Inspection·September 6, 2024

F 0580 Level of Harm - Actual harm drop in Resident #114's blood pressure after his injury Staff H said she did not think a blood pressure of 100/50 was low pressure. Staff H said she never noticed the drop in blood pressure. Staff H verified she did not notify the physician of the residents change in blood pressure. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 2 of 9 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 09/06/2024 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review, and staff interview, the facility failed to ensure 2 Residents (#48, and #220) of 3 sampled residents reviewed received the Skilled Nursing Advanced Beneficiary of Non-coverage form (CMS-10123) to inform the resident of potential liability for payment, and right to appeal. Residents Affected - Few The findings included: The facility policy titled Advance Beneficiary Notice of Medicare Non-Coverage with effective date 12/18/2009, Revised date 04/2/2024, specified Skilled Nursing Facilities are required to notify residents before .services are .terminated and Medicare is not expected to pay. The Notice of Medicare Non-coverage (NOMNC) is given by the facility to all Medicare residents at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The resident's appeal rights must be explained to the representative. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on the same day. Place a dated copy of the notice in the beneficiary's medical file and document the telephone contact to include the: the name of the person initiating the contact, name of the representative contacted, date and time of the contact and the telephone number called. Social Services will notify and document notification of resident or resident's representative . Social Services will mail notification via certified return receipt and provide the Business Office a copy for tracking and auditing. Review of Resident #48's census data information revealed Resident #48's Medicare part A skilled service episode started on date 1/12/24. The last covered day of Part A service was 2/29/24. The durable power of attorney signed the Advanced Beneficiary form of non-coverage on 3/13/24. Review of Resident #220's census data information revealed Resident #220's Medicare Part A skilled service episode start date was 5/10/24. The Last covered day of Part A service was 05/15/24. The durable power of attorney signed the Advanced Beneficiary form of non-coverage on 5/20/24. Review of the Beneficiary Protection Notification Review form revealed the facility initiated Resident #48 and #220's discharge from Medicare Part A Services with benefit days remaining. Record review of Resident #48 and Resident #220's coverage notice records failed to reveal any documentation that either resident had been provided with the Skilled Nursing Advance Beneficiary of Non-Coverage notice (CMS-10123) prior to the end of their services. On 9/06/24 at 2:42 p.m., during an interview, Staff K, Social worker program manager, said her process for advance notification is to give the beneficiary or the durable power of attorney notice when services are being terminated, including the date of the service being terminated, via regular mail, not certified mail. Staff K said there was no documentation of when the notice was sent via regular mail. Staff K said notice was provided verbally, but she said there was no documentation indicating notice was provided within 2 days prior to the end of service, and the right to appeal the decision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 3 of 9 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 09/06/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, record review, and staff interviews, the facility failed to review and revise the comprehensive person-centered care plan for 1 resident (Resident #16) based on the resident's ongoing clinical assessments and identified risks for falls. The findings included: The facility policy 5240, Fall and Fall Risk Management effective 5/15/24 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 assistive 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 residents 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. Review of the clinical record showed Resident #16 was admitted to the facility on [DATE]. Resident #16's diagnoses included Parkinson's disease with Dyskinesia (uncontrolled involuntary muscle movement), unspecified dementia, other abnormalities of gait and mobility, tremor, unspecified, Insomnia. The admission Minimum Data Set (MDS) assessment (standardized tool that measures health status in nursing home residents) with an assessment reference date of 4/22/24 documented Resident #16 required the assistance of 1 person for supervision of transfers, ambulation and toileting. The MDS noted the Resident #16's cognitive status was moderately impaired. The care plan initiated on 4/15/22 identified Resident #16 as a fall risk, had falls, was at risk for falls due to poor safety awareness, forgetting to ask for assistance and had a history of falls with a hip fracture. Fall prevention interventions included to keep personal items within reach, keep call light within reach at all times, anti-roll backs on wheelchair. On 4/15/22 a fall risk assessment documented Resident #16 had a fall risk score of 17, indicating he was at risk for falls. A fall risk score of 10 or higher represents a high risk for falls. Additional fall risk assessments scored 18, and were completed on 3/14/24, and 6/10/24 which continued to indicate a high risk for falls. The facility fall record review revealed Resident #16 had 18 falls since 11/17/23. Unwitnessed falls occurred on 11/27/23 at 5:49 a.m., 1/1/24 at 6:45 p.m., 1/27/24 at 10:30 a.m., 1/29/24 at 1:20 p.m., 2/2/24 at 9:19 p.m., 2/26/24 at 4:49 p.m., 3/12/24 at 12:28 a.m., 3/15/24 at 4:50 a.m., 7/16/24 at 8:45 a.m., 7/25/24 at 10:01 a.m., 8/4/24 at 7:30 a.m., 8/14/24 at 3:30 a.m., 8/23/24 at 8:23 a.m., 8/29/24 at 5:25 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 4 of 9 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 09/06/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Witnessed falls occurred on 2/16/24 at 5:20 a.m., 5/9/24 at 11:15 p.m., 7/16/24 at 7:44 p.m., and 7/21/24 at 8:46 a.m. On 9/6/24 at 1:08 p.m., during an