Health inspection·April 28, 2022

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, Resident and staff interview, the facility failed to identify, assess, address, and monitor individual underlying causes and contributing factors for decline in 4 areas in functional mobility for 1 Resident (Resident #17) who had a significant change in condition of 2 Resident reviewed. Residents Affected - Few On 4/25/22 at 12:15 p.m. Resident # 17 was observed in bed with staff assisting with feeding. On 4/25/22 at 1:36 p.m., Certified Nursing Assistant (CNA), Staff G, said Resident # 17 was now dependent on staff for eating. Resident #17 used to be able to feed herself. Staff G said Resident #17 used to be able to transfer with minimal assistance but now required a mechanical lift for transfers. On 4/26/22 at 8:09 a.m., Licensed Practical Nurse (LPN) Staff H said Resident # 17 was requiring more assistance with activities of daily living (ADL) from staff. LPN Staff H stated, it is a change for her. On 4/26/22 at 2/03 p.m. Review of Resident # 17's Annual Minimum data set (MDS) with an assessment reference date (ARD) of 12/8/21 indicated Resident was independent with eating and dressing and extensive assistance with bed mobility. Review of the activities of daily living log for the months of February, March and April 2022 showed Resident # 17 had declined in four areas, eating, personal hygiene, bed mobility and dressing. On 4/27/22 at 12:04 p.m., RN (Registered Nurse) MDS Coordinator confirmed Resident #17 had declined in bed mobility, dressing, eating and personal hygiene. RN Coordinator said in the areas of bed mobility, Resident # 17 went from extensive to total, dressing was supervision and now is total, eating was supervision and now is extensive, and personal hygiene is now total. RN MDS Coordinator said Resident #17 would have benefited from a significant change and the interdisciplinary team should have evaluate, assess, and find the root cause of the change. RN MDS said team should have attempted to address and update Resident # 17's plan of care. On 4/28/22 at 2:19 p.m., the Director of Nursing (DON) acknowledged a significant change in condition MDS should have been completed for Resident #17. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 2 of 10 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 04/28/2022 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS) Assessment within 14 days of the Assessment Reference Date (ARD) as required by regulation for 5 (Residents #85, #17, #13, #12, and #30) of 20 residents reviewed for quarterly assessments. Residents Affected - Some The findings included: On 4/27/22 record review revealed Resident #85 had a quarterly MDS with an ARD of 3/19/22 scheduled. As of 4/27/22, 39 days later, the required quarterly MDS assessment was still not completed. On 4/27/22 record review revealed Resident #17 had a quarterly MDS with an ARD of 2/28/22 scheduled. As of 4/27/22, 58 days later, the required quarterly MDS assessment was still not completed. On 4/27/22 record review revealed Resident #13 had a quarterly MDS with an ARD of 3/4/22 scheduled. As of 4/27/22, 54 days later, the required quarterly MDS assessment was still not completed. On 4/27/22 record review revealed Resident #12 had a quarterly MDS with an ARD of 2/22/22 scheduled. As of 4/27/22, 64 days later, the required quarterly MDS assessment was still not completed. On 4/27/22 record review revealed Resident #30 had a quarterly MDS with an ARD of 3/31/22 scheduled. As of 4/27/22, 27 days later, the required quarterly MDS assessment was not completed. On 4/27/22 at 9:00 a.m., in an interview, the RN (Registered Nurse) MDS Coordinator said the assessments are late because of the workflow and the volume of the MDS. On 4/27/22 at 2:15 p.m. the RN Regional Nurse MDS Coordinator provided a list showing the facility has 119 MDS assessment currently late as of 4/27/22. The RN Regional Nurse said, we have a problem. On 4/27/22 at 2:31 p.m., in an interview, the Director of Nursing DON said she knew we had late assessments but not that many. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 3 of 10 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 04/28/2022 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) tracking records were submitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion of the event for 6 residents (Resident #347, #72, #350, #351, #20 and #349) of 10 reviewed for timely submission. Residents Affected - Some The findings included: On 4/26/22 at 8:05 a.m., record review for the following residents revealed: Resident #20 had an entry with event date (admission date) of 2/26/22. The record should have been transmitted by 3/12/22. Facility transmitted on 3/14/22 (2 days late). Resident #347 had an entry with event date of 3/24/22. The record should have been transmitted