Inspection·January 11, 2024

F 0554 On 1/11/24 at 1:34 p.m., Licensed Practical Nurse (LPN) Staff I stated the resident was alert and oriented and was able to administer her own inhalers since she did it at home. Level of Harm - Minimal harm or potential for actual harm She stated she brings the inhalers to the resident who self-administers the medications. Residents Affected - Few Staff I stated she did not know if the resident has been evaluated for self-administration. On 1/11/24 at 1:39 p.m., in an interview Registered Nurse Staff P stated Resident #353's was not evaluated to determine if she could safely self-administer the inhalers. He also said the inhalers should be stored in a locked box. 2. On 1/8/24 at 10:00 a.m., observed at bedside of Resident #40 two respiratory inhalers, Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol 160 mcg/ 4.5 mcg. In an interview, Resident #40 said, I have two, one is mine and one is from the facility. I take it 2 or 3 times a day. On 1/8/24 at1:30 p.m., observed Resident #40 respiratory inhalers continue on bedside table unsecured. On 1/9/24 at 915 a.m., observed Resident #40 medication inhalers continue on bedside table unsecured. On 1/9/24 at 3:15 p.m., RN Staff L reviewed the resident's clinical record and verified Resident #40 was not evaluated to determine if the resident was able to safely self-administer the inhalers. RN Staff L said he administered the inhalers to the resident in the morning but was not able to locate the inhalers in the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 2 of 30 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 01/11/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, facility policy review, resident and staff interviews, the facility failed to provide housekeeping and maintenance services necessary to repair a broken toilet for 1 (Resident #84) of 27 sampled residents. The findings included: Review of facility policy titled Preventive Maintenance Program revised 3/10/23 which stated Purpose: To develop and implement a preventive maintenance program that promotes a safe, functional and comfortable environment for all residents .The maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, significant event reviews, life safety requirements, and/or experience. Review of clinical records for Resident #84 documents a Brief Interview for Mental Status (BIMs) dated 12/22/2023 with a score of 15 indicating the resident was cognitively intact. On 1/8/24 at 9:41 a.m., during an interview Resident #84 complained the toilet in his room has been broken for the past two months. Resident #84 said, I don't know why they don't get a plumber in here. The maintenance guy comes and checks it and then it is broken again in a day. The toilet in resident's bathroom was observed covered with a large black plastic garbage bag. Resident #84 said he had to use the toilet in the shower room. He said, We need to go down to the shower room. If someone is using the shower then we need to wait. It is annoying. I don't like it. The resident said the housekeeping staff covered the toilet with the black plastic bag since Saturday (1/6/2024). On 1/9/24 at 12:26 p.m., the toilet remained covered with a black garbage bag. Resident #84 confirmed the toilet was still not working. He said no one came to check the toilet or update him. On 1/10/24 at 9:23 a.m., in an interview Resident #84 said the toilet was still not fixed, and no staff had come to check the toilet or update him. Observed a black garbage bag still covering the toilet. Resident #84 said it was frustrating to have a toilet that was not working and did not like to have to go to the shower room to use the toilet. On 1/10/24 at 10:45 a.m., in an interview, the Maintenance Director said the toilet in Resident #84's room has had problems on and off for months. The Maintenance Director said, It works for a week or so and then it doesn't. I think they are using too much toilet paper. The Maintenance Director said he was planning on ordering a new toilet and confirmed he has not brought in a plumber to address the issues with the toilet. He said, We just plunge it and get it working. When asked how many times the toilet was broken in the past six months, the Maintenance Director replied, I don't know every couple of weeks. He confirmed the toilet being broken 12 times in the past six months was a fair description saying, Yes about that would be right. The Maintenance Director said he was not aware Resident #84's toilet has been broken since 1/6/24. The Maintenance Director observed the toilet covered with a plastic bag and said, If they did not let me know or put in a request for maintenance, I would not know it was broken again. The Maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 3 of 30 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 01/11/2024 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 0584 Director confirmed it was unacceptable to have a non-functioning toilet for five days. Level of Harm - Minimal harm or potential for actual harm On 1/10/24 at 11:33 a.m., in an interview CNA Staff E said the toilet in Resident #84's bathroom was always having problems. He said, If I see it is not working I plunge it and if that doesn't work I call maintenance. He confirmed the toilet has been broken on and off every week or so for the past several months. Residents Affected - Few On 1/10/24 at 11:45 a.m., in an interview, the Facility's Administrator said he was not aware the resident's toilet had not been functioning since 1/6/24. He said he didn't know why they had not called a plumber to fix it. The Administrator said a toilet shouldn't be out of service for even a day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 4 of 30 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 01/11/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, record review, staff and resident interview, the facility failed to revise the comprehensive care plans with individualized interventions to meet the needs of 1 (Residents #453) of 27 residents' care plans reviewed. The findings included: Review of the clinical record for Resident #453 revealed an admission date of 7/26/22. The Resident was transferred to an acute care facility on 12/5/23 and returned to the facility on 1/2/24. The Quarterly Minimum Data Set (MDS) assessment with a target date of 11/29/23 noted a diagnosis of End Stage Renal Disease (ESRD). Resident #453 received dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). The physician's orders as of 1/2/24 included: Hemodialysis at dialysis center A on Mondays, Wednesdays, and Fridays with a chair time of 7:00 a.m. Daptomycin (antibiotic) 750 milligrams intravenously every 48 hours related to an infection. Staff was to assess the hemodialysis access site to the right chest for bruising, bleeding, and symptoms of infection every shift as of 1/3/24. The care plan initiated on 12/7/22 and revised on 8/30/22 noted Resident #453 needed hemodialysis on Tuesdays, Thursdays, and Saturdays at dialysis center B, and the dialysis access site was on the left arm. The care plan was not updated upon the resident's readmission to the facility on 1/2/24 to reflect the new dialysis access site to the resident's right chest, the new dialysis center and schedule, or the infection for which the resident received intravenous antibiotics. On 1/8/24 at 12:35 p.m., Resident #453 was observed to have a wound vac (vacuum device to promote wound healing) to the left upper extremity, and an intravenous catheter to the right upper extremity covered with a dressing. Resident #453 said she developed complications to access site of the left arm and the graft had to be removed. The resident said they placed a new dialysis access site to the right upper chest. On 1/10/24 at 4:20 p.m., during an interview Minimum Data Set (MDS) Licensed Practical Nurse (LPN) Staff G stated upon readmission to the facility, the care plan is updated with any significant changes. On 1/11/24 at 12:00 p.m., LPN Staff G confirmed Resident #453's care plan was not updated to reflect the new dialysis center, access site, or the infection for which the resident received intravenous antibiotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 5 of 30 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 01/11/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review and review of facility policies and procedures, the facility of failed to provide the necessary care and services to maintain grooming and hygiene for 4 (Resident #8, #19, #38, and #60) of 8 residents reviewed for assistance with activities of daily living. Residents Affected - Some The findings included: The facility policy and procedures, Nursing- Activities of Daily Living (ADLS) effective 4/1/22 documented To ensure all residents needs are met in a manner that promotes their quality of life and preferences . A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming and personal hygiene . 