Inspection visit

Health inspectionNovember 30, 2023

NAPLES HEALTH AND REHABILITATION CENTERCMS #10543912 citations on this visit

12 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review, review of facility's policy and procedure, residents, and staff interviews, the facility failed to honor the bathing preferences for 4 (Residents #11, #15, #45 and #85) of 4 residents reviewed for bathing preferences. Residents Affected - Some The findings included: Review of facility policy titled Resident Showers implemented 11/2020 showed, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice . Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Partial baths may be given between regular shower schedule as per facility policy . Review of facility policy titled Activities of Daily Living (ADLs) reviewed / revised 11/29/22 stated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's ability in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene . Review of facility policy titled, Resident Rights reviewed/revised 3/8/2023 stated, . Respect and dignity. The resident has the right to be treated with respect and dignity including: . The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences . 1. Review of the clinical records for Resident #11 revealed a most recent readmission of 1/23/23. The resident's [NAME] (Provides instructions for care) documented Resident #11 was totally dependent on two or more persons physical assistance for bathing. The Quarterly Minimum Data Set (MDS) assessment with a target date of 9/20/23 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #11 was cognitively intact. The care plan initiated on 1/25/23 with a revision date of 6/28/23 showed the resident was at risk for decreased ability to perform ADLs (Activities of daily living) in bathing, and grooming. The interventions included extensive to total assistance with bathing, transfer with a mechanical lift, a sling and two person assistance. Review of facility's shower schedule showed Resident #11 was scheduled for showers on Wednesdays (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 28 Event ID: 105439 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 11/30/2023 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 0558 and Saturdays during the 3:00 p.m. to 11:00 p.m. shift. Level of Harm - Minimal harm or potential for actual harm Review of Certified Nursing Assistant (CNA) Point of Care (POC) documentation from 11/1/23 to 11/29/23 failed to show documentation Resident #11 received the scheduled showers on Wednesdays and Saturdays. The POC documentation documented the resident was only provided bed baths during the month of November 2023. There was no documentation that the resident refused the scheduled showers. Residents Affected - Some On 11/27/23 at 11:20 a.m., in an interview, Resident #11 said, I can't do showers because I need the sling to get out of bed. The water would just pool in the sling. When asked if the staff offers to use a mesh shower sling, the resident said he did not know that mesh shower slings even existed. When asked if he would prefer a shower the resident replied, Over a sponge bath? Hell yes. Resident #11 confirmed his shower days were on Wednesdays and Saturdays but twice a week he gets a sponge bath and his hair shampooed. On 11/28/23 at 8:53 a.m., in an interview, Resident #11 confirmed his shower/bath days were Wednesdays and Saturdays. He confirmed no one ever offers him a shower, they just give him a bed bath. Resident #11 said, I would love a shower. I did not know they have lift slings that are good for the shower. On 11/30/23 at 8:03 a.m., in an interview Resident #11 confirmed he did not receive a shower the day before, Wednesday. Resident #11 said, I would love to have a shower instead of a bed bath. No one ever offers me a shower. 2. Review of the clinical records for Resident #15 revealed an admission date to the facility of 10/18/21 with a most recent readmission date of 11/25/23. Review of the [NAME] documented resident #15 was totally dependent on two or more person physical assistance staff for bathing. Resident #15 used a mechanical lift with a large sling for transfers. The 5-day MDS assessment with a target date of 11/17/23 documented a Brief Interview for Mental Status (BIMS) score of 03 indicating Resident #11 was not cognitively intact but able to communicate his needs. Review of care plan showed the resident was at risk for decreased ability to perform ADLs in bathing and grooming. Review of facility shower schedule showed Resident #15 had scheduled showers on Mondays and Thursdays during the 7:00 a.m., to 3:00 p.m., shift. Review of the CNA Point of Care (POC) documentation from 11/1/23 to 11/29/23 showed the resident was only provided bed baths, no showers. There was no documentation that the resident refused the scheduled showers on Mondays and Thursdays. On 11/27/23 at 9:33 a.m., in an interview, Resident #15 he said he could not remember the last time he had been given a shower. On 11/27/23 (Monday) at 3:34 p.m., in an interview, Resident #15 said that he was not given or offered a shower on day shift that day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 2 of 28 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 11/30/2023 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/28/23 at 9:18 a.m., in a follow up interview, Resident #15 said he did not know the last time he was offered a shower. 3. Review of the clinical record for Resident #45, revealed an admission date of 3/7/23. Review of the [NAME] showed Resident #45 required physical help limited to transfer and one-person physical assistance for bathing. The Quarterly MDS assessment with a target date of 9/5/23 documented a Brief Interview for Mental Status (BIMS) score of 07, indicating Resident #45's cognition was moderately impaired but was able to communicate his needs. Review of care plan initiated on 4/26/23 showed the resident was at risk for decreased ability to perform ADLs in bathing and grooming. Review of the facility's shower schedule noted Resident #45's scheduled showers were on Mondays and Thursdays during the 3:00 p.m., to 11:00 p.m., shift. Review of CNA Point of Care documentation from 11/1/23 to 11/29/23 showed Resident #45 received bed baths, and one shower on 11/16/23. There was no documentation that the resident refused the scheduled showers. On 11/27/23 at 10:40 a.m., in an interview Resident #45 said he did not remember the last time he had a shower. He said, It would be nice. I would like a shower. On 11/28/23 at 9:45 a.m., in an interview, Resident #45 said he had not been offered or given a shower. He said he would like to have a shower. 4. Review of the clinical record revealed Resident #85 was admitted to the facility on [DATE] , and a most recent readmission date of 8/23/23. Review of the [NAME] showed Resident #85 required the physical assistance of one person for bathing. The Quarterly MDS assessment with a target date of 9/20/23 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #85 was cognitively intact. The care plan showed the resident was at risk for decreased ability to perform ADLs in bathing, grooming. Interventions included assistance of one with bathing. Review of facility shower schedule showed Resident #85's showers were scheduled on Wednesdays and Saturdays during the 7:00 a.m., to 3:00 p.m., shift. Review of the CNA Point of Care documentation from 11/1/23 to 11/29/23 showed Resident #85 was only provided bed baths. There was no documentation that the resident received his showers on Wednesdays and Saturdays or that the resident refused the showers. On 11/27/23 at 9:43 a.m., in an interview, Resident #85 said he couldn't remember the last time he had a shower. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 3 of 28 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 11/30/2023 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 0558 Level of Harm - Minimal harm or potential for actual harm On 11/28/23 at 9:00 a.m., Resident #85 said he would prefer to shower but he has not been offered a shower. On 11/29/23 at 1:00 p.m., in an interview, Resident #85 said, They only give me bed baths and never even mention showers. Residents Affected - Some On 11/29/23 at 9:00 a.m., in an interview, Registered Nurse (RN) Staff D said the CNAs have a schedule that they follow, then they chart in POC documentation. If the resident refuses a shower, the CNA is supposed to tell the nurse and we try to figure out why they have refused. On 11/30/23 at 8:20 a.m., in an interview, CNA Staff F said all residents have two shower days a week. A beds are done on day shift, and B beds are done on evening shifts. She said, You always offer a shower but sometimes they want a bed bath. If a resident refuses, then we need to document that they refused and tell the nurse. We then mark refused on the skin / shower sheet for the day. On 11/30/23 at 11:08 a.m., during an interview, the Regional Nurse Consultant reviewed the POC documentation, [NAME], and care plans for Residents #11, #15, #45, and #85. The Regional Nurse Consultant confirmed the lack of documentation Residents #11, #15, #45, and #85 received their scheduled showers. She verified the residents required staff assistance to shower and the lack of documentation the residents refused the showers. The Regional Nurse consultant said that the residents should have been given showers or had the reason they did not documented in the clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 4 of 28 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 11/30/2023 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility policy and procedures, staff and resident interviews, the facility failed to protect the resident's right to privacy during medical treatment for 1(Resident #249) of 2 residents observed. Residents Affected - Few The findings included: The facility policy Blood Glucose Monitoring (revised 1/2022) documented, It is the policy of this facility to perform glucose monitoring to diabetic residents as per physician's orders. The policy procedure instructed to provide privacy. On 11/28/23 at 8:57 a.m., Licensed Practical Nurse (LPN) Staff G was observed in the hallway on the South Nursing Unit obtaining a blood sample via fingerstick for blood glucose monitoring for Resident #249. The procedure was clearly visible to a hospice nurse, facility staff and other residents observed in the hallway. Resident #249 had his head down and appeared uncomfortable during the observation. On 11/28/23 at 9:00 a.m., in an interview, LPN Staff G said she was from a staffing agency and did not know she was supposed to provide privacy to the resident for blood glucose monitoring. She said, ok, I didn't know. On 11/28/23 at 10:20 a.m., in an interview Resident #249 said he felt a little funny having his blood sugar monitoring in the hallway but, they do it all the time. They don't care who is around. They are supposed to bring me to my room, but they don't do that. On 11/29/23 at 8:30 a.m., in an interview the Director of Nursing (DON) said the expectation for nurses obtaining blood glucose monitoring, was to complete the task in the resident's room and not in the hallway. The DON said there was an instruction binder located in the education room that agency staff have access to. The DON said there was not a binder at each nursing station. The DON said, most of our agency staff are not new and have worked here before and we educate them. The DON said there was nothing specific in the binder regarding a resident's right to privacy, and not providing care in the hallway. The DON confirmed he had no documentation LPN Staff G had received education on facility's policies and procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 5 of 28 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 11/30/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to provide maintenance and housekeeping services to maintain a clean and homelike environment in 4 (Rooms 136, 138, 148, and 149) of 12 rooms observed on the South Unit. The findings included: On 11/27/23 at 10:00 a.m., during an initial tour of the South Unit, the following was observed: room [ROOM NUMBER] A: The top drawer of the nightstand was broken. The floor next to the nightstand was littered with multiple personal items, soda bottles and plastic bags. The privacy curtain was stained and soiled with black and brown grime. Photographic evidence obtained. room [ROOM NUMBER] A: The paint on the wall behind the bed was peeling, exposing the dry wall. Photographic evidence obtained. room [ROOM NUMBER] A: The bed was made with a torn blanket. Photographic evidence obtained. room [ROOM NUMBER] B: The privacy curtain had multiple large brown stains. Photographic evidence obtained. On 11/29/23 at 8:43 a.m., during a joint observation, the Maintenance Director verified the broken nightstand and the soiled privacy curtain in room [ROOM NUMBER] A. On 11/29/23 at 9:50 a.m., during a joint tour of the South Unit with the Housekeeping Supervisor she verified the privacy curtains in rooms 136 A and 149 A were dirty and stained, and the torn blanket in room [ROOM NUMBER] A. The Housekeeping Supervisor said the privacy curtains are cleaned weekly. She provided a cleaning schedule but no documentation the privacy curtains were cleaned. On 11/30/23 at 9:44 a.m., the privacy curtains in rooms 136 A, and 149 A remained dirty and stained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 6 of 28 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 11/30/2023 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 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, review of facility's policies and procedures, staff and resident interviews, the facility failed to file and maintain an accurate record of grievances for 3 (Residents #74, #83, and #3) of 3 residents reviewed. The findings Included: The facility Resident and Family Grievances policy Implemented 11/2020 and revised 3/8/2022 stated, It is the policy of this facility to support each resident's and family member's right to voice grievances . The policy noted the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form; Forward the grievance form to; the Grievance Official as soon as practicable; The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. On 11/27/23 at 11:30 a.m., in an interview, Resident #74 said he had been a resident at the facility for three months. He said the laundry had lost all his clothes. He said he spoke with the laundry again five days ago and has not gotten his clothes back yet. On 11/27/23 at 12:20 p.m., in an interview, Resident #83 said he has not received any clothes back from the laundry in one month. He said that he was missing 96 out of 100 pieces of laundry and had told the Administrator about it. The resident said, I have to keep wearing the same dirty clothes. He said the facility had bought him clothes before to replace the lost ones but now they were lost too. On 11/29/2023 at 5:10 p.m., Resident #83 said the