Inspection·June 2, 2023

F 0565 Level of Harm - Minimal harm or potential for actual harm necessity here. The staffing here has been an issue for the last year, they are always short staffed at night and on the weekends. It is terrible, you don't get the help you need. Resident #34 said the facility's administration does not address the concerns and the administrator does not show up to scheduled meetings to discuss the concerns. Residents Affected - Few Review of the facility Grievance Log documented on 5/2/23 Resident #34 filed a grievance due to low staffing on 4/30/23. Resident #22 said the evening (3:00 p.m., to 11:00 p.m.) shift is the worst. He said, the staff have attitudes and don't care and are uneducated. They are short-staffed here and use agencies, they don't know us or what we need, and they don't answer the call lights. The facility does not address our concerns. The Administrator does not address our concerns. They need to put away the cell phones and take care of us. They are always on the phone here. Resident #94 said, the weekends are much worse. For me on the weekends sometimes they don't even get the medications right. He said during meetings, we report on the staff and the attitudes they have. They do not have enough staff here. They don't answer the call lights. I must go to the bathroom frequently and they don't want to come and answer my call light all the time. Their answer was to put a diaper on me. I don't want to wet myself and then sit in a wet diaper. I had to put three urinals hanging on my nightstand handle. That is how I solved the problem of no one coming to empty it. I'm a veteran and I deserve better. I told them about things, but they don't listen, they say I complain too much. Resident #13 said she had to wait over an hour before the call light was answered. She said, If I had a stroke or something I would be dead. They don't know what our problem is when we put the light on. They don't know if we need to use the toilet or if we had a fall. They are not answering the call light. It rings and rings and the staff on 3-11 are terrible. They ignore us on the 3-11 shift they don't keep an eye on you. They should not be allowed to use cell phones here at work unless on break. They sit on the phone all day. The call light is the biggest issue and sometimes the aides don't put it in your reach. The agency staff is the worst, they don't answer the call light. Last night they had a agency CNA and I waited an hour for the call light to be answered. They do not have enough staff here. The weekends and nights are the worst time, they will not answer the call light if you need help. Resident #399 said the facility was short staffed and staff are rude. He said, They retaliate against you if you report anything, they are mean to you. If you complain they just walk out and don't provide the care. When I need help, I need it. The resident said they don't answer the call lights, or they come in with an attitude. The group said staff do not answer the call lights. They turn the call lights off at the unit. The resident said they complain all the time. They said they report the concerns to the staff nurse and the Social Service Director. On 5/31/23 at 11:51 a.m., the Administrator said the process for grievances was the department who was responsible for the grievance would be given the grievance to resolve and the resident would sign it once it was resolved. The Administrator said some of the Hoyer lifts were broken and some were working. She said they were not functioning because they needed repair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 2 of 10 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 06/02/2023 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/1/23 at 9:09 a.m., the Director of Nursing (DON) said she was aware of the residents' concern brought up in Resident council meeting, including staffing. The DON said the Administrator attends Resident Council meetings and was aware of the staffing concerns. She said she has spoken to some residents individually. She said, I try to put two CNAs on each unit and one nurse. We have just received approval for a new hiring salary, and we have received several new hires/applicants. I try to staff to the acuity of the resident's care needs. If I have call offs or staff are a no show, I use an agency to ensure there are two CNAs on each unit this way one aide can be assisting a resident and the other can answer the lights. The nurses assist in feeding residents and answer call lights. The DON said, there is no policy on call lights, but the expectation would be the call lights were to be answered within 15 minutes. The DON said, the language of the facility is English, and they should not be speaking another language in front of the residents. The staff know they are not to use the cell phones when at work and no ear buds. On 6/1/23 at 9:20 a.m., the Human Resource Director said the staff are instructed upon hire they are not to be on the cell phones, and they are to speak English. She said It is in the new hire packet, and I review it with them. On 6/1/23 at 9:23 a.m., the Activity Director (AD) said she has been employed at the facility for four weeks. The AD said I just had my first Resident Council meeting with the residents and the Social Service Director (SSD). The SSD types the minutes from the meeting. I start with food/dietary concerns first. I do a review of the previous minutes and concerns that is the second step and then we discuss new business. The AD said the process is for Resident Council concerns was the concern gets reviewed by me and then in morning meeting I review the concerns with the other department