Inspection·November 20, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resuscitate). No vital signs noted (Pulse, respirations, blood pressure). A message was left for the resident's family to call the facility to notify them of the resident's passing. On 11/17/25 at 3:35 p.m., in a telephone interview Resident #115's responsible party said the facility never notified her of the resident's declining condition, the vomiting, the need to start a new medication and the laboratory test ordered.On 11/20/25 at 1:30 p.m., in an interview the Director of Nursing (DON) said there was documentation from any nurse about what happened to the resident. The DON said a Change in Condition note should have been completed and the resident's family should have been notified. Event ID: Facility ID: 105672 If continuation sheet Page 2 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure the Advanced Beneficiary Notice of Non-Coverage issued to 2 (Residents #66 and #92) of 3 residents was complete and accurately reflect the residents' decision to stop or continue skilled services and the financial liability.The findings included:Clinical record review revealed Resident #66 was admitted to the facility on [DATE]. The Medicare Part A Skilled Services episode start date was 5/2/25.The Notice of Medicare Non-Coverage form (Form CMS 10123-NOMNC), and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (Form CMS-10055) issued to Resident #66 contained conflicting information.The Notice of Medicare Non-Coverage form (Form CMS 10123-NOMNC) noted that the effective date coverage of the current skilled services would end on 6/7/25.Resident #66 signed the form on 6/5/25.The Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) Form noted, Medicare does not pay for everything, even some care that you or your health care provider think you need. The form specified that beginning on 5/2/25, Resident #66 may have to pay out of pocket for Physical Therapy, Occupational Therapy and Daily Skilled Nursing Care received at the facility if he did not have other insurance that may cover these costs.The form did not include the estimate cost the resident would have to pay per day/item or service.The form contained instructions to check the box for one of the 3 options listed to choose whether the resident wanted to continue the care listed, bill Medicare for an official decision on payment, assume financial responsibility or that they did not want to continue the care.Resident #66 signed the form on 6/5/25 but no option was checked.As of 11/20/25, Resident #66 remained in facility as a private payor.Clinical record review revealed that Resident #92 was admitted to the facility on [DATE].On 9/22/25 Resident #92 signed the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage that beginning on 9/25/25 Resident #92 may have to pay $470.00 per day for room and board and $75.00 per unit/per discipline for therapy. The form noted the care receiving during the Inpatient Skilled Nursing Facility included Physical Therapy, Occupational Therapy and Daily Skilled Nursing Care.The section where the resident is to indicate whether he wished to discontinue care, continue care and have Medicare billed, or continue care and pay privately was left blank.As of 11/20/25, Resident #92 remained in facility with a private payor source. On 11/20/25 at 4:50 p.m., in an interview, the Administrator said the Advance Beneficiary Notice of Non-coverage for Residents #66 and #92 were not filled out correctly. She said Residents #66 and #92 should have checked a box indicating whether they wished to continue care and whether they want Medicare to be billed if they choose to receive care after coverage ends. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105672 If continuation sheet Page 3 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policy and procedure and staff interview the facility failed implement their policy and procedure and notify the office of the Long-Term Care Ombudsman of residents' discharges. The notification to the Ombudsman's office is to protect residents' rights to prevent unwarranted or unnecessary transfers or discharges and to prevent facilities from refusing to allow the residents return to the facility.The findings included:Review of the facility's Policy and Procedure Admission, Transfer, Discharge with a created date of 12/2019 documented, . Procedure. Provide notification to local ombudsman of all involuntary discharges, facility initiated discharges, including hospital transfers. Social Service or designee should provide the information to the ombudsman according to the format and frequency the specific ombudsman has requested (monthly, weekly notification via email/fax/scan/etc.Review of the facility's Admission/Discharge log from 7/8/25 through 11/20/25 revealed the facility had 244 discharges including:65 residents were transferred to an acute care hospital.20 residents were discharged to an Assisted Living Facility.120 residents were discharged home.5 residents were transferred to a skilled nursing facility.Review of a sample of discharged residents revealed: Resident #112 was admitted to the facility on [DATE] and discharged home on [DATE].Resident #24 was admitted to the facility on [DATE] and discharged to an Assisted Living Facility on 11/17/25.On 11/20/25 at 11:18 a.m., in an interview the Director of Nursing (DON) said she was