Inspection·June 19, 2023

F 0600 The resident has provided the following description of the event: unable to describe Level of Harm - Actual harm Anger, agitation, distress causing increased or new onset of aggression Fear/anxiety 9e.g., trembling, cowering, flinching) diminished ability to think or concentrate [sic] Residents Affected - Few The following type of event is noted: skin alteration Details of the event are as follows: observed facial swelling Preventative interventions related to this event include: pain mediation[sic] changed, x-ray The name of the practitioner notified is: [Resident #1's primary Physician] The date and time of practitioner notification: 5/31/23 10:00p.m. Please note the following new orders: facial x-ray The name of the Resident Representative notified: family The date and time of the Resident's Representative was notified: 5/31/2023 11:00 PM. Review of Resident #1's progress notes revealed a progress note dated 6/1/23 at 6:07 a.m. revealed Received order for Nasal Xray (3view) STAT d/t facial discoloration and c/o [complaints of] pain. Bedside xray needed d/t [due to] res [resident] dementia diagnosis. Review of Resident #1's physician orders revealed an order dated 6/1/23 Nasal X-Ray STAT. Review of the Nasal X-ray dated 6/1/23 revealed Results: No acute fracture or dislocation. Nasal septum intact and midline. Soft tissue normal. Sinuses clear. Conclusion: Normal nasal bone series. Review of Resident #1's Lab/Diagnostics Note dated 6/1/23 at 9:21 a.m. revealed Nasal x-ray completed and reviewed with ARNP. NNO [no new orders] at this time. No acute FX [fracture] or dislocation. Nasal septum intact and midline. Soft tissues normal. Sinuses clear. Normal nasal bone series. RP made aware. Review of Resident #1's Progress Note (general) dated 6/2/23 at 12:03 p.m. revealed Resident oob [out of bed] with normal routine, no complaints of facial pain noted at this time. Skin lacerations to facial area remains bluish purple bilateral eyes with swelling to nose area. No apparent drainage noted. Condition stable. Further review of Resident #1's Post event note dated 6/2/23 at 4:36 p.m. revealed the following event has occurred: facial bruising The noted date and tome of the event are as follows: 5/31/23 9:30 AM the event took place in the following location: [resident's room] .On a scale of 0-10, the resident's pain level is reported to be a 8 The resident is cognitively impaired and evaluation of facial expression indicates there is substantial pain. The resident's response to pain is described as: Appropriate. The findings of the Skin Check that was completed include the following: redness to nose, lip eyes Treatment as follows was provided to the area or areas of concern: Assessment done, facial x-rays neg [negative]. Resident #1 was observed on 6/19/23 at 12:18 p.m. The resident was observed to be in the facility's secured unit, dressed in day clothes self-propelling in his wheelchair out of his room asking when he was going home. The staff were observed to interact with the resident by saying [Resident #1] this is your home. The resident stated I am going home call [family member]. The staff said okay we (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 2 of 7 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 06/19/2023 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 0600 Level of Harm - Actual harm Residents Affected - Few will call [family member] for you. The resident's face was observed to be free of bruising or swelling or open areas. Resident #1 was observed to be comfortable. In Spanish, the resident stated I'm good when asked how he was doing. In English he stated, can you call [family member] for me, I have to go home. An interview was conducted on 6/19/23 at 10:46 a.m. with Staff A, Licensed Practical Nurse (LPN) she stated I was here for 15 years then I left for a year then came back and I have been back now for two years. I normally work on the secured unit, and I am familiar with [Resident #1]. I was the one who reported. The CNA [Certified Nursing Assistant], Staff B, CNA, he came out of [Resident #1's] room and shut the door behind him. He [Staff B, CNA] was sweating and I heard a muffled sound that alarmed me. When I got up we both met each other outside of [Resident #1's] room and I asked him what is going on and he said [Resident #1] spat in his face and I said okay so I opened the door [Resident #1] was alert, he was sitting up in his wheelchair, he wasn't wearing a shirt and I saw specks of blood on his chest, his face, the floor, and the clothing that [Staff B, CNA] had taken off of him. I'm guessing he was trying to put the gown on him because the gown was on the floor and the shirt was on the floor and that had blood on it. I guess he tried to put the gown on but I'm not going to speculate but, I did see there was blood on the gown as well. I did not see the event I just saw the after math. I helped clean [Resident #1] up and I cleaned up his face and put the gown on him and I helped him into bed. [Staff B, CNA] got all the stuff off of the floor and bagged it up. Then I told [Staff B, CNA] to just leave the room and go get off of the floor. I made sure [Resident #1] was