Inspection·April 17, 2024

F 0559 write it down. Level of Harm - Minimal harm or potential for actual harm An interview conducted on 04/17/2024 at 1:42 p.m. with Staff A, LPN, UM. She stated, there was a conversation, one day, that she was aware of, 2-3 months ago. The conversation was between Resident #2 and Resident #1. She said, I was in the room with them. I explained to them, I worried about [Resident #1] getting up to help [Resident #2]. I told them that I am scared of the medication errors, staff not paying attention to last name and first name. I did not document. I have not talked to them separately. Residents Affected - Few A review of Resident #2's clinical chart documented an admission of 07/28/2023. On 04/18/2024 at approximately 12:00 p.m., Resident #2 returned a phone call. She stated she had moved to the facility to be with Resident #1. She stated she wanted to have Resident #1 as her roommate, she had been requesting the arrangement since both had been at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106041 If continuation sheet Page 2 of 4 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 04/17/2024 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a prompt effort to resolve a grievance regarding a roommate for one (Resident #1) of five sampled residents. Findings included: A review of Resident #1's clinical chart, the face sheet, documented her being admitted to the facility on [DATE]. An interview was conducted on 04/17/2024 at 10:16 a.m. with Resident #1. She was observed sitting in her wheelchair at bedside, alert, able to answer questions, and she agreed to an interview. Resident #1 confirmed her family member, Resident #2, was living at the facility. She stated she would like to room with Resident #2. Resident #1 said, They will not put us together because they will mix up the medications. Resident #1 confirmed Resident #2 lived on the same floor of the nursing home in a different hall. When asked about her current roommate, Resident #1 rolled her eyes. My roommate blinks and she gets what she wants. The television is fine right now, but she will turn it up for religious shows. She will have them turn up the temperature to 80 degrees. Resident #1 voiced she did not care for her roommate. A review of Resident #1's Psychology encounter notes, dated 02/05/2024, documented, chief complaint: depression, anxiety history of present illness: this provider is present for follow-up psychotherapy to address symptoms for depression and anxiety. Patient endorses feeling down, unhappy, frustrated, lonely. Patient reports feeling anxious and worrisome. Patient reports that feeling and being disconnected from close family exacerbates her symptoms of depression and anxiety. Patient endorses feeling the symptoms nearly every day of the week in the past 2 weeks. Summary of session: Patient endorsed experiencing feelings of anxiety and depression on the date of service. Quality of life concerns raised include feeling uncomfortable due to the level of heat in her room, stating it exacerbates her cough. Client also reported feeling uncomfortable in her current living situation due to discord with her roommate who she described as being demanding, and irritable. Patient expresses desire to move in with her daughter, who also lives in the facility, if possible. A review of the facility Grievance log from 01/01/2024 through the date of survey reflected no concerns documented regarding Resident #1's discord with her roommate. An interview was conducted on 04/17/2024 at 1:42 p.m. with Staff A, Licensed Practical Nurse (LPN) Unit Manager (UM). When asked how Resident #1 got along with her current roommate, Staff A, LPN stated, It is an iffy situation. They do not hardly talk to each other. [Resident #1] has alleged that her stuff has been moved closer to the wall by her roommate. [Resident #1] has complained about the volume of her roommate's television. For the stuff being moved over, I myself, have moved stuff back. I have told [the roommate] to keep her stuff on her side. It has probably been a month ago. For the television, the [roommate] likes to keep her tv on all the time. I have explained to her that it should go off at 10:00 p.m. so, [Resident #1] can sleep. [The roommate] will turn it down, but she will not turn it off. I have not heard [Resident #1] say anything about the tv at night. When Staff A was asked if she had reviewed the concerns documented in the 02/05/2024 Psychology encounter notes, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106041 If continuation sheet Page 3 of 4 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 04/17/2024 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 0585 she stated she had not looked at the psych notes, I will from now on. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Resident and Family Grievances policy and procedures, last revised 03/02/2023, documented the policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Residents Affected - Few The procedure included: a. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form b. Forward the grievance form to the Grievance Officer as soon as practicable. c. The Grievance Officer will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form . d. The Grievance Officer, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. .The facility will make prompt efforts to resolve grievances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106041 If continuation sheet Page 4 of 4