not able to locate documentation that the office of the Long-Term Care Ombudsman was notified of the discharges.On 11/20/25 at 12:01 p.m., a representative of the State Long Term Care Ombudsman's office reported in an email that the facility has not notified the Ombudsman's office of any discharges or transfers to the hospital since 7/7/25.On 11/20/25 at 12:30 p.m., in an interview the DON said the Administrator contacted the office of the Long-Term Care Ombudsman and verified that the facility had not sent any resident discharge or transfer notification to the Ombudsman's office since 7/7/25. Event ID: Facility ID: 105672 If continuation sheet Page 4 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to provide activities that meets the interests and accommodate the needs of 1 (Resident #7) of 3 residents reviewed for involvement in activities.The findings included:Review of the facility policy Activities Programs, effective 3/2005 (revised 8/2/23) revealed, Varied activities will be planned and routinely scheduled. Activities will focus on the following:1. To stimulate socialization and encourage fellowship.2. To help maintain muscle tone and coordination.3. To encourage and provide opportunities for mental functioning.4. To provide sensory stimulation.5. To reduce isolation, build self-esteem, and strengthen capabilities and identity.6. To provide entertainment.7. To strengthen existing spiritual tenets, and to provide an opportunity to express individual beliefs.Review of the clinical record for Resident #7 revealed an admission date of 6/14/24. Diagnoses included legal blindness, schizoaffective disorder with delusions, and major depressive disorder. The resident resided on the secured memory care unit.Review of the Annual Minimum Data Set (MDS) assessment submitted on 7/10/25 revealed Resident #7 scored 12 on the Brief Interview for Mental Status, indicating moderately impaired cognition.The MDS noted the resident's vision was severely impaired (no vision or sees only light, colors or shapes; eyes do not appear to follow objects) and did not wear corrective lenses.The resident interview for Activity Preferences noted it was very important to her to listen to music she likes, somewhat important to do things with groups of people and to do her favorite activities. Resident #7 required moderate assistance with ambulation.The care plan initiated on 6/15/24 noted Resident #7 would receive three one to one room visits and/or attend group activities per week for socialization and stimulation. The interventions as of 6/20/25 noted the resident's favorite thing to do was listening to music, she enjoyed live music, small social groups, hand and nail care. Staff was to offer reminders for activities and transport her to activities.Review of the Therapeutic Recreation Data Collection form dated 9/22/25 revealed to continue the resident care plan, Resident #7 had no changes in leisure interest. The form noted the resident enjoyed and observed live entertainment groups, listening to musicals, social groups, nail care and hand massages. She enjoyed listening to music, listening to the television and had visitors regularly. The resident also received one on one visit for social, emotional and stimulation needs.On 11/17/25 at 10:12 a.m., Resident #7 was observed in bed, in her room. She did not answer to her name. There was no activities going on at the time of the observation. The television set was not on. No radio was observed in the resident's room.On 11/17/25 at 10:30 a.m., Resident #7 remained in her room in bed. The television was not on. In an interview the resident said she was blind but was able to feed herself.On 11/17/25 at 12:24 p.m., Resident #7 remined in her room in bed.On 11/18/2025 at 11:42 a.m., Resident #7 was observed in her room in bed. The television was not on. There was no music playing.On 11/18/25 at 2:10 p.m., live music entertainment was observed in progress in the dining area of the secured unit. Resident #7 remained in her room. She was sitting on the edge of the bed.On 11/18/25 at 2:15 p.m., in an interview, Resident #7 said she enjoyed listening to all kind of music. When asked about participating in the live music entertainment in progress, she said she would have loved to go but she was blind and could not leave her room. She said she did not attend activities because no one assisted her to the activities. No staff was observed inviting and assisting Resident #7 to the live music entertainment from 2:10 p.m., to 2:40 p.m.On 11/19/2025 at 9:09 a.m., Resident #7 was observed in bed. The television was off. No radio was playing.On 11/19/25 at 9:13 a.m., in an interview about activities participation for Resident #7, Activity Assistant Staff C said, I do room visits and I talk to her. Staff C said she spent no more than 10 minutes Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105672 If continuation sheet Page 5 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete with the resident several times a week. She said Resident #7 attended activities every day this week. Staff C said Resident #7 loved music. She attended the music activity the day before and enjoyed it.When asked about the observation of Resident #7 in her room during the music activity the day before, Activity Assistant Staff C did not explain and said Resident #7 also loved to have her fingernails painted. She always made sure