Inspection·February 10, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm NUMBER], #224, and #226. He said, We do 10-minute touch ups, where we walk around with paint and touch up as needed. The Maintenance Director said there was no schedule for monitoring and completing the wall touch ups. The Maintenance Director also confirmed the clock in Resident #93's room was not working. He said If someone tells me I give them batteries for the clock. Anyone can do it. No, I do not monitor the clocks in the rooms. Residents Affected - Few On 2/10/22 at 10:18 a.m., in an interview about wall damage in residents' rooms the Administrator replied, Yes, I have noticed that there is a lot of wall damage here. When asked about the process for ensuring clocks are functioning in resident rooms, the Administrator replied, I know it's a problem. I walked into a new admission's room this morning and her clock wasn't functioning either. Based on observation, staff and resident interviews, the facility failed to maintain a sanitary, damage free, and homelike environment for 6 (#83, #300, #93, #95, #54 and #72) of 24 residents reviewed and 3 (room [ROOM NUMBER], #224 and #226) of 17 rooms observed. The findings included: The Supervision, Maintenance Services policy dated 2001 and revised May 2008 read, 1. Maintenance service shall be under the direct supervision of the assistant administrator. The day-to-day operation is under the supervision of the maintenance director. The assistant administrator is responsible for the overall supervision of the maintenance department. 2. The maintenance director is responsible for scheduling preventative maintenance service. 3. Duties and responsibilities of the maintenance director are outlined in his/her job description. On 2/7/22 at 11:09 a.m., a nebulizer machine (small machine that turns liquid medication into a mist) with a face mask dated 1/21/22 was observed stored on Resident #83's bedside table. The mask was uncovered. The wall behind the headboard was damaged, exposing the drywall. In an interview at the time of the observation, Resident #83 said she has been in this room before Christmas and there had been no attempt to fix the wall. Photographic Evidence Obtained On 2/8/22 at 9:00 a.m., the nebulizer face mask remained uncovered on the resident's bedside table. On 2/9/22 at 10:50 a.m., Certified Nursing Assistant Staff M verified the damage to the wall behind the headboard in Resident #83's room and the uncovered nebulizer tubing on the bedside table. She said when repairs are needed the process is to put in a work order. She said she would put in a work order to fix the resident's wall. On 2/10/22 at 10:00 a.m., in an interview Maintenance Assistant Staff D said he was not aware of the wall damage in Resident #83's room. He said the process if for staff to call him for emergency repairs. For normal repair, they put in a work order. Maintenance Assistant Staff D said his supervisor also made rounds to identify problems that need to be addressed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 2 of 14 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 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 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 On 2/10/22 at 10:20 a.m., in an interview the Director of Nursing (DON) said there was no policy for respiratory supply care. She said the facility requires tubings and masks to be changed once a week and to be stored in a plastic bag. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 3 of 14 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 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review, and staff interview the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment related to falls for 1 (Residents #60) of 3 residents reviewed for falls. This has the potential to lead to delayed care planning and services for the resident affected. Residents Affected - Few The findings included: Review of the clinical record showed Resident #60 had an admission date of 1/16/19. The facility's incident log noted Resident #60 sustained a fall at the facility on 11/5/21 and 12/12/21. The Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/30/21 was coded 0 indicating Resident #60 had not sustained a fall since admission, entry, reentry, or the prior assessment. On 2/8/22 at 2:59 p.m., in an interview Licensed Practical Nurse (LPN) MDS coordinator verified the Quarterly MDS assessment was inaccurate and did not reflect Resident #60's falls on 11/5/21 and 12/12/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 4 of 14 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 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure they arranged for a follow up re-evaluation with the ophthalmologist as required for 1 (Resident #94) of 1 resident who had visual complications. The failure to arrange and ensure follow-up ophthalmologist visits are conducted timely has the potential to lead a loss of vision and a deterioration of the resident's quality of life. Residents Affected - Few The findings included: On 2/9/22 at 1:37 