Administrator spoke with him again and he was confident that the laundry problem would be resolved to his satisfaction. On 11/27/2023 at 12:50 p.m., in an interview, Resident #3 said she had been at the facility for six months. She said she had reported lost laundry items to the Administrator a long time ago and nothing had been replaced. On 11/29/2023 at 4:40 p.m., in an interview, Resident #3 stated she had lost 12 bras that had been sent to the laundry. She said when she was admitted to the facility she had 16 bras with her. She said she has spoken to the Administrator, but nothing has been done regarding her missing items. She said she had them upon admission and remembered itemizing them on her property. Resident #3 hard chart was reviewed at the nurse's station. No inventory list of personal belongings were in the chart. On 11/30/23, review of the facility's Grievance Log provided by the facility failed to show documentation of Residents #74, #83, and #3's grievances for the missing laundry items. On 11/30/23 at 11:20 a.m., the Administrator said she knew Resident #74 had complained about missing clothing, but she was unsure what had happened to them. She verified the lack of a written (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 7 of 28 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 11/30/2023 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 grievance for Resident #74's missing clothes and steps taken to resolve the grievance. She said she was aware Resident #83 complained two different times about missing clothes. She said the facility replaced and paid for the lost clothes and now those were missing. The Administrator said she was not able to locate any grievance addressing Resident #83's missing clothes. The Administrator said the facility started a performance improvement plan in March 2023 for laundry and grievances. She said the facility had, Room for improvement for grievances. The Administrator said Resident #3 never spoke to her about any missing bras. She said inventories are not completed 100% upon admission as they are required to be. She said the facility has a PIP (Performance Improvement Project) that was initiated 3/6/2023 for laundry. It specifically states to use inventory sheet and label clothing items. They have a PIP for grievances that also started in March 2023. The Administrator said the facility Has room for improvement where the grievance PIP is concerned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 8 of 28 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 11/30/2023 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on record review, review of the facility's policies and procedures and staff interviews, the facility failed to ensure the appropriate Pre-admission Screening and Resident Review (PASARR) for 2 (Residents #87, and #77) of 2 residents admitted to the facility with a diagnosis of Serious Mental Illness or Intellectual Disability. Residents Affected - Some The findings included: Review of the facility policy for Resident Assessment - Coordination with PASARR Program revised 9/19/22 indicated the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder (MD), ID (intellectual disability), or a related condition receives care and services in the most integrated setting appropriate to their needs. PASARR Level II- a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. Review of the clinical record for Resident #87 revealed an admission date to the facility of 7/15/23. Resident #87 was transferred to the local hospital with return anticipated on 10/17/23 (returned on 10/20/23), and 11/10/23 (returned on 11/14/23). Review of the Level I PASARR form dated 7/12/23 completed at a local hospital noted the resident had a current diagnosis of an ID (Intellectual disability), mild, moderate, severe, or profound (Section I B). The form noted a Level II PASARR evaluation must be completed prior to admission is any box in section I.A. or I.B. is checked and there is a yes checked in Section II.1, II.2, or II.3, unless the individual meets the definition of a provisional admission or a hospital discharge exemption. Section II (II.1, II.2, and II.3) addressing other indications for PASARR Screen Decision-Making were all checked yes. The form noted Resident #87 was being admitted under the 30-day hospital discharge exemption. The instructions on the Level I PASARR form (Section III) specified, If a provisional admission or hospital discharge exemption is indicated, the individual may enter a NF (Nursing Facility) without a Level II PASRR evaluation/determination if the Level I screen indicates a suspicion of Serious Mental Illness, Intellectual disability or both, and the box in Section II.4 is checked no. Further review of the Level I PASARR form showed the box in Section II.4, Has the individual exhibited actions or behaviors that may make them a danger to themselves or others? was checked yes. Review of the admission Minimum Data Set (MDS) assessment (standardized assessment to facilitate care management in nursing homes) with a target date of 7/21/23 noted Yes was checked for the question, Has the resident been evaluated by Level II PASARR and determined to have a serious mental illness and/or mental retardation or a related condition? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 9 of 28 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 11/30/2023 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 0645 Level of Harm - Minimal harm or potential for actual harm The clinical record lacked documentation a Level II PASARR was completed prior to admission to the facility. On 11/29/23 at 9:33 a.m., the Regional Nurse said she could not locate a Level II PASARR screen in Resident #87's record. Residents Affected - Some On 11/29/23 at 4:07 p.m., in a telephone interview, a representative of the state designated authority confirmed Resident #87 required a Level II screen, but the facility had not applied for it. Review of the clinical record for Resident #77 revealed an admission date of 8/29/22. The documented medical history at the time of admission included diagnoses of bipolar disorder and Depression. Bipolar disorder is defined as a disorder associated with episodes of mood swings ranging from depressive lows to manic highs. On 11/27/23 at 12:40 p.m., in an interview Resident #77 said she was diagnosed with Bipolar Disease, years ago. On 11/30/23 at 11:20 a.m., the Administrator provided two level I PASARR forms dated 7/7/23, and 8/25/23 for Resident #77. The forms were inaccurate and did not list the diagnosis of Bipolar Disorder. There was no documentation that the facility completed an accurate Level I PASARR, or referred the resident for a level II review to ensure the resident received services appropriate to her needs. On 11/30/2023 at 1:55 p.m., in an interview, the Administrator said the PASARR I screen should have been corrected and Resident #77 should have been referred for a PASARR II screen since she had a diagnosis of bipolar disorder and depression. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 10 of 28 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 11/30/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of the clinical record, review of facility policies and procedures, and resident and staff interviews the facility failed to provide the necessary care and services to maintain personal hygiene and bathing for 3 (Residents #1, #9 and #249) of 10 residents reviewed for activities of daily living. Residents Affected - Few The findings included: The facility policy Activities of Daily Living ADL's) revised (11/29/22) documented The facility will, based on the resident's comprehensive assessment and consistent with the residents needs and choices, ensure a residence abilities and ADL's do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. The facility policy Resident Showers documented It is the practice of this facility to assist residents with bathing to maintain proper hygiene stimulate circulation and help prevent skin issues as per current standards of practice as resident request allows tolerates or agrees. 1. Review of the clinical record revealed Resident #1 had a readmission date of 11/14/23 with diagnoses including hemiparesis (weakness of one side of the body) following cerebral infarction affecting the left side. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 9/12/23 documented Resident #1 required extensive assistance of one person for personal hygiene, dressing and bathing. The MDS noted Resident #1's cognitive skills for daily decision making were intact. The plan of care revised on 4/13/23 identified Resident #1 had limited abilities for self-care. On 11/27/23 at 10:03 a.m., in an interview and observation, Resident #1 said the staff do not shower him and do not brush his teeth. Resident #1 smiled to show the food and debris on his teeth. His tongue was coated white. His fingernails were long, extending approximately 1/2 inch from the base with a brown substance under the nail beds. He said, The staff do not always assist me, and the agency staff are worse. On 11/28/23 at 9:24 a.m., Resident #1 said, I did not get my teeth brushed yesterday and I did not get a shower. I did not get shaved. Resident #1 had approximately two days of facial hair growth. His left hand was contracted at the wrist and the upper portion of his fingers on the left hand were contracted. Resident #1 had a strong odor of urine on his person. Review of the Certified Nursing Assistant (CNA) shower scheduled revealed Resident #1 was scheduled for showers on the 3-11 shift every Wednesday and Saturday. Review of the CNA documentation through November 28, 2023, showed Resident #1 did not receive his scheduled shower on 11/1/23, 11/4/23, 11/8/23, 11/15/23, and 11/22/23. The CNA documentation specified Resident #1 was to receive oral care each shift. The documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 11 of 28 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 11/30/2023 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 0677 showed in the last 28 days over 3 shifts with 84 opportunities Resident #1 received oral care 22 times. Level of Harm - Minimal harm or potential for actual harm Review of the progress notes showed no documentation Resident #1 had refused showers or oral care. Residents Affected - Few On 11/30/23 at 10:26 a.m., in an interview CNA Staff F said, I know my residents because I have been working a long time here. Resident #1 has uncontrolled movements because of his disease. When he has them, he does not want a shower, so I give a bed bath and I tell my supervisor. I will give him a shower the next day if he wants to take one. I know him very well because I am with him every day, this is my assignment. If a resident refuses a shower I tell the nurse. 2. Review of the clinical record revealed Resident #9 had an admission date of 12/10/21 with diagnoses including dementia, anxiety, major depressive disorder and chronic obstructive pulmonary disease. The Quarterly MDS with an assessment reference date of 9/1/23 documented Resident #9 required limited assistance of one person for personal hygiene, dressing and bathing. The MDS noted Resident #9's cognitive skills for daily decision making were intact. The plan of care initiated on 12/13/21 identified Resident #9 was at risk for decreased ability to perform ADLS in bathing, grooming, personal hygiene and dressing related to chronic disease process and impaired mobility. On 11/27/23 at 11:17 a.m., Resident #9 was observed in his room in bed. He had a pungent body odor. The room had a strong urine odor. The resident said he was not receiving showers and did not receive the assistance he needed with his care. He was unshaven with about three days growth; his fingernails had a brown substance under the nail beds. Resident #9 appeared unkempt, and his hair was not combed. On 11/28/23 at 9:00 a.m., Resident #9 was in his bed dressed in the same clothing as the prior day. Resident #9 said no one had assisted him or showered him. Resident #9 had a strong, unpleasant body odor and his room smelled of urine. Review of the shower schedule showed Resident #9 was scheduled for a shower on the 7:00 a.m., to 3:00 p.m., shift on Mondays and Thursdays. Review of the CNA documentation for November 2023, showed Resident #9 did not receive a scheduled shower on 11/9/23, 11/13/23, 11/16/23, 11/20/23 and 11/27/23. The documentation revealed resident #9 received only two showers from 11/1/23 to 11/28/23. On 11/29/23 at 4:00 p.m., the Regional Nurse Consultant (RNC) said, Resident #9, had agreed to a shower last night and the CNA got him into the shower room but she had to go and get towels and left him in the shower room. When she returned, he had wheeled himself out and refused to go back into the shower room. The CNA came and told me, and I was not able to talk him into a shower, so I made sure I documented that he refused. The RNC said the process when a resident refuses a shower after several attempts, it is documented as refused. The RNC said, I understand if it is not documented, there is no proof of it happening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 12 of 28 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 11/30/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/30/23 at 9:13 a.m., in an interview, CNA Staff A said the shower schedule was on the shower sheet in the CNA assignment binder. She said Resident #9 will fight you sometimes I have to keep going back and asking him. If he keeps refusing, I tell the nurse. 3. Review of the clinical record revealed Resident #249 had a readmission date of 11/3/23 with diagnoses including bilateral leg amputee, major depressive disorder, dizziness and adjustment disorder. The Quarterly MDS with an assessment reference date of 11/7/23 documented Resident #249 required partial assistance of one person for bathing. The MDS noted Resident #249's cognitive skills for daily decision making were intact. The plan of care initiated on 10/2/23 identified Resident #249 was at risk for decreased ability to perform ADLS in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, right below knee amputation and left above knee amputation. On 11/27/23 at 10:28 a.m., in an interview Resident #249 said he did not get showers because he was a double amputee and was not able to walk in to the shower room. He said he would love a shower, but the staff tell him he was not able to get one because he can't stand. He said the staff did not use any type of mechanical lift for him to bathe. On 11/28/23 at 10:18 a.m., Resident #249 said he still had not received a shower this month, he said, They wash you up in bed, what the hell is that? I want a shower and not in bed. I tell the Administrator and the Director of Nursing but nothing gets done. Review of the CNA shower schedule revealed Resident #249 was scheduled for showers on the day shift every Monday and Thursday. Review of the CNA documentation showed Resident # 249 received