Inspection·May 2, 2023

F 0660 Identified needs, such as medical, nursing, equipment, educational, or psychosocial needs. Level of Harm - Minimal harm or potential for actual harm c. Residents Affected - Few Caregiver/support person availability and the resident's or caregiver's/support person's capacity and capability to perform required care. d. Resident's goals of care and treatment preferences. Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge. Review of the clinical record for Resident #850 revealed an admission date of 10/5/22 with diagnoses including alcohol dependence with withdrawal; generalized weakness; unspecified dementia, Schizophrenia, generalized anxiety disorder, mood disorder and Wernicke's encephalopathy (type of brain injury caused by the lack of vitamin B 1 which may result from alcohol abuse). The resident's care plan initiated on 10/21/22 and revised on 4/7/23 noted the resident and representative express the desire for placement in the community at an assisted living facility. Interventions included family involvement in discharge process, anticipate the resident's needs, and services, provide written and verbal instructions to the resident and family for his level of understanding. Review of the progress notes revealed Resident #850 received psychiatry services. On 4/11/23 the psychiatrist documented diagnostic assessment and plan, Major depressive disorder, recurrent, moderate; Generalized anxiety disorder. The medications included Citalopram (antidepressant) 20 milligrams daily, Depakote 250 milligrams twice a day for bipolar and mood disorder. The practitioner noted, As per collected information and interview, it appears that patient is doing well overall. The symptoms are causing no or at times only mild distress. As patient is on psych meds, I considered gradual dose reduction (GDR). Based on history, it appears that patient will not be able to tolerate GDR and will likely become unstable (exacerbation of underlying psychiatric disorders that are mentioned in diagnosis section) if medications are reduced. Therefore, I feel patient is on minimal effective dosages of psychotropic medications to maintain functional status. GDR is therefore contraindicated at this time and so GDR was not performed today. We will do follow up appointment as needed . Plan of action: Ordered labs: Primary psych provider ordered Depakote related labs that is CBC (complete blood count), CMP (comprehensive metabolic panel), Depakote level in one week and repeat labs every three months. Dx (diagnosis: Mood disorder). On 4/14/23 at 2:53 p.m., the Advanced Practice Registered Nurse (APRN) documented a late entry note with an effective date of 4/14/23 at 8:56 a.m., which noted Resident #850 had a primary diagnosis of dementia, schizoaffective disorder, and a history of alcoholism. The APRN documented, The patient is requesting discharge home. Dr. [name] had an extensive conversation with the patient. I had an extensive conversation with the patient. The administrator had an extensive conversation with the Patient. The patient is requesting to discharge home to the Salvation Army. He will be going to his sister's house in North Carolina for several months then will return back to Florida. At this time the patient is able to make his own decisions, he is alert and oriented, and he is requesting to discharge to the Salvation Army with his belongings, and his medications. No additional prescriptions will be written, as the patient will need to find a PCP (Primary Care Physician) within 7-14 days . The patient is alert and oriented X3 (Person, place, and time) and although has some episodes of confusion, is aware of his surroundings, and is able to go home if he so chooses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 2 of 13 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0660 Level of Harm - Minimal harm or potential for actual harm The Discharge return not anticipated Minimum Data Set (MDS) assessment with a target date of 4/14/23 noted Resident #850's cognition was intact. The resident was discharged to the community (private home/apartment, board/care, assisted living, group home). Resident #850 required supervision for activities of daily living, including bed mobility, transfer, walking in room, walking in corridor, dressing, eating, toilet use, personal hygiene, and bathing. Residents Affected - Few On 4/24/23, review of the clinical record failed to reveal documentation of an evaluation of the resident's needs to ensure a safe discharge, including a post discharge plan of care, support needed and availability of support person, instructions, and arrangements for necessary follow up care, including post-discharge medical services. There was no documentation Resident #850 was discharged with his medications, and instructions provided related to the medications. On 4/25/23 at 8:50 a.m., the Social Service Director said Resident #850 was alert and oriented, and competent to leave the skilled nursing facility. She said the Salvation Army had space and the resident was ok with the decision to be discharged to the Salvation Army. She felt it was a safe discharge for the resident. She said she was