Health inspection·June 7, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm paranoia behavior. Resident #4, was accusing staff of stealing, calling out thief loudly, difficult to redirect aware from courtyard door, attempting to bite this writer when turning the resident around. On 7/3/22 LPN Staff F, documented resident #4 refused both breakfast and lunch. Resident #4 stated, I'm not crazy, you cannot fool me, I know what this food is. Residents Affected - Few On 7/5/22 LPN Staff F, documented Resident #4 was refusing meals, alternate meal choices, snacks. Resident stated, I don't know what you are saying. Resident has poor safety awareness and transfers multiple times throughout the day and is unsteady. Resident unable to understand or repeat verbal education to call for assistance before transferring. On 7/7/22 the Psychiatry evaluation noted the resident was alert and oriented x1 (person) and pleasantly confused on interview. Nursing reports her dementia persists, but no additional behaviors or concerns reported from staff. She remains compliant on her psychotropic medications without evidence of any medication side effects. On 7/8/22 at 11:20 a.m., LPN Staff F, documented Resident #4 threw an entire cup of Ensure over the nurse and yelled, Evil, Evil, Evil, you are lazy! You are a thief! Resident also grabbed a CNA (Certified Nursing Assistant) this morning and purposely scratched her causing bleeding, she scratched another CNA. Staff F documented the resident refused her medications, and food stating it was poisonous. On 7/9/22 at 5:00 p.m., LPN Staff F, documented Resident #4 refused 5:00 p.m. medications and dinner. The resident stated it is poisonous. Resident continually standing up from wheelchair and is unsteady when standing. Attempts to educate on safety awareness unsuccessful as resident attempts to bite, and hit and states, I don't care what you or anyone says. Resident continually going into male residents rooms and when asked to leave their room she yells at them, No!, you will not steal this room from me and you cannot make me leave. On 7/10/22 at 1:19 p.m., LPN Staff F documented Resident #4 refused both breakfast and lunch today. The resident stated, you are trying to poison me. Stop it!, stop trying to make me eat poison, you are not going to kill me. Resident continued to hit, bite and punch CNAs and nurses. The clinical record lacked documentation the physician was notified of the sudden increase in behaviors. There was no documentation of interventions to ensure adequate supervision to prevent unsafe transfers, ambulation, and wandering. A facility Incident report dated 7/11/22 at 8:10 p.m. noted Resident #4 was found on the floor next to bed with a hematoma (collection of blood in the tissues) to the forehead, a laceration to the nose. The resident was confused and complained of right hip discomfort. The resident was unable to give a description of what happened. The resident was transferred to the local hospital for evaluation of treatment of injuries to the head. On 6/6/23 at 4:30 p.m., the physician said she was not aware Resident #4 had been refusing medications, meals, assaulting staff and wandering in male rooms. She said the facility should have notified her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 2 of 6 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 06/07/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 6/7/23 at 12:18 p.m., the Advanced Practice Registered Nurse (APRN) said most of her interactions were with Resident #4's family after the resident returned from the hospital in July. She said she did not recall receiving any notification regarding behaviors, agitation, aggression. She said she would have wanted to be notified of the behaviors. On 6/7/23 at 4:00 p.m., the Director of Nursing (DON) said the facility's policy was to report any change in condition to the physician and the family should be called. She said she could not recall if staff notified her of the resident's onset of behaviors. She verified the lack of documentation the physician was notified of the resident's behaviors, including refusal to take her medications. The DON said, As a DON, I feel like the physician should have been notified. Event ID: Facility ID: 105497 If continuation sheet Page 3 of 6 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 06/07/2023 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy and procedures, record review, and staff interviews, the facility failed to accurately assess and reassess risk factors and provide necessary supervision and assistance to prevent falls, for 1 (Resident #4) of 3 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility, including a fall with injury requiring the resident's transfer to a higher level of care. The findings included: A review of the facility policy and procedure, Falls Prevention program, stated that each Resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Review of the clinical record for Resident #4 revealed a hospital physician progress note dated 6/7/22 which noted the resident was getting out of the shower and apparently fell and hit her head. The resident seemed a bit confused. The resident's friend stated the resident was unable to take care of herself alone any longer, as this was not the first fall she's had. Resident #4 was admitted to the facility on [DATE] with diagnoses including acute Right Cerebellar Infarct (Stroke), falls, hypertension (High blood pressure), Diabetes Type 2, and dementia. The admission Minimum Data Set (MDS) (a standardized assessment tool to measure the health status of nursing home residents), effective on June 18, 2022, noted the Resident scored 3 on the Brief Interview of Mental Status, indicating severe cognitive impairment. Resident #4 was not able to report the correct year, correct month, or correct day of the week. The resident was not able to recall the words sock, blue or bed during the interview. Resident #4 required limited physical assistance of one person for transfer. The admission MDS assessment was inaccurate and noted Resident #4 did not have a fall any time in the last month prior to admission. The fall risk evaluation tool utilized by the facility noted to assess the resident status. If the total score is 10 or greater, the resident should be considered high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. The fall risk evaluation dated 6/14/22 for Resident #4 was inaccurate and noted the resident had no history of falls in the past three months. Resident #4 scored 8 on the fall risk evaluation. The care plan initiated on 6/14/22 identified Resident #4 as at risk for falls and fall-related injuries related to impaired mobility. Interventions