Inspection·September 9, 2022

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few top and bottom which had a large tear, one purple pajama bottom with a large tear, and one blue jacket in her closet. She confirmed no other clothing was in Resident #16's room. On 9/8/22 at 11:30 a.m., the SSD and Administrator (AD), said the SSD is responsible to fill out each Resident's Inventory of Personal Effects form upon admission and when they receive new clothing items or personal items and updating the form for each resident when new clothing and/or personal items were given and/or taken from the resident. They said it is a team effort and everyone is responsible to ensure all residents' clothing are kept in good condition and informing the SSD when a resident needed clothing. The SSD and AD reviewed Resident #16's Inventory of Personal Effects form and confirmed the IPE form dated 5/27/2020 stated Resident #16 had a gold belt and two rings, and on 9/27/21 the SSD added one black t-shirt, a red/blue striped sock, and a diary to the form. The SSD and AD spoke with Resident #16, who told them she had been wearing the same worn and torn pajamas for the past several months. The SSD and AD confirmed after searching Resident #16's room she had one pink set of pajama top and bottom with a large tear in both, one purple pajama bottom with a large tear, and a blue jacket in her closet. They both confirmed Resident #16 had no other clothing. The SSD said he became aware two to three weeks ago Resident #16 needed new clothing. He said he tried to tell Resident #16's spouse she needed new clothing but was unable to reach him. The SSD, after reviewing Resident #16's medical record, was unable to find documentation he had tried to contact Resident #16's husband and/or documentation the facility had attempted to assist Resident #16 in getting new clothing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105774 If continuation sheet Page 2 of 8 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 105774 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian Beach Nursing and Rehab Center 1755 18th St Sarasota, FL 34230 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interviews, the facility failed to implement their policy and have documentation of prompt efforts to resolve a grievance for 1 (Resident #45) of 2 residents reviewed for unresolved grievances. The findings included: The facility's Filing Grievances/Complaints policy (Revised [DATE]) indicated, . Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident. Upon receipt of a grievance and/or complaint [blank space] will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. A written summary of the investigation will be also provided to the resident, and a copy will be filed in the business office. Clinical record review revealed Resident #45 was admitted on [DATE] with the following diagnoses: chronic pain, bipolar disorder, major depression, and bereavement for recent death of his wife On [DATE] at 11:26 a.m., Review of the 5 day scheduled Minimum Data Set (MDS) assessment with a target date of [DATE] showed Resident #45 scored 15 on the Brief Interview for Mental Status, indicative of intact cognition. On [DATE] at 11:26 a.m., Resident #45 said about two months ago he was diagnosed with COVID-19 and was transferred to a different room. He said he left his deceased wife's ashes on his bed. He returned to his room approximately 10 days later and the ashes were missing. Resident #45 said he reported it to the Social Service Director, a couple of nurses, and the Administrator. Resident #45 said no one has followed up with him since he voiced the grievance. On [DATE] at 1:58 p.m., Licensed Practical Nurse (LPN) Staff I, said about a month ago Resident #45 complained to her about the loss of his deceased wife's ashes. She said Resident #45 reported it to the former Administrator and the Social Service Director. She added, I don't know what happened and what is going to be done about it. On [DATE] at 10:35 a.m., review of the facility grievance log did not show evidence Resident#45's grievance was documented. On [DATE] at 1:15 p.m., Registered Nurse (RN) Staff F, said Resident#45 told her, They had lost his wife's ashes and was crushed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105774 If continuation sheet Page 3 of 8 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 105774 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian Beach Nursing and Rehab Center 1755 18th St Sarasota, FL 34230 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 4:29 p.m. RN, staff E, said a while back she heard about the missing ashes in morning meeting. She did not remember who brought it up, but the plan was to search for them everywhere. At that time the goal was to find the missing ashes. She said Resident #45 also told her personally of the missing ashes. On [DATE] at 8:45 a.m., the Social Services Director said around [DATE] Resident #45 was relocated to a different room for COVID-19 isolation. He