Inspection·June 9, 2022

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few B was located near the window. There was a wall mounted television located between the 2 beds that was shared by Resident #15 and her roommate. The privacy curtain was pulled from the head of the bed extending 12 inches from the foot of the 2 beds and partially blocked the view of the television from bed A. The television was not on and there was no radio in the room. On 6/6/22 at 12:21 p.m., in an interview Certified Nursing Assistant (CNA) Staff K, said Resident #15 did not speak much, only a word or two at times. CNA Staff K said the resident did not get out of bed because she doesn't want to, she will scream no, or she screams. On 6/8/22 at 10:54 a.m., in an interview Licensed Practical Nurse Staff B said, Resident #15 does not get out of bed frequently, but her family visits often. We talk with her during care for socialization, but she is rarely verbal. When I'm with her for care, I talk to her and once in a while, she responds. There is really not much more we can do for her. On 6/9/22 at 8:45 a.m., in an interview the Activity Director said Resident #15 does not like to get out of bed and will yell no and said Resident #15 rarely responded to her. The Activity Director said she would do video communication calls once a week with Resident #15 and her family, but the video communication system was not functioning for a couple of weeks. The Activity Director said Resident #15 liked to watch television and said sometimes I give her a snack. I do rounds every morning to pass out the menus and I make contact with the residents and greet them. The Activity Director confirmed she did not have documentation of the activity programs provided to Resident #15 and confirmed she did not have an individualized activity program to meet the needs for Resident #15. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105983 If continuation sheet Page 2 of 9 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 105983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harborview Sarasota 4783 Fruitville Road Sarasota, FL 34232 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, staff and resident interviews and record review the facility failed to ensure they stored smoking materials and obtained a signed agreement, from each resident, attesting they will abide by the facility smoking policies and procedures for 4 Residents (#18, #53, #39 and #47) of 4 residents reviewed who smoke at the facility. The findings included: On 6/06/22 at 10:30 a.m., during an interview with Resident #18, in her room, a cigarette pack was observed in her purse. Resident #18 said she smokes several times a day and the facility let her always keep her cigarettes and lighter with her. On 6/06/22 at 2:23 p.m., the Activity Director was observed monitoring Resident #18 and 3 other residents smoking in the designated smoking area. The Activity Director said, the residents who smoke would get their cigarettes and lighter from the nursing station and when the resident(s) were done smoking, they are required to return their cigarettes and lighter back to the nursing station. On 6/06/22 at 3:13 p.m., during an interview with Resident #18, she was observed to have had her cigarettes and lighter. Resident #18 said the facility staff did not ask her to return her cigarettes and lighter after she was done smoking and she didn't remember ever signing a smoking agreement stating she would abide by the facility smoking policies. On 6/07/22 at 3:30 p.m., Resident #47 said she was a smoker, and the facility staff allowed her to keep her cigarettes and lighter sometimes. She further said she didn't always have to return them to the nursing station after she was done smoking. Resident #47 said she didn't remember signing a smoking agreement stating she would abide by the facility's smoking policies when she was admitted to the facility. On 6/08/22 review of the facility's Smoking policy and procedure, revised on 2/07/20 stated the facility would retain and store matches, lighters, etc. for all residents and all residents who wished to smoke would sign an agreement they would abide by the facility's smoking policy and procedures. On 6/08/22 at 1:10 p.m., the Administrator confirmed the facility's Smoking policy and procedure revised on 2/07/20, which stated the facility would retain and store matches, lighters, etc. for all residents and all residents who wish to smoke would sign an agreement they would abide by the facility's smoking policy and procedures. He said when a resident was done smoking, they were required to return all smoking items as noted in their smoking policy to the nursing station for safe keeping. He further said it was the facility's policy to inform all residents who wish to smoke about their smoking policy and have them sign an agreement they would follow the facility's smoking policy and procedures. On 6/09/22 at 11:02 a.m., the Director of Nursing (DON) said when a resident was admitted to the facility and they wished to smoke, the admission office would have the resident sign the smoking agreement policy and the nurse would assess the resident to ensure they were a safe smoker. On 6/09/22 at 2:45 p.m., the DON said she was able to find documentation nursing had completed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105983 If continuation sheet Page 3 of 9 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 