Inspection·January 6, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff and resident interviews and review of facility policies and procedures for Advance Directives, the facility failed to ensure proof of advance directives review and advanced care planning was in place for 2 (Resident # 285 and # 81) of 9 residents reviewed for Advanced Directives. This failure may impact quality of care at the end of life for the residents. The findings included: Review of facility policy: Advance Directives. Reviewed/revised December 2021 revealed, .Procedure . 2. Prior to or upon admission, the admission Director/ designee will provide written information to the resident and or legal representative concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives . Each resident, family member or legal representative will be asked to sign an acknowledgement indicating they have been given the required Advance Directive information. 1. On 1/3/22 clinical record review of resident #285 revealed an admission date of 12/21/21 and a full code status (Administer cardiopulmonary resuscitation if heart stops beating or the person stops breathing). The clinical record lacked documentation to indicate advanced directives were reviewed with resident #285 and or legal representative. On 1/4/22 at 11:14 a.m., in an interview Resident #285, said there was never any discussion with facility staff pertaining to her advance directives wishes. On 1/4/22 at 3:53 p.m., in an interview, the Social Services Assistant from a sister facility said she comes over once per week for about six hours to assist with Minimum Data Set (MDS) and social services assessments. She said if she does not complete the advance directives there is no employees at the facility to complete them. On 1/5/22 at 12:41 p.m., in an interview, the MDS Coordinator confirmed resident #285 had no advance directives in her clinical record, and there was no documentation indicating advance directives' information was given and/or discussed with resident # 285 and/or her legal representative. On 1/6/22 at 8:18 a.m., in an interview, the Director of Nursing (DON) said Resident #285 was admitted from the hospital with no documentation for advanced directives, only documentation regarding funeral package/arrangements. The DON confirmed there was no written documentation to show facility staff provided and or discussed advance directive's information with resident #285 since being admitted to the facility. On 1/6/22 at 10:51 a.m., in an interview, the Business Development Director Staff F and Admissions Director Staff G, both confirmed resident # 285 had no advance directives on record and there was no documentation to show a discussion of advance directives with Resident #285 or that she received information regarding advance directives. On 1/6/22 at 11:10 a.m., in an interview, the Administrator said the previous Social Services Director kept an audit book that contained documentation listing residents/family members where discussions were had regarding advance directives. She confirmed Resident #285 was not listed in the audit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 2 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few book and there is no documentation indicating facility staff completed any discussion with Resident #285 or provided her any information regarding advance directives since admission to the facility on [DATE]. 2. On 1/5/22 at 3:10 p.m., review of Resident #81's clinical record revealed an admission date of 12/8/21 and documentation of a full code status. The clinical record lacked documentation advance directives were reviewed with resident and/or family representative. Review of comprehensive care plan on 1/5/22 at 4:02 p.m., for Resident #81 failed to document a care plan addressing advance directives. On 1/5/22 at 4:15 p.m., in an interview, assigned nurse Licensed Practical Nurse Staff #I said no when asked if Resident #81 had advance directives in place. On 1/5/22 at 4:41 p.m., in an interview with MDS Coordinator, regarding advance directives she verified the findings that Resident #81 had no advance directives in place and no Social Services documentation showing advance directives were discussed. She added the facility has not had a Social Services Director for a few months now. On 1/6/22 at 10:51 a.m., a joint interview was conducted with Staff #F and Staff #G from the Admissions Department. Both Staff reported advance directives are discussed during admission process, checkbox on page 8 of the admission agreement. If potential admissions do have an advance directive, a copy is given to the Social Services Director. If admission does not have an advance directive, that information is passed on the Social Services Director for follow up. Both staff added the facility has not had a Social Services Director for almost 3 months. On 1/6/22 at 11:03 a.m., a request was made to the Administrator for evidence advance directives were discussed upon admission and periodic review were conducted for resident #81. On 1/6/22 at 11:10 a.m., in an interview, the Administrator said she has a book with the last audit done showing if family/resident were asked about advance directives, but resident #81 is not listed. On 1/6/22 at 1:45 p.m., in an interview, the Administrator confirmed the facility failed to have documentation advance directives were discussed with Resident #81 and/or representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 3 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review, staff and resident interviews, the facility failed to ensure process to support resident's rights to voice grievances for 5 (Residents #83, #31, #3, #12, and 41) of 5 residents reviewed. Residents Affected - Some The findings included: The facility policy for Resident and Family Grievances, 2021 read, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal . The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility . On 1/4/22 at 9:45 a.m., in an interview Resident #41, Resident Council President, said she has been a resident at the facility since 9/11/2021. She said they usually have a resident council meeting once a month and there are about 7-8 residents who attend. She said Activities Director Staff B who has been here for a couple of months takes notes and keeps records for resident council. She said she thinks laundry was the biggest and most common complaint. She said sometimes the laundry comes back late or not at all. On 1/4/2022 at 2:00 p.m., a Resident Council Meeting was conducted. There were eight residents in attendance. The main complaint was the laundry. All the residents agreed there were multiple complaints about the laundry every month. They said lately it was a little bit better than usual, but it was still bad. The following complaints were made during the meeting: 1) Resident # 41 said she had a Polo blouse come back with all the buttons missing and nothing was done about it. 2) Resident # 83 said he had clothes missing and never got them back. 3) Resident # 31 said she was missing 3 pairs of white pants she just got for Christmas, and nothing was done. 4) Resident # 3 said he had shorts missing. 