comfortable and safe because he seemed frightened. I reported it to the RN [Registered Nurse] supervisor and the DON [Director of Nursing] and [Nursing Home Administrator [NHA]] . [Resident #1]'s face, and his nose was swollen. His eyes were puffy and the swelling was starting. There were scratches on the bridge of his nose, not lacerations, more like scratches. I have no idea where he was bleeding from. I asked [Staff B, CNA] where all the blood came from and he said it was from his nose. I did not see any indications of open areas, cuts, lacerations. After everyone was called, we got orders to get an x-ray. This happened about around 9 in the evening. [Resident #1] did not say he was in any pain. [DON] called [Staff B, CNA] to get his side of the story and [NHA] told him to leave the premises. After that event I have not seen [Staff B, CNA] back working with other residents .He [Resident #1] had an x-ray done and that was negative. He has chronic pain, but his pain was the same pain that he normally voices but we did give him a stronger pain medication. He never mentioned anything with his face or his head hurting it is always his back, but we did get pain management involved and they gave him a stronger pill for his pain. He is acting the same as he always acts, he does not seem fearful. He developed bruising from the bridge of his nose, and around the orifice of both his eyes, there was swelling to the nose. The mid part of the top lip was kind of puffed out a bit, it was mainly the eyes and the nose. I was surprised the bruising on his face only lasted for about a week .I always tell all the CNA' s let two or three CNA's help out with [Resident #1] especially with the residents who fight. But [Staff B, CNA] would get agitated really easily being back on the secured unit just dealing with that patient population . [Resident #1] has the violent type of dementia, all he thinks about is going home . He can be violent with ADL care. He likes to spit, pinch, kick, scratch and sometimes he picks up objects to try and throw them at you. Further interview was conducted with Staff A, LPN on 6/19/23 at 12:28p.m. she stated when [Staff B, CNA] came out of the residents room I asked him what happened and he said the resident spit on him and [Staff B,CNA] hit him. When I walked into the room and saw all the blood I was overwhelmed, and I asked him how hard did you hit him? [Staff B, CNA] did not answer me and he did not indicate if he hit him with a closed or open hand. He [Staff B, CNA] started to help me clean up, but the resident said he tried (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 3 of 7 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 06/19/2023 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 0600 to kill me, and I just told [Staff B, CNA] you need to go, leave. And he left. I made sure the resident was safe and then I immediately went and reported it. Level of Harm - Actual harm Residents Affected - Few A phone interview was conducted with Staff B, CNA on 2/19/23 at 3:34 p.m. he said I was in the middle of getting his [Resident #1] dirty clothes off and into his night clothes, he became agitated and he didn't want to go to bed. He started to hit me and then when he started to spit I turned and trying to block his spit and I don't know if he tried to lean in right when I did but my hand made contact with his face and it isn't intentional. After that I went and got the nurse, and I didn't notice any blood coming from his nose until after the fact and I went and got the nurse and she helped clean it up and she contacted the supervisor and the supervisor contacted the DON. Usually, I don't have a problem getting him [Resident #1] undressed and usually I get him a snack and that usually works but that day I guess he was overally agitated. I don't normally have that problem with [Resident #1]. The nurse was wiping his nose because there was some blood coming down, there wasn't a lot. I was helping while she was cleaning his nose and I guess the DON wanted to talk to me and they told me to wait in the break room after that .I would never do anything intentional to a resident. When that happened, I was in shock. The police came and talked to me that night and I told them the same exact story and they walked me out. I did not get arrested. I have never really experienced anything like this. Yeah, he'll try and hit here and there but I have never seen him that agitated I tried to reassure him that he wasn't going to bed but there is a big language barrier .I am a newer CNA and he is usually on my assignment. I'm still learning, I just usually approach in a calming way. The resident was sitting in the chair and I was standing beside him and I was bent down trying to put his arm in the gown. Then he tried to hit me but him trying to hit me that don't phase me but then he tried to spit on me and that's when I tried to block the spit and that's when I made contact with his face. My hand was open and I had a glove on when I tried to block his spit. An interview was conducted with Staff C, CNA on 6/19/23 at 12:20 p.m. he indicated he has worked at the facility for ten plus years and his normal assignment includes Resident #1. Staff C, CNA stated [Resident #1] keeps to himself, he usually stays in his room or he is out asking to go home, or asked for food. During care he will spit, hit, scratch, kick at you. When that happens, I remove myself, I reapproach and after the second attempt he's still combative I will remove myself and reapproach with another staff member and if he still doesn't want to do it I can't force him. He stated his approach is to walk away and retry. An interview was conducted with Staff D, CNA on 6/19/23 at 12:22 p.m. She indicated she has worked on the secured unit for 4 years. She said [Resident #1] is not on her typical assignment but she will help out with care if the assigned CNA needs it. [Resident #1] can be combative but we walk away and reapproach him later. We cannot force him to receive care. We just give him space and reapproach later. Review of Resident #1's behavioral care plan revised on 6/6/23 revealed The resident is noted with the following behaviors: places self on floor, may become combative at times 5.31.23 spitting at caregivers. Goals: Will be informed of the risk/outcomes associated with preference of choice. Will not harm themselves. Will not harm staff. Interventions included, speak softly and clearly when communicating. Allow time to communicate effectively. Discuss procedures and mediations [sic] prior to administration. Give clear explanation of all care activities prior to an as they occur during each contact. Provide resident with opportunities for choice during care provision. Do Not Corner if agitated. Provide space, remove other Residents, remain calm and Call [sic] for assistance. Psych Services as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 4 of 7 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 06/19/2023 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 0600 Level of Harm - Actual harm Residents Affected - Few Review of Resident #1's ADL (activities of daily living) care plan revised on 5/15/23 revealed The resident has an ADL Self Care Performance Deficit. Goals included, will prevent decline in ADL self-performance through next review . Will Improve level of self performance by next review. Interventions include but are not limited to AM/PM [morning/evening] Routine Care: Resident will be able to independently or sometimes independently perform ADL functions including but not limited to Bed Mobility, Personal Hygiene, Oral Care, Bathing, Dressing, Transferring, Feeding, Toileting, Encourage to perform at highest functional level. Res [Resident] can help with some ADLs, but need Physical Help from Staff to help complete task. Encourage resident to participate at highest level. Provide assistance required to complete task and document. Anticipate needs. Locomotion: Wheel Chair [sic] propels self. Personal Hygiene: assistance X [times] 1 as needed. Dressing: Assist of 1 An interview was conducted with the Nursing Home Administrator (NHA) and the DON on 6/19/23 at 1:33 p.m. The NHA said on 5/31/23 at approximately 9:30 p.m. [Staff A, LPN], the nurse on the unit, she called [DON] and [DON] called me. And she [Staff A, LPN], said she heard yelling coming from [Resident #1's room] and she said [Staff B, CNA] was coming out of the room. She [Staff A, LPN], opened the door the resident was sitting in his wheelchair with his shirt off and he had some blood on his face[Staff A, LPN], said she asked the CNA what happened and the CNA had said he was spitting on him and he [Staff B, CNA] reacted , trying to keep him [Resident #1] from spitting on him. So, [DON] called and told me I told [DON] I would call [Staff B, CNA] and we told him to go in the break room and not leave and I told him that I had to call the police and report it and the police would have to come to the facility and talk to him. So, I called the police and reported it and I reported it to DCF [Department of Children and Families] right then too. And I asked him what happened and he told me the resident was spitting in his face and he was trying to get him to stop and he wouldn't and he said he smooshed him. I asked him what smooshing meant and he said 'you know, I smooshed him to try and keep him from spitting in my face.' And after I talked to the police and I asked them to tell me what he said to them and the police called me and they said that he told them the same thing he told me. The police officer told me that he smooshed him too .I told [Staff B, CNA] he had to come in and do a reenactment with me too so I can see exactly what happened. He came into my office to show me and I had someone else witness it to. The NHA reenacted what she was shown by [Staff B, CNA]. The NHA acted as the resident sitting in the wheelchair, and said, [Staff B, CNA] took off the residents shirt off, [Staff B, CNA] was standing off to the side of the resident and when the resident was spitting he [Staff B, CNA], turned and put his hand out and he must've accidently made contact with the residents face. [Staff B, CNA] is about 7 foot tall. We train the staff when a resident gets combative to walk away and come back. The residents' eyes were discolored, both eyes under his eyes and up and around them. The NHA said we [NHA and DON] did not come