Health inspection·September 18, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from abuse for one resident (#3) out of 3 sampled residents. Findings included: An interview was conducted on 09/17/2025 at 10:30 a.m with Staff A,PCA (Personal Care Attendant). Staff A stated they witnessed Resident #3 being verbally abused by Staff B, CNA, whom they were training with that day. Staff A stated Resident #3, had finished receiving incontinence care from Staff B and was on the edge of the bed when Staff B voiced, Don't put your [EXPLICIT] hands on me or I'll let you fall on the [EXPLICIT] floor. Staff A stated they then saw the CNA aggressively lift up and set resident into her wheelchair and the resident was shaking after that. While assisting the resident with her shoe that had fallen off while being transferred into the chair, Staff A stated the resident voiced that the other CNA, Staff B, thought she was crazy. Staff A reported her observation to the Director of Nursing (DON), who directed them to return to the floor training with another CNA. Staff A stated the facility did an investigation, but the CNA did not know whether or not Staff B was still employed with the facility. Staff A reported being retaliated against because of reporting the abuse and stated being told when writing her statement, not to go into detail but write down the major points. Staff A stated Staff B came back upstairs and made a statement Snitches get stitches and this staff member felt it was directed to her. Staff A stated ever since that happened, the workplace has felt hostile, they talk about how some employees lie on other employees and they get fired. On 09/18/2025 at 2:55 p.m. an interview was conducted with Staff B, CNA. Staff B stated thinking Staff A, PCA, doesn't like me and she doesn't like to work because I made her get up and help change the resident and then they pulled me into the office and told me that the PCA complained about me. Staff B stated being suspended but refused to answer the question related to why she was suspended. She said she came back on the holiday and then a few days later she got suspended again because she was in the parking lot saying, snitches get stitches referring to Staff A. Staff B refused to acknowledge the allegation for Resident #3 and stated being done with the facility and not coming back to the facility. Staff B stated she already started another job and discontinued the interview. An observation of Resident #3 on 09/17/2025 at 3 p.m. revealed the resident in bed, resident appeared clean and dressed appropriately. Resident #3 presented pleasantly confused and was unable to answer questions about their care at the facility. When a CNA entered the room during the interview, the resident leaned back in the bed, closed eyes, and as though they were sleeping. The resident did not respond the CNA and discontinued the interview. Review of the admission record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mood disorder due to known physiological condition with depressive features, muscle weakness (generalized), unspecified protein-calorie malnutrition, sarcopenia, and anemia. A review of Resident #3's Minimum Page 1 of 4 106041 106041 09/18/2025 Harbourwood Post-Acute and Rehabilitation Center 549 Sky Harbor Dr Clearwater, FL 33759

