Inspection·February 26, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #318 started crying and said she didn't want to use a diaper like a baby, I am an adult. Resident #318 said during the overnight hours she sometimes did not bother requesting assistance since they do not come and knows the staff won't help her but will encourage her to go in the incontinent brief. On 2/23/21 at 3:05 p.m., in an interview PT Staff O said when he went to get Resident #318 for therapy this morning she said she was in a dirty diaper and needed to use the bathroom to be cleaned up before therapy. PT Staff O confirmed Resident #318 raised the concern to him regarding the staff not helping her to the bathroom. PT Staff O confirmed Resident #318 told him using a diaper makes her feel like a baby. On 2/24/21 at 9:54 a.m., in an interview Certified Nursing Assistant (CNA) Staff V said resident #318 was very alert and able to call for help to use the bathroom when needed. CNA Staff V said Resident #318 was not on a bowel or bladder retraining program. She said residents are offered toileting assistance every 2 hours. 2. Clinical record review revealed Resident #116 was admitted to the facility on [DATE]. The MDS admission assessment with a target date of 2/4/21 indicated it was very important for the resident to choose what clothes to wear and take care of his personal belongings or things. Review of the inventory of personal effects dated 1/30/21 showed Resident #116 had one T shirt, one jacket, one pair of shorts and one pair of underpants. On 1/31/21 additional items including three shirts, two briefs, two shorts were inventoried. On 2/1/21 the facility added one shirt, one sweater and one short to the inventory of personal effects. On 2/23/21 at 11:12 a.m., in an interview Resident #116 said his son brought him clothes weeks ago. He said he asked many times, but no one gave him his clothes. On 2/24/21 at 11:37 a.m., in an interview Resident #116 said he had no idea where his clothes were. He said when he asks for his clothes, staff ignore him. On 2/24/21 at 3:25 p.m., in an interview Registered Nurse (RN) Staff D said he was not aware Resident #116 had additional clothing items. On 2/25/21 at 9:14 a.m., in an interview Resident #116 said he still did not have his clothes. He said he asked staff for his clothes again and no one addressed it. On 2/26/21 at 9:35 a.m., Resident #116 said he was being discharged at 10:30 a.m., but they still had not given him his clothes. On 2/26/21 at 11:29 a.m., in an interview the East Unit Manager RN Staff S said she assisted RN Staff D with Resident #116's discharge. She said a certified nursing assistant (CNA) escorted Resident #116 out of the facility with about 3 bags of clothes. RN Staff S said they don't document that, and he didn't sign his inventory sheet. On 2/26/21 at 11:38 a.m., in a telephone interview Resident #116 said when they came to discharge him, a CNA brought in some bags of clothes but not all the clothes were his. He got some of his clothes, but not all of them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 2 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 2/26/21 at 3:05 p.m., in an interview the Housekeeping Director said when family brings clothes into the facility, the receptionist at the front desk inventories them. The clothes are then sent to laundry services to be labeled and then taken to the resident's room. The Housekeeping Director said Resident #116's clothes had been stored in the laundry room since the beginning of the month when they were brought into the facility. She said she found out the day before (2/25/21) Resident #116's clothes were mislabeled. She said she took Resident #116's clothes to him this morning before his discharge. Event ID: Facility ID: 105427 If continuation sheet Page 3 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews the facility failed to ensure they considered the views of Resident Council and act promptly upon their grievances, concerns, and recommendations for 7 (8/2020, 9/2020, 10/2020, 11/2020, 12/2020, 1/2021 and 2/2021) of 7 months reviewed. Residents Affected - Some The findings included: On [DATE] at 3:50 p.m., the Director of Activity (DOA) said because of Coronavirus Disease 2019 (COVID-19) and the death of the Resident Council President, the facility residents elected Resident #16 as the Interim Resident Council President (IRCP) in the [DATE] resident council meeting. Since the facility stopped all group meetings, they determined Resident #16 would be the representative for all the residents in the monthly resident council meetings starting [DATE]. The DOA said Resident #16 talked with most of the residents in the facility and when they had the monthly resident council meeting, he voiced all the residents' concerns and grievances for that month. On [DATE] at 10:05 a.m., Resident #43 said Resident #16 is the IRCP and the residents tell him all their concerns, grievances, and recommendations. She has told the IRCP and facility staff over the past 5 to 6 months her room floor was sticky, and her wheelchair was dirty and not being cleaned. She also said she told the IRCP sometimes the meals arrived cold and she did not always get her clothes back from laundry. On [DATE] at 10:30 a.m., Resident #16 said he became the IRCP in [DATE] after the Resident Council President died. He said the facility told him he would be the voice for the facility residents and every month the DOA would do a monthly resident council meeting with him. He said over the past few months he had expressed to the DOA in the resident council meetings and the Administrator (AD) during his weekly routine rounds, all the concerns, grievances, and recommendations the facility residents had told him during the month. He said residents told him their rooms and wheelchair were not cleaned on a routine basis, laundry did not always return their clothes, staff was slow answering call lights and meals were cold when delivered to the residents' rooms. He said he asked the DOA and AD several months ago if the residents could start having resident council meetings outside while practicing social distancing but as of this time neither the DOA and AD had gotten back to him related to any of his concerns, grievances or recommendations. On [DATE] review of the Resident Council Minutes dated [DATE], [DATE] and [DATE] noted the minutes were divided into sections that covered the Nursing department, Dietary department, Maintenance department, Housekeeping/Laundry, Activity department and Other Discussions. The minutes revealed the residents had multiple areas of concerns, grievances, and recommendations which the facility addressed at that time. Resident #16 was elected as the Interim Resident Council President in the [DATE] resident council meeting. Review of the Resident Council Minutes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] revealed it had 2 sections, the first section talked about COVID-19 testing and monitoring of all residents and staff were ongoing and the second section said the activity department was ongoing. The resident council minutes from [DATE] to [DATE] did not note any of the facility residents' concerns, grievances and/or recommendations. On [DATE] at 11:44 a.m., in an interview the Administrator said Resident #16 has been the IRCP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 4 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete since [DATE]. He confirmed Resident #16 had talked with him during his routine weekly rounds related to concerns and recommendations he had as the facility IRCP. He said if he thought the concerns and recommendations were true grievances, he would have filled out a grievance form. The AD said he did not document any of the IRCP concerns or recommendations. On [DATE] at 4:26 p.m., the DOA said the IRCP had spoken to her related to some concerns and recommendations over the past several months but did not document them on the resident council meeting minutes. She confirmed the resident council meeting minutes reviewed from [DATE] to [DATE] noted she talked with the IRCP about COVID-19 testing and monitoring and the activity program was ongoing but didn't note any concerns or recommendations mentioned by the IRCP. Event ID: Facility ID: 105427 If continuation sheet Page 5 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 - Some 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 interview and staff and resident interviews the facility the facility failed to ensure 10 (#43, #12, #23, #97, #9, #95, #90, #113, #40 and #98) of 14 resident's wheelchairs were clean and kept in a sanitary condition to prevent the spread of disease-causing organisms. The findings included: 1. On 2/22/21 at 9:49 a.m., Resident #43 said the housekeeping staff did not always mop her floor causing it to be sticky. She further said her wheelchair had not been cleaned in the past several months and the wheelchair was very dusty and sticky. Observation of Resident #43's wheelchair noted a thick layer of dust on the frame of the wheelchair. 2. On 2/22/21 at 10:06 a.m., observation of Resident #12's wheelchair revealed a thick layer of dust and dried food on the frame of the wheelchair. Resident #12 said his wheelchair had not been cleaned in a long time even though he had asked staff several times to clean his wheelchair. 3. On 2/25/21 at 9:25 a.m., observation of Resident #23 and Resident #97's wheelchairs revealed a thick layer of dust on the frames of their wheelchairs. Resident #97 said he had not seen the facility staff clean their wheelchairs in the past several months. 