Inspection·January 7, 2021

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 1/7/21 at 11:08 a.m., in an interview the UM said she reviewed Resident #73's record and determined the last documented time Resident #73 had a shower was 12/7/20. She said Resident #73 had not received her scheduled showers from 12/10/20 to 1/5/21. She said she interviewed the nursing staff who confirmed Resident #73 had not received her shower during the time period noted and the staff were unable to give a reason why Resident #73 did not receive her shower. She said there was no documentation Resident #73 had refused her showers between 12/10/20 through 1/5/21 and she should have had her showers as requested. Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Place Healthcare and Rehabilitation Center 2370 Harbor Blvd Port Charlotte, FL 33952 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the state's Long-Term Care Ombudsman Council (LTCOC) of facility-initiated transfers and discharges since October 2020. The local Ombudsman office was not notified of 3 (Residents #20, #36 and #70) of 3 sampled facility-initiated transfer/discharged of a total of 17 facility initiated transfers to the hospital from [DATE] through 1/6/21. The failure to send notices of facility-initiated transfers and discharges to the LTCOC potentially prevents inappropriately discharged resident's access to an advocate to inform them of their options and rights. The findings included: On 1/4/21 at 10:00 a.m., in an interview, the local LTCOC's office stated they had not received the required documentation from the facility related to all facility-initiated transfers and discharges as required. They stated they had not received any notices since October 2019. On 1/6/21, a review of the facility's discharge log from 9/1/20 through 1/6/21 revealed a total of 70 transfers and discharges from the facility which consisted of 17 to an acute care hospital. Sampling of facility-initiated transfers to the hospital from [DATE] through 1/2/21 found: September 2020, Resident #20 was transferred to an acute care hospital on 9/1/20. October 2020, Resident #36 was transferred to an acute care hospital on [DATE]. November 2020, Resident #70 was transferred to an acute care hospital on [DATE]. On 1/7/21 at 9:12 a.m., in an interview, the Social Service Director (SSD) said she was not the person who contacted the LTCOC when facility-initiated transfers and discharges from the facility occurred. She also said she didn't know who was responsible to contact the LTCOC when a resident was transferred or discharged from the facility. On 1/7/21 at 10:05 a.m., in an interview, the Regional Nurse and the Director of Nursing (DON) said they did not know who was responsible to notify the LTCOC office of facility-initiated transfers and discharges of residents. The DON said the discharging nurse was responsible to complete a Nursing Home Transfer and Discharge Notice form. This form had an area for the nurse to indicate the date the Resident, Legal Guardian or Representative, and the Local LTCOC office were notified of the facility-initiated transfers and discharge. The DON said she was unable to find documentation the LTCOC office was notified from 10/1/20 to 1/6/21 as required of facility-initiated transfers and discharges. On 1/7/21 at 12:00 p.m., in an interview, the DON said the facility did not have a written policy and/or procedure stating who was responsible to ensure the LTCOC's office was informed in a timely manner of a facility-initiated transfers and discharges. She confirmed the LTCOC was not notified of the facility-initiated transfer and discharge for Residents #20, #36 and #70 as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Place Healthcare and Rehabilitation Center 2370 Harbor Blvd Port Charlotte, FL 33952 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review the facility failed to ensure 2 (Residents #9 and #65) of 3 residents reviewed for vision impairment received proper treatment and assistive devices to maintain their vision at optimal condition. Residents Affected - Few The findings included: 1. On 1/4/21 at 2:13 p.m., in an interview Resident #65 said the eye doctor (ophthalmologist) told her the reason she was losing her vision, and everything was getting blurry was because she needed cataract surgery. She said he told her in August 2020 because her vision was blurry to tell the nurse when she was ready for the cataract surgery and the facility would arrange for her to have the surgery to correct her vision. She said she had told the head nurse and other people several times she was ready for the cataract surgery, but no one had gotten back to her. She said her vision was very blurry and she was unable to read or watch TV as she would like. On 1/6/21 a review of Resident #65's medical record, noted she was admitted to the facility on [DATE]. On 10/28/19 an ophthalmologist 's progress note contained documentation he discussed with Resident #65 cataracts caused a painless and progressive loss of vision. The appropriate time to perform cataract surgery was when the loss of vision was interfering with her daily activities and a change of glasses would not help. He instructed Resident #65 to contact the nurse if she noticed any decrease in vision so they could schedule her to be seen by the ophthalmologist to remove the cataracts. Resident #65's plan of care for impaired visual function showed one of the goals was for the resident to have no indication of acute eye problems and she would maintain