Health inspection·December 3, 2021

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the initial tour conducted on 11/30/21 at 10:45 a.m. on the 100 unit, Resident#1 was observed in his room with the door closed. The door was opened for the resident at this time, and Resident #1 was observed self-administering his own nebulizer treatment. There was no nurse present. Staff E, RN returned to the 100 Unit at 11:00 a.m. and was asked if Resident#1 was care planned to self-administer his own nebulizer treatment. Staff E stated that he thought he (Resident #1) had finished his treatment. He was not to self-administer his nebulizer treatment. Residents Affected - Few A medical record review was conducted for Resident#1 that revealed an admission date of 11/7/21 with an original admission date of 2/5/13. Resident #1's diagnoses included COPD, chronic respiratory failure, and pneumonia. A review of the active physician orders as of 12/2/21 revealed an order for: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligram/milliliter) 1 vial inhale orally via a nebulizer four times a day for COPD with an effective date of 11/7/2021. On 12/02/21 at 12:17 p.m. an interview was conducted with the DON regarding Resident #1 self-administering his own nebulizer treatment. She confirmed the resident was not to self-administer his nebulizer treatment. A review of the facility policy titled, Medication Administration Self-Administration by Resident, dated 10/07, revealed: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe. Based on observation, interview and record review, the facility failed to ensure two residents (#2 and #1) were assessed to safely self-administer medications related to nebulizer treatments and failed to ensure one resident (#2) did not self-administer medications that were not prescribed at the time of observation for two residents observed of a total sample of 31 residents. Findings included: 1. On 11/30/21 at 12:01 p.m. Resident #2 was observed self-administering a nebulizer treatment, removed the mouthpiece while talking to a staff member, who walked in and out of the room, and then Resident #2 replaced the mouthpiece. When Resident #2 finished self-administering the treatment, he removed the tubing and mouthpiece without cleaning it and placed the tubing in the bag and hung it on his wall. A nurse was not in the room during this observation. A review of Resident #2's active physician orders as of 12/2/21, did not reveal a current order for a nebulizer treatment. In an interview with Resident #2 on 11/30/21 at 4:04 p.m. the resident confirmed he did not have an order for a nebulizer treatment (Albuterol) and stated that he used his last two Albuterol treatments today. In an interview on 12/02/21 at 12:15 p.m. Staff C, Registered Nurse (RN) stated the resident (#2) did not have orders for a nebulizer treatment or to self-administer medications. A review of the admission Record revealed Resident #2 was admitted on [DATE] with diagnoses to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 2 of 5 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few include chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia and acute respiratory failure, unspecified whether with hypoxia or hypercapnia. The medical record did not reveal an additional transfer or discharge from the facility. A review of the admission Assessment completed on 8/13/21 revealed the resident did not want to self-administer medications. In an interview with the Director of Nursing (DON) on 12/2/21 at 1:40 p.m. she confirmed she spoke to the resident and he told her he had two nebulizer treatments left over from the hospital, so he gave them to himself. The DON confirmed the resident was not having difficulty breathing, so they removed the nebulizer machine from his room. The DON confirmed he did not have a physician order for the treatment and did not have the medication given to him by the nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 3 of 5 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St 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 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure care was consistent with professional standards of practice related to the care and lack of a physician order for care of an ileostomy at the time of admission for one resident (#2) of three residents with ostomy care. Findings included: During an interview and observation of Resident #2 on 11/30/21 at 4:04 p.m. he stated he had an ostomy as he lifted his shirt and revealed the ostomy on the right side of his abdomen. Resident #2 stated he changes it at least four times a day since he can not empty it on his own. An observation and interview on 12/2/21 at 9:52 a.m. revealed Resident #2 holding his ostomy bag under his shirt walking down the hallway. The ostomy was observed swollen and he stated he was going to change it. During an interview with Staff C, Registered Nurse (RN) on 12/02/21 at 12:15 p.m. she confirmed Resident #2 changes his own ostomy and should have physician orders for it. She confirmed she did not see any orders and stated the resident changes it himself and every morning she gets him the supplies to change it. Staff C, RN confirmed she does not document on the ostomy. A review of the admission Record revealed Resident #2 was admitted on [DATE] for diagnoses of Ileostomy status and chronic obstructive pulmonary disease (COPD). Review of the active physician orders as of 12/2/21 revealed no ostomy care orders or care until 12/2/21. Review of progress notes dated 8/13/21 revealed the resident was admitted with an ileostomy. Review of the progress notes dated 12/2/21 revealed, resident assessed with own colostomy care several times and has a completed understanding of how to change the whole appliance and or just emptying the bag. The resident wishes to care for his own colostomy therefore he will not allow staff to touch it. Review of the care plan focus area for ostomy, ileostomy initiated 8/14/21 revealed interventions created on 8/14/21 to observe ostomy care required daily and provide ostomy care as needed, observe for condition of stoma site with routine care, observe for change in elimination: consistency, odor, color, report to MD (medical doctor) as needed, and observe, document and report to MD for signs and symptoms of complications: pain, burning, bleeding at stoma site, change in stoma size, abnormal color of stoma, impaired skin integrity. During an interview on 12/2/21 at 12:28 p.m. with the Director of Nursing (DON), she confirmed Resident #2 was admitted with an ostomy that he takes care of and confirmed the staff should be observing the care to ensure competency, and an order for him to self care for the ostomy should have been added. Review of facility policy titled, Physician Orders, effective October 2021, 4.3.1 Page 1 to 3, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105274 If continuation sheet Page 4 of 5 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 105274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Center 1270 Turner St 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 0691 revealed: At the time each resident is admitted , the facility will have physician orders for their immediate care. Physician orders will be dated and signed at next physician visit. 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: 105274 If continuation sheet Page 5 of 5