4. On 2/25/21 at 9:45 a.m., observation of Resident #9's wheelchair revealed a thick layer of dust on the frame of her wheelchair. Resident #9 said the facility had not cleaned her wheelchair in the past several months. 5. On 2/25/21 at 9:53 a.m., observation of Resident #95's wheelchair revealed a thick layer of dust on the frame of their wheelchair. 6. On 2/25/21 at 9:55 a.m., observation of Resident #90's wheelchair revealed a thick layer of dust on the frame of his wheelchair. Resident #90 said the facility had not cleaned his wheelchair in the past several months. 7. On 2/25/21 at 10:01 a.m., observation of Resident #113's wheelchair revealed a thick layer of dust on the wheelchair. 8. On 2/25/21 at 10:08 a.m., observation of Resident #40 and Resident #98's wheelchairs revealed a thick layer of dust on their wheelchairs. Resident #98 said the facility had not cleaned his wheelchair since his admission to the facility several weeks ago. 9. On 2/25/21 at 3:46 p.m., the Housekeeping/Laundry Director (HLD) said the Housekeeping Department was responsible to clean the entire facility to include all resident's wheelchairs. She said every 2 weeks all wheelchairs in the facility were taken out to the courtyard where they were washed/cleaned and scrubbed with a brush to remove the dust and grime which builds up on the wheelchairs over time. She said this was the week all the wheelchairs in the facility would be cleaned/washed. On Monday (2/22/21) all the wheelchairs on the 100 hallway and part of the 300 hallway were washed, Tuesday (2/23/21) all the wheelchairs on the 200 hallway, and on Wednesday (2/24/21) all the wheelchairs on the 400 hallway to include the rest of the 300 hallway were washed. Thursday (2/25/21) the wheelchairs on the back end of the 200 hallway, rooms 217 to 228 will be washed and then they will repeat (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 6 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 - Some the same schedule in 2 weeks. She said she did not keep any paperwork on what wheelchairs were completed but was positive all the wheelchairs were cleaned this week as required. 10. On 2/25/21 at 4:00 p.m., a tour of the facility was conducted with the HLD and we inspected Residents #43, #12, #23, #97, #9, #95, #90, #113, #40 and #98's wheelchairs. She confirmed all 10 wheelchairs we reviewed had a thick layer of dust on the frame, wheels, and the brakes. She stated it appeared the wheelchairs had not been washed/cleaned in several weeks. She said the pressure washer had been broken for a long time and the staff were required to use the scrub brush to clean all parts of the wheelchairs to include the frame, brakes, and wheels. She confirmed the 10 wheelchairs we reviewed were not washed/cleaned as required. She said she didn't have any documentation/paperwork stating the last time all the wheelchairs in the facility were washed/cleaned by the housekeeping department on a 2-week rotation. 11. On 2/25/21 at 5:50 p.m., the Administrator said all the wheelchairs in the facility are pressure washed every 2 weeks. He said he was unaware the pressure washer was broken, and the housekeeping staff were not using the pressure washer to clean the resident's wheelchair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 7 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, resident and staff interview, the facility failed to accommodate the food allergies and offer appropriate alternative for 1 (Resident #28) of 3 residents reviewed for food allergies, intolerances, and preferences. The findings included: Review of the clinical record revealed a Patient demographic form from a local hospital printed on 2/9/21 with documentation Resident #28's had an allergy to tea. The reactions to the tea were hives and itching. Review of the progress notes revealed on 10/6/20 the advanced practice registered nurse (APRN) documented Resident #28 was allergic to tea. On 2/23/21 at 3:03 p.m., in an interview Resident #28 said he was given iced tea daily. Resident #28 said he was allergic to tea, it caused him to itch. On 2/23/21 at 3:04 p.m., in an interview resident #93 (Resident #28's roommate) said he had heard Resident #28 tell staff he was allergic to tea. He said Resident #28 was only given options if he raises hell. On 2/24/21 at 12:07 p.m., Resident #28 was observed having lunch. He exclaimed they did it again. He pointed to the cup of liquid on his tray and said it was iced tea. On 2/24/21 at 12:15 p.m., Resident #28's lunch tray was observed with Registered Nurse (RN) Staff D. RN Staff D said all drinks come from the kitchen, he could not speculate what drink was served on the lunch tray. On 2/24/21 at 12:24 p.m., Dietary Aide Staff U said iced tea was on the lunch trays. She said all lunch trays were served with iced tea. On 2/24/21 at 12:41 p.m., the Dietary Director said iced tea was the house beverage and all residents received iced tea if they didn't request otherwise. On 2/24/21 at 1:36 p.m., the Dietary Director said he and Registered Dietician dealt with food allergies. The process was to identify an allergy and add the allergy to the resident's meal ticket. On 2/25/21 at 8:26 a.m., the Dietary Director said he was familiar with Resident #28 and believed he had an allergy to tea. He said he believed his staff were placing tea on Resident #28's tray because there was no other beverage selected. The Dietary Director said he would speak with Resident #28 to discuss his preferences and alternatives to the tea. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 8 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE] revealed the resident had one stage 3 (partial thickness skin injury) and two stage 4 (full thickness skin injury) pressure injuries. The MDS noted the pressure injuries were all present on admission. A review of Resident #2's Wound Care Assessment/Consultation forms for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] noted the wounds were not present on admission. On [DATE] at 10:20 a.m., in an interview RN Staff N said the physician incorrectly filled out the wound care notes from [DATE] through [DATE]. The resident was sent to the hospital and was readmitted with the wounds in October of 2020. On [DATE] at 10:23 a.m., in an interview Resident #2's physician said the wound care notes were not documented correctly. 3. A review of the resident record for Resident #59 revealed missing or incomplete vital sign entries for [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] resident did not have documentation of administration for 2 doses of intravenous fluids for abnormal labs. No behavior monitoring, barrier cream treatment, and skin prep treatment to heels were documented for the evening of [DATE]. The resident record did not note Resident #59 was out of the facility on these dates. Based on record review and interview the facility failed to maintain complete and accurately documented medical records for 5 (Resident #2, #30, #40, #59, and #122) of 27 residents records reviewed. Accurate and complete records are necessary to document the course of a resident's care provided by the facility. The findings included: Review of the facility's policy (CN-3) with a revision date of 2/2019 revealed pertinent information should be documented in the individual's record in an accurate, timely, and legible manner. 1. On [DATE] at 8:49 a.m., review of the clinical record for Resident #30 showed multiple missing documentation on the Treatment Administration Record (TAR) for [DATE]. Resident #30 had a daily wound care order with Bactroban ointment 2% to the left and right buttock on the day shift. The treatment was not recorded on the TAR [DATE] through [DATE]. Resident #30 also had daily wound care orders with Santyl ointment to the right buttock. The treatment was not recorded on the TAR [DATE] through [DATE]. On [DATE] at 9:56 a.m., in an interview Licensed Practical Nurse (LPN) Staff G said when you are done the treatment, you check the box. If you don't check the box, you haven't done the treatment. I don't know why those aren't done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 9 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. On [DATE] clinical record review showed Resident #40 was medicated with Ativan 1 milligram (mg) intramuscularly for anxiety on [DATE] at 3:53 p.m., 2/8 at 7:40 p.m., [DATE] at 12:30 a.m., [DATE] at 9:17 p.m., [DATE] at 09:37 a.m., [DATE] at 12:00 a.m., and [DATE] at 07:26 a.m. On [DATE] at 9:32 a.m., in an interview Licensed Practical Nurse (LPN) Staff J said Resident #40 sometimes is aggressive, yelling and can occasionally hit. Staff J said, the behavior was worse when Resident #40 was up in the wheelchair. LPN Staff J said staff document aggressive behaviors on the Treatment Administration Record (TAR) in the behavior monitoring section each time the Ativan is administered. On [DATE] at 10:27 a.m., review of the treatment administration record (TAR) for resident #40 showed a behavior monitoring guide used to document the behaviors, interventions, outcome, and side effects of the Ativan use. The behavior monitoring guide did not document the behavior for the Ativan administered on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 5. Review of the clinical record for Resident #122 revealed the resident expired at the facility on [DATE]. The death record document dated [DATE] at 2:30 p.m., did not note the time of death, the time the physician was notified; the time the funeral home was notified. The form did not note the name of Funeral Home Personnel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 10 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety Based on