in that night but we did not see any blood the next day when we looked at [Resident #1]. [Staff A, LPN] said she did see some blood. I did have [Staff D, Registered nurse [RN]] go and look at the resident. I started the investigation that night over the phone. The DON said based on the statements, there was a small amount of blood around the resident's nose that she had cleaned up. [Staff D, RN] said she did not see any blood and there were no open areas. We did the nasal 3 views of the whole face and that showed no fractures . The DON said [Staff B, CNA] started on 10/4/22 as a PCA [Patient Care Technician]. He worked until 2/2/23. He was termed [terminated] because his 180 days to get his CNA license was up so we had to term him and told him to let us know when he gets his license. So, he returned back to us on 2/16/23 after he got his CNA license. When he worked here as a PCA he worked on the secured unit. When he was hired back as a CNA his designated area was the secured unit. The NHA said .This was not substantiated because no one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 5 of 7 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 06/19/2023 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 0600 Level of Harm - Actual harm Residents Affected - Few had seen it and he said he just put his hand . The NHA stopped talking then said, and that's what the police told me to. The NHA said . After [Staff A, LPN] wrote her statement that night, I had [Staff A, LPN] come to me and I talked to her on 6/7/23. She said he [Resident #1] has behaviors and we usually use 2 people when he punches, scratches, hits. It calms him down if you say you'll call the [family member]. She said she asked him [Staff B, CNA] what happened and he said he [Resident #1] spit in his face and I asked [Staff A, LPN] what exact words did he [Staff B, CNA] use? he spat in my face and his reaction, he smooshed . The NHA corrected herself and said it [statement documentation] says 'and hit him [Resident #1]. I went into the room and saw a little blood on his chest and clothes and saw a little bit on the floor. And I said did you ever see him [Staff B, CNA] get aggressive like this before? She said she saw him get anxious but not aggressive . it also says in the statement that [Staff B, CNA] said to her 'can you just write it up and say he fell and she said no I can't do that.' The DON said we did change his [Resident #1's] pain medication around with the facial bruising because he had been grimacing during therapy and he has chronic pain and was on tramadol so we called pain management and got him on hydrocodone. The NHA confirmed Staff B, CNA has not worked in the facility since the incident occurred, and is currently in the termination process. Review of the facility's Abuse Prevention Program with a effective date of 2012 and a change date of August 2022. Revealed Policy The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burnout, or resident behavior which may increase the likelihood of such events. Definitions: Abuse-Includes Verbal, Physical, Sexual, and Mental/Emotional Abuse Abuse Willful infliction of injury upon a resident by a staff member, another resident, a vendor, a visitor, or other individual. . Note: Willful is defined as meaning the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. .Physical Abuse Includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc . . Serious Bodily Injury An injury involving extreme physical pain; involving substantial risk of death; involving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 6 of 7 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 06/19/2023 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 0600 Level of Harm - Actual harm protracted loss of impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse. Residents Affected - Few .Procedure the facility has implemented the following processes in an effort to provide residents, visitors and staff with a safe and comfortable environment. The Administrator is responsible for designating an Abuse Coordinator The designated shift supervisor is identified as responsible for immediate initiation of the reporting process. The Administrator, DON and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. The Administrator, DON and/or designated individual are also ultimately responsible for the following: Implementation Ongoing Monitoring Investigation Reporting Tracking and Trending . Training Facility orientation program and ongoing training programs will include, but may not be limited to: 483.95(c): Freedom from abuse, neglect, & exploitation requirements in 483.13. .483.95(c): Dementia management & resident abuse prevention . Utilization of appropriate interventions to manage resident behaviors that might result in harm to the resident or staff, aggressive &/or catastrophic reactions of residents. . How to provide protection for residents. . Methods to reduce the risk of abuse, neglect, mistreatment, misappropriation, and exploitation that may include, but may not be limited to, recognizing signs of burnout, frustration and stress, stress management and relaxation techniques FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 7 of 7