no scheduled showers from 11/3/23 to 11/29/23, only random bed baths. There was no documentation in the clinical record to indicate Resident #249 had refused his scheduled showers. On 11/29/23 at 10:05 a.m., in an interview, Registered Nurse (RN) Staff D said the shower list was in the CNA schedule binder and it goes by room numbers not resident names. The RN said when the CNA completes the shower, they turn in a skin monitoring form that lets me know if there was a skin issue. The RN confirmed there was no way of knowing if a shower, or bed bath was provided. The RN said we know our residents and if the CNA signs the skin monitoring form, it means that resident got a shower. Some of the staff write bed bath on the sheet but it did not indicate a partial or full bed bath. RN Staff D said, We know some residents only take bed baths. If they refuse a shower I speak with them and see what it is I can do. On 11/29/23 at 10:09 a.m., in an interview, CNA Staff A said, The shower list is at the desk, and we sign the skin monitoring form. If a resident said they don't want a shower, I come back again and ask. I will tell the nurse at the end of the shift to see if she can talk them into it. Sometimes I can get the resident to say yes, and they take a shower or let me give a bed bath. On 11/30/23 at 3:00 p.m., in an interview the RNC, confirmed there was no documentation Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 13 of 28 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 11/30/2023 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 0677 #249 received the scheduled showers 11/3/23 to 11/29/23. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 14 of 28 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 11/30/2023 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 record review, and staff interview, the facility failed to ensure monitoring and care of cardiac pacemaker for 1 (Resident #90) of 1 resident reviewed for pacemakers. Residents Affected - Few The findings included: Review of the facility policy for Use of Pacemaker revised on 3/7/23 indicated residents with a pacemaker will be monitored according to protocol and plan of care. Documentation about the pacemaker will be placed in the resident's chart and part of their permanent record. Pacemaker checks will be performed as ordered by the physician. Review of the clinical record for Resident #90 revealed an admission date to the facility of 8/10/23. The hospital documentation dated 8/2/23 noted Resident #90 had a history of cardiac pacemaker. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 8/10/23 noted Resident #90 had a cardiac pacemaker. Review of Resident #90's admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident had a Cardiac Pacemaker. Review of the resident's care plan initiated on 8/11/23 revealed Resident #90 was at risk for cardiovascular complications related to A-fib, history of arrhythmias, and pacemaker. The interventions included to check the pacemaker as ordered. The physician's orders did not include instructions for the pacemaker. On 11/27/23 at 11:52 a.m., Resident #90 was observed in her room sitting on the side of bed. Resident #90 did not respond to interview questions and laid down in bed. On 11/28/23 at 04:04 p.m., Licensed Practical Nurse (LPN) Staff T said she was taking care of Resident #90, but she did not know the resident had a pacemaker. On 11/28/23 at 4:57 p.m., review of Resident #90's progress notes from 8/10/23 to 11/3/23 revealed no documentation addressing care of the resident's pacemaker. The last progress note was dated 11/3/23. On 11/28/23 at 4:45 p.m., Review of the appointment book on the North Unit from August 2023 through November 2023 revealed no follow-up cardiology appointments for Resident #90, including an appointment to check the pacemaker. On 11/29/23 at 10:44 a.m., in an interview, the Director of Nursing (DON) confirmed Resident #90 had a pacemaker. He verified the clinical record had no information on how to care for it. He said there was a care plan to check per doctor's orders, but no doctor's orders for the pacemaker. The DON said there should have been cardiology follow-up and instructions on how to care for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 15 of 28 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 11/30/2023 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 pacemaker. He confirmed the facility had not scheduled a cardiology follow-up appointment for Resident #90. On 11/29/23 at 12:00 p.m., in an interview, the Advanced Practice Registered Nurse said Resident #90 should be referred to cardiology for instructions for the pacemaker. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 16 of 28 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 11/30/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observations, record review, review of facility's policies and procedures, and interviews, the facility failed to provide appropriate urinary catheter care and monitoring for 2 (Residents #64 and #85) of 2 sampled residents with urinary catheter to prevent urinary tract infections. The findings included: Review of facility policy titled, Catheter Care revised 1/6/23 states, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use . Catheter care will be performed every shift and as needed by nursing personnel . 3. Privacy bags will be changed out when soiled, with a catheter change or as needed. 4. Leg bags may be used for ambulatory residents or per resident request . 1. Review of the clinical record for Resident #64 revealed an initial admission date of 3/8/22 with a most recent readmission date of 11/22/23. Diagnoses included bladder-neck obstruction. Resident #64 had an indwelling urinary catheter (catheter inserted into the bladder to drain urine). The physician's orders for Resident #64 dated 10/27/23 included to change the catheter drainage bag PRN (as needed) for blockage or leakage. The care plan initiated on 10/3/23 noted the resident had an indwelling catheter. The goal was for the resident to have no signs and symptoms of urinary tract infection. The interventions included to keep catheter off the floor. Reviewe of the resident's laboratory results showed the resident had a urinary tract infection on 3/27/23, 10/11/23 and 10/31/23. On 11/27/23 at 3:39 p.m., Resident #64 was observed walking down the South Unit hall to the alcove where the vending machines were located. The catheter urine collection bag was on the floor behind the resident. Resident #64 dragged the catheter urine collection bag behind her on the floor down the entire hall. Photographic evidence obtained. Registered Nurse (RN) Staff D was immediately notified of the observation. Staff D assisted the resident into a wheelchair and took her back to her room. Review of the Medication Administration Record (MAR) and Treatment Administration Records (TAR) noted on 11/28/23 the catheter was reinserted after Resident #64 pulled it out. This was the only reinsertion during November 2023 and no collection bag changes were documented for November 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 17 of 28 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 11/30/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/28/23 at 4:30 p.m., in an interview, RN Staff H caring for Resident #64 said the catheter urine collection bag and tubing should be changed right away if the catheter bag was on the floor due to contamination. Staff document on the TAR when the bag is changed and enter a progress note. On 11/29/23 at 9:00 a.m., in an interview, RN Staff D said on 11/27/23 when Resident #64's urinary catheter bag was observed on the floor, she assisted the resident back to her room. She said, I got her nurse since she was not on my assignment. I told her to assess the resident, make sure the catheter had not gotten dislodged and to get a stat device to secure the catheter to her leg. I told her she needed to change the collection bag and to document. She was not my patient, so I did not do those things myself. 