Inspection·March 9, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review, interviews, and review of facility policies the facility failed to file a federal report of an unwitnessed fall which resulted in a fracture requiring hospitalization for 1 (Resident # 16) of 4 reviewed for reporting requirements. The findings included: Review of facility policy titled, Incident Report and Investigation Guidelines, dated May 2021, which stated, Guidelines: All falls, injuries of unknown origin Leading to harm or injury to a visitor or resident occurring in the facility or on the facility property will be documented and investigated and recorded on the incident report. Procedure : The facility shall initiate an investigation and notify federal, state, and local authorities as required. The findings of the investigation . will be reported as required by Federal and State law. The facility Risk Manager is responsible for ensuring the timely and accurate reporting and for recording reporting as appropriate . Review of clinical records for Resident #16 documented resident originally admitted to facility 10/8/21, and readmitted on [DATE] with diagnosis of fracture of right pubis (bones that form the pelvis). The care plan noted Resident #16 was at risk for falls and fall related injury related to generalized weakness, impaired balance, unsteady gait. The resident required staff assistance with transfers and ambulation. Resident #16 was impulsive, attempts transfers, has poor safety awareness. The goal was to minimize risk of fall related injuries with staff intervention. Records documented resident had an unwitnessed fall at the facility on 1/26/23 resulting in transfer to the hospital for a higher level of care. The hospital clinical record dated 1/26/23 documented a fracture to right pubis, pelvic fracture, requiring admission to the hospital. On 3/9/2023 at 3:08 p.m., Licensed Practical Nurse (LPN) Staff M, caring for Resident #16 on 1/26/23 said there was no one in the room with Resident #16 when she fell. Since the resident was complaining of pain in her hip she was sent to the hospital. The hospital contacted the facility and told them it was a pelvic fracture, and she informed the physician. On 3/9/23 at 3:14 p.m., LPN Unit Manager Staff N, also confirmed Resident #16 had an unwitnessed fall on 1/26/23 which resulted in a hip fracture and hospitalization. LPN Staff N said she completed the notifications of the event to the Director of Nursing (DON). She said the Director of Nursing (DON) or her supervisor would decide if a report needed to be filed. On 3/9/23 at 3:20 p.m., the DON said she did not think Resident #16's unwitnessed fall resulting in a fracture needed to be reported since they had interventions in place for fall prevention. On 3/9/23 at 4:25 p.m., the Administrator confirmed Resident #16 sustained an unwitnessed fall and fracture and required hospitalization. He said it was not a reportable event based on the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 2 of 15 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 03/09/2023 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 0609 policy since the resident had fall interventions in place and the fall was out of the facility control. Level of Harm - Minimal harm or potential for actual harm On 3/9/23 at 6:35 p.m., the Administrator he filed a Federal Day 1 report with the State Survey Agency for Resident #16's unwitnessed fall resulting in fracture. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 3 of 15 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 03/09/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review, review of facility's policy and procedure, resident and staff interview, the facility failed to develop an individualized comprehensive care plan describing services to be furnished to meet the needs of 1 (Resident #73) of 2 sampled residents with an indwelling Foley catheter. The findings included: The facility's policy titled, Care Plans, Comprehensive Person-Centered revised December 2016 noted, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Review of the clinical record for Resident #73 revealed an admission date of 1/17/23. Diagnoses included history of malignant prostate neoplasm, urinary tract infection and obstructive and reflux uropathy (obstructed urinary flow, and back up of urine into the kidneys). Review of the admission Minimum Data Set (MDS) assessment with an assessment reference date of 1/21/23 noted Resident #73 had an indwelling catheter (catheter inserted into the bladder to drain urine). Diagnoses included a urinary tract infection, and renal insufficiency. The Care Area Assessment summary noted Resident #73 urinary incontinence was addressed in the care plan. On 3/6/23 at 10:30 a.m., Resident #73 said the indwelling catheter was inserted at the hospital. He said he was seeing a urologist in the community for treatments. The care plan initiated on 1/25/23 noted to observe the skin surrounding the catheter for signs of skin breakdown. The care plan updated on 2/22/23 noted to observe urine for sediment, cloudiness, odor, blood and quantity; report abnormal findings