p.m., in an interview Resident #94 said when she saw the ophthalmologist last year, he told her the reason for her blurred vision was because she had cataracts and would need surgery in the future to fix her blurred vision. He told her he would do a follow-up visit in several months to do a re-evaluation of her vision to determine if she was a candidate for cataract surgery. Resident #94 said the ophthalmologist never came back as promised to do the re-evaluation of her eyes to determine if she was a candidate for cataract surgery. She said for the past several months her vision had gotten worse and when she asked the nursing staff when the ophthalmologist would be doing her follow-up eye visit, they would tell her they didn't know when the ophthalmologist was coming to the facility, and no one would call the ophthalmologist's office to determine when he would be doing her follow-up visit. On 2/9/22 at 2:05 p.m., in an interview with Staff I, License Practical Nurse (LPN), she said when a resident and/or family member told her they would like to have an eye exam or get a new pair of glasses she would inform the Social Service Director (SSD) of their request, and they would let the ophthalmologist arrange for a visit. She said she doesn't think the facility had a policy or procedure in place to ensure the ophthalmologist did their initial and any follow-up visits. She said she thought the SSD was responsible to ensure all ophthalmologist appointments were completed as ordered and timely. On 2/9/22 review of Resident #94's medical record revealed a physician's order dated 5/11/2019 for ophthalmology, podiatry and dental services as needed. An ophthalmology progress note dated 4/29/21 stated Resident #94 had mild cataracts in both eyes. The ophthalmologist wrote he discussed with Resident #94 that due to the possible deterioration of her retina, this could cause gradual loss of vision, but surgery was not needed at that time. The physician further wrote he explained to the resident if she experienced a sudden loss of vision or an increase of blurriness to inform the nurse who could schedule a follow-up and re-evaluation of Resident #94's eyes. The physician wrote he would do a follow-up and re-evaluation in 6 to 7 months. The progress note was signed 5/2/21 by the ophthalmologist. Further review of the medical records revealed no documentation Resident #94 had the follow-up and/or re-evaluation of her eyes as documented in the 4/29/21 ophthalmologist progress notes. On 2/9/22 at 4:14 p.m., during an interview with SSD, she said she had been the SSD at the facility since 10/2018. She said when a resident, family or staff informed her a resident was requesting an eye exam she would gather the needed information and fax it to the ophthalmologist's office, who then would put the resident on their schedule to be seen by the physician. She said the ophthalmologist does not inform the facility of the dates of his visit or which facility residents he will be seeing the day of their visit to the facility. She said when the ophthalmologist has finished all his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 5 of 14 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 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few exams on the day of their visit to the facility, he would talk with the resident's nurse, and he would give her his residents' progress notes from that day visit. She would then file the ophthalmologist's progress note in the resident's medical record. She said she does not read ophthalmologist progress notes and the ophthalmologist was responsible to schedule any appointment and/or follow-up visits for the residents. She said the facility did not have a policy, procedure or tracking tool in place to ensure to ensure ophthalmologist initial visits and follow-up visits were conducted in a timely manner as of this time. The SSD reviewed Resident #94's medical record and confirmed the ophthalmologist progress note dated 4/29/21 stated he would be conducting a follow-up and re-evaluation of Resident #94's eyes in 6 to 7 months. The SSD said the ophthalmologist did not conduct Resident #94's follow-up and re-evaluation visit as documented in the 4/29/21 progress note. She said she was unaware Resident #94's follow-up visit was not conducted as required. On 2/10/22 at 11:54 a.m., in an interview with the Director of Nursing and Administrator, they said the facility did not have a policy and/or procedure in place to ensure all ophthalmologist initial and follow-up visits were conducted in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 6 of 14 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 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and staff interview the facility failed to administer medication according to the manufacturer's specification and physician's orders for 2 (Resident #50 and #349) of 3 residents observed for medication administration. Three Licensed nurses and 26 opportunities were observed. Four medication errors were identified resulting in a 15.38 % error rate. Residents Affected - Some The findings included: The facility's policy Administering Medications revised April 2019 reads, Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including time frame . Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . 1. On 2/9/22 at 9:02 a.m., Licensed Practical Nurse (LPN) Staff J was observed administering 11 different medications to Resident #50, including Breo Ellipta 100-25 micrograms inhaler and Incruse Ellipta 62.5 micrograms inhaler. LPN Staff J placed both inhalers on the table in front of the Resident. Resident #50 administered one inhalation of the Incruse Ellipta orally, immediately followed by one oral inhalation of the Breo Ellipta. LPN Staff J administered the rest of the oral medications to the resident with a glass of water. Upon reconciliation of the observation with the physician's orders, it was revealed the orders for the Incruse Ellipta and Breo Ellipta specified to rinse mouth after each use, do not swallow. Review of the manufacturer's patient information insert for the Breo Ellipta showed Breo Ellipta can cause serious side effects, including fungal infection in the mouth or throat (Thrush). The patients instructions specify to rinse the mouth with water after using the inhaler, spit the water out, do not swallow the water to help reduce the chance of getting thrush. 2. On 2/9/22 at 11:40 a.m., Registered Nurse (RN) Staff K was observed administering 10 different medications to Resident #349, including one tablet of Metformin 500 milligrams and one tablet of Metoprolol Tartrate 25 milligrams. The physician's orders dated 2/4/22 specified to administer one tablet of Metformin 500 milligrams two times a day for diabetes with meals. Review of the Medication Administration Record (MAR) for February 2022 showed the Metformin was scheduled to be administered at 8:00 a.m., with meal. Resident #50 received the Metformin two hours and 40 minutes past the scheduled time. The physician's orders dated 2/4/22 specified to give one tablet of Metoprolol Tartrate 25 milligrams by mouth two times a day for hypertension. Review of the MAR for February 2022 showed the Metoprolol was scheduled to be administered at 9:00 a.m. Resident #50 received the Metoprolol two hours and 40 minutes past the scheduled time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 7 of 14 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 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm On 2/9/22 at 11:40 a.m., at the time of the observation RN Staff K said she was aware she administered the Metformin and the Metoprolol late. She said she was, running behind. On 2/10/22 at 11:15 a.m., in an interview the Director of Nursing and the Administrator said they were not aware the medications have been administered late. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 8 of 14 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 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, record review, staff, and resident interviews the facility failed to identify and ensure safe storage of medications for 2 (Resident #12 and #83) of 22 residents reviewed for medication storage. This has the potential for other residents to have access to medications that can cause them harm. The findings included: The facility's policy Administering Medications revised April 2019 reads Medications are administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. 1. On 2/7/22 at 11:05 a.m., observed an unsecured bottle of antacid tablets on Resident #12's bedside table. Resident #12 said she's had the antacids for a while. She said she took the antacid as needed for stomach problems. Photographic evidence obtained On 2/7/22 at 2:31 p.m., clinical record for Resident #12 review showed no Physician order for the antacid tablets observed at the Resident's bedside. There was no documentation the Interdisciplinary Care Planning Team had assessed the resident to safely administer the medication. 2. On 2/7/22 at 11:10 a.m., a bottle of Pepcid Complete (medication used for acid reflux) was observed unsecured on Resident #83's bedside table. Resident #83 said she used it for her stomach problems. Photographic evidence obtained On 2/7/22 at 2:40 p.m., clinical record review for Resident #83 showed no Physician order for the Pepcid Complete observed at the Resident's bedside. There was no documentation the Interdisciplinary Care Planning Team had assessed the resident to safely administer the medication. On 2/9/22 at 9:02 a.m., in an interview Licensed Practical Nurse LPN, Staff J said she was unaware of any resident who self-administered medications. On 2/9/22 at 11:50 a.m., in an interview the Director of Nursing (DON), said currently there was no resident who self-administered medications. She said she was not aware Residents #12 and #83 kept medications in their room and staff should have noticed the medications. The DON confirmed Residents #12 and #83 had medications at the bedside and removed them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 9 of 14 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 