5) Resident # 12 said she was missing a nice nightgown with robe, and nothing was ever done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 4 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some All the residents said that at every resident council meeting that laundry was brought up but there was never any resolution. On 1/5/2022 at 3:30 p.m., received and reviewed Resident Council notes and logbook for the past 12 months. There was only one laundry issue for the year noted in the November meeting notes. The concern was missing laundry items, buttons missing from shirt, and laundry not being taken and returned in a timely manner. The log read, Residents state the housekeeping/laundry is sufficient aside form issues stated, which housekeeping manager will address. Housekeeping /Activities will hold monthly missing clothes drive for residents to claim their no name items. There were no minutes listed for April, August, and September due to COVID, so there was no Resident Council meeting held. There were no notes of grievances filed or resolutions to problems discussed. On 1/5/2022 at 3:40 p.m., reviewed the Grievance log for past six months. There were no grievances identified generated from Resident Council meetings. On 1/6/2022 at 8:45 a.m., in an interview Housekeeping Director Staff J said there was no scheduled laundry service. He said if a resident needed laundry done, they told their Certified Nursing Assistant (CNA) who puts laundry in the soiled laundry room. He said laundry was labeled with the new label maker, but the labels sometimes come off in the dryer. He said the activities director and him have missing monthly clothes drive but there was no set time or record of it and no set time that it is done. He said the last one was yesterday. On 1/6/2022 at 12:00 p.m., in an interview the Resident Council President reviewed the minutes from the December 2021 meeting that read, Resident council President went over previous minutes and issues that have been resolved. No further issues at this point. The Resident Council President said there were always issues and she did not approve the minutes for the December 2021 Resident Council meeting. She said there were laundry issues every month. She said when an item is mentioned in the Resident Council meetings, it is never addressed again. She said she did not know if a grievance was filed for the complaints mentioned in the Resident Council meetings. On 1/6/2022 at 1:30 p.m., in an interview, Activities Director Staff B said when complaints are brought up in the resident council meetings, she mentions it to administration to resolve it. She said there was no log and no grievance forms filed for complaints generated from the resident council meetings. She said they have the Resident Council meeting minutes for tracking resolutions. When asked about the monthly missing clothes drive, she said the only record of it was a calendar listing the monthly missing clothes drive. She said they did not keep a log of who attended and/or who received what items. On 1/6/22 at 2:00 p.m., the Administrator said she oversaw the grievances in lieu of having a social worker. On 1/6/22 at 3:50 p.m., in an interview, the Administrator said she was not in charge of grievances (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 5 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete but did address the issues in lieu of Social Services. She said there was one grievance for December, but she couldn't locate it and it was not listed in the Grievance log. She said it was a resident with a missing toothbrush and it was located. She said staff and residents were informed and educated on how to fill out a grievance form. She said she didn't know why the grievances from resident council meetings were not documented. She said all issued discussed in resident council meetings were resolved but not documented. Event ID: Facility ID: 105439 If continuation sheet Page 6 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to provide a written copy of the transfer notice to the resident and the Office of State Long Term Care Ombudsman (LTCO) office with written notice of hospital transfer and facility discharge for 3 (Resident #136, #137, and #139) of 4 sampled residents transferred to the hospital and discharged from the facility. The findings included: Review of the facility's policy titled Transfer and Discharge (Including AMA) dated November 2021, under sub-heading (7) Emergency Transfer/Discharge, the facility would, Complete and send with the resident (or provide as soon as practicable) a Transfer Form. The policy also noted the facility Social Services Director, or designee, shall provide notice of transfer to a representative of the Long-Term Care Ombudsman (LTCO) via monthly list. 1. Review of Resident #136's medical record revealed she was admitted to the facility on [DATE] with a diagnosis of cerebral infarction, encephalopathy, dysphagia and cognitive communication deficit. A nursing progress note dated 12/12/21 stated Resident #136 started vomiting blood. Documentation in the nursing progress note revealed the nurse notified the physician and received a physician order to send the resident to the hospital for an evaluation. Further review of Resident #136's medical record revealed no documentation a Nursing Home Transfer and Discharge Notice form was completed and given to the resident and the LTCO was notified of Resident #136 transfer to the hospital and discharged from the facility on 12/12/21. 2. Review of Resident #137's medical record revealed she was admitted to the facility on [DATE] with a diagnosis of acute kidney failure, anemia and hyperkalemia. A nursing progress note dated 11/24/21 stated the Advanced Registered Nurse Practitioner (ARNP) gave an order to send Resident #137 to the hospital for evaluation related to abdominal distention and decreased appetite/nutritional intake over two days and chest congestion. Further review of Resident #137's medical record revealed no documentation a Nursing Home Transfer and Discharge Notice form was completed with a copy provided to the resident or their representative. There was also no documentation the LTCO was notified with a copy of the Nursing Home Transfer and Discharge Notice for Resident #137's transfer to the hospital and discharge from the facility on 11/24/21. 3. Review of Resident #139's medical record revealed he was admitted to the facility on [DATE] with a diagnosis of respiratory failure, chronic pulmonary obstruction disease and hypertension. A physician order dated 9/7/21 to transfer Resident #139 to the hospital for evaluation related to respiratory distress and low oxygen levels. Further review of Resident #139's medical record revealed no documentation a Nursing Home Transfer and Discharge Notice form was completed with a copy provided to the resident or their representative. There was also no documentation the LTCO was notified with a copy of the Nursing Home Transfer and Discharge Notice for Resident #139's transfer to the hospital and discharge from the facility on 9/7/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 7 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/6/22 at 11:30 a.m., in an interview the admission Marketing Director (AMD) and admission Director (AD) said when a resident is transferred to a hospital, and the hospital determines the resident needs to be admitted , the facility would discharge them from the facility at that time. The AMD said she would wait 24 hours and contact the hospital Social Service Worker (SSW) related to when the resident will be returning to the facility. She said if the hospital SSW told her the resident would not be returning to the facility, she would contact the resident or their family to determine why the resident did not want to return to the facility. She confirmed Resident #136 was transferred and discharged from the facility on 12/12/21, Resident #137 was transferred and discharged from the facility on 11/24/21 and Resident #139 was transferred and discharged from the facility on 9/7/21. The admission Marketing Director said she talked with Residents #136 and #139's families and they wanted to the residents to be moved to a facility closer to them and Resident #137 should be returning to the facility sometime this month. The admission Marketing Director and the admission Director said the Social Service Director (SSD) was responsible to ensure the Nursing Home Transfer and Discharge Notice form was completed and given to the resident or family upon transfer from the facility and