F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interview, and observation, the facility failed to implement policies and procedures to
investigate allegations of abuse and neglect for 1 of 2 (#1) residents sampled.
Residents Affected - Few
The findings included:
A policy on Abuse, Neglect, Exploitation, Mistreatment, and Injury of Unknown Origin (ANEMMI) last
revised on 1/24 which stated that the Center will seek and accept concerns, complaints, or grievances from
residents, resident families and staff without reprisal. The right to report a concern or incident is not limited
to a formal, written grievance process, but includes any verbalized complaint to any facility staff member.
Any resident event that is reported to any staff by resident, family, or their staff or any other person will be
considered as possible ANEMMI if it meets any of the following criteria:
A.
Any resident or family complaint of physical harm, pain or mental anguish resulting from willful infliction
from others. Any and all staff observing or hearing about such events must report the event immediately to
the Administrator, Immediate Supervisor and one of the following, the Director of Nursing (DON), ANNEMI
Prevention Coordinator, or Risk Manager, so that appropriate reporting and investigation procedures take
place immediately.
B.
Any complaint of deprivation by an individual caregiver of goods and services necessary to attain or
maintain physical, mental, and psychological well-being to include toileting issues.
Resident #1 is a vulnerable adult who was admitted to the facility on [DATE]. She is diagnosed with
Parkinson's disease, vascular dementia, anxiety disorder, muscle weakness, dysphagia, and cognitive
communication deficit. Resident #1 was last assessed as cognitively intact on 1/29/25 by scoring a 13 on
the Brief Interview of Mental Status (BIMS), a test for potential cognitive impairment. The resident was
receiving Speech Therapy for her aphasia (language disorder which affects a person's ability to
communicate) until 4/22/24. The resident is not currently receiving speech therapy for her difficulty with
voice volume and phonation (ability to produce sound), she was last seen 4/22/24. A Social Service
Assessment was performed on 2/24/25 which showed that the resident had a negative trauma screen and
was documented as usually understood.
On 3/26/25 at 10:00 a.m., during an interview Resident #1 said, a man laid in bed with me when
(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 2
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
03/27/2025
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)
F 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
asked about the incident. There was an allegation of someone coming into her room. The resident was
asked, How did that make you feel? The resident said, scared and can't sleep. When asked was it a staff
member or a resident? She replied, A resident. The resident then began using repetitive words, and it
became difficult to continue the interview.
On 3/26/25 at 10:26 a.m., direct observation of Resident #1 sitting in a wheelchair in her room with a mesh
banner across her doorway that said STOP.
On 3/26/25 at 10:30 a.m., during an interview the Director of Nursing (DON) said that she did not interview
the resident when she became aware of the allegation. The DON verified she did not contact the resident's
daughter, did not interview other residents on the unit, and did not notify the Administrator of the allegation.
The DON didn't believe that any of the male residents on that floor could transfer from a wheelchair to a
bed without assistance. The DON said she believed that the STOP banner was sufficient to make the
resident feel safe and that the event was likely a matter of another resident wandering into her room by
mistake.
On 3/26/25 at 11:19 a.m., during an interview Resident #1 said that yes the uninvited resident put his
hands in the bed, and yes that she believed he was trying to get into bed with her. The resident was then
observed to draw both of her hands under her chin and her eyes became wide. The resident appeared
tense and the interview was stopped.
On 3/27/25 at 9:34 a.m., during a phone interview the Hospice Director said that Resident #1's daughter
notified Hospice via a phone call to report that her mother had a man come into her room and get in bed
with her. We were told that she reported the incident to the DON at the facility.
On 3/27/25 at 11:44 a.m., during an interview the Administrator stated, it is possible that someone getting
into bed with another resident could be an incident that needs to be reported, depending on the situation.
On 3/27/25 at 3:28 p.m., during an interview Staff A Licensed Practical Nurse (LPN) stated that the night
shift staff knows who can walk but was not aware of a list of residents who wandered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105965
If continuation sheet
Page 2 of 2