to physician. The care plan did not provide instructions for the catheter care, including frequency of cleaning insertion site, and monitoring for obstruction. On 3/8/23, at 9:30 a.m., the Director of Nursing (DON) said Resident #73's daughter takes him to urology clinical treatments but did not provide the facility with documents from the clinic. She said the resident's daughter dropped off a soap to clean the area before treatment but she did not have any information related to the outside treatments the resident was receiving. On 3/8/23 at 11:25 a.m., the DON verified the lack of a specific individualized care plan addressing catheter care and coordination with urology to ensure the resident's needs were met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 4 of 15 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 03/09/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policy and procedure, staff and resident interviews, the facility failed to ensure timely revision, and resident participation in care plan to meet the needs of 1 (Resident #39) of 5 residents reviewed for care plan. The findings included: The facility policy titled Care Planning-interdisciplinary team, revised September 2013, stated the facility ' s care planning team is responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive care plan is developed for each resident within 7 days of completion of the resident assessment. The resident, resident family, and/or legal representative are encouraged to participate in the development and revision of the resident ' s care plan. The care plan must be updated when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly MDS assessment. Clinical record review revealed resident #39 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessments revealed on 7/7/22 Resident #39 had an unplanned discharge to an acute care hospital. Resident #39 returned to the facility on 7/10/22. A Quarterly MDS assessment was completed on 7/26/22, 10/25/22 and 1/24/23. Complete review of the clinical record failed to show documentation Resident #39's care plan was reviewed and revised since the last documented care conference dated 5/27/22. There was no documentation the care plan was reviewed and revised by the interdisciplinary team when Resident #39 was readmitted from the hospital on 7/10/22. On 3/7/23 at 2:29 p.m., resident # 39 ' s son stated he attended the first care conference when she was admitted and has not been contacted about a care plan conference since that time. On 3/9/23 at 12:52 p.m., the Social Service Director (SSD) said she could not find any care plan conference notes for Resident #39 since 5/27/22. She said she could not locate any care plan sign-in sheets or notes for the resident. She said she did not recall holding a care plan meeting or communicating with Resident #39 regarding a care plan conference. On 3/9/23 at 1:03 p.m., Minimum data set coordinator (MDS) staff D said Resident #39 should have had a care plan conference within seven days of the MDS updates on 7/26/22, 10/25/22, and 1/24/23. On 3/9/23 at 3:00 p.m., the Regional Consultant said the only documentation available was from the conference held on 5/27/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 5 of 15 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 03/09/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, staff, and resident interview, the facility failed to provide the necessary assistance for showers for 1 (Resident #51) of 2 sampled dependent residents reviewed for Activities of Daily Living (ADL). Residents Affected - Few The findings included: The facility policy titled Activities of Daily Living (ADLs), Supporting revised March 2018, stated Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out necessary ADLs. Residents who cannot carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of the clinical record revealed Resident #51 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 12/27/22 documented Resident #51's cognition was intact. The resident was totally dependent on one person physical assistance for bathing. Resident #51 did not have any behaviors and did not reject care. The plan of care initiated on 9/19/2022 documented Resident #51 had a self-care deficit with dressing, grooming, and bathing related to the diagnosis of Cerebral Vascular Accident with hemiparesis/hemiplegia (paralysis of one side of the body). The goal is for the resident to have a neat appearance daily. Interventions included to gather and set up supplies for care, provide hands-on assistance with dressing, grooming, and bathing, and staff to anticipate residents' needs with ADLS. The ADL flow sheets for January, February and March 2023 noted Resident #51 was scheduled on Mondays, Wednesdays and Fridays for a bath. The flow sheets specified Resident #51 preferred showers. On 3/6/23 at 9:41 a.m., Resident #51 stated his shower days are during the day on Mondays, Wednesdays, and Fridays. He said, I generally only get showered once a week but really preferred three times a week. Resident #51 also stated he needed help to trim the fingernails on his left hand. The ADL flow sheets