Health inspection·October 19, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed. Observe and report changes in mood, behaviors, cognition, and level functioning caused by situational stressors to Medical Doctor. Reinforce appropriate expression of feelings. 2. Receives Antianxiety meds due to history of anxiety making resident at risk for medication side effects with interventions to include: Provide medications as ordered, Pharmacy consultant review every month, Observe resident's mood and response to medication, Observe medication side effects, Attempt non pharmacological interventions such as 1 on 1 and or TLC for increased anxiety, attempts to gradually dose reduction if warranted. On [DATE] at 8:00 a.m., an interview with both the Director of Nursing (DON) and the Minimum Data Set (MDS)/Care Plan coordinator Staff D, revealed Resident #151 was newer to the facility but they knew of her and her daily routines. Staff D and the DON confirmed the resident was visited by family on a daily basis and she participated in therapy. Staff D and the DON confirmed Resident #151 had been marked on the facility's Resident Matrix, which indicated she had Post Traumatic Stress Disorder (PTSD). Staff D revealed Resident #151 had PTSD related to behaviors that occurred to her as a child and also while with her now deceased husband. Staff D revealed after the admission MDS/5-day assessment, dated [DATE] was completed, it was brought to her attention the resident had PTSD. She revealed the care plan for the resident did not include PTSD with goals and interventions. Staff D reviewed the progress note, dated [DATE], and confirmed the 5 Day MDS assessment should have reflected Resident #151 had PTSD. She said there should have been a PTSD care plan developed. The Director of Nursing confirmed Resident #151 was not care planned with a specific problem area, goals and interventions related to PTSD as of yet, and they should have care planned that problem area during the interim care planning phase, within forty-eight hours of her admission. On [DATE], the Nursing Home Administrator (NHA) provided the Comprehensive Care Plans, policy with a last review date of 10/2023, for review. The Policy revealed; All residents will have a Comprehensive Care Plan (CCP) completed in accordance with Federal and State requirements. The CCP will include measurable objectives and timetables in order to meet the resident's medical and psychosocial needs that are identified from the comprehensive assessment (MDS). All applicable Care Area Assessment (CAA) will be reviewed. Any issues may be identified by members of the comprehensive care plan team and should be evaluated for inclusion in the comprehensive care plan. The Policy continued to reveal; The CCP will be developed within 7 days after the completion of the comprehensive assessment. The CCP will be periodically reviewed and revised by a team of qualified Clinicians after each MDS assessment and reassessment. Key points include but not limited to: Initial admission, readmission, and significant change; Episodically as plan of care changes. The Procedure section of the policy revealed; 1. The CCP will be initiated by all members of the team on admission. a. Problems will be identified from the MDS triggers and review of the CAA, and from the resident assessment, interviews, and direct observation. b. Team disciplines will write identified problems directly onto the care plan problem sheet. All disciplines are responsible for reviewing the plan of care and documenting interventions and initiating responsibility in the disciplinary column. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105529 If continuation sheet Page 2 of 12 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 105529 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Health Center by Harborview 2302 59th St W Bradenton, FL 34209 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 c. Disciplines will be responsible for updating the plan of care when there is a new problem that requires the discipline to intervene. d. Any discipline can initiate a special care plan meeting. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105529 If continuation sheet Page 3 of 12 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 105529 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Health Center by Harborview 2302 59th St W Bradenton, FL 34209 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure two (Resident #26, and #67) of three sampled residents for quality of care received treatment and care in accordance with professional standards of practice related to 1. Responding to a change in condition timely related to a skin condition for Resident #26, and 2. Monitor and provide care to an occlusive dressing for Resident #67. Residents Affected - Few Findings included: 1. On 10/16/23 at 10:58 a.m., Resident #26 was observed in her room sitting in the wheelchair next to her bed. A tube of [over-the-counter (OTC) medicated ointment, used for skin irritation] was observed sitting on the bedside table. She stated her husband always brought the [OTC medicated ointment] because she wanted to make sure she had it. She had an open area around her anus and in the groin area. Resident #26 stated it was very painful from sitting for so long. The wound care doctor came on Monday, and she needed to see them. She stated it hurt very bad when she urinated. They checked her for a Urinary Tract Infection (UTI) and it was negative. On 10/18/23 at 1:29 p.m., Resident #26 was observed in her room sitting in the wheelchair next to her bed. She received a phone call during the interview. Resident #26 reported to the person on the other end of the phone that her bottom was in pain and she needed to see the wound care doctor. On 10/19/23 at 9:20 a.m., Resident #26 was observed in her room sitting in the wheelchair next to her bed. She stated she had been feeling the pain on her buttocks and when she urinated for more than three months. She asked for the wound doctor to see her, and staff acted as if it was unusual. Staff were telling her it was just a raw opening and that was why the area was sore. Resident #26 stated when staff changed her, her bottom rubbed against the bed and it hurt. She stated sitting in the chair was hard. Every move she made hurt those places. She stated she wished staff could explain things to her better. At one point, they moved her to another room because her sores were so bad. It had not gotten any better. It started with just a burning on her buttocks. She could not consider going home because she was in so much pain. The burning and soreness have been going on for the last three months. When the pad was wet, it stayed up against her and it burned. She drank a lot of water, so she urinated a lot. Staff told her yesterday that she could not use the[OTC medicated ointment]. The ointment that was ordered for her was not helpful at all. The areas were really raw. The last person talked to her said it was raw with open patches with little flaky skin. Sometimes the staff would say it cleared up in a day and then it would come right back. A review of the Resident Face Sheet revealed Resident #26 was admitted into the facility on [DATE] with diagnoses to include urinary tract infection. The Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicted intact cognition. A review of the active orders revealed the following: Apply zinc cream to buttocks 3 times a day for redness and Head to toe skin checks weekly once a day. Special instructions: Complete non-pressure observation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105529 If continuation sheet Page 4 of 12 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 105529 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Health Center by Harborview 2302 59th St W Bradenton, FL 34209 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 0684 or wound management form if appropriate. Level of Harm - Minimal harm or potential for actual harm There was no order on the active orders list for the [OTC medicated ointment]. Residents Affected - Few A review of the Medication Administration Record (MAR) for August, September, and October 2023, showed the zinc cream was applied three times daily for all three months and skin assessments were completed as ordered. Resident Progress Notes revealed the following: 10/18/23 18:57 (6:57 p.m.) - Patient showing increasing confusion and agitation. The doctor was notified. New orders for Urinalysis and Culture and Sensitivity to be completed. 10/13/23 10:53 a.m.- Weekly skin assessment completed, resident had excoriation to her coccyx and groin, continue current treatment until healed, and will continue to monitor for any changes in condition. 10/11/23 15:41 (3:41 p.m.) - Resident had reddened area to groin and coccyx, continue current treatment until healed, will continue to monitor for changes of condition. 10/09/23 13:57 (1:57 p.m.) - Patient had non-blanching area to coccyx, purple in center. Notified doctor and he requested for wound care to follow. 10/06/23 12:05 p.m. - Weekly skin assessment complete. Resident has no skin impairments at this time, resident had reddened area to sacrum with treatment, will continue to monitor for any changes of condition. 09/30/23 12:01 p.m.- Weekly skin assessment complete. Resident had reddened area to coccyx, no other skin issues noted, continue current treatment until resolved. Will continue to monitor for any changes of condition. 