observation, policy review and staff interview, the facility failed to follow the manufacturer's specification to clean and disinfect multiuse Evencare G3 blood glucose meters for 5 (Residents #16, #24, #63, #116 and #371) of 5 residents observed with a physician's order for blood glucose monitoring (test that measures the amount of sugar in the blood). Residents Affected - Some The facility failed to apply the disinfectant necessary for the minimum wet contact time per manufacturer's instructions to kill bloodborne pathogens on shared multiuse blood glucose meters. Inadequate disinfection may result in indirect contact transmission (the transfer of an infectious agent through a contaminated inanimate object) of pathogens through the improperly disinfected glucometers. The facility had a total of 12 blood glucose meters used for 42 diabetic residents with orders for blood glucose checks. The failure to properly disinfect the blood glucose meters used for multiple residents resulted in a pattern of noncompliance at Immediate Jeopardy (IJ), scope and severity of K starting on 2/23/21. The Administrator was notified of the IJ on 2/25/21 at 7:20 p.m. The Immediate Jeopardy was removed on 2/26/21 at 4:22 p.m., and the scope and severity lowered to E after the facility provided an acceptable removal plan. The findings included: According to the Journal of Diabetes Science and Technology (March 2009, Volume 3, Issue 2): Finger-stick devices, blood glucose testing meters, or even a health care worker's hands may all become vehicles for indirect transmission of viruses if they become contaminated with blood. Since Hepatitis B Virus (HBV) is highly infectious and environmentally stable, even invisible amounts of blood are sufficient to spread infection. According to the Food and Drug Administration (Content current as of 12/27/2017): For blood glucose meters, the primary viruses of concern for bloodborne pathogen transmission between multiple patients are Human Immunodeficiency Virus (HIV), HBV, and Hepatitis C Virus (HCV). However, due to its robust nature, HBV is the most common virus in the observed outbreaks to date. Therefore, Blood Glucose Monitoring System sponsors should demonstrate that their disinfection protocol is effective against human Hepatitis B Virus. Studies have demonstrated that viruses can remain infective on surfaces for different time periods. The disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. The Food and Drug Administration, https://www.fda.gov/medical-devices/vitro-diagnostics/letter-manufacturers-blood-glucose-monitoring-systems-listed-fda, accessed on 2/25/21. According to the Centers for Disease Control and Prevention: Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put persons at risk for infection include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 11 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 0880 . Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses. [Blood glucose meters are devices that measure blood glucose levels.] . Level of Harm - Immediate jeopardy to resident health or safety .Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. Residents Affected - Some .If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. The Centers for Disease Control and Prevention, https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html, accessed on 2/25/21. Review of facility's policy titled Blood glucose monitoring, last revised September 2020 read . Clean and disinfect blood glucose meter after each use according to manufacturer's specifications. (See Cleaning of Glucose Monitoring Device Policy) . Train the licensed staff on the use of the glucose monitors and cleaning process. The facility's policy and procedure titled Blood Glucose Monitor/Prothrombin Time Meter Cleaning and Disinfecting last revised on September 2020 read . Remove a disposable disinfectant wipe from the storage container. Clean the outside of the meter with a disposable disinfectant wipe. Avoid coming in contact with the electronic components and/or strip insertion area. Follow manufacturer's label regarding time disinfectant must remain in contact with meter (visibly wet) for effectiveness. Place meter on protective surface/towel/paper towel and allow the meter to air dry. On 2/22/21 at 4:40 p,m., in an interview the Director of Nursing (DON) said the facility uses the Evencare G3 glucometer and the Micro-Kill Bleach wipes to disinfect the blood glucose meters. The Evencare G3 user manual procedure for disinfecting the Evencare G3 meter read Clean the meter with a disinfecting wipe. All external areas of the meter including both front and back surfaces until visibly wet. Allow the surface of the meter to remain wet at room temperature for the contact time/kill time listed on the canister. Then wipe meter or allow to air dry . The Micro-Kill Bleach germicidal bleach wipes directions for use read In health care settings or other settings in which there is an expected likelihood of soiling of inanimate surfaces/objects likely to be soiled with blood/body fluids can be associated with the potential for transmission of HIV-1 (associated with AIDS), HBV (Hepatitis B virus) and HCV (Hepatitis C virus) . Special instructions for cleaning and decontamination against HIV-1, HBV, and HCV on surfaces/objects soiled with blood/body fluids . Allow surface(s) to remain wet for 30 seconds to kill all of the bacteria and viruses . Photographic evidence obtained. 