Inspection·October 7, 2021

F 0700 Level of Harm - Minimal harm or potential for actual harm yellow mesh bag that contained personal items tied to the bed rail. The pull string to the overhead light was tied to a hanger and then wrapped around the bed rail. There were additional personal items hanging from the bed side rail. Resident #69 said, if I put the head of the bed up and the side rail is down, then my papers fall off the bed, so I keep the side rails up. Resident #69 had stacks of personal papers stuffed between the side rails and mattress. Residents Affected - Few Resident #69 said he was not afraid of falling out of the bed and said he used the bed rail once in a while to pull himself up but can get up without them. On 10/7/21 at 10:04 a.m., the Director of Nursing (DON) provided a maintenance log that showed a Facility Wide Bed Safety Check form with a date of 1/13/21 and 2/18/21. The DON confirmed the bed rail log did not contain documentation the side rails were checked after 2/18/21. On 10/7/21 at 11:19 a.m., in an interview, Maintenance Worker Staff A said he did not check the bed rails, the Maintenance Director was responsible, but he had been on leave for several months. Maintenance Worker Staff A said he did not know when the bed rails were checked, or how often. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 2 of 5 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 106059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Douglas Jacobson State Veterans Nursing Home 21281 Grayton Terrace Port Charlotte, FL 33954 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1(Resident #10) of 4 residents reviewed for dementia and mental health care needs. This led to Resident #10 being sent to the hospital under the [NAME] Act (allows people with a mental illness to be held for 72 hours in a mental health facility). Residents Affected - Few The findings included: The facility policy number 1607, [NAME] Act Transfer (revised 10/18/17) documented, The staff of the facility will make every effort to provide appropriate psychiatric interventions in an attempt to avoid referrals to a receiving facility. However, if all appropriate on-site interventions prove ineffective and are fully documented in a resident's record, a referral to a [NAME] Act receiving facility may be necessary. On 10/5/21 a review of the clinical record for Resident #10 showed an admission date of 4/22/21. Resident #10's diagnoses included urinary tract infection, altered mental status, advanced dementia, and Alzheimer's disease. A Brief Interview for Mental Status completed on 4/22/21 documented a score of 7, indicating severe cognitive impairment. The care plan for Resident #10 identified, resident might perceive that his daily routine was very different from prior patterns. Interventions specified, Refer to psych interventions and other supportive services if needed. A review of the progress notes for Resident #10 revealed the following: The activities progress note dated 4/26/21, documented Resident #10 was a very pleasant resident who loved to talk about his past jobs and where he used to live. The Interdisciplinary team note on 4/26/21, documented the team completed a phone care plan with daughter. Resident appeared to be happy with no complaints. The nursing progress note on 5/2/21 at 1:00 p.m., documented Resident #10 wandered off the unit where he was located around lunch time as he was heading to lunchroom, resident was normally confused and frequently redirected. He continued walking and went past the dining room to [NAME] unit. Staff immediately went looking for resident when he was not seen in the dining room and found him sitting at table in [NAME] 1. Assessment was done no mental/cognitive changes noted. On 5/3/21 at 11:02 a.m., the nursing progress note documented resident walked around Alpha looking around, confused, encouraged to sit in recliner and relax, resident agreed. On 5/3/21 at 9:33 p.m., documented Resident #10 was confused, sitting on side of bed. said he had to sit there because he had no chair to sit on, pointed to a chair on the other side of his bed and he said it wasn't his, assured him that it was. He then made a sound like the chair was possessed or something. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 3 of 5 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 106059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Douglas Jacobson State Veterans Nursing Home 21281 Grayton Terrace Port Charlotte, FL 33954 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/10/21 at 10:10 p.m., resident was up in day room most of the shift. Confused, saying he was waiting for a bus to take him to worksite. Reminded him he was retired and didn't go to work. On 5/15/21 at 6:05 p.m., nursing progress note documented resident confused to time and place, wandered to the [NAME] unit, and redirected by this staff, call to daughter as well as his brother, he spoke with them and stated wanted to leave, staff made aware and close monitoring in progress. On 5/18/21 at 9:23 p.m., nursing progress note documented Resident alert but confused, friendly most of the time but did have occasional anger outbursts. Like tonight he couldn't find his room and was arguing with Certified Nursing Assistant that another resident's room was his room. On 5/20/21 at 8:02 p.m., the nursing progress note documented friendly most of the time but did have occasional outbursts. Resident was not found in his room or common areas, was found in another resident's room. On 5/23/21 at 7:46 p.m., documented confused, could not remember where he was. Friendly most of the time but occasional anger outbursts. On 5/27/21 at 11:16 a.m., the registered nurse documented, approached resident while he stood in doorway of room and offered a mask if he was coming out of room. Resident looked outside of room to both sides of doorway, stated they took the belt and returned to his room. Heard loud talking 5 minutes later and observed resident lying on his right side in bed calling out to get me to the hospital. When writer approached resident, resident kicked writer in left hip. Social Worker then approached resident and resident grabbed her wrists and adamantly stated he wanted to go to the hospital. Resident then placed himself on the floor on side of bed. Resident refused assistance to get up and threatened to hit and kick staff. 911 was called. Ambulance and Sheriff responded, sent to hospital for evaluation and treatment. On 5/27/21 at 11:37 a.m., Licensed Clinical Social Worker (LCSW) documented notified by unit that resident physically violent, trying to harm staff. LCSW went to unit, visually saw resident physically violent. During his attempts, he hurt right wrist/hand area. Resident unable to focus any conversation with the writer. LCSW alerted Administrator and then 911 who sent police and ambulance. On 10/6/21 at 11:40 a.m., in an interview, the Registered Nurse Risk Manager said Resident #10 had an acute change in his mental status on 5/18/21 and began to exhibit behaviors. The Risk Manager (RM) said, we do not notify the Physician for every behavior or change in a resident. The RM confirmed the Physician was not notified of Resident #10's ongoing change in behaviors. The RM said they did not make a psychiatric referral for Resident #10 because he did not have any behaviors until 5/18/21. The RM said, we do not have a psychiatrist on site, it could take 1-2 weeks or more before they are seen. The RM said on 5/27/21 Resident #10 was a risk for harming himself and others, you cannot do 1-1 or other interventions, you need to keep the resident safe from harm, it is the main priority. The RM confirmed there was no documentation of interventions provided to Resident #10 to address his behaviors prior to the [NAME] Act. On 10/6/21 at 11:45 a.m., in an interview, LCSW said, Resident #10 had an acute change and I never saw anyone like that before. He was harming himself and others. I made the decision to [NAME] Act him, I did not get a physician order for that because I can [NAME] Act residents, I do it all the time. The LCSW confirmed a Physician order documented, send the resident to the hospital for eval and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 4 of 5 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 106059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Douglas Jacobson State Veterans Nursing Home 21281 Grayton Terrace Port Charlotte, FL 33954 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete treatment. The LCSW said, that is what we did. I [NAME] Acted him because we needed the police and EMS to do it because Resident #10 was combative and out of control. 911 and EMS were needed to subdue him. The LCSW confirmed there was no documentation of interventions attempted to address Resident #10's behaviors prior to the [NAME] Act on 5/27/21. The LCSW said the interventions attempted were documented in the care plan for Resident #10, the care plan was the intervention. Event ID: Facility ID: 106059 If continuation sheet Page 5 of 5