Inspection·August 26, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/24/21 at 10:36 a.m., Resident #36 said she didn't remember the last time anyone had cleaned the bedroom and bathroom floors and the caulking around the toilet base had been missing for a long time. On 8/26/21 at 10:34 a.m., License Practical Nurse (LPN) Staff J said if he saw any room or facility damage, he would tell the Maintenance Director and fill out a maintenance slip which he would leave in a basket at the nurse's station, he would not put the information into the TELS (tracking) system. On 8/26/21 at 10:40 a.m., the Activity Assistant said if she observed any room or facility damage, she would go to the front desk and let them know what she saw. She said she was not told she had to document any concerns and or room damage into the TELS system. On 8/26/21 at 10:44 a.m., Housekeeping Staff I said if she observed any room or facility damage, she would report it to the Maintenance Director. She said she was not told she had to document what she saw into the TELS system. On 8/26/21 at 10:55 a.m., the Maintenance Director said all the facility staff were required to put all room damage and/or concerns into the TELS computer system. He printed 3 copies, one for him, his assistant, and the Administrator, every morning and split the work to be done between him and his assistant. He said he also reviewed the TELS system several times a day for any other concerns that needed to be addressed. He pulled the TELS work orders for this week and proceeded to conduct an environmental tour of the facility. The Maintenance Director confirmed the rooms from 150 to 170 floor tiles were discolored with a thick wax build up on the bathroom floor tiles and the vent in the bathrooms had a thick layer of dust. rooms [ROOM NUMBERS] had missing floor tiles. room [ROOM NUMBER], the drywall behind the window bed was damaged and part of the caulking around the base of the toilet was missing and discolored. room [ROOM NUMBER], the caulking around the base of the toilet was missing in some places and was discolored. room [ROOM NUMBER], the drywall next to the bathroom door was damaged, the metal corner strip was showing, and the caulking around the base of the toilet was missing in some places and was discolored. room [ROOM NUMBER], the drywall across from bed A was damaged and the caulking around the base of the toilet was missing in some places and was discolored. He said all the areas identified were not put into the TELS system as required and he was unaware of the areas we identified during the tour. On 8/26/21 at 11:25 a.m., the Maintenance Director said he was currently the Maintenance and Housekeeping Director. He stated due to the facility being short staffed in the kitchen, he had been sending the housekeeping staff to assist in the kitchen, causing him to be short a housekeeper to maintain the floors and dusting in the resident's room. He said he had not stripped and waxed the floors in the resident's room in a long time and that he had recognized there was a problem with the floors and was working on a schedule to start addressing the wax buildup, missing floor tile, and the missing caulking and discoloration around the base of the toilets in the resident's rooms. On 8/26/21 review of the Guardian Angel Rounds policy, not dated, stated the Department Managers would be assigned a block of rooms. Three times a week they would visit the residents in their section and complete the Room Rounds form and bring the completed form to the next morning meeting for review. Any maintenance or housekeeping issues should be entered into the TELS system. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 2 of 11 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Guardian Angel Room Round form dated 8/23/21, documents for rooms 160 to 168 stated the floors in those rooms needed cleaning, the paint in most rooms was scratched, room [ROOM NUMBER] needed new window blinds, there was a gap behind the air conditioner, and there were missing floor tiles in rooms [ROOM NUMBERS]. On 8/26/21 at 1:10 p.m., the Rehabilitation Director said she did the Guardian Angel Rounds for rooms 160 to 168 once a week and documented her findings on the Room Rounds form. She said she was not aware the Guardian Angel Rounds policy stated the Angel Rounds should be completed 3 times a week. She confirmed she filled out the Room Rounds form dated 8/23/21 for rooms 160 to 168. She also confirmed she had documented the floors in those rooms needed cleaning, the paint in most rooms was scratched, room [ROOM NUMBER] needed new window blinds and there was a gap behind the air conditioner and there were missing floor tiles in rooms [ROOM NUMBERS]. She said she brought the Room Round form to the morning meeting but did not document her findings in the TELS system. On 8/26/21 at 1:45 p.m., in an interview the Administrator (AD) said due to staff shortage in dietary they had been pulling the housekeeping staff to work in the kitchen. She confirmed Guardian Angel Rounds policy stated the Department Managers were required to monitor resident's rooms for cleanliness and room damage and document their findings on the back of the form. She confirmed the Room Rounds form dated 8/23/21 for rooms 160 to 168 stated the floors in those rooms need cleaning, the paint in most rooms was scratched, and there were missing floor tiles in rooms [ROOM NUMBERS]. She also confirmed the room damage and concerns were not documented in the TELS system and addressed by the Maintenance Director