1. On 2/23/21 at 3:38 p.m., Licensed Practical Nurse (LPN) Staff C (training with Registered Nurse Staff E) was observed doing a blood glucose check for Resident #24. LPN Staff C and Registered Nurse (RN) Staff E performed a fingerstick, used the blood glucose meter and left Resident #24's room at 3:40 p.m. LPN Staff C used a Micro-Kill bleach wipe, wiped the blood glucose meter for 6 seconds and placed it on a Styrofoam tray. Continued observation of the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. Staff C did not reapply the Micro-Kill wipe to ensure a 30 seconds wet contact time as per the manufacturer's specification. On 2/23/21 at 3:44 p.m., observed LPN Staff C preparing to perform the next blood sugar check. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 12 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 0880 said since the blood glucose meter had been drying three minutes, I can check the next blood sugar. Level of Harm - Immediate jeopardy to resident health or safety On 2/23/21 at 3:55 p.m., LPN Staff A was observed removing a blood glucose meter from a plastic bag. She wiped the meter for 5 seconds with a Micro-Kill bleach wipe placed it on the medication cart. LPN Staff A said, and dry to 3 minutes. Continued observation of the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. The nurse did not reapply the Micro-Kill bleach disinfectant to the blood glucose meter to ensure a 30 seconds wet contact time as per the manufacturer's specification. Residents Affected - Some 2. On 2/23/21 at 4:00 p.m., LPN Staff A was observed doing a blood sugar check for Resident #371. LPN Staff A performed a fingerstick, used the blood glucose meter and left the resident's room at 4:02 p.m. LPN Staff A wiped the blood glucose meter with a Micro-Kill bleach wipe for 10 seconds and placed the meter on the medication cart. Continued observation of the meter from the time the nurse started to wipe the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. LPN Staff A made no attempt made to reapply the Micro-Kill bleach wipe to the glucometer to ensure a 30 seconds wet contact time as per the manufacturer's specification to ensure proper disinfection. On 2/24/21 at 9:49 a.m., in an interview Registered Nurse (RN) Staff B said she was assigned to 2 diabetic residents receiving blood sugar checks. She said she cleans the blood glucose meter between residents. She said the process was to wipe the glucometer and let air dry for 30 seconds to 3 minutes. She said to ensure the meter is really clean she lets it dry the longer time. 3. On 2/24/21 at 11:32 a.m., RN Staff D was observed doing a blood sugar check on Resident #116. RN Staff D performed a fingerstick, used to blood glucose meter and left the resident's room at 11:39 a.m. RN Staff D wiped the blood glucose meter for 6 seconds with a Micro-Kill bleach wipe and placed it on the medication cart. Continued observation of the meter from the time the nurse wiped the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. Staff D made no additional attempts to reapply the Micro-Kill bleach wipe to ensure a wet contact time of 30 seconds to properly disinfect the glucometer. 4. On 2/24/21 at 11:55 a.m., RN Staff B was observed doing a blood sugar check for Resident #63. She left the resident's room at 11:58 a.m. She wiped the glucometer for 8 seconds with a Micro-Kill bleach wipe. Continued observation of the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. RN Staff B made no attempt to reapply the Micro-Kill bleach disinfectant to ensure a 30 seconds contact time to disinfect the meter. 5. On 2/25/21 at 4:39 p.m., LPN Staff F was observed performing a blood sugar via fingerstick for Resident #16 (dialysis resident). After performing the blood sugar, she donned a pair of gloves and wiped the blood glucose meter for 5 seconds with a Micro-Kill bleach wipe. She placed the meter on a Styrofoam tray on the medication cart. She said she would allow it to air dry for 2 minutes. Continued observation of the meter from the time the nurse started to wipe the meter revealed the meter progressively drying. The meter was completely dry at 20 seconds. LPN Staff F said she alternates the use of both blood glucose meters on the medication cart. She said she usually lets the meters dry for 2 minutes except when the resident has an infection such as C-diff (infection that causes severe diarrhea). In that case she lets the meter dry longer. 