Inspection·April 7, 2022

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs and preferences for 1 (Resident #30) of 1 resident reviewed with mobility limitations by failing to provide access to a functional phone and radio. Accommodating their needs helps residents to maintain independence and dignity and improves overall well-being. Residents Affected - Few The findings included: On 4/4/22 at 9:44 a.m., Resident #30 was observed in his room lying in bed. Resident #30 said he cannot get out of bed due to paralysis of his left side. He said he would like to talk to his son, but he does not have a phone and does not have his son's number. Resident #30 said no one visits him, and no one at the facility has helped him to contact his family. Resident #30 said he enjoys listening to music, but no one will turn it on for him. There was an unplugged boombox on the nightstand and an unplugged phone on the wall between the two beds of the semi-private room. Both the boombox and phone were unreachable to Resident #30. On 4/4/22 at 4:11 p.m., Resident #30 was observed in his room with eyes closed lying-in bed. Resident #14, who shared the semi-private room with Resident #30 was in the room at the time. Resident #14 said Resident #30 sleeps and does nothing else. Both the boombox and phone remained unplugged and unreachable to Resident #30. On 4/05/22 at 4:30 p.m., Resident #30 was observed in his room lying in bed eating dinner. Resident #30 said again he would like to speak to his son, but he is not able to call and does not have a telephone or the number. Again, the phone and boombox were out of reach and unplugged. On 4/05/22 at 4:14 p.m., Certified Nursing Assistant Staff Y said Resident #30 does not have a cell phone. On 4/05/22 at 4:25 p. m., Resident #30 was observed in his room lying in bed. The boombox and the telephone were still unplugged and unreachable to Resident #30. On 4/5/22 at 5:35 p.m., Resident #30 was in his room lying in bed. He said neither the social work director or activities director come to see him, and he does not attend care planning meetings. Resident #30 said he does not know where the phone is. On 4/6/22 at 10:23 a.m., the Social Services Director (SSD) said she started working at the facility a month ago and has not met Resident #30 yet. On 4/6/22 at 10:37 a.m., Social Services Staff Z said she knows Resident #30 a little. She said Resident #30 does not get out of bed and is in bed whenever she's seen him. She said she would only reach out to Resident #30's family if necessary and through care planning with the Minimum Data Set (MDS) team. On 4/6/22 at 10:42 a.m., MDS Staff AA said he has worked at the facility almost 4 years. He said he is familiar with Resident #30. He said he mails a letter to the Resident #30's Power of Attorney notifying them of the care planning meetings. On 4/6/22 at 10:42 a.m., MDS Staff BB said Resident #30 has told her he wants to go home. Staff BB (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 2 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said Resident #30 asks about his son at times. Staff BB said she has talked on the phone to Resident #30's son but has not facilitated a call between the two. On 4/6/22 at 11:05 a.m., Staff AA and Staff BB went to Resident #30's room. Resident #30 was lying in bed. The boombox and telephone remained unplugged and unreachable to Resident #30. Staff BB said it was an unacceptable situation for Resident #30. On 4/6/22 at 11:08 a.m., Staff BB said the phone on the wall of Resident #30's room was broken and could not be used to make or receive a call. On 4/6/22 at 11:13 a.m., Staff AA said the boom box in Resident #30's room was broken and could not be used to play music. On 4/6/22 at 11:13 a.m., the Director of Nursing (DON) was made aware of the broken boom box on the nightstand and the broken phone on the wall in Resident #30's room. The DON was made aware Resident #30 wanted to call his family but had not been assisted by the facility to do so. The DON confirmed it was an unacceptable situation for Resident #30. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 3 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, record review, review of the facility's abuse and neglect policy and procedure, and staff interviews, the facility failed to protect vulnerable residents' rights to be free abuse and neglect. The facility failed to implement adequate supervision for 2 (Resident #4 and Resident #38) of 2 sampled residents with known behaviors, from resident-to-resident verbal and physical abuse. The findings included: The facility policy Abuse, Neglect and Misappropriation of Property (revised 5/8/19) Policy Statement indicates It is the organizations intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or state laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the facility administrator, the state survey agency, and other appropriate state and local agencies in accordance with federal and state law. .Abuse if the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. .Physical abuse includes, but is not limited to hitting, slapping, pinching, kicking, controlling behavior through corporal punishment, or any similar touching of a resident that does not have an appropriate therapeutic purpose, and that is not reasonably related to the appropriate provision of ordered care and services. 1. On 4/5/22 at 9:26 a.m., observation at the A wing nursing station, Resident #38 and Resident #4 were heard loudly, yelling at each other. Resident #4 and Resident #38 were in wheelchairs face to face and approximately 3 feet from each other. Resident #4 said if you hit me again, I'm gonna hit you back. Resident #4 was shaking her finger at Resident #38. Several staff members were at the nurse's station including the Licensed Practical Nurse (LPN)Unit Manager Staff I. The staff at nursing station did not intervene during the verbal argument. Resident #4 was yelling and cursed at resident #38. Resident #38 was moving toward Resident #4 in his wheelchair. Resident #4 said I'm telling you if you hit me again, I'm going to punch you. Resident #38 raised his left leg and kicked Resident #4 in the right knee. The Business Office Manager (BOM) was at the nursing station and heard the verbal altercation. The BOM turned around from the desk as Resident #38 was raising his left leg toward Resident #4 for the second time. The BOM removed Resident #38 out of area and away from resident #4. LPN Unit Manager Staff I and other staff members did not attend to Resident #4 or Resident #38. Staff did not check Resident #4 after the incident or ask her if she had been hit. 2. On 4/5/22 at 11:23 a.m., the BOM, she said she observed Resident #38 in an altercation with Resident #4 and removed Resident#38 from the area. I took him to Activity Director and explained to him what had happened and asked if there was anything to keep Resident #38 redirected. He said the resident often gets that way, kicking walls etc., and he took him outside. I reported what happened to the Unit Manager. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 4 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 3. On 4/5/22 at 11:29 a.m., Unit Manager LPN Staff I said she was aware of the incident between Residents #4 and #38. Unit Manager Staff I confirmed she had not physically assessed Residents #4 or #38 for injuries and had not put interventions in place once the abuse occurred. 4. On 4/5/22 at 12:00 p.m., the Director of Nursing said she spoke with the staff and said no one saw the abuse, so they did not investigate it. She confirmed the BOM and State surveyors had reported the altercation to Unit Manager LPN Staff I and said the residents were arguing so they assumed no abuse occurred. 5. On 4/5/22 at 1:00 p.m., interview with Resident #4, who was not able to reply to questions due to cognitive impairment. Review of Resident #4's clinical record revealed a Brief Interview for Mental Status (BIMS) of 3, indicating severe cognitive loss. Resident #4's diagnoses included vascular dementia with behavioral disturbance, need for assistance with personal care, mood disorder due to known physiological condition with mixed features. The care plan initiated 2/13/20, identified Resident #4 had behavior problems including, altercations with roommate both in the room and in facility common areas. Interventions included redirect resident when/if behavior occurs, offer options to alleviate confrontations and if reasonable discuss the behavior with the resident. 6. On 4/5/22 at 1:15 p.m., attempted interview with Resident #38 but he did not comprehend and provided no verbal response. Review of Resident #38's clinical record revealed a BIMS score of 99, indicating the interview was not conducted due to cognitive loss. Diagnoses for resident #38 included dementia, altered mental status, traumatic brain injury, psychosis and anxiety. The care plan initiated 8/9/19 identified Resident #38 had physical behavioral symptoms toward others (eg., hitting, kicking, pushing, refusal of care, rolling backwards in wheelchair, disruptive behavior). The interventions included, avoid power struggles with resident, assess whether the behavior endangers the resident or others and intervene, if necessary, maintain a calm, slow, understandable approach with the resident. 7. On 4/6/22 at 7:50 a.m., the Activity Director said he did not witness the incident between Resident #38 and #4. He said the BOM brought Resident #38 to him and said he had tried to kick another resident and asked if I could help to redirect him with an activity. The Activity Director said Resident #38 had a history of kicking other residents and wandered about the facility, likes to watch people. He said he tried to take Resident #38 outside because he likes it but after a few minutes he is at the gate kicking it, trying to get out. The Activity Director said Resident #38 had not had any episodes of kicking others in the past 8 months that he was aware of. He said Resident #38 wanders about the halls on the units and I bring him to activities but cognitively he is so impaired, he stays a few minutes and leaves. 8. On 4/6/22 at 9:35 a.m., the BOM said she was making rounds and answering call lights when she saw Resident #38 swinging at resident #4. She said she saw him kick at resident #4 but did not actually see him kick her and she wanted to remove him from the situation. The BOM said she did not hear the verbal argument. She said the Unit Manager LPN Staff I was sitting at the desk, I told her she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 5 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 might want to keep an eye on Resident #38 because he was being aggressive toward Resident #4. Level of Harm - Minimal harm or potential for actual harm 9. On 4/6/22 at 10:40 a.m., the Unit Manager LPN Staff I said she was sitting here at the nurse's station on 4/5/22 charting when the BOM told me about the altercation with Residents #4 and #38 but I heard nothing at all, no arguing, nothing. I was sitting right here. I had no knowledge, I did not know he had kicked her, no one saw it. Residents Affected - Few Unit Manger LPN Staff I said the BOM told me there was an altercation I checked on Resident #38 and gave him a snack, I checked on him frequently. The BOM told me there was almost an altercation, but she diverted it. The Unit Manger LPN Staff I said Resident #38 was combative at times and wanders. To my knowledge he is never combative with residents only staff and had no recent behaviors since December. Unit Manager LPN Staff I said the interventions for Resident #38, were he gets frequent naps, and we watch him. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 6 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to ensure 1(Resident #41) of 1 resident reviewed was free from physical restraints. Potential negative outcomes of restraint use included but are not limited to declines in resident's physical functioning and muscle condition, increased incidence of infections, pressure ulcers, agitation, and incontinence. Residents Affected - Few The findings included: The facility policy Use of Restraints (revised 9/5/18) specified, Restraints only may be used for the safety and well-being of the resident(s), and only after consideration, evaluation, and the use of all other viable alternatives. All residents have the right to be free from restraint or seclusion used as a means of coercion, discipline, convenience or retaliation .Physical restraints are defined as any manual method, or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that an individual cannot remove easily and which restricts the resident's freedom of movement or normal access to his/her body. On 4/4/22 at 9:30 a.m., Resident #41 was observed sitting in the hallway in a reclining wheelchair, leaning forward. The