heads. The concerns then go to the Administrator. The AD said the facility Care and Concern forms and Grievances are completed by the SSD. The AD said, I can tell you staffing issues have been a concern with the Resident Council since I started here. On 6/1/23 at 10:44 a.m., the Social Service Director said the Resident Council did voice complaints about the staffing needs in the facility. The SSD confirmed she records and types the minutes from the Resident Council meetings and said the concerns with the call lights were brought up in one-to-one meetings with residents that the staff are slow to respond to the call lights. The SSD said she was responsible to follow up with the residents to ensure the grievances are resolved. The SSD had no documentation of actions taken, and responses to address the concerns voiced by the resident council group. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 3 of 10 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 06/02/2023 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the clinical record for Resident #76 revealed diagnoses including, Cerebrovascular Accident (CVA) with left side weakness, muscle wasting, and atrophy left hand and upper arm, difficulty in walking, generalized muscle weakness, muscle spasm, urge incontinence, anxiety disorder, and need for assistance with personal care. The annual Minimum Data Set assessment (MDS), dated [DATE], documented under Functional Status: Bed Mobility - Extensive Assistance, one person physical assist. Transfer, Bed to Wheelchair - Extensive Assistance, two person physical assist. Walk in Room - Activity did not occur during the assessment period. Toilet Use - Extensive Assistance, two person physical assist. The Nursing Progress Note dated 1/14/23 documented Resident #76 was found on the floor in the bathroom, Aide notified nurse that resident was on the floor in the bathroom. Resident said he put on his light but could not wait for assistance, so he tried to transfer his self to the toilet and fell on the floor. Resident was found lying on left arm . Complaint of back pain 7/10. Administer PRN (as needed) Tylenol with good effect. On 1/15/23, the Nursing Progress Note documented, Complaint of left arm pain. On 1/31/23 at the end of a physical therapy session Resident #76 complained of wrist pain. Was getting routine medication for chronic pain with history of CVA. Still attending therapy. On 2/1/23 at a doctor appointment for treatment of shoulder pain, the physician noted dislocation in wrist, deformity, and swelling. The doctor took an x-ray. On 2/8/23 the resident went to an orthopedist for evaluation of the dislocation. Outpatient surgery was scheduled for 4/10/23. On 6/1/23 at 10:00 a.m., Registered Nurse (RN) Staff H said Resident #76 had a history of CVA (Cerebrovascular accident) with left side weakness and required assistance to transfer from wheelchair to toilet and the use of a lift to transfer to bed. RN Staff H said she was aware the resident had a fall but wasn't sure the fall was the cause of the dislocation of the wrist. She said the dislocation was discovered about two weeks after the incident. On 6/1/23 at 10:15 a.m., Resident #76 said he fell trying to get to the toilet. The resident said he put on his call light for assistance and waited for a long time. The resident said he could not wait any longer and he tried to transfer from the wheelchair to the toilet on his own. He said he could not get a grip on the bar, lost his balance and fell. The resident said he needs assistance to transfer from the wheelchair to the toilet and has a lift to get in and out of bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 4 of 10 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 06/02/2023 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 0689 Level of Harm - Actual harm On 6/2/23 at 11:42 a.m., the Risk Manager (RM), Executive Director (ED), and Director of Nursing (DON), they said Resident #76 required one person assist to transfer for toileting. The RM said there were no changes to the care plan or interventions after the fall. The ED said Resident #76 did not complain of pain after the fall. She also acknowledged the resident was receiving narcotics for chronic pain. Residents Affected - Few The resident was not examined by a physician at the time of the fall. The ED said the incident report documented the resident did not receive assistance with toileting. Based on record review, review of the policies and procedures, and resident and staff interviews, the facility failed to provide the appropriate supervision, and assistance to prevent avoidable accidents for 2 (Resident #27, and #76) of 8 residents reviewed who were identified as being at risk for falls and sustained falls at the facility, including falls with major injury. The findings included: The facility policy 5240, Fall and Fall Risk Management effective 5/15/2017, documented The facility will ensure that the residents environment remains as free from accident hazards as possible and each resident receive adequate supervision and assistance devices to prevent accidents. A fall is defined as an unintentional coming to rest on the ground, floor or other lower level that is not the result of external force. Based on resident assessment, the facility will identify interventions related to the resident's specific risk and behaviors and develop a plan of care to try to prevent the resident from falling and to minimize complications if a fall does occur.Facility staff will identify appropriate resident specific interventions to reduce the risk of falls. The clinical team will monitor and document each resident's response to interventions intended to reduce falls or the risk of falls. If a resident continues to fall, the clinical team in consultation with the physician will re-evaluate the situation and determine whether it is appropriate to continue and or change current information. 