the staff brought the resident to get her nails done. She said she kept a log of the activity attendance for each resident.Review of the activity calendar for the Memory Care Unit for November 2025 revealed Nail Care was listed for November 11 at 10:30 a.m. Hand and nail care was listed for November 18 at 9:30 a.m.Review of the individual recreation participation record for Resident #7 for November 2025 failed to show documentation Resident #7 attended the music activity on 11/18/25.On 11/11/25, U (unable) was entered for hand massage. Nail care was left blank.On 11/17/25, U was entered for nail care.There was no documentation Resident #7 participated in the hand and nail care listed in the activity calendar for 11/18/25.11 Room visits one to one were documented from 11/1/25 through 11/17/25.For Hymn sing, U was entered on 11/5/25 and 11/13/25.For Sing-a-longs, U was entered on 11/2/25, 11/8/25, 11/10/25, 11/15/25 and 11/16/25.On 11/19/25 at 10:00 a.m., in an interview, Resident #7 said she did not attend the music program the previous day because no one came to pick her up. The resident's fingernails were observed extending approximately 1/2 inch past the tip of the nail and had an accumulation of brown substance under the nails. The resident's fingernails were not painted.On 11/19/25 at 10:20 a.m., Activity Assistant Staff C was observed entering Resident #7's room. The resident was in bed. The television was not on and there was no radio in the room. In an interview, Activity Assistant Staff C verified Resident #7 did not have a radio. She said, I check on her all the time. I try to get her up. She likes music. She said she did not know if they put the music channel on the television for the resident. She said Resident #7 had a language barrier. She spoke creole and there were some staff who could communicate with her. Staff C did not reply when told Resident #7 was able to answer all interview questions in English. She said, I just do the basics, maybe she would like a book in [NAME]. Staff C said she did not know if the facility had books on tape but she had not seen any. On 11/19/25 at 10:30 a.m., in an interview the Activity Director said Resident #7 was blind but really loved music. She said, I do sensory, nail care for her, she comes out here and there. I spend 20 - 30 minutes with her several times a week.The Individual Recreation Participation Record for Resident #7 for November 2025 did not document the sensory care, nail care or the 20 - 30 minutes the Activity Director said she spent with Resident #7 several times a week. Event ID: Facility ID: 105672 If continuation sheet Page 6 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on observation, record review and interviews, the facility failed to ensure the safe transfer with a mechanical lift of 1 (Resident #14) of 3 residents by failing to ensure the sling was properly placed and secured, resulting in a bruise to the resident's left upper extremity. The findings included:Review of the facility's Policy and Procedure titled, Free of Accident Hazards/Supervision/Devices policy (last revised 10/2021) noted, All resident environments will remain free of accident hazards as is possible and each resident will receive adequate supervision and assistive devices to prevent accidents.The policy further noted Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident . The facility must provide an environment that is free from accident hazards over which the facility has control.Review of the facility's Policy and Procedure titled, Mechanical Lifts (last revised 8/14/2023) noted all staff receive orientation and annual training for mechanical lifts. This training includes safety considerations and how to operate the mechanical lift based on manufacture specifications. The training also includes sling selection, inspection and maintenance.Record review for Resident #14 showed an admission date of 2/26/23 with a diagnosis of ataxic gait (unsteady, uncoordinated ambulation) and repeated falls. Resident #14's Brief Interview for Mental Status (BIMS) score was 13 indicating intact cognition.Resident #14's Care Plan revealed, I may need two assist and a lift to transfer to the toilet or bath (dated 5/12/2025). Resident #14's Care Plan also noted to use padding between patient and lift sling during transfers as/if needed to prevent friction of skin/underarms (dated 6/23/2025).Review of the Nursing Weekly Skin Checks revealed on 10/16/25 Resident #14 had no skin issues.Review of a Incident-Post Incident Review dated10/22/2025 revealed Resident #14 had a 11.5 x 4 cm bruise dark with slight fading edges above the left antecubital (left elbow).On 11/20/25 at 7:28 a.m., in an interview Resident #14 said a Certified Nursing Assistant (CNA) used the mechanical lift to help her stand. She said while using the mechanical lift, the battery went out. She said the CNA left her hanging in the sling for 5 to 10 minutes while she left the room to go get a new battery. Resident #14 said she was very uncomfortable, was in pain and got a bruise on her left arm from the sling.Observation during the interview revealed a black and yellow discoloration measuring approximately 6 centimeters in length by 2 centimeters on the resident's upper left outer arm. Resident #14 said she did not know the CNA's name but said she had black and red hair. The resident said she told the CNA how to do