Inspection·December 27, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 12/27/23 at 9:55 a.m., an observation was made under the head of bed of the window bed in room [ROOM NUMBER] was a bed bolster with remnants of unknown substances on it, under the bed the floor and along the vinyl baseboard was lumps of unknown substances, and dirty dust was observed on tiled window sill behind the lowered window blind (Photographic evidence was obtained). On 12/27/23 at 10:04 a.m., an observation was made in room [ROOM NUMBER] of one gray water basin directly under the sink lying on the plumbing and another gray water basin with unknown dirt and water stain turned upside down on the floor under the sink vanity. Staff D, Licensed Practical Nurse (LPN) stated she did not know why the basins were under the sink. She removed the overturned basin on the floor and a dead cockroach was observed (Photographic evidence was obtained). On 12/27/23 at 11:19 a.m., an observation was made of an over-bed table in room [ROOM NUMBER] which was pitted with rust and uncleanable (Photographic evidence was obtained). On 12/27/23 at 11:21 a.m., an observation was made of an over-bed table in room [ROOM NUMBER] which was pitted with rust and uncleanable (Photographic evidence was obtained). On 12/27/23 at 11:22 a.m., an observation was made of a piece of wallboard buckled away from plaster of the wall behind the entry door and beside the bathroom door in room [ROOM NUMBER] (Photographic evidence was obtained). On 12/27/23 at 11:24 a.m. an observation was made of uneven, uncleanable attempted repair of the wall behind the entry door of room [ROOM NUMBER]. The observation revealed broken tile used for the window sill, in the shared bathroom was an area of broken wall board exposing the uncleanable pitted cement underneath, and a wet-looking washcloth on a wall shelf in the shared bathroom (Photographic evidence was obtained). During an initial tour of the Birch Hall (200s) on 12/27/23 at 9:25 a.m., an overwhelming pungent foul odor was present in the hallway toward the nurses' station. An observation of the bathroom in room [ROOM NUMBER] at 9: 38 a.m. revealed the toilet raised chair had with red and brown areas of dried spillage (photographic evidence obtained). During an interview on 12/27/23 at 10:20 a.m. with Resident #13, the resident stated her air conditioning (AC) unit leaks when it is running so she must shut it off and wait until it becomes too hot in her room and then she will turn the AC back on but it will start leaking again. An observation of the AC unit revealed a pool of water was observed on the floor with various blankets, towels and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 105690 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 12/27/2023 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)