1. Review of the clinical record revealed Resident #8 had an admission date of 11/16/17 with diagnoses including hemiplegia and hemiparesis (weakness or inability to move on one side of the body) of the right side. The plan of care initiated on 1/16/23 and revised on 1/5/24 noted Resident #8 required substantial assistance with personal hygiene and grooming. On 1/8/24 at 1:51 p.m., during an observation and interview, Resident #8 said he had a stroke and was not able to use his right hand or arm. The resident's right hand fingers were curled in a fist. He demonstrated how he used his left hand to open to move the right hand's fingers. Upon observation the fingernails on the right hand extended over ¼ inch from the nail beds with a brown and black substance under the nail beds. He said the staff were supposed to cut and clean his nails, but they did not always do it. On 1/9/24 at 9:03 a.m., Resident #8 was in his room in a wheelchair, with the bedside table in front of him awaiting breakfast. A urinal half filled with urine was on the bedside table in front of the resident. Certified Nursing Assistant (CNA) Staff C entered the room, placed the breakfast tray on the bedside table next to the urinal and turned to exit the room. The resident said he was used to eat his meals with the urinal, because staff did not always empty it. On 1/9/24 at 2:37 p.m., in an interview CNA Staff C said there was a shower list at the nurse's desk and the staff follow it. Staff C said there were shower sheets at the desk and each CNA completes it when you give a shower or bed bath. The CNA explained you circle the sheet when a was shower given. The Resident Shower Sheet tasks listed cleaning and trimming fingernails. Staff C said you complete the form and sign it and then you give it to the nurse and the nurse signs it. We do nails, shave everything when you give the shower. On 1/10/24, review of the shower sheets for Resident #8 revealed the CNA noted on 1/6/24 and 1/10/24 the resident's fingernails had been cleaned and trimmed during the day shift. On 1/10/24 at 3:12 p.m., Resident #8 was observed exercising his right hand, using the left hand. The right hand fingernails remained untrimmed with a brown and black substance under the nails. The resident's hand had a foul odor. On 1/11/24 at 11:45 a.m., the resident's right hand nails remained untrimmed with an accumulation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 6 of 30 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 01/11/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of black and brown substance under the nails. Unit Manager Staff A confirmed the observation of Resident #8's right hand. Staff A said she would have the CNA wash and soak the residents right hand and trim the fingernails. 2. On 1/8/24 at 11:39 a.m., Resident #19 was sitting on the side of his bed. His feet were blue and dark purple in color from the toes to approximately four inches above his ankles. He said he had a heart attack several years ago but did not know why his feet were discolored. Review of Resident #19's clinical record revealed an admission date of 5/10/22 with diagnoses including acute ischemic heart disease, peripheral vascular disease, and type 2 diabetes mellitus. Review of the physician order dated 8/11/23 included to apply compression stockings (worn to reduce blood clots and promote blood flow) to bilateral legs. The stockings were to be applied in the morning and removed at bedtime. On 1/9/24 at 8:58 a.m., Resident #19 was observed seated on the side of the bed and did not have the compression stockings on. Resident #19's wife said, the staff are supposed to put the white stockings on him every day, but they are never on him. On 1/9/24 at 2:50 p.m., Resident #19 was lying in his bed and did not have the compression stockings on as ordered. On 1/9/24 at 2:58 p.m., during a joint observation with the Director of Nursing (DON), she confirmed Resident #19 was not wearing the compression stockings as ordered by the physician. On 1/10/24 at 11:21 a.m., in an interview CNA Staff D said the CNA's were to apply the compression stockings. Staff D said, the CNA's put the stockings on and we get the information from the care plan or CNA care [NAME], it will tell you what each resident needs. 3. Review of the clinical record revealed Resident #38 had an admission date of 8/16/16 with diagnoses including anxiety disorder, histrionic personality disorder, mood disorder and depression. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 12/14/23 documented Resident #38 was dependent on staff for bathing. The MDS noted Resident #38 scored 03 on the Brief Interview for Mental Status, indicative of severely impaired cognitive skills for daily decision making. The plan of care for Resident #38 initiated 2/16/23 noted the resident required total assistance of one staff for bathing and showers. The care plan of care specified to provide a sponge bath when a full bath or shower cannot be tolerated. On 1/8/24 at 1:36 p.m., Resident #38 was observed sitting on the side of his bed. The resident's hair was uncombed and greasy, and he was disheveled. Resident #38 did not respond appropriately to questions. On 1/9/24 at 8:41 a.m., Resident # 38 was observed in bed with the covers over his head. He did not respond when spoken to. On 1/9/24 at 9:42 a.m., in an interview CNA Staff C said the resident has no balance, he shakes, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 7 of 30 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 01/11/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and you hold his hand, and he walks to the bathroom and back. He does not refuse care or hit you. We have a shower schedule, and it is by room and days of the week. We complete the shower sheet sign it and give it to the nurse. On 1/9/24 at 10:30 a.m., Resident #38 was observed in his bed, and smiled when greeted. He was dressed in his own clothing. His hair remained uncombed and greasy. He had a strong body odor. Review of the shower schedule documented Resident #38 was scheduled for showers on 7:00 a.m., to 3:00 p.m., shift on Mondays and Thursdays. Review of the CNA documentation for showers documented Resident #38 received a shower on 1/4/24 and his hair was washed. On 1/8/24 (Monday) the CNA documentation showed the resident received a bed bath. There was no documentation Resident #38 refused his scheduled shower which included hair washing. On 1/10/24 at 9:09 a.m., in an interview Unit Manager Staff A said Resident #38 did not like to get out of bed. She said she had not observed the resident refusing care, hit anyone, yell or be combative. 