Inspection·July 23, 2021

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few minutes showed Resident #14 requested for staff to check the call light board behind the nursing station on Garden View. On 7/20/21 at 12:30 p.m., room [ROOM NUMBER]'s call light was observed to have a light on at the Garden View nursing station (Rooms 100-200s). There was no audible sound noted coming from the call light board to alert staff the call light was on. Certified Nursing Assistant (CNA) Staff A present during the observation verified the call light system was not sounding at the nursing station. On 7/20/21 at 1:30 p.m., in an interview the Activity Director said residents complained of call light response time at every resident council meeting. She said she did not document the issue at every meeting because she considered the issue old business. The Activity Director verified the residents complained about the call light system not working. She also verified the DON was present at the last meeting when residents asked for the call light system be checked. On 7/21/21 at 11:30 a.m., in an interview the Maintenance Director verified the call light system not sounding had been an issue for over 4 months. He said a company came to check the system. They told him it needed to be replaced and it would cost $8,000. The Maintenance Director said he notified the owners of the facility, and they said no. He said the system was worked on was 4 months ago and staff had not reported any issues with the system since then. On 7/21/21 at approximately 1:00 p.m., the DON said he was not aware of there being an issue with the call light system on Garden View. He verified residents had been complaining of call light response time and he audited the call lights response time. The DON provided documentation of call light response time audit for the Lake View Nursing Station (room [ROOM NUMBER]-400s) but no audit of call light response time for the Garden View (room [ROOM NUMBER]-200s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 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 105761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Lake Healthcare and Rehabilitation Center 832 Sunset Lake Boulevard 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 7/19/21 at 11:28 a.m., in an interview with Resident #389, she said she was admitted on [DATE] and no one spoke with her about her plan of care or gave her a copy. On 7/20/21 at 11:30 a.m., in an interview the Minimum Data Set (MDS) coordinator verified the baseline care plan was not completed for the resident. 6. On 7/20/21 at 11:00 a.m., record review showed Resident #387 was admitted to the facility on [DATE]. The clinical record lacked documentation of a baseline care plan. On 7/20/21 at 11:30 a.m., a copy of incomplete/unsigned baseline care plan for Resident #387 was obtained from MDS Coordinator Staff E. She verified that baseline care plan was incomplete for the resident. On 7/21/21 at 11:30 a.m., in an interview, Licensed Practical Nurse (LPN) Staff B said she did not do baseline care plans with residents. On 7/21/21 at 11:45 a.m., in an interview, Registered Nurse Staff F said it was MDS Coordinator Staff E's responsibility to go over Baseline Care plans with the residents. Based on record review, staff and resident interview, the facility failed to provide the resident and the representative, if applicable, with a written summary of the baseline care plan which included initial goals and a summary of current medications and dietary instructions for 6 (Resident #69, #79, #287, #288, #387, and #389) of 9 residents reviewed for baseline care plans. This has the potential to cause confusion as to the care expected to be provided by the facility. The findings included: The facility's policy for Care Plans - Baseline Revised 12/16 read, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. 1. On 7/19/21 at 3:15 p.m., Resident #69 said he did not recall receiving a written summary of the baseline care plan. On 7/20/21, record review revealed an admission date of 4/27/21. There was no evidence a written summary of the baseline care plan, which included initial goals, a summary of current medications, and dietary instructions was provided to the resident or resident representative as required. 2. On 7/20/21 at 1:33 p.m., Resident #79's son said he did not recall receiving a written summary of the baseline care plan. On 7/21/21, record review revealed and admission date of 6/25/2. There was no evidence 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 representative as required. 