Inspection·February 11, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few The investigation noted that on 12/23/24 at approximately 10:00 a.m., the Risk Manager observed scattered purple bruising to Resident #1's hands and wrists. When asked what happened to his hands and wrists, the resident stated they were grabbed by staff. The resident said no when the Risk Manager asked if he felt the staff intentionally tried to hurt him, but they were rough . The Risk Manager asked Resident #1 if he was combative with staff when they were trying to clean him, he said yes. Resident #1 displayed signs and symptoms of mental anguish due to the event, and psychological support is being provided. On 12/23/24 at approximately 11:00 a.m., the Risk Manager spoke to LPN Staff A about Resident #1's care on 12/20/24. LPN Staff A said Certified Nursing Assistant (CNA) Staff B was having a difficult time with the resident's behavior and asked him to help. When CNA Staff B went in the room around 3:30 a.m., Resident #1 had an incontinent episode and was smearing feces on the bed and the mattress. When they attempted to clean the resident, he was very combative, grabbing their arms, and also pushing them away. LPN Staff A said they tried to hold Resident #1's by his hands and wrists so he wouldn't fall out of bed, he was flailing his arms everywhere and at one point grabbed his aluminum reacher and was swinging it at them. After they cleaned him up, Resident #1 kept trying to get out of bed so they placed him in the wheelchair and placed him in the dayroom for observation and monitoring. On 12/24/24 at approximately 10:30 a.m., the Risk Manage spoke with CNA Staff B about Resident #1's care on 12/20/24. CNA Staff B said when she went in the resident's room at approximately 3:30 a.m., the resident had a bowel movement and was playing with the feces. She asked LPN Staff A to help her clean the resident. CNA Staff B said throughout the care, the resident was very combative, swinging his arms at them and grabbing their arms. He used his reacher like a baseball bat to swing at them while they were trying to clean him. She said LPN Staff A and her had to hold Resident #1 by his hands when they were providing care so he wouldn't hit them or fall out of bed. They both decided to place Resident #1 in a wheelchair and took him to the dayroom where they could keep an eye on him. The Risk Manager documented in the incident investigation Resident #1 had significant cognitive impairment due to Parkinson's and dementia, which includes memory loss, paranoia and confabulation. She documented, After a complete and thorough investigation, it has been determined that the allegation of abuse is not verified. During the alleged incident, Resident #1 was smearing feces on his bed and pillowcase when staff entered the room, which was a new behavior for him. Resident #1 was very combative and resistant to care while they were trying to clean him. The resident grabbed both staff members' arms repeatedly as well as pushing them away. Resident #1 used his reaching device as a weapon trying to hit both staff. In order to keep the resident safe, both staff did hold his hands and wrists during care to avoid being hit and to prevent him from falling out of bed due to his combative behaviors. On 2/10/24 at 12:20 p.m., in an interview the Risk Manager verified Resident #1's family members told her the bruising to the resident's hands were from prying his fingers from the handrail when LPN Staff A and CNA Staff B forcibly removed him from the bed. She said she did not document in her investigation as it was hard to understand the resident's answer to her question. She verified she did not ask LPN Staff A or CNA Staff B about prying the resident's fingers from the handrail and forcibly removing him out of bed. She said staff should not have removed the resident from the bed against his will. When asked about the resident's mental anguish documented in her investigation, the Risk Manager said the resident was frustrated when talking about the incident and had a contorted face. On 2/10/25 at 1:00 p.m., Resident #1 was observed in the hallway in his wheelchair with a staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 2 of 3 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 02/11/2025 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 0600 member. In an interview, Resident #1 was asked if staff had forcibly removed his hands from the bedrails during the night of 12/20/24 causing bruising to his hands. Resident #1 replied, yes. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106059 If continuation sheet Page 3 of 3