contact the LTCO office of all transfer and discharges from the nursing home. They said the SSD resigned and left the facility late October 2021 and they did not know who was assigned to ensure the Nursing Home Transfer and Discharge forms were completed and the LTCO was notified of all discharges. The admission Marketing Director said the facility has transferred and discharged 16 residents to the hospital from [DATE] to 1/6/22 who have not returned to the facility as of this time. On 1/6/22 at approximately 12:00 p.m., in a telephone interview with the LTCO representative, she said the last time the nursing home sent them a list of residents who were discharged from the facility was July 2021. On 1/6/22 at 12:15 p.m., in an interview the Administrator said in November 2021 the LTCOC representative informed her the last time the facility had sent LTCO office the monthly list of residents discharged from the facility was 7/23/21. The Administrator said the SSD was responsible to inform the LTCO of all facility discharge at the end of each month but resigned on 11/2/21. She said on 11/28/21 she created a Performance Improvement Plan (PIP) to ensure the LTCO office was notified monthly of all facility discharges. She confirmed since 8/1/21 to 12/31/21 the facility has transferred 16 residents to the hospital who were discharged from the facility. She said as of today the facility has not been informing the LTCO office of all facility discharges as required. The Administrator confirmed again the last time the LTCO office was notified of all facility discharges was 7/23/21. The Administrator said she discovered on 11/28/21 when creating the PIP related to notifying the LTCO office of all facility discharges she found out the nursing department was not filling out the Nursing Home Transfer and Discharge Notice form as required and giving a copy to the resident or their representative as required by facility policy. The PIP identified the objective and goal was the Discharge/Bedhold Form with a target date of on going. The status of the action steps for Discharge/Bedhold Form was the Facility will bring current with upkeep. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 8 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete The Administrator stated she had assigned herself the completion of this task as noted on the PIP. She confirmed as of 1/6/22 the notification had not been updated with overdue notices nor had the upkeep been done for residents who were recently discharged from the facility. On 1/6/22 at 2:00 p.m., in an interview the Director of Nursing (DON) said she was unaware until today the nursing department was not completing the Nursing Home Transfer and Discharge Notice form and giving a copy of the form to the resident, or their representative as required. She said the Nursing Home Transfer and Discharge Notice is the form the facility uses to be in compliance with Florida Administrative Code 59A-4.106(1) and the notification of the LTCO office for all resident discharges from the facility. She said after reviewing the medical records for Residents #136, #137 and #139, she was unable to find documentation the nursing department had completed a Nursing Home Transfer and Discharge form and provided a copy to the resident or their representative and the LTCO office to notify them of the discharge as required. Event ID: Facility ID: 105439 If continuation sheet Page 9 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, the facility failed to provide the resident and their representative, if applicable, with a written summary of the baseline care plan which included initial goals and a summary of current medications and dietary instructions for 9 (Residents #9, #24, #25, #30, #38, #66, #81, #82 and #285) of 10 residents reviewed for baseline care plans. This had the potential to cause confusion as to the care expected to be provided by the facility. The findings included: Review of the facility's policy Baseline Care Plan, implemented and revised on 2/12/21 read, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy explanation and compliance guideline: 1. The baseline care plan will be: a. developed within 48 hours of a resident's admission . 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. the initial goals of the resident. b. A summary of the residents' medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. 5. A supervising nurse or MDS nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative . 1. On 1/3/22 at 12:08 p.m., interview with Resident #25 said he was not invited to his care plan meeting and was never given a copy of his baseline care plan. He said he was unaware of the plan of care the Interdisciplinary Team (IDT) has determined for him as of this time. On 1/5/22 a review of Resident #25's medical record confirmed he was admitted to the facility on [DATE] with diagnoses of Chronic Hepatic Failure, Bipolar Disorder, and Alcohol-Induced disorder. Further review of the medical record revealed no documentation Resident #25 had attended his IDT care plan meeting on 11/10/21 and/or he was given a copy his baseline care plan containing the initial plan of care goals determined by the IDT, a summary of current medications and dietary instructions as required. 2. On 1/3/22 at 12:52 p.m., in a telephone interview Resident #82's son, who is Resident #82's Power of Attorney (POA) said since his father's admission to the facility on [DATE] the facility had not given him a copy of his father's baseline care plan and the facility had not updated him about the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 10 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0655 plan of care for his father. Level of Harm - Minimal harm or potential for actual harm On 1/5/22 a review of Resident #82's medical record confirmed Resident #82 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure, and Dementia. Further review of the medical record revealed Resident #82's care plans were initiated on 12/10/21 and were completed the day of the IDT care plan meeting on 12/30/21. There was no documentation the POA was notified of the 12/30/21 care plan meeting or given a copy of Resident #82's baseline care plan containing Resident #82's initial plan of care goals determined by the IDT, a summary of current medications and dietary instructions as required. Residents Affected - Some On 1/5/22 at 11:06 a.m., interview with the Minimum Data Set (MDS)/Care Plan Coordinator confirmed Resident #82 was admitted to the facility 12/9/21 and Resident #25 was admitted to the facility on [DATE]. She said the admitting nurse was required to initiate and complete a baseline care plan for all residents upon admission within 24 to 48 hours. She said the baseline care plan was used to ensure a personalized plan of care was started for each resident upon admission and which then should be finalized by the IDT during the care plan meeting and a copy of the baseline care plan should be given to the resident, or their representative. She said they have the resident, or the representative sign the Baseline Care Plan Policy and Summary Form to ensure the resident or representative are aware of all the care plan goals, medications and dietary information, and services and treatments initiated for that resident. She said a copy of the Baseline Care Plan Policy and Summary Form signed by the resident and a facility representative is kept in the medical record and a copy should be given to the resident or their representative as required per their policy and regulation. The MDS Coordinator Reviewed Resident #25's medical record and confirmed his IDT care plan meeting was held on 11/10/21 and she was unable to find documentation he was given a copy of his baseline care plan as of 1/5/22. The MDS Coordinator reviewed Resident #82's medical record and confirmed the facility had an IDT care plan meeting for Resident #82 on 12/30/21. She said she is unable to find documentation Resident #82's POA was given a copy of Resident #82's baseline care plan as required. On 1/6/22 at 12:30 p.m., during an interview with the Director of Nursing (DON), she said the admitting nurse was required to initiate the residents Interim admission (Interdisciplinary Care Plan)/Baseline Care Plan upon admission, fill out the Baseline Care Plan Policy and Summary Form and give a copy of the form to the resident or their representative. She said she was unaware until today the admitting nurse or the IDT during the care plan meeting were not providing a copy of the baseline care plan with the resident's care plan goals, medications, dietary information and services, and treatments initiated when the resident was admitted to the facility as required. 