09/22/23 8:20 a.m.- Weekly skin assessment complete. Coccyx reddened, continue current treatment until healed, will continue to monitor for any changes in condition. 09/14/23 20:58- (8:58 p.m.) Weekly skin assessment complete. Resident had reddened area to her buttocks, continue current treatment until healed. 09/07/23 1:04 a.m. - Weekly skin check complete. Reddened area left buttocks. Continue current treatment. Will continue to monitor for any changes in conditions. 09/04/23 18:17 (6:17 p.m.) - Weekly skin assessment completed. Open area to right buttock. No signs and symptoms of infection noted. Treatment order in place. 09/01/23 14:46 (2:46 p.m.) - Weekly skin assessment complete. Patient had open area on right buttock, treatment in place. Will continue to monitor. 08/25/23 18:54 (6:54 p.m.) - Weekly skin assessment. Patient had open area on right buttock, treatment in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105529 If continuation sheet Page 5 of 12 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 105529 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Health Center by Harborview 2302 59th St W Bradenton, FL 34209 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 0684 Level of Harm - Minimal harm or potential for actual harm 08/24/23 14:22 (2:22 p.m.) - Weekly skin assessment complete. Resident had small open area on right side below her coccyx. Continue current treatment until healed. Will continue to monitor for any changes in condition. 08/20/23 19:23 (7:23 p.m.)- The doctor was notified of new open areas on back of thigh. Orders placed. Residents Affected - Few 08/20/23 0:07 (12:07 a.m.)Certified Nursing Assistant (CNA) reported skin alteration to the patient's right buttock. On observation, the patient had slight excoriation to the right buttock, on the fold of skin. The area was cleansed with soap and water. Barrier cream applied. Skin alert completed and placed in the unit manager's box. 08/18/23 11:19 a.m. - Weekly skin assessment completed. No new skin conditions noted. Will continue to monitor. 08/16/23 17:52 (5:52 p.m.) - Weekly skin assessment completed. No new skin issues noted. 08/11/23 11:07 a.m. - Weekly skin check completed. Resident had reddened area to coccyx. Continue current treatment until healed. 08/04/23 10:10 a.m. - Weekly skin check complete. Reddened area to coccyx. Continue current treatment until healed. Will continue to monitor for any changes in condition. 08/02/23 14:53 (2:53 p.m.) - Weekly assessment completed. No new skin issues noted. The progress notes showed on 10/11/23, Resident #26 was noted to have a new reddened area to her groin and on 10/13/23 she was noted to have a new area of excoriation to her groin with no orders in place for treatment. The most Recent Wound Evaluation and Management Summary dated 07/10/23, showed the patient presented for follow up of wound on her sacrum. Prior healing wound had improved. The progress notes showed on 10/09/23 the doctor requested for wound care to follow up. There was no evidence of a follow up from the wound care doctor. The care plan related to skin integrity with a problem date of 12/09/20 showed the resident had a risk for skin integrity. Interventions included but were not limited to report changes in skin status to the physician. There was no evidence the physician was contacted related to the changes in skin condition. On 10/18/23 at 1:30 p.m., Staff E, CNA, stated Resident #26 had complained of pain to her buttocks and groin area but it was getting better. The nurse was aware, and the nurse was responsible for doing treatment. On 10/19/23 at 9:32 a.m., Staff F, Licensed Practical Nurse (LPN) stated Resident #26 had not complained to her about pain on her buttocks or groin area. She did not like the wheelchair and she would not let them turn her because she said it was uncomfortable. She hated the wheelchair and preferred to lay in bed. She had been very confused and agitated so the doctor was contacted. They ordered a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105529 If continuation sheet Page 6 of 12 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 105529 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Health Center by Harborview 2302 59th St W Bradenton, FL 34209 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few urinalysis because of the agitation and confusion. Staff F stated the resident had a pack of sour cream and was saying it was a cream for her bottom. Staff F reported the resident had not reported to her about the pain while urinating. She stated, Well that would be perfect for a UTI. On 10/19/23 at 10:21 