6. On 2/25/21 at 3:50 p.m., the Nurse Educator said she has been employed at the facility since 8/1/19. She described the process to disinfect the blood glucose meters as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 13 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 0880 Pull a wipe out of the tub. Make sure to wipe the whole glucometer. Don't get any water on the port. Wipe the glucometer and then put it on the Styrofoam tray to dry. Level of Harm - Immediate jeopardy to resident health or safety The Nurse Educator said, the contact time is the time you allow the glucometer to dry to kill the pathogens. Residents Affected - Some The Nurse Educator said she routinely conducts audits of the nurses disinfecting the blood glucose meters but she did not have a piece of paper to show. The Nurse Educator said the CDC (Centers for Disease Control and Prevention) says the contact time is the time to allow the glucometer [also known as glucose meter] to dry. The Nurse Educator provided a competency (not dated) titled Disinfecting of blood glucose testing machine which she said she used to teach the licensed nurses. It read .To disinfect the meter, use Germicidal Cloth. Remove wipe from container and thoroughly wipe down the meter. Allow the meter to dry for at least one (1) to five (5) minutes to gain full benefit of the disinfecting. Note: If the wipe is very saturated (wet), squeeze or gently wring excess liquid before use. *CLEAN and disinfect daily between patient use. The education did not address the wet contact time for proper disinfection of the glucometers. 7. On 2/25/21 at 4:00 p.m., the DON who was present during the interview said, The nurses are basically doing it the way they were instructed to. The Immediate Jeopardy was removed on 2/26/21 at 4:22 p.m., and the scope and severity lowered to E after verification the facility completed a removal plan which included: All facility glucometers were disinfected according to manufacturer's specification on 2/25/21. Documentation that 32 licensed nurses were educated and demonstrated competency on proper disinfection of the glucometers on 2/26/21. Documentation of an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting on 2/25/21 to develop a new competency checklist that specified To disinfect the meter: Use Germicidal Cloth to wipe down the meter, then wrap the meter in the Germicidal cloth. Allow the surface of the meter to remain wet at room temperature for 3 minutes or reference the manufacturer recommended time. Observation on 2/26/21 of 6 licensed nurses, including the Staff Educator disinfecting the blood glucose meters according to manufacturer's specification of wet contact time to ensure disinfection of the shared blood glucose meters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 14 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation and residents and staff interview the facility failed to ensure 4 (Residents #44, #34, #90 and #49) out of 10 siderails checked out of a possible 129 bed with siderails installed were in safe operating condition at all times. The findings include: 1. On 2/25/21 at 9:00 a.m. revealed Resident #49 has 2-upper quarter siderails attached to her bed. Resident #49 said all the residents are required to have siderails/bedrails on their bed. She said she uses the 2-upper quarter siderails to assist her in repositioning herself in bed but due to them being loose she is scared they might break if she pulls to hard. She said she has asked the nurses and housekeeper staff several times if someone could ask the maintenance department to tighten the siderails to her bed but as of this time no one has tighten the siderails as requested. 2. On 2/25/21 at 9:19 a.m. revealed Resident #44 has 2-upper quarter siderails attached to his bed. The left upper siderail is leaning on the mattress and the right upper siderail is loosely attached to the bed. 3. On 2/25/21 at 9:35 a.m. revealed Resident #34 has 2-upper quarter siderails attached to her bed. The left upper siderail is leaning on the mattress and the right upper siderail is loosely attached to the bed. 4. On 2/25/21 at 9:55 a.m. revealed Resident #90 has 2-upper quarter siderails attached to his bed. Resident #90 said both his siderails are very loose and he is worried they are a potential safety hazard. He said he has asked multiple staff if they could tighten the siderails to the bed but no one at this time has tighten his siderails to his bed as requested. 