Inspection·August 18, 2022

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, record review and resident and staff interviews, the facility failed to implement adequate supervision for 1(Resident #78) of 19 residents reviewed with known unsafe wandering behaviors. The findings included: Review of the clinical record for Resident #78 revealed an admission date of 7/15/22 with diagnoses including altered mental status, and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #78 scored a 10 on the Brief Interview for Mental Status, indicative of moderately impaired cognition. On 7/28/22 the psychiatric Advanced Practice Registered Nurse (APRN) documented Resident #78 had poor insight or judgement, was constantly pacing the halls, and had significant cognitive processing deficits. The APRN ordered to start Xanax 0.25 mg twice a day, and Xanax 0.25 milligram (mg) every two hours as needed for anxiety. On 8/5/22 at 9:57 p.m., the psychiatric APRN documented Resident #78 was very agitated, exit seeking, not responding to the current medication regimen. The APRN ordered to administer Ativan (medication that acts on the brain and nerves to produce a calming effect) intramuscularly (IM) as needed for 14 days. On 8/11/22 at 9:24 a.m., the psychiatric APRN documented Resident #78 overall was restless, behavioral sundowning (worsening of restlessness, agitation as daylight begins to fade), impulsive not responding to redirection. The IM Ativan had moderate effectiveness. The plan was to add routine Ativan and discontinue the Xanax (Antianxiety). Staff support behavioral interventions have been tried and are not successful. On 8/11/22 at 3:02 p.m., the psychiatric APRN documented an urgent telephone call with the director. Resident #78 was now combative, paranoid (feelings of extreme distrust, suspicion), not responding to any behavioral interventions. The plan was to resume Ativan 1 milligram (mg) IM every eight hours as needed. On 8/11/22 the Social Service Director documented in a grievance form a concern of Disruptive roommate voiced by Resident #78's roommate. A room change was initiated. On 8/15/22 at 9:33 a.m., Resident #78 was observed barefoot wandering in the 400 hall. Resident #78 was going in and out of other residents' rooms with no staff intervention or redirection. On 8/15/22 at approximately 9:40 a.m., Licensed Practical Nurse (LPN) Staff E confirmed Resident #78 was wandering unsupervised into other residents' rooms. She said Resident #78 wandered all the time and was combative. On 8/15/22 at 9:45 a.m., Resident #16 said he used to share a room with Resident #78. He said three or four days ago, Resident #78 placed his hands around his throat and tried to choke him. Resident #16 said he punched Resident #78 in the face to protect himself. He reported the incident to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 2 of 10 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 08/18/2022 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 0689 staff on duty, and an incident report was filed. Level of Harm - Minimal harm or potential for actual harm On 8/15/22 at 10:00 a.m., LPN Staff E was informed Resident #16 said three or four days ago Resident #78 placed his hands around his throat and tried to choke him. He had to punch Resident #78 in the face to protect himself. LPN Staff E said Resident #78 was combative and wandered in and out of other residents' rooms. Residents Affected - Few On 8/15/22 at 10:10 a.m., Resident #78 was observed barefoot at the back hallway exit door. Resident #78 pushed the exit door, activating the alarm. Three staff members were observed in the hallway conversing and did not attempt to redirect Resident #78. Approximately three minutes later, LPN Staff E redirected Resident #78 away from the exit door. On 8/15/22 at 4:00 p.m., Resident #78 was observed wandering unsupervised in the hallway and going in and out of other residents' rooms. LPN Staff E said Resident #78 was combative and wandered. A wandering device was applied to alert staff of attempts to exit the facility. On 8/16/22 at 12:00 p.m., Resident #98 said during the night, between 2:30 a.m., and 3:30 a.m., Resident #78 wandered in and out of her room, dressed in a hospital gown. He was rummaging through her belongings and got close to her face. She said Resident #78 tried to get in her bed which frightened her. She activated the call light, but no one responded for over an hour. Resident #98 said she was frightened and was screaming. Finally, the nurse came and removed him from the room. The nurse just kept saying Resident #78 was confused. On 8/16/22 at 12:10 p.m., Resident #16 said Resident #78 wandered into his room several times last night and was going through his belongings. He said, I told him to get out. I get upset because I don't want him going through my things. I want to sleep, and he comes in and will go through my things. Resident #16 said he reported it to the nurse on duty. On 8/16/22 at 12:15 p.m., LPN Staff D said she did not know anything about Resident #78 wandering. LPN Staff D was informed Resident #16 said three or four days ago Resident #78 placed his hands around his throat and tried to choke him. He had to punch Resident #78 in the face to protect