2. Review of the clinical record for Resident #85 revealed an initial admission date of 6/23/23 and a most recent readmission date of 8/28/23. Diagnoses included obstructive uropathy and urinary retention. Resident #85 had a urinary catheter inserted in the bladder. The care plan for the urinary catheter included interventions to keep the catheter bag off the floor. Review of the laboratory results showed the resident had a urinary tract infection on 10/23/23. On 11/27/23 at 9:43 a.m., and 10:12 a.m., observed Resident #85 in bed. The catheter urine collection bag was on the floor by the bed, slightly under wheelchair. Photographic evidence obtained. On 11/27/23 at 3:29 p.m., the urinary catheter collection bag remained on the floor under wheelchair. Photographic evidence obtained. In an interview at the time of the observation, Resident #85 said, I think they do what they are supposed to do. On 11/28/23 at 4:30 p.m., in an interview, RN Staff H who was caring for Resident #85 said the catheter urinary collection bag and tubing should be changed right away if the catheter bag was on the floor due to contamination. The staff document on the TAR when the bag is changed and enter a progress note. On 11/28/23 at 4:45 p.m., in an interview, Certified Nursing Assistant (CNA) Staff J said if she saw a collection bag on the floor, she would have the nurse change the collection bag. On 11/29/23 at 1:39 p.m., in an interview, the Director of Nursing (DON) verified the lack of documentation that the urinary collection bags and tubing were changed for Residents #64 and #85 when the bags were observed on the floor. The DON said, That should not have happened, they should have changed the bag right away. We have a lot of education to do. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 18 of 28 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 11/30/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm On 11/30/23 at 12:32 p.m., in an interview, the facility's Infection Preventionist confirmed that if a urinary collection bag was on the floor it was an infection control concern. She said, They should have changed everything, the bag and the tubing. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 19 of 28 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 11/30/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to provide an ordered therapeutic carbohydrate control diet for a diabetic for 1 (Resident #11) of 1 diabetic resident reviewed. Residents Affected - Few The findings included: Review of facility clinical services policy titled, Therapeutic Diet Orders implemented 11/3/2020 stated, Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment / plan of care, in accordance with his/her goals and preferences . Therapeutic Diet is a diet ordered by a physician, or delegated registered or licensed dietician, as part of treatment for a disease or clinical condition. It also may be ordered to eliminate, decrease, or increase specific nutrients in a diet. Examples include low salt, diabetic, or low cholesterol diets . 2. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to: .d. Medical conditions such as diabetes, renal disease, or heart disease .5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/ or the appropriate nutritive content as prescribed. Review of facility dietary services policy titled, Therapeutic Diets, Policy #008 with a revision date of October 2019 noted, It is the Center policy to ensure that all residents have a diet order, including regular, therapeutic, and texture modified, prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines . Diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care . Review of the clinical record for Resident #11 documented an admission date to the facility of 1/23/23. Diagnoses on admission included Type 2 Diabetes Mellitus. The Physician dietary orders dated 1/23/23 noted a therapeutic diet of Consistent Carbohydrate (CCHO) diet. The care plan revised on 11/10/23 noted Resident #11 has a potential for alterations in nutritional status related to the therapeutic diet. The interventions included to explain and reinforce to the resident the importance of maintaining the diet ordered, encourage the resident to comply, and provide diet as ordered. On 11/27/23 at 11:20 a.m., in an interview, Resident #11 said the meals don't reflect what the meal ticket says. The resident said he has asked for sugarless maple syrup many times since he is diabetic, but he still gets the regular syrup. Resident #11 said, They never give it to me. I bought some for myself from the store. I am diabetic I know I am not supposed to have the other one. On 11/28/23 at 8:55 a.m., Resident #11 was observed having breakfast at bedside. The resident had pancakes. The meal ticket said, Diet table syrup. The syrup provided to the resident as part of his meal was not diet. The ingredients listed on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 20 of 28 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 11/30/2023 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 0692 packet of syrup included corn syrup and high fructose corn syrup. Level of Harm - Minimal harm or potential for actual harm Photographic evidence obtained. Resident #11 said, See I told you. I can't have that. I am diabetic. Residents Affected - Few On 11/29/23 at 8:30 a.m., in an interview Certified Nursing Assistant (CNA) Staff J said the nursing staff check the meal trays and the meal tickets before bringing them to the resident. CNA Staff J confirmed she knew Resident #11 was on a diabetic diet. When asked what she would do if the ticket and meal did not match. CNA Staff J said she would not give it to the resident and instead bring to the kitchen to have it corrected. When asked if she knew if the facility had no sugar pancake syrup, CNA Staff J said she thought they did. On 11/29/23 at 12:24 p.m., the Certified Dietary Manager (CDM) confirmed the facility has sugar free items including pancake syrup for the diabetic residents. The CDM reviewed the photographic evidence obtained of the syrup provided to Resident #11 with the breakfast meal and confirmed it was not a sugar free syrup. The CDM verified the meal ticket noted Resident #11 was on a therapeutic diet that was carbohydrate controlled due to the diabetes. The CDM said, He should have gotten the sugar free syrup. When asked about the process for ensuring the tray items matched the meal ticket, the CDM said, The second person in the kitchen is usually the check person and they put on the condiments at the end. I am not sure how they do it, I'm not sure if they have a standardized process in the kitchen. The CDM said the risks of providing the resident the incorrect syrup was that their sugar could go right through the roof and there could be other complications as well. On 11/29/23 at 12:36 p.m., the Director of Nursing (DON) was interviewed about the process for checking the meals at time of delivery to ensure correct items are on the meal tray. The DON said the CNA would be the person that checks the tray at the point of delivery. After reviewing the photographic evidence obtained for the breakfast meal of Resident #11, the DON said, This should not have happened. The DON confirmed the risk to the resident included an elevated blood sugar. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 21 of 28 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 11/30/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to ensure that 1 (Resident #15) of 17 residents receiving respiratory treatment received physician ordered oxygen consistent with professional standards of practice, and the comprehensive person-centered care plan. Residents Affected - Few The findings included: Review of facility policy titled Oxygen Therapy reviewed/revised 5/4/2022 stated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia. Oxygen is administered under orders of a physician, except in the case of an emergency . Review of the clinical record for Resident #15 document initial admission to the facility on [DATE] and readmission to the facility on [DATE]. Diagnoses included history of influenza virus with other respiratory manifestations. The physician orders dated 11/25/23 included, Oxygen at 2 liters/ min via nasal cannula (device with two nasal prongs to deliver oxygen into the nostrils), every shift. The care plan created 4/26/23 noted, Resident exhibits or is at risk for respiratory complications related to dx (diagnosis) of SOB (shortness of breath), Cough. The interventions included, Administer oxygen as ordered. On 11/27/23 at 9:33 a.m., Resident #15 was observed in bed. The oxygen concentrator was set at one liter per minute. Photographic evidence obtained. The nasal cannula prongs were on the resident's left cheek, not in the nostrils. On 11/27/23 at 3:34 p.m., Resident #15 was observed in bed. The oxygen concentrator remained set at one liter per minute. Photographic evidence obtained. The nasal cannula prongs were resting on the resident's neck not in the nostrils. On 11/28/23 at 9:18 a.m., Resident #15 was observed in bed. The oxygen concentrator remained set at one liter per minute. Photographic evidence obtained. The nasal cannula was not in the resident's nostrils and observed hanging over concentrator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 22 of 28 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 11/30/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview at the time of the observation, Resident #15 was asked if they had stopped his oxygen. Resident #15 replied, No they took it off last night and did not give it back. On 11/28/23 at 12:30 p.m., in an observation of Resident #15 with Licensed Practical Nurse (LPN) Staff G, she verified the oxygen concentrator was set to one liter and the nasal cannula was draped over the concentrator and not in use. LPN Staff G said the concentrator should be set to two liters. Staff G said, I don't know why it was not on the resident or set low. Review of the Medication Administration Records (MAR) for oxygen administration, progress notes and oxygen therapy showed no documentation that the resident refused the oxygen therapy. On 11/29/23 at 1:45 p.m., in an interview, the Director of Nursing (DON) confirmed Resident #15 was supposed to be on two liters of oxygen via nasal cannula. The DON reviewed all three photographic evidence obtained and verified the oxygen concentrator was set to one liter on all three observations. The DON confirmed the clinical record did not document the resident refused the oxygen. The DON said, If he won't wear it then they need to document that, but the flow is definitely wrong. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 23 of 28 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 11/30/2023 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy and procedure and resident and staff interview, the facility failed to ensure freedom from significant medication error for 2(Resident #9 and #56) of 6 residents reviewed for medication administration. Failure to administer medications accurately puts residents at risk for adverse health consequences. Residents Affected - Some The findings included: The facility policy Medication Administration (revised 10/23) documented Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. The policy specified to sign the MAR (Medication Administration Record) after the medication was administered. On 11/27/23 at 11:09 a.m., in an interview, Resident #9 said he was supposed to receive eye drops for his dry eyes but rarely gets it. He said, the nurses tell me they don't have it. He said his eyes bother him because they get very dry when he does not receive the drops. Review of Resident #9's clinical record revealed a physician order for Lubricant Eye Drops Ophthalmic Solution. Instill one drop in both eyes two times a day for dry eyes. Review of the Medication Administration Record (MAR) for November 2023 lacked documentation Resident #9 received 32 of 50 doses of the eye drops as ordered in 25 days. The MAR documented a 9 in place of a nurses initials for the 32 missed doses. On 11/29/23 at 8:46 a.m., in an interview the Director of Nursing (DON), said he was not aware Resident had missed 32 doses of his eye medication. The DON said, Resident #9 likes to refuse everything. He refuses care, medications, you name it. The DON said he would find out why the resident was not receiving the scheduled eye drops. On 11/29/23 at 11:15 a.m., in an interview Registered Nurse Staff I said Resident #9 did not receive his eye drops because the medication was changed from a drop to a gel and we did not have the medication in stock. The Pharmacy was informed they would need to send it but they never did. I called the pharmacy, and he has the medication now, it came in the other night. I have charted that we did not have the eye drops and I notified the Registered Nurse Practitioner. On 11/30/23 at 8:34 a.m., in an interview the Regional Nurse Consultant (RNC) said the reason Resident #9 did not receive his eye drops was because he refused them and the MAR was not coded correctly. She explained the nurse should have documented the drops were refused. The RNC said there was no other documentation as to why he did not receive the drops, the nurses just coded the MAR wrong and it should have documented he refused the doses. On 11/30/23 at 10:50 a.m., in an interview the RNC said she was not able to locate any documentation for the reason Resident #9 did not receive the ordered eye drops and no documentation the Physician was notified, there is nothing. The RNC said 9 on the MAR indicates a nurses note was written regarding why the medication was not administered but did not find any documentation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 24 of 28 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 11/30/2023 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 0760 Level of Harm - Minimal harm or potential for actual harm 2. Review of the clinical record showed Resident #56 had an admission date of 6/22/21 and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus. On 11/27/23 at 1:12 p.m., Resident #56 said he does not receive his insulin as scheduled, receiving the morning insulin at noon and the other dose at 2:00 p.m., on occasions. Residents Affected - Some He said he was lucky because he did not get sick, dizzy or anything but was concerned about getting the morning insulin too close to the evening dose. Review of