aware the resident had mental health issues. The Social Service Director said she spoke to the Salvation Army and collaborated with them. They offer a multitude of services for people with mental health issues therefore she did not have to make any post discharge arrangements for the resident. She said she discussed the discharge with the Interdisciplinary team, and if not documented she still made it known to her colleagues and communicated via email. The Social Service Director provided a copy of an email dated 4/14/23 at 12:59 p.m., addressed to several staff members, including the Unit Manager, the Director of Nursing, the Assistant Director of Nursing, and the Administrator. The subject of the email was, [Resident #850] (early release d/c (discharge) TODAY). The email read, Oh, GOOD NEWS!!! Resident stated his daughter DID drop off his ID/Debit Card; He is good to be d/c TODAY!!! I will call for a taxi to pick him up by 2pm, since he is eating lunch now. First come first served (first 15 people) to get a bed . On 4/25/23 at 9:35 a.m., the Social Service Director said, We as a group did not document a discharge plan of care or a discharge summary. She added she had three other discharges that week and did not have time to document what she had done for Resident #850. On 4/26/23 at 9:39 a.m., in a telephone interview the Salvation Army Director said the facility was a no touch shelter. No one who requires supervision can reside in the shelter. They do not provide any supervision or medical assistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 3 of 13 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, family member, resident and staff interviews the facility failed to schedule the necessary orthopedic follow up care within specified timeframe for 1 (Resident #1011) of 2 residents reviewed who sustained a fracture at the facility. Residents Affected - Few The findings included: The facility policy titled Provision of Physician Ordered Services, revised 1/2023 stated the policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. The policy explanation and compliance guidelines include the following: 1. Facility will maintain a schedule of diagnostic tests in accordance with the physician orders. 2. Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity. 3. Qualified nursing personnel will receive and review the diagnostic reports or consults and communicate the results to the ordering physician, Nurse Practitioner, Physician Assistant within 24 hours of receipt. 4. Documentation of consultations, diagnostic test, the results, and date/time of physician notification will be maintained in the resident's clinical record. 5. In instances where diagnostic testing or consultations are not available to be performed on site or the physician has requested services be performed at and off-site facility, this facility will work with the resident and their family to secure appropriate transportation arrangements for such appointments. Review of the clinical record revealed Resident #1011 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) Assessment with an assessment reference date of 3/10/23 noted the resident's cognition was severely impaired. Resident #1011 required physical assistance of one person for activity of daily living, including bed mobility and transfer. Review of the facility's incidents and incidents investigations revealed on 3/21/23 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 4 of 13 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0684 Level of Harm - Minimal harm or potential for actual harm approximately 7:00 a.m., Resident #1011 complained of left thumb pain to the nurse. The left thumb was swollen, dark black in color. The resident was sent to the local hospital for evaluation and treatment of the left thumb, and was diagnosed with a left thumb fracture. Residents Affected - Few On 4/24/23, review of the hospital progress note, and discharge instructions dated 3/21/23 located in the clinical record noted to specific instructions to follow up with an orthopedic specialist in three days. The discharge instructions listed the name, address, phone number and fax number of the orthopedic specialist. The clinical record lacked documentation of a follow up appointment with an orthopedic specialist within three days as specified on 3/21/23 in the discharge instructions from the hospital. On 4/24/23 at 10:53 a.m., Resident #1011 was observed in a wheelchair with a splint on the bed. The resident said he was seen at the hospital, and they gave him a splint for his thumb. He said he was supposed to follow up with another physician for his broken thumb. On 4/26/23 at 8:57 a.m., Licensed Practical Nurse (LPN) staff M verified Resident #1011 had not had a follow up with the orthopedic specialist since the discharge from the hospital on 3/21/23. She said all nurses are responsible to schedule follow up appointment. She said the floor nurse who reviewed the discharge paperwork should have scheduled the appointment. LPN Staff M said she will schedule a follow up appointment with an orthopedic specialist for May 1, 2023. On 4/26/23 at 10:33 am, the Director of Nursing (DON) said the follow up appointment should have been done by March 24, 2023. The Unit Manager or assigned nurse was responsible to schedule the appointment. She said she was not aware the follow up appointment had not been scheduled. On 4/27/23 at 4:45 p.m., Resident #1011's daughter said her father was supposed to follow up with the orthopedic specialist within three days of discharge on [DATE] and the facility still had not arranged for the consult for his broken thumb. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 5 of 13 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on record review, resident's family and staff interviews, the facility failed to ensure 1 (Resident #850) of 3 discharge sampled residents with a history of alcohol abuse disorder received appropriate supervision, treatment, and services, to maintain the highest practicable mental and psychosocial wellbeing. The findings included: Review of the clinical record for Resident #850 revealed an admission date of 10/5/22 with diagnoses including alcohol dependence with withdrawal; generalized weakness; unspecified dementia, Schizophrenia, generalized anxiety disorder, mood disorder and Wernicke's encephalopathy (Neurological symptoms caused by vitamin B1 deficiency). The Significant Change in Status Minimum Data Set (MDS) Assessment with an assessment reference date of 12/06/2022 documented Resident #850's cognition was intact. The resident was experiencing delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS noted the resident was receiving antidepressants, and antipsychotic medications. Review of the Medical Professional progress notes revealed on 10/10/22 the Advanced Practice Registered Nurse (APRN) documented the resident was being admitted status post hospitalization for acute alcoholic intoxication. He sustained a fall with a wound to his right arm. Significant history of alcohol use and abuse. The care plan initiated on 10/24/22 noted the resident had a diagnosis of Major Depressive Disorder, anxiety, dementia, with history of alcohol abuse, and alcohol dependence withdrawal. The resident was at risk for complications related to the use of psychotropic drugs. The interventions included a gradual dose reduction as ordered, monitor for continued need of medication as related to behavior and mood, monitor for changes in mental status and functional level and report to physician as indicated, monitor for side effects, and consult physician or pharmacist as needed, obtain psych evaluation as ordered, psychiatry services, and/or psychological services as needed and ordered. The care plan did not include provision for behavioral health services, such as individual counseling to address the resident's diagnosis of alcohol abuse. On 11/13/22 the physician documented the resident has underlying dementia plus alcohol abuse in the past. He also has limited depressive disorder. Social history: history of alcohol abuse. The physician documented to continue care in the dementia unit. The diagnoses listed on the physician order summary report included alcohol dependence with withdrawal. The physician orders dated 10/5/22 and 11/18/22 included psychiatry consult for evaluation and follow up as needed. On 3/13/23 the nurse documented the resident became agitated. He threw a plate during dinner and began walking up hallway with his fist balled up. He expressed he was upset because his room was changed. Staff attempted to redirect him by calling his daughter. He began cursing at the daughter via (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 6 of 13 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few phone. Male staff arrived and resident was directed to going to his room. Resident was requesting rum and coke. The nurse practitioner gave order to give Haldol (antipsychotic) 5 milligrams intramuscularly. On 4/25/23 at 3:30 p.m., the Medical Director said Haldol was appropriate for alcohol induced delirium. Review of the psychiatry progress notes revealed the resident was evaluated by psychiatry on 12/21/22, 1/3/23, 2/7/23, 2/28/23, 3/14/23, 4/7/23, and 4/11/23. The progress notes listed diagnostic assessment and plan for recurrent Major depressive disorder, bipolar disorder, and generalized anxiety disorder. The progress notes did notes did not include a specific plan of action for alcohol abuse. On 4/25/23 at approximately 11:00 a.m., the psychiatry Advanced Practice Registered Nurse said during each visit she addressed the history of alcohol abuse with Resident #850 but did not document her evaluation. She said she was not aware on 3/13/23 the resident was requesting rum and coke. She said she would have liked to be notified. She would have addressed it and ordered Naltrexone (medication used to treat alcohol use disorder). On 4/25/23 at 4:00 p.m., the Director of Nursing provided the survey team with a copy of Resident #850's Medication Review Report and highlighted the order for Thiamine (Vitamin B 1)100 milligrams tablet one tablet by mouth one time a day for alcohol abuse. She said the Thiamine was the intervention implemented by the facility to address the resident's alcohol abuse. On 4/11/23 the psychiatrist documented the resident was on one on one