were documented as anticipate needs, provide prompt assistance, ensure call light is within use and encourage use for assistance with standing, transferring, ambulation; follow facility fall protocol; invite, encourage, remind, escort to activity program; keep frequently used items within reach; review information on past falls and attempt to determine cause of falls; record possible root causes, alter, remove and potential causes if possible. The care plan also noted the resident was at risk for decreased ability to perform activities of daily living related to impaired mobility, recent illness, and hospitalization, including transfer, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 4 of 6 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 06/07/2023 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 0689 locomotion. Level of Harm - Actual harm On 6/15/22 an activity progress note documented the Activity Director met the resident for an admission Assessment. Resident #4 was, quite confused and unable to answer questions. A call was made to the contact person to assist with the admission assessment. Residents Affected - Few On 6/26/22 a nursing progress note documented Resident #4 was oriented to self only. Review of the Physical Therapy progress report dated 6/28/2022 noted Resident #4 was able to perform functional transfers such as: coming to a standing position from a bed or wheelchair and transferring to and from a bed to a wheelchair with partial assistance. The resident was able to ambulate 15 feet with two wheel walker and contact guard assist, however required constant verbal cues for safety. The therapist documented due to the documented physical impairments and associated functional deficits, without skilled therapeutic interventions, the resident was at risk for falls. On 6/30/22, Licensed Practical Nurse (LPN) staff F documented Resident #4 was observed sitting in the hallway in her wheelchair and stood up and fell; no injuries were identified. The care plan was updated on 6/30/22 to encourage the resident to not stand without assistance. On 6/7/23 at 2:15 p.m., the Director of Nursing (DON) said Resident #4 was not able to understand instructions in general. The intervention to, Encourage her to call for assistance was not something she could have done. The DON said she did the investigation. She said, I had no idea what she was wearing, what she was going to do or where she was trying to go. I was not there so I don't know if she was hungry, thirsty, or looking for something to eat. She said she did not have any documentation to reflect what interventions were in place at the time of the fall. On 7/1/22, LPN Staff C documented in a progress note Resident #4 was observed having paranoid behaviors. The progress note stated, Resident was accusing staff of stealing, calling out thief loudly, difficult to redirect away from courtyard door, attempting to bite this writer when turning the resident around. On 7/5/22, LPN Staff F documented Resident has poor safety awareness and transfers multiple times throughout the day and is unsteady. Resident #4 was unable to understand or repeat verbal education to call for assistance before transferring. On 7/9/22 at 5:00 p.m., LPN Staff F documented resident refused 5 p.m. medication and dinner and stated, It is poisonous. The Resident continually stands up from the wheelchair and is unsteady when standing. Attempts to educate on safety awareness were unsuccessful as the Resident attempted to bite and hit and stated, I don't care what you or anyone says. Resident continually went into male residents' rooms, and when asked to leave their room, she yells at them, No!, you will not steal this room from me, and you cannot make me leave. On 7/10/22 at 1:19 p.m., LPN Staff F documented resident refused both breakfast and lunch today, stating you are trying to poison me. Stop it! stop trying to make me eat poison; you are not going to kill me. Resident continued to hit, bite and punch CNAs and nurses. The clinical record lacked documentation the physician was notified of the increased in behavior. There was no documentation the resident's fall risk was reassessed for the need of increased (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 5 of 6 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 06/07/2023 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 0689 supervision due to the increase in behavior, including continually standing up, wandering into other residents' rooms, and the resident's inability to understand safety instructions. Level of Harm - Actual harm Residents Affected - Few On 7/11/22, a facility incident report noted Resident #4 was found on the floor next to the bed with a hematoma (blood collection in the tissues) to the forehead, and a laceration to the nose. The Resident was confused (as was reported at shift change) and complained of right hip discomfort. The Resident was unable to describe what happened. The Resident was transferred to the local hospital for evaluation and possible sutures. The predisposing situation factors included, Ambulating without Assist. The physician progress note from the local hospital dated 7/11/22 noted the resident was seen at 10:32 a.m. for an injury to the face. The injury occurred just prior to arrival. Staff told EMS (Emergency Medical Services) that while she was putting on her pants she missed her leg and fell forward onto her face causing a laceration to bridge of the nose and a hematoma on the central forehead. The decision was made on 7/11/22 at 2:12 p.m. to discharge the resident to the facility. On 6/7/23 review of the investigation dated 7/11/22 showed witness statements noting staff found the resident on the floor on 7/11/22 at 7:50 p.m. and the nurse assessed the resident on 7/11/22 at 8:53 p.m. On 6/7/23 the DON provided a statement from the physician which noted the Cerebellar infarct, which was new, but the timeline couldn't tell if it was pre-fall or a result of the fall. This pathology would have caused the fall and contribute to subsequent falls, as her ability to balance would have been lost . On 6/7/23 at 4:11 p.m., the DON said, We don't have any witness statements for the morning fall. The witness statements we have are null and void. She said the nurse who was on duty at the time of the fall did not write an incident report. She said there was no report of the incident from the day shift at all. The DON said, We know she was found face down on the floor, but we don't know how she got there. Last rounds are usually done at 6:00 a.m., but I am not able to access records to confirm last care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105497 If continuation sheet Page 6 of 6