as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 3 of 11 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure 1 (Resident #55) of 2 residents reviewed for activities of daily living for grooming had nail care completed in a timely manner. The lack of routine grooming could affect a resident's psychosocial well-being and the prevention of infection. Residents Affected - Few The findings included: On 8/24/21 at 10:04 a.m., observed Resident #55 in bed with her feet exposed. This observation revealed, all of Resident #55's toenails were long, discolored, and thick. The right foot big toenail and 4th toenail extended approximately ½ inch from the base. The left foot big toenail extended ½ inch and curved at a 90-degree angle to the toe. On 8/26/21 review of the facility policy titled, Care of Fingernails/Toenails version 1.2, stated the purpose of this procedure was to clean the nail bed, to keep nails trimmed, and to prevent infections. Under the General Guidelines it stated nail care included daily cleaning and regular trimming. The staff were to report any changes in color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, and swelling, bleeding, etc. Staff should stop and report to the nurse supervisor if evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. On 8/25/21 at 11:45 a.m., Occupational Therapist (OT) Staff G said he had been working with Resident #55 for the past 2 weeks for positioning to her left hand and right leg. He said he had taken a picture on 8/23/21 (Monday) showing how he wanted Resident #55 positioned with the pillow between her legs. The picture showed Resident #55's right foot with the long toenails. He said Resident #55's feet had looked like that for a long time and did not remember the last time Resident #55's toenails were trimmed. On 8/25/21 at 11:58 a.m., observation of Resident #55's toenails was done with Staff G and the Director of Rehabilitation (DOR). They confirmed all of Resident #55's toenails were long, discolored, and thick. They also confirmed the left foot big toenail was approximately ½ inch long and at a 90-degree angle to the toe and the right foot big toenail and 4th toenail were also approximately ½ inch long. Resident #55 said when Staff G touched the left foot big toenail it hurt. Staff G and DOR said it appeared Resident #55's toenails had not been cut or trimmed in a long time. On 8/25/21 at 12:30 p.m., the Regional Nurse Consultant said she just did an evaluation of Resident #55's feet and confirmed all of Resident #55's toenails were long, discolored, and thick. She also confirmed the left foot big toenail was approximately ½ inch long and at a 90-degree angle to the toe and the right foot big toenail and 4th toenail were also approximately ½ inch long. She said Resident #55 told her during her evaluation of her feet, the left foot big toenail hurt when it was touched. She said she reviewed Resident #55's medical record and could not find documentation she was being seen by podiatry services. On 8/25/21 at 12:45 p.m., the Director of Nursing said after reviewing Resident #55's medical record, she was unable to find documentation the facility staff were trimming Resident #55's toenails as required in the Care of Fingernail/Toenails facility policy. She further said neither the nursing staff nor the therapy staff had reported Resident #55's long toenails to the primary care physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 4 of 11 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0676 for referral to podiatry services to address Resident #55's toenails. Level of Harm - Minimal harm or potential for actual harm On 8/26/21 at 1:30 p.m., the Administrator (AD) confirmed the facility policy, Care of Fingernails/Toenail stated staff are required to monitor resident's fingernails and toenails for changes in color, poor circulation, cracking and evidence of ingrown nails, infection, pain and if the nails are hard or too thick to cut easy. She confirmed Resident #55's toenails on both feet were thick, discolored, and long. She confirmed the facility did not keep Resident #55's toenails clean and trimmed as required to prevent infection and did not report their findings to the primary care physician and/or initiated podiatry services to address Resident #55's toenails as required. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 5 of 11 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. 2. On 8/23/21 at 9:41 a.m. and 3:45 p.m., observed Resident #17 in her bed with both upper side rails in the up position. On 8/24/21 at 9:00 a.m. and 3:55 p.m., observed Resident #17 in her bed with both upper side rails in the up position. On 8/25/21 at 9:05 a.m. and 3:45 p.m., observed Resident #17 in her bed with both upper side rails in the up position. On 8/25/21 review of facility policy titled, The Proper Use of Side Rails version 1.3 stated side rails are only permissible if they are used to treat a resident's medical symptoms to assist with mobility and transfer of residents. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails and will be addressed in the resident care plan. On 8/25/21 review of Resident #17's medical record revealed she was admitted to the facility 12/18/18. The Side Rail/Entrapment Evaluation form dated 11/20/19, noted side rails were not necessary at the time. The Entrapment Risk Evaluation section of the form was not completed. The Quarterly/Annual/Significant Change Nursing Evaluation form dated 5/29/21, section B stated side rails were not necessary at this time. The Entrapment Risk Evaluation section of the form was not completed. Further review of the medical record revealed no physician's order for the use of the 2 upper side rails. On 8/25/21 at 4:02 p.m., Certified Nursing Assistant (CNA) Staff H confirmed Resident #17 was in her bed, with both upper side rails in the up position. Staff H reviewed Resident #17's Kardex and Task documentation and said Resident #17 was not coded for the use of side rails. She said Resident #17 was not care planned for the use of the side rails and they should not be in use. On 8/25/21 at 4:13 p.m., the Director of Nursing (DON) via observation confirmed Resident #17's was in her bed with both upper side rails in the up positions. The DON said prior to the use of side rails, a resident evaluation for the use of side rails and an entrapment evaluation must be completed. Then the facility would obtain a consent for the use of the side rails, a physician's order for the side rails, and the plan of care and the CNA's Kardex would be updated to note the use of the side rails. The DON reviewed Resident #17's medical record and confirmed the Side Rail/Entrapment Evaluation form dated 11/20/19 and the Quarterly/Annual/Significant Change Nursing Evaluation form dated 5/29/21 stated, side rails were not necessary at the time. She further said they did not have a consent for the use of the side rails and a physician's order for the use of side rails for Resident #17 as required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 6 of 11 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 105523 B. Wing (X3) DATE SURVEY COMPLETED A. Building 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0700 Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interviews, and facility policy review, the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 residents (Resident #4 and #17) of 3 residents reviewed for bed rails. The findings included: Residents Affected - Few 1. Review of facility policy titled, Proper Use of Side Rails revised December 2016 which stated, The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. And The use of side rails as an assistive device will be addressed in the resident care plan. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. On 8/23/21 at 10:00 a.m., Resident #4 was observed in bed asleep, with elevated side rails in use on both sides of his bed. On 8/24/21 at 10:47 a.m., Resident #4 bed observed with side rails elevated. On 8/25/21 at 8:41 a.m., Resident #4 observed awake in bed side rails elevated on both sides of bed. On 8/26/21 at 9:00 a.m., Resident#4 observed in bed side rails elevated on both sides of bed. On 8/25/21 clinical records were reviewed for Resident #4 including care plan, current orders, and consents. No documented physician order for side rails, no care plan for side rails, and no consent for side rails was present in clinical record for Resident #4. Resident #4 was admitted to facility on 2/19/21. On 8/26/21 at 9:10 a.m., interviewed Licensed Practical Nurse (LPN) Staff D, who confirmed Resident #4 had side rails the entire time he had cared for him while at the facility. On 8/26/21 at 10:03 a.m., Unit Manager Staff C confirmed the process for putting side rails on any residents' bed included a side rail assessment, obtaining consent, two copies of the consent were made, one with resident's records and one to Director of Nursing (DON). Unit Manager Staff C confirmed Resident #4 had side rails on both sides of his bed. Unit Manager Staff C was unable to find a side rail consent for resident in clinical record. On 8/26/21 at 10:44 a.m., interviewed DON who confirmed she did not have a copy of the consent for side rails for Resident #4. DON said, I looked in the electronic medical record and he does not have a consent in his file. I do not have one for him. On 8/26/21 at 11:13 a.m., interviewed Certified Nursing Assistant (CNA) Staff E who said, regarding Resident #4's side rails, He has had the side rails the entire time I have worked with him since his admission. On 8/26/21 at 12:30 p.m. interviewed Minimum Data Set (MDS) Coordinator, Staff F who said side rails should be present on the resident care plan. MDS Coordinator Staff F, said she was unable to find side rails documented on the resident care plan. MDS Coordinator Staff F said, I do not see it on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 7 of 11 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete his current care plan, and I do not find it on his resolved care plans. Of course, I will be adding it immediately. I see they added an order today for the side rails and that is usually what triggers us to add to the care plans. On 8/26/21 at 1:42 p.m., interviewed Assistant Director of Nursing (ADON) and DON. Both confirmed Resident #4 did not have a physician order for the side rails observed in use. Both confirmed side rail use had never been care planned for Resident #4. Both confirmed they did not have the required consent needed to use side rails at the facility. Event ID: Facility ID: 105523 If continuation sheet Page 8 of 11 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and procedure and staff interviews, the facility failed to assure the facility's medication cart was locked and under direct observation of authorized staff in an area where residents and staff could access it for 1 of 2 medication carts reviewed. The findings included: Review of facility policy titled, Medication Storage in the Facility, dated April 2018, stated in policy section, Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 8/24/21 at 