a.m., Staff G, LPN/Unit Manager (UM), reported she saw Resident #26 a couples of times a day; but, the resident did not say anything to Staff G about pain when she urinated. The resident would always report that the areas were sore. She got excoriated. It went away and came back. Resident #26 seemed to like the [OTC medicated ointment] and she knew she was not supposed to have it. The resident never told Staff G the cream she had ordered was not working and never asked her about seeing the wound care doctor. Staff G said if there was anything other than a red area, the resident could be seen by the wound care doctor. The area was not open so she was not on the schedule to see the wound care doctor. Staff G, LPN/UM stated they could send a wound care referral. The area to the groin was observed during the middle of last week when she did a skin assessment. She confirmed the resident did not have an order in place for treatment to the groin area. On 10/19/23 at 10:12 a.m., the Director of Nursing (DON) stated the resident had a history of pain. The resident had not reported any skin concerns to her. She was ordered a barrier cream that the nurse put on her twice a day. When the nurses perform skin checks, and the note indicated redness or excoriation, she or Staff G, LPN/UM would look at the area. If there was a concern, they would fax that information to the wound care doctor and the wound care doctor would see them that following Monday. If the area was open, then the wound care doctor would see the resident. The wound care doctor was here on Monday. She stated the wound care doctor did not see the resident because the area was not open. The nurse would indicate the area of concern on the 24-hour report, the UM would review the report, and then the UM would go assess the patient. She confirmed the resident was not seen by the wound care doctor as ordered by the physician because on 10/11/23, the resident was seen and assessed by the UM and the area was red. There was no need to see the wound care doctor. The [NAME] Wound Round Policy provided by the facility revised on 05/22 revealed the following: In addition to the Attending Physician, the residents will receive services from consultants if ordered by the attending physician. 2. Review of Resident #67's face sheet revealed she was admitted on [DATE] from an acute care hospital. Resident #67 had medical diagnoses to include but were not limited to, infection and inflammatory reaction due to her internal orthopedic prosthetic devices, implants and grafts, sepsis due to Methicillin susceptible staphylococcus aureus, osteomyelitis, fracture of right femur, encounter for closed fracture with routine healing, periprosthetic fracture around internal prosthetic right hip joint, and the need for assistance with personal care. An observation was conducted on 10/16/23 at 10:48 a.m. Resident #67 was observed to be lying in bed with an intravenous (IV) pole next to her bed. The resident was observed to have an IV in her left arm with a clear dressing that was intact and dated 10/16/23. The resident was observed to also have a bandage on her right upper arm which was dated 10/12 the bandage was intact but soiled with dark reddish brownish substance that filled more than half of the occlusive bandages absorbent pad. Resident #67 said she used to have an IV in that arm and they took it out and put the bandage on. Photographic evidence obtained. Review of Resident #67's physician orders did not reveal any orders related to the right upper arm occlusive dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105529 If continuation sheet Page 7 of 12 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 105529 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Health Center by Harborview 2302 59th St W Bradenton, FL 34209 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 10/16/23 at 11:13 a.m., with Staff L, Certified Nursing Assistant (CNA) who was Resident #67's assigned CNA. She stated she had not worked with Resident #67 in a while, and she did not know anything about the bandage. An interview was conducted on 10/16/23 at 11:31 a.m., with Resident #67's nurse Staff K, Licensed Practical Nurse (LPN). She said Resident #67 used to have an IV in her right arm but it got clogged and the IV team came and put a new one in. They did not take the old one out so on Thursday last week, Staff K contacted the doctor and received an order to remove the old IV. Staff K said, The DON removed it and I put a bandage on it last Thursday. I'm pretty sure I dated the dressing. I didn't work yesterday but on Saturday I tried to take the bandage off but the resident didn't want me to so I told her it is going to have to come