interview the Director of Nursing (DON) said she did not see any documentation of new interventions added to the care plan following each fall, except for 1/1/24 when nonskid footwear was added, and 8/29/24 when a protective bumper was added to the sink and for the caregiver to assist Resident #16 with brushing his teeth because he has a history of falling near the sink. The DON said the facility fall report noted Resident #16 sustained 7 skin tears following a fall on 2/26/24. The care plan was updated on 2/27/24 and specified new interventions to use handrails and hand grips. The DON said, he would not be able to remember to do that intervention. The fall program encourages purposeful rounding which means frequent rounding. The DON said, short of putting someone 1:1 with him all the time I'm not sure what else we can do. The DON stated Resident #16 is not cognitive enough for new interventions. The only possible intervention would be one-on-one supervision, but we did not want to take away his independence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 5 of 9 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 09/06/2024 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of facility policy and procedure, and record review the facility failed to ensure they provided an ongoing program to support the residents in their choice of activities which are designed to meet the resident's interests and support the resident physical, mental and psychosocial well-being for 3 (Residents #109, #31 and #62) of 3 residents reviewed for involvement in the activity program. The lack of an ongoing activity program could lead to anxiety, boredom, agitation, wandering and a decline in the residents' physical, mental, and psychosocial well-being. Residents Affected - Some The findings included: The facility policy #1303 Activity Program (revised 7/1/23) documented Activity programs are designed to meet the interests and support the physical, mental and psychosocial well-being of each resident. The activity programs are designed to support the well-being of residents and to encourage independence and community interaction. 1. Review of the clinical record revealed Resident #109 had an admission date of 2/9/24 with diagnoses including dementia, Parkinson's disease, anxiety, major depressive disorder and restlessness and agitation. The record documented Resident #109 had vision and hearing loss and a history of falls. On 9/3/24 at 9:50 a.m., Resident #109 was observed sitting in the television (TV) area on the unit, but he had no awareness of the TV program. He was noted to be restless, combative and was calling out. Certified Nursing Assistant (CNA) Staff F said the resident was often combative with care and attempts to climb out of the wheelchair unassisted. Staff F said the nurse had just given the resident medication to calm him down. At 3:40 p.m., the resident was observed sitting in the w/c in front of the TV and was speaking to himself, he was unaware of the program on the TV. Review of the activity calendar for 9/3/24 specified the activities for the day were BINGO at 10:00 a.m., Wellness Group at 11:00 a.m., [NAME] T entertainment at 2:00 p.m., and Bible study at 3:00 p.m. During random observations on 9/4/24 at 10:54 a.m., and 9/5/24 at 9:55 a.m., Resident #109 was observed sitting in the TV area and was noted to be restless, attempting to climb out of his w/c. He required frequent redirection from the staff for safety. The TV was on, but he showed no awareness or interest. Review of the activity calendar for 9/4/24 documented non-denominational church at 10:00 a.m., Crafts at 11:00 a.m., Room chats at 3:00 p.m., Poker at 5:45 p.m. The activity calendar for 9/5/24 documented 10:00 a.m., BINGO, 11:00 a.m., Port [NAME] AM Vet, 11:15 Darts, 2:00 p.m., Entertainment, 3:00 p.m., Room visits. 2. Review of the clinical record revealed Resident #31 had an admission date of 7/18/23 with diagnoses including dementia, Alzheimer's disease, major depressive disorder, post-traumatic stress disorder, unspecified mood disorder, hearing and vision loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 6 of 9 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 09/06/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/3/24 at 10:51 a.m., Resident #31 was observed sitting at the counter on the secured memory care unit. Music was playing but the resident was sleeping. Several other residents were seated at the counter and a staff member was seated behind the counter. Review of the activity calendar documented the following activities for the day with no designated times: Balloon exercise, Music and Poems, Joke of the day. At 2:00 p.m., Entertainment. On 9/4/24 at 11:02 a.m., Resident #31 was observed in his w/c sitting at the counter on the secured unit. No scheduled activity was in progress. Resident #31 smiled and made eye contact but did not respond when spoken to. CNA Staff C said the resident was Spanish speaking and spoke to him in Spanish, but he did not reply. CNA Staff C said the resident was able to speak when he wanted to and understands English. On 9/4/24 at 2:02 p.m., Resident #31 was seated at a table in the dining area of the unit, sleeping. Review of the activity calendar documented the following activities for the day: Non-Denominational Church, Exercise, Snoezeien and Nail Care. On 9/4/24 at 3:00 p.m., in an interview licensed practical nurse (LPN) Staff E said no one from activities was on the unit today during her 7 a.m., to 3 p.m., shift. Staff E said we play music and turn the TV on for them but no one from activities was here today on the unit. On 9/5/24 at 9:04 a.m., Resident #31 was observed sitting at the counter on the secured unit with a newspaper in front of him, but he made no attempt to hold it or look at it. Music was playing on a radio, but no structured activity was in progress. Review of the activity calendar specified the following activities for 9/5/24: Sit and be fit, Matching game, Room chats, 2:00 p.m., Entertainment, Socializing. 