Inspection·June 16, 2022

F 0565 April 19, 2022 Level of Harm - Minimal harm or potential for actual harm *Evidence obtained. Residents Affected - Some On 6/14/22 at 10:30 a.m. the Activity Director said an average of 10 residents participate in the monthly meeting. Those meetings are held monthly, she is the record keeper, and the minutes are accurate. On 6/14/22 at 11:00 a.m. the Resident Council Meeting was held with 5 residents who attend regularly (Resident's # 63, # 44, # 71, #62 and # 56) and the Activity Director. When inquired about grievance process, Resident # 63 said we discussed our concerns in the meeting. We always have concerns we bring up every month. Our main and constant issue is the food. The Activity Director can confirm that. On 6/14/22 at 02:18 p.m., in a follow up interview, the Activity Director said she attends as a support for the group and takes the minutes. She further said for some reasons I did not list any of the concerns; I see now how that can be an issue because their grievances cannot be acted upon and resolved because they are not listed in the minutes. On 6/14/22 at 4:10 p.m. the Administrator said she was told about the concerns by her Activity Director and the Facility will start education. The Administrator said Resident Council meetings are used to voice concerns and those should be documented and brought up to the administration. The administrator further said, my understanding is that this was not being done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, staff and residents' interview, the facility failed to ensure the residents are aware the results of the most recent inspection of the facility conducted by a federal or state agency are available to read, and where results are located. The resident census was 100. Residents Affected - Few The findings included: On 6/14/2022 at 2:00 p.m. requested the Resident Council policy. Review of facility Administrator's Standards of Practice, Resident council section (n.d.) (Resident Council policy) did not contain a statement about resident rights to review the most recent facility inspection report, nor the location of the document. On 6/14/22 at 11:00 a.m. the Resident Council Meeting was held with 5 residents (Resident's # 63, # 44, # 71, 62 and # 56) who attend the monthly meeting regularly. The Activity Director was also in attendance. When asked question # 20 of the Resident Council questionnaire, which reads Without having to ask, are the results of the state inspections available to read?, All 5 residents said no. The Resident Council President and [NAME] President said they had no knowledge that survey results were readily available and where they were located. The Activity Director said I did not know I had to share that information with them. None of them will be able to answer that question because I don't go over that. On 6/14/22 at 02:18 p.m., in a follow up interview, the Activity Director said I did not know the residents had to know that they could have access to the survey results. I will make sure talk about it in the next Resident Council Meeting. On 6/14/22 at 4:10 p.m., the Administrator said she expected that survey results and location will be discussed in next resident's and will all newly admitted residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 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 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on facility record review, staff and family interview, the facility failed to respond to resolve a grievance for 1 (Resident #20) of 2 residents reviewed for lost items. Residents Affected - Few The findings included: Review of policy Lost and Found Version 1.1 (H5MAPL0473) revised January 2008 indicates resident or family complaints of missing items must be reported to Social Services. On 6/13/22 at 11:49 a.m. during a visit, daughter and Power of Attorney (POA) said Resident # 20 lost his cellular telephone. Facility had packed and stored in their storage room during one of her dad's recent hospitalization last month. Resident #20's daughter said she told a nurse last month, but facility has not acknowledged the loss thus far. On 6/14/22 at 10:09 a.m., a review of facility grievance was conducted and show no complaint listed for Resident #20's loss of items. On 6/15/22 at 11:21 a.m., Licensed Practical Nurse (LPN) Staff # B said Resident #20's daughter told me he had lost a cellular. Staff # B said she did not fill out a grievance and could not remember if she told the Social Services. On 6/15/22 at 11:46 a.m., Review of Resident # 20's inventory log sheet dated 12/20/21 lists a cell phone and cord. On 6/15/22 at 11:40 a.m. during a telephone interview, Social Services Director said she had not received a grievance for Resident # 20 and does not know of loss items. On 6/15/22 at 1:17 p.m. Administrator said facility has a grievance process that was not used by LPN Staff B. Facility will contact Resident # 20's daughter and fill out a grievance and initiate investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to develop a comprehensive plan of care to address critical medication usage for 2 (Residents #19 and #90) of 5 residents reviewed. The findings included: On 6/14/22, record review revealed Resident # 19 was admitted on [DATE] with a diagnosis of acute embolism (blood clot that breaks off and travels) and thrombosis (blood clot) and atrial fibrillation (irregular, often rapid, heart rate). On 6/14/22 at 4:01 p.m. further review of the record for Resident # 19 revealed a physician's order for Apixaban (anticoagulant or blood thinner) tablet 2.5 milligrams (mg) for pulmonary embolism (clot in an artery to the lung). There was no evidence of a care plan addressing the use of an