for January, February, and March 2023 documented Resident #51 received four of 13 scheduled showers in January, six of 12 scheduled showers in February and two of the four scheduled showers through March 8, 2023. There was no documentation the resident refused the showers. On 3/7/23 at 9:13 a.m., and 3/9/23 at 10:45 a.m., Resident #51 again said he wanted to shower more than once a week. On 3/9/23 at 1:35 p.m., Certified Nursing Assistant (CNA) Staff U stated if a resident refused care, then the process is to let the nurse know. She said she did not recall resident #51 refusing care. On 3/9/23 at 2:07 p.m., Unit Manager Staff Nurse L, reviewed the ADL flow sheets and verified Resident #51 wanted to have three showers weekly and only received only one shower a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 6 of 15 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 03/09/2023 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and resident and staff interviews the facility failed to provide care and services, including application of splints to prevent a decline in range of motion for 1 (Resident #97) of 1 dependent resident with limited range of motion. The findings included: Review of the clinical record revealed Resident #97 had an admission date of 6/11/22 with diagnoses including hemiplegia and hemiparesis (muscle weakness or paralysis) of the left side. The Quarterly Minimum Data Set (MDS) assessment (standardized tool that measures health status in nursing home residents) with an assessment reference date of 12/13/22 documented Resident #97 was dependent on staff for dressing and had functional limitations of range of motion in upper and lower extremities. The MDS noted Resident #97's cognitive skills for daily decision making were intact. The physician's order dated 1/20/23 documented apply left hand splint in the morning and remove at bedtime as tolerated. The Certified Nursing Assistant (CNA) resident care [NAME] (provides instructions for care) documented to apply the left hand splint in the morning and remove at bedtime and or as tolerated. Monitor skin integrity when applying and removing. On 3/6/23 at 2:35 p.m., observed a splint on the wheelchair seat, across from the bed. Resident #97 said she had a stroke and is not able to move her left side. She said staff is supposed to apply the splint to her left hand, but they do not consistently apply the splint. Review of the CNA documentation for February 2023 revealed no documentation on the day shift on 2/8/23, 2/18/23 and 2/21/23 the splint was applied. The documentation showed not applicable on 2/1/23, 2/2/23, 2/3/23, 2/4/23, 2/5/23, 2/9/23, 2/11/23, 2/12/23, 2/13/23, 2/15/23, 2/16/23 and 2/17/23. The evening shift showed no documentation of splint application or removal on 2/2/23, 2/7/23, 2/12/23, 2/16/23 and 2/22/23. The documentation showed not applicable on 2/1/23, 2/2/23, 2/3/23, 2/4/23, 2/5/23, 2/6/23, 2/8/23, 2/11/23, 2/14/23. 2/15/23, 2/17/23, 2/18/23, 2/23/23, 2/24/23 and 2/25/23. Review of the CNA documentation for March 2023 revealed no documentation on the day shift 3/7/23 and not applicable on 3/6/23. The evening shift showed no documentation of splint application or removal on 3/2/23 and not applicable on 3/1/23, 3/3/23, 3/4/23, and 3/5/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 7 of 15 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 03/09/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm On 3/9/23 at 1:51 p.m., CNA Staff P said she did not apply the splint to Resident #97's left hand. She said the therapist applies the splints for the residents. On 3/9/23 at 2:00 p.m., the Therapy Director said the CNAs are responsible to apply the splint to Resident #97's left hand, the instructions are posted on the inside of the resident's closet door. Residents Affected - Few On 3/9/23 at 2:08 p.m., the Rehab Director provided a copy of a restorative nursing splint program initiated on 9/1/22. The program documented Pt to wear splint daily to left upper extremity incidence of contracture. On 3/9/23 at 2:56 p.m., the Director of Nursing said she did not have restorative staff and the CNAs were responsible to apply splints for residents not on therapy caseload. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 8 of 15 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 03/09/2023 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 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 Based on record review, review of the policies and procedures, and staff and family interviews, the facility failed to implement appropriate interventions, including adequate supervision to prevent avoidable falls, including fall related major injuries for 1 (Resident #74) of 3 residents reviewed who sustained multiple falls at the facility. The failure to implement appropriate interventions to prevent falls and fall related injuries resulted in Resident #74 sustaining preventable falls, including falls with major injury requiring transfer to a higher level of care. The findings included: The facility policy Falls-Clinical Protocol (revised 3/18) documented The physician will help identify individuals with a history of fall and risk for falling. Staff will ask the resident and the caregiver about a history of falling. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Based on preceding assessment the staff and physician will identify pertinent interventions to try to prevent subsequent falls and address the risks of clinically significant consequences of falling. The staff and the physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Review of the clinical record revealed Resident #74 had an admission date of 2/6/23 with diagnoses including fracture of the left pubis, dementia, and anxiety. The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 2/10/23 documented Resident #74 required extensive assistance of two persons with transfers and bed mobility. The MDS documented ambulation in the room and corridor did not occur. The MDS noted Resident #74's cognitive skills for daily decision making was moderately impaired. The care plan initiated on 3/1/23 documented Resident #74 was at risk for falls or fall related injury related to impaired balance, unsteady gait, and poor safety awareness. The goal was to minimize the risk of falls and fall related injury. The interventions included provided hands on assistance with ambulation, observe for use of appropriate foot ware and assist as needed, keep call light within reach, educate/remind resident to request assistance prior to ambulation/transfers as needed, report falls to physician and responsible party as needed, physical therapy (PT) and occupational therapy (OT) as indicated. A fall risk evaluation dated 2/28/23 documented a score of 11 indicating a risk for falls. On 2/28/23 a SBAR Communication Form (a tool for communication between health care team about a patient's condition) documented Resident was sitting on side of bed leaning over to put shoes on when she lost her balance falling forward hitting her face on the arm of the wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 9 of 15 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 03/09/2023 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 The care plan documented 2/27/23 resident observed on floor in room. The care plan was updated with the intervention staff education to ensure resident has her shoes on when out of bed. Level of Harm - Actual harm Residents Affected - Few On 3/2/23 the nursing progress note documented Resident #74 was found on the floor getting out of her room using a walker. The resident was sent to the local emergency room (ER) for evaluation. A CT (Computerized Tomography) scan was obtained in the ER and documented a new acute nondisplaced fracture of the right greater trochanter(hip). Resident #74 returned to the facility on 3/2/23 with conservative measures for the fracture. The care plan was updated on 3/2/23 with the intervention staff to assist resident with toileting upon arising, before and after and at bedtime. On 3/7/23 at 8:49 a.m., in an interview registered Nurse Staff Q said Resident #74 had another fall last night and was found on the floor next to bed. He said Resident #74 had sun-downing (a state of confusion occurring in the late afternoon and lasting into the night) behaviors starting around 4:00 p.m., each night and said staff are monitoring her. On 3/6/23 at 9:24 a.m., Resident #74 was observed in her room sitting on the side of the bed eating morning meal. There was one floor mat on the left side of the bed, no floor mat on the right side. Resident #74 had bruising to the right eye, and cheek and said she had fallen at home and fractured her pelvis and had fallen since her admission to the facility and fractured her leg. On 3/6/23 at 12:43 p.m., in an interview Resident #74 daughter said her mother had a fall at home and fractured her pelvis and came to this facility for therapy. She said her mother had a fall on 3/2/23 and fractured her right femur but had no surgical repair. Resident #74's daughter said she had concerns with her mother's safety due to sun-downing and said therapy reported today that her mother was not able to stand or ambulate and was unable to do tasks. She said she had asked the facility to place another floor mat on the left side of the bed. On 3/7/23 at 8:25 a.m., Resident #74's Power of Attorney (POA) was at her bedside and said her mother had another fall last night and is now complaining of increased right leg pain down to the knee. The POA said her mother had sun-downing related to dementia and will pack her things at night wanting to go home. She said the nurse called her to report the fall but was not able to tell her how the fall occurred. On 3/9/23 at 9:11 a.m., Staff Q said he tries to keep a close eye on Resident #74. She is assisted with transfers and toileting and is non weight bearing on the left leg related to the pelvic fracture. She has sun downing and tries to get out, she wants to leave the facility. We educate her to use the call light, but she has dementia. The staff just keep a close eye on her, it is not documented, I try and keep my med cart outside of her room when I'm doing medications. On 3/9/23 at 9:01 a.m., the Director of Rehab said Resident #74 was planning