3. On 7/19/21 at 10:40 a.m., Resident #287 said she did not receive a written summary of the baseline care plan. On 7/20/21, record review revealed an admission date of 7/1/21. There was no evidence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 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 105761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Lake Healthcare and Rehabilitation Center 832 Sunset Lake Boulevard 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 4. On 7/19/21 at 10:48 a.m., Resident #288 said she did not receive a written summary of the baseline care plan. On 7/21/21, record review revealed an admission date of 7/3/21. There was no evidence 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 7/21/21 at 9:58 a.m., in an interview Registered Nurse (RN) Staff C said she completed an assessment of new residents, but it did not include a baseline care plan. On 7/21/21 at 10:10 a.m., in an interview Licensed Practical Nurse (LPN) Staff H said she did not complete a baseline care plan as part of the admission process. On 7/21/21 at 11:15 a.m., in an interview the Director of Nursing (DON) confirmed there was no documented evidence Resident #69, #79, #288, #287, #387, and #389 or the resident representative were provided with a written summary of the baseline care plan that included initial goals and a summary of current medications and dietary instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 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 105761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Lake Healthcare and Rehabilitation Center 832 Sunset Lake Boulevard 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation and interview the facility failed to ensure alarmed exit doors in the building were functioning properly to prevent cognitively impaired residents assessed as elopement risk from leaving a safe area without supervision. The findings included: On 7/22/21 at 11:10 a.m., in an interview the Director of Maintenance said when opened the courtyard gates leading to the parking lot of the facility needed to be closed within three seconds. If the door was not closed within three seconds, it did not latch properly unless the door is physically pushed back into place. The Maintenance Director said he was told Resident #66 kicked the door opened last Friday. He said it was impossible to kick the door opened when it is properly latched. The Maintenance Director said staff went in and out of the gate to get to their cars and they did not ensure the gate is latched. He said he had to place a sign on the gate in large letter to remind staff to make sure the gate is locked. He was not aware of anything the facility had done after resident #66 left the building through the gate. On 7/22/20 at 11:30 a.m., the front gate of the courtyard was observed with the Director of Nursing (DON). A sign was on the door read Ensure gate is locked. The DON entered a pin on the keypad and opened the door. After 3 seconds, an audible click was heard, and the door would not latch until the DON forcefully pushed the door into the locking mechanism. Once the door was in place, the DON pushed on the door which opened easily without entering the pin on the keypad. The DON verified the gate was not properly secured and any unsupervised resident could easily go through the gate into the parking lot. He said when Resident #66 went through the gate on Friday, he did not complete an incident report or an investigation since the Maintenance Director assured him the gate was properly functioning. On 7/22/21 at 3:40 p.m. in an interview the Administrator and Regional nurse verified a resident did exit the facility through the courtyard gate and the concern with the locking mechanism of the gate was not identified and fixed. The Administrator said residents who had dementia and at risk for elopement were able to go in the courtyard where the open gate was observed. He acknowledged this was a concern. On 7/23/21 at approximately 9:00 a.m., in an interview the Maintenance Director said the previous owners had cameras installed but no one was monitoring them. He said in December 2020 after a resident eloped through the courtyard gate, he placed the sign on the gate to alert staff to make sure the door was latched when going out the gate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 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 105761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Lake Healthcare and Rehabilitation Center 832 Sunset Lake Boulevard 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, clinical record review, policy and procedure review, and staff and resident interview, the facility failed to handle urinary catheter (a tube inserted into the bladder to drain urine) bag and tubing in accordance with infection control standards of practice (guidelines used in healthcare settings to prevent the spread of infection) for 1 (Resident #9) of 2 residents sampled with indwelling catheters. The findings included: The facility policy Catheter Care, Urinary documented, The purpose of this procedure is to prevent catheter-associated urinary tract infections . Be sure the catheter tubing and drainage bag are kept off the floor. Record review showed Resident #9 required a suprapubic catheter due to a neurogenic bladder. Resident #9 required assistance of staff for all activities of daily living. On 7/19/21 at 9:52 a.m., Resident #9 was observed sitting in a wheelchair in his room. The catheter drainage bag was on the floor, and not in a privacy bag. The catheter tubing was on the floor. On 7/19/21 at 1:25 p.m., during an observation, Resident #9 was in bed with the catheter drainage bag uncovered and lying on the brakes of the bed and resting on the bedside table leg. On 7/20/21 at 9:27 a.m., during an observation, Resident #9 was out of bed in his wheelchair. The catheter drainage bag was in a