5. On 2/25/21 at 10:16 a.m. the Maintenance Director (MD) said his department is responsible to ensure all facility and resident equipment are always in good working order and the equipment remain safe for resident use. He said siderails/bedrails, and bed enablers were all considered critical resident equipment which have to remain in good working order at all times due to the potential safety and entrapment hazards. He said all staff are required if they note any facility or resident equipment not in good working order and/or not safe for resident or staff use to create a work order in the TELS system on the computer. He reviews the TELS computer program daily and prioritize all workorders by severity. Siderails/bedrails and bed enablers are a high priority due to the risk/hazard they represent to the residents. He said due to the risk of resident entrapment, the resident's siderails/bedrails and bed enablers are checked twice yearly to ensure they are safe for resident use. He said the last time he checked all the beds with siderail/bedrails in the facility was 12/29/20. He said since there were 129 beds in the facility with siderails/bedrails or bed enablers he relied on the facility staff to inform him and/or document in the TELS system if a siderails becomes unsafe and/or is a hazard to the residents. The Maintenance Director said the facility had multiple types of siderails/bedrails in the facility, he thought they have 3 to 4 different types of siderails/bedrails in the facility. The Maintenance Director said he did not have the manufacturer's recommendation and specifications for installing and maintaining the siderail/bedrails for the multiple different types of siderail/bedrails in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 15 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 0909 facility. Level of Harm - Minimal harm or potential for actual harm On 2/25/21 at 10:35 a.m., the Maintenance Director confirmed Residents #49, #44, #34 and #90 siderails were loose and were a potential safety hazard to the residents. He said the staff did not create a work order in the TELS system about the loose siderails as required and he was unaware Residents #49, #44, #34 and #90 were loose and needed to be repaired. Residents Affected - Some 6. On 2/25/21 at 4:50 p.m., the Maintenance Director said he did an audit of all the beds with siderails in the facility and it appeared there were 7 different types of siderails/bedrails or bed enablers in the facility. He said he did not have the manufacturer's recommendation and specifications for installing and maintaining the siderails/bedrails or bed enablers in the facility at this time. 7. On 2/25/21 at 5:15 p.m., the Administrator said the Maintenance Director did an audit of all the beds with siderails in the facility and they have 5 different types of siderails in the facility at this time. He confirmed the staff are required to inform the Maintenance Director and create a work order in the TELS computer program of all loose or malfunctioning siderails to ensure the siderails/bedrails or bed enablers remain safe for the residents use at all time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 16 of 17 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 105427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Myers Rehabilitation and Nursing Center 7173 Cypress Drive SW Fort Myers, FL 33907 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 0917 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. Based on observation, resident and staff interview, the facility failed to provide private closet space for 2 (Resident #94 and #116) of 2 residents reviewed for physical environment. The failure to provide private closet space inhibits the ability to protect personal effects from casual access by others and allow items to remain clean and accessible to residents. The finding included: 1. Observation on 2/24/21 at 11:37 a.m., revealed Resident #94 and Resident #116 shared a room. The room had one dresser but no private closet space. Resident #94's personal items, including incontinence care items, were observed stacked on a chair in the corner of the room and on the floor. The same observation was made on 2/25/21 at 9:14 a.m. Resident #116 said the facility had not given him his clothes, but he would have nowhere to put them if they did. 2. On 2/25/21 at 9:26 a.m., the Maintenance Director said there were no work orders for closets for the shared room for Resident #94 and Resident #116. He acknowledged the double occupancy room had no closet or armoire with individual closet space with clothes racks and shelves. On 2/26/21 at 12:43 p.m., the Maintenance Director said he is the one responsible for ensuring residents have closets. He said sometimes he just puts something in the middle of the room, so they have something to put something in. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 17 of 17