to discharge home before her fall on 3/2/23. She said, we had the meeting with the family before discharge to provide education and to ensure they were able to provide the care for her at home. We are working on transfer training and balance with muscle weakness. Resident # 74 was able to ambulate with supervision and transfer, she was doing very well. She required supervision because of her cognitive loss, she required constant verbal cues. The Director of Rehab said Resident #74 was not safe to ambulate or transfer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 10 of 15 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 03/09/2023 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 - Actual harm Residents Affected - Few unassisted. Resident #74 had a fall 2 days before the planned discharge and now she has declined significantly and is non weight bearing on the left leg. She has been reporting increased pain since the fall and we recommended the nurse get an X-ray of the right leg. The x-ray was obtained on 3/8/23 but did not show any new fractures. She said all falls are reviewed daily in the morning interdisciplinary team meeting and any new interventions are put on the care plan. The Director of Rehab said right now Resident #74 needs 24/7 supervision for safety and cues. She is not safe to ambulate or transfer on her own. On 3/9/23 at 11:18 a.m., the Director of Nursing (DON) said after Resident #74 had the first fall she was working with therapy. The DON said we try and educate the resident and put interventions in place, but she is getting up no matter what. She packs her things daily and she has a wander guard on. We are meeting with family today to take her home. They want to take her home. On admission we had her as a high fall risk, and we recommended call lights and floor mats, and she was receiving therapy. The first fall here was 2/27/23 at 10:45 p.m., leaning over to put shoes on and fell forward hitting her face on the wheelchair arm. The DON said we reviewed the fall the very next day, and the intervention was to encourage shoes when out of bed, if no shoes are on then, nonskid socks. A low bed was initiated but not updated on the care plan. The second fall was on 3/2/23 at 12:30 a.m., she was found on floor with walker, trying to go to the bathroom and prompted voiding was initiated before and after meals, upon rising and bedtime. The third fall was on 3/6/23 at 4:12 in the p.m., she had no socks on, the floor mat was down, and she was sitting on floor mat. A new intervention for nonskid socks was added to the care plan. The DON said the root cause of Resident #74's falls was bad dementia, she came to us as a high fall risk, and she was packing her things everyday wanting to leave and we placed a wander guard on her at admission. The DON said the resident was a high score for elopement risk on admission. She is redirected but forgets what we say to her. I know she is walking. Her fracture did not have any weight bearing issues. The resident can get out of bed by herself, she is not safe. The DON said the facility had a falling star program, where the staff bring residents at risk for falls in to do activities, but this is not occurring daily. It depends on staffing. Resident #74 needs 1-1 (one-to-one) supervision, but we have no staff to provide the 1-1 supervision. On 3/9/23 at 2:03 p.m., Certified Nursing Assistant (CNA) Staff P said Resident #74 required assistance with transfers and toileting and uses a walker but is not safe to ambulate on her own. The CNA said the resident was a fall risk, and she was instructed to an eye on her more often. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 11 of 15 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 03/09/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observations, clinical record review, interviews, and facility policy review the facility failed to ensure effective coordination for implementation of timely intervention to prevent weight loss for 1 (Resident #16) of 5 residents reviewed for nutrition. Residents Affected - Few The findings included: Review of facility policy titled, Weight Assessment and Intervention revised September 2008 which stated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Weight Assessment 1. The nursing staff will measure resident weights on admission, If no weight concern noted at this point, weights will be measured monthly thereafter. 2. Weights will be recorded in each individual's medical record. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian. 4. The Dietitian will respond upon notification. 5. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a.1 month- 5% weight loss significant; greater than 5% is severe. b. 3 month- 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 month- 10% weight loss is significant; greater than 10% is severe. Review of clinical records for Resident #16 revealed diagnoses including adult failure to thrive, history of malignant neoplasm of the esophagus, chronic kidney disease, Alzheimer's disease, and chronic obstructive pulmonary disease. Resident #16 initial admission date to facility was on 10/8/21 and most recent admission 2/2/23 after a 7-day hospitalization. Weight documented on 11/23/22 was 138.6 pounds. The resident did not have a weight documented in records for December 2022 or January 2023. On 2/16/23 two weights were documented 115.8 pounds and 203.8 pounds with repeat weight on 2/17/23 of 115.8 pounds measuring a severe weight loss of 16% in 3 months. On 3/5/23 weight was documented as 114.2 pounds showing additional weight loss. Review of Annual Nutrition Risk Assessment completed 11/ 17/22 documented resident was not at risk for malnutrition. readmission Nutritional Risk Evaluation completed 2/6/23, after 7 days at the hospital, documented a weight of 138.6 pounds and normal nutritional status. This assessment was later identified as having been based on weight taken in November 2022. The care plan initiated on 10/19/21 and revised 2/6/23 documented resident has potential for an alteration in nutrition with interventions including weights as ordered and as needed. Notify physician of significant weight changes if noted. No nursing or dietary progress notes or change in condition physician notification notes regarding weight loss in clinical record for Resident #16. No new orders or intervention to address weight loss in the clinical record. Orders reviewed and Resident was on a renal diet, regular consistency thin consistency fluids. Certified Nursing Assistant task list showed resident was an independent eater with set up assist for meals. On 3/07/23 at 3:30 p.m., interviewed Certified Nursing Assistant (CNA) Staff B about weight (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 12 of 15 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 03/09/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few monitoring process at the facility. CNA Staff B said weights are done monthly except some residents have orders for once a week. Said there was a list in the nurses' station of who is weighed once a week. She writes the weight on the paper and tells the nurse who documents the weight in the computer. Said she was not aware that Resident #16 had a weight loss. On 3/07/23 at 3:39 p.m., interviewed CNA Staff C about obtaining resident weights. Confirmed routine is to weigh residents monthly. The CNA writes down the weight when done and communicates to the nurse for charting. On 3/8/23 at 11:00 a.m., interviewed Licensed Practical Nurse (LPN) Staff A about weight process. LPN Staff A said most patients have monthly weights. The CNAs obtain the weights and give the information to the nurse for review and charting. As a nurse if we see a big difference then I ask for a reweigh before I chart the information. If there really is a significant weight change we document on the 24 hour report, notify the physician, notify the family and the oncoming Assistant Director of Nursing (ADON) or Director of Nursing (DON). LPN Staff A said she was unaware of the weight loss experienced by Resident and #16 and said after reviewing the weights documented, It should have been identified and documented. On 3/08/23 at 11:39 a.m., interviewed Registered Dietician (RD) about weight monitoring at facility. RD said she only works 16 hours a week at the facility. Said she depends on the nursing team to inform her if there is a concern for weight changes and does not have time to review all weights done at facility. RD said she was not currently monitoring anyone for weight loss. Confirmed that the facility does have weight meetings and participates in weight meeting, if I am here that day and if I am invited. RD asked to review clinical records for Resident #16. Confirmed resident did not have a weight done December 2022 and January 2023 saying, I don't know why she was not weighed for December or January. RD confirmed severe weight loss documented saying, I don't have an answer for that one either . It would be a good question for the director of nursing. RD said she does a nutritional reassessment after a readmission to the facility. RD said she looks for a reentry weight and if it is not available, she uses the most recent weight available in the record. Confirmed she used the weight from November 2022 for her readmission assessment completed February 2023 for resident #16. Asked about documented weight loss and said, It is concerning now that I am aware of it. I was not informed so I was not aware. RD confirmed no new interventions had been implemented for Resident #16 since RD was unaware of the weight loss. RD said, I will have to look thru the whole charts again to determine interventions. On 3/8/23 at 12:36 p.m., interviewed Director of Nursing (DON) about Resident #16 weight loss. DON said she was unaware that resident had lost weight and the dietician should have picked up on it. DON said, We have weight meetings on Thursdays, but they have been inconsistent. DON unable to provide weight meeting minutes for review. The DON confirmed the physician should have been contacted and informed of the weight loss for Resident #16. The DON said the process is to weigh, if needed reweigh and if a significant loss or gain contact physician, contact dietician and document. On 3/9/23 at 8:33 