4. Review of Resident #60's clinical record revealed an admission date of 9/12/20 with diagnoses including dementia and major depression. The Quarterly MDS dated [DATE] documented the resident was dependent on staff for bathing and hygiene. The MDS noted Resident #60's cognitive abilities for daily decision making were severely impaired with a BIMS score of 04. The plan of care for Resident #60 documented the resident was dependent on one to two staff for bathing, needed substantial assistance for dressing the upper body and was dependent on staff for dressing the lower body. Staff was to make sure the resident was safe if he became combative and attempt again another time. On 1/8/24 at 9:49 a.m., and 12:13 p.m., Resident #60 was observed in bed. The resident's fingernails extended approximately half inch from the fingertips and had an accumulation of brown substance under the nails. Resident #60 was not able to answer most questions. He was dressed in a green T-shirt and had an incontinent brief on. On 1/9/24 at 8:30 a.m., and 10:30 a.m., Resident #60 was observed in bed wearing the same green T-shirt as the previous day. On 1/10/24 at 9:10 a.m., Resident #60 was observed in bed with a neon green T-shirt on and a brief. On 1/11/24 at 10:32 a.m., Resident #60 was observed in bed wearing the same bright neon green T-Shirt. Review of the shower schedule revealed Resident #60 was scheduled for showers on the 7:00 a.m., to 3:00 p.m., shift on Tuesdays and Fridays. Review of the CNA documentation for December 2023 and January 2024 failed to reveal documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 8 of 30 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 01/11/2024 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 0677 Resident #60 received the scheduled showers from 12/30/23 through 1/10/24. Level of Harm - Minimal harm or potential for actual harm On 1/6/24 the CNA documented on the shower sheet she gave a bed bath. There was no documentation that the resident refused the shower. Residents Affected - Some On 1/11/24 at 10:36 a.m., in an interview CNA Staff E said they received an in-service approximately two months earlier. The Unit Manager told staff they needed to change the residents' clothes when they get up and when they go to bed. On 1/11/24 at 11:10 a.m., Unit Manager LPN Staff A reviewed the shower sheets for Resident #60 and said she realized there was a problem with staff giving showers on the unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 9 of 30 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 01/11/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records review, policy and procedure review, residents and staff interviews, the facility failed to monitor and treat a skin rash for 1 (Resident #84) of 3 residents reviewed for skin conditions. The facility failed to provide appropriate care of a midline intravenous catheter for 1 (Resident #453) of 1 sampled resident receiving intravenous therapy. Residents Affected - Few The findings included: 1. Review of facility policy for prevention of Pressure Ulcers/ Injuries revised 2/21/23 which states, Inspect the skin on a daily basis when performing or assisting with personal care or ADLs (Activities of Daily Living) . Monitoring - evaluate, report and document potential changes in the skin . On 1/8/24 at 12:30 p.m., during an interview Resident #84 was observed scratching his chest. The resident had visible scattered small red bumps on the chest and upper abdomen. Resident #84 said he's had that rash on his chest and back for a long time. He said, I have had it for months. They said I would see a dermatologist, but it has been months. It isn't getting any better. They gave me ointment and cream. I am using a tube of cream a day since it is itchy. On 1/9/24 9:53 a.m., in an interview Resident #84 complained about the rash on his chest and back. Resident #84 said, They said I will get checked by a dermatologist. Someone said it might be scabies, but I don't think so. On 1/9/24 at 12:17 p.m., in an interview Resident #84 said he has been waiting to see the dermatologist for the rash for a couple of months. He said the Physician Assistant gave him a cream to apply to the rash, and he's going through a tube of the cream every day. A tube of Hydrocortisone cream 1% was observed at the resident's bedside. Resident #84 said no one told him how much or how frequently he should apply the cream. He said, They just gave me the cream and I put it all over my chest. On 1/9/24 at 3:05 p.m., in an interview Certified Nursing Assistant (CNA) Staff N assigned to Resident #84 said she was aware Resident #84 had a rash. She said, I think he has had it for a few weeks. CNA Staff N said the resident complained of being itchy a lot. Staff N said the rash was mostly on the resident's stomach and had little red bumps. She said she was not always assigned to care for the resident, but she notified the assigned nurse two weeks ago when the resident told her about the rash. CNA Staff N said she heard the resident had a cream for the rash, but the nurses apply the cream. Review of the clinical record revealed Resident #84 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment with a target date of 12/21/23 noted the resident's cognition was intact with a Brief Interview for Mental Status score of 15. The physician's orders dated 3/29/23 included, Dermatology consult and treat as needed. Review of the Medication Administration Record (MAR) for December 2023 showed on 12/14/23 at 9:41 a.m., 12/28/23 at 2:14 p.m., 12/31/23 at 5:30 a.m., and 10:07 p.m., and on 1/2/24 at 9:15 a.m., Resident #84 received Hydroxyzine HCL 25 milligrams by mouth as per the physician's order dated 12/10/23 for pruritis (itchy skin). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 10 of 30 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 01/11/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Treatment Administration Record (TAR) for December 2023 noted staff applied BPCO ([NAME], [NAME] Oil) as per the physician's order dated 7/18/23 to Resident #84's back and chest every day and night shift for rash until 12/27/23. There was no physician's order in the clinical record for the Hydrocortisone cream 1% observed at the resident's bedside. The weekly skin evaluations for 11/6/23, 11/13/23, 11/20/23, 11/27/23, 12/1/23, 12/4/23, 12/11/23, 12/18/23, and 12/25/23 documented the resident's skin was intact. Review of nursing and physician progress notes from 12/1/23 to 1/9/24 failed to show documentation of an evaluation of Resident #84's rash to the chest and abdomen. The care plan initiated on 12/28/23 noted the resident had a rash on the back and chest. The interventions included: Apply topical medication to the rash as ordered and note effectiveness. Give anti-pruritic (itching) medication as ordered by the physician. Monitor, document side effects and effectiveness. Monitor skin rashes for increased spread or signs of infection. The weekly skin evaluations for 1/1/24, and 1/8/24 documented the resident's skin was intact, and did not document the rash on the resident's skin. On 1/9/24 at 3:15 p.m., in an interview Registered Nurse (RN) Staff L, assigned to Resident #84, confirmed the resident had a rash. RN Staff L said, He has complained of itchiness and a rash. He has a cream ordered to be applied and Hydroxyzine HCL as needed every six hours for itchiness. I was told he has gone out to see a dermatologist. Staff L went to the resident's room and observed the Hydrocortisone cream 1% at the resident's bedside. She said she was not aware the resident was using the Hydrocortisone. Resident #84 told RN Staff L, The Unit Manager gave it to me. After reviewing the physician's orders, RN Staff L confirmed there was no physician orders for the Hydrocortisone cream 1% the resident kept at the bedside. On 1/9/24 at 3:45 p.m., Licensed Practical Nurse (LPN) Unit Manager Staff A confirmed she was aware Resident #84 had a continued rash for several weeks and had not seen the dermatologist yet. She verified the resident had hydrocortisone cream 1% at his bedside. Unit Manager Staff A said she thought the dermatologist was coming soon. On 1/9/24 at 5:34 p.m., RN Staff L documented in a progress note Resident #84 complained of an itchy rash on his skin. The facility completed a skin assessment on 1/9/24 which noted Resident #84 had a scattered rash to chest, abdomen, back, buttocks, thighs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 11 of 30 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 01/11/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/10/24 at 3:27 p.m., in an interview the Director of Nursing (DON) said the rash should have been assessed and documented in the weekly skin checks. The DON said the risks for not addressing the rash for several weeks included that the resident would be more uncomfortable and that they could not say if the rash was infectious or not. 2. Review of the facility's policy and procedure titled Catheter Insertion and Care revised 1/17/2019 showed Midline catheter (catheter inserted into a vein) dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. The policy noted to label the dressing with initials, date and time. On 1/9/24 at 11:56 a.m., Resident #453 was observed with a midline intravenous catheter inserted to the right upper arm. The midline dressing was lifting around the edges. The dressing was not dated. Resident #453 said the dressing keeps getting unglued. Review of the clinical record revealed Resident #453's most recent admission to the facility was 1/2/24. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted Resident #453 scored 15 on the Brief Interview for Mental Status, indicating intact cognition. The physician's orders dated 1/2/24 included administering Daptomycin (antibiotic) 750 milligrams intravenously every 48 hours for staphylococcus aureus infection and changing the midline dressing every seven days and as needed if soiled. Review of the Treatment Administration Record (TAR) revealed the midline dressing change was scheduled for 1/9/24. Licensed Practical Nurse Staff F placed her initials on the TAR on 1/9/24 indicating the dressing change was done as ordered. On 1/10/24 at 12:30 p.m., Resident #453's undated midline catheter dressing remained unchanged and lifted on three sides. The resident's sleeve was caught underneath the dressing. Resident #453 said she was receiving antibiotics through the midline for a blood infection, and no one had changed the dressing since the midline was inserted. She said she told a few nurses, including the nurse who infused her antibiotic the night before the dressing was coming off and needed to be changed. The nurse did not change it. Photographic evidence obtained. On 1/10/24 at 2:20 p.m., in a joint observation, the Director of Nursing (DON) verified the resident's midline dressing was coming off and was not dated. Resident #453 told the DON the dressing has not been changed since the midline was inserted. On 1/10/24 at 4:20 p.m., the DON said Resident #453's midline dressing was from the hospital prior to the resident's readmission date of 1/2/24. She also verified LPN Staff F documented on the TAR she changed the dressing on 1/9/24. On 1/11/24 at 8:24 a.m., in an interview LPN staff F confirmed she did not change Resident #453's midline dressing on 1/9/24 but documented in the TAR she had changed the dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 12 of 30 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 01/11/2024 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate care and services to prevent an avoidable fall for 1 (Resident #26) of 3 dependent residents reviewed who sustained a fall at the facility. The findings included: Review of the clinical record revealed Resident #26 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment with a target date of 12/8/23 noted the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. Diagnoses included Parkinson's Disease (disorder of the central nervous system that affects movement), Cerebrovascular Accident, Transient Ischemic attack, or Stroke. Resident #26 had functional limitation of both lower extremities and required substantial assistance to roll left and right. The care plan initiated on 11/21/23 noted the resident was at risk for falls related to debility, and bilateral fixed knee contractures (joint deformity and loss of movement around the joint). On 12/15/23 the care plan noted Resident #26 had an actual fall with a goal to minimize the risk of further incident through the next review date. The interventions included to continue with bilateral grab bars to the bed to assist with bed mobility and provide substantial assistance of two staff members for bed mobility and incontinence care. On 1/8/24 at 11:18 a.m., Resident #26 was observed in bed, awake, oriented to person and place, able to converse and answer questions appropriately. Resident #26 said she recently fell out of bed when Certified Nursing Assistant (CNA) Staff AA rolled her away from her while providing incontinent care. Review of the fall investigation dated 12/15/23 at 3:30 a.m., revealed Licensed Practical Nurse W documented Resident #26 was found in a sitting position at her bedside. The CNA said the resident fell due to continuing to roll over on her side when changing linens and incontinence care .The resident was not able to explain what happened . The fall investigation included a witness statement from CNA Staff AA which noted Resident #26 fell due to continuing to roll over on side. The CNA documented she advised the resident not to turn too much so she would not fall but the resident continued to turn and resulted in the fall. The investigation noted the root cause of the incident was the resident rolled too far over while the CNA repositioned her for incontinence care. The investigation did not address CNA Staff AA rolling the dependent resident away from her while providing care. On 1/11/24 at 10:44 a.m., in an interview the Director of Nursing (DON) said she personally reviewed the incident, looked at the interventions, observed the room and spoke with the resident. She verified CNA Staff AA rolled the dependent resident away from her and said she did not think the CNA was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 13 of 30 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 01/11/2024 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 - Minimal harm or potential for actual harm Residents Affected - Few at fault. She said Resident #26 had grab bars at the head of the bed and was able to use them to roll in bed therefore there was no need to re-educate the CNA. The DON said the CNAs should roll more dependent residents toward them while providing care to prevent falls. The DON said the Occupational Therapist provided in-service to the CNAs twice a year on positioning, moving, and transferring residents. On 1/11/24 at 10:57 a.m., Resident #26 was observed in bed with grab bars elevated at the head of the bed bilaterally. Resident #26 had a splint to the left hand and wrist. The middle finger of the right hand was curled toward her palm. Resident #26 said she had a Trigger finger (finger stuck in a bent position). Resident #26 was not able to grab the bars and reposition herself in bed. The DON was present at the time of the observation. Resident #26 said she was still upset about the fall. She said CNA Staff AA was rolling her away from her in the bed. She repeatedly told the CNA to stop as she was falling but she did not listen and kept rolling her until she fell. On 1/11/24 at 11:42 a.m., Physical Therapist Staff U said Resident #26 would not be able to reposition herself in bed is she was falling. Review of the CNA skills fair dated 5/24/23 noted the Director of Therapy reviewed the proper techniques for assisting residents to perform transfers and bed mobility safely. The technique for dependent roll included, Pre-roll positioning. The person assisting positions him/herself on the side of the bed toward which the resident is to roll . Gently roll the resident toward you onto his/her side . There was no documentation CNA Staff AA attended the training. On 1/11/24 at 1:51 p.m., the DON verified CNA Staff AA did not use proper technique by rolling Resident #26 away from her while providing care. She also verified CNA staff AA did not attend the CNAs skills fair on 5/24/23 or in November 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 14 of 30 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 01/11/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the clinical record for Resident #11 revealed an admission date of 3/7/20. Diagnoses included Alzheimer's disease, and a history of urinary tract infections. The Quarterly Minimum Data Set (MDS) assessment with a target date of 10/20/23 noted Resident #11 scored 05 on the Brief Interview for Mental Status, indicative of severely impaired cognition. Resident #11 was always incontinent of bladder and was dependent on staff for toileting and incontinence care. Resident #11's Care