3. On 1/3/22 at 9:41 a.m., in an interview Resident #30 said he never had a discussion with the facility staff regarding his care plan and he did not receive a written summary of the baseline care plan. On 1/5/22 record review revealed an admission date of 10/29/21. The clinical record lacked evidence a written summary of the baseline care plan including initial goals, and a summary of current medications and dietary instructions was provided to the Resident as required. On 1/6/22 at 9:27 a.m., in an interview with the Minimum Data Set (MDS) Coordinator Staff E confirmed there was no documentation the baseline care plan which include initial goals and a summary of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 11 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0655 Level of Harm - Minimal harm or potential for actual harm current medications and dietary instructions was discussed with the Resident and a copy provided to resident # 30 legal representative. 4. On 1/3/22 at 10:43 a.m., Resident #38 said she did not recall ever receiving a written summary of the baseline care plan. Residents Affected - Some On 1/5/22, record review revealed an admission date of 11/15/21. The clinical record lacked evidence a written summary of the baseline care plan which included initial goals, and a summary of current medications and dietary instructions was provided to the Resident as required. On 1/6/22 at 11:28 a.m., in an interview Resident #38's Power of Attorney, stated she never received a written summary of the baseline care plan with initial goals, a summary of current medications and dietary instructions for her mother since she has been admitted to the facility. 5. On 1/03/22 at 11:38 a.m., Resident #285 said she did not recall ever receiving a written summary of the baseline care plan. On 1/5/22, record review revealed an admission fate of 12/21/21. The clinical record lacked documentation a written summary of the baseline care plan which included initial goals, a summary of current medications and dietary instructions was provided as required. On 1/5/22 at 2:08 p.m., in an interview the DON stated, currently the baseline care plans are not being completed, and there is no documentation of baseline care plans being completed, discussed and provided to the resident/representatives as required. On 1/5/21 at 3:08 p.m., in an interview MDS Coordinator Staff E, stated the admission nurse was responsible to complete the baseline care plans for residents upon admission to the facility within 24 - 48 hours. Staff E said, The residents or their representatives haven't been provided documentation of the baseline care plans recently, which includes initial goals and a summary of current medications and dietary instructions as required. 6. On 1/5/22 at 3:21 p.m., record review for Resident #66 revealed an admission date of 12/1/21. The clinical record lacked evidence a written summary of the baseline care plan, which included initial goals and a summary of current medications and dietary instructions, was done for Resident #66 and provided to the resident representative as required. On 1/5/22 at 3:26 p.m., the MDS Coordinator verified the baseline care plan summary for Resident #66 was blank, unsigned, and had not been completed. 7. On 1/3/22 at 3:10 p.m., in an interview Resident #9 said he did not receive a copy of the medications the facility would be giving to him, or any other document related to his care when he was admitted to the facility. On 1/5/22 at 3:30 p.m., record review revealed an admission date of 10/1/21. The clinical record lacked evidence a written summary of the baseline care plan which included initial goals, and a summary of current medications and dietary instructions was provided to Resident #9 or resident representative as required. On 1/5/22 at 3:35 p.m., the MDS Coordinator verified there was no baseline care plan summary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 12 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0655 completed for Resident #9. Level of Harm - Minimal harm or potential for actual harm 8. On 1/5/22 at 11:32 a.m., record review of the medical record for Resident #81 revealed an admission date of 12/8/21. The clinical record lacked evidence of completion of a baseline care plan. Residents Affected - Some On 1/5/22 at 3:40 p.m., the MDS coordinator verified a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions, was not completed and reviewed with the family/resident representative as required. On 1/6/22 at 9:14 a.m., Unit Manager Registered (RN) Nurse Staff D, said the admitting nurse filled out the Interim/admission Care Plan''. Unit Manager Registered Nurse Staff D said the nurse did not complete the base line care plan and did not review it with the families or resident as required. 9. On 1/5/22 at 11:54 a.m., Resident #24 said he did not receive a copy of his care plans or medications when he was admitted to the facility. On 1/5/22 at 3:21 p.m., record review revealed an admission date of 10/18/21. The clinical record lacked evidence a written summary of the baseline care plan, which included initial goals and a summary of current medications and dietary instructions, was done for Resident #24. On 1/5/22 at 3:43 p.m., the MDS Coordinator verified the baseline care plan summary for Resident #24 was blank, unsigned, and was not completed as required. On 1/6/22 at 1:12 p.m., in an interview the findings were presented to the Director of Nursing (DON). She concurred the facility failed to develop a baseline care plan for Residents #66, #9, #24, and #81. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 13 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to provide evidence a care plan conference was conducted with the resident and/or resident representative after completion of the comprehensive admission Minimum Data Set (MDS) assessment for 2 (Resident #82 and #25) of 2 residents reviewed. This did not allow the resident and/ or representative to participate in decision making related to the plan of care. The findings included: 1. On 1/3/22 at 12:08 p.m., in an interview Resident #25 said he was not invited to his care plan meeting and was never given a copy of his baseline care plan. He said he was unaware of the plan of care the Interdisciplinary Team (IDT) had determined for him as of this time. On 1/5/21 a review of Resident #25's medical record confirmed he was admitted to the facility on [DATE] with diagnoses of Chronic Hepatic Failure, Bipolar Disorder, and Alcohol-Induced disorder. Further review of the medical record revealed no documentation Resident #25 attended his IDT care plan meeting on 11/10/21 and/or he was given a copy his baseline care containing the initial plan of care goals determine by the IDT, a summary of current medications and dietary instructions as required. 