supervision trying to get out of the building. He documented as per collected information the resident was doing well overall. The symptoms are causing no or at times only mild distress. As the resident was on psych medications, he considered gradual dose reduction. Based on history it appeared the resident would not be able to tolerate a gradual dose reduction and would likely become unstable. On 4/14/23 Resident #850 was discharged to the Salvation Army. There was no documentation in the clinical record at the time of the survey the facility offered or arranged for services or support to assist Resident #850 coping with alcohol abuse. On 4/24/23 at 4:20 p.m., during a telephone interview, Resident #850's daughter said her father had a long history of alcohol abuse, with multiple admissions to the hospital related to alcohol abuse. She said she spoke to several people at the facility, including the Social Worker, the Director of Nursing, and the Administrator and begged them not to discharge her father. She said he was not able to take care of himself, but the facility said he was his own person therefore she did not have a say in their decision to discharge the resident. They said her father was allowed to make bad decisions. She said he only stayed at the Salvation Army for one night, slept in the streets on Saturday and Sunday. He got drunk, got picked up in the streets and sent to the hospital. She said he was still at the hospital until they could safely discharge him. Review of the local hospital initial psychiatric consultation report dated 4/18/23 at 10:06 p.m., noted Resident #850 had multiple diagnoses including alcohol use disorder. He was found drinking, was later kicked out of that long-term care facility, and referred to the Salvation Army. Since that time, the patient has been drinking heavily, has been going to bars and spending a significant amount of money on alcohol. On evaluation, the patient states, sometimes I feel confused. The physician documented, Based upon this evaluation, which was performed over telemedicine, the patient does meet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 7 of 13 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0740 Level of Harm - Minimal harm or potential for actual harm criteria for treatment under the [NAME] Act (Involuntary admission) petition. At this point, it appears he also lacks medical decision making capacity. He will almost certainly needs to be placed into the care of others in assisted living facility or nursing home . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 8 of 13 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to implement individualized interventions, as well as revise the care plan with appropriate interventions, including meaningful activities to address dementia care needs for 2 (Resident #1000 and #1001) of 6 sampled residents with known wandering behavior. Residents Affected - Some The findings included: Review of the clinical record revealed Resident #1000 was a vulnerable [AGE] year-old female admitted to the facility on [DATE]. Resident #1000 resided on the secured unit for increased supervision. Resident #1000's diagnosis included Alzheimer's disease, Paranoid Schizophrenia, unspecified dementia with behavioral disturbance, major depressive disorder, and other mixed anxiety disorder. The care plan for Resident #1000 included a focus on potential to be physically aggressive behavior related to Anger and Dementia, Paranoia with schizophrenia. The interventions were not individualized to prevent unsafe wandering and avoid resident-to-resident altercations. Review of the clinical record for Resident #1000 revealed the resident was involved in multiple incidents of resident to resident altercations (1/8/23, 2/14/23, 3/13/23, and 4/3/23) when she wandered unsupervised into other residents' rooms. The care plan did not include a person centered program for activities. On 4/28/23, a review of group activities and one-to-one activities for the last 30 days prior to survey showed no documentation the resident was offered or participated in activities. On 4/28/23 11:46 a.m., the Activities Director verified Resident #1000 had nothing care planned for activities. The Activities Director said there should be one on one activities for residents who don't attend group activities, and these should be documented. On 5/1/23 at 2:53 p.m., Resident #1000's daughter said her mother wanders the halls frequently and no one had asked her about her mother's interests or what she liked to do. Resident #1000's daughter said she was not aware of staff doing any activities with her. 2. Review of the clinical record revealed Resident #1001 was a vulnerable adult admitted to the facility on [DATE]. Diagnoses included unspecified dementia with other behavioral disturbance, major depressive disorder, anxiety disorders. Resident #1001 resided in the secured unit of the facility for increased supervision. The Care Plan for Resident #1001 has a focus on aggressive behavior, easily agitated, entering other residents' rooms without permission, physically aggressive, restlessness, verbally aggressive. He tends to refuse his medication at