Health inspection·October 21, 2020

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. On 10/18/20 at 1:44 p.m., in an interview Resident #54 said no one spoke to him about his baseline care plan and no copies were provided. On 10/20/20, a record review revealed there was no evidence of a written summary of the baseline care plan which included initial goals and a summary of current medications and dietary instructions was provided to the resident as required. 2. On 10/21/20 at 8:41 a.m., Resident #28 was not interviewable. A record review revealed there was no evidence of a written summary of the baseline care plan which included initial goals and a summary of current medications and dietary instructions was provided to the resident or resident representative as required. On 10/21/20 at 8:41 a.m., in an interview the Minimum Data Set (MDS) Director confirmed there was no documented evidence of Resident #9, #28 and #54 or the residents' representatives (if applicable) were provided with written summary of the baseline care plan which included initial goals and a summary of current medications and dietary instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 2 of 7 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 105497 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Venice Health and Rehabilitation Center 1240 Pinebrook Road Venice, FL 34292 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and interview the facility failed to provide care and services to minimize the risk of infection during wound care for 1 (Resident #48) of 1 resident reviewed with pressure ulcers. Residents Affected - Few The findings included: According to the Wound, Ostomy and Continence Nursing (WOCN) reference: http://journals.lww.com/jwocnonline/Fulltext/2012/03001/Clean_vs__Sterile_Dressing_Techniques_for.7.aspx: Clean technique. Clean means free of dirt, marks, or stains. 3 Clean technique involves strategies used in patient care to reduce the overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another. Clean technique involves meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves and sterile instruments, and preventing direct contamination of materials and supplies. Review of the facility's policy and procedure for Clean Dressing Changes (Copyright 2019 The compliance Store, LLC) revealed: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination . 7. Wash hands and put on clean gloves. 8. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. 9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or the surfaces of the wound. (i.e. clean outward from the center of the wound). Pat dry with gauze. 13. Measure wound using disposable measuring guide . 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. 16. Secure dressing. [NAME] with initials and date . 17. Discard disposable items and gloves into appropriate trash receptacle and wash hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 3 of 7 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 105497 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Venice Health and Rehabilitation Center 1240 Pinebrook Road Venice, FL 34292 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 18. Return resident to a comfortable position. Place call light within reach. Open door, blinds, or curtains if desired by resident. Review of the clinical record revealed Resident #48 developed a pressure ulcer to the right buttock at the facility on 7/14/20. The wound worsened to a stage IV pressure ulcer. Residents Affected - Few On 10/20/20 at 11:33 a.m., Licensed Practical Nurse (LPN) Unit Manager (UM) Staff D was observed doing a clean wound vac dressing change to Resident #48's pressure ulcer to the right buttock. LPN UM Staff D picked up a pair of bandage scissors and a few packets of alcohol wipes from the top of a treatment cart in the hallway and placed them on an overbed table covered with a plastic bag in the resident's room. LPN Staff F and Registered Nurse (RN) Staff E positioned Resident #48 in bed to her left side, unfastened the incontinent brief and exposed the wound. LPN/UM Staff D donned a pair of clean gloves and readjusted her protective goggles. She pulled off the soiled dressing from the wound and wiped the intact skin around the wound with a cleansing wipe. She removed her gloves and donned a new pair of gloves without performing hand hygiene. She poured saline on a 4 by 4 gauze, inserted the gauze into the wound and wiped the wound bed several times with the same gauze. She removed and donned a new pair of gloves without performing hand hygiene. She used the bandage scissors to cut a piece of sterile black foam which she inserted into the wound. LPN/UM Staff D did not sanitize the scissors before using them to cut the sterile foam. She used the scissors to cut the protective adhesive drape and applied it over the foam sponge and surrounding intact skin. LPN/UM Staff D wiped the resident's rectal area with a cleansing wipe, removed her gloves and donned a pair of clean gloves without performing hand hygiene. She cut and applied additional protective adhesive drape over the foam. She removed her gloves, applied a pair of gloves and attempted to turn on the wound vac. LPN/UM Staff D wiped the soiled scissors with an alcohol wipe and wrapped them in a paper towel. She gathered the soiled dressing in a plastic bag and discarded it into the soiled utility across from the resident's room. LPN/UM Staff D placed the scissors on the sink in the soiled utility room and washed her hands with soap