a.m., the Facility Medical Director who confirmed he was not aware of the weight loss experienced by Resident #16. The Medical Director said he should have been notified and expected to be notified so they could discuss, as part of the interdisciplinary team meeting, additional interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 13 of 15 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 03/09/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 3. Review of the clinical record revealed Resident #28 had an admission date of 1/3/23 with diagnoses including dementia, muscle weakness and fracture of upper end of left humerus. The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 1/7/23 documented Resident #28 required limited assistance with bed mobility. The MDS noted Resident #28's cognitive skills for daily decision making was moderately impaired. The clinical record showed a side rail evaluation dated 2/13/23, which documented side rails were recommended as an enabler to assist with bed mobility/transfers. Alternatives to side rails have been discussed with resident. The side rail evaluation form did not document the alternate interventions attempted prior to the use of the side rails. On 3/6/23 at 1:36 p.m., Resident #28 was observed in bed with grab bars (side rails) on both sides of the bed in the raised position. Resident #28 said she did not request the grab bars, but she used them. 4. Review of the clinical record revealed Resident #74 had an admission date of 2/6/23 with diagnoses including dementia, fracture of right femur and falls. The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 2/10/23 documented Resident #74 required extensive assistance of two persons with transfers and bed mobility. The MDS noted Resident #69's cognitive skills for daily decision making was moderately impaired. The clinical record showed no documentation of a side rail evaluation or alternate interventions attempted prior to the use of the grab bars. On 3/6/23 at 9:24 a.m., Resident #74 was observed in her room sitting on the side of the bed with grab bars on both sides of the bed in raised position. On 3/9/23 at 11:50 a.m., the Director of Nursing said the grab bars were not considered side rails and no alternate interventions were attempted. Based on observations, interviews, records review, and facility policy review the facility failed to review the risks and benefits of bed rails or to attempt alternative interventions prior to bed rail (side rail) installation with the resident/representative for 4 residents, (#1, #66, #74, and #28) of 4 residents reviewed for bed rails. The findings included: Review of the facility policy titled, Proper Use of Side rails, revised December 2016 which stated, Purpose: The purpose of these guidelines are to ensure the safe use of side rails as resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 14 of 15 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 03/09/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks .While the resident or family (representative) may request a restraint, the facility is responsible for evaluating the appropriateness of that request. 1. Review of clinical records for Resident #1 documented Side Rail Evaluation completed on 12/6/2022. No documented alternative measures prior to the installation of the side rails were present in the clinical record. On 3/6/23 at 9:20 a.m., observed Resident #1 in bed with bilateral 1/8th raised side rails in place on bed. On 3/8/23 the facility provided a consent signed and dated 3/8/23 by resident #1. 2. Review of clinical records for Resident #66 documented Side Rail Evaluation completed on 12/30/2022, and a consent signed by resident on 8/21/21. The consent form documented per resident request for initiating side rails. No documented alterative measures were present in the clinical record. On 3/6/23 at 11:30 a.m., 3/7/23 at 10:05 a.m., Resident #66 was observed in bed with bilateral raised 1/3rd side rails in place on bed. On 3/7/23 at 3:30 p.m., Certified Nursing Assistant (CNA) Staff B said, We don't use side rails unless the patient requests them. On 3/8/23 at 11: 00 a.m., Licensed Practical Nurse Staff A said a physician's order is needed for side rails. On 3/8/23 at 1:00 p.m., the Director of Nursing (DON) said therapy does an assessment and we make sure everyone has a consent for the grab bars. The DON said she was not sure what alternative measures therapy used prior to placing the grab bars. On 3/8/23 at 3:00 p.m., the Director of Rehabilitation confirmed therapy screens residents for the use of enablers or side rails. The Director of Rehabilitation said they had documentation of a screen for the use of the side rails but did not have documentation an alternative was attempted prior to the use of the enabler side rails. On 3/8/23 at 3:47 p.m., a joint interview was conducted with the Administrator and Regional Nurse Consultant. The Regional Nurse Consultant said she did not have any additional documentation regarding the use of the side rails for Resident #1 and #66. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105761 If continuation sheet Page 15 of 15