himself. LPN Staff D was also informed Resident #98 complained the night before Resident #78 wandered in her room and tried to get in her bed. On 8/16/22 at 12:25 p.m., Resident #78 was observed wandering in the hallway on the unit by the back door attempting to exit the facility. Resident #78 wandered into another resident's room and then back to the exit door. Patient Care Assistant (PCA) Staff A was observed attempting to redirect Resident #78 away from the door. PCA Staff A said she was assigned to sit with the resident after lunch due to the wandering. On 8/16/22 1:15 p.m., Occupational Therapist (OT) Staff M said Resident #98 complained to her about Resident #78 wandering in and out of her room. OT Staff M said Resident #78 constantly wanders and goes in and out of resident rooms. On 8/16/22 at 1:20 p.m., Unit Manager Staff L said sometimes Resident #78 wanders in other residents' rooms. Unit Manager Staff L was informed Resident #16 said Resident #78 placed his hands around (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 3 of 10 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 08/18/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his throat and tried to choke him. He had to punch Resident #78 in the face to protect himself. She was also informed Resident #98 complained about Resident #78 wandering in her room and trying to get in her bed. She said she was not aware of the incidents. On 8/17/22 at 9:15 a.m., Resident #98 said the previous evening (8/16/22) Resident #78 wandered in her room and tried to get into her bed again. She said, I had the call light on, and no one came. I called my daughter in law, and she called the facility last night to report it. They removed him and then they had a staff member stand guard at my room to keep him out. On 8/17/22 at 9:38 a.m., in a telephone interview, Resident #98's daughter in law said Resident #98 called her on 8/16/22 at approximately 6:30 p.m. and complained there was a man in her room who was trying to get into her bed. She called the facility and reported the incident to Registered Nurse (RN) Supervisor Staff I. RN Supervisor Staff I called her back and verified Resident #78 was found in her mother in law's room. The care plan initiated on 7/15/22, and revised on 7/21/22 did not include individualized interventions, and supervision to address the wandering behavior. On 8/18/22 at 12:45 p.m., the Social Service Director said on 8/11/22 she wrote a grievance noting Resident #16 complained of a disruptive roommate but did not elaborate on it. She said Resident #16 complained on 8/11/22 at approximately 4:00 a.m., his roommate (Resident #98) was acting crazy, knocking things off the wall, pulling cords off the wall. He knocked over his tray table and Resident #98 fell on his bed. On 8/18/22 at 1:20 p.m., the Director of Nursing (DON) said Resident #78 should have been supervised to prevent the multiple incidents of wandering into other residents' rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 4 of 10 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 08/18/2022 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, review of facility policy and procedure, and record review, the facility failed to ensure 4 (Residents # 16, #69, #78 and #98) of 5 residents reviewed for accidents were assessed for alternative interventions prior to the use of bed rails. This had the potential to have bed rails installed when alternatives with less chance of negative consequences could be utilized. The findings included: The facility policy Side Rail Use/ Enabler Use revised 3/22, documented, The policy addresses safety measures to reduce the risk of bed entrapment related to the use of side rails/enablers. Side rails/enablers will only be used by a resident to assist his or her bed mobility in accordance with the individual's interdisciplinary team assessment. Side rails/enablers will not interfere with the residents' ability to egress from the bed. Review of the facility's Consent for use of side rails showed, . It is the policy of this facility to use side rail(s) only after evaluation and care planning deem it appropriate to assist the resident in attaining or maintaining his or her highest practicable physical and psychological well-being, and other methods or interventions are inadequate. In all instances the least restrictive device, which is effective will be used . 1. On 8/15/22 at 9:45 a.m., Resident #16 was observed in his bed with 1/4 side rails in the raised position on both sides of the bed. Resident #16 said he did not request the rails but used them to move in bed. Review of Resident #16's clinical record showed on 5/17/22 Resident #16 signed the Consent for Use of Side Rails. The clinical record showed an admission side rail assessment dated [DATE] recommending the use of bilateral enablers. The form documented alternatives have been discussed with the resident. The form did not document the alternatives attempted prior to the use of the enablers. 