Health inspection·May 29, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3/16/24, and on 4/16/24 and not again for the month of May. She acknowledged there was no documentation to indicate the resident refused his showers, and a care plan for refusal of showers was not identified. The DON confirmed that based on the records reviewed, showers were not provided for resident #1 as scheduled. She stated if a resident refused showers, the CNA should notify the nurse, and any refusals should be documented. If the resident's preference was for bed baths, the task should be changed to reflect the resident's preference. On 5/29/24 at 4:33 PM, CNA A stated she worked on the 3 PM to 11 PM shift every other weekend, and sometimes picked up shifts during the week. The CNA confirmed she had resident #1 in her assignment sometimes, and stated he did not refuse showers. The resident's Documentation Survey Report was reviewed with CNA A. She acknowledged documentation indicated resident #1 received two showers for the periods reviewed. CNA A stated she could not recall why she provided a bed bath for the resident instead of a shower on his scheduled shower days. On 5/29/24 at 4:44 PM, CNA B recalled providing care for the resident previously, and stated the resident showers were scheduled on the afternoon shift. The resident's Documentation Survey Report was reviewed with CNA B, she acknowledged her signature, but could not recall why she did not provide a shower for the resident on his scheduled shower days. On 5/29/24 at 4:55 PM, CNA C stated if the resident refused showers, she would notify the resident's nurse, and document refusal in the POC. CNA C said resident #1 did not refuse his showers, however, sometimes when the resident was in bed, she provided him with a bed bath, instead of his showers. The CNA said the resident required the assistance of two persons and sometimes there was no one available to assist her. 2. Resident #5, an 82- year-old female was admitted to the facility on [DATE], with diagnose including mitochondrial metabolism disorders, functional quadriplegia, and generalized anxiety disorder. The resident's quarterly MDS assessment with ARD of 2/14/24, revealed the resident's cognition was moderately impaired with a BIMS score of 11 out of 15. Review of the facility's Grievance Log for the period March 2024 to current revealed an entry pertaining to the resident on 3/21/24. Resident #5's responsible party verbalized the resident was scheduled for showers in the PM, and the preference was for showers in the AM. The facility's resolution was for the, Resident to continue to receive accommodation when possible, to have her showers in AM on scheduled days. Review of the CNA tasks revealed she was scheduled for showers on Monday and Wednesday on the 3 PM-11 PM shift. Documentation read, prefers early shower. Review of the resident's Documentation Survey Report for the periods March 2024, April 2024, and May 2024 revealed the resident received showers on 3/02/24 documented at 2:59 PM, 4/08/24, 4/14/24, 4/15/24 documented between 9:15 PM and 10:59 PM, 5/04/24 documented 5:42 PM, and 5/10/24 documented 9:15 PM. There was no documentation to indicate the resident received showers per the resident/responsible party's preference on her scheduled shower days on 3/04/24, 3/06/24, 3/11/24, 3/13/24, 3/18/24, 3/20/24, 3/25/24, 3/27/24, 4/01/24, 4/03/24, 4/17/24, 4/22/24, 4/24/24, 4/29/24, 5/01/24, 5/06/24, 5/13/24, 5/15/24, 5/20/24, and 5/27/24. The Assistant DON (ADON) provided paper documentation to indicate the resident received showers on 5/16/24, and 5/23/24. These dates were not reflected in the POC documentation. When asked why, the ADON stated she could not provide an answer. She stated CNAs should document in the POC and on a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105843 If continuation sheet Page 2 of 3 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 105843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harborview Health Center West Altamonte 1099 West Town Parkway Altamonte Springs, FL 32714 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 0677 shower sheet. Level of Harm - Minimal harm or potential for actual harm On 5/29/24 at 5:05 PM, the DON acknowledged showers were not provided as scheduled/ and as per the resident/responsible person's preference. Residents Affected - Few On 5/29/24 at 5:21 PM, the Unit Manager recalled she was made aware of a grievance filed by the resident's responsible party pertaining to shower preference. The UM stated resident #5's responsible party told staff the resident preferred to have her showers earlier in the shift, and not after dinner. However, documentation on the resident's Documentation Survey Report revealed showers were not provided per the resident's /responsible party's preference. On 5/29/24 at 5:26 PM, the resident was lying in bed on her back, she was alert, but confused and could not answer questions appropriately. The resident's care plan for ADL self-care performance deficit initiated on 11/30/23 with revision on 5/06/24 read, resident has a tendency to refuse showers if not offered when she wants. The facility's policy Activities of Daily Living Maintain Abilities dated 1/24 indicated that staff should ensure, care and services provided are person-centered, and honor and support each resident's preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105843 If continuation sheet Page 3 of 3