1. Review of the clinical record showed Resident #27 had an admission date of 12/2/22. The resident was discharged to the hospital on 3/18/23 with return anticipated. Resident #27 had a readmission date of 3/30/23 with diagnoses including dementia, fracture of the left femur, fracture of the left lower leg and traumatic subdural hemorrhage without loss of consciousness. The admission Minimum Data Set (MDS) assessment (standardized tool that measures health status in nursing home residents) with an assessment reference date of 4/7/23 documented Resident #27 required extensive physical assistance of two people with bed mobility, transfers, and toileting. The MDS noted Resident #27's cognitive skills were severely impaired. The care plan initiated on 3/30/23 identified Resident #27 had falls and was at risk for falls due to diagnosis osteoarthritis, history of left ankle fracture, left hip fracture and dementia. On 3/31/23 a fall risk assessment documented Resident #27 had a fall risk score of 20, indicating the resident was at risk for falls. Review of the Event Report dated 11/24/22 documented Resident #27 had an unwitnessed fall at 12:50 a.m. The nurse documented the resident was on the floor, lying on his back next to the sink. Resident #27 complained of left leg pain 6/10 with movement of the left leg and was sent to the hospital (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 5 of 10 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 06/02/2023 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 0689 for treatment. Resident #27 required surgical repair of a left ankle fracture. The Resident returned to the facility on [DATE] with a hard surgical boot in place. Level of Harm - Actual harm Residents Affected - Few A nursing progress note dated 12/6/22 documented at 4:40 p.m., writer called down the hall to assist due to resident being on the floor. Entered resident bathroom to find resident lying on the floor in front of the toilet with feet on either side of toilet. Resident stated he attempted to stand himself up in bathroom and lost his balance/became weak. There was no documentation of care plan interventions in place at the time of the fall. Review of the Event Form dated 3/18/23 at 2:55 p.m., documented Resident #27 was in bed ready for lunch. At 12:30 p.m., heard a loud noise and ran into resident's room. Observed resident on the floor between bed and window. Pain observed by moan, yelling, facial grimace with movement and holding left hip. Resident #27 was transferred to the local emergency room and required surgical repair of a left femur fracture. Resident #27 returned to the facility on 3/31/23. On 5/2/23 between 2010 (8:10 p.m.), and 2105 (9:05 p.m.), the nurse documented the resident was sitting at the counter, the nurse heard a noise/bang and saw the resident #27 on the floor. A hematoma (pool of blood in body tissue) was noted to his head and his left leg was rotated externally. Resident #27 was transferred to the local emergency room and returned on 5/3/23. On 6/2/23 at 12:07 p.m., the Registered Nurse Risk Manager said at the time of the fall on 11/24/22 Resident #27 was ambulating in his room and lost his balance and fell to the ground. It was an unwitnessed fall at 12:50 a.m., he was unable to state what happened to him. He was in bed prior to the fall. The CNA said she saw the resident two minutes prior to the fall, and he was in bed the CNA had just toileted him. He seemingly got up again to use the bathroom. The Risk Manager said on 3/18/23 Resident #27 had a fall at 12:25 p.m., he was found by the nurse on his back on the floor between the bed and the wall with his head leaning against the wall. Resident #27 was confused and unable to say what happened, it was an unwitnessed fall. Resident #27 had left hip pain with range of motion and three new skin tears on his left hand, right shin, and lower leg. 911 was notified and he was sent to the emergency room (ER) for evaluation. The Risk Manager said the CNA completed rounds prior to the fall and left the room at 12:20 and 12:25 heard the fall. Resident #27 was non weight bearing at the time due to the left ankle fracture. The assumption was he stepped off the bed onto the left ankle and fell. Resident #27 sustained a fracture to the left hip requiring surgical intervention. On 6/2/23 at 12:46 p.m., the Care Plan Coordinator said once the resident returns and is a new admission the care plan falls off (disappears) and a new admission is completed. I looked at the history and saw the history of falls for Resident #27. I can't get to his previous care plan. The facility was not able to provide documentation of care plan updates prior to 3/30/23. The facility was not able to provide documentation of interventions placed after Resident #27 had a fall on 11/24/22, 12/6/22, and 3/18/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 6 of 10 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 06/02/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, resident and staff interview and record review, the facility failed to provide sufficient and consistent nursing staff to meet the needs of 5 residents (Resident #13, #22, #34, #94, #399) of 5 residents sampled. The failure to maintain sufficient and consistent staffing, resulted in the inability of nursing staff to respond to call lights and provide nursing related services to the residents to maintain the highest practicable