Inspection·February 6, 2024

F 0694 Level of Harm - Minimal harm or potential for actual harm IV antibiotics due to being diagnosed with a UTI and the resident should have orders in place for dressing changes of the IV site, flushing of the IV line to ensure patency, and assessment of the site every shift. Staff D, LPN reviewed Resident #7's physician's orders and addressed Resident #7 did not have orders related to the assessment or changing of dressings for Resident #7's IV site. Staff D, LPN stated nursing staff should be documenting assessment of the IV site every shift. Residents Affected - Few A telephone interview was conducted on 2/6/2024 at 11:30 AM with the facility's Director of Nursing (DON). The DON stated unit managers and the Assistant Director of Nursing (ADON) should be ensuring IV related orders are in place and residents with IV's should have orders for monitoring the site for signs and symptoms of infection or infiltration every shift. The DON also stated residents with IV's should have orders in place to change the IV dressing weekly and to flush the IV line to ensure the line is patent. A review of the facility policy titled Intravenous Therapy, with an implementation date of 12/2/2023, revealed under the section titled Policy the facility will adhere to accepted standards of practice regarding infusion practices. The policy also revealed under the section titled Compliance Guidelines IV sites are changed every 72 hours unless otherwise ordered by the physician, if the site becomes infiltrated, or if the resident exhibits signs and symptoms of phlebitis. In the event the IV is left in place for longer than 72 hours, IV site care will be done every 24 hours. The policy also revealed a doctor's order is obtained before starting IV therapy and IV documentation is recorded in the nurse's notes and/or Medication Administration Record (MAR). 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 02/06/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement an effective infection control and prevention program to prevent the spread of infection by 1.) failing to ensure a sufficient supply of Personal Protective Equipment (PPE) was made available outside of resident rooms under transmission based precaution for two (#8 and #9) of six residents in the facility under transmission based precautions; 2.) failing to ensure staff donned appropriate PPE before entering the rooms of residents on transmission based precautions for two (#8 and #9) of six residents in the facility under transmission based precautions; 3.) failing to ensure residents under transmission based precautions had physician's orders in place for two (#8 and #9) of six residents in the facility under transmission based precautions; and 4.) failing to ensure a resident with a transmissible disease was placed on transmission based precautions for one (#6) of seven residents in the facility with transmissible diseases. Residents Affected - Some Findings included: A review of Resident #6's medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage, bipolar disorder, and dementia. A review of Resident #6's Lab Results Report revealed a urine culture dated 1/30/2024. The urine culture revealed Resident #6's urine tested positive for presence of Extended Spectrum Beta-Lactamase (ESBL). A review of Resident #6's physician's orders revealed an order, dated 2/1/2024 for Ertapenem Sodium solution 1 gram intravenously (IV) every morning for infection, for a duration of seven days. Resident #6's physician's orders did not reveal orders related to transmission based precautions. A review of Resident #8's medical record revealed Resident #8 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses of peripheral vascular disease, type 2 diabetes mellitus, and anxiety disorder. A review of Resident #8's emergency department documents dated 1/27/2024 revealed Resident #8 presented to the emergency room from the facility with cough, shortness of breath, and increased weakness. Resident #8 tested positive for influenza A and was returned to the facility on 1/27/2024. A review of Resident #8's physician's orders did not reveal orders related to transmission based precautions. A review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses of congestive heart failure, cerebral palsy, and hypertension. A diagnosis of hemophilus influenza was added on 1/28/2024. A review of Resident #9's progress notes dated 1/28/2024 at 8:39 PM revealed Resident #9 was readmitted from the hospital with diagnoses of acute respiratory failure and hypoxia. A review of Resident #9's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form with an admission date of 1/26/2024 and a discharge date of 1/28/2024, revealed under Section F: Infection Control Issues, Resident #9 was being returned to the facility under (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 02/06/2024 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 0880 contact and droplet isolation precautions. Level of Harm - Minimal harm or potential for actual harm A review of Resident #9's physician's orders did not reveal orders related to transmission based precautions. Residents Affected - Some A tour of the facility was conducted on 2/5/2024 at 12:10 PM. A observation of Resident #6's room revealed the resident was not under transmission based precautions. No PPE or signage was observed outside of Resident #6's room. An observation of Resident #8's room revealed signage indicating the resident was on contact/droplet isolation precautions. Instructions on the sign revealed staff perform hand hygiene, don an isolation gown, don a mask and eye cover, and don gloves when entering the resident room. An caddy containing PPE was observed outside Resident #8's room. The caddy contained isolation gowns, a box of large sized gloves, and a box of extra large sized gloves. Eye protection and masks were not observed on the caddy outside of Resident #8's room. Staff A, Certified Nursing Assistant (CNA) was observed entering Resident #8's room. Staff A, CNA was not observed donning any PPE before entering Resident #8's room. An interview was conducted with Staff A, CNA upon exiting Resident #8's room. Staff A, CNA stated Resident #8 was on transmission based precautions due to testing positive for influenza A. Staff A, CNA also stated she did not don any PPE before entering Resident #8's room because she was told by Staff C, Licensed Practical Nurse (LPN) and Unit Manager (UM) the PPE was not required unless they were giving care to the resident. Staff A, CNA stated she was only going into the room to check on the resident and did not perform care on the resident. During the interview, Staff B, Personal Care Assistant (PCA) was observed entering the room of Resident #9. An observation of Resident #9's room revealed signage indicating the resident was on contact/droplet isolation precautions. Instructions on the sign revealed staff perform hand hygiene, don an isolation gown, don a mask and eye cover, and don gloves when entering the resident room. An