Inspection·April 30, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policies and procedures and staff interviews, the facility failed to protect the resident's rights to be free from neglect by failing to follow safety precautions specified in the care plan to prevent avoidable accident with injury for 1 (Resident #1) of 3 dependent residents reviewed. The findings included: Review of facility Policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injury of unknown source and Investigations, effective date 4/01/22 revealed neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of facility Policy titled Nursing - Activities of Daily Living (ADL's), effective date 4/01/22 revealed its primary goal is to ensure all resident's needs are met in a manner that promotes their quality of life and preference. (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. Review of medical records revealed Resident #1 was admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease (a progressive neurodegenerative disorder that primary affects the brain, causing a gradual decline in memory, symptoms affecting memory, thinking and social abilities), anxiety disorder (feeling of fear, dread or uneasiness), and major depressive disorder (persistent feelings of sadness or hopelessness). The admission Minimum Data Set (MDS) with a target date of 4/23/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. Review of Care Plan dated 3/8/23 revealed Resident #1 has an ADL self-care performance deficit related to Alzheimer's Disease. Resident #1 was weak with impaired balance and mobility. Interventions included Resident #1 was dependent on staff for ADL's and required substantial/maximum assistance of two staff with bed mobility (changing positions while in bed). Review of [NAME] (an electronic system used to summarize resident information) revealed Resident #1 required substantial/maximum assistance of two staff with bed mobility. Review of incident note dated 4/6/25 revealed that Certified Nursing Assistant (CNA) Staff A was (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 4 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 04/30/2025 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)