Inspection·January 15, 2021

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the comprehensive care plan was revised to reflect residents' currents needs related to falls and Activities of Daily Living (ADL's) for 2 of 21 (#46, #65) sampled residents. Findings included: 1. Review of Resident #46's record revealed that this resident was admitted to the facility on [DATE] and had a fall risk assessment dated [DATE] with a score of 13.0 (High Risk); and a fall risk assessment dated [DATE] with a score of 12 (High Risk) Review of the residents progress notes revealed the following: -12/21/20-Informed by staff resident sitting on floor in room upon entering room noted resident sitting on floor next to bed on buttocks states he did not hit his head did not hurt himself request to get up assessed patient no injury noted able to move all extremities without difficulty notified family notified MD. -12/28/20-APRN progress note refers to a fall on 12/21/20 with no injury. -12/23/20-Psych note found on floor, med eval per staff. Recommendations UA (urinalysis) per primary; No medication changes at this time. -1/9/21 fall-Progress note- At approximately 8 pm, CNA (Certified Nursing Assistant) walked past room and observed resident sitting on floor with legs in sitting position bent but apart in the bathroom facing the toilet with wheelchair behind him. Resident was in the bathroom trying to empty his bag when he said he had to sit down he went to sit in the wheelchair when he slipped out of the wheelchair and landed on his butt. When asked resident why were you on the floor, resident stated he was emptying his bag and it was to much so he tried to sit in his wheelchair and sat on the floor. Resident stated he did not hit his head. Review of Resident #46's care plan related to falls r/t (related to) impaired mobility, h/o (history of) falls, poor safety awareness due to dementia, HTN, anemia, use of psychotropic medications and convulsions. The care plan had an initiated date of 5/23/19 and a most recent revision date to the Interventions of 4/9/20 Closer review of the care plan related to falls revealed that it did not reflect the resident's most recent falls or needs related to the most recent falls. 2. Review of the Resident #46's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that at that time the resident required limited assist of 1 person. Continued review of the resident record revealed an Annual MDS (Minimum Data Set) dated 11/25/20 which indicated that the resident had declined in the area of dressing and now required extensive assist of one person 1 person. Review of Resident #46's care plan dated 5/23/19 with the most recent revision dated 6/1/20 related to ADL (Activity of Daily Living) self-care performance deficit r/t impaired mobility, anemia and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 2 of 6 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 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 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 0657 Level of Harm - Minimal harm or potential for actual harm generalized weakness. Has dx (diagnosis) of right hemiplegia and hemiparesis H/O TIA(transient ischemic attack). Closer review of the care plan related to ADL's revealed that it did not reflect the resident's most recent decline or needs. Residents Affected - Few Review of the ADL sheets 7 days prior to the 11/25/20 assessment reflects that during this time period the resident had a decline in dressing. Interview with the MDS Coordinator on 1/14/21 at 11:53 AM revealed that she would need to do research to see what was documented and what was going on when the ADL assessment was being completed. She reported that related to falls if there are any recommendations the care plan is up-dated to reflect the recommendations or new interventions. Interview on 1/14/21 at 1:34 PM with the MDS Coordinator revealed via the 7 day look-back period the activity that actually occurred revealed that Resident #46 had a decline. She confirmed that the documentation was accurate, and that the resident had a UTI (Urinary Tract Infection) at the time. She reported that she was new and was still in training and has not had a chance to ensure that all care plans are updated. 