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, the facility failed to assist in obtaining routine dental services for 1 (Resident #7) of 7 residents sampled for provision of dental services. Residents Affected - Few The findings included: The facility's policy titled Dental Services revised December 2016 read, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care . Social services representatives will assist residents with appointments, transportation arrangements, and for the reimbursement of dental services under the state plan, if eligible . On 2/8/22 at 8:43 a.m., in an interview Resident #7 said he had not seen a dentist since his admission to the facility and it was very important to him. Resident #7 said he was having difficulty chewing. Review of the clinical record showed Resident #7 had an admission date of 2/13/20. The clinical record lacked documentation Resident #7 received routine dental services. On 2/9/22 at 11:23 a.m., in an interview the Social Services Director (SSD) said Resident #7 was not enrolled in the facility's dental plan. She verified the Resident had not received routine dental services since his admission on [DATE]. The SSD said the facility does not routinely enroll residents in a dental plan unless they ask for it or a staff member believes a resident needs to see a dentist. She said she did not know if residents received routine dental hygienist services. On 2/10/22 at 9:49 a.m., in an interview the Administrator said it was the facility's responsibility to offer dental services to residents. She said she was unable to locate documentation of efforts made by the facility to provide routine dental care to Resident #7. The Administrator said she will ensure the Resident is seen by a dentist as early as possible. On 2/10/22 at 10:13 a.m., in an interview the SSD said she did not have documentation Resident #7 was offered and declined dental services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 10 of 14 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 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, record review, resident and staff interview the facility failed to distribute meal in a manner to ensure 1 (Resident #3) of 2 residents observed received the correct meal to accommodate resident's documented allergies and preferences. The findings included: On 2/8/22 at 12:11 p.m., Resident #3 was observed with untouched lunch tray in front of him and not eating. In an interview Resident #3 said, They know that I am not to get fish and they gave me tuna fish. I'm not going to eat it. I have told them I can't have fish. Resident #3 lifted the cover of the lunch dish. A tuna fish sandwich was observed on the plate. A review of the meal ticket showed the meal tray belonged to Resident #93. On 2/8/22 at 12:14 p.m., observation of Resident #93's tray showed a meal ticket that bore Resident #3's name and indicated he was to receive no fish or seafood. On 2/9/22 at 12:15 p.m., Certified Nursing Assistant (CNA), Staff C confirmed Resident #3 received the wrong meal tray. CNA Staff C said, it's a big problem since Resident #3's meal ticket documented no fish, he could be allergic. On 2/9/22 at 4:16 p.m., in an interview the Director of Nursing, (DON), said the expectation for resident identification for meal tray distribution was, to check the ticket, the name on the door and verify that the correct resident receives the correct tray. She said it is the responsibility of the nursing staff, nurses and CNAs, to confirm they give the correct trays to each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 11 of 14 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 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review, and staff interview, the facility failed to provide a clean, safe, and sanitary environment in the kitchen, and 3 of 3 nourishment rooms observed by not having clean food preparation and storage equipment. This failure had the potential to cause food borne illness in residents receiving an oral diet. The findings included: The facility's policy titled Ice with a date of October 2019 noted, It is the center policy that ice is prepared and distributed in a safe and sanitary manner . The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed, or according to manufacturer guidelines . The Dining Services Director will ensure that the exterior of the ice machine is cleaned weekly . The facility's policy titled Environment with a date of October 2019 noted, . The Dining Service Director will insure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces . On 2/7/22 at 9:34 a.m., during initial tour of the kitchen the following was observed: The rubber gasket around the juice refrigerator door was soiled with grime, and black bio growth. Photographic evidence obtained Baking pans stored on a shelf had dried food residue, grime, and debris. Photographic evidence obtained The juice dispensing pour spout was hanging loose leaning on a box in close proximity to the floor. Photographic evidence obtained The shelf under the steam table was heavily soiled with grime, and debris. Metal