Health inspection·November 5, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2) A review of the admission record for Resident #106 revealed that she was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include chronic respiratory failure with hypoxia, urinary tract infection, cerebral infraction, and metabolic Encephalopathy. A review of Resident #106's MDS dated [DATE], in Section C (Cognitive Patterns), reflected a Brief Interview for Mental Status score (BIMS) of 15 indicating that her cognition was intact. Further review of Section G (Functional Status) revealed a score of 3, which indicated that Resident #106 required Two +persons physical assist with toileting, and bed mobility. On 11/2/2021 at approximately 8:40 a.m. during a tour of the facility east wing, Resident#106 was observed lying in bed. Her urinary drainage bag was observed attached to bed frame. The drainage bag was visible from the hallway with the door opened. A subsequent observation on 11/03/21 at 7:57 a.m., revealed Resident #106's drainage bag attached to the bed frame towards the door. The urinary drainage bag was not covered nor was a privacy bag in place. On 11/03/21 8:09 a.m., an interview was conducted with Staff J, Certified Nursing Assistance (CNA). She stated that Resident #106's drainage bag should have been placed in a privacy bag. She stated that she thought she had provided a privacy bag for the drainage bag yesterday. On 11/03/21 at 8:12 a.m., an interview was conducted with Staff H, Licensed Practical Nurse (LPN). Staff H stated that urinary catheter drainage bags should be placed in a privacy bag. He stated that he was not sure of the facility policy related residents with urinary drainage bags. On 11/03/21 at 10:10 a.m., an interview was conducted with the Regional Registered Nurse. She stated that urinary drainage bags should be covered to provide dignity. 3) A review of Resident #20's medical records revealed that she was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include osteomyelitis of vertebra, lumbosacral Region, pressure ulcer of sacral region stage 4, and type 2 Diabetes Mellitus A review of Resident #20 's MDS dated [DATE], documented in Section C (Cognitive Pattern) a Brief Interview for Mental Status (BIMS) score of 14, indicative of intact cognition. On 11/02/21 at 11:09 a.m., Resident #20 was observed sitting in her bedroom in a motorized wheelchair, with a urinary drainage bag attached to the front of the wheelchair. The drainage bag was visible to anyone entering the room. There was no privacy bag or covering to protect the drainage bag. On 11/02/21 at 3:15 p.m., Resident #20 was observed in her electric wheelchair in the hallway, with her urinary drainage bag attached to the front of the wheelchair. The urinary drainage bag was not covered, and was visible to staff, other residents, and visitors in the hallway. On 11/3/2021 at 9:00 a.m., during an interview with Staff I, Registered Nurse (RN), Unit Manger, she stated that Resident #20 had a privacy bag for her urinary drainage bag. She stated that Resident #20 removed her privacy bag as desired. Staff I concurred that the resident's urinary drainage bag should have been covered. On 11/03/21 at 10:10 a.m., during an interview with the Regional Registered Nurse, she stated that Resident #20 was noncompliant with the privacy bag for her urinary drainage bag. She confirmed that residents' urinary drainage bag should have been covered to provide dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105697 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 105697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and medical record review, the facility failed to ensure care plans were followed related to checking for incontinence and repositioning for one (Resident #89) of fifty one sampled residents. Findings included: On 11/4/2021 from 7:20 a.m. -10:22 a.m., Resident #89 was observed seated in a fully reclined [Brand name] chair, positioned in the [NAME] unit television/activity lounge, which was directly across from the nurses' station. Resident #89 was positioned in the lounge and in front of the television. She was observed lying in a manner where she could watch the television. She was observed in the same position and without staff checking on her or interacting with her from at least 7:20 a.m. through to 10:22 a.m., which was over three (3) hours. During this period, staff did not speak with her, offer her hydration, nor repositioned her. Resident #89 was noted as dressed for the day and had a blanket over most of her body up to her neckline. She was observed with padding positioned off the head rest of the [Brand name] chair with her head positioned on the bar of the head rest. On 11/4/2021 at 10:22 a.m. Staff A, Certified Nursing Assistant (CNA) walked over to Resident #89 and asked her how