Health inspection·October 28, 2021

F 0641 (ARD) of 10/14/21, showed under Section M Skin Conditions that a total of 3 pressure ulcers were coded and 0 venous/arterial ulcer. Description as follows: Level of Harm - Minimal harm or potential for actual harm Item 300A Number of Stage 1 pressure injuries was incorrectly coded as 1 (Yes). Residents Affected - Few M300 C1 Number of Stage 3 pressure ulcers was incorrectly coded as 1 (yes). M300 C2 Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry was incorrectly coded as 1 (Yes) G1. Number of unstageable pressure injuries presenting as deep tissue injury was incorrectly coded as 1 (Yes) G2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry was incorrectly coded as 1 (Yes) Enter the total number of venous and arterial ulcers present was incorrectly coded as 0 (none). On 10/28/21 at 10:08 a.m., in an interview, MDS Staff D confirmed the ARD date as 10/14/21 and reviewed her coding under section M of the MDS assessment. MDS Staff D said she coded the MDS based on documentation in the medical record. She acknowledged there were 5 skin issues on admission and only coded 3 skin issues not 5 and did not code arterial ulcer as well. MDS Staff D confirmed Resident #261's admission assessment was not accurate. MDS Staff D said she may have used the wound assessment dated [DATE] (a day after the ARD) as documentation for the admission assessment. 2. Resident #2's clinical closed record revealed a discharge MDS dated [DATE]. The MDS was inaccurately coded to reflect the resident's payor source was Medicare when the resident was admitted to the facility on [DATE] and discharged on 6/20/21 under a managed care payor. MDS staff transmitted a 5-day MDS to Centers for Medicare & Medicaid Services (CMS) for payment causing the discharge MDS to flag/trigger resulting in episode of care at facility remaining opened. In an interview on 10/27/21 at 11:25 a.m., MDS Staff D confirmed the MDS had been coded incorrectly for Resident #2's payor source and the submission of a 5 day MDS to CMS for payment had been an error as the resident's stay was being covered by Managed Care not Medicare. 3. A discharge MDS 3.0 assessment was completed for Resident #110 on 8/3/21. The MDS was coded to indicate the resident was discharged to an acute hospital. A review of Resident #110 clinical record indicated he was discharged home on 8/3/21 with medications and home health services. On 10/26/21 at 3:00 p.m., interview with Director of Nursing (DON) confirmed the discharge MDS was incorrectly coded for Resident #110. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105982 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 105982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Harbor Healthcare 18480 Cochran Blvd Port Charlotte, FL 33948 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted 8. The baseline care plan for Resident #160 was completed 9/29/21 (the date of admission) and signed by the nurse and verbal signature of resident's representative. There was no documentation the resident or resident's representative was given a copy. On 10/27/21 at approximately 3:46 p.m., in an interview, the facility Director of Nursing confirmed there was no documented evidence Resident #54, #100, #112, #160, #261, #262, #266 and #267, or resident's representative if applicable, were provided with a copy of a written summary of the baseline care plan that included initial goals and a summary of current medications and dietary instructions. 4. Resident #262's clinical record revealed an admission date of 10/14/21 and a baseline care plan completed by a licensed nurse on 10/15/21. In an interview on 10/27/21 at 12:58 p.m., Resident #262 said he did not recall getting a list of his medications and summary of his orders. There was no evidence a copy of the baseline care plan was provided to the resident and/or his representative. 5. Resident #266's clinical record revealed an admission date of 10/20/21 and a baseline care plan was signed as completed by Licensed Practical Nurse (LPN) Staff B. There was no evidence the baseline care plan was reviewed and/or a copy given to the resident's representative. On 10/27/21 at 1:00 p.m., Resident #266 was unable to answer if he had received a copy of his baseline care plan. There was no evidence a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions was actually provided as required. 6. Resident #267's clinical record revealed an admission date of 10/21/21 and a baseline care plan was signed as completed by the licensed nurse. There was no evidence the baseline care plan was reviewed and/or a copy given to the resident's representative. On 10/27/21 at 1:05 p.m., Resident #267 said he did not recall receiving a written summary of his baseline care plan and would not be able to read anything without his glasses, as he left them at his daughter's house. 7. Resident #261's clinical record revealed an admission date of 10/10/21 and a baseline care plan signed as completed by LPN Staff C. The baseline care plan was not reviewed with the resident's representative until 10/26/21. There was no evidence a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions was actually provided as required. On 10/28/21 at 9:17 a.m., Resident #261 said she had been in quarantine for a few days when she arrived and did not get any summary of her medications or a baseline care plan. In an interview on 10/28/21 at 9:41 a.m., LPN Staff B said he did go in and review the baseline care plan with Resident #261 but did not give her a copy. Based on record review, staff and resident interview, the facility failed to provide documented evidence resident and/or representative, if applicable, were provided with a copy of a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions for 8 (Resident #54, #100, #112, #160, #261, #262, #266, and #267) of 8 residents reviewed for baseline care plans. The findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105982 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 105982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Harbor Healthcare 18480 Cochran Blvd Port Charlotte, FL 33948 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/27/21, review of facility policy Plan of Care, revised 9/25/17, revealed Develop and implement an individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, Preadmission Screening and Resident Review (PASARR) recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. 