Inspection·November 8, 2023

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance and Performance Improvement Program (QAPI). The facility was actively involved in the creation, implementation and monitoring of the plan of correction for deficient practice identified during a complaint survey conducted 11/8/23 and was cited F684. On 12/27/23 a revisit survey was conducted, and the facility was recited F684. The facility had developed a Plan of Correction with a completion date of 12/8/23. Findings included: The facility developed a plan of correction that included the Director of Nursing (DON)/Designee re-educating licensed nurses on 11/8/23 of the facility's policy titled Dressing Change Vascular Access with a focus on changing the dressing to the site weekly and as needed (PRN) if non-occlusive or soiled. The facility developed a plan of correction that included: the DON/designee conducted audits of all residents with vascular accesses to ensure that the dressings to (the) site were intact, clean, and dated. The plan identified: - The DON/Designee would provide education to remaining licensed nurses on the facility's policy titled Dressing Change to Vascular access, to include the importance of adhering to physician orders. - Observation of residents vascular access sites to be included on Checklist used during shift-to-shift rounds, also to be included on Checklist used by Unit managers during daily rounds. - The DON/Designee will conduct audits of residents with IVs to ensure dressings are clean, dry, intact, and dated one time a week x [for] 4 weeks, then monthly x [for] 2 months. - Results of audits will be brought to QAPI monthly x [for]3 months or until substantial compliance is achieved. During the revisit survey conducted 12/27/23, the facility failed to ensure the skin conditions of two (#7 and #8) of two sampled residents were documented, the physician was notified of the areas of concern, orders were received from the physician to apply dressings, dressings were dated when applied, and changed when soiled. On 12/27/23 at 8:42 a.m., an observation was made of Resident #7 sitting in wheelchair on the sidewalk in front of the facility with two other unknown residents. The observation revealed a large tan-colored foam dressing on the resident's right forearm. As the resident entered the facility, a white dressing dated 12/26/23 was observed to the resident's left below knee amputation. On 12/27/23 at 2:26 p.m., an observation was made of Resident #7 lying in bed. The resident reported falling in the gym last week while attempting to transfer. The resident said staff change the dressing every day. The observation revealed an undated large 6x6 foam dressing, with an area of discoloration, attached to the resident's right forearm below an abrasion to the right elbow. The dressing to the left below knee amputation was dated 12/27/23. Photographic evidence was obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 2 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident #7's Medication and Treatment Administration Records revealed no order had been received for the care of the wound to the resident's right forearm. The records did show the dressing to the resident's left lower extremity surgical incision had been changed on 12/27/23. A review of Resident #7's admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to Type 2 Diabetes mellitus with hyperglycemia, encounter for orthopedic aftercare following surgical amputation, unspecified chronic obstructive pulmonary disease, and history of falling. The facility failed to provide a copy of the resident's 10/20/23 Minimum Data Set (MDS) Brief Interview of Mental Status score as requested. The psychiatry note, dated 11/7/23, revealed a BIMS score of 12 indicative of mild cognitive impairment. Review of Resident #7's progress notes revealed the resident was admitted on [DATE]. The note on 12/4/23 revealed Skin noted intact with exception of surgical site to left below knee amputation (LBKA). Review of a progress note, dated 12/21/23 at 6:23 p.m., revealed Resident #7 allowed nursing to complete head to toe observation and continued to have resolving surgical site status post (s/p) amputation site. The note did not show the resident had any other skin condition requiring a dressing. Review of a progress note dated 12/22/23 at 5:37 p.m., revealed nursing was alerted by therapy of resident being assisted to the floor during a stand/pivot transfer. Resident complained of the left hand was slightly sore post therapy and an order was received for a mobile x-ray. The note did not show the resident had suffered any other consequence from the incident. A review of Resident #7's progress notes did not reveal any further notes written by nursing from 12/22/23 at 5:37 p.m., to 12/27/23. The notes did not show the resident's right forearm had been assessed, documented, or physician orders had been received regarding the application of a dressing to the resident's right forearm. Review of the documentation did not reveal if, when, or how often the resident's right forearm dressing had been changed. Review of Resident #7's care plan revealed the resident has Diabetes Mellitus as evidence by: Type 2 Diabetes. The interventions included Observe/document/report to MD (medical doctor) as needed (PRN) for signs and symptoms (s/sx) of infection to any open areas: redness, pain, heat, swelling, or pus formation. An observation and interview was made on 12/27/23 at 2:48 p.m., with the Director of Nursing (DON) of Resident #7's right forearm. The resident informed the DON of staff changing the dressing yesterday. The DON confirmed the dressing was not dated. She reviewed the facility's Risk forms, stating there was no information (regarding the injury to the resident's forearm), and after reviewing the resident's physician orders, the DON confirmed there was no order for the dressing application