by 4/7/22. Facility transmitted on 4/19/22 (12 days late). Resident #349 had an entry with event date 3/31/22. The record should have been transmitted by 4/14/2. Facility transmitted entry tracking on 4/25/22 (11 days late). Resident #350 had an entry with event date of 3/29/22. The record should have been transmitted by 4/12/22. Facility transmitted on 4/27/22 (15 days late). Resident #351 had death tracking form with event date of 3/22/22. The record should have been transmitted by 3/26/22. Facility transmitted on 4/22/22 (27 days late). Resident #72 had an entry with event date of 4/1/22. The record should have been transmitted by 4/15/22. Facility transmitted entry tracking on 4/22/22 (7 days late). On 4/27/22 at 9:09 a.m., record review of validation reports for Resident #347, #72, #350, #20 and #349 noted Warning: Record submitted late. The submission date is more than 14 days after A1600 and for Resident #351, Warning. Record submitted late. The submission date is more than 14 days after A2000. On 4/27/22 at 09:50 a.m., in an interview, Registered Nurse MDS Coordinator confirmed the entry tracking records for Residents #347, #72, #350, #20 and #349 and the death tracking form for Resident #351 were submitted late. She said entry and death tracking records should be submitted no later than 14 days after the event date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 4 of 10 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 04/28/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, review of facility policies and procedures, review of clinical records and resident and staff interviews, the facility failed to provide appropriate services and interventions for the management of contractures for 1(Resident #63) of 2 residents reviewed with limited range of motion. The findings included: The facility policy Functional Maintenance Program, (revised 1/5/21) specified the program is designed to assist patients in maintaining functional status achieved in skilled therapy. The program goal is to maintain the resident's functional capacity, improve quality of life, improve, or maintain resident safety and to decrease risk for physical or medical complications. The therapist will develop a patient specific, written functional maintenance plan for nursing/caregiver staff to carry out. On 4/25/22 at 2:51 p.m., during an observation and interview, Resident #63 had limited range of motion (ROM) of both hands and did not have splints in place. Resident #63 was not able to fully open his right hand. Resident #63 said he had splints at one time, but no one had put them on for him. On 4/26/22 at 1:44 p.m., Resident #63 was in his wheelchair and did not have a splint on the right hand. A review of the clinical record revealed Resident #63 diagnoses included Parkinson's, disease, muscle weakness and lack of coordination. The Quarterly Minimum Data Set (MDS) with a target date of 2/4/22, documented Resident #63 had functional limitation in Range of Motion (ROM) on both sides of upper and lower extremities. The care plan initiated on 5/1/20 and revised on 11/2/21 identified the resident was at risk for decreased ability to perform ADLs (activities of daily living). The interventions included to monitor for ADL decline and refer to therapy, monitor complications of immobility including contractures. On 4/26/22 at 4:28 p.m., the Therapy Director said Resident #63 was not currently on therapy case load for management of contractures. He said the process is when a resident is discharged from therapy with a splinting device, they train the certified nursing assistant (CNA) and nurse who work with the resident and then they in turn pass it along to the staff on the other shifts. He said the facility did not have a restorative program and no one to ensure the splints and braces were applied once a resident was discharged from therapy. The OT said I wish the facility had someone to monitor the application of the splints and braces, but they don't have that here. The OT said Resident #63 had received occupational therapy beginning in February 2021 through March 2021 and had been discharged with a right-hand splint to be applied and removed every 2 hours. The OT said, every resident was screened annually to assess the need for therapy. He said the nurse would send a therapy referral for any resident who had a change in condition and therapy would complete a screen to determine if the resident would benefit from therapy. Review of the occupational therapy discharge summary for Resident #63, dated 3/1/21 documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 5 of 10 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 04/28/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Functional Maintenance Program established/trained- splint and brace program. Splint for 2 hours a day. Resident does