1. On 10/27/21 at 3:00 p.m., record review of Resident #112 revealed there was no documented evidence a copy of a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions was provided to the resident or resident's representative as required. 2. On 10/27/21 at 3:10 p.m., record review of Resident #54 revealed there was no documented evidence a copy of a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions was provided to the resident or resident's representative as required. 3. On 10/27/21 at 3:25 p.m., record review of Resident #100 revealed there was no documented evidence a copy of a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions was provided to the resident or resident's representative as required. On 10/27/21 at approximately 3:46 p.m., in an interview, the facility Director of Nursing confirmed there was no documented evidence Resident #54, #112, and #100, or resident's representative if applicable, were provided with a copy of a written summary of the baseline care plan that included initial goals and a summary of current medications and dietary instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105982 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 105982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Harbor Healthcare 18480 Cochran Blvd Port Charlotte, FL 33948 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete and accurate records in the area of wound assessments for 1 (Resident #261) of 2 sampled residents reviewed for pressure ulcers. Accurate and complete records are necessary to document the course of a resident's care provided by the facility. The findings included: The facility's Clinical/Medical Records policy- MR195, revised on 8/25/17; stated Clinical records are maintained in accordance with professional practice standards to provide complete and accurate information on each resident for continuity of care. The purpose of the clinical record is to document the course of the resident's plan of care and to provide a medium of communication among health care professionals involved in this care. On 10/27/21, review of Resident #261's clinical record revealed a facility Admission/readmission Data Collection form which indicated the resident was admitted on [DATE] at 3:15 p.m. Under the section M. skin, Licensed Practical Nurse (LPN) Staff C noted the resident had pressure wounds to bilateral buttocks and sacrum, (triangular bone just below the lower vertebrae) and mushy discoloration to both heels. On 10/10/21 at 12:19 p.m., 12:21 p.m., 12:24 p.m., 12:27 p.m., and 12:28 p.m., LPN Staff B completed Pressure Ulcer Wound Round forms for Resident #261. The wound forms indicated the resident had been admitted with the following pressure ulcers: a deep tissue injury (DTI) on the left heel measuring 3.0 centimeters (cm) by 3.0 cm in size; a DTI on the right heel measuring 3.0 cm by 4.0 cm in size; a stage II (partial thickness loss of dermis) pressure ulcer to the sacrum measuring 4.0 cm by 4.0 cm in size with a depth of 0.1 cm; a stage 1 (superficial reddening of the skin) pressure ulcer measuring 2.0 cm by 2.0 cm in size to the left elbow; and a stage 1 pressure ulcer to the right elbow measuring 3.0 cm by 2.0 cm in size. A Non-Pressure Skin Condition form was completed by LPN Staff B on 10/10/21 at 12:23 p.m., indicating the resident had an arterial wound (ulcer caused by arterial insufficiency) on the left lower leg measuring 2.3 cm by 0.8 cm in size. The wound assessments were dated as being completed 2 hours and 45 minutes before the resident arrived at the facility. On 10/15/21 the Advanced Practice wound care nurse noted Resident #261 had a stage III (full thickness skin loss) pressure injury on the left buttock measuring 0.7 cm by 1.0 cm in size with a depth of 0.2 cm.; a stage III pressure injury to the sacrococcygeal area measuring 0.5 cm by 0.5 cm with a depth of 0.1 cm.; a stage I to the right buttocks measuring 1.0 cm by 1.0 cm in size; and a DTPI (deep tissue pressure injury) measuring 5.0 cm by 6.0 cm in size on the right heel. There was no documentation by the clinician of the presence of an arterial ulcer on the resident's left lower leg or status of the left heel DTI and stage I pressure injury to both elbows. On 10/27/21 at 9:11 a.m., in an interview, LPN Staff B said the admitting nurse does the initial skin assessment and he does a second skin assessment to verify the findings. LPN Staff B said the first assessment for Resident #261 was on 10/10/21 at 3:15 p.m., at the time of her admission and identified pressure wounds to both buttocks and sacrum. LPN Staff B said he would not have been on duty the evening of Resident #261's admission and said the wound assessments he completed were dated wrong (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105982 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 105982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Harbor Healthcare 18480 Cochran Blvd Port Charlotte, FL 33948 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and would have been the next day (10/11/21). LPN Staff B said he measured the sacrum as one large area instead of 3 separate areas. He identified the area on the resident's lower leg as an arterial ulcer because of the location. He confirmed there was no documentation by a physician in the resident's record of an arterial ulcer being present or any further documentation of pressure injuries to the left heel and elbows or when they were resolved. At 9:15 a.m., LPN Staff B confirmed he was not able to assess or stage a wound as this needed to be done by a Registered Nurse (RN). He said the Director of Nursing was present for the wound rounds and told him the stage. On 10/27/21 at 10:02 a.m., in an interview, the Director of Nursing said she made wound rounds with LPN Staff B on 10/11/21. She did not know where the documentation of the arterial ulcer came from as she did not identify this and would have to be done by a clinician. She confirmed the record was inaccurate as to when the assessments were completed and did not document she was the one doing the assessments as the RN. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105982 If continuation sheet Page 6 of 6