physical, mental, and psychosocial well-being. The findings included: The facility policy #8702 Staffing Guidelines Per Resident Per Day (revised 3/20/17) documented The facility will provide sufficient nursing staff on a 24-hour basis to provide nursing and related services to residents as determined by resident assessment and individualized resident care plans. On 5/31/23 at 10:30 a.m., during Resident Council meeting, attended by five residents, all residents in attendance said they have brought up the lack of adequate staffing to meet their needs and the failure of staff to respond to call lights in a timely manner in the last council meeting with no improvement, and no response from the facility's administration. Resident #34 said, The weekend staffing and the holidays are very short with little to no staff here. A few weeks ago, the CNA told me he had 30 patients to care for. The issues I discuss don't reflect the real issues. They breeze over it and do not document it in the Resident Council minutes. If you complain about the care, they get mean and treat you badly. I have filed a grievance about the staff attitudes. I feel if the request is reasonable, they should do it but most of the time they don't. The staffing here has been an issue for the last year, they are always short staffed at night and on the weekends. It is terrible, you don't get the help you need. Resident #34 said the facility's administration does not address the concerns and the administrator does not show up to scheduled meetings to discuss the concerns. Review of the facility Grievance Log documented on 5/2/23 Resident #34 filed a grievance due to low staffing on 4/30/23. Resident #22 said the evening (3:00 p.m., to 11:00 p.m.) shift is the worst. He said, the staff have attitudes and don't care and are uneducated. They are short-staffed here and use agencies, they don't know us or what we need, and they don't answer the call lights. The facility does not address our concerns. The Administrator does not address our concerns. They need to put away the cell phones and take care of us. They are always on the phone here. Resident #94 said, the weekends are much worse. For me on the weekends sometimes they don't even get the medications right. He said during meetings, we report on the staff and the attitudes they have. They do not have enough staff here. They don't answer the call lights. I must go to the bathroom frequently and they don't want to come and answer my call light all the time. Their answer was to put a diaper on me. I don't want to wet myself and then sit in a wet diaper. I had to put three urinals hanging on my nightstand handle. That is how I solved the problem of no one coming to empty it. I'm a veteran and I deserve better. I told them about things, but they don't listen, they say I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 7 of 10 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 06/02/2023 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 0725 complain too much. Level of Harm - Minimal harm or potential for actual harm Resident #13 said she had to wait over an hour before the call light was answered. She said, If I had a stroke or something I would be dead. They don't know what our problem is when we put the light on. They don't know if we need to use the toilet or if we had a fall. They are not answering the call light. It rings and rings and the staff on 3-11 are terrible. They ignore us on the 3-11 shift they don't keep an eye on you. They should not be allowed to use cell phones here at work unless on break. They sit on the phone all day. The call light is the biggest issue and sometimes the aides don't put it in your reach. The agency staff is the worst, they don't answer the call light. Last night they had a agency CNA and I waited an hour for the call light to be answered. They do not have enough staff here. The weekends and nights are the worst time, they will not answer the call light if you need help. Residents Affected - Few Resident #399 said the facility was short staffed and staff are rude. He said, They retaliate against you if you report anything, they are mean to you. If you complain they just walk out and don't provide the care. When I need help, I need it. The resident said they don't answer the call lights, or they come in with an attitude. The group said staff do not answer the call lights. They turn the call lights off at the unit. The resident said they complain all the time. They said they report the concerns to the staff nurse and the Social Service Director. On 6/1/23 at 9:23 a.m., in an interview the Activity Director (AD) said this was her fourth week here at the facility. The AD said, I can tell you staffing issues have been a concern with the Resident Council since I started here. On 6/1/23 at 10:44 a.m., in an interview the Social Service Director (SSD) said the Resident Council did voice complaints about the staffing needs in the facility and the staff are slow to respond to the call lights. On 6/1/23 at 9:09 a.m., in an interview with the Director of Nursing (DON) said she was aware the residents had concerns with staffing. The DON said I have spoken to some of the residents one to one regarding the staffing issues. The DON said, the Administrator and I are aware of the residents' concerns regarding staffing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 8 of 10 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 06/02/2023 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, review of facility policy and procedures and resident and staff interviews, the facility failed to develop and implement resident centered care plan and interventions to ensure the