optimal quality of life. The interventions noted the facility would monitor for any signs and symptoms for acute eye problem to include blurred or hazy vision. On 1/6/21 at 12:50 p.m., during an interview the Unit Manager (UM) said she didn't remember Resident #65 telling her she needed to be seen by the ophthalmologist because her vision was getting blurry and she needed cataract surgery. She said the Social Service Director (SSD) was the person who kept track of all the eye physician visits, did the end of the day visit exit with the eye physician, collected his progress notes and informed nursing if he had any recommendation for the residents he examined that day. She said the SSD did not inform nursing the ophthalmologist had told Resident #65 if her vision was worsened, she would need cataract surgery to correct her blurry vision. On 1/6/21 at 1:41 p.m., the Social Service Director (SSD) said she had been working at the facility for 5 years. She said she didn't keep a formal and complete list of which residents saw the ophthalmologist on his visits. She also said she did not do the exit with the ophthalmologist when he had seen all the residents in the facility, and she thought the nursing department followed up with the ophthalmologist for any recommendation he had for the residents. She said the UM had just called her about the ophthalmologist recommendation for cataract surgery for Resident #65 and new glasses for Resident #9. She then called the ophthalmologist who told her he was not in his office but would fax her his progress notes for Resident #9 and #65. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Place Healthcare and Rehabilitation Center 2370 Harbor Blvd Port Charlotte, FL 33952 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 0685 Level of Harm - Minimal harm or potential for actual harm After reviewing Resident #65's medical record, the SSD confirmed the ophthalmologist had written on 10/28/19 stating due to the resident's vision getting worse she would need corrective cataract surgery. She said she was unaware the ophthalmologist had recommended Resident #65 needed cataract surgery to correct her blurry vision. She confirmed there was no documentation in the medical record the facility was monitoring Resident #65's vision as required in Resident #65's plan of care for impaired visual function. Residents Affected - Few The SSD said the ophthalmologist office faxed her Resident #65's progress notes. She said the progress notes state the ophthalmologist visited Resident #65 at the facility on 8/28/20 and stated Resident #65 should inform the nurse if she was noticing a decrease in vision so they can schedule for cataract surgery. She said she was unaware the ophthalmologist had seen Resident #65 on 8/28/20 and was unaware he had recommended cataract surgery to correct progressive vision loss. 2. On 1/4/21 at 2:00 p.m., in an interview Resident #9 she said the ophthalmologist came to the facility several weeks ago and said she needed a new pair of glasses due to her poor vision. She said she had asked the nursing staff several times if her new glasses had come in but they told her they had not arrived at the facility. She said she needed the new glasses since her vision was so poor. The resident said she was unable to watch TV because everything was blurry. On 1/6/20 review of Resident #9's medical record revealed no documentation Resident #9 was seen by the ophthalmologist in 2020 and he had ordered a new set of glasses to correct Resident #9's blurry vision. Resident #9's plan of care for impaired visual function stated Resident #9 required eyeglasses to maintain adequate vision, the plan of care was created 5/4/18 and last revised on 1/3/20. On 1/6/21 at 12:45 p.m., in an interview the UM confirmed Resident #9 wears glasses to correct her vision. She said she knew the ophthalmologist had been to the facility several times but didn't know if he had examined Resident #9 or ordered her a new set of glasses. She said the SSD kept track of the ophthalmologist visits and if Resident #9 had new glasses the SSD would receive them to pass out to the residents. She said the SSD did not inform her Resident #9 would be getting a new pair of glasses. On 1/6/21 at 1:25 p.m., in an interview after SSD reviewed Resident #9's medical record, she confirmed Resident #9's plan of care for impaired visual function stated Resident #9 required eyeglasses to maintain adequate vision. The plan of care was created on 5/4/18 and last revised on 1/3/20. She said after reviewing all her documentation and notes she did not have documentation if, when, and how many times the ophthalmologist visited the facility and who he saw during those visits for 2020. After a phone conversation with the ophthalmologist, the SSD stated, he (the ophthalmologist) was going to fax over his progress notes for Resident #9 for 2020. She said she would investigate if the ophthalmologist had ordered new glasses for Resident #9 and determine when they would be delivered to the facility. On 1/6/21 at 5:15 p.m., in an interview the Executive Director (ED) said normally the SSD oversaw the tracking of all visits from the ancillary physician service visits. She should also make sure the residents received the services ordered by the physicians had been completed in a timely manner. On 1/7/21 at 9:02 a.m., during an interview the SSD said on 1/6/21 the ophthalmologist faxed an ophthalmologist progress note dated 10/26/20 for Resident #9. She said upon review of the progress (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Place Healthcare and Rehabilitation Center 2370 Harbor Blvd Port Charlotte, FL 33952 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 0685 Level of Harm - Minimal harm or potential for actual harm note, she noted on 10/26/20 the ophthalmologist ordered a new pair of glasses for Resident #9. The SSD stated during her investigation about Resident #9's glasses, she found 4 pairs of glasses in a paper bag which were delivered to the facility on [DATE] and one of the pairs belonged to Resident #9 which she gave to her last night. She said she was unaware the ophthalmologist had ordered a new set of eyeglasses for Resident #9 and was unaware they were delivered to the facility on [DATE]. Residents Affected - Few As a result of ancillary physician service visits not being monitored, Resident #65 did not have her cataract surgery scheduled timely and Resident #9 did not receive the new glasses for a month after they were delivered to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Place Healthcare and Rehabilitation Center 2370 Harbor Blvd Port Charlotte, FL 33952 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, record review, and staff and resident interview, the facility failed to demonstrate effective coordination and follow physician orders and care plan interventions for the application of knee braces for 1 (Resident #7) of 2 residents reviewed with contractures (a tightening of muscles, tendons and ligaments that prevent joint movement). This had the potential to cause pain and worsening of the contracture. The findings included: On 1/4/21 at 12:11 p.m., during an initial observation and interview, Resident #7 was in her bed with her knees flexed and drawn up toward her abdomen. The resident had her left hand in a closed, tight fist. She said she was not able to open the hand. Resident # 7 did not have a splint or positioning device for her left hand. Resident #7 said she was not able to extend or bend her legs at the knee. The resident said she did not have any splints for her knees. On 1/4/21 a review of Resident #7's clinical record showed a care plan identifying Resident #7 had self-care deficit related to limited mobility and limited range of motion (ROM). The interventions included to apply knee braces to bilateral knees to address contractures. The clinical record documented a physician order dated 1/31/20 to apply knee brace for 2 hours, promoting knee extension to bilateral knees to address contractures. On 1/6/21 at 9:08 a.m., in an interview Resident # 7 said she was not able to stretch out her legs, saying pain was a 10 on a scale of 1-10. Resident #7 said she asks for pain medication and it makes the pain better. The resident said the staff did provide ROM but no splints or braces for her knees. Resident #7 was able to open her left hand. On 1/6/21 at 10:12 a.m., in an interview the Rehab Director (RD) said Resident #7 received therapy from 7/9/19 through 7/31/19 for contractures and positioning. The RD said the resident was evaluated again on 12/24/19 and received therapy until 1/31/20. The RD said Resident #7 often declined services. On 1/6/21 at 10:22 a.m., in an interview the Occupational Therapist (OT) said Resident #7 received knee braces and a splint for her left hand over a year ago but declined to allow them to be applied. The OT said the resident had not had the splints applied for a long time. The OT said if the staff had a concern with a resident, they would complete a request for a therapy evaluation. The OT confirmed Resident #7 was not currently receiving therapy because she refused and confirmed they did not receive a referral for another evaluation. On 1/6/21 at 11:13 a.m., a review of the treatment administration record (TAR) for December 2020 showed Apply knee brace for 2 hours promoting knee extension to bilateral knees to address contractures. The TAR had an X entered each day making it impossible to determine if the nurse applied the brace to the resident's knees as ordered. On 1/6/21 at 11:19 a.m., in an interview the Director of Nursing (DON) verified the nurses were not signing the TAR for the application of the knee braces. She said the application of the brace was on the record for information only and did not require the nurses to place their initials. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Place Healthcare and Rehabilitation Center 2370 Harbor Blvd Port Charlotte, FL 33952 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 0688 Level of Harm - Minimal harm or potential for actual harm On 1/6/21 at 11:25 a.m., in an interview the Unit Manager (UM) said if a resident had an order for a splint or a brace they would sign the TAR. If the resident refused to allow the application of the brace, the nurse would enter R or refused and document. The UM said Resident #7 did not have a physician's order for the leg braces. After reviewing Resident #7 clinical record the UM verified a physician's order dated 1/31/20 for Resident #7 to have knee braces applied daily for two hours. Residents Affected - Few The UM said the Certified Nursing Assistant (CNA) was applying the knee brace from 1/2020 through 7/31/20 but the Restorative Program was discontinued due to resident refusal. The UM said if a resident refused the nurse would document the resident refusal in the clinical record. On 1/6/20 at 11:35 a.m., the UM said she would demonstrate the application of the braces to Resident #7 knees. Upon entering and searching the resident's room the UM was not able to locate the