the transfer, but she continued to do it wrong 2 days in a row.Review of facility provided undated investigation revealed:The resident was unsure this was the same incident previously reported on 10/9/2025.The CNA with red and black hair was CNA Staff G.On 10/9/25 Resident #14 said staff left her in a (brand name) full body mechanical lift. CNA Staff H and 3 Student CNAs were present during the transfer. The 3 student CNAs reported The [brand name full body mechanical lift] stopped functioning due to a depleted battery. CNA Staff H immediately retrieved and replaced the battery.The facility's investigation included an undated interview with CNA Staff H who stated that Resident #14 was upset because the battery of the full body mechanical lift had to be replaced and she was unable to explain to the resident.The incident investigation noted that on 10/22/25 at 9:30 a.m., the Assistant Director of Nursing (ADON) observed CNA Staff K and CNA Staff L conduct a sit to stand transfer with Resident #14. The observation noted, The resident was abruptly shifted sideways in the bed without any prewarning. The resident yelled ouch during the transfer. The resident was then pulled up into the sitting position by each CNA holding an arm and abruptly sitting her up and slid to the side of the bed. Her feet were placed onto the foot of the lift but were not properly placed until prompted by this nurse. The lift was locked with 1 lock only.The ADON documented, The CNAs then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105672 If continuation sheet Page 7 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete placed the sling under the resident's arms with her shirt wrinkled and bunched up. The sling was not properly placed on the resident. The sling was directly placed under the axilla area. The waist stabilizing belt was not connected around the resident to prevent the sling from slipping up into the axilla. The resident was lifted in the sling and taken to the bathroom and lowered onto the toilet.On 11/20/25 at 9:29 a.m., in an interview the Director of Rehab said Resident #14 refuses to use the mechanical lift because it is too painful. The Director of Rehab said Resident #14 reported that sometimes staff do not use the Sit-to-Stand lift correctly and it pinches her skin.On 11/20/25 at 12:04 p.m., in an interview the ADON said Resident #14 sustained the bruise because the resident refused to use the support belt on the Sit-to-Stand mechanical lift. The ADON said there was never a battery issue.When asked about intervening when she observed the 2 CNAs improperly place the sling to transfer the resident, she said, When they lifted her up, I needed to see how they were transferring. The ADON said she did not realize the safety belt was not on until after Resident #14 was in the air. The ADON said it would have been too dangerous to stop at the time.On 11/20/25 at 9:27 a.m., in an interview CNA Staff G said she did not work with Resident #14 in October 2025 and has never helped CNA Staff H with a resident transfer.On 11/20/25 at 1:59 p.m., in an interview CNA Staff H said Resident #14 has always used a Sit-to- Stand mechanical lift and has never used a full body mechanical lift. CNA Staff H said on 10/9/25 the lift stalled out during the transfer with 3 CNA students. She said CNA Staff G was not present during the transfer. CNA Staff H said they lowered the resident using the safety lever, retrieved a new battery and came back to complete the transfer. CNA Staff H said Resident #14 never complained of pain or bruising to her left arm. CNA Staff H said she was suspended and when she came back, she was told Resident #14 got a bruise from her which she said was not true.Review of the Incident-IDT Team Initial Post Investigative Review dated 10/23/25 noted The specific CNA the resident accused had not worked for a period of time and the bruise was new.On 11/20/25 at 12:33 p.m., in an interview the Nursing Home Administrator said they think the incident happened on 10/9/25 but was not reported until 10/21/25. The Nursing Home Administrator said CNA Staff H left Resident #14 with 3 student CNAs when the battery went out mid transfer to go get a different battery. She said the CNA got the battery, came back and lowered her. She said when it was reported on 10/21/25, the resident was unclear when it happened. She said she made suggestions on when it may have happened and narrowed it down to the two CNAs (CNA Staff G and CNA Staff H). The Nursing Home Administrator said the ADON reported the bruises to be fresh and could not be more than 1 to 2 days old. The Nursing Home Administrator said she believes Resident #14 sustained the bruise during transfer with the Sit-to-Stand mechanical lift because the resident refused to use the safety belt. The Administrator said there was no documentation Resident #14 refused to use the safety belt before 10/21/25. Event ID: Facility ID: 105672 If continuation sheet Page 8 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 observations and interviews, the facility failed to properly store medications in a safe manner. Throughout the survey, medications were observed unattended at bedside, unsupervised on medication carts and medication carts left unlocked leaving these medications to be easily accessible to residents.The findings include:Review of facility Storage and Expiration Dating of Medications