off in a week. Review of Resident #67's progress note dated 10/12/23 at 3:12 p.m. showed old PICC [peripheral intravenous central catheter] line removed 40 cm long. Pressure applied, and no bleeding noted. An interview was conducted with the Director of Nursing (DON) on 10/19/23 at 2:01 p.m. She said, Resident #67 had an IV upon admission. It was removed because it was leaking and not flushing, so a new IV was inserted. Review of the facility's Clean Dressing Change policy undated, revealed Intent: It is the policy of the facility to ensure change in dressings in accordance with State and federal Regulations, and national guidelines. Procedure: 1. Verify and review physician's order for procedure. .27. Document the completion of dressing change on the treatment record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105529 If continuation sheet Page 8 of 12 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 105529 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Health Center by Harborview 2302 59th St W Bradenton, FL 34209 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent enteral feeding complications related to not providing the ordered nutrition for one (Resident #28) out of 32 residents sampled. Findings included: Review of Resident #28's face sheet revealed she was admitted to the facility on [DATE]. Resident #28 was receiving hospice services. Her medical diagnoses included but were not limited to dysphagia, gastrostomy status, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness, major depressive disorder, and dementia. Review of Resident #28's physician orders revealed an order with a start date of 8/23/23 without an end date for enteral feeding: Formula Jevity, strength 1.5 calorie, Flow rate 70 ml/hr. (milliliters per hour) for 20 hours. Further physician order review revealed an order with a start date of 8/16/23 without an end date for free water flush 250 ml via peg tube every 4 hours. Another order with a start date of 6/20/23 without an end date for off Tube feeding at 10 AM once a day and another order with a start date of 6/20/23 without an end date for Start tube feeding at 2 PM once a day. On 10/16/23 at 9:08 a.m., Resident #28 was observed lying in bed. She was nonverbal but was intermittently moaning. The resident was observed to be hooked up to her enteral feeding pump. The pump was running a bottle of Jevity 1.5 calories and the pump was set for the resident to receive 65 ml' s' per hour with 250 ml water flush every 4 hours. Further observations were conducted on 10/17/23 at 10:18 a.m. Resident #28 was observed lying in bed, eyes closed, with her enteral feeding pump turned off. On 10/17/23 at 2:19 p.m. Resident #28 was observed lying in bed, eyes closed, with her enteral feeding pump turned off. On 10/17/23 at 2:35 p.m. Resident #28 was observed lying in bed, eyes closed, and her enteral feeding pump turned off. On 10/17/23 at 3:07 p.m., Resident #28 was observed lying in bed, eyes closed, her enteral feeding pump was turned on and running Jevity 1.5 calories. The pump rate was set for Resident #28 to receive 65 ml/hr, and the water flush was set for Resident #28 to receive D2000 of water every four hours. Photographic Evidence Obtained. An interview was conducted on 10/17/23 at 3:20 p.m. with Staff K, Licensed Practical Nurse (LPN). She reviewed the physician orders for the feeding rate, went into the resident's room, placed the pump on hold and said, I'm going to put this on hold because I thought it was supposed to be going at 65 ml/hr. Let me see if the dietitian changed the order. Staff K, LPN reviewed the feeding order and confirmed the order had been in place since August 23, 2023. She reviewed the record and said she was having trouble finding the dietitian's note but the night nurse, who was an agency nurse, gave her in report the pump was at a rate of 65 ml/hr. Staff K, LPN also said she took the resident off of her tube feeding at 10:00 a.m. and put her back on at 2:00 p.m. like the order says. Staff K, LPN went into the resident's room cleared the volume infused and changed the feeding pump rate to 70 ml' s' per hour and said she would need to talk to her unit manager to see what the dietitian said. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105529 If continuation sheet Page 9 of 12 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 105529 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Health Center by Harborview 2302 59th St W Bradenton, FL 34209 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #28's October Medications Administration History revealed on 10/17/23 the physician's orders Off Tube feeding at 10 AM and Start tube feeding at 2 PM were signed off as administered. Review of Resident #28's progress note dated 9/22/23 at 7:18 p.m., written by the facility's dietitian revealed, Unstageable sacrum wound. On Jevity 1.5 @ 70 mls/hour X [times] 20 hour via PEG [Percutaneous Endoscopic Gastrostomy]. Add [brand name of liquid protein supplement] AWC [advanced wound care] 30 mls via PEG daily for 200 Kcals and 30 grams protein, administer per enteral instructions on bottle. Significant loss noted from 113.5 lbs [pounds] to weight 100 lbs on 7-12-23. [Resident #28] is on hospice. NPO [nothing by mouth] diet order continues. F/U PRN [follow up as needed]. A progress note dated 8/15/23 at 9:58 a.m. revealed, called hospice about getting residents tube feed orders adjusted r/t [related to] weight loss, and about her pain meds not being sent from pharmacy due to insurance, they to [sic] call back with new orders. A progress note dated 8/15/23 at 2:54 p.m. revealed, spoke to hospice they called and got the billing corrected with the pharmacy, meds to be delivered today, referral sent to hospice dietitian to review the tube feeding and give recommendations. A progress note dated 8/23/23 at 8:51 a.m. revealed, Pt [patient] seen by [Hospice] dietitian orders to increase Jevity to 70 ml/hr running for 20 hours. Orders confirmed and carried out. Review of Resident #28's care plan, last reviewed on 10/12/23 revealed, Resident has a need for use of a feeding tube related to: (insufficient caloric intake, dysphagia, failure to thrive, cognitive impairment). Resident has risk for complication secondary to tube feeding use. The goal included, Resident will remain free from complications r/t [related to] the use of a feeding tube AEB [as evidence by] no s/s [signs and symptoms] of aspiration, no N&V [nausea and vomiting], no diarrhea, no abdominal distension. The interventions included but were not limited to Administer tube feeding formula and flushes as ordered. An interview was conducted on 10/18/23 at 3:37 p.m. with the Director of Nursing (DON). She said, I am aware she was not getting the ordered amount. We educated the nurse. I also talked to the dietitian, she is new to us, and I educated her that we don't do weights on hospice residents. Review of the facility's Enteral Nutrition policy undated revealed Physician Orders For Enteral Feeding Policy: Enteral formulas are provided to meet the nutritional needs of those residents unable to take liquids or food by normal means. .Quantum Feeding Pump Policy: Tube feedings will be administered as per MD orders, using the Quantum Enteral Feeding Pump . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105529 If continuation sheet Page 10 of 12 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 105529 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Health Center by Harborview 2302 59th St W Bradenton, FL 34209 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and facility record review, the facility failed to ensure; 1. One of one dish washing machine was operating at its low temperature wash and rinse specifications; 2. One of one walk in freezer was free from icing, ice sheeting build up on floors, inside walls, shelving and packaged food items; 3. One of one walk in refrigerator had an internal thermometer to gauge the internal temperatures; and 4. One of one hand washing sink had soap available to wash hands. Findings included: 1. On 10/16/2023 at 9:32 a.m., a kitchen tour was conducted with the Certified Dietary Manager (CDM). There was a hand pump soap dispenser attached to the wall directly above the hand sink. The soap dispenser was empty. The Dietary Manager confirmed the wall mounted soap dispenser was empty and did not know how long it had that way. She further confirmed the sink was where the staff who come into the kitchen washed their hands. She confirmed using an alcohol base sanitizer was not acceptable for her and her staff to use in lieu of washing their hands at the sink with soap and water. 2. On 10/16/2023 at 9:37 a.m., the CDM said the the kitchen had a Low temperature sanitizer dish washing machine. She revealed the wash cycle temperature and the rinse cycle temperature should reach 120 degrees Fahrenheit (F), and the sanitizer parts per million (PPM) should reach 100 - 200 PPM. She reviewed the last two months of the dish machine temperature log. Both months 10/2023 and 9/2023 the dish machine temperature logs showed appropriate temperatures logged, reaching at least 120 degrees F for both the wash and rinse cycle and the sanitizer was 50 ppm. The CDM pointed out on the wall next to the dish machine, informational posters that showed what the PPM expectations were for the sanitizer. She pointed out the machine's specification