and water. She picked up the scissors walked around the hall and placed them on the desk in her office. On 10/20/20 at 2:25 p.m., during an interview the Director of Nursing (DON) said she would expect the nurses absolutely to wash or sanitize their hands with gloves changes. On 10/20/20 at 2:58 p.m., during an interview LPN/UM Staff D verified she failed to wash her hands as appropriate during the wound care. She said she was aware she kept readjusting her protective goggles throughout the dressing change. She explained the goggles were too large and she had to make the decision to readjust them or to take them off. She said she did not wash or sanitize her hands because she was more worried about the resident's safety being in the same position for a long time during the wound care. LPN UM Staff D said next time she would use a hand sanitizer between glove changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 4 of 7 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 105497 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Venice Health and Rehabilitation Center 1240 Pinebrook Road Venice, FL 34292 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, record review, interview, the facility failed to coordinate with the pharmacy to ensure the timely removal of expired medications in 2 of 2 emergency drug kits and 1 of 1 automated medication dispensing system observed. The findings included: On 10/18/20 at 10:40 a.m., an observation of the medication storage room with Registered Nurse (RN) Staff G revealed 2 emergency drug kits (EDK). Each kit was labeled with an expiration date of 6/2020. Observation of the content of the emergency drug kits revealed: 10 tablets of Hydrocodone with acetaminophen (10/325) with an expiration date of 7/2020 10 tablets of Morphine Sulfate 30 milligrams with an expiration date of 8/2020 10 tablets of Morphine Sulfate 15 milligrams with an expiration date of 7/2020 4 vials of Hydromorphone (2 milligrams per milliliter) with an expiration date of 7/2020 10 tablets of pregabalin 75 milligrams with an expiration date of 7/2020 10 tablets of pregabalin 50 milligrams with an expiration date of 7/2020 5 tablets of Alprazolam 0.5 milligram with an expiration date of 8/2020 5 tablets of Zolpidem 5 milligrams with an expiration date of 6/2020 1 Fentanyl patch of 50 micrograms per hour with an expiration date of 9/2020 On 10/18/20 at 10:50 a.m., in an interview RN Staff G she said the facility used both EDK boxes and an automated medication dispensing machine for emergency medications. She said they use the EDK boxes to refill the machine. She wasn't sure how often the pharmacy replaced the EDKs to ensure expired medications were not accidentally administered to residents. On 10/19/20 at 9:28 a.m., in an interview the Director of Nursing (DON) said the facility switched pharmacies at the end of April and started using an automated medication dispensing system. She said the traditional EDKs were still available to the nurses if needed. On 10/19/20 at 9:30 a.m., a review of the inventory list of the current emergency medications in the automated medication dispensing system revealed 26 medications expired between 9/30/20 through 10/10/20. On 10/19/20 at 9:35 a.m., observation of the content of the automated medication system revealed 4 tablets of Tegretol 100 milligrams and 4 tablets of Amiodarone 200 milligrams with an expiration date of 10/3/20. The DON verified 26 different medications in the automated medication dispensing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 5 of 7 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 105497 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Venice Health and Rehabilitation Center 1240 Pinebrook Road Venice, FL 34292 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 0755 system were expired. She said no one in particular was assigned to review the content for expiration dates. Level of Harm - Minimal harm or potential for actual harm On 10/19/20 at 12:00 p.m., the Regional Manager said she contacted the pharmacy and they were investigating where the breakdown occurred. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 6 of 7 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 105497 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Venice Health and Rehabilitation Center 1240 Pinebrook Road Venice, FL 34292 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and staff interview, the facility failed to ensure proper storage, labeling, and dating of two insulin pens on 1 (600 cart) of 3 medication carts observed. This had the potential to administer expired medications to residents. The findings included: On 10/20/20 at 9:30 a.m., an observation of the 600 hall medication cart with Licensed Practical Nurse (LPN) Staff H revealed one Lantus Insulin Pen with Resident #64's last name written with a sharpie marker. The insulin pen was not bagged and was not labeled with the prescribed dose, strength, route of administration and date opened. On 10/20/20 at 9:35 a.m., LPN Staff H verified the observation. She said Resident #64 still used insulin and she would replace the pen with a new one properly labeled. Further observation of the 600 hall medication cart revealed a Novolog (insulin) pen that bored Resident #18's name. The Novolog pen had a documented open date of 9/21/20 with instructions to discard after 28 days. LPN Staff H verified the insulin pen expired on 10/19/20 and should not be stored in the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 7 of 7