times, he also refuses Hygiene/Bathing frequently. He tends to smear feces on bedroom wall at times. The care plan did not include person-centered interventions were not person-centered interventions to prevent the resident from wandering, entering other resident rooms or avoiding resident to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 9 of 13 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0744 resident altercations. Level of Harm - Minimal harm or potential for actual harm Documentation in the clinical record revealed on 4/23/23 at 8:00 a.m., Resident #1001 was found in Resident #1008's room. Resident #1001 struck Resident #1008 in the face. Residents Affected - Some The care plan for Resident #1001 also revealed nothing was care planned for activities. On 4/28/23, a review of the activity documentation showed the resident participated in five group activities, and three one to one activities in the last 30 days. On 4/28/23 11:46 a.m., the Activities Director verified Resident #1001 had nothing care planned for activities. On 5/1/23 2:57 p.m., Resident #1001's significant other said he had not been getting involved with activities or other people and that had become normal for him. She said Resident #1001 could no longer hold a conversation and had shrunk into himself and lashes out. She said the facility had never discussed things he would like to do but, but everything he used to like he doesn't like anymore. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 10 of 13 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on observation, interviews, and record reviews the facility failed to revise The Facility Assessment to include the assessment and resources needed to safely care for residents with severe cognitive impairment in the secured memory care unit with known unsafe wandering and aggressive physical behaviors. The findings included: On 4/24/23 from 9:40 a.m. to 10:00 a.m. during the initial tour of the facility, seven residents were observed wandering aimlessly throughout the secured memory care unit hallways. Residents were observed standing near and attempting to open exit doors without staff redirection. Review of the facility's incidents log revealed three resident-to-resident incidents in January 2023, 15 resident-to-resident incidents in February 2023, 10 resident-to-resident incidents in March 2023, and as of 4/28/23 seven resident-to-resident incidents in April 2023. Review of the clinical record of a sample of six cognitively impaired residents with known aggressive behaviors residing in the memory care unit of the facility from January 2023, through April 2023 revealed a total of 14 resident-to-resident altercations involving the six residents. Three of the six residents reviewed had three or more incidents of unsafe wandering into other residents' rooms resulting in physical altercations. Review of the Facility assessment completed on 3/23/23 showed the facility identified 56 residents with behavioral health needs. There was no specific documentation on the facility assessment as to what behavioral needs these residents have and how the facility would meet the residents' needs. The facility documented on the facility assessment they would Manage medical conditions and medications related to issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses . The facility documented they would, Provide Person Centered/directed care: Psycho/social/spiritual support: The facility included they would, Provide opportunities for social activities/life enrichment (individual, small group, community) .Prevent abuse and neglect. There was no specific documentation as to how the facility would provide social activities specific to residents with severe dementia and aggressive behaviors. The facility assessment showed no documentation they determined the number of staff and competency needed to provide the necessary care and services. The facility documented under Facility Resources Needed to Provide Competent Support and care for our Resident direct care staff would be provided by staffing ratios as per Florida regulations and center acuity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 11 of 13 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility assessment did not identify who would be responsible for assessing the acuity levels to ensure sufficient and competent staffing to meet the needs of the residents. The assessment did not document how often acuity measures would be obtained and what process or system would be used to measure the acuity levels. There was no documentation on the facility assessment to show increased needs for supervision, activities, and resources to prevent resident wandering and resident to resident altercations. There is no specific staff education documented on the facility assessment to initiate interventions to prevent resident wandering and resident to resident altercations. Under Staff training/education and competencies the facility documented, Attachment: Education in-services/Mandatories. The attachment was the facility's education calendar. On 4/25/23 at 10:15 a.m., a joint meeting was held with the Administrator, the Director of Nursing, the