3. Review of the clinical record revealed Resident #62 had an admission date of 4/30/24 with diagnoses including Parkinson's disease, seizures, and vision and hearing loss. The record noted the resident's cognition was severely impaired. On 9/3/24 at 9:46 a.m., Resident #62 was observed sitting in a reclining chair in front of the TV with a group of other residents. CNA Staff F said the resident was blind only able to see shadows and hard of hearing. Staff F said the resident does not always comprehend when spoken to and did not keep his hearing aids in. At 2:48 p.m., Resident #62 was observed in the same chair in the TV area. The TV was on, but he was unaware and showed no interest. Review of the activity calendar for 9/3/24 specified the activities for the day were BINGO at 10:00 a.m., Wellness Group at 11:00 a.m., [NAME] T entertainment at 2:00 p.m., and Bible study at 3:00 p.m. During random observations on 9/4/24 at 9:50 a.m., and 2:28 p.m., Resident #62 was observed in the recliner in front of the TV. He was not able to hear or see the TV. There were no activities in progress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 7 of 9 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 09/06/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the activity calendar for 9/4/24 documented non-denominational church at 10:00 a.m., Crafts at 11:00 a.m., Room chats at 3:00 p.m., Poker at 5:45 p.m. On 9/4/24 at 3:07 p.m., a joint interview was conducted with CNA Activity Staff A and CNA Activity Staff B. Staff A said there are 2 separate calendars one for the secured memory care unit and another one for the rest of the facility residents. She said for Resident #62 we do provide 1-1 visits for him and bring him out to music programs. Staff A confirmed she did not have the necessary credentials in therapeutic recreational activities as required. Staff A said I'm an Activity Staff member and I do activities. CNA Activity Staff B said we bring the residents who can attend the activity program to the activity room. We have someone stay with them while we get the rest of the residents and bring them in. Staff B said not everyone wants to attend or can attend the activity programs. Staff B confirmed there were no activities provided to the residents who were not able to attend the scheduled activity program. On 9/4/24 at 3:15 p.m., in an interview CNA Activity Supervisor Staff G confirmed no one in the activity department had the necessary credentials in therapeutic recreational activities. Staff G said, right now I am supervising what is done. We are short one activity staff who has been out sick. We can't always get to the secured unit and not everyone there can come off the unit or is able to participate in the activity. We do 1-1 room visits with the residents who are not able to come off the secured unit 1-2 times a week for 10 minutes. Staff G said, we are very short staffed right now and we don't have the time to do activities on the units or to follow the activity calendars. Staff G confirmed she did not do any special individualized activities for residents with vision and hearing loss. On 9/4/24 at 3:21 p.m., in an interview the Administrator confirmed the facility has not had a qualified Activity Director since 8/1/24. She said we are looking to hire someone. The Administrator said, we had a regional interim Activity Director here last week and she was here for the entire week to oversee everything. On 9/5/24 at 10:05 a.m., in an interview LPN Staff D said the activity department does activities at times on the secured unit. Staff D said they are short staffed so sometimes they do the activities but not every day. Staff D said the activity aids will come and take residents off the unit to different activities but said not all the residents could attend off unit activities. She said there were usually 4 residents who could attend the activities off the unit. Staff D confirmed that no activities were provided for the residents who could not go off the unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 8 of 9 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 09/06/2024 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 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility Position Description for the Activity Directory and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professional. This has the potential to affect all current residents residing in the facility. Residents Affected - Some The findings included: The Position Description for the Activity Director Duties and Responsibilities specified, The Activities Director is responsible for the development, implementation, supervision and ongoing evaluation of the activity programs. Provides and properly documents an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental and psychosocial well-being of each resident on a daily basis. On 9/4/24 at 3:15 p.m., in an interview, Activity Staff A confirmed she did not have the necessary credentials in therapeutic recreational activities as required. Staff A said I'm an Activity Staff member and I do activities. On 9/4/24 at 3:15 p.m., in an interview, Activity Supervisor Staff G confirmed no one in the activity department had the necessary credentials in therapeutic recreational activities. Staff G said right now I am supervising what is done. We are short one activity staff who has been out sick. We can't always get to the secured unit and not everyone there can come off the unit or is able to participate in the activity. We do 1-1 room visits with the residents who are not able to come off the secured unit 1-2 times a week for 10 minutes. Staff G said, we are very short staffed right now and we don't have the time to do activities on the units or to follow the activity calendars. Staff G confirmed she did not do any special individualized activities for residents with vision and hearing loss. On 9/4/24 at 3:21 p.m., in an interview, the Administrator confirmed the facility has not had a qualified Activity Director since 8/1/24. She said we are looking to hire someone. The Administrator said we had a regional interim Activity Director here last week and she was here for the entire week to oversee everything. On 9/6/24 at 5:15 p.m., in an interview, the Administrator said we had someone with the required necessary credentials in therapeutic recreational activities to oversee the activities program here last week for the entire week. The Administrator confirmed the staff member was on site for one week only. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 9 of 9