residents individualized behavioral health needs were met for 1(Resident #14) of 2 residents reviewed with Post Traumatic Stress Disorder (PTSD). The findings included: The facility policy 8516, Trauma Informed Care documented, The facility will develop, implement and maintain an ongoing facility wide program to ensure that the residents identified as trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful threatening and lasting adverse effects on the individuals functioning and physical, social, emotional or spiritual well-being. Trauma informed care is an approach to delivering care that involves understanding, recognition and response to the effects of all types of trauma. A trauma informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents and incorporates knowledge about trauma into policies, procedures and practices to avoid re-traumatization. Based on results of the information gathered by clinical team, a plan of care will be developed by the interdisciplinary team to address the needs of the resident. Review of the clinical record for Resident #14 showed an admission date of [DATE] with diagnoses including Lewy Bodies Dementia, insomnia, left below knee amputation and major depressive disorder. The clinical record for Resident #14 revealed a Trauma Informed Care Screening dated [DATE] completed by the Social Services Director. The form documented Resident #14 had experienced an event that was frightening, horrible or upsetting. The following questions were asked: Have you ever served in a active combat zone where you may have been injured or witnessed causalities? - yes. Have you ever experienced a major disaster such as but not limited to fire, tornado, hurricane, flood, or earthquake? Yes, hurricane [NAME]. Do you recall ever having been attacked, beaten, or mugged? -yes. Any traumatic event not listed above? - yes fell in a swamp, witnessing [NAME] and shootings, killing the enemy during Vietnam war. When experiencing periods of distress what symptoms are present? - flashbacks and nightmares. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 9 of 10 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 06/02/2023 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 0740 What contributes to you feeling distress (triggers)? - War movies. Level of Harm - Minimal harm or potential for actual harm Care plan developed? - yes. Residents Affected - Few Review of the care plan for resident #14 showed no documentation of a care plan to address the resident's symptoms of trauma and interventions to avoid re-traumatization. Review of the Psychiatry Consultation dated [DATE] documented the resident's chief complaint I'm depressed. Review of the psychiatry progress note dated [DATE] documented the resident's mood was depressed. The patient is with decreased impulse control. The diagnosis for the visit was major depressive disorder, recurrent severe without psychotic features and unspecified dementia with agitation. On [DATE] at 12:56 p.m., Resident #14 said he served 20 years in the [NAME] Corps. I was in Vietnam. I did reconnaissance, one shot one kill. We were the first ones in and the last ones out. I have PTSD and depression. I had a buddy, and we were going on furlough. I was supposed to go to [NAME] Kong, and he was to go to another area. He asked me to trade with him and on the way back from the furlough, the plane went down, they all died, and it should have been me. Now his name is on the Vietnam Memorial Wall, and it should have been me, my name should be on the wall not his. He was young, a really nice kid, I was 17 and he was younger. The resident said, we killed a lot of people more than in the picture, even women and children, you did what you had to do. Resident #14 was tearful, opening and closing his right hand, making a fist anxiously. He was rocking back and forth in his wheelchair using his right leg. He said, sometimes I just have to keep moving to forget about things for a while. No one here believes me about the things I've seen, no one talks about it. He said he did attend some activities and enjoyed playing bingo. On [DATE] at 10:55 a.m., the Social Service Director (SSD) said Resident #14 had PTSD and mental health care needs. The SSD said Resident #14 has depression and emotionally eats. He wants to go home, but his wife is not able to care for him, we did discuss his goals for a return home for him and his options. The SSD said we have a trauma informed screen here for PTSD and when completed we look at medications and review the documentation provided for medical and psychiatric history and develop a care plan. The SSD said I look for resources for the resident with PTSD, we develop a care plan and identify their flash backs and triggers what can send them into a PTSD episode. I ask them what they do for healthy coping strategies, and it is in the care plan as well. It could be certain music, quite time or cognitive behavioral therapy I do that as well. I am responsible for finding out the triggers are for the residents. I have identified triggers for Resident #14, he said war movies were a trigger and he has flash backs and nightmares due to combat in Vietnam. The resident said Hurricane [NAME] was disturbing to him as well. Once I identify the trigger, I develop a trauma informed care plan. The SSD was not able to provide a copy of a care plan addressing Resident #14's behavioral health needs. She said, I do not see a trauma informed care plan for him. I don't see where I developed one, I will have to add one. The SSD confirmed she had not developed and implemented a trauma informed care plan for Resident #14. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 10 of 10