2. On 1/3/22 at 12:52 p.m., in a telephone interview Resident #82's son, who is Resident #82's Power of Attorney (POA), he said since his father's admission to the facility on [DATE] the facility did not give him a copy of his father's baseline care plan and the facility had not updated him about the plan of care for his father. On 1/5/22 a review of Resident #82's medical record confirmed Resident #82 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure, and Dementia. Further review of the medical record revealed Resident #82's care plans were initiated on 12/10/21 and were completed the day of the IDT care plan meeting on 12/30/21. There was no documentation the POA was notified of the 12/30/21 care plan meeting or given a copy of Resident #82's baseline care containing Resident #82's initial plan of care goals determined by the IDT, a summary of current medications and dietary instructions as required. On 1/5/22 at 11:06 a.m., in an interview the Minimum Data Set (MDS)/Care Plan Coordinator confirmed Resident #82 was admitted to the facility 12/09/21 and Resident #25 was admitted to the facility on [DATE]. The MDS/Care Plan Coordinator said the baseline care plan was used to ensure a personalized plan of care was started for each resident upon admission and which then should be finalized by the IDT during the care plan meeting and a copy of the baseline care plan should be given to the resident, or the representative. She said they should have the resident, or the representative sign the Baseline Care Pan Policy and Summary Form to ensure the resident or representative were aware of all the care plan goals, medications and dietary information and services, and treatments initiated for that resident. She said a copy of the Baseline Care Plan Policy and Summary Form signed by the resident and a facility representative should be kept in the medical record and a copy should be given to the resident or their representative as required per their policy and regulation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 14 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 The MDS Coordinator Reviewed Resident #25's medical record and confirmed his IDT care plan meeting was held on 11/10/21. She said when they went to Resident #25's room to invite him to the IDT meeting he was sleeping. She said she was unable to find documentation Resident #25 was informed about his care plan goals determined by the IDT on 11/10/21 or given a copy of his baseline care plan with his care plan goals, medications, dietary information and services, and treatments initiated when he was admitted to the facility as required as of 1/5/22. The MDS Coordinator reviewed Resident #82's medical record and confirmed the facility had an IDT care plan meeting for Resident #82 on 12/30/21. She said she was unable to find documentation Resident #82's POA was given a copy of Resident #82's baseline care plan, was invited to the care plan meeting or was ever updated about IDT plan of care goals for Resident #82 as of 1/5/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 15 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0679 Provide activities to meet all resident's needs. 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, staff and resident interview, the facility failed to ensure 2 (Residents #18 and #50) of 17 residents surveyed received activities according to the activities assessment, care plan, and the abilities of the resident. This has a potential to cause loneliness and mental anguish for residents. Residents Affected - Few The findings included: 1. On 1/3/22 from 11:00 a.m., to 12:00 p.m., on 1/4/22 from 10:00 a.m., to 12:00 p.m., and on 1/4/22 from 1:00 p.m. to 3:00 p.m., Resident #18 was observed in her bedroom not involved in an activity. Further observation noted the television was not on nor was there a radio playing music for Resident #18. On 1/4/22 at 1:30 p.m., interview with Resident #18 confirmed she only spoke Spanish. She said there was not much to do at the facility. On 1/5/22 review of Resident #18's medical record revealed she was admitted to the facility on [DATE]. An activity plan of care and the Activities Quarterly Participation Review dated 10/20/21 stated Resident #18 enjoyed listening to music, being outside and going to the park with family, resting, and participating in activities with groups of people. The quarterly assessment stated Resident #18 was a Jehovah's Witness and enjoyed participating in spiritual activities. Under the limitation and special need section, the assessment noted Resident #18 needed assistance with transport to activities and required accommodation for visual deficit, with large print or participating in activities that do not involve much visual demand. 2. On 1/3/22 from 11:00 a.m. to 12:00 p.m., and 1/4/22 from 10:00 a.m., to 12:00 p.m., Resident #50 was observed in his wheelchair (w/c) in the hallway in front of his room door not involved in an activity. On 1/4/22 from 1:00 p.m. to 3:00 p.m. Resident #50 was observed in his bed not involved in an activity. Further observation noted the television was not on nor was there a radio playing music for Resident #50. On 1/4/22 at 3:00 p.m., in an interview Resident #50's roommate said Resident #50 only spoke Spanish and he had not seen him involved in any Spanish speaking activities. On 1/5/22 from 10:00 a.m. to 11:00 a.m., Resident #50 was observed in his w/c alone in the activity room located at the end of his hallway with the lights off. On 1/5/22 at 11:00 a.m., in an interview Resident #50 confirmed he only spoke Spanish. He said he was bored and there was not much to do at the facility. On 1/5/22 review of Resident #50's medical record revealed he was admitted to the facility on [DATE]. An activity plan of care and the Activities Quarterly Participation Review dated 10/18/21 stated Resident #50 would engage in appropriate activities and routine according to his preferences. Interventions noted on the care plan were watching television, listening to music of his choice, and reading material. The care plan noted Resident #50 was Spanish speaking and enjoys socializing with peers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 16 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0679 in his language, participating in ice cream social and outdoor group. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Activities policy and procedure, stated the facility will provide an ongoing activity program to support the residents in the choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Activities refer to any endeavor, other than routine activity of daily living which a resident participated in that was intended to enhance his/her sense of well-being and promoted or enhanced physical cognitive, and emotional health. Residents Affected - Few On 1/5/22 at 3:42 p.m., in an interview the Activity Director (AD) said the nursing home was a 120-bed facility and currently there were only two people working in her department. She said she and the activity assistant worked five days a week and only the same day on Wednesdays and Thursdays. She said on the days they overlapped she attempted to get the paperwork completed for the residents and attended the Interdisciplinary Team meetings if scheduled. The AD confirmed after reviewing activity plan of care and the Activities Quarterly Participation Review dated 10/20/21 for Resident #18 stated she enjoyed listening to music, being outside and going to the park with family, resting, and participating in activities with groups of people. She also confirmed the quarterly assessment stated Resident #18 was a Jehovah Witness and enjoyed participating in spiritual activities. Under the limitation and special need section, the assessment stated Resident #18 needed assistance with transport to activities and required accommodation for visual deficit, with large print or participating in activities that do not involve much visual demand. The AD confirmed after reviewing activity plan of care and the Activities Quarterly Participation Review