to the resident's forearm. On 12/27/23 at 11:07 a.m., Resident #8 was observed sitting in wheelchair, propelling self in hallway of the Reflections (memory care) unit. An undated small, approximate 2 x 2 centimeter (cm) white bordered dressing was observed on the resident's left lower leg. The dressing was discolored with a yellowish-color, the fabric was pilled, and a corner of it was not adhered. An interview and observation was made with Staff C, Licensed Practical Nurse (LPN), reviewed the clinical record of Resident #8 and confirmed there was no physician order for the dressing. The staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 3 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some member stated the injury probably done yesterday. She observed the dressing and confirmed it was not applied yesterday and was undated. Staff C removed the dressing which was covering a red moist-looking abraded area approximately 2 x 0.5 cm. Photographic evidence was obtained. Review of Resident #8's Weekly and as needed (PRN) Skin Check, dated 12/27/23 at 11:49 a.m. (approximately 40 minutes after the observation), revealed the resident had an open area measuring 0.5 x 0.1 with no depth. A review of Resident #8's Treatment Administration Record (TAR) showed an order had been obtained on 12/27/23 at 11:45 a.m. (approximately 38 minutes after the observation) for staff to cleanse left shin with normal saline (N/S), apply Triple Antibiotic Ointment (TAO) and 4x4 dressing daily until healed one time a day for open area. The TAR showed the order was to scheduled to start at 9:00 a.m. on 12/28/23 (the day after the observation). Review of a nursing note, dated 12/27/23 at 3:23 a.m., revealed Resident #8 had a fall event and a skin check was completed and no redness, swelling, bruising, or other concern is noted. Review of a Post Event note, dated 12/25/23 at 2:48 p.m., revealed Resident #8 had an unwitnessed fall and the findings of the Skin Check was no new skin alterations. The review of the Weekly and PRN Skin Check forms for Resident #8 dated 12/14 and 12/21/23 revealed No New Areas of Skin Impairment. A review of further progress notes showed the following documentation related to Resident #8's skin conditions: - 12/27/23 at 3:23 a.m., Post Event Note - A Skin Check was completed and no redness, swelling, bruising, or other concern is noted. - 12/25/23 at 2:48 p.m., Post Event Note - The findings of the Skin Check that was completed included the following: no new skin alterations. - 12/23/23 at 8:01 p.m., Medication Administration Note (eMAR) - right cheek wound/abscess resolved. - 12/22/23 at 10:11 p.m., eMAR note - right cheek wound/abscess resolved. - 12/22/23 at 4:01 p.m., eMAR note - left elbow area resolved. - 12/19/23 at 1:46 p.m., Skin/Wound Note - schedule shower given this shift, old purple discoloration noted to right topical hand, old healing wound right hip, (and) old skin tear right elbow closed. - 12/12/23 at 3:18 p.m., Post Event Note - skin check was completed with no redness, swelling, bruising, or other concern is noted. - 12/10/23 at 11:30 p.m., Post Event Note - a fall event occurred with left eye orifice facial discoloration noted. - 12/10/23 at 11:28 p.m., progress note - left eye facial discoloration surrounding orifice remains (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 4 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 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 0867 apparent. Level of Harm - Minimal harm or potential for actual harm - 12/9/23 at 10:32 a.m., Post Event Note - a skin check was completed with red discoloration noted to left eye. Residents Affected - Some - 12/8/23 at 10:57 a.m., Initial Event note - skin check completed and included bruise to right eye. - 12/8/23 at 9:03 a.m., Care Plan/Interdisciplinary Team note - skin is intact with exception of skin tear to left elbow and small discoloration to left side of temple. The review of Resident #8's progress notes did not reveal the injury to the resident's left lower leg had been assessed and the review of Medication and Treatment Administration Records did not show an order had been obtained for the treatment to the area prior to the observation on 12/27/23. A review of Resident #8's care plan revealed the resident was at risk for developing a wound related to (r/t) cognitive deficit, decreased mobility, Activities of Daily Living (ADL) functioning, Adult Failure to Thrive (AFTT), incontinence, and hard cast to right arm. The associated interventions included: The interventions included observed for any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care; Report to nurse if noted, nurse will report to MD if noted. The care plan also showed the resident had a skin tear/potential for skin tear related to (r/t) the decreased mobility and ADL functioning. The interventions included to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. An interview was conducted 12/27/23 at 3:00 p.m. with the Director of Nursing (DON). The DON reviewed the physician orders for Resident #8 and confirmed the physician order was obtained by Staff C on 12/27/23. The policy and procedure - Wound Prevention and Treatment Overview, effective October 2021, revealed The facilities strives to ensure that a Resident/Patient entering the facility without ulcers does not develop them unless the individual's clinical condition demonstrates they were unavoidable. The facility implements the following interventions to prevent the development of pressure ulcers: Identify Residents/Patients at risk and the specific factors placing them at risk then implement an individualized plan of care based on the identified factors. -Reduce occurrences of pressure over bony prominences to minimize injury. Protect against the adverse effects of external mechanical forces (pressure, friction, shear). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 5 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 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 0867 Increasing awareness of ulcer prevention through educational programs. Level of Harm - Minimal harm or potential for actual harm The policy showed a resident with ulcers will receive continued preventive interventions and necessary treatments and services to promote healing and prevent infection. Wound characteristics will be documented by measuring length, width and depth in centimeters and additional documentation shall also include color of drainage, wound bed, color, order, amount of drainage, wound bad tissue type, and tunneling/undermining with depth if applicable. The policy instructed to review skin integrity on a weekly basis as a proactive approach enabling the facility staff to identify possible changes in skin integrity/condition. Residents Affected - Some The policy and procedure - Treatment Protocols for Skin Tears, effective October 2021, revealed A skin tear is a traumatic wound occurring principally with older adults. Often a result of friction alone or shearing and friction forces that separate the epidermis from the dermis (partial thickness). Nursing staff will observe and evaluate treatments according to the following procedure. 1. Assess and evaluate the wound and the periwound area. 2. Initiate and or revise the Skin Grid for all Other Skin Problems. 3. Review nutrition and hydration status. 4. Include the Resident/Patient and or responsible party in the development of the Plan of Care. 5. Review risk reduction measures. 6. Notify physician and obtain orders. 7. Notify the responsible party if applicable. 8. Implement physician orders. 9. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 6 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 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 0867 Evaluate the wound with dressing changes for the following including but not limited to: Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Some a. Periwound redness, swelling, warmth or coolness, a firm or boggy feel, and assess for changes in sensation. b. Pain. c. Foul odor d. Increased drainage. 10. update the Skin Grid for all Other Skin Problems weekly and PRN with changes in the wound characteristics. 11. Review and revise the plan of care 12. Educate Resident/Patient and responsible party on risk factors and their role in risk reduction. The treatment portion of the policy showed staff was to initiate the treatment protocol. During an interview on 12/27/23 at 4:20 p.m., the Director of Nursing (DON) reported the previous survey was conducted on 11/8/23 and she started in the facility on 11/15/23 at which time she was notified of the survey and citation. The DON reported the Regional Nurse Consultant had started staff education, the facility had an Ad Hoc QA meeting on 12/8 and a monthly meeting on 12/14/23. She said the facility checked all residents who had intravenous (IV) access, educated all nursing staff, were auditing IV sites, she visualized residents with IV sites daily, she audits weekly, and the Unit managers audit (the IV accesses) on a daily basis, when the RNC would come in she also would audit the sites, stating Because that's been a high focus. The DON stated the facility placed an order on the Medication Administration Record (MAR) instructing nursing staff to check the IV site every shift and reported she checks the MAR daily. The DON stated she had focused on just IV dressings. An interview was conducted on 12/27/23 at 5:22 p.m., with the Nursing Home Administrator (NHA). The NHA stated an Ad Hoc meeting was held with department heads regarding citations and on 12/8/23 with the facility Medical Director. He stated the DON implemented the Plan of Correction (POC) and would have to speak with her regarding it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 7 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility policy - Quality Assessment and Assurance (QA&A) Compliance, changed November 2022, revealed: The facility will form a QA&A compliance committee, designed to meet monthly. The committee must include, at minimum, the medical director, administrator, director of nursing, infection control specialist, maintenance, housekeeping, pharmacist, business office manager (BOM), medical records, therapy representative, staff development coordinator, and social service director. Ad hoc members are approved by the committee. The purpose of the committee is to review and analyze facility related data, evaluate the effectiveness of improvement plans, and direct appropriate actions for the facility response. It is the responsibility of the QA&A compliance committee to consider all data presented by the improvement team(s) and to direct the team(s) to continue, change, or conclude the assignment. Department heads/disciplines are required to develop department specific audit plans and report activities, and audit findings to the committee at intervals determined by department specific risk analysis, and at the direction of the nursing home administrator. Audit findings that identify opportunities for improvement are addressed through education, development of a quality assurance and performance improvement plan or performance improvement plan or other means as indicated. System failures and slash or in depth and now sis of processes are addressed through development of a QAPI. QAPI requires a systematic review of data, identification of the root cause(s) of the system failure, and implementation of corrective action through the use of a Plan, Do, Study, Act (PDSA). Team should be introduction, should include members from any department impacted by the concern and may include other members such as residents, family members, or local persons with information pertinent to the issue under analysis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105690 If continuation sheet Page 8 of 8