shelving panels being held in place with a pan. Photographic evidence obtained On 2/7/22 at 9:52 a.m., in an interview Certified Dietary Manager (CDM) Staff N confirmed the grime and debris on the shelf under the steam table. Staff N said the metal panels under the steam table were broken. He said they were the steam table doors and needed repair. On 2/9/22 at 12:10 p.m., the Certified Dietary Manager (CDM) confirmed the food residue on the baking pans, black bio growth on the juice refrigerator door and juice dispenser spout on boxes near to the floor. He stated the juice dispenser spout should be stored in a container. On 2/7/22 at 11:25 a.m., observation of the B wing nourishment room revealed the exterior of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 12 of 14 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 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 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 0812 ice machine was corroded. The interior was heavily soiled with grime, brown and pink bio growth. Level of Harm - Minimal harm or potential for actual harm Photographic evidence obtained The refrigerator exterior was heavily stained and soiled. Residents Affected - Many Photographic evidence obtained On 2/7/22 at 11:31 a.m., observation of the A wing nourishment room revealed the exterior of the ice machine was corroded. The interior was soiled with grime, debris, and a brown substance. Photographic evidence obtained On 2/7/22 at 11:40 a.m., observation of the C wing nourishment room revealed the exterior of the ice machine was heavily stained and corroded. The interior was soiled with grime and debris. On 2/8/22 at 10:34 a.m., the same observations were made in the nourishment rooms of A, B and C wings. On 2/8/22 at 10:50 a.m., a tour of nourishments rooms was conducted with the CDM. He confirmed the ice machines in the A, B, and C wing nourishment rooms were heavily soiled with grime, debris, bio growth and corrosion on the exterior and interior. He said the nursing staff use the ice machines to prepare and supply ice water for the residents. The CDM said the maintenance department was responsible to clean the ice machines. On 2/8/22 at 10:58 a.m., a tour of the nourishment rooms was conducted with the Maintenance Assistant. The Maintenance Assistant verified the ice machines in the nourishment rooms of the A, B, and C wing were dirty. He said he wasn't sure how often the contracted company came out to clean the machines. On 2/8/22 at 11:04 a.m., in an interview Licensed Practical Nurse (LPN) Staff A said the nursing staff uses the ice machines in the nourishment rooms to supply ice water to the residents. Staff A confirmed the ice machine on A wing was heavily soiled on the exterior and interior with corrosion, grime and debris. On 2/9/22 at 4:49 p.m., upon request to review the cleaning log, the Maintenance Assistant said there was no documentation indicating the last time the ice machines in the nourishment rooms were cleaned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 13 of 14 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 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview the facility failed to maintain documentation of a water management program to minimize the risk of waterborne pathogens, including Legionella. Residents Affected - Many The findings included: The Center for Clinical Standards and Quality/Survey and Certification group (Ref S&C 17-30) revised on 6/9/17 notes, . The bacterium Legionella can cause a serious type of pneumonia . in persons at risk . Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water . implement a water management program that considers the ASHRAE [American Society of Heating, Refrigerating and Air Conditioning Engineers] industry standard and the CDC [Center for Disease Control] toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspection, and environmental testing for pathogens. Specify testing protocols and acceptable range for control measures and document the result of testing and corrective actions taken when control limits are not maintained . On 2/9/22 at 1:23 p.m., in an interview the Maintenance Director said he has been employed at the facility for two years and was not doing anything regarding a water management program to reduce the risk of legionella. He said he had no other information to provide to the survey team. On 2/9/22 at 1:31 p.m., in an interview the facility's Infection Preventionist said the Maintenance Director was responsible for the water management program to reduce the risk of legionella disease and infections from other opportunistic pathogens. Upon request to review the facility's documentation of the water management program, the Infection Preventionist said she was not involved and did not have documentation related to the water management program. On 2/10/22 at 10:26 a.m., the Administrator said she plans to meet with the Maintenance Director and go over a generic policy for legionella. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105522 If continuation sheet Page 14 of 14