resident had a bedside table in front of him, with the base of the table pushed under the footrests of the wheelchair. A chair was pushed against the table to prevent the table from moving. On 4/4/22 at 12:30 p.m. Resident #41 was in the same position with the table and chair in front of him. Photographic evidence obtained. On 4/5/22 at 9:28 a.m., Resident #41 was sitting outside of room the reclining wheelchair with the bedside table in front of him and a chair was pushed against the table. Registered Nurse (RN) Staff K said the chair was there to keep the table in place. RN Staff K said the resident likes to have the table like that and it was part of his care plan. RN Staff K said Resident # 41 asked to have table and chair like that to keep from falling as he leans forward and likes to rest his head on table. A review of Resident #41's care plan revealed the resident had an activity of daily living deficit due to Parkinson's with bilateral upper extremity tremors, poor trunk control, The care plan identified the resident was at risk for falls. The care plan interventions did not include the bedside table and placement of a chair against the table. On 4/6/22 at 10:57 a.m., Resident #41 was outside of room with bedside table under leg rests and chair pushed against the table. Resident #41 was not able to verbalize a desire to have the table and chair in front of him. On 4/6/22 at 11:00 a.m., Licensed Practical Nurse Unit Manager Staff I said the chair was kept in front of the table people could sit and talk to Resident #41 and for staff to sit there to assist the resident at meals. On 4/6/22 at 11:05 a.m., RN Staff L said the chair was there to keep the table in place. RN Staff L said it was a whole procedure to keep the table in place then the chair is put there. RN Staff L said the chair keeps the table in place, so it does not move. RN Staff L confirmed the resident was not able to push the table with the chair in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 7 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 4/6/22 at 11:10 a.m., the Physical Therapist (PT) said Resident #41 was not able to push the table with the chair there and was not able to push the table with his hands if the chair was not there. The PT moved the chair and showed how he had to assist the resident to move the table. When instructed by PT, Resident #41 pushed the table 6 inches. On 4/6/22 at 11:20 a.m., the Director of Nursing (DON) said Resident #41 likes to people watch and likes to sit outside of the room with the bedside table in front of him. The DON said she was not aware staff had placed a chair against the table to prevent the table from moving and confirmed it was considered a restraint. Event ID: Facility ID: 105387 If continuation sheet Page 8 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report two incidents of injury of unknown origin for 1 (Resident #182) of 1 resident surveyed for injury of unknown origin. The findings included: Resident #182 is a [AGE] year old female admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident's Brief Interview for Mental Status (used to determine cognition level) was a 4, indicative of severe cognitive impairment. The resident required a two-person extensive assist with bed mobility and transfers. The resident also required extensive assistance with dressing and toileting. Review of the clinical record showed Unit Manager Staff I documented on 3/11/22 at 9:27 a.m. for 3/10/22 an Xray of the pelvis completed for Resident #182 showed a dislocation. The provider was notified a gave an order to send the resident to the hospital. Review of the hospital history and physical dated 3/10/22 showed Resident #182 presented to the emergency room with complaint of acute right hip pain. The right hip prosthesis was dislocated and confirmed by imaging. The ED (Emergency Department) was unable to manually realign. The hospital records showed on 3/11/22 Resident #182 was taken to surgery and the right hip was successfully realigned. Resident #182 returned to the facility on 3/14/22. Further review of the clinical record showed on 3/22/22 Resident #182 was transferred to the hospital for the second time for treatment of a right hip dislocation. On 4/5/22 at 4:29 p.m., the Director of Nursing said she did not complete an incident report since she did not believe Resident #182 had a fall. She said she did not report the incidents of the right hip dislocation to the appropriate State Agencies as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 9 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have documentation of investigation of two incidents of injury of unknown origin for 1 (Resident #182) of 1 resident surveyed for injury of unknown origin. Residents Affected - Few The findings included: Resident #182 is a [AGE] year old female admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident's Brief Interview for Mental Status (used to determine cognition level) was a 4, indicative of severe cognitive impairment. The resident required a two-person extensive assist with bed mobility and transfers. The resident also required extensive assistance with dressing and toileting. Review of the clinical record showed Unit Manager Staff I documented on 3/11/22 at 9:27 a.m. for 3/10/22 an Xray of the pelvis completed for Resident #182 showed a dislocation. The physician was notified a gave an order to send the resident to the hospital. Review of the hospital history and physical dated 3/10/22 showed Resident #182 presented to the emergency room with complaint of acute right hip pain. The right hip prosthesis was dislocated and confirmed by imaging. The ED (Emergency Department) was unable to manually realign. The hospital records showed on 3/11/22 Resident #182 was taken to surgery and the right hip was successfully realigned. The hospital records dated 3/14/22 showed a Physician's Assistant (PA) progress note that read, . Patient still contracting her hip we have abductor brace in between she is going with the abductor brace to skilled nursing facility today . The PA wrote, Patient will need to wear the abductor pillow (special pillow used to prevent the hip from moving out of the joint) at night even at the skilled nursing facility most likely for the next 2 weeks may be longer. In the next two weeks the patient is at a high propensity to dislocate the hip again. Total healing will be 6 to 8 weeks . No crossing