and Biologicals (last revised 6/30/3035) states the facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. The policy further states facility should ensure all controlled substances are stored in a manner that maintains their integrity and security. The policy also notes the facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and facility administration.On 11/17/2025 at 8:16 a.m. 2 medication cups containing pills were observed on Resident #66's tray table. Photographic evidence obtained. Resident #66 said the nurse left them there this morning.Review of Resident #66's Self-Administration of Medications form said the resident does not wish to self-administer medications or keep them at bedside.On 11/17/2025 at 8:30 a.m. B-Wing treatment cart was observed unlocked. Photographic evidence obtained. RN Staff J verified that the cart should be locked but was not.On 11/17/2025 at 8:35 a.m. treatment cart in the Cove Unit had 4 tubes of medicated cream on top of the care. Medication cart also had a loose pill on top of the cart. Photographic evidence obtained. RN Staff E verified the observations.On 11/17/2025 at 8:39 a.m. medicated creams were observed on Resident #94's nightstand. Photographic evidence obtained. RN Staff E verified the medicated cream was in the room and should not have been there.On 11/18/2025 at 8:25 a.m. the Cove Unit medication cart was observed unattended and unlocked. When RN Staff F was showed the unlocked medication cart and said oh that's horrible. She said the cart should have been locked. She said she went to give a resident medication and did not lock the medication cart.On 11/18/2025 at 2:22 p.m. the Cove Unit medication storage cart check was conducted with RN Staff F. Lorazepam 0.5 mg tablet (a controlled substance) seal was observed broken for pill #27. The pill was observed behind the broken foil and easily accessible. Photographic evidence obtained. RN Staff F said she questioned it during the narcotic count that morning but was told it was fine.During an interview on 11/18/2025 at 2:32 p.m. the Director of Nursing was informed of the Lorazepam storage on the Cove Unit medication cart. The Director of Nursing said it should not be stored like that and it should have been wasted.During an interview on 11/20/2025 at 2:54 p.m. the Director of Nursing said medications should not be at bedside. She said if a resident wants to have their medications at bedside, they need to complete the self-medication administration form. She said medication carts should not be left unlocked. She said medication creams and loose pills should not be stored on top of medication carts. Event ID: Facility ID: 105672 If continuation sheet Page 9 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, review of facility policy and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.The findings included:Review of the facility policy Food Storage documented Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Food will be stored a minimum of 6 inches above the floor 18 inches from the ceiling and two inches from the wall with adequate space on all sides of the stored items to permit ventilation.Refrigerated food storage, All foods should be covered, labeled, and dated. Frozen foods- All freezer units will be kept clean and in good working condition at all times. All foods will be stored off of the floor.On 11/17/2025 at 7:30 a.m., during the Initial Kitchen Tour with the Certified Dietary Manager (CDM), the following observations were made.Dietary Staff were not wearing hair restraints during meal preparation. The CDM explained the kitchen was shared with the Independent Living Facility and verified the Independent Living Facility dietary staff were crossing over to the nursing home side during meal preparation without hair restraint. On 11/17/25 at 7:40 a.m., an opened plastic container of a three bean salad and an opened plastic container of pudding were stored undated in the reach-in refrigerator. Photographic evidence obtained.On 11/17/25 at 7:40 a.m., the yellow emergency eye wash sink was dusty and had several small, deceased bugs in the basin. Photographic evidence obtained.On 11/17/25 at 7:55 a.m., the floor of the walk-in freezer was dirty with a large accumulation of black and brown dirt. A large amount of frozen white chunky substance was observed on the floor underneath the shelf to the right of the walk-in freezer.A clear plastic bin of fish was stored uncovered on the floor of the dirty walk-in freezer. Photographic evidence obtained.In the Bistro pantry food storage, there were two boxes of children's shoes containing child's pajamas in one box, the other was empty. The CDM said she did not know what the boxes were doing in the Bistro pantry. Photographic evidence obtained.Observation of the Bistro dining area revealed the cabinet under the coffee maker that was heavily soiled with brown and black dirt. Photographic evidence obtained.On 11/17/25 at 12:00 p.m., during an observation of the lunch meal in the memory care unit, multiple, small, flying insects were observed in the dining area. Family members were observed swatting at the flying insects.On 11/17/25 at 12:15 p.m., observation of the lunch meal in the Bistro dining area revealed multiple small flying insects.On 11/18/25 at 9:45 a.m., observation of the Transitional Care Unit (TCU) revealed the ice machine spout was rusty and coated