privacy bag attached to the wheelchair. The tubing was unsecured and was on the floor. **Photographic Evidence Obtained** On 7/19/21 at 1:26 p.m., in an interview Resident #9 said the staff provided the care for the catheter. On 7/21/21 at 9:10 a.m., in an interview, Licensed Practical Nurse (LPN) Staff H said all staff were responsible for catheter care. The LPN was able to describe the placement of the drainage bag. The LPN confirmed the drainage bags should be below the level of the bladder and not on the floor. The LPN said some residents did not want to use a privacy bag. The LPN confirmed the catheter drainage bag and tubing should be off the floor. On 7/21/21 at 9:13 a.m., in an interview, Certified Nursing Assistant (CNA) Staff N said after providing catheter care, she secured the catheter and tubing. On 7/21/21 at 3:53 p.m., in an interview, CNA Staff L said after completing catheter care she placed the drainage bag in a privacy cover and secured it on the side of the bed or wheelchair. The CNA said the tubing and drainage bag should not be on the floor. On 7/21/21 at 9:47 a.m., the facility Infection Preventionist said the catheter drainage bag and tubing should not be on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 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 105761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Lake Healthcare and Rehabilitation Center 832 Sunset Lake Boulevard 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on clinical record review and staff interview, the facility failed to follow through with Consultant Pharmacist recommendations for gradual dose reduction of psychotropic medications for 1 (Resident #7) of 5 residents reviewed for unnecessary medications. The failure to ensure gradual dose reductions has the potential for residents to continue to receive medications that are no longer necessary. The findings included: The facility policy, Tapering Medications and Gradual Dose Reduction (revised 4/07) specified: 1. After medications are ordered for a resident the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. 2. All medications shall be considered for possible tapering. Tapering that is applicable to antipsychotic (medications that affect a person's thinking) medications shall be referred to as gradual dose reduction. 3. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Clinical record review for Resident #7 showed diagnoses including adjustment disorder, anxiety, depression, psychotic disorder with delusions, bipolar disorder, and post-traumatic stress disorder (PTSD). The physician monthly orders for July 2021 showed Resident #7 was receiving the following psychotropic medications: Buspirone HCI 5 milligrams (mg) once a day for anxiety and Post Traumatic Stress Disorder (PTSD), Clonazepam 0.5 mg one tablet a day, Clonazepam 1 mg one tablet at bedtime for adjustment disorder with mixed anxiety and depressed mood, Quetiapine Fumarate 200 mg give 2 tablets one time a day, along with Quetiapine 100 mg for a total of 500 mg for psychotic disorder with delusions, Sertraline HCI 100 mg give 2 tablets once a day for major depressive disorder. The clinical record showed the following Consultant Pharmacist recommendations to the physicians: On 10/26/20 the Consultant recommended review for a dose reduction for Clonazepam 0.5 mg one tablet a day, and Clonazepam 1 mg one tablet at bedtime. The form was not signed by the physician indicating the recommendations were reviewed and no dose reduction was attempted. A review of the behavior monitoring documentation for the month of October 2020 documented Resident #7 had one episode of anger and yelling on 10/25/20. On 2/28/21, the Consultant recommended a dose reduction for Quetiapine Fumarate and Sertraline Hcl. The form was not signed by the physician indicating the recommendations were reviewed and no dose reduction was attempted. A review of the behavior monitoring documentation for the month of February 2021 documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 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 105761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Lake Healthcare and Rehabilitation Center 832 Sunset Lake Boulevard 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 0758 Resident #7 had no behaviors. Level of Harm - Minimal harm or potential for actual harm On 3/30/21 the Consultant recommended the physician review Buspirone Hcl 5 milligrams (mg) once a day, Clonazepam 0.5 mg one tablet a day, Clonazepam 1 mg one tablet at bedtime for dose reduction. The form was not signed by the Physician to indicate the recommendations were reviewed, and no dose reduction was attempted. Residents Affected - Few A review of the behavior monitoring documentation for the month of March 2021 documented Resident #7 had no behaviors. On 7/22/21 at 11:22 a.m., in an interview, the Director of Nursing (DON), confirmed the physician did not sign or address the pharmacy consultant recommendations. On 7/22/21 at 1:10 p.m., in an interview, the DON said the process for Consultant Pharmacist Recommendations was, the Consultant Pharmacist would send the forms by fed ex with the recommendations to him and then he reviewed them. The DON said the forms were reviewed during