Inspection·November 27, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On Monday 11/20/23, LPN Staff S wrote a statement noting the nurse for the 3:00 p.m., to 11:00 p.m., shift stated Resident #1's visitor said that someone had hurt him on the face, but she did not observe any injury. On 11/26/23 at 1:20 p.m., in a telephone interview, Resident #1's friend said on Sunday 11/19/23 when she walked into the resident's room, two CNAs were providing incontinent care. He has wounds on his feet. His foot got bumped causing a lot of pain and agitated him. He was yelling and cursing at the CNAs and said that she had hit him in the left eye and pointed to just below the left eye. One of the CNAs said Resident #1 had hit her in the chest as she was bending over. The CNA did not say that she hit him, but she did not deny hitting him either. She did not say anything either way. She said she was concerned about it because he had never accused anyone of hitting him ever. She reported the incident to LPN Staff S who works on Sundays. LPN Staff S said she would notify the supervisor. Shortly after, the supervisor came in, she looked at Resident #1's eye and said she did not see any redness. She tended to side with the aides because the resident tended to get upset. She said she would go back to the CNAs and get their side of the story. Resident #1's visitor said she never heard back from anyone after that, the supervisor never came back in the room. On 11/26/23 at 2:30 p.m., in a telephone interview, LPN Staff S said on 11/19/23 Resident #1's friend said last weekend the resident's friend reported to her two CNAs were providing care, and one of them hit him in the face. The friend described the staff to her, and what they were wearing. She reported the incident to the desk nurse, LPN Staff T who got up right away and looked for the staff described. On 11/26/23 at 2:45 p.m., in an interview LPN Staff T said when LPN Staff S reported the alleged incident to her, she went in the room to speak to Resident #1. At first, the resident said, nothing happened. When asked again, he pointed to his face and said someone hit him. She said she did not see any marks or bruising. She said Resident #1 would kick or punch when he is being changed. She identified the two CNAs who were providing care to the resident but did not notify anyone about the allegation until the police came to the facility a day or two later. On 11/27/23 at 11:40 a.m., CNA Staff W said on 11/19/23 she was assisting CNA Staff V changing Resident #1. When they turned Resident #1 to his side, CNA Staff V was in front ho him. He grabbed CNA Staff V's hand and kicked her in the chest. Her glasses were hanging on her shirt, and he broke them. On 11/27/23 at 11:46 a.m., CNA Staff V verified on 11/19/23 she helped CNA Staff W providing incontinent care for Resident #1. She said Resident #1 was violent and required two CNAs and two nurses when providing care to him. She said, I do not abuse people. CNA Staff W said she rolled Resident #1 to one side, he does not like that, he wants it done quickly. She said she turned to him and put her hand on his head. Resident #1 then hit her in the chest and broke her glasses. She said she reported the incident to LPN Staff S. The CNA said the resident's friend was in the room, behind the privacy curtain when they were providing care and did not say anything. There was no documentation of steps taken by the facility on 11/19/23 to immediately report, investigate and protect Resident #1 from harm during the investigation. On 11/27/23 at 11:00 a.m., the Director of Nursing (DON) said she was not aware of the allegation of staff to resident abuse until 11/20/23 when the police officer came to the facility. She said no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 2 of 5 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 11/27/2023 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 0607 one called her that Sunday. Level of Harm - Minimal harm or potential for actual harm On 11/27/23 at 1:25 p.m., the Administrator said no one called her on 11/19/23 to report the allegation of abuse. She said she reported it to the appropriate authorities on 11/20/23, Once the police came. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 3 of 5 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 11/27/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, review of facility's policy and procedure, resident and staff interview, the facility failed to ensure the reporting of an allegation of staff to resident abuse to the State Survey Agency, and Adult Protective Services within the specified timeframe for 1 resident (Resident #1) of 3 residents reviewed for abuse. The findings included: Review of the facility's policy, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and injury of unknown origin( ANEMMI) revision 10/2022 noted, with response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect . are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse OR result in bodily injury . The facility procedure noted, any and all staff observing or hearing about such events must report the event immediately to the Administrator, immediate Supervisor AND one of the following: Director of Nursing, ANEMMI Prevention Coordinator, or Risk Manager so that appropriate reporting and investigation procedures take place immediately . Review of the facility's abuse investigations revealed on 11/20/23 (Monday) at approximately 3:20 p.m., a police officer came to the facility to interview Resident #1. Resident #1 stated, sometimes yesterday [Sunday 11/19/23] someone punched him in the face. On Monday 11/20/23, Licensed Practical Nurse (LPN) Staff T documented a statement noting on Sunday afternoon the nurse told her Resident #1's friend said someone hit him. She went to Resident #1 and asked what had happened. Resident #1 replied nothing. The resident's friend again said Resident #1 told her someone hit him. LPN Staff T documented when she asked Resident #1 where he was hit, he said to the left side of his cheek. LPN Staff T documented she spoke to the Certified Nursing Assistant (CNA) who was taking care of the resident. The CNA said Resident #1 refused to be changed, was kicking at them, cursing them, kicking one of the CNAs on her breast, damaging her glasses. On 11/26/23 at 1:20 p.m., in a telephone interview, Resident #1's friend said on Sunday 11/19/23 when she walked into the resident's room, two CNAs were providing incontinent care. He has wounds on his feet. His foot got bumped causing a lot of pain and agitated him. He was yelling and cursing at the CNAs and said that she had hit him in the left eye and pointed to just below the left eye. One of the CNAs said Resident #1 had hit her in the chest as she was bending over. The CNA did not say that she hit him, but she did not deny hitting him either. She did not say anything either way. She said she was concerned about it because he had never accused anyone of hitting him ever. She reported the incident to LPN Staff S who works on Sundays. LPN Staff S said she would notify the supervisor. Shortly after, the supervisor came in, she looked at Resident #1's eye and said she did not see any redness. She tended to side with the aides because the resident tended to get upset. She said she would go back to the CNAs and get their side of the story. Resident #1's visitor said she never heard back from anyone after that, the supervisor never came back in the room. On 11/26/23 at 2:30 p.m., in a telephone interview LPN Staff S verified she worked on Sunday 11/19/23. She verified Resident #1's friend reported to her Resident #1 said two CNAs were providing care, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 4 of 5 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 11/27/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and one of them hit him in the face. She reported the incident to the desk nurse, LPN Staff T who got up right away and looked for the staff described. On 11/26/23 at 2:45 p.m., in an interview LPN Staff T verified on 11/19/23 LPN Staff S reported to her Resident #1's friend said two CNAs were providing care, and one of them hit him in the face. She verified she did not notify anybody until the police came to the facility another day or maybe a couple of days later. There was no documentation that the allegation of staff to resident abuse was reported to the State Survey Agency or Adult Protective Services on 11/19/23 within the required time frame. The abuse investigation noted the allegation was reported to the State Survey Agency and the Abuse Registry on 11/20/23. On 11/27/23 at 11:00 a.m., the Director of Nursing (DON) said she was not aware of the allegation of staff to resident abuse until 11/20/23 when the police officer came to the facility. She said no one called her that Sunday. On 11/27/23 at 1:25 p.m., the Administrator said apparently on 11/19/23 when two CNAs were taking care of Resident #1, he hit CNA Staff V in the shoulder. She said Resident #1's friend visited every Sunday and mentioned the resident reported to the staff nurse that someone hit him. She said no one called her on 11/19/23 to report the allegation of abuse. She said she reported it to the appropriate authorities on 11/20/23, Once the police came. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 5 of 5