Health inspection·March 20, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to protect the resident(s') right to be free from neglect when it failed: 1) to provide to structural processes necessary to ensure ongoing incontinence care to two residents (#1 and #2); and 2.) to prevent emotional anguish to 1 resident (#2). The findings included: Record Review of Abuse and Neglect-Clinical Protocol Policy last revised in March 2018 stated that neglect is defined as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Record Review of ADL Policy, last revised on March 2018 stated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, including Hygiene (bathing, dressing, grooming, and oral care). Resident #1 was admitted to the facility on [DATE] for skilled nursing care. Resident #1 has a diagnosis of Alzheimer's disease, impaired gait and mobility, and generalized muscle weakness. Resident #1 requires staff assistance with hygiene care and transfers in and out of her wheelchair. Record Review of the facility's neglect allegation showed that the facility verified the Certified Nursing Assistant (CNA) who was assigned to this resident did not provide incontinent care during breakfast service or lunch service resulting in the resident sitting in a puddle of urine at breakfast and lunch time on 2/20/25. Record review of staff training logs for neglect at the time surrounding the incident involving Resident #1 showed facility lacked ongoing training for staff regarding the incident, and that the only staff trained on neglect at the time of the incident were the 24 staff working at the facility on 2/26/25. Record review of facility's Quality Assurance Performance Improvement (QAPI) agenda shows that the incident involving Resident #1 was included on the agenda dated 3/19/25. Page 1 of 4 105538 105538 03/20/2025 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #2 was admitted on [DATE] with history of Dementia and requires staff assistance with getting out of bed and into the wheelchair. Interview with Resident #2 on 3/20/25 at 10:47 a.m. who stated that the Certified Nursing Assistants (CNA's) don't assist with toileting or incontinence during dinner time, they will tell you they are too busy. Resident #2 said, someone told me just go in the diaper, as if that's what it is supposed to be for, they tell you they'll be back and then you never see them again. On 3/20/25 at 2:50 p.m., during an interview the Administrator stated that he was aware of an incident in which a former staff member had told another resident to just go in your diaper. The facility had recently terminated that employee but was not aware of other residents with the same complaint. Interview with Resident #2 on 3/25/25 at 10:47 a.m., who stated that she recently refused to allow staff to care for her because she was uncomfortable with them telling her to just go in your diaper. She stated that she was so upset by the interaction that she reported the incident to her nurse, and the facility agreed to remove the staff from caring for her, but no one ever asked her why or what had happened. On 3/20/25 at 2:50 p.m., an interview was conducted with the Administrator who stated that there were currently no ongoing audits in place to ensure that neglect was not occurring in the facility because QAPI was not held until 3/19/25, and that audits had not been considered prior to the meeting. The Administrator also stated that the facility had not conducted training to all caregivers after the neglect allegation was made for Resident #1, but that ongoing training would be something the facility would look into going forward. 105538 Page 2 of 4 105538 03/20/2025 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, as a result of a facility's investigation, when an alleged violation was verified, the facility failed to take appropriate corrective action to protect residents and oversee the implementation of corrective action and evaluate whether it is effective for 2 of 2 incidents reported by the facility. Residents Affected - Few The findings included: On 10/30/24, the facility reported an investigation into 19 possible instances of drug diversion regarding prescribed, as needed, pain medications. During the investigation, the facility interviewed staff and residents, in-serviced staff on misappropriation of property, and discussed the incident in a Quality Assurance Performance Improvement (QAPI) meeting on 11/20/24. The facility investigation concluded that they could not verify any medications were diverted but did verify documentation was incomplete in 19 instances involving 9 separate residents' as needed pain medications. Staff members involved was subsequently terminated. There was no further actions taken to verify this action was effective. On 2/20/25, the facility reported in investigation regarding incontinence care. During the investigation, the facility interviewed staff and residents, in-serviced staff on abuse and neglect and discussed the incident in a Quality Assurance Performance Improvement (QAPI) meeting on 3/19/25. Facility investigation verified the allegation of neglect and terminated the staff member involved. There was no further actions taken to verify this action was effective. On 3/20/25 at 2:56 p.m., the Administrator said no Performance Improvement Plans (PIPs) had been put in place and no continued monitoring/audits had been conducted for either reported incident. The Administrator agreed there was no way to prove the actions taken by the facility had been effective in dealing with the problems related to the investigation. 105538 Page 3 of 4 105538 03/20/2025 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure incontinence care was provided to 2 residents (#1 and #2). The findings included: Record review of the Activities of Daily Living (ADL) Policy, last revised on March 2018 said, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, including Hygiene (bathing, dressing, grooming, and oral care). Resident #1 was admitted to the facility on [DATE] for skilled nursing care. Resident #1 has a diagnosis of Alzheimer's disease, impaired gait and mobility, and generalized muscle weakness. Resident #1 requires staff assistance with hygiene care and transfers in and out of her wheelchair. Record review of the facility's investigation of the ADL care received by Resident #1 showed that the Certified Nursing Assistant (CNA) was made aware on 2/20/25 the resident was sitting in a puddle of urine at 8:00 a.m. and did not receive incontinence care until after lunch. On 3/20/25 at 10:47 a.m. an interview with Resident #2 who stated that I have to ask for help to the bathroom, the CNA never offers to help or anything, and one time recently I waited so long I had to go in my diaper and had to wait until after dinner to be changed when someone finally came and helped me. On 3/20/25 at 12:00 p.m., in an interview the Administrator verified that he was made aware that incontinent care had not been done for Resident #1 and verified that the CNA documented that the resident was not available for incontinence care. The Administrator confirmed this was determined to be falsely documented. On 3/20/25 at 12:15 p.m., in an interview the Administrator stated that there are currently no performance improvement plans in place to monitor for toileting and incontinence care at the facility. 105538 Page 4 of 4