Inspection·March 28, 2024

F 0849 Level of Harm - Actual harm Residents Affected - Few The facility will immediately contact and communicate with the hospice staff, attending physician/practitioner and the family resident representative regarding any significant changes in the resident's status, clinical complications, or emergent situation. On 3/27/24, a review of Resident #1's medical record revealed Resident #1 was admitted to hospice services on10/23/23 for the diagnosis of End Stage Cerebral Atherosclerosis. Resident #1 was admitted to the facility on [DATE]. On 2/20/24, Resident #1 fell out of bed. An X-ray was completed showing a femur (upper leg) fracture. Resident #1 was sent to the emergency room and returned the same day with a leg immobilizer after consulting with the emergency room physician and decided for comfort measures and conservative treatment. On 3/27/24 at 12:34 p.m., during an interview the Unit Manager said the nurse will enter a progress note in the electronic health record when hospice provides any updates. Ultimately the facility nurse is responsible for that patient. I was told during a routine skin assessment she had developed a small wound and the bone was sticking out on 3/6/24. My first call to hospice related to the exposed bone was on 3/13/24. I did not call the primary physician or the Nurse Practitioner and tell them the bone was sticking out. I did not call the family at any point about the resident having pain or a bone sticking out of her leg. That call would have been done by the primary nurse taking care of her. On 3/27/24 at 2:33 p.m., Resident #1's Responsible Party/Power of Attorney (POA) said, When she fell and fractured her leg, the facility did not call me. They told my wife the next day when she came to visit the facility. The Responsible Party said Resident #1 developed a wound which became infected. She was being moved to inpatient hospice because of the pain. The inpatient hospice called and told us they were sending her to the hospital. That was the first I heard about the bone sticking out. The doctor called and said the only appropriate action is to amputate because the bone was dead. She was discharged to inpatient hospice and passed away on March 23rd, 2024. On 3/27/24 at 2:50 p.m., Staff A, Registered Nurse (RN) said, I called hospice and asked them about her pain and activity. I did the dressing on her leg, there was not so much drainage, and she was started on antibiotics. Staff B, Licensed Practical Nurse (LPN) found the bone and he should have contacted everyone. They were supposed to discuss it with the hospice doctor. I didn't call the family. On 3/27/24 at 3:05 p.m., the facility wound care nurse said she became aware of the exposed bone and wound during the weekly skin check on 3/6/24 with the Nurse Practitioner. The facility wound care nurse said, I didn't speak with the family or responsible party. On 3/27/24 at 3:17 p.m., the Administrator verified Resident #1 had a piece of bone come through the skin on 3/6/24. The administrator said the normal procedure would be for the assigned nurse to call the responsible party when the wound developed, and the bone was exposed. The Administrator said, I am the risk manager, but I personally don't make notifications to the family. The Administrator said the Director of Nursing said on 3/13/24 Resident #1 was not someone we could provide care for and suggested transfer to either the hospital or inpatient hospice for continued care. The unit manager contacted the hospice on 3/13/24 and Resident #1 was transferred to inpatient hospice. The hospice manager contacted the family and they agreed to have Resident #1 transferred to inpatient hospice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 2 of 3 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 03/28/2024 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 0849 Level of Harm - Actual harm Residents Affected - Few On 3/27/24 at 4:00 p.m., Resident #1's friend/ spouse of POA said, They never called and told us anything about the bone sticking out. The spouse of POA confirmed the transport company took Resident #1 to inpatient hospice but discovered the exposed bone and notified the hospice provider. Hospice did not accept Resident #1 for inpatient services and they called 911 for her to be sent to the hospital. The hospital surgeon called us and explained the bone was dead, there was infection and the leg needed to be amputated or she would die. The facility never called about the infected wound, or exposed bone and the hospice nurse never called. POA spouse said, I had one meeting with a social worker and nurse when she was admitted to the nursing home and hospice did not come to the meeting. We would have wanted to know what was happening. On 3/27/24 at 4:10 p.m., Staff B, LPN said in a telephone interview he was aware the bone was sticking out and gave report to the oncoming shift that hospice was called and would be out to assess the increased pain. LPN Staff B said when a resident is under hospice care we call them with any changes, and they notify the family or responsible party. On 3/27/24 at 4:20 p.m., during an interview the Director of Nursing said she returned from leave on 3/13/24 and was informed the bone was protruding for Resident #1. We called hospice and explained the concerns about the bone and wound. They said they contacted the hospice doctor who recommended consulting the family. My understanding was they talked about it and decided no aggressive treatment and she was transferred to hospice. On 3/28/24 at 8:10 a.m., the Hospice manager said the unit manager called and reported increased pain and requested the resident be sent to inpatient hospice. The hospice manger confirmed the facility did not talk to the family about having the resident moved saying, They should have. They are the primary caretaker of the patient; they need to let the family and hospice know but they said no they called us first. They did not explain why she had so much pain. When she arrived at the inpatient unit, we found the bone sticking out, I took pictures. If they had let us know we would have told them to call 911 because that is a medical emergency. Even if she was on hospice, that was an emergency and she needed to be seen in the hospital. We did not know about the bone. Hospice manager said they had talked to the unit manager who said the transfer was for pain management and never said anything about the bone. On 3/28/24 at 8:55 a.m., the facility social worker confirmed he had not had any conversations with the responsible parties for Resident #1 after the initial care plan meeting. On 3/28/24 at 9:06 a.m., during a telephone interview the medical director verified Resident #1 was her patient. The Medical Director said the Nurse Practitioner (N)P informed me and hospice about the bone being exposed. Hospice saw the patient first and opted to do conservative management. I believed my NP, or the nursing staff talked with the family about a plan and options. I assumed hospice had talked with the family, but I should have reached out to confirm with them myself. The NP initially wanted to send the Resident #1 to the hospital, but the nursing staff told her hospice decided on conservative treatment. On 3/28/24 at 1:00 p.m., the NP said, I knew she was on hospice. When she fell, I sent her to the hospital. The nursing staff told me about the wound and bone the next day when I arrived on 3/7/24. My recommendation to Staff nurse B was to contact the family and the hospice for re-evaluation. I knew their preference was for conservative treatment but I did not call them after the bone came through the skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105439 If continuation sheet Page 3 of 3