with white residue. The inner aspect of the dispensing spout was rusty. The ice tray was rusty, and dusty. Photographic evidence obtained.On 11/20/25 at 7:15 p.m., in an interview the Administrator said they were working on addressing the fruit flies in the dining areas and the Certified Dietary Manager was doing weekly audits of the kitchen and dining areas. Event ID: Facility ID: 105672 If continuation sheet Page 10 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review, review of facility's Policy and Procedure, and staff interview the facility failed to ensure the clinical records were completely and accurately documented for 3 (Residents #115, #34 and #109) of 3 residents reviewed. The findings included:Review of the facility's Policy and Procedure titled, Change in Condition (CIC) Policy and Procedure revealed the purpose was to ensure timely identification, assessment, communication, documentation, and intervention when a resident experiences a change in physical, mental, or functional condition, in order to promote resident safety, meet regulatory requirements, and prevent avoidable transfers or adverse outcomes. A licensed nurse will assess the resident, notify the provider and family/responsible party as appropriate, initiate interventions, and document all actions . Change in Conditions Definitions: Any worsening, or sudden change in resident's: vital signs, cardiovascular status, respiratory status, pain level, skin integrity, mobility/functional ability signs of infection, bowel or bladder function or behavioral/emotional status. Responsibilities: Licensed Nursing Staff: Perform immediate assessment upon notification of change. Document finding in electronic health record. Notify the following as appropriate: Attending physician/Nurse Practitioner, resident and/or legal representative, and Director of Nursing (DON) or nursing supervisor. Monitor and re-assess the resident. Document follow-up actions and resident response.Review of the clinical record for Resident #115 revealed an admission date of 1/12/24. Diagnoses included diverticulosis of large intestine, gastrointestinal hemorrhage, pressure ulcer of sacral region, dementia, and bipolar disorder.Review of the Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/19/24 documented that the residents' cognitive status was moderately impaired.Review of the Advance Practice Registered Nurse (APRN) progress note dated 8/29/24 revealed Resident #115 was seen today at the request of staff after having 1 episode of emesis (vomiting) this a.m. Upon examination resident appears stable heart rate 98, blood pressure 145/72, respirations 18, oxygen saturation on 2 liters oxygen 98% and with no fever at this time. CBC (complete blood count) and CMP (comprehensive metabolic panel) in the a.m. to rule out acute infection or electrolyte imbalances.On 8/29/24 at 1030 a.m., the APRN ordered Zofran 4 milligrams 1 tablet to be administered every 4 hours as needed for nausea and Zofran 4 milligrams 1 tablet to be administered 4 times a day for 4 days for nausea/vomiting. Review of nursing progress notes revealed no documentation of the change of condition, and no follow up assessments.On 8/30/24 at 4:45 a.m., an alert note documented Resident #115 was a DNR (Do Not Resuscitate). No vital signs were noted. The Director of Nursing was notified. A message was left for the family to call the facility. They needed to be notified of the resident's passing.Review of the CBC and CMP collected on 8/30/24 at 1:35 a.m., showed the facility was notified of the lab results on 8/30/24 at 1:17 p.m. Resident #115 white blood cell count was 37.3 (normal 4.0-11.0).On 11/20/25 at 1:30 p.m., an interview was held with the Director of Nursing (DON) related to documentation of change in condition and follow up assessments. The DON verified the lack of change in condition documentation and follow up assessments. She said there was no nursing documentation about what happened to the resident. A Change in Condition form should have been completed. The family should have been notified. She said the laboratory results showed the resident had a massive infections somewhere.Review of the Facility Policy Activities of Daily Living (ADL's) dated 5/1/25 revealed, A resident who is unable to carry out ADLs will be provided the necessary care and services to maintain good nutrition, grooming, and personal and oral care. (b) The facility will provide care and services for the following ADLs: (1) Hygiene-bathing, dressing, and oral care.Review of the clinical record revealed Resident #34 was admitted to the facility 12/20/17. Diagnoses included cerebral palsy (neurological (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105672 If continuation sheet Page 11 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete disorder affecting movement, balance and posture), congenital hydrocephalus (excess cerebrospinal fluid in the brain) and osteoporosis (weakened bones).Review of the Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 8/21/25 documented that the resident was dependent on staff all ADLs. The MDS noted Resident #34 scored 03 on the Brief Interview for Mental Status (BIMS), indicative of severe cognitive impairment.Review of the Care Plan initiated on 4/4/25 revealed Resident #34 was dependent on the staff for bathing. The resident preferred a bath/shower 2-3 times per week in the morning.Review