Inspection·July 16, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and they moved the resident in his room under the (brand name) mechanical lift tract. She avoided touching the resident's paralyzed arm and they hooked him up to the lift.Review of CNA Staff B's written statement revealed that Resident #899 was on the floor by the dresser. She asked CNA Staff A if she needed help getting the resident up. Resident #899 was not close to the (brand name) mechanical lift track. She (CNA Staff A) dragged him by the collar of his shirt to be closer to the track, got him in the sling and back to bed.The investigation noted that on 7/1/25 at approximately 1:45 p.m., the Nursing Home Administrator and the Risk Manager interviewed CNA Staff B. Staff B stated that she was in a different room caring for a resident. She exited the room and walked past Resident #899's room. She noted CNA Staff A standing over Resident #899. The resident was laying on the floor in front of his armoire. She offered her assistance to CNA Staff A, which she accepted. She closed the door. At this time, CNA Staff A grabbed Resident #899 by his shirt and moved him closer to the track of the lift to get the resident off the floor. CNA Staff B demonstrated to the Risk Manager and the Nursing Home Administrator the location of Resident #899 when she entered the room. CNA Staff B stated to the Risk Manager and the Nursing Home Administrator that this was not right, she was not going to participate in moving a resident this way. Staff B said when she presented this to CNA Staff A, the response was, This is how I do it.On 7/1/25 at approximately 2:00 p.m., the Nursing Home Administrator and the Risk Manager spoke with CNA Staff A regarding the concerns brought to their attention. CNA Staff A stated that she noted Resident #899 in the doorway and wanted to move him away from the doorway. She grabbed his left arm and shoulder, and he assisted by scooching himself. CNA Staff A stated that she only moved Resident #899 2 inches and the other CNA (CNA Staff B) assisted by lifting the legs. CNA Staff A went to the resident's room and demonstrated for the Nursing Home Administrator and the Risk Manager what she did. Resident #899's head was by the room to his door. CNA Staff A used the resident's left arm and shoulder and moved him approximately 4 to 5 feet from the door, spinning him around to have his head by the armoire in his room.The conclusion of the investigation documented, The investigation determined that the allegation of abuse was verified by improperly transferring the resident without properly utilizing a lift sling or lift equipment provided by the facility as per policy. CNA [Staff A] action replay and verbal recollection of the event determined that she did not use the provided equipment nor follow facility policies for transferring a resident safely resulting in potential injury both physically and emotionally on the resident's behalf.On 7/16/25 at 9:15 a.m., in an interview the Risk Manager said the root cause of the incident involving Resident #899 was negligence. CNA staff A's story kept changing during the interview. On 7/16/25 at 9:26 a.m., an attempt was made to interview Resident #899. He did not respond to interview questions.On 7/16/25 at 9:50 a.m., in an interview CNA Staff B said that on 7/1/25 she was walking past Resident #899's room and saw CNA Staff A standing over the resident who was on the floor. She asked CNA Staff A if she needed help because 2 people are needed to use the mechanical lift. She said she entered the room and closed the door. Resident #899 was not in front of the door, otherwise, she would not have been able to close the door. CNA Staff B said, The next thing I saw was she [CNA Staff A] grabbed the resident by the shirt, spun him around and pulled him across the floor by the shirt.She said the resident's head was facing the bed, [CNA Staff A] whipped him around by his shirt and pulled him over about 4 to 5 feet. I don't know why she didn't just use the portable lift to get him off the floor. I know what I saw and I told the DON. That is not how you treat residents, you can't pull on them.On 7/16/25 at 11:12 a.m., in a telephone interview CNA Staff A said Resident #899 was on the floor and she needed help to get him into bed. She said, I didn't see him get on the floor, but he does that. He was by the wall in his room, about one foot from the bed. She needed help to get him to the (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 07/16/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete lift and put the sling under the resident. CNA Staff B came into the room. She grabbed the resident's arms and CNA Staff B grabbed his legs. They placed the lift pad under Resident #899. She said, I did not in any way pull him by the arm or the shirt. It did not happen. I did not grab him or pull him by the arm.On 7/16/25 at 11:30 a.m., in an interview Registered Nurse (RN) Staff C said on 7/1/25 she was the nurse on duty and asked CNA Staff B to help CNA Staff A with Resident #899 who was on the floor. She did not see where the resident was in the room. She clocked out and went to lunch for 30 minutes. She later found out what had happened. RN Staff C said, I never saw CNA Staff A hit a resident, but she was rough with them on occasions when she was transferring them. By rough I mean, she was fast when she was transferring them. A lot faster than I or anyone else would do it. Event ID: Facility ID: 106059 If continuation sheet Page 3 of 3