anticoagulant medication and the risks of bleeding and interventions and guidance for staff to use in the event of complications. On 6/14/22, record review revealed Resident # 90 was admitted on 8//27/21 with a diagnosis of hallucinations, psychosis, major depression, and Parkinson's disease. On 6/14/22, further review of Resident # 90's medical record revealed a physician's order for the following psychotropic (medications that effect the chemical makeup of the brain) medications: Escitalopram Oxalate Tablet 10 mg for depression, Seroquel Cream 12.5 mg for psychosis and Buspirone HCl tablet 5 mg for anxiety related to psychosis. There was no evidence of a care plan addressing the use of psychotropic medications to monitor for side effects, minimize decline and avoid complications. On 6/15/22 at 1:41 p.m. in an interview, the facility Minimum Data Set Coordinator confirmed there was no evidence of a care plan addressing the use of an anticoagulant medication for Resident #19. She also confirmed there was no evidence of a care plan addressing the use of psychotropic medication for Resident #90. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 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 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, interview, and record review the facility failed to develop and implement individualized one-to-one activity for two residents (Resident #7 and #12) of 5 residents surveyed. The lack of activities has a potential to cause mental and physical decline due to a lack of physical activity and mental stimulation. Residents Affected - Few The findings include: 1. On 6/13/22 at 10:00 a.m. Observed Resident #7 lying in bed, contractures both upper extremities. The television was turned on and watching the news channel. Resident #7 said someone visits twice a week but not sure what they do. Resident #7 said she watches mostly watches television. Resident #7 said she used to read books about history, and she liked to listen to classical music, and she likes to keep up with current events. Resident #7's Brief Interview for Mental Status (BIMS) was noted to be 15 which showed the resident was interviewable and able to make her needs known. Resident #7's Activity assessment completed last year 2021. Activities as necessary. No Documentation. Review of visitation documentation provided by activity staff shows no documentation of one-to- one visit after 4/11/22. On 6/15/22 at 8:45 a.m. The Activity Director said Resident # 7 is on the list to receive one-to-one activity from the department. She said that Resident #7 does not like to do anything but does like the company to talk. Activity staff goes to Resident #7's room and delivers the daily chronical and will converse with her. Activity staff does not read the chronical to Resident #7, she said Resident #7 can pick up the paper herself and read. The Activity Director said that activity staff goes into the room throughout the day, she does not know why they have not been documenting their visits. Review of Resident #7's activity care plan with revision date 6/3/22 showed no individualized activities, or interventions for one-to-one activities. On 6/15/22 at 10:00 a.m. Resident #7 was observed in her room in her bed. The resident was observed not to be able to pick up a paper that was on her bedside table due to the contractures in her hands and arms. On 6/16/22 at 9:00 a.m. Review of Resident #7's Activity Task Sheet in the resident's electronic medical record for fourteen days (June 2, 2022, to June 15, 2022) showed one documented one to one activity occurred on 6/10/22 which was documented as conversation and sensory activities. On 6/15/22 a one-to-one activity was documented as conversation. There were no further activities noted to be documented over the two-week period. On 6/16/22 at 12:00 p.m. Interview with Staff G said she works on Tuesday and Thursday. Staff G Explained that there is an activity sheet in the computer program Point Click Care where she documents her 1:1 activity right away. Staff G said that there is nothing planned or scheduled that she provides to the residents except for the daily chronical. Staff G said she gets information regarding resident's activities by getting to know them and when the activity director completes the initial assessment. Staff G explained that there is nothing set for staff to review on what the residents' activities should be completed for Resident #7. Staff G said she usually provides conversation and sensory input such as lotion for the Resident #7. Staff G said she completes one-to-one activity when she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few has time in between assisting in the dining room and the regular activities she provides in the activities room with other residents. Staff G said she spends 15 minutes with Resident #7 when she provides one-to-one activity. On 6/16/22 at 12:30 p.m. in an interview with Activity Director she said she had just found out yesterday there was a place to document activities in the resident's electronic record. The Activities Director said going forward activity staff will document in Point Click Care for one-to-one activity. The Activity Director said she did not have a care plan with specific individualized activities for Resident #7. The Activities Director said there are no specific activities written down and that she communicates verbally with her staff regarding activities for residents receiving one-to one activity. The Activities Director was not able to recall the type of music Resident #7 liked. Regarding the lack of documentation for Resident #7's one-to -one activity, The Activities Director was unable to state how often she reviewed the activities staff's documentation of one-to-one activity for Resident #7. The Activities Director verified she had not reviewed the documentation since April of 2022. On 6/16/22 at 1:15 p.m. interviewed Resident #7 on her history and her likes. Resident #7 worked in research and read a lot of history and biography books. Would like to try books on tape/audio books. She enjoyed shopping, gardening and art. She enjoys classical music her favorite composer is [NAME]. Likes to keep up on current events. 