of Certified Nursing Assistant (CNA) Documentation Survey Report for October 2025 and November 2025 revealed, ADL-Bathing: Friday & Tuesday night only . Must wash hair.There was no documentation Resident #34 received a bath/shower on 10/1/25 through 10/6/25, 10/8/25 through 10/30/25. There was no bathing or shower documented for November 2025.Review of clinical record revealed Resident #109 was admitted the facility 11/3/25. Diagnoses included pubis fracture (Break in one of the pelvic bones).Review of the admission MDS with an assessment date of 11/9/25 revealed the resident required substantial/maximal assistance with showering/bathing.Review of the Care Plan initiated on 10/2/25 revealed the resident triggered in ADLs. The interventions listed included no weight bearing restrictions, physical help to transfer into bath/shower and one person assist for bathing.The CNA Documentation Survey Report for November 2025 documented ADL-Bathing: Monday and Thursday 7pm-7a, full body shower done by staff. The Survey Report documentation showed Resident #109 refused a bath/shower on 11/3/25,11/13/25, and 11/17/25. Code 97 not applicable was documented for bath/shower on 11/6/25 and 11/13/25. There was no nursing documentation indicating the resident had refused a bath or shower on 11/6/25 and 11/13/25.On 11/20/25 at 2:55 p.m., in an interview the Director of Nursing (DON) said the expectation was for residents to get bath/showers on their scheduled days. The DON said if a resident refuses a bath/shower, the CNA should notify the nurse. She said the nurse should speak to the resident and document in the clinical record the reason for refusal. The DON verified there was no documentation that Resident #34 received a bath/shower 10/3/25, 10/10/25, 10/14/25, 10/17/25, 10/21/25, 10/24/25 and 10/28/25. The DON said CNA documentation did not exist for November for Resident #34. She said there was a glitch in the system and they were investigating. The DON said she could not explain why bath/shower was documented as not applicable for Resident #109. Event ID: Facility ID: 105672 If continuation sheet Page 12 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review, review of policy and procedure and staff interviews the facility failed to develop and implement systemic appropriate corrective actions related to identified quality of care deficiencies related to falls and failed to identify and address unresolved quality deficiency related to food safety and sanitation in the kitchen.The findings included:Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) dated 4/22/25 revealed the objective of QAPI was to, Ensure care delivery systems function consistently, accurately, and incorporate current and evidence-based practice standards where available.Prevent deviation from care processes to the extent possible;Identify issues and concerns with facility systems, as well as identify opportunities for improvement; andDevelop and implement plans to correct and/or improve identified areas.Program Systemic Analysis and Systemic Action:(a) The facility will take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained .1. Review of the facility's survey history revealed:During a recertification survey conducted on 11/4/24 the facility failed to store and prepare food in a sanitary manner. A flying insect was observed on a bucket of chicken bouillon in the dry food storage area. Food items were stored on the floor of the dry food storage area. Black bio growth was observed on the walk-in refrigerator and walk-in freezer.The identified deficiencies were found corrected as of 12/5/24.During a recertification survey conducted on 5/1/25 the facility failed to maintain sanitary conditions in the kitchen, including a visibly soiled ice machine, and improper storage of a scoop in the ice machine. The three-compartment sink had an inadequate sanitizer level. Dietary staff were not wearing proper hair restraint, posing a risk of food contamination.The identified deficiencies were found corrected as of 5/30/25.During the recertification survey conducted on 11/20/25 the facility failed to maintain ongoing compliance related to sanitary condition in the kitchen, dining areas, storage and preparation of food. Flying insects were observed during meals in 2 of 3 dining areas observed. Dietary staff were not wearing hair restraints during meal preparation. Unlabeled and undated food was stored in the refrigerator. Uncovered fish was observed stored on the heavily soiled floor of the walk-in freezer. The outer aspect of the spout of the ice machine in the Transitional Care Unit was coated with white residue. The inner aspect of the spout was rusty. The ice tray was soiled and rusty.On 11/20/25 at 7:15 p.m., a meeting was held with the Administrator and the Director of Nursing (DON) related to the ongoing noncompliance related to unsanitary condition in the kitchen, and dining areas of the food serving institution.The Administrator said that they were working on addressing the fruit flies but had no documentation of interventions implemented or progress towards resolution. When asked about ensuring that improvements were sustained in the kitchen, she said, As far as the kitchen, the CDM (Certified Dietary Manager) is doing weekly audits.She said, If the audits are coming back good, then it's not an issue. If it is coming back with an issue, then it needs