3:17 p.m., medication cart C was observed unlocked and unattended with drawers facing hallway by resident room [ROOM NUMBER]. Two residents were observed independently moving via wheelchairs in hallway near cart while unattended. On 8/24/21 at 3:23 p.m., observed Licensed Practical Nurse (LPN) Staff A lock medication cart as she was preparing to leave facility. LPN Staff A confirmed the cart had been unlocked, that she had given report, gone thru the cart, and left the oncoming nurse LPN Staff B, at the open cart. On 8/24/21 at 3:29 p.m., in an interview, LPN Staff B verified she left the medication cart unlocked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 9 of 11 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation, record review, and staff interview, the facility failed to conduct regular inspection of all bed frames, mattresses, and side bed rails, as part of a regular maintenance program to identify areas of possible entrapment. The findings included: On 8/26/21 at 10:00 a.m., the Director of Nursing (DON) said the facility staff conducted a facility wide side rail audit to determine how many facility beds had side rails attached, how many residents had side rails on the bed, and which resident had orders for the use of the side rails. She said they currently had a resident census of 80, with 41 facility beds with side rails attached and 38 residents evaluated for the use of the side rails which was confirmed via a tour of the facility. On 8/26/21 review of the facility's Bed Maintenance and Inspection policy dated 11/2017, #5 stated, bed frame, mattress, and bed rail inspections will be conducted upon each item entering the facility and then place on a regularly scheduled inspection and maintenance cycle according to the manufacture's recommendations, to include manufacturer's timeframe recommendation. The Bed Entrapment Guide by Direct Supply under Implement Quality Monitoring section, stated to reduce the risk of entrapment in a facility, it will be necessary to closely monitor plans of action to ensure your residents stay protected. Monitoring should be done on an ongoing basis. The Preventative Maintenance and Entrapment Risk Inspection dated 1/17/17 stated the purpose of the policy is to provide a safe environment for the resident to prevent entrapment risk, through initial and regular preventative maintenance and inspections of resident bed frames, mattresses, and bed rails. Under the Entrapment Inspection/Preventative Maintenance Procedure stated during the weekly and monthly preventative maintenance, the maintenance personnel will follow guidelines to inspect bed rails to note any entrapment location/measurements indicating immediate removal of equipment, corrective action. On 8/26/21 at 11:20 a.m., the Director of Maintenance (DOM) said he got notified by nursing when a bed needed side rails. He would then attach the side rails and make sure they were in good working order and within specification. He said once he attached the side rails, he didn't do anything else with the side rails unless someone told him there was an issue with a side rail and then he would check and fix the side rail issue. He said he didn't know which resident beds currently had side rails on them and would have to ask nursing to find out which beds had side rails. On 8/26/21 at 11:40 a.m., the DOM said the Bed Maintenance, Bed Entrapment Guide, and the Preventative Maintenance and Entrapment Risk Inspection policy and procedures were the facility's current policies for installing, monitoring the safety, and continued maintenance of the resident's beds with side rails attached. The DOM said he did not have a system in place or documentation for monitoring resident's bed with side rails to ensure the side rails/bedrail stayed within factory specifications on a regular inspection and maintenance schedule as required in the Bed Maintenance and Inspection policy. On 8/26/21 at 12:45 p.m. interview with the Administrator (AD) confirmed the Bed Maintenance and Inspection policy stated bed frame, mattress, and bed rail inspections would be conducted upon each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 10 of 11 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0909 item entering the facility and then placed on a regularly scheduled inspection and maintenance cycle. Level of Harm - Minimal harm or potential for actual harm The AD said she was unaware the DOM was not monitoring the side rails after installation. She said administrative staff had divided up the facility and did weekly rounds in their section and were required to write down their findings on the Room Round form. She said as part of their weekly rounds they should be inspecting the side rails to ensure they remain safe for the residents to use. Residents Affected - Some After reviewing the Room Rounds form, the AD stated there was not a section for the administrative staff to document they had conducted a side rails evaluation for safety, entrapment, and the side rail remaining within factory specification. On 8/26/21 at 2:07 p.m., during an interview with Rehabilitation Director, she said she was assigned to do weekly room rounds for rooms 160 to 168. She confirmed, after reviewing the Room Rounds form dated 8/23/21, it did not have a section for side rail assessment. She said she was unaware until that day they were responsible to inspect the side rails on the resident's bed for entrapment, safety, and ensure they remained within manufactures specification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 11 of 11