Inspection·July 15, 2021

F 0563 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 7/14/21 at 1:40 p.m., in an interview Certified Nurse Assistant (CNA) Staff B said she screened visitors on Fridays and Saturdays. CNA Staff B said, We don't have visitors on Sundays, unless someone is actively dying or if it is a holiday, like Mother's Day that falls on a Sunday. They are still limited to 30-minute visits unless actively dying. On 7/14/21 at 3:27 p.m., in an interview the Director of Nursing (DON) confirmed the posted visitation hours for facility and confirmed they did not permit Sunday visitation, except for compassionate care visitation. On 7/14/21 at 3:45 p.m., in an interview Resident #6 said, My husband comes but I wish he could stay longer. I would like visits on Sundays, too. On 7/14/21 at 3:55 p.m., interviewed Resident #16 who said, I would rather have longer visit with my family. They have to work, and I feel bad that they can't come on Sundays. On 7/14/21 at 4:00 p.m., in an interview Resident #51 said, I wasn't aware that there was no visitation on Sundays, and I don't think that is good. I am not happy about that since my grandniece is moving to the area and my daughter lives here. It would be good for them to be able to come anytime on the weekend. They both work during the week so Sundays should be open. On 7/15/21 at 11:30 a.m., in an interview Resident #113's daughter said, They explained on admission that only 1 person could visit once a day. I don't understand why they don't have visitation on Sundays. Families should be allowed to visit whenever they want. On 7/15/21 1:02 p.m., in an interview about visitation Licensed Practical Nurse (LPN) Staff A said, I don't know why we don't have Sunday visitation. I asked in general once and was told that we don't have Sunday visits because we do not have screeners and we can't keep going to the front to screen people. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105342 If continuation sheet Page 2 of 7 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 105342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehab & Healthcare Center of Cape Coral 2629 Del Prado Blvd Cape Coral, FL 33904 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to have documentation of a discharge summary including recapitulation and post discharge plan of care to ensure a safe transition home for 3 (Resident #413, #164, and #165) of 3 sampled discharged residents. The findings included: 1. On 7/14/21 review of the clinical record revealed Resident #413 was admitted to the facility on [DATE] with diagnoses including muscle wasting, gastrointestinal hemorrhage, history of fall with injury to the face, dementia, and anemia. Review of the Minimum Data Set (MDS) admission assessment with an assessment reference date of 5/30/21, revealed the resident required limited physical assistance of 1 person for transfer and ambulation. Resident #413 received Physical and Occupational Therapy from 5/29/21 through 6/14/21. The Physical Therapy Discharge summary dated [DATE], noted Resident #413's goals were not met. The explanation was Pt [patient] and family's decision to go home and have home health care. The physician's orders dated 6/14/21, noted to discharge the resident home and the patient requested no home health care and no durable medical equipment. On 6/11/21 the nurse documented in a progress note she spoke with the resident at length, who verbalized she was looking forward to discharging home on Monday 6/14/21. She had progressed well in therapy. The note also noted the nurse spoke with the resident's neighbor at length regarding the discharge process, medications, and the importance of following up with primary care physician once she returned to the community. She also encouraged her to call back if she had any more questions. The clinical record lacked documentation Resident #413 received a written individualized, detailed discharge summary and instructions for safe transition home. The clinical record lacked documentation of a concise summary of the resident's stay and course of treatment in the facility. On 7/14/21 at 1:00 p.m., in an interview the Director of Nursing and the Regional Nurse Consultant said they could not locate a discharge summary or post discharge plan of care for the resident. On 7/14/21 at 1:40 p.m., in a telephone interview Resident #413's neighbor said as far as discharge paperwork she got nothing for her. She said she scheduled and took Resident #413 to a follow up doctor's appointment in the community. She said the physician complained about the lack of information. 