Inspection·July 21, 2022

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few been sitting on his over bed table. He said the medication had been there since this morning. Photographic evidence was obtained. An observation was made on 07/20/22 8:55 a.m. of a cup of liquid medication on Resident #100 bedside table. Resident #100 stated the medication was there since 8:30 a.m. Observed Resident #100 take the medication left on the table. During an interview with Staff D, Licensed Practical Nurse (LPN), on 07/20/22 at 9:57 a.m. she stated she was not sure what was given to him this morning. An observation was made on 07/20/22 at 10:11 a.m. of Staff E, LPN/Unit Manager, looking at the empty medication cup found on Resident #100 bedside table. Observed Staff E swirl the remainder of the dark yellow liquid in the cup and sniff the cup. He stated he was not sure what was given to Resident #100. He noted he will find out what it was. An interview was conducted with the Director of Nursing (DON) and the Regional Nurse on 07/20/22 at 11:10 a.m. stating they are not sure what the medication was and when it was given to him. Stating it could have been given to Resident #100 last night or that morning but cannot confirm. They stated they will be investigating and conducting interviews with the nurses. An interview was conducted with the DON on 07/20/22 at 11:28 a.m. stating the liquid in the cup was Nystatin. She confirmed there is not an order for Resident #100 to self-administer the medication. Observation revealed the DON holding a medication cup with the same dark yellow liquid found in Resident #100 room. She noted it was magic wash, which was a mixture that contained Nystatin. An interview was conducted with the DON on 07/20/22 at 2:02 p.m. She said she went into Resident #100 room and spoke with him and asked him if he took the medication this morning. He confirmed he took his medication from the nurse at 6:30 a.m. He stated the medication left on the bedside table was from yesterday and stated he swished some of the medication and left some to take later. The DON stated the nurse on the shift stated she saw Resident #100 swish the medication and left. The DON stated she told the nurse she did not complete the medication administration. Review of Resident #100 orders revealed an order dated 07/19/22 for Magic Mouthwash 1:1 20 cc (cubic centimeters) PO (by mouth) swish and swallow for every 8 hours for mouth pain for 10 days. There was no order allowing the resident to self administer the medication. Review of the Care Plan revealed a focus area dated 07/18/22 of Resident #100 having a potential for actual oral/dental problem related to thrush. The goal stated the resident would comply with mouth care at least daily (07/18/22) .The interventions included assist/complete oral care with routine morning personal hygiene and as needed (07/18/22) .and medicate for oral condition as ordered (07/18/22) . Review of the admission Data Collection for dates of 03/25/20 and 03/23/22 revealed in Section R. Medication: Resident #100 did not wish to self-administer medications. Review of the Medication Administration General Guidelines revealed under Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber .15. Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 2 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 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 0761 self-administration of medications and state regulations .20. The resident is always observed after administration to ensure that the dose was completely ingested . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 3 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation of the dietary staff washing dishes, interview with dietary staff, and review of facility documents, the facility failed to ensure that the dish machine was maintaining wash and rinse water temperatures according to the manufacturer's guidelines, and failed to document temperatures during each meal period, which could potentially cause the use of unclean dishes in the meal service. Findings included: On 07/18/2022 at 10:20 a.m., two dietary staff were observed washing breakfast dishes by running racks of dirty dishes through the dish machine. Staff I, Dietary Aide, reported when asked, that the wash temperature of the dish machine must be 140 degrees Fahrenheit (F) and the rinse water temperature must be 180 degrees F when washing dishes. The thermometers were registering 140 degrees F for the wash water and 180 degrees F for the rinse temperature during the interview. The face of the thermometer dials had the required temperatures on a sticker attached to the glass of the dial. The thermometer for the wash temperature indicated the wash water must reach 160 degrees F to be in compliance with the manufacturer's guidelines. The face plate attached to the dish machine indicated the wash temperature must be at a minimum of 160 degrees F and the rinse water must be a minimum of 180 degrees F. The dietary aide ran several empty racks through the dish machine in an attempt to get the wash water up to 160 degrees F but it did not increase to the minimum required to wash the dishes. Staff J reported they would stop washing the dishes and have the Manager call the company. A review of the Dish Machine Log where staff documented wash and rinse temperatures revealed the temperatures were not documented according to the guidelines on the log: record temperatures once during each meal period. Most entries on the log were for one meal on each day from 07/03 to 07/17/2022. The log included 20 entries for July (07/01 to 07/17/22) when there should have been fifty-one entries (three entries for each day). The log revealed five entries which documented the wash water was under 160 degrees F: (07/02, 07/13, 07/17 at breakfast; 07/15 and 07/16 at lunch). There were twelve entries documenting the rinse water was under 180 degrees F: (7/2 and 7/13 for breakfast and lunch; 7/1 for breakfast and dinner; 7/5, 7/7, 7/10, 7/15 for lunch; 7/6 and 7/17 for breakfast). An interview conducted with the Certified Dietary Manager (CDM) on 07/18/2022 beginning at 2:00 p.m., revealed a repair man had arrived to check the dish machine and he confirmed that the wash water was not reaching the required 160 degrees F because the machine was still in de-lime mode. The CDM reported that the dietary staff had de-limed the machine over the weekend and forgot to switch it back to regular mode which made the machine run at a lower temperature. The repair man's Regular Service Call report was reviewed and noted to have documented the concern with the water not heating to the required temperature based on remaining in the delime mode. The CDM in an interview conducted on 07/21/2022 beginning at 11:30 a.m. could not explain why dietary staff had not alerted him to the temperatures that were not meeting the required temperatures. He reported that he would have to train all staff and monitor the logs closer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 4 of 4