she was doing. Staff A did not reposition the resident's head cushion so that her head was not lying on the bare metal frame. Staff A visited the resident for about twenty seconds and then left. On 11/4/2021 at 12:15 p.m., the [NAME] Unit Manger came into the lounge area, removed Resident #89 from the television/activity lounge, and transported the resident to her room. The door was closed after the Unit Manager took the resident into her room. The door was opened at 12:17 p.m. and the Unit Manager left the room. At 12:23 p.m., a staff member brought a meal tray to the roommate of Resident #89. However, Resident #89 was not provided her meal tray or eating assistance. Resident #89's roommate continued to eat from 12:23 p.m. until 12:44 p.m. On 11/4/2021 at 12:44 p.m., Staff B, CNA, was observed to a carry a lunch meal tray to Resident #89's room. Staff B confirmed she was bringing in Resident #89's meal tray. She said she would set up the meal tray and assist her with eating. Staff B could not provide an answer as to why the resident sat in her room for twenty-one minutes while her roommate was eating. She confirmed the resident did not have hydration served during that time. On 11/5/2021 at 7:07 a.m., Resident #89 was observed dressed for the day and reclined in her Geri chair in the [NAME] unit television lounge/activities area. She was noted positioned in front of the television and had a blanket over her upper body and entire head. On 11/5/2021 at 7:23 a.m., Staff C, CNA was observed to walk over to Resident #89, reposition her closer to the television, and remove the blanket from her head. The aide did not speak with her, but rather just moved her and then walked away. Staff C did not ask the resident if she was ok, if she needed anything, nor did she check her for incontinence. On 11/5/2021 from 7:23 a.m. through to 9:48 a.m., which was over two hours and twenty-five minutes, Resident #89 was observed in the lounge/activities area facing the television, with a blanket over (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105697 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 105697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764 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 0656 her head, in the same position, and with no staff interaction. Level of Harm - Minimal harm or potential for actual harm On 11/5/2021 9:48 a.m., Staff C was observed to walk over to the resident, pull the blanket off her head, pull up the surgical mask to cover both her mouth and nose, and walk away. Residents Affected - Few On 11/5/2021 from 9:48 a.m. through to 9:54 a.m., Resident #89 again sat in the same position without any further staff interaction. At 9:54 a.m., Resident #89's husband came over to her, sat down in a chair, removed the blanket from her face, spoke to her for about four minutes, and then left. On 11/5/2021 from 9:58 a.m. through to 11:00 a.m., Resident #89 sat in the same position totally reclined in her Geri chair without any staff interaction, without being repositioned, and without being checked for incontinence. On 11/5/2021 at 11:00 a.m., Staff C was observed to walk to the resident. She took off the resident's right shoe, replaced it, and tied the laces. She then repositioned the blanket over the resident's entire body and repositioned the resident's head and feet. On 11/5/2021 at 7:10 a.m., an interview with Staff G, CNA revealed that the expectation was to check, change, and reposition a resident whether they were in bed, in a chair, or out of their room, at least every two hours per shift. He confirmed that he did not have Resident #89 on his work assignment. On 11/5/2021 at 10:00 a.m., an interview with Staff F, CNA revealed that during the shift, he was to check, change, and reposition a resident at least every two hours. He confirmed that even if the resident was out of the room and seated in a chair, the resident was to be checked for incontinence, or checked on to see if they needed anything. If positioned in a chair, they were to be repositioned at least every two hours. Staff F confirmed that he did not have Resident #89 on his work assignment. On 11/5/2021 at 11:01 a.m., an interview was conducted with CNA Staff C. She revealed that she checked her assigned residents for incontinence episodes twice a shift. She revealed that for Resident #89, she checked on her more than twice a shift. She revealed she would usually ask if she needed anything to drink or wanted anything. Staff C confirmed that she checked on the resident one time since breakfast this morning, 11/5/2021. She said the resident was sleeping so she did not wake her, nor did she check her for incontinence. Staff C further explained that the resident had therapy but not today. She confirmed that the resident was usually positioned in front of the television in the