Plan revised on 3/19/2023 revealed the resident was a risk for self-care deficit related to dementia. The resident needed to be checked for incontinence on routine rounds and provided incontinence care per facility protocol. On 1/8/24 at 9:19 a.m., observed Resident #11 sitting in a Broda chair in her room. Resident was awake but did not respond when asked questions. Resident #11 was wearing an incontinent brief. The room had a strong odor of urine. On 1/8/24 at 10:00 a.m., and 10:55 a.m., Resident #11 remained sitting in the same position in the Broda chair in the room. The resident appeared to be sleeping. The room remained with a very strong urine odor. On 1/8/24 at 12:00 p.m., Resident #11 remained in the same position in the Broda chair. The room remained with a strong urine odor. Resident #11 was awake but did not reply to questions. Staff was not observed providing incontinent care to the resident up to this point. On 1/8/24 at 2:51 p.m., Resident #11 remained in the same position in the Broda chair. CNA staff J was observed entering the resident's room. She pushed the resident in the Broda chair to the dining room. The resident had a strong odor of urine. Staff was not observed changing the resident before taking her to the dining room for lunch. On 1/8/24 at 3:11 p.m., a strong smell of urine was noted in the dining room. Multiple residents were participating in an activity in the dining area. A large wet spot was observed on the floor. On 1/8/24 at 3:12 p.m., the Activities Assistant said Resident #11 was incontinent and the urine drained off the chair onto the floor. She said staff took the resident out of the dining room after lunch and brought her back within minutes for the scheduled activity. On 1/11/24 at 12:24 p.m., LPN Staff I verified Resident #11 had an incontinent episode in the dining room after lunch on 1/8/24. She said residents who are incontinent should be checked and changed every two hours and as needed. On 1/11/24 at 1:17 p.m., CNA Staff K said he was assigned to Resident #11 on 1/8/24. He said he had not changed the resident's brief that morning. He said before lunch he only looked at the brief. He did not notice it to be wet, so he did not change the resident before she went to the dining room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 15 of 30 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 01/11/2024 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 0690 A review of facility policy titled Nursing - Activities of Daily Living (ADLS) Level of Harm - Minimal harm or potential for actual harm Reveals that the purpose of the policy is to ensure all resident's needs are met in a manner that promotes their quality of life and preferences. Procedure: 1. The facility shall ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. 2. The facility shall provide care and services for the following activities of daily living as needed, based on the individual care plan of each resident. And that would include. Number C toileting. 3. A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain. Good nutrition, grooming, and personal. And oral hygiene. Residents Affected - Some On 1/11/24 at 1:03 p.m., the DON stated that the policy for ADLs should be followed. Residents who are incontinent should be checked and changed every couple of hours and as needed. Based on observation, record review, review of policies and procedures, staff and residents interview, the facility failed to provide services to restore bladder function and prevent urinary tract infections to the extent possible for 3 (Residents #92, #254, and #11) of 3 residents reviewed for bladder function. The findings included: 1. Review of the clinical record revealed Resident #92 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment with a target date of 12/12/23 noted the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 13. Resident #92 had an indwelling catheter (catheter inserted in the bladder to drain urine). The care plan initiated on 12/5/23 noted the resident had an indwelling catheter related to urinary retention. The Certified Nursing Assistant Kardex (provides instructions for care) noted the resident was not toileted. Staff was to empty the catheter drainage bag and perform catheter care per policy. Review of the physician's orders revealed the orders related to the resident's urinary catheter were discontinued on 12/19/23. The care plan and the Kardex were not updated when the catheter was removed. On 1/8/24 at 10:30 a.m., in an interview Resident #92 said she had a urinary catheter which was removed in December. She said she has been wearing incontinent briefs since her admission and staff did not always answer the call light to assist her to the bathroom. Resident #92 said she was aware of the need to urinate, but it often took three hours for staff to answer the call light and she was not able to hold her urine for that long. On 1/10/24 at 10:22 a.m., in an interview Resident #92 said the previous night when she turned on the call light, the girl came, turned it off and said she would be back. She put the light on again after 15 minutes. It took an hour for staff to answer the call light. On 1/11/24 at 9:10 a.m., Resident #92 said she never wore incontinent briefs at home. She could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 16 of 30 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 01/11/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm always hold her urine and then go to the bathroom. She said she has been timing her urine and she wets the brief every 3 hours. She said the urologist told her the facility should offer toileting every 3 hours, but they do not, and then she wets herself. Resident #92 said when she puts the call light on, staff comes in, turn off the light and say they'll be right back. They do not come back until one to three hours later. By that time, it's too late and she wets the brief. Residents Affected - Some On 1/11/24 at 9:17 a.m., CNA Staff J said she came on duty at 7:00 a.m. and was assigned to Resident #92. She said Resident #92 had an indwelling catheter therefore she did not need to offer toileting. CNA Staff J said she got her information from the Kardex. Review of the potential for bowel and bladder retraining program with an effective date of 12/8/23 and signed on 12/19/23 by Unit Manager Licensed Practical Nurse (LPN) Staff H noted Resident #92 always voided correctly without incontinence and was usually mentally aware of toileting needs. Unit Manager Staff H checked no to proceed with personalized toileting schedule and retraining program. Review of the Bowel and Bladder Report from 12/19/23 through 1/11/24 revealed multiple CNA entries noting the resident was incontinent of urine. On 1/11/24 at 9:26 a.m., Unit Manager, LPN Staff H said he obtained the information to complete the potential for bowel and bladder retraining program from the CNAs who told him the resident was continent of urine. He verified the lack of bladder assessment to restore or improve Resident #92's bladder function to the extent possible after the indwelling catheter was removed. On 1/11/24 at 9:38 a.m., MDS coordinator LPN Staff X verified the care plan and Kardex were not updated on 12/19/23 when the indwelling catheter was removed. On 1/11/23 at 10:05 a.m., the Director of Nursing said there was no process in place to assess continence status when an indwelling catheter is removed to restore bladder function. 