Inspection·June 8, 2023

F 0584 Photographic evidence obtained. Level of Harm - Minimal harm or potential for actual harm 7. room [ROOM NUMBER] on the bathroom floor was a pile of soiled linen, and trash on the floor. Personal care items were stored uncovered and unlabeled on the sink and on the handrail near the toilet. Residents Affected - Some Photographic evidence obtained. 8. On nursing unit 1 in the back hall was a commode, a standing room fan, a wheelchair and a mechanical lift stored in the hall outside resident rooms. Photographic evidence obtained. 9. room [ROOM NUMBER] the mattress on the bed was soiled and had a large surface area of missing fabric, from the mattress cover. The mattress had debris on the cover. The Director of Nursing (DON) said he had several mattresses covers on order and did not remove the damaged mattress cover because he did not have any to replace it with. Photographic evidence obtained. 10. room [ROOM NUMBER] in the shared bathroom an unlabeled plastic caddy containing personal grooming supplies was uncovered and stored on the bathroom floor. Photographic evidence obtained. 11. room [ROOM NUMBER] had a bottle of shampoo and an uncovered and unlabeled urinal on the shared bathroom handrail. The urinal had a layer of black grime inside the bottom of the urinal. Photographic evidence obtained. 12. room [ROOM NUMBER] in the shared bathroom were two uncovered urinals hanging from the handrail. There was an uncovered wash basin on the seat of a portable commode. The findings in room [ROOM NUMBER] were verified by DON, who confirmed all personal items should be labeled and stored in plastic bags. Photographic evidence obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105342 If continuation sheet Page 2 of 6 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 06/08/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, review of facility policies and procedures and staff interviews, the facility failed to maintain ice and water dispensers in a clean and sanitary manner for residents, staff and the public. This had the potential to cause contaminated ice and water to be consumed. The findings included: The facility policy Maintenance and Repair to Prevent spread of Infection, effective 10/21 specified The facility maintenance department assists in the prevention and or spread of Healthcare Associated Infection and communicable disease through the maintenance and repair of facility structures, equipment and utilities as applicable. Ice makers, perform regular preventive maintenance including cleaning the condensers, flushing lines, and rinsing bins with sodium hypochlorite solution. On 6/7/23 at 8:45 a.m., an observation of the nursing unit 2 pantry, the ice machine had dirt and grime in the drainage tray. The ice machine front and the dispensing tube was grimy and dirty. The surrounding area of the ice machine was covered in grime, dust and debris. Photographic evidence obtained. On 6/7/23 at 9:30 a.m., an observation of the nursing unit 1 pantry, the ice machine had a large area of rust on the front of the machine, and on the dispenser tube. The front of the machine was dirty, and grimy. The drainage tray had brown rust, and debris on the tray. The counter where the machine was located was covered in white and brown grime. The sink next to the ice machine had a water drainage pipe draining into the sink. The sink had a layer of white grime, rust and debris. The Director of Nursing (DON) and the Administrator verified the observation. Photographic evidence obtained. On 6/7/23 at 9:40 a.m., an observation with the DON of the dining room ice machine used by the kitchen staff, visitors and residents was noted to have a large amount of white grime on the front of the machine. The drainage collection tray was dirty with trash and debris. The area of the machine where the water and ice are dispensed was covered with rust, dirt and had a white grimy substance on the machine surrounding the dispensing tubes. The DON verified the observation. Photographic evidence obtained. On 6/8/23 at 10:15 a.m., the Administrator said the Maintenance Director was responsible for cleaning the ice machines weekly. He said the machines were serviced twice a year by the contracted company. On 6/8/23 at 10:30 a.m., in an interview the Maintenance Director said, I clean the ice machines monthly; I clean the trays and I reach my hand up into the areas I can reach and make sure they are clean. The contracted company comes twice a year to do deep cleaning and repairs of the ice machines. I don't know who is responsible for cleaning them daily or weekly and there is no log of when the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105342 If continuation sheet Page 3 of 6 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 06/08/2023 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 0921 machines are cleaned. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105342 If continuation sheet Page 4 of 6 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 06/08/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and procedures, and resident and staff interviews, the facility failed to maintain an effective pest control program and a sanitary environment free from pests for 3 (Resident #1, #472 and #995) of 108 residents residing in the skilled nursing facility. Residents Affected - Few The findings included: The facility policy Pest/Insect Control, effective 6/12 specified The facility strives to protect the residents/patients, staff and visitors from insects and other pests by controlling infestation through contracts with outside agencies. Evaluate effectiveness of services and contact pest control agency if additional services are needed. On 6/7/23 at 10:00 a.m., in an interview with Resident #1 said there were roaches in the room every week and she reported seeing one yesterday on her bedside table. On 6/7/23 at 10:10 a.m., in an interview, Resident #995 said I had a small brown roach run on my bedside table this morning during breakfast and I chased it, and it ran onto my bed. I have not reported the bug yet, but I will. I usually tell the nurse or the aide. I see roaches here all the time, they spray but they are here. On 6/7/23 at 10:25 a.m., in an interview Resident #472 who was the acting Resident Council President, said there are small, brown and large black roaches here. The guy comes and sprays, they disappear for a few days, but they always come back. On 6/7/23 at 10:45 a.m., in an interview Certified Nursing Assistant (CNA) Staff A said the facility has bugs and I see them in the resident rooms, the time of the day doesn't matter. The facility knows about the bugs, we have meetings. On 6/7/23 at 11 a.m., CNA Staff B said the roaches big and small, they are a problem. I see them in the resident rooms, in their things and in their dressers. We report it to the Administration, and they spray but it doesn't help, they are still here. On 6/7/23 at 11:10 a.m., in an interview CNA Staff C said there are small brown bugs here all the time in the rooms. I always report it but they are still here. On 6/7/23 at 11:20 a.m., in an interview CNA Staff D said she has seen bugs in the resident's rooms. On 6/7/23 at 11:30 a.m., in an interview Registered Nurse Staff E said, I occasionally see bugs in the resident rooms, small and large, take your pick. On 6/7/23 at 12:15 p.m., in an interview with the Administrator, he said he was aware of the concerns regarding the pests in the facility. He said the pest control company is contracted for scheduled pest control treatments and any extra treatments between the monthly visits as needed. He said there were pest control logs on each nursing unit and staff were to write concerns and observations for the exterminator in the logs. The Administrator said most of the staff do not use the logs and inform the maintenance director who will notify the pest control company. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105342 If continuation sheet Page 5 of 6 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 06/08/2023 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 0925 Level of Harm - Minimal harm or potential for actual harm On 6/8/23 at 10:30 a.m., in an interview, the Maintenance Director said, the process previously for pest control concerns was the staff would let me know if they saw a bug and I contacted pest control. The Maintenance Director said two weeks ago the exterminator delivered the pest control logs for staff to write pest observations and concerns. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105342 If continuation sheet Page 6 of 6