of the legs no abductor lift greater than 60 degrees . Resident #182 returned to the facility on 3/14/22. Review of the facility's progress note dated 3/14/22 showed Resident #182 arrived from the hospital after a close reduction of the right hip. Licensed Practical Nurse Staff X documented Resident #182 was to wear a hip abductor in the wheelchair. The care plan did not list the use of the abductor pillow. The facility physician's orders did not include an order to use an abductor pillow. The clinical record lacked documentation staff used the abductor pillow to prevent recurrence of hip dislocation. On 3/22/22 at 6:50 p.m., in a progress note the Director of Nursing (DON) documented, . A new Xray of right hip had been ordered due to resident non compliant with the abductor pillow and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 10 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0610 continuously is pulling it out . Resident would not tolerate the abductor pillow . Level of Harm - Minimal harm or potential for actual harm Further review of the clinical record showed on 3/22/22 Resident #182 was transferred to the hospital for the second time for treatment of a right hip dislocation. Residents Affected - Few Review of the hospital record revealed a physician's progress note dated 3/23/22 that read Resident #182, .is known to our practice for a failed total hip arthroplasty secondary to dislocation. She has previously been treated . for dislocated hip with a close reduction procedure. Unfortunately in a short period of time she has had a repeat dislocation. Her dislocation mechanisms seem to be positional she consistently sits in the fetal position with her legs flexed and internally rotated. This is her second dislocation in a very short period of time . On 4/5/22 at approximately 3:00 p.m. the DON verified the abductor pillow was not added to the care plan when Resident #182 returned from the hospital on 3/14/22. She also verified the Resident was sent back to the hospital on 3/22/22 for the second time for dislocation of her right hip. On 4/5/22 at 4:29 p.m., the Director of Nursing said she did not complete an incident report or investigate the two incidents of dislocation since she did not believe Resident #182 had a fall. She said she did not report the incidents of the right hip dislocation to the appropriate State Agencies as required. On 4/6/22 at approximately 5:00 p.m., the Medical Director said she was not made aware Resident #182 needed to use an abductor pillow to prevent dislocation of her right hip when she returned from the hospital on 3/14/22. The physician said she would have written an order for the use of the abduction pillow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 11 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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, review of policies and procedure, interview, and record reviews the facility failed to provide regular individualized activities for 3 (Resident #30, #48, and #63) of 3 sampled residents with dementia. Failure to provide activities has a potential to increase loneliness and depression and prevent residents form maintaining their highest practical physical and psychological well-being. Residents Affected - Few The findings included: The Facility's Policy Activity Program last revised on 7/25/17 read, This facility will provide on-going Activities program designed to support residents in their choice of activities and to meet the interests of and support the physical, mental, and psychological well being of each resident encouraging both independence and interaction in the community .Activities are scheduled daily and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the program .Individualized and group activities are provided that-a. Reflect the schedules, choices, and rights of the residents; b. Are offered at hours convenient to the resident's, including holidays and weekends; and c. Reflect the cultural/traditions and religious interests of the residents; and d. Encourage meaningful interactions to enhance a person's sense of well-being and feelings of connectedness . 1. Record review showed Resident #48 is a [AGE] year-old female with dementia. The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident has a Brief Interview of Mental Status (BIMS) of 12, indicative of mild cognitive impairment and would be interviewable. The Activities interview was conducted with the resident during the quarterly interview. The interview showed it was somewhat important to keep up with the news and to do her favorite activity. The assessment noted the resident received anti-anxiety and antidepressant medications seven days weekly. On 4/4/22 at 10:20 a.m., Resident #48 was observed lying in bed with her head toward the door. The TV was observed on but not within the vision of the resident as she was laying on her back. The resident was not responsive to simple questions. On 4/4/22 at 1:00 p.m., 4/4/22 at 2:30 p.m. and On 4/5/22 at 10:00 a.m., Resident #48 was observed sleeping in bed. Review of Resident #48's care plan shows she was care planned for Hospice on 9/1/21. The Hospice care does not list any specific activities provided by Hospice staff. Review of Resident #48's activity care plan created on 8/27/21 showed no updates to interventions since that time. On 4/7/22 at 11:35 a.m., the Activities Director (AD) said he does a one-to-one visit with the resident for 10 to 15 minutes once a week. The AD said this is based on a check off sheet provided by his company. Review of the form shows the more interactive the resident is the less activities need to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 12 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 be provided by staff. The AD verified he does not have any structured activities that he provides for residents who are bedridden. 