2. On 8/16/22 at 1:45 p.m., Resident #69 was observed in bed, with ½ side rails on both sides of the bed in the raised position. Resident #69 said the rails were on the bed when she was admitted , and she used the rails for mobility in bed. Review of Resident #69's clinical record showed a Consent for Use of Side rails dated 6/28/22 and signed by the resident. The record showed an admission side rail assessment dated [DATE], documented side rails or enablers were recommended and alternatives to side rails were discussed with the resident. The form did not document alternatives attempted prior to the use of the side rails. 3. On 8/16/22 at 1:45 p.m., Resident #78 was observed in bed with ½ side rails on both sides of the bed in the raised position. Resident #78 was confused and not able to answer questions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 5 of 10 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 08/18/2022 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #78's clinical record showed a Consent for Use of Siderails dated 7/17/22 and signed by the resident's family member. The record showed an admission side rail assessment dated 7/15/ 22, documented side rails or enablers were recommended and alternatives to side rails were discussed with the resident. The form did not document alternatives attempted prior to the use of the side rails. 4. On 8/15/22 at 10:10 a.m., Resident #98 was observed in bed with side rails in the raised position on both sides of the bed. Review of Resident #98's clinical record showed a Consent for Use of Side rails dated 7/27/22 and signed by the resident's family member. The record showed an admission side rail assessment dated [DATE] documenting side rails or enablers were recommended and alternatives to side rails were discussed with the resident. The form did not document alternatives attempted prior to the use of the side rails. On 8/17/22 at 12:57 p.m., the Director of Nursing confirmed the side rail assessments did not show documentation of the interventions attempted prior to the use of the side rails for Residents #16, #69, #78 and #98. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 6 of 10 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 08/18/2022 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review and staff interviews, the facility failed to ensure its medication error rate remains below 5%. Five licensed nurses on two different shifts with 27 opportunities were observed. Four medication errors were observed resulting in a 14.81% error rate. Residents Affected - Some The findings included: The facility policy 1.0, Medication Dispensing System (No effective date), documented, . Crushing oral medications requires a physician's order since some medications are not designed to be crushed (e.g., time release capsules, coated tablets, etc.). Medications are to be crushed in accordance with pharmacy guidelines and /or facility policy . Prior to medication administration: Verify each medication preparation that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer. Verify that the MAR [Medication Administration Record] reflects the most recent medication order. 1. On 8/15/22 at 4:25 p.m., Licensed Practical Nurse (LPN) Staff F was observed administering two different medications to Resident #2, including one tablet of Xifaxan (antibiotic) 550 milligrams (mg), and three tablets of Sevelamer Hydrochloride 800 mg (medication used to treat too much phosphate in the blood for dialysis patients). LPN Staff F placed the four tablets into a plastic medication bag and crushed them. LPN Staff F mixed the crushed medications with pudding and administered them to Resident #2. LPN Staff F discarded the medication cup leaving a portion of the medication mixture in the cup. A review of the manufacturer's guidelines for the use of Xifaxin and Sevelamer Hydrochloride specified Do not crush or chew tablets. 2. On 8/15/22 at 5:06 p.m., LPN Staff J was observed administering 14 different medications to Resident #63, including two tablets of Baclofen (a muscle relaxer) 20 mg, and two tablets of Gabapentin (medication used to treat seizures and nerve pain) 800 mg. On 8/15/22 at 5:30 p.m., review of the clinical record revealed a physician order specifying to administer one tablet of Baclofen 20 mg four times a day for muscle spasms and one tablet of Gabapentin 800 mg three times a day for neuropathic pain. On 8/15/22 at 7:00 p.m., in an interview, LPN Staff J confirmed she had administered two tablets of Baclofen 20 mg and two tablets of Gabapentin 800 mg to Resident #63. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 7 of 10 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 08/18/2022 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 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** 4. Record review of the Minimum Data Set (MDS) with Assessment Reference Date of 8/4/22 indicated Resident #108 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS revealed several active diagnoses for Resident #108 including Non-Alzheimer's Dementia, Depression, Psychotic Disorder, and Schizophrenia. On 8/15/22 at 4:30 p.m., during an observation and interview with Resident #108 she said she keeps her medicine in her chest drawers. Resident #108 stood up from bed, walked to the chest of drawers across from her bed and removed a red, 7-day pill organizer from the top drawer. She opened one section of the pill organizer and placed several pills in her hand, including a large