dated 10/18/21 for Resident #50, she stated the plan noted Resident #50 would engage in the appropriate activities and routine according to his preferences, and the interventions noted on the activity care plans are watching television, music of his choice, reading material, Resident #50 is Spanish speaking and enjoyed socializing with peers in his language, participating in ice cream social, and outdoor group. The AD said she entered all the daily activity tracking data for each resident into the computer but did not know how to retrieve and/or review the activity tracking data entered in the computer as of 1/5/22. She said she would have to ask someone in administration how to retrieve the data. On 1/6/22 at 10:45 a.m., interview with the AD said she was able print the activity tracking log for Residents #18 and #50 for November and December 2021. Review of Resident #18's activity tracking log for November 2021 revealed Resident #18 walking the hallways was marked as an activity 5 times, watching TV-7 times, folding laundry-1 time, food/snacks-1 time and talking/conversation-1 time. For the month of December 2021 Resident #18 was only documented as attending 1 activity, an ice cream social for the month of December 2021. Review of Resident #50's activity tracking log for November 2021 revealed Resident #50 wheeling himself down the hall was marked as an activity 2 times, watching TV-4 times, napping-1 time, and outdoor activity-5 days in a row. For the month of December 2021 Resident #50 was only documented as attending 1 activity for the month of December 2021. The AD confirmed the daily activity tracking documentation showed Resident #18 and #50 only attended one activity in December 2021. She said when there was only 1 activity person in a 120-bed nursing facility for 5 days a week it was hard to ensure all the residents personalized activity goals were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 17 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0679 met and documented on a routine basis. Level of Harm - Minimal harm or potential for actual harm On 1/6/21 at 1:00 p.m., in an interview the Administrator confirmed the facility had two people working in the activity department and the only days they have two activity persons in the facility were on Wednesdays and Thursdays. She also confirmed the AD was also responsible to attend the IDT meetings and other administrative duties. She said they identified the need for a third assistant, and she was in the process of hiring someone to work in the activity depart to ensure the residents activity interests and needs were being met on a continuous and routine basis as required. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 18 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 observation, record review, staff, and resident interviews the facility failed to assess, document, monitor, and provide care in a manner to promote healing for 1 (Residents #50) of 1 resident reviewed for edema (swelling caused by excess fluid). There was no evidence of a nursing assessment of the resident's edema to his lower legs to determine the extent of the swelling, blood flow to each leg, pain level, interventions which could be put in place to reduce the edema, and/or signs of infection. Ongoing monitoring and documentation of Resident #50's lower extremities allow clinical staff to detect complications and implement new interventions to prevent worsening of the lower extremity edema. Residents Affected - Few The findings included: On 1/3/21 at 11:40 a.m., Resident #50 was observed sitting in his wheelchair in the hallway. Resident #50 pointed to his right leg and said that it was swollen, and it hurt. Observation of Resident #50's lower extremities noted the right leg was larger than the left leg. On 1/3/21 at 11:44 a.m., Licensed Practical Nurse Staff Q was observed briefly evaluating Resident #50's lower extremities and confirmed Resident #50's right leg and foot was larger than his left leg. She said she was Resident #50's nurse last week Friday (12/31/21) and the edema to Resident #50's right leg was new. She said she would inform the charge nurse and Resident #50's physician of the edema to the right leg and administer pain medication to Resident #50 for the right leg pain. On 1/4/21 review of Resident #50's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included but were not limited to Parkinson's disease, Hepatic Failure, Polyneuropathy, Dementia, Right Leg Pain and Chronic Kidney Disease. Further review of the medical record revealed a physician progress note dated 12/22/21 which stated Resident #50 was a [AGE] year-old male who was seen today for a follow-up of his chronic health conditions, medication review and follow-up of his lower extremity edema. Nursing stated edema had improved some since starting on Lasix (diuretic). The physician wrote to continue Lasix 20 milligrams (mg) for another 7 days and continue Gabapentin Capsule 300 mg, 1 capsule two times a day for nerve pain. Review of the Medication Administration Record (MAR) revealed Resident #50 received the last dose of Lasix 20 mg on 12/31/21. The January 2022 MAR revealed documentation the nursing staff had assessed Resident #50's pain level as '0' on all 3 shifts for January 1, 2, 3 and the day shift on the 4th and no pain medication was administered. There was no documentation pain medication was administrated to Resident #50 for the pain he reported on 1/3/22. The nursing Skilled Evaluation completed on 12/30/21 and the Weekly Skin Evaluation completed on 12/28/21 did not state Resident #50's lower extremity was edematous or that his right leg was larger than his left leg. The Skilled Evaluation stated the right and left pedal pulses were normal with no abnormalities noted to the lower extremities. Review of Resident #50's nursing progress note revealed no documentation on 1/3/22 and 1/4/22 of an evaluation, of Resident #50's lower extremities, was conducted and the physician was notified about Resident #50's lower leg edema. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 19 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 1/4/21 review of the facility's policy for Conducting Resident Assessment/Evaluation dated 11/3/2020 stated a qualified staff who was knowledgeable shall conduct a resident assessment/evaluation addressing each resident's status, need, strengths, and area of change in condition. The assessment/evaluation shall be documented in the medical record. On 1/4/21 review of the facility's undated policy for Notification of Changes stated The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. On 1/4/21 at 3:54 p.m., interview with Licensed Practical Nurse, Staff R, he said he was Resident #50's nurse for the evening shift on 1/3/21. He said the day shift nurse, Staff Q reported to him Resident #50 was having right leg pain. Staff R said Resident #50 had a history of leg pain and lower extremity edema and Resident #50 received Lasix 20 mg for 7 days, which ended on 12/31/21 and resolved the edema to Resident #50's lower legs. LPN Staff R said he did not do an evaluation of Resident #50's lower extremities even though Staff Q told him in shift report Resident #50 was complaining of leg pain. He said he placed a call to Resident #50's physician to tell them Resident #50 was complaining of leg pain but was unable to reach the physician. When asked when he was unable to talk with Resident #50's physician why he did not contact the Director of Nursing (DON) or the facility's Medical Director, he did not give an answer. Staff R said he did not evaluate Resident #50's lower extremities to determine the source of his leg pain and did not document in Resident #50's medical record his attempt to contact Resident #50's physician related to his complaint of leg pain. On 1/4/21 at 4:25 p.m., Staff R evaluated Resident #50's lower