2. On 4/4/22 at 10:00 a.m., Resident #63 was observed in bed. The resident was not observed in any interactions with staff or activities. The resident was not able to respond coherently to simple questions. Resident #63 was confined to bed and had a feeding tube. On 4/4/22 at 12:30 p.m.,4/4/22 at 2:00 p.m., and 4/5/22 at 9:00 a.m., Resident #63 was observed in bed. The resident was not observed in any type of activities. Review of the one-to-one assessment form dated 1/24/22 showed Resident #63 had two visits weekly with family. On 4/5/22 at 3:00 p.m., Resident #63's Guardian said he had not visited with the resident since October of 2021. On 4/7/22 at 11:40 a.m., the AD said the resident has a daughter who visits her weekly. The AD was informed the resident had a guardian who stated he had not visited with the resident since October of 2021. The AD verified the three checks of the one to one assessment form justified one to one visits with the resident once a week for 10 to 15 minutes. On 4/7/22 When the AD provided a copy of the one-to-one assessment form he had written Baptist Preacher next to the assessment of the resident being visited twice weekly. 3. The Annual Minimum Data Set (MDS) dated [DATE], noted Resident #30 has a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment noted Resident #30 required extensive assistance of two or more staff for bed motility. Resident #30 was totally dependent on staff of two or more for transfer, walking in the room did not occur, and Resident #30 has upper and lower body impairments on one side. In the Activity Preferences, the MDS assessment noted it was very important for Resident #30 to keep up with the news, somewhat important to have books, newspaper, and magazines to read, listen to music he likes, be around animals such as pets, do his favorite activities, go outside to get fresh air when the weather is good, and participate in religious services or practices. The Signature Health Care One on One Needs Guidelines dated 1/24/22, noted Resident #30 interacts with staff during daily care, receives a minimum of two visits weekly from family, friend, or volunteer, listens to music, watches TV programs of choice, reads or writes independently and has a telephone in the room and keeps in contact with family and friends. The Signature Health Care One on One Needs Guidelines indicates Resident #30 scored a 5 and only requires supervision/monitoring of activity level. Resident #30's Care Plan for Activities included to allow resident to express feelings and desires, arrange visits by volunteers, interview resident for daily preferences, and room visits weekly for 1 to 1 conversation. On 4/4/22 at 9:44 a.m., Resident #30 was observed in his room lying in bed. Resident #30 had contractures of both his left elbow and left hand. His left hand was tightly shut and pulled to his chest. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 13 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 Resident #30's eyes were open, and he was looking toward the ceiling. There were no visitors in the room, and he was not engaged in any sort of activity. There were no books, newspapers, or magazines in the room. Resident #30 said he cannot get out of bed because he is paralyzed on the left side. Resident #30's roommate was watching TV, but Resident #30 said he did not like to watch TV. Resident #30 said he likes to listen to music and tinker with airplane models. There was an unplugged boom box on the night stand next to Resident #30's bed, but he said he could not reach the boom box, and no one turns it on for him. There was a telephone on the wall, out of reach of Resident #30, but it was broken and unplugged. Resident #30 said he would like to talk to his son, but his son lives out-of-state, and no one has helped him to call. Resident #30 said he has no family or friends that visit him at the facility. He said there are staff here, but he does not want to bother them. Observations of Resident #30 were made again on 4/4/22 at 4:11 p.m., 4/5/22 at 8:51 a.m., 4/5/22 at 4:30 p.m., 4/5/22 at 5:35 p.m., and 4/6/22 at 11:05 a.m. Every time, Resident #30 was in his room, lying in bed not engaged in any activity or interaction with another person. Each time, there was no music playing for Resident #30 to enjoy, there were no books, magazines, or newspapers in the room for Resident #30 to read. There were no visitors in the room, and the phone remained on the wall out of reach, unplugged and broken. On 4/6/22 at 11:25 a.m., the Activity Director said he provides activities for Resident #30 by delivering the Daily Chronical and talking to him for 10-15 minutes. He said whenever he goes into the room, Resident #30 is lying in bed. The Activity Director said he has talked with Resident #30's son on the phone but has never offered Resident #30 an opportunity to call or video chat with him. He said he was not aware that Resident #30 liked to listen to music. On 4/7/22 at 2:00 p.m., Resident #30's roommate said Resident #30 does not get out of bed. He said the Activity Director drops off the Daily Chronicle in the morning and talks with Resident #30 for a few minutes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 14 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement adequate interventions and supervision to prevent incidents two incidents of joint dislocation for 1 (Resident #182) of 1 resident surveyed for injury of unknown origin. The findings included: Resident #182 is a [AGE] year old female admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident's Brief Interview for Mental Status (used to determine cognition level) was a 4, indicative of severe cognitive impairment. The resident required a two-person extensive assist with bed mobility and transfers. The resident also required extensive assistance with dressing and toileting. Review of the clinical record showed Unit Manager Staff I documented on 3/11/22 at 9:27 a.m. for 3/10/22 an Xray of the pelvis completed for Resident #182 showed a dislocation. The physician was notified a gave an order to send the resident to the hospital. Review of the hospital history and physical dated 3/10/22 showed Resident #182 presented to the emergency room with complaint of acute right hip pain. The right hip prosthesis was dislocated and confirmed by imaging. The ED (Emergency Department) was unable to manually realign. The hospital records showed on 3/11/22 Resident #182 was taken to surgery and the right hip was successfully realigned. The hospital records dated 3/14/22 showed a Physician's Assistant (PA) progress note that read, . Patient still contracting her hip we have abductor brace in between she is going with the abductor brace to skilled nursing facility today . The PA wrote, Patient will need to wear the abductor pillow (special pillow used to prevent the hip from moving out of the joint) at night even at the skilled nursing facility most likely for the next 2 weeks may be longer. In the next two weeks