Inspection·December 11, 2023

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some follow up to the LPN's admission evaluation of the resident. She confirmed there had been no assessment of the new open area on the resident's sacrum until the WCP's assessment on 10/16/2023 and there was no treatment order for the sacrum until 10/16/2023. An interview was conducted with the Director of Nurses (DON) on 12/11/2023 at 3:45 p.m The DON reported the Wound Doctor would have seen Resident #2 due to his history of multiple areas of skin breakdown to his feet and toes. She confirmed the Wound Doctor had been following Resident #2 prior to his transfer to the hospital on [DATE] and return on 10/09/2023. The DON reported the Wound Doctor conducts a full body scan of residents when they return from a hospital admission when she evaluates on going skin concerns. The DON confirmed it was the Wound Doctor who assessed the open area to the resident's sacrum and ordered the treatment. The DON confirmed it was not apparent a Registered Nurse provided follow up to the LPN's admission evaluation of the resident. She confirmed there had been no assessment of the new open area on the resident's sacrum until the Wound Doctor's assessment on 10/16/2023 and there was no treatment order for the sacrum until 10/16/2023. Based on interview and record review, the facility failed to provide care consistent with professional standards of practice related to assessments and promoting the healing of pressure ulcers for two (#1, #2) of three sampled residents. Findings included: 1. A review of clinical records showed Resident #1 was admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Review of the admission face sheet showed diagnoses which included but was not limited to displaced transverse fracture of shift of right tibia, displaced fracture of lateral malleolus of right fibula, orthopedic aftercare, end-stage renal dialysis, muscle weakness, protein-calorie malnutrition, and a history of falling. Review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact); Section GG, Functional Abilities and Goals showed dependent in toileting and bathing; Section M, skin conditions showed Resident #1 did not have one or more unhealed pressure ulcers / injuries which included unstageable, Deep tissue injury; showed she had a surgical wound. Review of the admission / readmission Nursing Evaluation dated 10/25/2023 revealed under C. Skin Integrity: dialysis port to right upper chest, AV fistula in right upper arm, fracture to right foot (had surgier), redness to left leg and left heel and redness/ discoloration to right arm from IV. Very moist skin. Completely immobile. Review of physician order summary and the October and November 2023 Treatment Administration Records (TAR) showed the following: -Bilateral buttock, cleanse with normal saline, pat dry, apply calcium alginate and foam dressing every night for Moisture-associated skin damage (MASD) as of 10/31/23 to 11/04/23 -Bilateral buttock, cleanse with normal saline, pat dry, apply calcium alginate and foam dressing daily for MASD from 11/04/23 to discharge. Bilateral buttock wound care was not documented as performed on 11/03/2023. -Left heel: cleanse with normal saline, pat dry and apply foam dressing every night Monday, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106041 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 106041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbourwood Post-Acute and Rehabilitation Center 549 Sky Harbor Dr Clearwater, FL 33759 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 0686 Level of Harm - Minimal harm or potential for actual harm Wednesday, Friday for Deep Tissue Injury (DTI) as of 11/01/23 to 11/04/2023. Left heel wound care was not documented as performed on 11/03/2023. -Left heel: cleanse with normal saline, pat dry and apply foam dressing every Monday, Wednesday, Friday for DTI as of 11/06/23 to discharge. Residents Affected - Some Review of the attending physician's new admission note dated 10/26/2023 and 10/30/20 23 showed resident recently hospitalized for RLE [right lower extremity] break secondary to MVA [motor vehicle accident]. She has a cast on her right lower extremity. Skin: no suspicious lesions, warm and dry. Review of the wound care physician initial (new admission) progress note dated 10/30/2023 showed Resident #1 with displaced transverse fracture of the shaft of the right tibia. The resident was presenting with a wound of the left heel, the left buttock, and the right buttock. The resident had a right leg orthopedic cast, making it unable to remove for exam. The left leg with removable ortho boot- able to remove for exam. The DTI of the left heel was 3.5 x 3 x 0.1 centimeters (cms), and it was complicated by the ortho boot in place. The wound was expected to have a delay in healing. The left buttock, MASD, was 1.7 x 1.7 x 0.1, had 100% granulation tissue and was expected to heal. The right buttock, MASD, was 1 x 0.7 x 0.1, had 50% epithelial and 50% granulation tissue and was expected to heal. Review of the wound care physician follow up visit on 11/06/2023 showed the resident resting in bed. Her right leg cast was removed. She currently had ortho boots on bilateral legs. She evaluated the left heel wound, right and left MSDA wounds. The DTI of the left heel was 4.5 x 4.3 x 0.2 with 90% necrotic tissue and 10% granulation tissue in place. The wound was expected to have a delay in healing. The left heel ulcer was debrided during the visit. The left buttock, MASD, was 0.3 x 0.3 x 0.1, had 100% granulation tissue and was improving and expected to heal. The right buttock, MASD, was 2.5 x 2.5 x 0, had 100% epithelial tissue and had no change and was expected to heal. Review of the state form, AHCA-5000-3008, dated 10/16/2023 showed section T, skin care was blank. Review of the Weekly Pressure Wound Note dated 10/31/2023 and 11/06/2023 showed Resident #1 was admitted with the left heel pressure ulcer / DTI. Review of the care plans showed Resident #1 had DTI pressure ulcer to left heel or potential for pressure ulcer development related to immobility as of 11/01/2023. The goal was for the pressure ulcer to show signs of healing and remain free from infection. Interventions included but not limited to administering treatments as ordered and monitor for effectiveness as of 11/01/23. Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document stats of wound perimeter, wound bed and healing progress report improvement and declines to the MD as of 11/01/2023. Follow policies / procedures for het prevention / treatment of skin breakdown as of 11/01/2023. Treatment to left heel three times a week as of 11/01/2023. Care plan related to having potential/actual impairment to skin integrity related to right lower extremity surgical wound, MASD to bilateral buttocks. Goals included for skin injury to right lower extremity will be healed. Interventions included but not limited to following facility protocols for treatment of injury as of 11/01/2023. Weekly treatment documentation included measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations as of 11/01/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106041 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 106041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbourwood Post-Acute and Rehabilitation Center 549 Sky Harbor Dr Clearwater, FL 33759 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 0686 Review of the nursing progress notes revealed the following: Level of Harm - Minimal harm or potential for actual harm On 11/03/2023, Skin Observation progress note showed resident had existing skin impairment. Resident being followed by wound care. Residents Affected - Some On 11/06/2023, an Interdisciplinary team meeting occurred, the resident was currently on therapy services. She was non-weight bearing to the right lower extremity and partial weight bearing to the left lower extremity. An interview was conducted with the Wound Care Physician (WCP), the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 12/11/20223 at 1:25 p.m. The WCP stated she saw Resident #1 twice. The resident had a cast on her right leg and a removable boot on her left leg. The WCP stated she does not see post-surgical wounds for at least 90 days post operative. For the first 90 days the resident belongs to the surgeon. The WCP stated she does not change the surgeon's orders or give any orders related to the surgical site. The surgeon will evaluate the surgical site and give any new or changed orders. The DON stated Resident #1 was admitted on [DATE] and verified there were no wound care orders for the wounds until 11/01/2023. The DON verified after reviewing the medical record there was no documentation of an assessment or description of the left heel on admission except the left heel had some redness. The DON verified there was no documentation related to the buttocks on the admission even though the first wound care note dated 10/30/2023 referred to the buttocks MASD being present on admission. The DON stated the admission was performed by the Licensed Practical Nurse (LPN) and a Registered Nurse (RN) note was not found showing a skin assessment was performed including staging of the left heel pressure area. The DON stated the left heel and buttocks MASD should both have been considered wounds on admission. The DON stated there was not an assessment nor orders put into place for the heel or buttocks from 10/25/23 to 10/31/23. The DON verified she was unable to find any reference to the boot on the left lower extremity on the admission. There was no documentation regarding the boot or cast on her lower extremities. Continuing the interview with the DON at 3:30 p.m. she stated the nurse performing the admission should be assessing the wound / pressure ulcer, including describing it at the time and obtaining wound care orders. If an LPN performs the admission, then an RN should reassess for staging of the wound. The DON stated, We have an RN in the building every day. She stated when a wound needed consultation, a referral was sent to the WCP, including the face sheet and an order was put into place for the wound consultation. She stated they discuss all admissions in the morning meetings and a wound admission would generate a wound care consult order. Review of the facility's policy, Wound Treatment Management, implemented on 08/25/2022 showed that to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106041 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 106041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbourwood Post-Acute and Rehabilitation Center 549 Sky Harbor Dr Clearwater, FL 33759 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 0686 5. Treatment decisions will be based on: Level of Harm - Minimal harm or potential for actual harm a. Etiology of the wound: Residents Affected - Some i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical. iii. Incidental. iv. Atypical. B. characteristics of the wound: i. pressure injury stage. ii. Size-including shape, depth, and presence of tunneling and / or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. presence of infection or need to address bacterial bioburden. vi. Condition of the tissue in the wound bed. vii. Condition of peri-wound skin. C. location of the wound. D. goals and preferences of the resident / representative. 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing evaluation of the wound. Considerations for needed modifications included: a. Lack of progression towards healing. b. Changes in the characteristics of the wound. Review of the facility's policy, Skin Evaluations, dated 08/22/2022 showed it is our policy to perform a full body skin evaluation as part of our systematic approach to pressure injury prevention and management. Policy and Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin evaluation will be conducted by a licensed or registered nurse upon admission / re-admission, and weekly thereafter. The Evaluation may also be performed after a change of condition or after any newly identified pressure injury. 3. Consider the general status of the resident's skin. A. color. B. temperature. C. moisture status. D. sensory perception. E. skin texture / turgor. F. perfusion. 7. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106041 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 106041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbourwood Post-Acute and Rehabilitation Center 549 Sky Harbor Dr Clearwater, FL 33759 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Documentation of skin assessment: a. includes date and time of the assessment, your name, and position title. B. document observations. C. document type of wound. D. describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). E. document if resident refused assessment and why. F. document other information as indicated or appropriate. Review of the facility's policy, Comprehensive Care Plans, dated 09/7/2022 showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. 3. the comprehensive care plan will describe, at a minimum, the following: a. the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. F. resident's specific interventions that reflect the resident's needs and preferences . Event ID: Facility ID: 106041 If continuation sheet Page 6 of 6