extremities. Staff R confirmed Staff Q's evaluation on 1/3/22 the Resident's right leg and foot were swollen and larger than the left leg. He said the right foot and leg was a +2 or more edema and he would call Resident #50's physician and inform him of the change in condition to Resident #50's lower extremities. On 1/4/21 at 4:40 p.m., during an interview with the DON after she assessed Resident #50's lower extremities, she confirmed his right leg was swollen and with a +2 or more edema and was much larger than the left leg. She also confirmed Resident #50 had complained of pain and discomfort to his right leg and foot. She said the pain and discomfort was most likely related to swelling to the right foot and leg. The DON reviewed Resident #50's medical record and confirmed Staff Q and Staff R did not evaluate Resident #50's lower extremities and document their findings in the medical record as required. She also confirmed Staff Q and Staff R did not medicate Resident #50 related to his complaint of leg pain and did not notify Resident #50's physician related to right leg edema and pain as required per their policies. The DON said even though Resident #50 had a history of lower leg pain and edema the nurses should have evaluated Resident #50's lower extremities and determined the cause of the pain, informed the primary care physician of their assessment and documented their evaluation, and any new physician orders in the medical record as per the facility's policies and nursing professional standards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 20 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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, staff and resident interview, and review of facility policy and procedures, the facility failed to ensure the resident environment remains free of hazards and provide adequate supervision when smoking for 1 (Resident #17) of 2 resident reviewed for smoking. The findings included: The facility policy: Resident Smoking Implemented November 2020, Revised October 2021, read, This facility provides a safe environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Policy explanation and compliance guidelines: . 6. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process . 8. All residents will be supervised while smoking . 10. All safe smoking measures shall be documented on each resident's care plan and communicated as applicable . 12. Smoking materials of residents shall be maintained by nursing staff. An admission Minimum Data Set 3.0 (MDS) assessment, dated 10/18/21, indicated Resident #17 had no current tobacco use. Review of the smoking evaluation completed upon admission on [DATE] for resident # 17 indicated the resident did not smoke and was not fully completed as required. On 1/3/21 at 11:25 a.m., observed Resident #17 in his room with a package of cigarettes in his walker with used burnt cigarette butts in the seat of his walker. In an interview at the time of the observation Resident # 17 stated he smoked and kept his cigarettes. On 1/4/22 at 11:10 a.m., in an interview Registered Nurse (RN) Staff K, said she heard Resident #17 smoked and kept his cigarettes in the room, which she observed in his walker in the room. Staff K stated the smoking policy for the facility was for the residents cigarettes/smoking materials to be kept at the nurse's station and staff would assist and supervise residents with smoking materials in the designated smoking area during designated smoking times. On 1/5/22 at 9:05 a.m., in an interview Licensed Practical Nurse (LPN) Staff I, said as far as she knew there were only two smokers on the South Hall. Staff I stated there was a smoking list kept at the nurse's station with the names of residents who smoke, resident #17 was not on the list, he was not a smoker as far as she knew. Staff I stated she was not sure how often the smoking list was updated, and the facility policy indicated residents were not allowed to keep cigarettes or smoking materials in their rooms. On 1/5/22 at 9:21 a.m., Observed Resident #17 and three other residents smoking unsupervised in the smoking area. Resident #17 had a package of 305 cigarettes in his walker. On 1/5/22 at 9:23 a.m., in an interview Resident #41 who was smoking stated staff never supervised them when smoking. Record Review of Resident #17 comprehensive care plan contained no documentation indicating he was a smoker, no safe smoking measures, and no orders indicating it was safe for Resident #17 to keep cigarettes/smoking materials in his room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 21 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 On 1/5/22 at 2:04 p.m., in an interview the Activities Director stated Resident #17 had his own cigarettes, and some residents were allowed to keep their own cigarettes in their rooms. On 1/5/22 at 2:18 p.m., in an interview the Director of Nursing, (DON) said for residents that are smokers at the facility, there were scheduled times for smoking and staff from the different departments were scheduled to supervise the residents when outside in the smoking area. She said cigarettes were kept at the nurse's station in a locked box and staff took the cigarettes with the residents and escort them to the designated smoking area at smoking times and supervised them. When finished cigarettes are to be returned to the locked box at the nurse's station. The DON said residents were not allowed to keep cigarettes and or lighters or any smoking materials in their room, that was the facility policy as it was a safety hazard. On 1/5/22 at 3:57 p.m., Observed Resident #17 with cigarettes in his walker in his room. On 1/5/22 at 4:24 p.m., in an interview Registered Nurse Staff D said per the facility's smoking policy cigarettes, lighters, or any smoking material were not kept in resident's rooms but at the nurse's station. During the interview, observation of Resident #17's room with Staff D, she confirmed cigarettes and burnt cigarettes in resident #17's walker in his room. Staff D said this was against the facility's smoking policy. On 1/5/22 at 4:41 p.m., in an interview, the Administrator said the facility's policy for resident's who are smokers included a smoking evaluation completed upon admission, quarterly and significant change. The Administrator stated residents' cigarettes and smoking materials were kept at the nurse's stations with staff supervision of residents during smoking in the designated smoking area. The Administrator reiterated it was the facility's policy that no resident kept cigarettes, smoking materials in the rooms, as it was a safety hazard for the residents and the facility. On 1/5/22 at 4:58 p.m., observation of Resident #17's room with the Administrator and DON confirmed the resident kept cigarettes in his room in his walker which was against the facility's policy. The DON stated she was unsure who gave resident #17 the package of cigarettes to keep in his room. On 1/6/22 at 10:03 a.m., in an interview the DON confirmed Resident #17's smoking evaluation completed at admission indicated he was not a smoker, and the smokers list was not updated to include Resident #17. The [NAME] stated, the fact that the resident was keeping his cigarettes in his walker in the room indicates that he was not being supervised appropriately. On 1/6/22 at 10:44 a.m., in an interview the DON confirmed the resident was never care planned to keep his cigarettes or smoking materials in the room and there was no documentation or orders allowing resident #17 to keep cigarettes and or smoking materials in his room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 22 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 - Few 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. Based on observation, policy review and staff interview the facility failed to ensure proper storage and labeling of medications for 2 (Residents #43, and #385) of 7 sampled residents. The facility also failed to properly label and store medications in 2 (Medication Cart A and B ) of 2 medication carts observed on the North Unit. The findings included: Facility policy Resident Self-Administration of Medications, 2021 noted, . A resident may only self-administer medications after the facility's interdisciplinary team determined which medications may be administered safely . 