lounge after breakfast and just before lunch meal. Staff C said she had Resident #89 on her work assignment today and usually did every day. She did not have a reason as to why Resident #89 was not checked and repositioned for over two hours on both 11/4/2021 and 11/5/2021. On 11/5/2021 at 11:56 a.m., an interview with Staff E , [NAME] Unit Nurse revealed that residents were expected to be checked or changed every two hours at the very least. She revealed that Resident #89 sat out in the lounge so they (staff) could see and monitor her from the nurses' station at all times. She could not confirm that staff had repositioned the resident, checked the resident for incontinence, or asked her if she needed anything to drink this morning,11/5/2021. She further confirmed that the CNA should have checked and repositioned the resident while seated in the [Brand name] chair at least every two hours. Review of the medical record revealed that Resident #89 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105697 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 105697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764 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 0656 Review of the advance directives revealed the resident had a Health Care Surrogate in place. Level of Harm - Minimal harm or potential for actual harm Review of the diagnosis sheet revealed diagnoses to include but not limited to: Dehydration and Huntington's disease. Residents Affected - Few Review of the Minimum Data Set for a significant change assessment dated [DATE] revealed: Cognition/Brief Interview Mental Status score - No score but indicated short term and long term memory problem and with Severely Impaired decision making skills; Activities of Daily Living - Toileting was total dependence on staff; Bowel and Bladder - Always incontinent of Bowel and Bladder and not on a retraining program. Review of the current Physician's Order Sheet dated for the month 11/2021 revealed the following orders: [Brand name] chair with side supports when OOB (out of bed) with seat encouraged to keep in reclined position when not participating in any structured activities. [Brand name] chair to assist with optimal comfort and positioning, recline as needed to minimize the risk of falls Dx.(diagnoses) Huntington's disease dated 3/26/2021. Review of the current care plans with next review date 12/28/2021 revealed the following areas: 1. Resident #89 prefers identification/arm band on her wheelchair. Resident #89 likes to put a blanket over her head and face when sitting in the common areas. She uses a [Brand name] chair and prefers to rest her head on the side of the chair instead of using a pillow or other supportive device, she will remove padding/pillow from the chair to rest her head on the chair. Interventions included but not limited to: Offer and assist with providing pillow/padding to chair for her to rest her head on as tolerated; Offer and assist with repositioning frequently to prevent pressure due to resting head on the chair instead of pillow while in chair. 2. Resident #89 is at risk for falls related to Huntington's disease, decreased safety awareness, weakness, gait disorder, and incontinence with interventions in place to include: [Brand name] chair to be utilized for safety and positioning; Is incontinent of Bowel and Bladder and is dependent on staff for incontinence care. 3. Resident #89 is at risk for constipation related to decreased mobility with interventions in place to include but not limited to: Encourage intake of fluids and food is not contraindicated, Encourage resident to sit on toilet to evacuate bowels if possible and assist as needed, Follow facility bowel protocol for bowel management 4. Resident #89 has bowel incontinence related to confusion, immobility, disease process with interventions to include but not limited to: Check resident frequently during each shift and assist with toileting as needed. 5. Resident #89 has risk of pressure injury related to immobility, incontinence, multiple co-morbidities with interventions to include but not limited to: Follow facility policies/protocols for the prevention/treatment of skin breakdown. 