the patient is at a high propensity to dislocate the hip again. Total healing will be 6 to 8 weeks . No crossing of the legs no abductor lift greater than 60 degrees . Resident #182 returned to the facility on 3/14/22. Review of the facility's progress note dated 3/14/22 showed Resident #182 arrived from the hospital after a close reduction of the right hip. Licensed Practical Nurse Staff X documented Resident #182 was to wear a hip abductor in the wheelchair. The care plan did not list the use of the abductor pillow. The facility physician's orders did not include an order to use an abductor pillow. The clinical record lacked documentation staff used the abductor pillow to prevent recurrence of hip dislocation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 15 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0689 Level of Harm - Actual harm Residents Affected - Few On 3/22/22 at 6:50 p.m., in a progress note the Director of Nursing (DON) documented, . A new Xray of right hip had been ordered due to resident non compliant with the abductor pillow and continuously is pulling it out . Resident would not tolerate the abductor pillow . Further review of the clinical record showed on 3/22/22 Resident #182 was transferred to the hospital for the second time for treatment of a right hip dislocation. Review of the hospital record revealed a physician's progress note dated 3/23/22 that read Resident #182, .is known to our practice for a failed total hip arthroplasty secondary to dislocation. She has previously been treated . for dislocated hip with a close reduction procedure. Unfortunately in a short period of time she has had a repeat dislocation. Her dislocation mechanisms seem to be positional she consistently sits in the fetal position with her legs flexed and internally rotated. This is her second dislocation in a very short period of time . On 4/5/22 at approximately 3:00 p.m. the DON verified the abductor pillow was not added to the care plan when Resident #182 returned from the hospital on 3/14/22. She also verified the Resident was sent back to the hospital on 3/22/22 for the second time for dislocation of her right hip. On 4/5/22 at 4:29 p.m., the Director of Nursing said she did not complete an incident report or investigate the two incidents of dislocation since she did not believe Resident #182 had a fall. On 4/6/22 at approximately 5:00 p.m., the Medical Director said she was not made aware Resident #182 needed to use an abductor pillow to prevent dislocation of her right hip when she returned from the hospital on 3/14/22. The physician said she would have written an order for the use of the abduction pillow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 16 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility policy and procedure, clinical record review and staff interviews, the facility failed to provide thickened liquids for 3 (Resident #5, #38 and #77) of 3 residents identified with swallowing difficulty. This had the potential to cause, choking and aspiration (food or liquid entering the lungs). Residents Affected - Few The findings included: The facility policy Thickened Liquids revised 6/8/21 documented, Residents on thickened liquids shall receive adequate hydration .Residents shall be evaluated to determine the safest food and liquid consistency for oral intake. .Residents requiring thickened liquids may have an identifier which may include: .Colored dot next to the door of the resident's room. Thickened liquid alert on tray card. Thickened liquids can be maintained at the resident's bed side .Thickened liquids are identified on the meal tray card and delivered on meal trays as ordered by the physician order. 1. On 4/4/22 at 10:15 a.m., observed signage (red dot with N) on the name plate for Resident #5 indicated the resident required nectar thick liquids. Resident #5 had a large Styrofoam drinking cup with regular thin liquids. The cup was half empty. Review of Resident #5's clinical record revealed a Physician order for nectar thickened liquids. A care plan for Resident #5 specified the resident had impaired swallowing. 2. On 4/4/22 at 10:16 a.m., observed signage on the name plate for Resident #77 indicated the resident required nectar thick liquids. Resident #77 had regular ice water in a large Styrofoam cup on the bedside table. The cup was half empty. Review of Resident #77's clinical record revealed a Physician order for nectar thickened liquids. A care plan for Resident #77 specified the resident was at risk for dehydration due to nectar thick liquids and impaired swallowing. The care plan specified Resident #77 required a pureed diet and nectar thick liquids Photographic evidence obtained. 3. On 4/4/22 at 10:27 a.m., Registered Nurse (RN) Staff E said the red dots with N by the resident's name plate indicated they were on nectar thick liquids. The RN confirmed Residents #5 and #77 were on nectar thick liquids. RN Staff E checked the water cups for Residents a#5 and #77 and confirmed they contained regular thin water. 4. On 4/4/22 at 12:45 p.m., at the noon meal the following was observations were made: a. Resident #5 was served vegetable soup with diced potato in a thin broth and had consumed over 50% of the soup. The meal ticket specified Resident #5 was to receive nectar thick liquids. Photographic evidence obtained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 17 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0692 Level of Harm - Minimal harm or potential for actual harm b. Resident #38 was served vegetable soup with diced potato in a thin broth. The meal ticket specified Resident #38 was to receive Nectar thick liquids. Resident #38 had consumed 25% of the thin soup. c. Resident #77 was served vegetable soup with diced potato in a thin broth and had consumed over 25% of the soup. The meal ticket specified Resident #77 was to receive nectar thick liquids. Residents Affected - Few 5. On 4/5/22 at 3:38 p.m., the Certified Dietary Manager (CDM) said residents who are on thickened liquids, the soup would be thickened with powder thickener before going to the resident. She said we have a 3-check process, 2 dietary aides check before the tray is put on the cart, then the nurse or aide on the floor check before the tray is given to the resident. The CDM said she was not here yesterday and did not know why the soup was not thickened. 