to be addressed.Review of the Plan of Correction Audit forms provided by the Administrator revealed the last audit was dated 11/7/25. A check mark was placed in the box under Hairnet Check, Ice Machine Check, Ice Scoop Check.The Administrator said she and the Regional go in the kitchen and audit. She said she went to the kitchen last week and saw hair nets, labeling and dating. The Administrator said she had no documentation of the audits she completed.The Administrator offered no explanation for the unsanitary condition observed in the kitchen and dining areas. She said some of the departments were effective, and some were not. They were moving in another direction in dietary. When asked to explain, she said the CDM resigned on Monday.2. On 11/20/25 at 7:30 p.m., during a review of the facility's Quality Assurance and Performance Improvement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105672 If continuation sheet Page 13 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete (QAPI) Program, the facility provided a list of fall incidents from June 1, 2025, through November 20, 2025.Review of the facility provided fall incidents revealed:June 2025: 2 falls.July 2025: 7 falls.August 2025: 9 falls.September 2025: 14 falls.October 2025: 13 falls.On 11/20/25 at 7:35 p.m., in an interview the DON said as of 11/20/25 the facility has had 16 falls. One resident sustained 3 falls.Review of the QAPI minutes for September 25, 2025, revealed the number of falls reported during the QAPI meeting for August 2025 differed from the number of falls listed on the facility incident report list.The facility documented a total of 19 falls for August 2025 as follows:9 falls on the night shift (11:00 p.m., to 7:00 a.m.),5 falls on the evening shift (3:00 p.m., to 11:00 p.m.), and5 falls on the day shift (7:00 a.m., to 3:00 p.m.).The QAPI meeting minutes noted under Performance Improvement Plan (PIP) review: Falls 24%. Root cause: Saturday. Location: B wing.On 11/20/25 at 7:40 p.m., the Administrator said B wing was the Long Term Care wing of the facility. She said there was nothing documented in clinical leadership to show what they were doing to address the increase in falls.The DON said the number of falls reported to QAPI for August 2025 was inaccurate.Review of the meeting minutes for October 23, 2025, revealed the number of falls reported to QAPI for September 2025 differed from the number of falls listed on the facility's incident list for September 2025.The QAPI minutes documented a total of 25 falls with 7 repeat falls. 9 residents sustained minor injuries, and 2 residents were transferred to the Emergency Room. The meeting minutes noted 22 of the 25 falls occurred in residents' rooms.The QAPI minutes documented, QAPI to review fall locations and develop targeted prevention strategies.On 11/20/25 at 7:54 p.m., in an interview the Administrator said she did not have documentation of the QAPI targeted prevention strategies.The Administrator verified that the increased number of falls at the facility was a problem area that needed to be addressed. She verified that falls were discussed in QAPI but she had no documentation that the facility trended the falls to determine the root cause in order to implement appropriate systemic interventions to reduce the number of falls at the facility. Event ID: Facility ID: 105672 If continuation sheet Page 14 of 15 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 105672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Village 1333 Santa Barbara Blvd Cape Coral, FL 33991 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility policy and staff interview, the facility failed to maintain an effective pest control program to ensure a sanitary environment free from pests for residents. The findings included: Review of the facility's policy Pest Control documented The facility maintains an affective pest control program to remain free of pests and rodents. On-going measures are taken to prevent, contain, and eradicate common household pests.On 11/17/25 at 12:00 p.m., observation of the lunch meal in the memory care unit revealed multiple small flying insects in the dining area. Family members were observed swatting at the flying insects.On 11/17/25 at 12:30 p.m., observation of the lunch meal in the Bistro dining area revealed multiple small flying insects.Review of the facility control company summary of service reports revealed:On 10/17/25, 10/22/25, 10/29/25, 11/5/25 and 11/12/25 in the memory care unit the log documented Be sure to keep garbage can clean. Drain trap is dry allowing pest entry. Please add water to the drain to block pest entry. Recommend fly light.On 11/19/25 at 11:00 a.m., in an interview the Director of Nursing (DON) said this was the first time she was hearing about the fruit flies. She said she was new to the facility but would check with the Maintenance Director.On 11/19/25 at 11:15 a.m., flying insects were observed on an uncovered tray of Danishes provided by the kitchen and placed in the conference room table. The DON observed the flying insects on the Danishes and said, Don't eat them. The DON said they had a meeting with family members of residents in the Memory Care Unit the previous evening. She said 5 family members mentioned the flying insects on the unit. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105672 If continuation sheet Page 15 of 15