said he was made aware of the missing ashes when Resident #45 returned to his previous room at the end of the isolation period and could not find his deceased wife's ashes. The Social Service Director verified he did not document a grievance form and the steps taken towards resolving Resident #45's grievance. He said If it is not on the log, I did not do it. I don't know why I did not do that. On [DATE] at 10:02 a.m., the Administrator said a grievance was not filled out for Resident #45's complaint of the missing ashes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105774 If continuation sheet Page 4 of 8 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 105774 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian Beach Nursing and Rehab Center 1755 18th St Sarasota, FL 34230 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 observation, staff interview and record review the facility failed to revise and/or update the plan of care for 1 Resident (#24) of 1 resident with exit-seeking behaviors. The findings included: On 9/6/22 review of Resident #24's medical record revealed he currently resided in the facility's locked and secured memory care unit. Resident #24 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, old myocardial infarction, major depressive disorder, mood disorder, anxiety disorder, and adjustment disorder. A nursing progress note dated 7/7/22 at 6:00 a.m., noted Resident #24 used his window to exit his room on the secure memory unit and was found outside the facility. They brought Resident #24 back inside the facility. An untimed nursing progress note dated 8/10/22, stated while the nurse was doing her rounds in the memory care unit, she observed Resident #24 outside the building in the courtyard. The nurse wrote that she brought Resident #24 into the building and Resident #24 had exited the building through the window in room [ROOM NUMBER]. The nurse also wrote she notified administration and the Assistant Director of Nursing (ADON) of Resident #24 being found outside of the facility. A review of Resident #24's plan of care revealed an Exit Seeking/Elopement plan of care created on 4/28/22, with a stated goal that the facility would keep Resident #24 safe at all times, with interventions which included redirecting Resident #24 away from exits, encouraging attendance at group activities, placing resident picture and information in the Elopement Book, ensuring all staff were aware of exit seeking behaviors and placing Resident #24 in the secure nursing unit. Further review revealed no documentation Resident #24's Exit Seeking/Elopement plan of care had been reviewed and updated and/or revised with new exit-seeking interventions after Resident #24 was observed outside of the facility on 7/7/22 and 8/10/22. On 9/9/22 at 11:01 a.m., an interview with the Administrator (AD) and ADON confirmed Resident #24 was admitted to the facility on [DATE] and was placed in the memory care unit due to his exit-seeking behaviors. They confirmed after reviewing Resident #24's medical record, Resident #24 exited the secured memory care unit via a window in rooms [ROOM NUMBERS] on 7/7/22 and 8/10/22 and was found outside the facility. They said they did not have documentation of interviewing facility staff related to Resident #24 having exited the secure memory care unit and the interdisciplinary team (IDT) had reviewed Resident #24's Exiting Seeking/Elopement care plan after Resident #24 was found outside the facility on 7/7/22 and 8/10/22 to determine if exit seeing care plan needed to be revised and/or updated to ensure Resident #24 did not exit the facility without supervision. On 9/9/22 at 11:54 a.m., the Minimum Data Set (MDS) Coordinator and Care Plan Coordinator confirmed Resident #24 was admitted to the facility on [DATE]. She confirmed he was admitted to the secure memory care unit and an Exit Seeking/Elopement plan of care was created on 4/28/22 with interventions to ensure Resident #24 did not exit the facility without supervision. She said the IDT had a care plan conference on 7/28/22 but she was unable to find documentation the IDT had discussed Resident #24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105774 If continuation sheet Page 5 of 8 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 105774 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian Beach Nursing and Rehab Center 1755 18th St Sarasota, FL 34230 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 being found outside of the secure memory care unit on 7/7/22. Level of Harm - Minimal harm or potential for actual harm The MDS Coordinator said the facility did not have documentation Resident #24's Exit Seeking/Elopement plan of care created on 4/28/22 was reviewed by the IDT and the care plan was updated and/or revised with new interventions when Resident #24 was found outside the facility on 7/7/22 and 8/10/22. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105774 If continuation sheet Page 6 of 8 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 105774 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian Beach Nursing and Rehab Center 1755 18th St Sarasota, FL 34230 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure controlled drugs (narcotic) count records where complete for 2 (Split Hall and [NAME] Hall) of 2 controlled drugs records reviewed. Residents Affected - Few The findings included: On 9/7/22 at 11:00 a.m., a review of the Controlled Drugs-Count Record for the [NAME] Hall and Split Hall provided by the Assistant Director of Nursing (ADON) showed, Signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on the controlled Drug Administration Record. 1. The Controlled Drugs-Count Record for the Split Hall for August 2022 and September 2022 lacked the signature of the oncoming nursing staff for the first shift on 8/1/22, 8/2/22, 8/3/22, 8/4/22, 8/5/22, 8/10/22, 8/11/22, 8/12/22, 8/13/22, 8/14/22, 8/16/22, 8/17/22, 8/18/22, 8/21/22, 8/22/22, 8/23/22, 8/28/22, 8/30/22, 8/31/22, 9/2/22, 9/5/22, 9/6/22, and 9/7/22. For the 2nd shift on 8/2/22, 8/4/22, 8/5/22, 8/7/22, 8/8/22, 8/9/22, 8/11/22, 8/12/22, 8/13/22, 8/14/22, 8/15/22, 8/16/22, 8/18/22, 8/23/22, 8/24/22, 8/26/22, 8/28/22, 8/30/22, 8/31/22, 9/2/22, 9/3/22, and 9/5/22. For the 3rd shift on 8/1/22, 8/3/22, 8/8/22, 8/11/22, 8/13/22, 8/16/22, 8/18/22, 8/23/22, 8/24/22, 8/27/22, 8/28/22, 8/29/22, 8/30/22, and 8/31/22.9/2/22, 9/3/22, 9/4/22, and 9/5/22. The Controlled Drugs-Count Record for the Split Hall for August 2022 and September 2022 lacked the signature of the outgoing nursing staff for the first shift on 8/4/22, 8/5/22, 8/6/22, 8/7/22, 8/8/22, 8/9/22, 8/11/22, 8/12/22, 8/13/22, 8/14/22, 8/16/22, 8/18/22, 8/23/22, 8/28/22, 8/29/22, 8/30/22, 8/31/22, 9/2/22, 9/3/22, and 9/5/22. For the second shift on 8/2/22, 8/3/22, 8/8/22, 8/9/22, 8/11/22, 8/13/22, 8/16/22, 8/18/22, 8/23/22, 8/24/22, 8/26/22, 8/27/22, 8/28/22, 8/30/22, 8/31/22, 9/2/22, 9/3/22, 9/4/22, and 9/5/22. For the third shift on 8/1/22, 8/2/22, 8/3/22, 8/4/22, 8/9/22, 8/10/22, 8/11/22, 8/13/22, 8/16/22, 8/20/22, 8/21/22, 8/22/22, 8/23/22, 8/27/22, 8/29/22, 8/31/22, 9/1/22, 9/4/22, 9/5/22, and 9/6/22. Split Hall total number of items present: The record lacked a total on 8/6/22, and 8/14/22. 2. The Controlled Drugs-Count Record for the [NAME] Hall for July 2022 and August 2022 lacked the signature of the oncoming nursing staff for the first shift on 7/1/22, 7/2/22, 7/6/22, 7/13/22, 7/14/22, 7/15/22, 7/16/22, 7/17/22, 7/18/22, 7/25/22, 7/27/22, 7/28/22, 7/30/22, 7/31/22, 8/1/22, 8/3/22, 8/7/22, 8/8/22, and 8/18/22. For second shift on 7/1/22, 7/13/22, 7/14/22, 7/16/22, 7/17/22, 7/18/22, 7/20/22, 7/31/22, 8/2/22, 8/5/22, 8/7/22, 8/15/22, 8/16/22, 8/17/22, 8/19/22, 8/21/22, 8/22/22, 8/27/22 and 8/31/22. For the third shift on 7/5/22, 7/9/22, 7/10/22, 7/12/22, 7/15/22, 7/17/22, 7/23/22, 7/27/22, 7/31/22, 8/2/22, 8/6/22, 8/10/22, 8/17/22, 8/23/22, and 8/25/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105774 If continuation sheet Page 7 of 8 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 105774 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian Beach Nursing and Rehab Center 1755 18th St Sarasota, FL 34230 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Controlled Drugs-Count Record for the [NAME] Hall for July 2022 and August 2022 lacked the signature of the outgoing nursing staff for the first shift on 7/1/22, 7/13/22, 7/16/22, 7/17/22, 7/18/22, 7/20/22, 8/5/22, 8/6/22, 8/7/22, 8/15/22, 8/17/22, 8/19/22, 8/21/22, 8/22/22, 8/27/22, and 8/31/22. For the second shift on 7/5/22, 7/9/22, 7/10/22, 7/15/22, 7/17/22, 7/23/22, 7/27/22, 7/28/22, 7/31/22, 8/10/22, 8/17/22, 8/23/22, 8/25/22, and 8/26/22. For the third shift on 7/1/22, 7/5/22, 7/11/22, 7/12/22, 7/15/22, 7/16/22, 7/17/22, 7/27/22, 7/31/22, 8/2/22, 8/7/22, 8/8/22, 8/10/22, and 8/17/22. West Hall total number of items present: the record lacked a total on 8/2/22, 8/7/22, 8/12/22, 8/15/22, and 8/29/22. On 7/5/22, 7/11/22, 7/18/22, 7/23/22, 7/29/22, and 7/31/22. On 9/7/22 at 11:00 a.m., the Assistant Director of Nursing (ADON) said nursing staff should sign the narcotic (controlled drugs) count sheet before and after their shifts. The ADON verified signatures were missing on the split hall narcotic count sheet for the months of August and September. On 9/7/22 at 11:13 a.m., Licensed Practical Nurse Staff K, said nurses are supposed to sign in on their shift and sign off after reconciling with oncoming shift. Staff K verified signatures were missing for the [NAME] Cart controlled Drugs-Count record for the months of July and August. On 9/9/22 at 9:35 a.m., the ADON said the facility had an issue with drug diversion back in February. On 9/9/22 at 2:45 p.m., the Administrator, said he was informed about missing signatures on the Controlled Drugs-Count Record. He said, We dropped the ball on that. He said they did not have a Policy and Procedure for Controlled Drugs-Count Records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105774 If continuation sheet Page 8 of 8