6. On 4/7/22 at 7:45 a.m., the Certified Nursing Assistant (CNA) Staff G said residents who need thickened liquids are identified with a sticker by the name on door and on the meal tickets. If on thickened liquids and receiving soup the kitchen will thicken it before it comes on the tray. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 18 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, staff and resident interviews, review of facility policy and procedure, and record review, the facility failed to ensure 3 (Residents #5, #34 and #77) of 3 residents were assessed for alternative interventions prior to the use of bed rails. The facility failed to ensure they had informed the residents and/or their representative of the risks and benefits of bed rails, obtain an informed consent prior to use of the bed rails and to conduct periodic maintenance of the bed rails to ensure they remained safe for residents' use. The findings included: The facility policy Bed Safety (revised 1/2/19) specified .Before application, an evaluation for use of Side Rails is to be completed upon admission for residents only if side rails are being considered for usage or are requested. To try to prevent deaths/injuries from the bed and related equipment (including the frame, mattress, side rails, headboard, footboard and bed accessories) the facility shall promote the following approaches: a. If a bed/side rail is to be used it will be installed when the attempt to use an appropriate alternative has not been effective and did not meet the resident's needs. b. Conduct regular inspections of all bed frames, mattresses, bed rails and related equipment by maintenance staff as part of our bed safety program to identify problems including potential entrapment risks. 1. On 4/4/22 at 10:35 a.m., Resident #5's bed was observed with assist rails raised on the upper portion of the bed. The resident said he did not ask for the assist rails and did not use them to position himself. Review of Resident #5's clinical record revealed an Observation Detail List Report for Resident #5, dated 12/31/21 indicated side rails were not considered and the remainder of the form was blank and not signed by the resident or his representative. The facility failed to have documentation of risk versus benefits or alternatives attempted prior to installation of the assist rails. 2. On 4/4/22 at 11:00 a.m., Resident #34 was in bed with half rails up on both sides of the bed. Resident #34 said he does not use the side rails and did not know why they were on the bed. Review of Resident #34's clinical record revealed an Observation Detail List Report dated 12/31/21 indicated side rails were not considered and the remainder of the form was blank and not signed by the resident or his representative. The facility failed to have documentation of risk versus benefits or alternatives attempted prior to installation of the assist rails. 3. On 4/4/22 at 10:30 a.m., Resident #77 was in bed and observed with bed rails raised on the upper portion of the bed. On 4/5/22 at 9:40 a.m., The rails were raised on both sides of the bed. Resident #77 said he did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 19 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0700 not ask for them and does not use them. The resident said, they were just there on the bed. Level of Harm - Minimal harm or potential for actual harm Review of the clinical record revealed an Observation Detail List Report with a date 4/5/22 indicated side rails were recommended. The risks and benefits and alternative interventions was blank, and the form was not signed by the resident or his representative. Residents Affected - Few 4. On 4/5/22 at 3:20 p.m., the Director of Nursing (DON) said the facility purchased 45 new beds in May 2021 and the rails were on the bed. The DON said we used the old assessments for the residents who had the siderails and it just carried over. The DON confirmed there was no documentation of interventions attempted prior to the use of the side rails and no consents for the side rails for Residents #5, #34 and #77. The [NAME] confirmed there was no documentation the resident or family was educated on the risk for entrapment. 5. On 4/6/22 at 10:18 a.m., the Maintenance Plant Operations Director said the facility used an electronic TELLS Work History Report system for the bed checks. He said it is a check list and it did not include documentation of checking the assist bars for entrapment or mattress compatibility with the side rails or assist bars. He said he checks all the beds monthly and removes side rails when residents are discharged . The Maintenance Plant Operations Director confirmed he had no documentation the side rails were checked for entrapment or compatibility with mattress. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 20 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on clinical record review, personnel file review, and staff interview the facility failed to ensure 1 (Licensed Practical Nurse Staff Q) of 7 Licensed Practical Nurses reviewed had the required certification and competency prior to administer Intravenous Medication. The finding included: On 4/6/22 at 10:19 a.m., Resident #66 clinical record revealed orders for Intravenous medication. Review of the Administration Medication Record from 3/7/22 to 4/6/22 revealed Licensed Practical Nurse (LPN) Staff Q administered Daptomycin 350 milligrams (mg) intravenously (IV) to the Resident on 3/27/22. Further review of the MAR for 3/2022 and 4/2022 showed on 3/19/22, 3/20/22, 3/23/22, 4/1/22, and 4/3/22, LPN Staff Q administered Cefepime 2 grams intravenously to Resident #333. On 3/27/22 LPN Staff Q administered Daptomycin 350 mg IV to Resident #333. On 4/6/22 at 12:36 p.m., the Staff Developer confirmed LPN Staff Q did not have the required certification and competency to administer intravenous medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 21 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure 1(Staff B) of 5 Certified Nursing Assistant (CNA) reviewed for training received 12 hours annual in-service education as required. Residents Affected - Few The findings included: 1. Record review for CNA Staff B revealed a date of hire of 3/16/2011. Further review found staff B did not have evidence of 12 hours annual in-service education from 3/16-20 to 3/16/21. Most recent education completed on 10/25/20 was only for 8.23 hours. In addition, Staff B did not have evidence of annual training in abuse, neglect and exploitation. Most recent training on abuse neglect and exploitation was 12/26/19. 