3. Review of Resident #65's Annual MDS dated [DATE] revealed that the resident required limited assist of 1 person for bed mobility, and supervision of 1 person for transfers. Review of the Quarterly MDS dated [DATE] revealed that the resident had a decline in Bed mobility and now required extensive assist of 1 person to complete the task. Continued review of the MDS revealed that the resident also had a decline in transfers and now required extensive assist of 1 person to complete the task of transfers. An interview on 01/15/21 at 11:44 AM with the MDS Coordinator revealed that she had a note that indicated that the resident does better in the morning rather than in the afternoon. She reported that this is not reflected in the care plan. She reported that based on the documentation the care plan for Resident #65 should have been revised to reflect her current needs. Review of the care plan dated 7/31/19 with revision dated 5/13/20 related to ADL self care performance deficit r/t impaired mobility, left side hemiplegia and hemiparesis and generalized weakness. The plan did not reflect the resident requiring more assistance as the day goes on and did not reflect the resident's current needs. An interview on 1/15/21 at 7:55 AM with the DON/Regional nurse revealed that now that she is checking she is finding that the care plans have not been updated which should be done by the MDS Coordinator. She reported that in the absence of the MDS Coordinator the DON and the Nursing Home Administrator (NHA) are responsible to ensure that the care plans are updated. 4. Review of the facility policy titled Care Plans, Comprehensive Person-Centered with a revised date of December 2016 revealed that 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 3 of 6 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 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to administer Intravenous medications (IV) consistent with physician orders for two (#59 and #48) of two residents receiving IV fluids. Residents Affected - Few Findings Included: 1. An observation was conducted on 1/12/21 at 9:30 a.m. of Resident #59 lying in bed with an IV pole positioned by the bed near the door, IV fluids were not running. An observation was conducted of Resident #59 on 1/12/21 at 12:00 p.m. sitting up in bed drinking fluids during lunch. The IV was observed not running or attached to Resident #59. An observation conducted of Resident #59 on 1/12/21 at 2:45 p.m. revealed the IV pole without an IV bag; a replacement IV bag was on the bedside table with IV tubing. Staff member O, LPN was present and stated that the resident pulled out the IV last night some time and the IV team will be coming to put the IV back in. Staff member O, LPN stated she is not certified to insert the IV but Staff member N, LPN Supervisor can start the IV when the IV team comes. During an interview with Staff member N, LPN Supervisor on 1/12/21 at 2:46 p.m. he said the doctor wanted the IV team to come and the night nurse should have called the doctor, the IV team and the resident's responsible party. After review of the electronic record, Staff member N, LPN Supervisor confirmed the notes in the record did not reflect that the physician or the POA (power of attorney for the resident) were called and the note did not confirm when the IV was pulled out or how much IV fluid was infused. Staff member N, LPN did confirm the IV came out sometime last night (1/11/21) on the 3 to 11 p.m. shift and no one had called the IV team to follow up or called the physician until the IV had been out at least 13 hours. During an interview with the Director of Nursing (DON) on 1/12/21 at 3:00 p.m. she confirmed the physician and POA should have been notified and the chart updated. The DON also confirmed the medical record should reflect when the IV came out and how much IV fluid was infused. Review of physician orders revealed: Infuse D5 1/2 normal saline at 80 ml/hr for 3 days every shift to maintain hydration for 3 days started on 1/11/21 to end on 1/14/21. Reinsert peripheral line to infuse D5 1/2 NS at 80 ml/hr x 3 days. One time only for lab dated 1/11/21 to 1/13/21. Review of care plan revealed the focus area of risk for dehydration or potential fluid deficit related to diuretic use and poor intake initiated and revised on 11/20/19. Interventions/tasks revealed to administer intravenous fluids and or medications as ordered initiated on 1/12/21. Administer medications as ordered. Monitor/document for side effects and effectiveness dated 11/20/19. Review of the nursing progress notes dated 1/11/21 at 11:36 p.m. Late entry - attempted IV insertion right upper arm, unsuccessful. IV nurse to be notified, per night shift nurse. Review of the nursing progress notes dated 1/12/21 at 12:02 a.m. resident pulled out peripheral line on 3 to 11 shift. Trying to insert a new one but resident was combative and IV team called to reinsert