105983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harborview Sarasota 4783 Fruitville Road Sarasota, FL 34232 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some smoking evaluation as required for the residents who smoke at the facility, but they were unable to find documentation the residents who smoke had signed the facility's smoking agreement as required and noted in their Smoking policy and procedures acknowledging all smoking materials would be returned after each smoking session. On 6/8/22 at 12:00 p.m., in an interview Resident #53 said she keeps her cigarettes and lighter with her. Resident #53 cigarettes were observed in the basket of her walker. On 6/8/22 at 12:05 p.m., during an interview Resident #39 said she gives the nurses the cigarette carton her family brings in. Resident #39 confirmed she keeps her cigarettes and lighter with her in her room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105983 If continuation sheet Page 4 of 9 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 105983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harborview Sarasota 4783 Fruitville Road Sarasota, FL 34232 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on staff interviews and staff record reviews, the facility failed to ensure 4 (Staff E, H, I, and J) of 4 Certified Nursing Assistant (CNA)'s employee records reviewed had a performance review completed at least once every 12 months. The facility failed to ensure staff had in-service education based on the outcome of their performance reviews by not having annual competency evaluations. Residents Affected - Some The findings included: On 6/08/22, a review of Employee Guidebook revealed on page 25, section Performance Evaluation, it stated employee performance is reviewed on a continuous and ongoing basis, periodically and employees will receive a formal written appraisal from their supervisor. The performance evaluation provides an opportunity to discuss the employee's past performance as well as future goals. All performance evaluations become a permanent part of their employee record. The performance evaluation should be completed 90 days after hire and annually on the employee anniversary date of hire per facility policy. On 6/08/22, a review of Certified Nursing Assistant (CNA) Staff E's employee file revealed a hire date of 8/06/2008. There was no documentation an employee performance evaluation review was completed for Staff E in 2021. On 6/08/22, a review of CNA Staff H's employee file revealed a hire date of 11/08/2016. There was no documentation an employee performance evaluation review was completed for Staff H in 2021. On 6/08/22, a review of CNA Staff I's employee file revealed a hire date of 3/13/2019. There was no documentation an employee performance evaluation review was completed for Staff I in 2021. On 6/08/22, a review of CNA Staff J's employee file revealed a hire date of 10/02/2020. There was no documentation an employee performance evaluation review was completed for Staff J in 2021. On 6/08/22 at 10:25 a.m., the Human Resources Director (HRD) said the corporate office told her last year not to do the employee performance evaluations because they were not giving their employees a pay raise. The HRD reviewed the Employee Guidebook and confirmed the facility is required to conduct a written Performance Evaluation on all their employees 90 days after hire and yearly on each employee's hire date. The HRD reviewed Staff E, Staff H, Staff I, and Staff J employee records and confirmed there was no documentation they had completed their required yearly performance evaluation. The HRD said they did not do any employee performance evaluation last year as per the corporate office directive. On 6/09/22 at 11:00 a.m., the Director of Nursing (DON) said throughout the year the HRD would generate an employee performance evaluation annually prior to the employee's hire date to be completed by the director of each department. She said she gives the employee performance evaluation to the unit managers. The unit managers will give her the completed employee performance evaluation which she reviews to determine and ensure each employee is performing as required and conduct staff education as determined by their employee performance evaluation. The DON said HRD did not generate any employee performance evaluation in 2021 and she does not remember herself and/or the unit managers conducting any nursing staff performance evaluation in 2021 as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105983 If continuation sheet Page 5 of 9 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 105983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harborview Sarasota 4783 Fruitville Road Sarasota, FL 34232 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 0730 written in the Employee Guidebook. Level of Harm - Minimal harm or potential for actual harm On 6/09/22 at 2:03 p.m., the DON said she talked with the unit managers, and they were unable to find documentation they had completed the required annual employee performance evaluation for Staff E, Staff H, Staff I, and Staff J as required. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105983 If continuation sheet Page 6 of 9 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 105983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harborview Sarasota 4783 Fruitville Road Sarasota, FL 34232 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, facility policy review, and staff interviews, the facility failed to secure medication by leaving two loose pills on top of an unlocked, unattended medication cart and secure a computer screen from view on the 400-hallway for 1 of 2 medication carts observed. The findings included: Review of medication storage Section 5: Delivery, Receipt, Storage, and inventory of medications/product reads With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy. On 6/6/22 at 04:23 p.m., Medication cart # 400 hall was observed unlocked and unattended. A medication cup with two loose pills, typed written report sheet with resident' name, diagnosis and other personal information and nurse personal item, an opened water bottle were observed on the cart. (photographic evidence obtained). On 6/6/22 at 4:28 p.m., Licensed Practical Nurse (LPN), Staff A came back to her cart and said, Oops I am sorry. LPN Unit Supervisor, Staff B, was asked policy about unlocked cart, unsecured medication, and personal items on cart. Staff B said the cart must be locked if not in nurse line of vision and no personal items should be on the cart. On 6/2/22 at 4:41 p.m., during medication observation, LPN Staff A went into a room and left computer screen unlocked with resident's demographics and medical information clearly visible. The Director of Nursing (DON) was present at this time and confirmed findings. The DON locked the computer screen while nurse was in the room and said, Computer screen must be locked and reiterated that no personal items should be on the cart and the medication cart should be locked when unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105983 If continuation sheet Page 7 of 9 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 105983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harborview Sarasota 4783 Fruitville Road Sarasota, FL 34232 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on review of the facility records and staff interviews the facility failed to provide documentation of an updated, written agreement for the provision of hospice services to reflect current ownership for 3 (Resident #16, #46, and #60) of 3 residents reviewed for hospice services. The findings included: On 6/6/22, upon request of the facility agreement with the hospice provider, the Administrator provided a hospice agreement signed 4/1/14 between the hospice and the previous owner of the facility. On 6/8/22 at 12:02 p.m., in an interview the Director of Nursing (DON) confirmed the facility had changed ownership. The DON confirmed the current hospice agreement provided by the facility was not valid with the new corporation and the facility needed to obtain a new contract. On 6/8/22 at 3:30 p.m., the DON confirmed the facility currently had 3 residents receiving hospice services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105983 If continuation sheet Page 8 of 9 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 105983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harborview Sarasota 4783 Fruitville Road Sarasota, FL 34232 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on staff interview and record review, the facility failed to ensure 5 (Staff L, M, N, O and P) of 10 staff reviewed had the required education and training in abuse, neglect, and exploitation. Failure to provide staff with abuse, neglect, and exploitation training prior to working with facility residents could lead to staff not knowing how to prevent and report abuse, neglect, and exploitation. The findings included: On 6/8/22, review of Physical Therapy Assistant (PTA) Staff L's employee record revealed her start date was 1/7/20. Review of her employee training records revealed she did not receive education or training in abuse, neglect, and exploitation prior to working with the facility residents. On 6/8/22, review of Register Nurse (RN) Staff M's employee record revealed her start date was 2/22/22. Review of her employee training records revealed she did not receive education or training in abuse, neglect, and exploitation prior to working with the facility residents. On 6/8/22, review of Certified Nursing Assistant (CNA) Staff N's employee record revealed her start date was 12/7/21. Review of her employee training records revealed she did not receive education or training in abuse, neglect, and exploitation prior to working with the facility residents. On 6/8/22, review of Certified Nursing Assistant (CNA) Staff O's employee record revealed her start date was 1/24/22. Review of her employee training records revealed she did not receive education or training in abuse, neglect, and exploitation prior to working with the facility residents. On 6/8/22, review of Occupational Therapist (OT) Staff P's employee record revealed her start date was 11/16/21. Review of her employee training records revealed she did not receive education or training in abuse, neglect, and exploitation prior to working with the facility residents. On 6/8/22 at 1:01 p.m., in an interview with the Human Resource Director (HRD), she confirmed Staff L, M, N, O and P were current employees and had resident contact. She confirmed Staff L's, M's, N's, O's and P's hire dates and confirmed as of 6/8/22 they had not had the onboarding required training in abuse and neglect and exploitation as required for new hires. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105983 If continuation sheet Page 9 of 9