2. On 7/15/21 review of the clinical record revealed Resident #164 was admitted to the facility on [DATE] and discharged home on 6/22/21. The Minimum Data Set (MDS) admission assessment, with an assessment reference date of 5/31/21, noted diagnoses including heart failure, anxiety disorder, and asthma. Resident #164 required extensive physical assistance of two persons for activities of daily living, including transfer and bed mobility. Further review of the progress notes revealed on 6/22/21 the nurse documented Resident #164 ambulated for 3 minutes with oxygen off. The oxygen saturation was 73% after ambulation and increased to 94% with oxygen on and sitting. The resident became short of breath with pulse of 116 without oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105342 If continuation sheet Page 3 of 7 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 105342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehab & Healthcare Center of Cape Coral 2629 Del Prado Blvd Cape Coral, FL 33904 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 0661 The resident recovered after several minutes with oxygen on, as ordered with oxygen saturation of 93%. Level of Harm - Minimal harm or potential for actual harm The clinical record lacked documentation Resident #413 received a written, individualized, detailed discharge summary and instructions for safe transition home, including a medication reconciliation. Residents Affected - Some The clinical record lacked documentation of a concise summary of the resident's stay and course of treatment in the facility. On 7/15/21 at 12:35 p.m., the Medical Record Custodian said she was unable to find a recapitulation of stay, discharge summary, or post discharge plan of care for Resident #164. 3. On 7/15/21 review of the clinical record revealed Resident #165 was admitted to the facility on [DATE] with diagnoses including alcohol dependency withdrawal, heart disease, disorder of the kidneys. Review of the physician's orders revealed on 6/14/21 the physician ordered for the resident to be discharged on 6/14/21 with home health care follow up. The interdisciplinary resident/patient discharge instructions form signed by the Resident on 6/14/21 listed the name and telephone number of a home health agency. The form noted a wheelchair to be delivered to home. Resident #165 also signed a copy of the order summary report, which included a list of all medications. The clinical record lacked documentation of a recapitulation of stay and a post discharge plan of care for a safe transition home. On 7/15/21 at 12:35 p.m., in an interview the Medical Record Custodian verified the lack of documentation of a recapitulation of stay and post discharge plan of care for Resident #165. On 7/15/21 at 12:35 p.m., in an interview the Regional Nurse Manager Consultant verified the lack of discharge planning documents. She said the process was for the Social Worker to open the discharge summary on the computer for all the disciplines to fill out their part. Once completed, the Social Worker closed the discharge summary. She said she was aware the discharge process was not complete. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105342 If continuation sheet Page 4 of 7 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 105342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehab & Healthcare Center of Cape Coral 2629 Del Prado Blvd Cape Coral, FL 33904 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 Based on observation, interview, and record review, the facility failed to provide a meaningful, resident centered activity program for 3 (Resident #88, #92 and #5) of 3 residents with cognitive impairment. The lack of individualized activity program has the potential to not maintain a physical and psychological quality of life. Residents Affected - Some The findings included: Review of the facility policy 12.1.1 titled, Activities Program, dated November 2013 which said, . Scheduled activities shall be planned to include recreational, social and educational opportunities, offering no less than 12 hours weekly of activities, 6 days each week. The activities policy provided by the facility did not list specific activities for residents with cognitive decline. 1. Review of the admission Activity Assessment dated 6/29/21, showed Resident #88 required physical assistance to and from activities. The assessment noted Resident #88 would prefer or benefit from sitting outside, listening to music, watching movies and enjoyed sports and fishing. The admission Minimum Data Set (MDS) assessment with a target date of 6/25/21 noted it was very important for Resident #88 to do things with a group of people, go outside to get fresh air when the weather is good and to be around animals such as pets. On 7/12/21 at approximately 10:40 a.m., Resident #88 was observed lying in bed in a tee shirt and an adult brief. The resident was not interviewable due to ongoing cognitive decline related to a history of a Cerebral Vascular Accident. No activities were observed. On 7/12/21 at approximately 2:30 p.m., Resident #88 was observed lying on his back with his head elevated. No activities were observed. On 7/13/21 at 11:15 a.m., Resident #88 was observed lying in bed on his back with the head of his bed elevated. No activities were observed with staff or other residents. On 7/13/21 at 3:00 p.m., Resident #88 was observed lying in bed on his back with his foot hanging off the bed. No activities were observed with staff or other residents. On 7/14/21 at 9:20 a.m., Resident #88 was observed lying in the bed on his back. No activities were observed. On 7/14/21 at 1:30 p.m., Resident #88 was observed lying in the bed. No activities were observed. On 7/15/21 at 9:00 a.m., review of the Documentation Survey Report V2 under the title, Self-Directed Activity, showed no documentation staff members provided activities with Resident #88 from 7/1/21 through 7/14/21. On 7/15/21 at 9:20 a.m., in an