2. On 6/13/22 at 9:37 a.m., Resident #12 was observed lying in bed sleeping. At 1:13 p.m., being assisted with lunch by Certified Nursing Assistant (CNA). At 2:45 p.m., no one on one activity noted for Resident #7 during these observations. On 6/14/22 at 9:07 a.m., Resident #12 was observed lying in bed awake, non-verbal, lights were off. At 12:30 p.m., Resident #12 was lying in bed awake TV on, and light was off. Resident #12 at 1:35 p.m., was in lying in bed, TV on, and light was on. No one on one activity noted for Resident #12 during these observations. On 6/15/22 at 10:10 a.m., Resident #12 was observed lying in bed awake, no-verbal, lights were on. At 1:05 p.m., Resident #12 was being assisted by Nurse on the Unit for lunch. At 3:40 p.m., Resident was lying in bed sleeping, TV was on, and light was on. No one on one noted for Resident #12 during these observations. On 6/15/22 2:33 p.m., an interview with Director of Activities (DOA) verified that there was no documentation for Resident #12 getting one on one since April of 2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interviews and policy review, the facility failed to ensure medications were not left unsecured and unattended at bedside for 1 Resident (Resident #19) of 20 Residents reviewed. The findings included: Review of facility storage of medication 1.3 (H5MAPL0851) policy revised November 2020 reads: Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have to have access to locked medications. On 6/13/22 at 09:19 a.m. observed Resident # 19 with medication bottes (Milk of Magnesia (MOM) and Calcium carbonate antacid TUMS) at bedside. Resident #19 said he has had those bottles for the past 2 to 3 weeks now. **Photographic evidence obtained** On 6/13/22 at 2:13 p.m. Review of Resident # 19 medical record revealed no assessment was done by the facility for self-administration. Clinical review also revealed no care plan for self-administration of medication was initiated. Resident #19 has an order for MOM but not for Calcium carbonate antiacid (TUMS). On 6/14/22 at 08:32 a.m. observation revealed a medicine cup with two red pills was sitting on Resident's #19 bedside table. **Photographic evidence obtained** On 6/14/22 at 9:42 a.m. in an interview, the Minimum Data Set (MDS) Coordinator confirmed Resident #19 did not have a care plan to self-administer medication. On 6/14/22 at 02:06 p.m., in an interview, Licensed Practical Nurse (LPN) Staff #F said she saw the two loose pills this morning at Resident #19's bedside. On 06/15/22 at 1:21 p.m. Administrator said leaving pills at bedside is not facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 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 106072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to provide Restorative Services as ordered by Physician for 2 (Residents #12 and #68) of 3 Residents reviewed for Restorative Services. This has the potential to increase ADL functions and contractures in non-active Residents. Residents Affected - Few The findings included: Review of clinical record for Resident #12 revealed restorative orders for Passive ROM - Assist with moving arms for ROM exercises 1 set of 10 repetitions. This is reflected on his [NAME] under Restorative and Maintenance. On 6/13/22 at 9:37 a.m., Resident #12 was observed lying in bed sleeping. At 1:13 p.m., being assisted with lunch by Certified Nursing Assistant (CNA). At 2:45 p.m., Medication Cart was being checked which was located across from his room, no one noted going into his room. On 6/14/22 at 9:07 a.m., Resident #12 was observed lying in bed awake, non-verbal, lights were off. At 12:30 p.m., Resident #12 was lying in bed awake TV on, and light was off. At 1:35 p.m., Resident #12 was in lying in bed, TV on, and light was on. On 6/15/22 at 10:10 a.m., Resident #12 was observed lying in bed awake, no-verbal, lights were on. At 1:05 p.m., Resident #12 was being assisted by Nurse on the Unit for lunch. At 3:40 p.m., Resident #12 was lying in bed sleeping, TV was on, and light was on. Review of clinical record for Resident #68 revealed restorative order for Active ROM-Assist with active ROM for trunk flexion and bilateral lower extremity adduction and Passive ROM-Left upper extremity and hip flexion while supine. This is reflected on his [NAME] under Restorative and Maintenance. On 6/13/22 at 9:40 a.m., Resident #68 was observed lying in bed sleeping. At 1:01 p.m., Resident #68 was awake, had lunch tray in front of him but not eating, drank his health shake. On 6/14/22 at 9:08 a.m., Resident #68 was observed lying in bed sleeping. At 12:30 p.m., Resident #68 was observed lying in bed sleeping. At 1:36 p.m., Resident #68 was observed lying in bed sleeping. On 6/15/22 at 10:11 a.m., Resident #68 was observed lying in bed resting. At 11:00 a.m., Resident #68 was observed awake, up in a Geri-chair in his room facing the door. At 12:55 p.m., Resident #68 was being assisted with lunch tray by Unit Nurse. At 3:40 p.m., Resident #68 was being put back to bed. On 6/15/22 at 1:30 p.m., in interview with RCNA (Restorative Certified Nurses Assistant) Staff H, verified that she had not done Restorative in the North Unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106072 If continuation sheet Page 9 of 9