Medical Director, the [NAME] President of Clinical Services, and the Regional Director of operation. The Administrator said he was aware of the multiple incidents of resident-to-resident altercations in the memory care unit. He said in March 2023, the facility initiated an activity program with mid-morning and mid-afternoon activities to decrease unsafe wandering and prevent incidents of resident-to-resident altercations for residents with known aggressive behaviors. The Administrator provided the survey team with a facility, Quality Improvement Initiative dated March 2023 (no specific date), Target Measure: Memory Care unit programming. The document noted the stated problem was, Programming in Memory Care unit, engaging all staff to participate in providing short interval activities/programming to engage residents to decrease wandering and resident to resident negative interactions. The goal for compliance was listed as, The goal to reach compliance is to reduce the resident to resident negative altercations by 50% within 60 days. The action steps included: 1. Identify evening small group activities designed to calm and relax residents for preparing for bed. 2. Review residents at high risk for resident to resident negative interaction and high fall risk on the unit. 3. Educate evening CNAs (Certified Nursing Assistants) on gathering high risk residents in the common area prior to bed with a CNA completing calming group activities. The remaining CNAs on the unit will come get the residents one at a time to get cleaned up and settled in bed while the high risk residents are being monitored . On 4/28/23 at 10:15 a.m., Certified Nursing Assistant (CNA) Staff C stated she had not had any training to provide care for people with Alzheimer's or dementia. She said, we have had some general information about the disease and what it is. Nothing about how (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 12 of 13 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0838 Level of Harm - Minimal harm or potential for actual harm to care for the residents, what to do with them, or provide safety. She stated she had not been given any suggestions for activities or interventions we just have to figure it out. We get ignored a lot, that's one of my main problems, no one listens. We could have avoided a lot of altercations and falls if they had listened to us. Staff C said she can tell a nurse there is something wrong with someone and they brush it off and two days later they start falling. Residents Affected - Some On 4/28/23 at 10:44 a.m. Staff B, Licensed Practical Nurse and Unit Manager said when residents wander in and out of rooms we are supposed to ask why, look for causes, they may be hungry, thirsty, or might need to use the bathroom they might be in pain. I don't know what the CNAs on the memory care unit have been taught. I don't feel they have been educated to work in this unit. The CNAs and nurses need major education about what to do, how to communicate. Staff get upset with the resident because they ask the same questions over and over. I've been shocked that the staff don't know interventions or how to work with dementia residents. On 5/1/23 at 3:10 p.m. the Director of Nursing (DON) was asked how she assessed and what system was in place to determine resident acuity. The DON reviewed the staffing information which showed the facility staffed the facility with the minimum state required number of two CNA hours, and one Licensed Nursing hour per day. The DON said she would have to get back with the survey team with information. On 5/1/23 at 4:30 p.m., the DON provided a blank copy of a form for determining root causes of incidents of pain and falls. She stated this was the form she had been using to determine acuity since she was hired in March of 2023 year. On 5/2/23 at approximately 2:30 p.m. The [NAME] President of Clinical Services verified all direct care staff had not been completed Hand-to-Hand dementia training the facility utilizes. The [NAME] President said the facility was in the process of teaching module 3 of the hand-to-hand module to all staff working on the memory care unit. She said they were teaching Module 3 to staff because the module covered residents wandering. The [NAME] President of Clinical Services said all agency staff would be required to have Module 3 of the hand-to-hand dementia training. The [NAME] President of Clinical Services verified the facility had added a hall monitor on 4/27/23 to ensure wandering residents did not enter other resident's rooms. The [NAME] President of Clinical Services said they had added an addition hall monitor (two hall monitors) on the secured memory unit after another incident of resident-to-resident physical altercation occurred on 5/1/23 when a resident wandered into another resident's room and struck the resident residing in the room. On 5/2/23 at 4:40 p.m., the Administrator said he could not provide any documentation staffing had been increased to provide individualized activities to decrease resident to resident abuse on the secured memory care unit in the midmorning or late afternoon. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 13 of 13