interview the Activity Director said she did room visits with Resident #88, provided television and music but did not have time to document her visits. She said family members visited him once and she should have documented the visit as an activity. The Activity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105342 If continuation sheet Page 5 of 7 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 105342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehab & Healthcare Center of Cape Coral 2629 Del Prado Blvd Cape Coral, FL 33904 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 Director said she had some puzzles, and she assisted some residents with dementia in playing but had no special training in providing activities to residents with dementia or cognitive impairment. On 7/15/2021 at 11:31 a.m., in an interview Resident #88's stepdaughter said when she visited, she always found the resident in bed and had not seen him engaged in any activities. She said her father would like to go outside and get fresh air. He enjoyed just sitting outside and watching activities going on around him. On 7/15/2021 at 12:15 p.m., in an interview the Administrator stated she was aware of the lack of documentation with providing resident's activities. She verified at the time, the lack of in-service training for the Activities Director in providing on-going activities to residents with impaired cognition. 2. Review of the admission Activities Assessment completed on 6/28/21 showed Resident #92 enjoyed attending group, sitting outside, watching television, word puzzles, listening to music, pet interaction and crafts. Review of the Documentation Survey Report V2 for the months of June and July of 2021, showed no documentation that staff provided activities for Resident #92 while she was residing at the facility. Review of the admission MDS with a target date of 6/18/21 noted Resident #92 scored a 10 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. On 7/12/2021 at 12:57 p.m., in an interview Resident #92's son said when his mother resided at the facility, he never saw her engaged in any activities when he visited. He said staff would get his mother up to a chair once a day and put her back in the bed. He said he met with the previous Administrator and let her know how unhappy he was with the care his mother was receiving. On 7/15/21 at 10:00 a.m., in an interview the Activities Director said she remembered Resident #92 and had provided one to one activity with her. She stated she had not documented this interaction and could not provide any specifics about times or activities provided to the resident. 3. Review of the Quarterly Activities Assessment for Resident #5 dated 4/15/21 revealed documentation Resident #5 requires physical assistance to and from activities, resident would benefit from large group, in room and general activities, resident prefers sitting outside, watching TV, watching movies, listening to music, pet interaction, crafts and painting. The Quarterly MDS assessment with a target date of 3/27/21 noted Resident #5 had short term, long-term memory problem and severely impaired cognitive skills for daily decision making. On 7/14/21 at 3:30 p.m., observed Resident #5 in wheelchair, in the hallway near the nurses' station. Resident #5 smiled and responded when surveyor greeted her. On 7/15/21 at 10:24 a.m., interviewed Activity Director about Resident #5's activities program. The Activity Director said, I do individualized activities and go around room to room. Resident #5 likes her baby doll, and she likes to get snacks. I go and visit with her. Review of the activities progress notes with the Activity Director noted 37 entries from 1/1/21 to 7/15/21 which included 30 notes about communicating with the Resident's daughter, five room visits, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105342 If continuation sheet Page 6 of 7 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 105342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehab & Healthcare Center of Cape Coral 2629 Del Prado Blvd Cape Coral, FL 33904 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 one note for bingo and one note for church. Level of Harm - Minimal harm or potential for actual harm The Activity Director said, I have gotten behind on charting. She confirmed there was no specific activity program for residents with dementia or Alzheimer's disease. Residents Affected - Some On 7/15/21 at 12:30 p.m., in an interview the Director of Nursing (DON) reviewed Resident #5's documentation for individual activity, group activities, and self-directed activities for the past thirty days. The DON confirmed there had been no documentation for activities placed in the clinical record. On 7/15/21 at 12:36 p.m., in an interview Certified Nursing Assistant (CNA) Staff E confirmed, there was not a formal activity program set up for Resident #5 but we distract her with singing and puzzles. Licensed Practical Nurse (LPN) Staff A who participated in the interview said, Nothing is scheduled but Resident #5 likes her baby doll and likes to sing. On 7/15/21 at 12:45 p.m., Resident #5 observed in bed after lunch in hospital gown with television on. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105342 If continuation sheet Page 7 of 7