Inspection·July 8, 2024

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, record review, residents and staff interviews, the facility failed to provide timely assistance with dining for 2 (Residents #2 and #3) of 3 sampled dependent residents reviewed for dining services. Residents Affected - Few The findings included: Review of the clinical record for Resident #2 revealed an admission date of 5/28/24. Diagnoses included Parkinson's Disease (a disorder of the central nervous system that affects movement). The admission Minimum Data Set (MDS) assessment with a target date of 5/29/24 noted Resident #2 required partial to moderate assistance to go from a lying to sitting position and supervision or touching assistance with eating (The helper provides verbal cues or touching/steadying assistance as the resident completes the activity). Resident #2's cognition was intact with a Brief Interview for Mental Status score of 13. On 7/8/2024 at 8:15 a.m., Resident #2 was observed lying supine in a low bed, eyes closed. A breakfast tray was observed on an over the bed table to the right side of the bed. The over the bed table was in a high position and not within reach of the resident. Review of the clinical record for Resident #3 revealed an admission date of 5/28/24 with a diagnosis of malignant neoplasm (cancer). The admission Minimum Data Set (MDS) assessment with a target date of 6/4/2024 noted Resident #3's cognition was intact with a Brief Interview for Mental Status score of 15. Resident #3 required partial to moderate assistance from lying to sitting on the side of the bed, and setup or clean up assistance with eating (Helper sets up or cleans up). On 7/8/24 at 8:15 a.m., Resident #3 was observed lying supine in bed on a low bed. A breakfast tray was observed on the over the bed table to the side of the resident's bed. The over the bed table and breakfast tray were not within reach of the resident. Resident #3 asked for the orange juice on the tray. On 7/8/2024 at 8:24 a.m., Certified Nursing Assistant (CNA) Staff C was observed going in Resident #3's room. In an interview, Staff C verified the breakfast tray was not within Resident #3's reach. She said she delivers all the meal trays to the rooms, then comes back to assist the residents who need set up or feeding assistance. She stated, I leave it on the over bed table and leave it out of reach until I come back in to feed her. I need to pass all the other trays first. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105387 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 07/08/2024 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)