caddy containing PPE was observed outside Resident #9's room. The caddy contained isolation gowns and a box of surgical masks. No gloves or eye protection were observed in the caddy outside of Resident #9's room. Staff B, PCA was observed walking out of Resident #9's room and looking at the signage outside of the room indicating Resident #9 was on contact/droplet precautions. Staff B, PCA was observed walking down the hallway, then re-entered Resident #9's room without donning any PPE before entering. An interview was conducted following the observation with Staff B, PCA. Staff B, PCA stated they are educated to don appropriate PPE before entering the room of a resident on transmission based precautions and the PPE should be donned any time they enter the room. Staff B, PCA also stated he did not don PPE before entering Resident #9's room because he did not see the signage outside of Resident #9's room. During the interview with Staff B, PCA, Staff C, LPN UM was observed entering Resident #9's room. Staff C, LPN UM did not don PPE before entering Resident #9's room. An observation was conducted on 2/5/2024 at 1:15 PM outside of Resident #9's room. Staff C, LPN UM was observed donning an isolation gown and a surgical mask before entering Resident #9's room. Staff C, LPN UM was wearing eye glasses at the time of the observation but was not observed donning eye protection before entering Resident #9's room. An interview was conducted with Staff C, LPN UM following the observation. Staff C, LPN UM stated Resident #9 was on contact/droplet isolation precautions due to a diagnosis of influenza A and staff must don a mask, gloves, and an isolation gown before entering the room. Staff C, LPN UM also stated she did not don eye protection because she was told her eye glasses were sufficient as eye protection. Staff C, LPN UM stated she sanitized her eye glasses with hand sanitizer after leaving the room of a resident under transmission based precautions, but that was not part of her infection control training. Staff C, LPN UM stated any resident under transmission based precautions should have a physician's order in place for the precautions. Staff C, LPN also stated if staff entered the room and were not providing direct care to the resident, they were not required to don PPE when entering the room of a resident on (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 02/06/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some transmission based precautions. Staff C, LPN reviewed Resident #8 and Resident #9's physician's orders and addressed the residents did not have orders in place for transmission based precautions. Staff C, LPN also reviewed Resident #6's urine culture dated 1/30/2024 and addressed Resident #6 should be placed on contact isolation precautions due to ESBL in the urine. An interview was conducted on 2/5/2024 at 3:19 PM with the facility's Infection Control Preventionist (ICP). The ICP stated any resident diagnosed with influenza would be placed on droplet precautions. The ICP also stated to enter a room of a resident on droplet isolation precautions, staff would have to don a mask and an isolation gown before entering the room. The ICP stated she was not sure if eye protection was required to enter the room of a resident on droplet precautions and stated I'll have to check. The ICP also stated if staff were unsure of what they needed to don before entering the room they could speak to herself or the facility's Director of Nursing (DON). The ICP stated either the floor nurses, supervisors, or the central supply staff should be ensuring the isolation carts outside of the resident rooms have a sufficient stock of PPE and carts should be stocked before staff enter the resident's room. The ICP stated facility staff were only required to don PPE if they were providing direct care to a resident and stated droplets could not be transmitted if the staff member is only going into the room to collect a meal tray. The ICP also stated all of the guidance she provides related to infection prevention and control is based on the facility policy. A telephone interview was conducted on 2/6/2024 at 11:28 AM with the DON. The DON stated if a resident had a urine culture test positive for ESBL, the resident would be placed on contact isolation precautions. The DON also stated if a resident tested positive for influenza, the resident would be placed on droplet isolation precautions. The DON stated she would expect facility staff to don a face shield, mask, isolation gown, and gloves any time they enter the room because they are exposing themselves before they go into the room. The DON also stated regular eye glasses are not considered eye protection and a face shield or goggles should be worn over the eye glasses. The DON stated PPE is kept in the central supply room but any staff member can get PPE for the carts when they need it. The DON also stated the facility infection control practices are based on Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) guidelines. A review of the facility policy titled Infection Prevention and Control Program, last revised on 7/13/2023, revealed under the section titled Policy the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines all staff are responsible for following all policies and procedures related to the program. The policy revealed under the section titled Isolation Protocol a resident with an infection or communicable disease shall be placed on transmission based precautions. A review of the facility policy titled Transmission-Based (Isolation) Precautions, with no effective date, revealed under the section titled Policy it is the facility policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogen's mode of transmission. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines facility staff will apply Transmission-Based Precautions in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. The policy revealed the following under the section titled Initiation of Transmission-Based Precautions: (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 02/06/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - An order for transmission-based precautions/isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. - The order for transmission-based precautions/isolation will specify the type of precautions and reason for the transmission-based precaution. The duration will depend upon the infectious agent or organism involved. The policy revealed the following under the section titled Contact Precautions: - Contact Precautions is intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. - Healthcare personnel caring for a residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. - Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. The policy revealed the following under the section titled Droplet Precautions: - Droplet precautions is intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Photographic evidence was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106041 If continuation sheet Page 6 of 6