1. On 1/3/22 at 9:46 a.m., observed an unsecured Ventolin inhaler stored at Resident #43's bedside. Resident #43 reported he used it, some days more often than others. On 1/4/22 at 8:45 a.m., Licensed Practical Nurse (LPN) Staff I said medication should not be left at bedside. Staff I confirmed Resident #43 did not have an assessment completed authorizing self-administration of the inhaler and leaving the inhaler at bedside would be an error. 2. On 1/4/22 at 9:15 a.m., observation of medication cart A of North Unit revealed a cup of unidentifiable loose pills in a cup in the first drawer. Licensed Practical Nurse (LPN) Staff H said those pills were meant to be administered to resident #385. Staff H reported she tried to administer the pills, but resident #385 was not available. Staff H said she kept the pills on the top drawer to give later. 3. On 1/4/22 at 09:22 a.m., observation of medication cart B of North Unit showed an unidentifiable loose capsule in an unlabeled cup in apple sauce. Photographic evidence obtained A nail clipper, cigarette lighter for residents and a full bottle of drink were stored in the medication cart. LPN Nurse H stated the drink was hers and she kept the other items for convenience. Staff H acknowledged those items are not permitted in medication cart. On 1/6/22 at 9:43 a.m., in an interview the DON verified staff should not keep their drinks in the medication cart. She also verified residents care items such as nail clippers and cigarette lighters should not be stored in the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 23 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, record review, and staff and resident interviews, the facility failed to maintain a safe, sanitary, and comfortable homelike living environment for 3 (Residents #48, #37, and #22) of 3 residents reviewed. The findings included: On 1/3/22 10:05 a.m., in an interview Resident #48, said last Wednesday he was short of breath and was given a nebulizer (a small machine that turns liquid medicine into a mist) treatment. The nebulizer tubing and mouth piece were observed uncovered at the Resident's bedside. Resident #48 said it had been there since last Wednesday. On 1/5/2022 at 9:15 a.m., the nebulizer tubing and mouth piece remained stored uncovered on the Resident's dresser. Resident #48 reiterated the nebulizer tubing and mouth piece had been on the dresser since last Wednesday. On 1/6/22 at 12:15 p.m., the nebulizer tubing and mouth piece remained uncovered on the Resident's dresser. 2. On 1/3/22 at 10:08 a.m., Resident #37 was observed in bed watching television. She said the light above her bed was not working and made it difficult to see things when there was no light. She said the light had been out for a month. On 1/6/22 at 12:30 p.m., in an interview Resident #37 complained her light was not working again. Resident pulled power cord to light multiple times and the light never came on. Resident said it has been this way as long as she has been in this room and there was no one from maintenance to fix it. 3. On 1/3/22 at 10:35 a.m. in an interview with Resident #22 she said she has a problem with maintenance. She said the remote for her television has not worked for over a month and no one will fix it or bring her a new one. She said she had to look at her roommate's television if she wanted to watch television. On 1/5/22 at 9:30 a.m., in an interview Resident #22 said she still has not received a new remote for her television. She said she was not physically able to get up and turn on the television. She also said the air conditioner plug will not stay in the outlet. She said she had to lock and prop her wheelchair up against plug so it will stay plugged in. Observed wheelchair propped against plug. When the wheelchair was moved the air conditioner's plug pulled halfway out of electrical socket. She said she has been trying to get it fixed but they don't have anyone in maintenance to fix it. Photographic Evidence Obtained On 1/6/22 at 12:30 p.m., in an interview Resident #22 said she still did not have a functioning remote control for the television and the electrical outlet was not repaired. She said she has been trying to get it fixed since she moved into the room three months ago. She said she has told everyone, but no one has fixed it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 24 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0921 Level of Harm - Minimal harm or potential for actual harm On 1/5/22 at 10:30 a.m., review of grievance log failed to document a grievance to address light, remote control, or electrical outlet plug issues. On 1/5/22 at 2:05 p.m., in an interview with Certified Nursing Assistant Staff C, said she was unaware of any problems with the light, TV remote, or electrical outlet in residents #22 and #37's rooms. Residents Affected - Few On 1/5/22 at 2:35 p.m., in an interview Licensed Practical Nurse Staff H said she couldn't remember Resident #22 or #37 mentioning any maintenance issues for their room. On 1/5/22 at 3:05 p.m. in an interview the Director of Nursing said the facility did not have a full time maintenance person at this time. She said a maintenance assistant from a sister facility came once a week to assist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 25 of 26 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 105439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide 12 hours of annual in-service education for 2 (Staff L and Staff M) of 2 Certified Nursing Assistants reviewed. The findings included: On 1/5/22, record review revealed no evidence of 12 hours of annual training for Certified Nursing Assistants (CNA) Staff L and Staff M with a date of hire of 4/1/20. On 1/5/22 at 8:15 a.m., the Business Office Manager (BOM) said the Assistant Director of Nursing (ADON) was in charge of staff development and training, but the ADON resigned. She said there was no one responsible for staff development and training. On 1/5/22 at 8:22 a.m., the Administrator said the ADON's last day at the facility was 12/24/21. The Administrator said the Director of Nursing (DON) and Unit Manager Staff D, Registered Nurse (RN) were responsible for staff development and training. She said they use [Name] University and the training records would be in the computer. On 1/5/22 at approximately 11:00 a.m., RN Unit Manager Staff D said the DON was responsible for staff development and training. On 1/5/22 at 5:20 p.m., the DON said she just took over the staff development and training position two weeks ago. She said she was not very familiar with [Name] University. The DON said the Regional Director of Operations Staff P was better versed in the system and may be able to obtain training information. On 1/6/22 at approximately 9:30 a.m., Regional Director of Operations Staff P said she could not locate the required annual training for CNA Staff L and Staff M. On 1/6/22 at 12:47 p.m., in an interview, the DON said the ADON's job was to ensure staff development and training was being completed by the staff. She said the facility discovered the required CNA training was not being completed and the ADON was let go. The DON said she has no proof the 12 hours of CNA required training was being performed on [Name] University. On 1/6/22 at 4:10 p.m., in an interview the DON said there was no facility policy for CNA training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 26 of 26