plate on the lower end of the machine. Both indicated a Low temperature dish machine with chemical sanitizer at optimum levels of 50-100 ppm for the sanitizer, and 120 degrees F for the wash and rinse cycles. The Dietary Manager confirmed the chemical sanitizer should be at 50 - 100 PPM. While speaking with the Dietary Manager, Staff A, dietary aide and Staff B, dietary aide were operating the dish machine. Staff A and Staff B said the dish machine had been running for about 15 minutes. Both Staff A and B confirmed the machine was operating well and there were no problems with it. Staff A and B said the machine was a Low temperature dish washing machine and temperatures for both wash and rinse should reach at least 120 degrees F. They also both said the chemical sanitizer was tested on ce every meal service. Staff A and B did not know the PPM range for the sanitizer. On 10/16/23 at 9:43 a.m., both Staff A and B demonstrated the use of the dish machine. Staff B ran a crate of dishes through the machine. After the crate of dishes was in the machine, the wash temperature only reached 103 degrees F ,according to the machine's analog thermometer. After the rinse cycle finished, and the machine clicked, the rinse cycle revealed a temperature only reaching 119 degrees F. The thermometer attached to the machine was heavily fogged and difficult to read. The CDM said, I can read it just fine. Photographic evidence obtained. On 10/16/23 at 9:44 a.m., a second dish machine demonstration was observed. Staff B ran another crate of dishes though the machine. After the crate of dishes were sent through the machine, the wash temperature only reached 115 degrees F. After the wash cycle ended and the machine clicked, the rinse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105529 If continuation sheet Page 11 of 12 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 105529 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Health Center by Harborview 2302 59th St W Bradenton, FL 34209 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 cycle reached only 118 degrees F. Both Staff A and B said they primed the machine prior to washing the first crate of dishes. They said the wash and rinse temperatures were at 120 degrees F. before they started running crates of dishes through the machine. Staff B said she could not read the temperature gauge. The Dietary Manager said she would notify the dish machine company of the issue and have them come out to fix the gauge and the water temperature. Residents Affected - Many 3. As the kitchen tour continued, the walk in refrigerator was found without a thermometer. The CDM and cook were unable to locate the refrigerator thermometer. During this observation, the internal temperature of the walk in refrigerator could not be confirmed. The Dietary Manager was unable to provide the daily/weekly/monthly temperature log for the walk in refrigerator. 4. As the kitchen tour continued, the walk in freezer was observed with a thick sheeting of ice on the floor on the left side of the unit. The sheeting of ice was approximately three feet long and three feet wide, with a thickness of about two inches or more in some spots. Further observations revealed the top left side shelf was observed with heavy icing and long icicles, with heavy icing built up on three boxes of packaged food items. Also, the flow pipes leading from the motor fan housing to the back of the unit wall were observed with heavy ice build up. An interview with the Dietary Manager revealed she was not aware of the icing on the floor and on the packages of food items. She confirmed the freezer iced up at times and believed the Maintenance Director was aware of the situation. Photographic evidence obtained. On 10/19/2023 at 1:00 p.m., an interview with the Maintenance Director confirmed he was aware of the walk in freezer ice build up but did not have a work order to show what he was currently doing to fix the issue. On 10/19/2023 at 2:00 p.m. the Nursing Home Administrator provided the undated Dish Machine Policy and Procedure. The Policy showed the following procedures: 1. The dirty carts/dishes must enter the dirty area and exit the clean area when possible considering architectural design and kitchen layout. 2. Check unit chemical container levels and run dish machine while empty (as many times as necessary) to get desired temperature. 3. Run dishes through the unit cycles of wash and rinse. 4. Record temperature and chemical level of unit at least 3 times per day. 5. Follow unit specifications for proper temperature and chemical levels to assure proper sanitation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105529 If continuation sheet Page 12 of 12