6. Resident #89 at risk for skin breakdown related to incontinence, decreased mobility, advancing disease process with interventions to include but not limited to: Check as required for incontinence, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105697 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 105697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Keep clean, dry, odor free as needed 7. Resident #89 is incontinent of bowel and bladder. Risk for UTI/skin breakdown related to incontinence. Resident is not a candidate for retraining and with interventions to include but not limited to: Check as required for incontinence. The Director of Nursing was unable to provide a policy and procedure related to implementation of care plan interventions. However, the Director of Nursing did explain that direct care staff were trained and in-serviced on care plans and interventions. He further explained that the expectation was for staff to follow each intervention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105697 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 105697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, record reviews, and interviews, the facility failed to store, distribute, and prepare food in accordance with professional standards for food service safety related to food stored underneath vents with an excessive amount of black build up in the mechanical room, a window blind with an excessive amount of dust and black build up directly behind food in the mechanical room, water stored on the floor in the mechanical room, a broken foot petal device on the trash can at the hand washing sink, inappropriate storage of utensils, and black buildup on the ice machine. Findings included: On 11/02/21 at 9:47 a.m., the Kitchen Manager reported that the hurricane supply was stored in the mechanical rooms, and he would have to get a key to open the door. At 9:49 a.m., the Kitchen Manager returned with the key and escorted the surveyor to the mechanical room next to the conference room near the 200 unit. The vent above cases of mashed potatoes, graham crackers, canned tuna, and juices was observed with an excessive amount of black build up. The window blind behind cans of chicken and dumplings was observed with an excessive amount of dust and black buildup (photographic evidence obtained). A second mechanical room near the 100 unit was observed with the Kitchen Manager. Three cases of water and one big bottle of water was stored on the floor. On 11/02/21 at 10:00 a.m., an initial tour of the kitchen was conducted. The foot petal device used to lift the lid of the trash can at the handwashing sink near the three-compartment sink was not working. There was a second trash can at this handwashing sink without a foot petal to lift the lid of the trash can. There was a spoon observed hanging from the bin of flour that was uncovered. The Kitchen Manager stated that the spoon was used to get flour from the bin and immediately removed the spoon. The ceiling and ceiling vents throughout the kitchen were observed with an excessive amount of dust and black buildup. The white flap in the inside of the ice machine was observed with black build up (photographic evidence obtained). The Kitchen Manager stated it looked like mold and that he would get it cleaned. On 11/04/21 2:40 p.m., an interview was conducted with the Kitchen Manager, the Assistant Kitchen Manager, and the Regional Director of Employee Relations and Purchasing. During the interview, the Kitchen Manager reported that Maintenance was responsible for cleaning the vents, ceilings, and blinds. He stated that there was a work order in for the vents and ceiling, but the work order was probably not completed due to the change in Administration. He reported that the cases of water should be stored at least six inches off the floor. The Regional Director of Employee Relations and Purchasing stated that they use a system to submit work orders, but there was not an option in the system to submit a work order for vents. The Kitchen Manager reported that all kitchen staff was responsible for completing the Dietary Service Monitoring Sheet. The policy provided by the facility Food Storage Overview with a copyright date of 2015 revealed the following: Food is stored by methods designed to prevent contamination. 11. Food is stored a minimum of 6 inches above the floor and 18 inches from the ceiling on clean racks or other clean surfaces, and is protected from splash, overhead pipes, or other contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105697 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 105697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764 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 The policy provided by the facility Cleaning Ice Machines and Equipment with a copyright date of 2015 revealed the following: The ice machine and equipment (scoops) will be cleaned on a regular basis to maintain a clean, sanitary condition. Residents Affected - Some The Daily Cleaning List reflected the following areas that would be checked: ice machine wiped down and ceiling clean. The Monthly Cleaning Schedule indicated that the interior of the ice machine would be cleaned. The Dietary Service Monitoring Sheet with a copyright date of 2015 indicated that the ceiling tiles would be free of stains and the ceiling vents would be free from dust. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105697 If continuation sheet Page 8 of 8