stated she left the sample in the bathroom and walked back into the bathroom while pulling the sample out of her left pocket. She stated, Oh I put it in my pocket and should not have done that. Staff L then walked to the nurse's station to look for a biohazard bag with the COVID-19 vial in the glove. Staff L obtained the medication room keys from another nurse and placed the glove on the counter containing the COVID-19 sample while looking for a biohazard bag. After locating the biohazard bag Staff L emptied the vial into the biohazard bag and disposed of the glove. During an interview with the DON on 3/17/21 at 12:09 p.m., she said, the nurse should have donned personal protective equipment to include a face shield, mask, gown, and gloves to test the resident. On 3/16/21 at 4:57 p.m., Staff M, Certified Nursing Assistant (CNA) was observed in a resident's room without PPE using a rolling blood pressure machine, with thermometer and pulse oximeter. Staff M was observed leaning against the resident's bed nearest the door. The sign on the door was a large red stop sign that stated to see the nurse. The Infection Control Consultant was asked what the resident was on precautions for and they confirmed the resident to have Clostridium Difficile. The Consultant asked Staff M to leave the room and don PPE when they see the stop sign on the door and then instructed staff M to clean the rolling blood pressure machine. On 3/18/21 at 5:00 p.m., Staff N, LPN was observed walking up to her medication cart holding a glucometer in her bare hand. She said she just used it. She pulled out an individual bleach wipe, opened it with her bare hands, cleaned the glucometer, and left it wrapped in the bleach wipe. Staff N confirmed she probably should be wearing gloves while cleaning the glucometer. On 3/16/21 at 3:34 p.m., Staff N was observed completing a blood sugar check then using bare hands (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 22 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to carry the glucometer to the medication cart. Staff N confirmed she should have been using gloves to hold the glucometer after use. She reached in her right hand shirt pocket to remove an individually packaged bleach wipe, cleaned the glucometer without gloves, and performed hand hygiene. On 3/16/21 at 4:45 p.m., Staff O, LPN was observed leaving a resident room with a sign on the door that stated droplet precautions. Staff O removed her gown and gloves, washed her hands, went to the door, removed her face shield, placed it in the original plastic packaging without disinfecting it, and placed it in the isolation precaution bin outside the room in the top drawer. Staff O stated that she had a face shield earlier and it disappeared so she would keep this face shield. Staff O stated she would need to put her name on the face shield that she put in the drawer so others would know it was used and hers. Staff O opened the plastic in the drawer and pulled the face shield out enough to write her name then closed the plastic and shut the drawer. 03/17/21 4:31 p.m. during an interview with the DON, she confirmed her expectation would be to wear PPE when completing a nasal swab for COVID - 19 to include, face shield, gown, and gloves, as they already wear KN95's, and a contact precaution room should wear a gown, gloves and mask. The DON confirmed one room was on isolation precautions for Clostridium Difficile (C-Diff) and six rooms were residents readmitted from the hospital and on droplet precautions. During a phone interview with the Assistant Director of Nursing (ADON) on 3/17/21 at 12:39 p.m., she stated she was the Infection Preventionist for the facility. The ADON stated her expectation would be to clean the rolling blood pressure cart at the point of use and to wear a gown, gloves, and mask in a contact isolation room. The ADON confirmed all staff are wearing KN95's in the building. Review of the facility policy related to Covid-19 testing effective October 2020, 4 pages, reflected: During specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher level respirator (or facemask if a respirator is not available), eye protection, gloves and a gown, when collecting specimens. Review of the facility policy for hand hygiene effective February 21, 2 pages reflected: 5. employees must wash their hands for 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after any invasive procedure (finger stick blood sampling). Upon and after coming in contact with a resident's intact skin (when taking a pulse or blood pressure) After contact with a resident with infectious diarrhea including, but not limited to infections caused by C. difficile (hand washing with soap and water). Review of the facility policy for glucometer cleaning and disinfecting policy effective October 2020 one page, revealed: 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2. The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C, Hepatitis B virus, and C-Diff. 3. Glucometers should be cleaned and disinfected before and after each use and according to manufacturer's instructions regardless of whether they are intended for single use or multiple resident use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 23 of 24 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 4. Two (2) glucometers will be maintained on the cart to allow drying time between residents Level of Harm - Minimal harm or potential for actual harm 5. Procedure: h. reapply gloves, retrieve (2) disinfectant wipes from container Residents Affected - Few i. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. j. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following manufacturer's instructions. k. Discard disinfectant wipe in waste receptacle. l. Take off gloves and wash hands. Review of the facility policy for Isolation precautions - Categories of transmission-based infections, effective 2021, 4 pages: Transmission-based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. In addition to standard precautions, implement contact precautions for residents known or suspected to be infected that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 2) diarrhea associated with Clostridium difficile. c. Gloves and handwashing D. Gown - 1. In addition to wearing a gown as outlined under standard precautions, wear a gown for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. 2. After removing the gown, do not allow clothing to contact potentially contaminated surfaces. F. When possible, based on the individual's ability to contain infected fluids, resident's personal hygiene habits and the risk of transmission. 2. If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. G. A sign will be used to alert staff and visitors of the implementation of transmission based precautions, while respecting the resident's privacy. The sign will be placed on the resident's door and should state: Report to nurse before entering room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 24 of 24