Health inspection·February 1, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 and staff interview the facility failed to ensure clinical records contained complete and accurate documentation of care provided for 2 (Residents #1 and #3) of 3 residents reviewed for accuracy of clinical records. The findings included: 1. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/2/23 noted the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 00. The MDS noted Resident #1 was severely cognitively impaired with a Brief Interview of Mental Status score of 0. Resident #1 used a manual wheelchair for mobility, was frequently incontinent of urine and always incontinent of bowel. The current physician orders included to assist the resident with all meals. No assistance with meals was documented in the clinical record on 1/3/24, 1/7/24, 1/16/24, 1/17/24, 1/21/24 or 1/24/24. The physician's orders also included to encourage and assist resident with turning and repositioning when in bed and as needed for skin care. No assistance with turning and repositioning was documented for the day shift from 7:00 a.m., to 3:00 p.m., on 1/3/24, 1/7/24, 1/16/24, 1/17/24 or 1/21/24. No assistance with turning and repositioning was documented for the evening shift from 3:00 p.m., to 11:00 p.m., on 1/17/24, 1/21/24 or 1/24/24. No assistance with turning and repositioning was documented for the night shift from 11:00 p.m., to 7:00 a.m., on 1/6/24 or 1/20/24. The Certified Nursing Assistant (CNA) task form did not reflect Turning and Repositioning was done on Day shift from 1/2/24 through 1/8/23, 1/11/24, 1/14/24 through 1/19/24, 1/21/24 through 1/25/24. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105965 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 105965 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capri Health and Rehabilitation Center 1450 East Venice Avenue 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)