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Data Set (MDS) dated [DATE] revealed the resident to have a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. The MDS revealed the resident required partial/moderate assistance for oral hygiene, eating; substantial/maximal assistance for personal hygiene and upper body dressing, and was dependent for toileting hygiene, showering/bathing, lower body dressing, and footwear and revealed resident was always incontinent of bowel & bladder. Review of Resident #3's care plan focus on self-care performance revised on 10/03/2034 showed the resident has deficits related to confusion, dementia, visual deficit r/t (related to) bilateral cataracts, depression and anxiety with goal of resident maintaining current level of function through the review. Interventions showed the resident was to request from staff to turn/reposition in bed, staff to check resident's nail length and trim as necessary, resident was to be assisted by staff with dressing, eating, bathing, and oral/personal hygiene. Staff was to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse.A second focus in the same care plan showed the resident was at risk for falls related to cognitive deficits, weakness, incontinence, visual deficit and side effect of medication use with goal of resident would not sustain serious injury through the next review date and interventions of 1/4 side rails (sides of bed) per consent to aid in positioning, staff would anticipate and meet the resident's needs, staff to ensure resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance, staff to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, staff to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, staff to ensure that the resident was wearing nonskid footwear when out of bed, resident needed a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; call light within reach, personal items within reach. On 09/17/ 2025 at 5:00p.m., the DON and the Nursing Home Administrator (NHA) reviewed the incident for Resident #3. The NHA stated on 8/22/2025 at approximately 12 p.m. the DON notified them of an allegation of verbal abuse. The DON told them they were approached by Staff A alleging that Staff B used curse words and was aggressive with Resident #3 while providing care. The DON stated an investigation was completed with the staff and resident, and the resident did not have any psychosocial distress, so they deemed the investigation inconclusive. The NHA stated they did not substantiate the allegation based on their investigation and Staff B returned to work 4 days after the incident and a suspension. The NHA stated all staff who interviewed Resident #3 after the investigation found no concerns of abuse and neglect from the resident or other residents in the area. The DON stated because Resident #3 had cognitive deficits and was not able to answer interview questions, they looked for nonverbal cues or behaviors different from resident's baseline when interviewing and they did not feel any of those were present. The DON stated the reason the resident was not seen by psych until 08/28/2025 when the incident occurred on 08/22/2025 was because the PMNP was on vacation and the facility did not realize the resident had not been evaluated until their 5-day report, when they then got in touch with the psych doctor and did a telehealth evaluation. The DON stated that they use a lot of agency staff, and they just want to pass meds and leave. The DON said, They are not invested in the residents. On 09/18/25 at 3:54 p.m. an interview was conducted with Resident #3's Psychiatric-Mental Health Nurse Practitioner (PMHNP). The PMHNP stated they had signed a note for the resident dated 08/28/2025. The PMHNP stated the facility told him that there was a verbal altercation between staff and the resident. The PMHNP stated he could not remember the specific words used. He stated he conducted a telehealth visit the resident and she was extremely confused and couldn't remember anything or give him any details. He stated 106041 Page 2 of 4 106041 09/18/2025 Harbourwood Post-Acute and Rehabilitation Center 549 Sky Harbor Dr Clearwater, FL 33759

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few he believed they told him of the altercation, and he did the telehealth the same day. The PMHNP could not comment if there was any psychosocial impact as the resident was extremely confused. Review of a psychiatry progress note dated 08/28/2025 showed the resident was seen via telehealth following a reportable safety allegation from staff. During the interview, the patient appeared confused and was unable to engage in meaningful conversation. From the telehealth assessment, the patient appeared safe and stable with no immediate risk factors observed. Staff will continue to monitor. In the interview with DON on 09/17/ 2025 at 5:00 p.m. the DON stated because Resident #3 had a baseline of confusion and was severely cognitively impaired. The DON stated they relied on monitoring behavior changes and body language to determine if the resident had any psychosocial distress. A review of a social services progress note dated 08/22/2025 showed, This SW (social Worker) visited with [Resident#3] post incident in her room. She was resting with her eyes open in bed. [Resident#3] presented with no signs and symptoms of distress. She was pleasant with confusion but was able to engage in simple questions. [Resident#3] was unable to recall the incident. An interview was conducted with multiple CNAs on 09/17/2025 from 9:56 a.m. Staff D stated hearing of an instance where there was an allegation of verbal abuse to a resident. Staff D stated it was brought up in the education, but they weren't given the details. Staff D stated if they heard of any type of abuse, they would immediately report it to Risk Manager. Staff E stated hearing about an incident upstairs where one of the aides was really rough with a patient and wasn't cleaning them. Staff E stated a few weeks ago- heard it got reported and the police came. Staff F, CNA stated there was a verbal abuse incident recently and to their knowledge, that staff member was let go. Staff G, CNA confirmed hearing of the abuse incident and said one of the residents reported the CNA was was really rough with the resident, and it was reported. the CNAs all confirmed having received abuse and neglect training. An interview was conducted with resident #3's Primary Care Physician (PCP). The PCP stated they were notified of the abuse allegation the day it happened. they stated the facility stated they were investigating, and their NP (nurse Practitioner) may have seen the resident during rounds. The PCP did not have anything else to add regarding the incident. Review of a facility policy titled, Abuse, Neglect and Exploitation, dated 09/01/2023 revealed - It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A). Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individua which may include the development of or the presence of an ongoing sexually intimate relationship.Possible indicators of abuse 106041 Page 3 of 4 106041 09/18/2025 Harbourwood Post-Acute and Rehabilitation Center 549 Sky Harbor Dr Clearwater, FL 33759

F 0600 include but are not limited to: 5.) Verbal abuse of a resident overheard. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 106041 Page 4 of 4