not want to wear more than that and does not want to wear at night. On 4/27/22 at 9:30 a.m., Certified Nursing Assistant (CNA) Staff E said Resident #63 did not have any splints for his hands. She said if a resident had a splint or brace therapy would show the staff how to put it on and take it off. CNA Staff E said she gets report from the previous shift and the nurse would tell her if anything had changed with a resident. On 4/27/22 at 9:31 a.m., Certified Occupational Therapy Assistant (COTA) Staff K said Resident #63 was discharged from services in March 2021 with a resting right-hand splint. The COTA said once a resident was discharged from therapy, they provide the CNA and nurse with education on the use and application of the device, and the resident is considered to be on a Functional Maintenance Program. The COTA confirmed there was no one to oversee the Functional Maintenance Program, she said she suppose it would be the nurse. On 4/27/22 at 9:44 a.m., the Director of Nursing (DON) said once a resident was discharged from therapy with a splint or device, therapy places them on a functional maintenance program and the CNA and nurse would be responsible to ensure the device was applied. The DON confirmed no staff member assigned to ensure the Functional Maintenance Program was followed and the positioning devices were applied. On 4/28/22 at 1:05 p.m., Licensed Practical Nurse (LPN) Staff H said she did not know what the Functional Maintenance Program was or who was responsible to apply splints or braces for residents. On 4/28/22 at 1:06 p.m., LPN Staff I said there was no one to oversee the Functional Maintenance Program or keep track of the residents who had a splint or brace. LPN Staff I said therapy discharges the resident with a splint and educates the staff who care for the resident but there was no record or individual responsible to ensure the splints or braces were applied. On 4/28/22 at 2:03 p.m., the Therapy Director said he had evaluated Resident #63 today and was not able to locate the resident's right hand splint. The Therapy Director said he planned to place him on case load and order a new resting hand splint for the resident's right hand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 6 of 10 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 04/28/2022 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, review of facility's policy, and staff interview, the facility failed to maintained medications in locked compartment when not under direct observation for 1 (400 hall) of 6 medication carts observed. The findings included: The facility policy for medication storage implemented on 4/20/20 and reviewed on 1/2/22 indicated, All drugs and biologicals will be stored in locked compartments i.e., medication carts. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On 4/26/22 at 7:53 a.m., the medication cart in the 400 hall was unlocked. Licensed Practical Nurse (LPN) Staff H was behind closed door in a resident's room. The unlocked cart was not within her direct observation. LPN Staff H returned to the medication cart at 8:01 a.m. Surveyor introduced self and said she was going to observe medication pass for some residents. LPN Staff H stated, I have to go wash my hands. She left the medication cart unlocked and unattended and returned at 8:04 a.m. for an additional 2 minutes. LPN Staff H verified the medication cart was left unlocked and not under direct supervision. She said oh I should have locked it. On 4/26/22 2:55 at p.m., the Director of Nursing (DON) said she would make sure it does not happen again. On 4/26/22 at 4:12 p.m., the medication cart on the 400 hall was observed unlocked and unattended. On 4/26/22 at 4:16 p.m., LPN Staff J returned to the unlocked medication cart and said, I am sorry, my cart should be locked . On 4/26/22 at 5:03 p.m., the observation was shared with the DON. she said, In-services are needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 7 of 10 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 04/28/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and staff interviews, the facility failed to maintain the kitchen in a clean and sanitary manner to prevent possible contamination of food on the tray line from dirty air vents. The lack of sanitation in the kitchen has a potential to affect all residents who consume an oral diet. The findings included: On 4/26/22 at 11:30 a.m., the air vent located directly over the steam table containing uncovered residents' food items had a large accumulation of dust. Photographic evidence obtained On 4/27/22 at 9:00 a.m., the air vent over the steam table remained with a large accumulation of dust. On 4/28/2022 at 9:15 a.m., the Regional Food Service Director verified the air vent over the steam table was covered in dust and debris. He said he would move the steam table, cover the food with plastic bags, and clean the dirty vents himself to prevent further chance of food contamination. He said he was unsure why housekeeping had not gotten to it already. On 4/29/2022, the facility provided a cleaning schedule for the kitchen which included the air vents. The schedule was signed off as completed for March 2022 but not for April 2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 8 of 10 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 04/28/2022 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 0825 Provide or get specialized rehabilitative services as required for a resident. 