braces. The UM said there were here yesterday, I saw them. I will ask the Certified Nursing Assistant where she put them. On 1/6/21 at 11:45 a.m., in an interview the UM said she spoke with the Rehab Director and was informed the leg braces for Resident #7 were removed and taken back to therapy last year because the resident refused them. The UM confirmed there was no documentation Resident #7 refused the knee braces once the Restorative Program was discontinued. The UM confirmed there was a physician order for the application of the knee braces for Resident #7 and the braces were not being applied. On 1/6/21 at 12:23 p.m., the Regional Registered Nurse (RRN) said the facility had no policy for the application or use of splints and braces. The RRN said there was no policy for following physicians orders it is just expected practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Place Healthcare and Rehabilitation Center 2370 Harbor Blvd Port Charlotte, FL 33952 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on record review, review of policy, menu and physician's orders, observation and interview the facility failed to provide the physician ordered diet for 2 (Residents #44 and #388) of 3 sampled residents with prescribed renal diets. The failure to follow the prescribed physician's diet order could negatively affect the residents' nutritional status. The findings included: Review of the contracted food service company's Policy on Therapeutic Diets, dated October 2019, noted Statement: It is the Center policy to insure that all residents have a diet order, including regular, therapeutic, and textured modified, prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. 'Therapeutic diet' is defined as a diet ordered by a physician or delegated registered or licensed dietitian as part of the treatment for a disease or clinical condition, to eliminate or decrease specific nutrients in the diet (e.g. sodium) or to increase specific nutrients in the diet (e.g. potassium) or to provide food that a resident is able to eat (e.g. mechanically altered diet). 1. Review of the extended therapeutic diet menu revealed residents with physician ordered diets for liberalized renal diets were to be served 4 meatballs instead of baked ziti with meat sauce. On 1/6/21 at 11:51 a.m., in an interview at the beginning of the lunch tray line observation, the Certified Dietary Manager said residents who were prescribed renal diets were going to be served spaghetti, meatballs and tomato sauce. 2. Review of the clinical record for Resident #44 revealed a physician's order for a liberalized renal diet, regular texture, regular liquids consistency. The individualized care plan for the resident included is at risk r/t (related to) ESRD (End Stage Renal Disease) requires HD (Hemodialysis) with the goal of resident will not experience significant weight change. Nutrition approaches included provide, serve diet as ordered. Monitor meal intakes. Resident receives a specialized diet (check with nurse, or check orders prior to offering additional foods). On 1/6/21 at 11:51 a.m., during the lunch tray line observation, Resident #44 was served spaghetti, meatballs, and tomato sauce. 3. Resident #388 had a physician's order for a liberalized renal diet, regular texture, regular liquids consistency. The individualized baseline care plan dated 1/5/21 included resident needs dialysis with the goal resident will have dialysis as ordered by the doctor and will not develop complications related to dialysis. Nutrition approaches included consult with dietitian for nutritional support related to renal disease. On 1/6/21 at 11:51 a.m., during the lunch tray line observation, Resident #388 was served spaghetti, meatballs, and tomato sauce. ***Photographic evidence obtained*** FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Place Healthcare and Rehabilitation Center 2370 Harbor Blvd Port Charlotte, FL 33952 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to provide evidence of a functioning antibiotic stewardship program to monitor the use of antibiotics. Residents Affected - Few The findings included: The facility Policy number 21.11.001 titled Standards and guidelines: Antibiotic Stewardship with an issued date of 11/1/17, documented Antibiotic usage and outcome data will be collected, monitored and tracked. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility - wide antibiotic stewardship. On 1/5/21 at 4:00 p.m., in an interview the designated Registered Nurse Infection Preventionist (RN IP) said the facility reviewed antibiotic use with the Interdisciplinary Team (a group of health care professionals with various areas of expertise) and if there was a problem, the facility contacted the physician. The RN IP said she met every morning with team members, and they reviewed antibiotics and infections in the facility and if there was a problem, they contacted the physician. On 1/5/21 at 4:21 p.m., in a telephone interview the Consultant Pharmacist for the facility said, he said did not review the antibiotics usage for the facility. He said he did not attend antibiotic stewardship meetings because the facility stopped having them. On 1/5/21 at 4:30 p.m., the RN IP confirmed she was not able to produce any minutes from the antibiotic stewardship meetings or activities and said she did not document them. The RN IP was not able to provide evidence of a functioning facility-wide antibiotic stewardship program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 If continuation sheet Page 10 of 10