as soon as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 4 of 6 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 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 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 0694 Level of Harm - Minimal harm or potential for actual harm Review of the nursing progress notes dated 1/12/21 at 11: 40 a.m. Catheter intact after removal. No redness, swelling, no complaint of pain or tenderness at site. Review of the nursing progress notes dated 1/13/21 at 12:03 a.m. revealed the peripheral IV was inserted on right upper arm and started D 5 1/2 NS at 80 cc/hr without problems at this time. Residents Affected - Few Review of the nursing progress notes dated 1/13/21 at 5:04 a.m. revealed the IV patent, family and physician notified at 11:00 p.m. on 1/12/21. Physician extended therapy to 1/15/21. During an interview with the DON on 1/13/21 at 9:55 a.m. she stated she started training on IV's with the nurses. During an interview with the ARNP (Advanced Registered Nurse Practitioner) on 1/15/21 at 10:25 a.m. she said she would expect the facility to call and let her know the resident had not received the ordered IV solution for more than 12 hours. The ARNP stated she would expect that a nurse hanging an IV would assure the IV is infusing as ordered. Review of the facility policy for Administering Medications dated 2001, revised 4/2019, 3 pages, reflected: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescribe orders, including any required time frame. Review of the Charting and Documentation policy revised July 2017, two pages revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2) On 1/12/2021 at 10:35 a.m. Resident #48 was observed lying in bed with IV fluids hanging on an IV pole, the bag connected to Dial A Flow tubing to the resident's left lower arm. The IV bag contained 250 ml of Normal Saline Solution. On 01/12/2021 at 12:30 p.m. the resident was in bed with the IV connected to the left forearm via Dial A Flow tubing, and the IV bag contained 250 ml of Normal Saline Solution. On 01/12/2021 at 2:00 p.m., upon closer observation, the IV bag contained Normal Saline Solution (NS) and was connected to dial a flow tubing, but the drip chamber was not dripping. The dial a flow tubing was dated 01/10/21 and was set at a flow rate of 75 ml/hr. (milliters /hour). The bag was full, just as it was observed at 10:35 a.m. (Photographic evidence obtained). On 01/12/21 02:16 p.m. An interview was conducted with Staff A, Registered Nurse (RN). Staff A said that she had connected the IV at 9:30 a.m. and checked the IV before her lunch break at 1:30 p.m. She stated that the IV is not running at full rate, and she was going to call the doctor, but she was busy watching residents in the activity room. The nurse stated that the IV bag contained 250 ml NS solution and was infusing at a rate of 75 ml/hr and should have been completed in about 3.5 hours. Staff A confirmed that the solution should have been completed before 2:00 pm. During an interview on 01/12/2021 at 2:23 p.m., the Director of Nursing (DON) confirmed that the IV fluid should have been completed if hung at 9:30 a.m. The DON stated that she was going to call the doctor and inform the doctor that the IV was not infusing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 5 of 6 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 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the medical record for Resident #48 revealed that he had been admitted to the facility on [DATE]. Diagnoses included: COVID-19; Viral Pneumonia; Respiratory failure; Hemiplegia and Hemiparesis following Cerebral Infraction affecting right dominant side; Cognitive Communication deficit; Dysphagia, and Oropharyngeal. The most recently completed Quarterly Minimum Data Set (MDS) dated [DATE] revealed the following: A Brief Interview of Mental Status (BIMS) score of 09, indicating a moderately impaired cognition. The resident required extensive to total dependence for mobility and activities of daily living (ADL). A review of the active physician orders revealed an order initiated on 1/10/2021 to infuse Normal Saline at 60 ml/hrs. X 2 Liters for hydration. Review of the Medication Administration Records (MAR) for 1/10/2021 revealed that the order to infused Normal Saline at 60 ml/hr. X 2 liters for hydration until 01/11/2021 was administered on 01/10/2021. A physician order dated 1/11/2021 was noted to infuse Normal Saline and at 60 ml/hrs. X 2 Liters until 1/12/2021 for hydration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 6 of 6