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, resident and staff interview, the facility failed to provide Therapy Services as ordered by Physician for 1 (Resident #251) of 5 Residents reviewed for Rehabilitation Services. Residents Affected - Few The findings included: Review of the clinical record for Resident #251 revealed she was admitted to the facility on [DATE]. Further review revealed Physician orders on 4/4/22 for physical therapy 5 times a week for 30 days and occupational therapy 5 times a week for 4 weeks. On 4/25/22 at 10:48 a.m., Resident #251 was observed lying in bed sleeping. At 3:45 p.m., was observed sitting in her wheelchair sleeping. On 4/26/22 at 9:35 a.m., Resident #251 was in bed, she said she has not had therapy since last Thursday. No one had talked to her, and she was worried she would get cut from Medicare services since she needs to be attending therapy. On 4/26/22 at 2:00 p.m., Resident #251 was observed sleeping in bed. On 4/27/22 12:40 p.m., Resident #251 was observed in her room sitting up in her wheelchair eating lunch, she stated she had no therapy on 4/26/22. On 4/27/22 at 1:05 p.m., the Rehab Director confirmed Resident #251 was on Therapy caseload. After reviewing therapy schedule, he verified Resident #251 had not received therapy on 4/22/22, 4/23/22, 4/24/22, 4/25/22, and 4/26/22. Therapy Rehab Director confirmed Resident # 251 was scheduled for therapy on Saturday, Monday and Tuesday, and there were no minutes recorded, and he had no explanation why Resident # 251 had not received therapy services on those days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 9 of 10 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 04/28/2022 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. On 4/25/22 at 2:51 p.m., Resident #63 said he was assisted out of bed with the sit to stand mechanical lift and pointed to the lift located in the hall outside of his room. Residents Affected - Few On 4/25/22 through 4/27/22, during random observations, a large amount of debris and grime was observed on the base of the sit to stand lift. Photographic evidence obtained. On 4/27/22 at 3:33 p.m., Certified Nursing Assistant Staff D observed the lift and confirmed there was debris and grime on the base of the sit to stand lift. CNA Staff D confirmed staff used the sit to stand lift daily to assist Resident #63 with transfers. On 4/27/22 at 4:05 p.m., the DON said the facility had no policy for the cleaning and sanitation of the sit to stand lifts and said the CNAs were responsible to clean the lifts and equipment after use. Based on observation, review of the facility policy and procedure, resident and staff interview the facility failed to maintain a clean, and sanitary environment by failure to store resident personal care items in a sanitary manner for 2 (Resident #16 and #31) of 25 rooms observed and failed to ensure shared resident care equipment is routinely cleaned. The findings included: Based on the facility policy Disinfection of Bedpans and Urinals, Copyright 2021 The Compliance Store, LLC: #2. Store bedpans and urinals in the resident's bedside cabinet or drawer. On 4/26/22 at 9:00 a.m., observed unwrapped, unlabeled bedpan resting on the back of the toilet in semi-private bathroom in Resident #31's room. Resident #31 said the bedpan has been there a long time. Photographic Evidence obtained On 4/26/22 at 11:12 a.m., observed unwrapped urinal hanging on the grab bar next to the toilet in the semi-private bathroom of Resident #16's room. Resident #16 said he uses the toilet to urinate and does not use a urinal. Resident #16's daughter, who was visiting at the time, said it bothered her to have the urinal in the bathroom because of germs. Photographic Evidence obtained The same observation of the improperly stored urinal and bedpan in Resident #16 and #31's rooms was made on 4/27/22 at 1:06 p.m., and 4/28/22 at 9:55 a.m. On 4/28/22 at 10:32 a.m., the Director of Nursing observed the unlabeled, uncovered bedpan in Resident #31's bathroom and unlabeled and uncovered urinal in Resident #16's bathroom. She acknowledged they were being stored improperly and not according to facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 10 of 10