the monthly psychotropic drug review meeting, attended by the DON, Pharmacist, Social Service Director, and the Physician/Advanced Registered Nurse Practitioner (ARNP). The DON said he was responsible to ensure the physicians reviewed, addressed, and signed the Consultant Pharmacist recommendations. The DON confirmed the Consultant Pharmacist recommendations for Resident #7 were not reviewed and were not acted upon on 10/26/20, 2/28/21, and 3/30/21. On 7/23/21 at 12:09 p.m., in a telephone interview the Physician said he had not received Consultant Pharmacist recommendations for Resident #7. The Physician said the facility will usually just place them in his box and when he comes in the facility, he reviews and signs them if he agrees or makes other changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 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 105761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Lake Healthcare and Rehabilitation Center 832 Sunset Lake Boulevard 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and staff and resident interview, the facility failed to ensure advance directives related to healthcare decision making was correctly documented in the resident record for 1 (Resident #1) of 24 residents sampled for advance directives. This has the potential to lead to confusion when making decisions related to resident care and choices. The findings included: The facility policy, Advance Directives (revised 12/16) specified, Advance Directives will be respected in accordance with state law and facility policy . information about whether or not the resident has executed an advance directive will be displayed prominently in the medical record .The Director of Nursing Services or designee will notify the Attending Physician of advance directives so the appropriate orders can be documented in the resident's medical record and plan of care. On [DATE], a review of the clinical record for Resident #1 showed the monthly physician orders for [DATE], documented the resident was a full code indicating cardiopulmonary resuscitation (CPR) would be initiated in the event of cardiac or respiratory arrest. The clinical record also contained a State of Florida Do Not Resuscitate (DNR) form with a date of [DATE] signed by Resident #1 and the Physician directing the withholding or withdrawing of CPR in the event of cardiac or respiratory arrest. The care plan for Resident #1 documented the resident had Advanced Directives on record, Do Not Resuscitate. The care plan documented, the resident's Advance Directives were in effect, and their wishes and directions would be carried out in accordance with their advanced directives. If the resident's heart stopped, or if they stopped breathing, cardiopulmonary resuscitation (CPR) would not be initiated in honor with their DNR wishes. On [DATE] at 3:36 p.m., in an interview, Licensed Practical Nurse (LPN) Staff H said each nursing unit had a DNR book and any resident who had a DNR would have a copy of it in the book. LPN Staff H said the residents' code status was also located in the clinical record. LPN Staff H reviewed the DNR book and could not locate a DNR order in the book for Resident #1. LPN Staff H said the resident was a full code, since the book did not contain a copy of the DNR form. On [DATE] at 3:59 p.m., in an interview, the Social Service Director (SSD) said she met with all new admissions and reviewed advanced directives. The SSD said if the resident had a DNR she would obtain a copy and would have the physician sign a DNR form if a resident requested it. The SSD said once she confirmed the resident's advanced directives, she documented it in the care plan. The SSD confirmed the physician order documented Resident #1 was a full code. On [DATE] at 9:31 a.m., during an interview, Unit Secretary Certified Nursing Assistant (CNA) Staff J said, if a resident coded and the nurse asked me to check the DNR status, I would first check the DNR book. That is the number one go to and then I check the electronic record. Staff J said the SSD was responsible to update the DNR book. Staff J said when a resident came to the facility the SSD would ask the resident about advanced directives and would get the DNR signed by the resident and the physician. The SSD would place the signed DNR in the book. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 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 105761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Lake Healthcare and Rehabilitation Center 832 Sunset Lake Boulevard 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 0842 Level of Harm - Minimal harm or potential for actual harm On [DATE] at 9:00 a.m., during an interview, Licensed Practical Nurse (LPN) Staff K said if a resident coded, she would look for the code status in the electronic record. On [DATE] at 9:19 a.m., during an interview, Resident # 1 said he had a DNR form and that was his wish. Resident #1 said he had spoken to the staff regarding his wishes for the DNR and said, I have a DNR. Residents Affected - Few On [DATE] at 4:09 p.m., the Regional Registered Nurse confirmed the physician order indicated Resident #1 was a full code. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 10 of 10