pink pill identified as Depakote 500 milligrams (mg), which is used to treat seizures and mood disorders. Resident #108 confirmed the chest drawer was not locked and she possessed no key for access to the contents inside. Photographic evidence obtained. Review of the medical record indicated Resident #108 was admitted to the facility on [DATE]. Resident #108's Medication Administration Record for August 2022 indicated the facility was administering medication to the resident daily, including Depakote 500 mg for mood stability. On 8/17/22 at 9:24 a.m., Licensed Practical Nurse (LPN) Staff W said she gave Resident #108 her medication this morning. Staff W said Resident #108 was diagnosed with Stage 3 Kidney Disease and Paranoid Schizophrenia and was sometimes confused. On 8/17/22 at 9:33 a.m., during an observation, Resident #108 was lying in bed dressed in street clothes. Resident #108 said she takes both the pills in the organizer and the ones the staff give her at the facility. The red pill organizer was in a plastic bag in the top drawer of the dresser. On 8/17/22 at 9:37 a.m., LPN Staff W entered Resident #108's room. Staff W shook the pill organizer. The pill organizer contained pills in each section except for 2 sections. On 8/17/22 at 9:50 a.m., Registered Nurse (RN) Unit Manager Staff L entered Resident #108's room and acknowledged the medications in the pill organizer. RN Unit Manager Staff L told Resident #108 she was not allowed to have the medication in her room because the facility administers her medication. RN Unit Manager Staff L left the room with the pill organizer. Review of Resident #108's electronic record including assessments, care plans, miscellaneous records, progress notes, and MARs did not indicate Resident #108 was deemed safe for to keep or self-administer medication while she was admitted to the facility. Review of Resident #108's paper chart revealed no indication Resident #108 had been deemed safe to keep or self-administer medications while at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 8 of 10 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 08/18/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 08/17/22 at 12:56 p.m., RN Unit Manager Staff L verified Resident #108 was not evaluated to keep or self-administer medications. Based on observation and staff interview, the facility failed to ensure proper storage/labeling of medications for 1 (Resident #108) of 1 resident observed with unsecured medications at the bedside, 2 (100 odd and even medication carts) of 3 medication carts and 1(East unit) of 2 medication rooms. This has the potential for expired medications to be administered to residents. The findings included: The facility policy 5.0 Medication Storage (Undated), documented Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and in accordance with FL (Florida) Department of Health Guidelines. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy . 1. On 8/15/22 at 10:40 a.m., observation of the 100 odd numbered hallway medication cart with Licensed Practical Nurse (LPN) Staff F revealed the following: One box of [NAME]/Opium suppositories expired 7/31/22. One unopened bottle of Aspart (Novolog) insulin with directions to keep refrigerated until opened. The medication was warm to touch. One opened bottle of glargine (Lantus) insulin with no date to indicate when the insulin was opened. One unopened bottle of Lantus insulin with directions to keep refrigerated until opened. The insulin was warm to touch. LPN Staff F verified the findings in the medication cart. 2. On 8/15/22 at 10:45 a.m., observation of the 100 even numbered hallway, medication cart with Registered Nurse (RN) Staff G, revealed the following: One opened bottle of lispro insulin with no open date. One insulin Glargine (Lantus) pen not opened with directions to keep refrigerated until opened for Resident #26. One unopened bottle of Lispro insulin stored in the cart. The label specified to keep refrigerated until opened. One bottle of Lispro insulin opened and undated. One Levemir insulin pen not opened with directions to keep refrigerated until opened. One opened bottle of Lispro insulin with no date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 9 of 10 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 08/18/2022 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 0761 One unopened insulin Glargine pen with directions to keep refrigerated until opened. Level of Harm - Minimal harm or potential for actual harm One open insulin Glargine pen with no date open. One unopened bottle of Novolog insulin with directions to keep refrigerated until opened for Resident #83. Residents Affected - Some 3. On 8/15/2022 at 11:00 am, observation of the medication storage room of the East Unit with the Unit Manager revealed the following: One bottle of Two Cal HN tube feeding solution with an expiration date of July 1, 2022. One bottle of Senna Syrup with an expiration date of 1/22. One bottle of regular strength antacid and anti-gas with expiration date of 3/22. The Unit Manager verified the Two Cal HN solution, the Senna Syrup and the bottle of antacid were expired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105427 If continuation sheet Page 10 of 10