2. On 4/6/22 in an interview, the staff developer coordinator/human resources, confirmed the lack of 12 hours of annual in-service education, including training on abuse, neglect and exploitation for Staff B. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 22 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to establish a system of disposition of controlled drugs in sufficient detail to enable accurate reconciliation of narcotics for disposal. Keeping accurate records of narcotics for disposal ensures staff who have access to the narcotics are not diverting the narcotics for personal use. The findings included: Record review of the facility policy, Destruction of Controlled Substances, last reviewed 6/26/18, Guideline Steps #1. Two licensed healthcare professionals must complete, sign, and date a disposition log and provide an exact count of controlled substances that will be disposed. On 4/7/22 at 1:03 p.m., the Director of Nursing (DON) said when a resident is discharged and there are unused narcotics left at the facility, those narcotics are collected and stored in a locked file cabinet behind her desk. She said she collects these narcotics weekly and they are destroyed with the pharmacist monthly. The DON opened the file cabinet to expose several packs of unused narcotics that filled the drawer. The DON said she does not have an accurate count of the narcotics in the file cabinet, and she does not keep a log or list of the narcotics in the drawer. She said when the pharmacist comes the Control Drug Disposition Form is created. The DON said she does not keep a record or count of narcotics in the drawer. On 4/7/22 at 1:13 p.m., Licensed Practical Nurse (LPN) Staff W said she gives the unused narcotics to the DON for disposal. She said she does not sign a Controlled Substance Discontinued Control Sheet; she just verifies the number of narcotics left and gives them to the DON. On 4/07/22 at 3:12 p.m., LPN Staff X said she gives the unused narcotics to the DON. She said she does not sign a Controlled Substance Discontinued Control Sheet when she gives them to the DON. She said the DON takes the narcotics to her office. On 4/7/22 at 2:05 p.m., the DON submitted an example of the drug disposition form she completes with the pharmacist when the narcotics are being destroyed. The form was blank and without any entries. On 4/7/22 at 2:27 p.m., the DON submitted an example of the Controlled Substance Discontinued Control Sheet. The form was blank without any entries. The DON said she just found the form and had not utilized it in the past to keep track of the narcotics she was storing in the locked file cabinet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 23 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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, review of policy and procedure and staff interviews, the facility failed to ensure safe storage of medications for 2 (Residents #57 and #332) of 2 residents observed with unsecured medication at the bedside. The findings included: The facility's policy titled, Resident Arrives with Medication reviewed:10/1/18 read, . If the physician and Charge Nurse agree the Resident is capable of self-storage and self-administration of medication, the Resident's medications are stored in a locked compartment in his/her room. The Self Administration form must be completed . On 4/4/22 at 2:52 p.m., observation of Resident #332's room showed an inhaler at the bedside. Resident #332 said, This is my recovery inhaler. I was in the hospital for pneumonia and got here Thursday. On 4/5/22 10:14 a.m., Resident #332's inhaler was observed stored on the nightstand. On 4/6/22 at 11:43 a.m., during a tour with the Director of Nursing a Proair HFA inhaler, Fluticasone Nasal spray, and Ellipita 100-62.5-25 microgram inhaler were observed stored in an unlocked dresser drawer in Resident #332's room. On 4/4/22 at 2:58 p.m., a bottle of Prevagen, and Preservision were observed stored on the floor in Resident #57's room. Certified Nursing Assistant EE picked up the medication and placed them on the over the bed table. On 4/6/22 at 12:00 p.m., during a tour with the Director of Nursing she verified Resident #57 had a bottle of Prevagen and Preservision stored in an unlocked drawer in her room. The Director of Nursing verified Resident #332 and #57's medications were not safely stored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 24 of 25 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 105387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambassador Healthcare at College Park 13755 Golf Club Pkwy Fort Myers, FL 33919 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, and staff interview the facility failed to prepare, store, and distribute food in a sanitary manner. Residents Affected - Many The findings included: On 4/3/22 at 8:49 a.m., the walk-in refrigerator had an opened bag of frozen cauliflower that was not dated. The Dietary Manager said she checks on Mondays and Wednesdays to ensue all food items are properly labeled and dated. On 4/6/22 at 12:20 p.m., a Server was observed touching her face with gloves then picking up bun with the same gloved hand. On 4/6/22 at 12:24 p.m., the Dietary Manager (DM) was observed removing cooked chicken from the oven and grinding it in the food processor. A small amount of prepared chicken fell on the preparation table. The DM picked the chicken up with gloved hands and placed it on a resident's plate to be served. On 4/6/22 at 12:27 p.m., the DM was observed preparing a grilled cheese sandwich. The DM served the sandwich without taking the temperature. The cheese was not completely melted. On 4/6/22 at 12:30 p.m., the DM was observed grinding a piece of chicken in the food processor. The chicken's temperature was 97.3 degrees Fahrenheit. The DM placed the chicken on a plate to be served to a resident. Upon surveyor's intervention the chicken was reheated. On 4/6/22 at 12:35 p.m., during meal service, the DM was observed cooking grilled cheese sandwiches, getting frozen carrots out of the freezer and touching the carrots with gloved hands. The DM did not wash his hands or change his gloves between tasks. The DM was observed processing food in the food processor with the same gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 25 of 25