2. Review of the facility policy on Urinary Catheter Care with a revision date of 2/21/23 indicated the purpose of this procedure was to prevent catheter-associated urinary tract infections. The policy specified to be sure the catheter tubing and drainage bag are kept off the floor for infection control. Review of the clinical record revealed Resident #254 was admitted to the facility on [DATE]. The admission MDS assessment with a target date of 12/24/23 noted the resident had an indwelling catheter. The care plan initiated on 12/19/23 noted the goal was for the resident to show no signs or symptoms of urinary infection. On 1/8/24 at 3:34 p.m., observed Resident #254 in the wheelchair wheeling himself down the hallway. The urinary catheter drainage bag was on the floor and being dragged under the wheelchair. Several staff stopped to talk with the resident, including a Certified Nursing Assistant (CNA), but none moved the drainage bag off the floor. On 1/8/24 at 4:10 p.m., Licensed Practical Nurse (LPN) Unit Manager Staff H confirmed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 17 of 30 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 01/11/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indwelling catheter bag was on the floor. Staff H said the drainage bag should not be on the floor for infection prevention. Staff H repositioned the bag so it was not touching the floor. On 1/9/24 at 8:35 a.m., Resident #254 was observed in bed. The urinary catheter drainage bag was stored on the floor. Registered Nurse (RN) Staff P verified the drainage bag was on the floor. Staff P repositioned the drainage bag, so it was not touching the floor. On 1/9/24 at 3:28 p.m., CNA Staff Q said she was providing care to Resident #254 and did not make sure the drainage bag was off the floor. She said was aware the drainage bag should never be stored on the floor. On 1/10/24 1:48 p.m., the Director of Nursing (DON) said the catheter drainage bag should never come in contact with the floor. The DON said staff should have changed the drainage bag after it was found on the floor the previous day, but they didn't. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 18 of 30 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 01/11/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to ensure 2 (Residents, #21 and #40) of 3 sampled residents received oxygen therapy accurately and appropriately. Residents Affected - Few The findings included: 1. Review of facility policy titled, Nursing - Oxygen Administration, effective date 4/1/2022 which stated, Purpose: The purpose of this procedure to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure . On 1/8/24 at 10:19 a.m., and 12:40 p.m., observed Resident #21 sleeping in bed with nasal cannula oxygen therapy prongs in place. Oxygen concentrator observed delivering oxygen at 2.5 liters per minute. Review of clinical records for Resident #21 revealed an admission date of 8/29/2022. The physician's orders did not include oxygen therapy. On 1/8/24 at 3:27 p.m., in a joint observation, Unit Manager Licensed Practical Nurse (LPN) Staff A verified Resident #21 was receiving oxygen via nasal cannula at 2.5 liters per minute. Upon review of the clinical record Staff A said she could not locate a physician's order for the oxygen. She verified a physician's order was needed for oxygen therapy. On 1/8/24 at 3:34 p.m., in an interview the Director of Nursing (DON) confirmed Resident #21 was receiving oxygen without a physician's order. On 1/11/24 at 12:23 p.m., in an interview Respiratory Therapist (RT) Staff O said she was not aware that Resident #21 was on oxygen therapy and had not assessed the resident. 2. Review of Resident #40's clinical record revealed a physician's order dated 7/12/23 for Oxygen inhalation via nasal cannula at two liters per minute every shift. Review of Resident #40 Treatment Administration Record (TAR) for December 2023 and January 2024 showed staff signed each shift verifying the resident was receiving oxygen therapy via nasal cannula consistently. On 1/8/23 at 10:00 a.m., in an interview Resident #40 said she uses oxygen mostly at night for her COPD (Chronic Obstructive Pulmonary Disease). A nasal cannula oxygen tubing dated 1/3/24 was observed draped over the oxygen concentrator without a protective cover. On 1/9/24 at 9:14 a.m., Resident #40 was observed sitting in a wheelchair. The oxygen tubing dated 1/3/24 was on the floor under the bed. Resident #40 confirmed she only uses oxygen at night. On 1/9/24 at 3:30 p.m., the oxygen tubing dated 1/3/24 was observed stored in a plastic bag dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 19 of 30 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 01/11/2024 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 0695 1/9/23. Level of Harm - Minimal harm or potential for actual harm On 1/9/24 at 3:45 p.m., in an interview Unit Manager LPN Staff A verified the oxygen tubing dated 1/3/24 that was observed on the floor had not been replaced. She said it should have never been taken off the floor and bagged. LPN Staff A said, It is an infection control issue. If it touched the floor, then it needs to be thrown out and replaced. LPN Staff A said over a month ago, Resident #40 started using her oxygen at night only. Residents Affected - Few On 1/11/24 at 9:46 a.m., during an interview the DON and LPN Staff A confirmed the documentation on the TAR for December 2023 and January 2024 was inaccurate since the resident had not been using the oxygen mostly at night as needed for over a month. The DON said they should have obtained a new order and revise the care plan. On 1/11/24 at 12:34 p.m., in an interview, Respiratory Therapist (RT) Staff O said on 11/20/23 Resident #40 transitioned to oxygen at 2 liters at nighttime and as needed., and the order should have been changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 20 of 30 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 01/11/2024 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 complete a performance review of 6 (Certified Nursing Assistants Staff W, X, Y, Z, AA, and BB) of 8 Certified Nursing Assistants (CNAs) employed at the facility greater than 12 months. Residents Affected - Some The findings included: Review of the facility Performance Review Policy effective 4/1/22 revealed It is the policy of the facility to complete annual performance reviews for all employees who work in the facility. If an employee is performing below average and has ongoing performance issues, then a performance improvement plan is put in place. On 1/9/24, Review of the employee files failed to reveal documentation of a performance review and in-service education based on the outcome of the review for: CNA Staff BB, date of hire (DOH) of 8/16/22, CNA Staff AA DOH of 9/13/22, CNA Staff W DOH of 6/14/22, CNA Staff X DOH of 6/7/22, CNA Staff Y DOH of 9/20/22, and CNA Staff Z DOH of 7/19/22. On 1/9/24 at 3:43 p.m., the Human Resources Coordinator confirmed there were no annual performance reviews for the CNAs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 21 of 30 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 01/11/2024 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 1/8/2024 at 12:45 p.m., during an interview with Resident #20, she was observed to have multiple medications on the table at her bedside. She said they were her medications that the nurses gave her to use as needed. Included in the medications were: Diclofenac Sodium Topical gel which is a medication to treat arthritis pain. Vitamin D Tablets. [NAME] Oil 500mg Dietary Supplement. Osteo Bi-Flex joint health Glucosamine & Chondroitin is taken to improve joint care. Brimonidine tartrate eye drops. 6. On 1/9/24 at 12:30 p.m., in an interview with Resident #53, she said she takes Albuterol as needed for shortness of breath. She said the staff let her keep it at bedside, so she has it when she needs it. A cannister/inhaler of Albuterol Sulfate was observed on Resident #53 bedside table. On 1/10/ 24 at 11:35 a.m., in an interview Resident #53 said she put the Albuterol Sulfate in a locked box the day before after staff came in running in yesterday and told me to. On 1/11/2024 at 11:40 a.m., in an interview Resident #20 said the staff came in and took all the medications out of her room and put them in the medication cart. The bottle of (brand name) eye drops were still on the windowsill. She said, they must not have seen those. On 1/11/2024 at 3:00 p.m., in an interview the DON said she was made aware Residents #20 and #53 had unsecured medications at the bedside. She removed the medications from Resident #20's room and instructed Resident #53 to use a locked box. Facility policy for Medication Storage states Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with Florida Department of Health guidelines; With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy. 3. On 1/8/24 at 10:00 a.m., observed at bedside of Resident #40 two respiratory inhalers, Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol 160 mcg/ 4.5 mcg. In an interview, Resident #40 said, I have two, one is mine and one is from the facility. I take it 2 or 3 times a day. On 1/8/24 at1:30 p.m., observed Resident #40 respiratory inhalers continue on bedside table unsecured. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 22 of 30 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 01/11/2024 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 On 1/9/24 at 915 a.m., observed Resident #40 medication inhalers continue on bedside table unsecured. Level of Harm - Minimal harm or potential for actual harm On 1/9/24 at 3:45 p.m., Unit Manager Licensed Practical Nurse Staff A verified Resident #40 had two unsecured inhalers at the bedside. She said the resident should not have them. Residents Affected - Some 4. On 1/9/24 12:17 p.m., rounded with Resident #84 who said he has been waiting to see the dermatologist for a couple of months. Resident #84 said the Physician Assistant (PA) gave him some cream and he is going through a tube a day. Observed hydrocortisone 1% cream at bedside. The resident said they gave him the cream and he puts it all over his chest. On 1/9/24 at 3:15 p.m., during an interview Registered Nurse (RN) Staff L, assigned to Resident #84 verified Resident #84 had hydrocortisone 1% at the bedside. On 1/9/24 at 3:45 p.m., Unit Manager LPN Staff A verified the tube of Hydrocortisone 1% was unsecured at the resident's bedside. She said the resident should not have medications at the bedside. On 1/10/24 at 3:00 p.m., in an interview the Director of Nursing (DON) said Residents #40 and #84 should not have had the medications at their bedsides. Staff should have noticed them, and it is not acceptable. 2. On 1/9/24 at 8:52 a.m., Resident #86 was in bed and bed side table was out of reach against the wall. There was a pill cup on the table containing 6 unidentified medications. The resident did not answer questions. Photographic evidence obtained. On 1/9/23 at 8:55 a.m., in an interview Registered Nurse Staff R confirmed the pills were left at the bedside and said, I recognize these as his night time medications. Based on observations, staff and resident interviews and record review the facility failed to safely store medication in the facility for 6 (Resident #20, #40, #53, #84, #86, and #353) of 6 residents who had medication at bedside. The findings included: 1. Review of the clinical record revealed Resident #353 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Chronic Diastolic Congestive Heart Failure (CHF). The admission Minimum Data Set (MDS) with a target date of 12/29/23 revealed Resident #353 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The physician's orders included Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-5-25 micrograms (mcg) one puff orally one time a day, and Ventolin HFA inhalation Aerosol Solution 108(90 base) mcg/act (albuterol sulfate) two puffs orally twice a day related to chronic obstructive pulmonary disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 23 of 30 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 01/11/2024 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 On 1/9/24 at 3:10 p.m., two inhalers stored in a plastic container were observed at the resident's bedside. Level of Harm - Minimal harm or potential for actual harm Resident #353 stated in an interview that she kept her inhalers at the bedside because she needed them. She stated she has COPD and CHF. When she asks the nurses for the inhalers they might not have them, so she keeps them at her bedside. Residents Affected - Some On 1/11/24 at 1:34 p.m., Licensed Practical Nurse (LPN) Staff I stated the resident was alert and oriented and was able to administer her own inhalers since she did it at home. She stated she brings the inhalers to the resident who self-administers the medications. On 1/11/24 at 1:39 p.m., in an interview Registered Nurse Staff P stated the inhalers should be stored in a locked box. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 24 of 30 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 01/11/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/08/24 at 10:53 a.m., Resident #49 stated that the food delivered to her room is always cold. She said in the morning the eggs and pancakes are terrible when they are cold. She said she can barely eat them. She said that it happened every meal and she said they will heat it up but then it is rubbery. Residents Affected - Some During an interview on 1/09/24 at 9:14 am, Resident #49 was observed during breakfast. She stated her eggs were not warm again. During an interview on 1/09/24 at 8:50 Resident #353 stated that the food was not good, it lacked flavor and was often cold when it arrived to her room. Based on observations and staff and resident interviews, the facility failed to provide food that was palatable, attractive, and at an appetizing temperature as determined by the type of food to ensure resident's satisfaction for 8 of 22 residents reviewed, (Resident #76, #20, #34, #61,#53, #49, #353 and #77). The findings included: On 1/8/2024 at 12:00 p.m., in an interview with Resident #76, she said she had been a resident at the facility for approximately one year. She said the food was terrible and she never gets a Renal Diet. On 1/8/2024 at 12:45 p.m., in an interview with Resident #20, she said the food is so bad here she cancelled lunch and dinner service and provides her own food. On 1/9/2024 at 11:45 a.m., in an interview with Resident #34 and Resident #61who are roommates together, said the food is always cold and doesn't taste good except for once in a while. Resident #61 said she has been to the food committee meetings, but it seems like the complaints are not addressed. They are just told there is nothing they can do about it. On 1/9/2024 at 1:00 p.m., observed the lunch meal on the 200 hall. The Lunch meal consisted of three small Swedish meatballs on top of pasta noodles and a little sauce with carrots on the side. Most of the pasta noodles looked plain with no sauce. The food was served on a white plate and did not appear appetizing. On 1/9/2024 at 1:30 p.m., in an interview with Resident #53 who has been a resident for approximately three years, she said her food tastes average and is usually cold. She said it sits out on the corner in the cart for sometimes 20 minutes before the trays are distributed and that's one of the reasons the food is always cold. On 1/10/2024 at 10:45 a.m., in an interview with the Certified Dietary Manager (CDM), she said she attends the Food Committee meeting twice monthly. She provided the log for review. She said she and the Dietician sometimes complete audits for food temperature when delivered to floor. She admitted that food temperature had been an issue, but the food was hot when it leaves the kitchen. She said the reason the food gets cold is because it takes the Certified Nursing Aides (CNA) a long time to deliver the trays. She said she gives the completed audits to the Social Services Director. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 25 of 30 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 01/11/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm On 1/10/2024 at 11:45 a.m., in an interview with Resident #53, she said her hallway is the last to be served lunch trays and that 80% of the time the food is cold. She said the food just sits on the carts because the CNAs are too busy to deliver them. She also said that no one gets drinks until after all the trays are served. She said that the trays don't come with drinks and the staff have a drink cart to deliver drinks after all the trays are served. Residents Affected - Some On 1/11/2024 at 11:20 a.m., in an interview with Resident #76, she said she does not eat the food from here at all anymore. She eats cereal or has family bring her food from home because the food tastes so bad. On 1/11/2024 at 11:40 a.m., in an interview with Resident #20, she said she always has food she buys at the supermarket because the food here is so bad. She said they still send her a tray but she usually will only eat the fruit or snacks off of it. On 1/11/2024 at 12:00 p.m. in an interview with the Social Services Director, she said she gets the completed audits from the CDM but does not compile any information from it. She said she just adds the information to the grievance that was filed. The Food committee minutes were reviewed as provided from June 1, 2023, through October 20, 2023. The minutes documented attendees and issues the issues discussed. The issues discussed were vague with no implementation or documentation of resolutions. The facility grievance log was reviewed. Audits were completed for complaints of cold food on 8/20/2023, 9/13/2023, 9/22/2023, 9/26/2023, 10/5/2023 and 11/8/2023. On 1/11/2024 at 9:30 a.m., in an interview the Administrator said the kitchen is subcontracted. He said he had been aware of the cold food complaints but thought it was taken care of since they purchased new heated bases for the plates in September. He said the CDM had been performing audits of trays to determine temperatures based on grievances. On 1/8/24 at 10:40 a.m., in an interview Resident #77 said the food was institutional food did not taste good and was served cold. On 1/9/24 at 8:40 a.m., reviewed breakfast meal ticket with Resident #77. She said the western scrambled eggs did not taste good. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 26 of 30 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 01/11/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview and record review, the facility failed to provide beverages according to preferences for 3 (Residents #86, #19, and #17) of 11 sampled residents. Residents Affected - Some The findings included: On 1/8/24 at 12:28 p.m., during an observation of the noon meal in room tray pass the following was observed: There was a hydration cart provided that contained hot coffee, tea, and juices. Resident #86 received no liquids provided with the meal. The meal ticket specified 8 ounces (oz) of lemonade and 2 servings of the house shake (supplement provided for weight management). Registered Nurse Staff S verified the resident did not receive the liquids as specified on the meal ticket. Resident #19 received no liquids with the meal. The meal ticket specified 1 house shake, 4 oz of apple juice, and 6 oz of hot tea. Resident #17 received no liquids with her meal. The meal ticket specified 8 oz of chocolate milk 8 oz and 8 oz of iced tea. Resident #17 said I never get chocolate milk. The Unit Manager Staff A verified no liquids were provided for Resident # 17 and Resident #19. Staff A provided the liquids and went to the kitchen for the chocolate milk. Staff A returned and said there was no chocolate milk or house shakes available. Staff A was observed providing on the spot education to the Certified Nursing Assistants (CNAS) to read the meal tickets and provide the liquids specified. On 1/9/24 at 8:59 a.m., during an observation of the breakfast tray for Resident #17, did not have chocolate milk and the ticket was changed to milk 8 oz. Resident #17 said, I only drink chocolate milk. The meal ticket specified 4 oz of orange juice and 6 oz of coffee but the liquids were not on the tray. On 1/9/24 at 9:00 a.m., Resident #19 had 6 oz of hot tea on his tray. The meal ticket indicated he was to receive 4 oz orange juice and 4 oz of cranberry juice. On 1/9/24 Staff A confirmed the liquids specified for Residents #17 and #19 were not provided as specified on the meal tickets. Review of the Grievance log showed Resident #17 filed a grievance on 8/8/23, and 8/21/23 related to her dietary concerns. On 1/10/24 at 11:21 a.m., in an interview CNA Staff D said at meals if we are serving the trays, the CNA is responsible to read the ticket and put the liquids on the tray before you serve the residents in their rooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 27 of 30 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 01/11/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 1/10/24 at 12:00 p.m., in an interview with the Certified Dietary Manager, said the dietary staff were responsible for putting the supplements on the meal trays. They were to read the tickets and put the supplements on the tray. The kitchen provided fluid carts and the Certified Nursing Assistants were responsible to place the drinks on the trays. The CDM said the kitchen has been out of chocolate milk for about two weeks and could not provide any chocolate milk for Resident #17. Event ID: Facility ID: 105387 If continuation sheet Page 28 of 30 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 01/11/2024 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, staff interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in a safe and sanitary manner. Residents Affected - Many The findings included: Policy 027 dated 5/2014 with a revision date of 2017 for Equipment stated All food service equipment will be clean, sanitary, and in proper working order. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials; All staff members will be properly trained in the cleaning and maintenance of all equipment; All food contact equipment will be cleaned and sanitized after every use; All non-food contact equipment will be clean and free of debris; The dining services director will submit requests for maintenance or repair to the Administrator and or Maintenance Director as needed; Copies of service repairs and preventative maintenance reports will be submitted monthly. On 1/8/24 at 9:15 a.m., the Initial kitchen tour was conducted with the Certified Dietary Manager (CDM). Small appliances were dirty. Panini press had caked on food. Photographic evidence obtained. The CDM said it did't work and needed to be disposed of. Toaster over had caked on debris also. The CDM said it is scheduled to be cleaned every day. Iced tea machine also appeared dirty. *Photographic evidence obtained. The clean dish rack contained dirty appearing dishes and the dish rack was dirty. Photographic evidence obtained. The floor had a lot of debris and dust. Photographic evidence obtained. Cooking area observed. Old appearing dried pureed bread per CDM sitting by steamer and stovetop. Appliances dirty with caked on grease and grime. A Pot with butter sitting on stovetop appeared full of debris. Dirty ragged oven mitts sat on shelf by the oven. The stove and flat top were dirty with caked on food. The oven appeared dirty. Photographic evidence obtained. The ceiling tiles, sprinkler heads, lights, and vents over steam table were dusty, and had black biogrowth and debris. Photographic evidence obtained. The fans in the walk in refrigerator had black biogrowth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 29 of 30 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 01/11/2024 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 Photographic evidence obtained. Level of Harm - Minimal harm or potential for actual harm On 1/10/2024 at 10:25 a.m., in an interview with the Maintenance Director he said the maintenance department and the kitchen share the duties of cleaning the ceiling tiles. The kitchen puts in a work order for cleaning vents, sprinklers, etc. He said the kitchen ceiling was cleaned yesterday. He said maintenance had a monthly cleaning schedule. Residents Affected - Many On 1/10/2023 at 10:45 a.m., during a follow up kitchen tour the CDM said the kitchen staff were not responsible to clean the ceiling. she could not remember the last time the ceiling was cleaned. She said she usually tells the Maintenance Director but does not keep any documentation. She said a couple of kitchen had not been doing their part to maintain the cleanliness in the kitchen. On 1/11/2024 at 9:30 a.m., in an interview the Administrator said the kitchen was subcontracted. He said he makes rounds through the kitchen every Monday and Keeps a monthly walk-through log that he discusses with the CDM. After reviewing the photographice evidence obtained, the Administrator said, 'The kitchen needs cleaning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105387 If continuation sheet Page 30 of 30