the clinical record revealed a physician order for Lispro (75-25) 100 unit/milliliter suspension pen-injector. Inject 5 units subcutaneous two times a day. Review of the MAR showed Resident #56 's insulin was ordered for administration at 9:00 a.m., and 5:00 p.m. On 11/29/23 at 12:17 p.m., the RNC provided the Medication Administration Audit Report for Resident #56 for the month of November from 11/5/23 to 11/29/23. The report documented the time the nurse administered the insulin. The report documented the 9:00 a.m., insulin dose was documented as administered on: 11/5/23 at 2:17 p.m. 11/7/23 at 10:07 a.m. 11/8/23 at 12:18 p.m. 11/11/23 at 10:56 a.m. 11/12/23 at 10:45 a.m. 11/14/23 at 10:19 a.m. 11/17/23 at 1:23 p.m. 11/18/23 at 10:56 a.m. 11/21/23 at 10:59 a.m. 11/26/23 at 10:14 a.m. The 5:00 p.m., insulin dose was documented as administered late on: 11/6/23 at 7:31 p.m. 11/13/23 at 6:23 p.m. 11/19/23 at 7:48 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 25 of 28 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 11/30/2023 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 0760 11/2023 at 8:16 p.m. Level of Harm - Minimal harm or potential for actual harm Review of the clinical record revealed no documentation for the late administration of the insulin and no documentation the physician was notified. Residents Affected - Some On 11/30/23 at 12:36 p.m., in an interview, the RNC said she understood the concern but felt it may just be a documentation error as the nurse may have forgotten to go back and change the administration time to 9:00 a.m., or 5:00 p.m. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 26 of 28 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 11/30/2023 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 - 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** 2. On 11/27/23 at 1:06 p.m., Resident #56 was observed with two bottles of CQ-10 supplements and one bottle of vitamins stored on the bedside table. The resident said he has been taking the supplements for years and keeps them on the bedside table. He said, They are right there on the table, it's not like I'm hiding them. Photographic evidence obtained. On 11/27/23 at 3:30 p.m., during observation and interview, Licensed Practical Nurse (LPN) Staff E verified the unsecured bottles of medication at Resident #56's bedside. LPN Staff E said she did not know what the process was for residents who had medications at the bedside, but would find out and obtain a physician's order. On 1/30/23 at 8:39 a.m., in an interview the Regional Nurse Consultant (RNC), confirmed Resident #56 had not had an assessment completed to see if he was capable to safely administer the medications and safely store them at his bedside. Based on observations, review of facility policy, staff and residents interviews, the facility failed to ensure safe storage of medications for 3 (Residents #3, #74, and #56) of 3 residents observed with unsecured medications at the bedside and 1 unlocked, unattended medication cart (South Unit) of 2 units observed. The findings included: Review of facility policy titled Medication Storage reviewed/ revised 5/4/2022 which stated, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanations and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls .c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the mediation storage area/ cart. 1. On 11/29/23 at 12:15 p.m., an unsecured and unattended medication cart was observed in South B Hall. Photographic evidence obtained. Several staff members, residents, and two visitors were observed in the hall walking next to the unsecured, unattended medication cart. On 11/29/23 at approximately 12:20 p.m., Licensed Practical Nurse (LPN) Staff G walked out of room [ROOM NUMBER]. LPN Staff G verified she left the medication cart unlocked and unattended. She locked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 27 of 28 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 11/30/2023 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 the cart and said, I know it is supposed to be locked. LPN Staff G was asked what risks were for leaving the medication cart unsecured. She said, Anyone could open it up and get at the meds. On 11/29/23 at 4:30 p.m., in an interview the Director of Nursing (DON) said staff should never leave the medication cart unlocked and unattended. He said, It is a risk that anyone could access the medications. Residents Affected - Some On 11/30/23 11:00 a.m., in an interview the Regional Nurse Consultant (RNC) confirmed all medication carts were to be locked when the nurse was not actively at the cart. She confirmed it was against policy and procedure to leave the medication cart unlocked and unattended. 3. On 11/27/2023 at 12:50 p.m., during an interview with Resident #3, a bottle of over the counter Benzocaine oral pain relief was observed on the resident's bedside table. Photographic evidence obtained. She said she's had the medication for a long time and used it as needed. She said the nurses were aware she had the medication. During medical record review Resident #3's Physician orders did not include any order for resident to store or self-administer any medications; There was no Physician order for the Benzocaine. There was no assessment to self-administer and store medications, and the care plan did not identify the resident as able self-administer and store medications in her room. 4. On 11/27/23 at approximately 11:20 a.m., in an interview with Resident #74, he said he had been a resident at the facility for months. He had a bottle of Docusate Sodium (stool softener) at bedside. Photographic evidence obtained. He said he's kept the bottle of Docusate Sodium on his bedside table since admission and took it as needed for constipation. He said the staff were aware he had the medication at the bedside. On 11/30/2023 at 9:30 a.m., in an interview, the Regional Nurse Consultant said she was made aware that Resident #74 had a bottle of Docusate Sodium at bedside, and verified the resident did not have a physician's order for the Docusate Sodium and had not been evaluated for self administration and the safe storage of the Docusate Sodium. She said she was not aware Resident #3 kept the oral Benzocaine at bedside but would address it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 28 of 28

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Citations

12 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0558GeneralS&S Epotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0583GeneralS&S Dpotential for harm
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0585GeneralS&S Epotential for harm
F585 - Grievances
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.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0690GeneralS&S Epotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0760GeneralS&S Epotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
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.
0645GeneralS&S Epotential for harm
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities

FAQ · About this visit

Common questions about this visit

What happened during the November 30, 2023 survey of NAPLES HEALTH AND REHABILITATION CENTER?

This was a inspection survey of NAPLES HEALTH AND REHABILITATION CENTER on November 30, 2023. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at NAPLES HEALTH AND REHABILITATION CENTER on November 30, 2023?

Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·November 30, 2023