Inspection·June 10, 2021

F 0561 reviewed for choices. This has the potential to cause skin breakdown, embarrassment, and frustration. Level of Harm - Minimal harm or potential for actual harm The findings included: Residents Affected - Few The facility policy, Bathing (revised 7/2016) specified, .Fill bathtub or adjust shower water temperature to patients' comfort .document in plan of care, care provided, unusual observations and or complaints and subsequent interventions . 1. On 6/9/21 at 2:09 p.m., in an interview, Resident #54 said he had not received his showers due to a lack of hot water in the facility and would like more sponge baths but does not get sponge baths often. Resident #54 said he had spoken to the staff, but the girls said they had no time. Review of the clinical record for Resident #54 showed a Certified Nursing Assistant (CNA) Care Kardex (provides details on the care the resident requires) which documented Resident #54 was scheduled to receive showers on Tuesday and Friday evenings. The clinical record contained a care plan (detailed instruction of the care a patient requires) which documented Resident #54 had an activity of daily living (ADL) self-care deficit due to physical limitations. The goal documented the resident would receive assistance necessary to meet ADL needs. The care plan interventions specified to assist to bathe/shower as needed. Review of the CNA documentation for May 2021 through June 10, 2021, showed Resident #54 refused a shower on 5/1/21, 5/14/21, 5/21/21, 5/29/21, and 6/4/21. On 6/1/21, the record contained no documentation of a shower or bed bath provided. The record did not document the reason the showers were refused. The record showed Resident #54 received a bed bath on 5/8/21, 5/21/21 and 6/8/21. On 6/10/21 at 11:33 a.m., in an interview, the South Wing Unit Manager Registered Nurse (RN), said if a resident refused a shower the Certified Nursing Assistant (CNA) would document it and then tell the nurse. The RN said the nurse was responsible to document the resident refusal and why in a progress note or daily assessment note. On 6/10/21 at 11:18 a.m., in an interview, CNA Staff B said Resident #54 was scheduled for an evening shower and she worked the day shift. CNA Staff B said, if the resident wants a bed bath during my shift, I give it to him. CNA Staff B said Resident #54 had complained of the water being cold in the past and she was aware the water in the shower rooms did not get hot. A review of the facility's Water Management Program, hot water system temperature log noted the return water temperature on 5/17/21, 5/25/21, 6/1/21, and 6/7/21 was 90 degrees. On 6/10/21 at 10:00 a.m., in an interview the Maintenance Director confirmed the hot water temperature in the shower rooms was 90 degrees. The Maintenance Director said the water temperature should be between 95-105-degree range. On 6/10/21 at 12:32 p.m., in an interview, Director of Nursing (DON) said she was not aware Resident #54 had not received his scheduled shower for May 2021 through June 10, 2021, because of the water temperature. The DON confirmed there was a problem in the facility with the hot water temperature. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 2 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on a Resident Council meeting and staff interview the facility failed to ensure they acted promptly upon grievances and recommendations made by the Resident Council related to resident care and life in the facility. Residents Affected - Few The findings include: On 6/08/21 at 11:00 a.m., interviewed Residents #8, #13, #31, #78 and #87. They said they normally attend the monthly resident council meetings. The group said the Activity Director (AD) ran the meetings and wrote down their concerns, grievances, and recommendations. The group said they had brought multiple concerns and recommendations to the monthly resident council meetings which had not been addressed and/or the facility had not explained to them why their request could not be implemented. The group said on 3/31/21, during the Resident Council meeting, they told the AD they would like to have the daily menus passed out to all the residents, they would like to have more food options like fresh fruit, the fish was tough, and the residents were receiving food items on their meal trays which were on their do not want list and food allergy list routinely. They also said they told the AD the staff was noisy, on their cell phones at night which was keeping them awake at night. The group said in the next Resident Council meeting held on 4/28/21, their concerns and recommendations voiced in the 3/31/21 resident council meetings were not addressed. The group said in the 5/26/21 Resident Council meeting, they again asked the AD if the facility could address their concerns related to the dietary department not following the resident's dislikes and food allergy list, could they have more/different food options like fresh fruit. The group said they told the AD staff were being loud at night, talking on their phones and talking in different languages making it hard for them to sleep at night. The group said the concerns and dietary recommendations voiced in the 3/31/21 were not addressed and/or explained to them, why they were not addressed in the 4/28/21 and 5/26/21 Resident Council meetings. On 6/7/21, review of the Resident Council meeting minutes dated 3/31/21 noted the group stated they would like fresh fruit or different breakfast options, the fish was too tough, the residents were receiving food on their do not like and allergy list and they would like the facility to pass out the daily menus to the residents. Resident #8 was missing a pink night gown, and the facility staff were not quiet in the resident's rooms and nursing pods. The 4/28/21 Resident Council meeting minutes did not address any of the concerns and recommendation documented in the 3/31/21 Resident Council meeting. The Resident Council meeting minutes dated 5/26/21 noted the residents were getting the same thing for breakfast with no options, the dietary department was not following the resident's menu by serving the resident's their dislike and food(s) they are allergic too. The Resident Council meeting notes also documented the staff were being loud at night, talking on their cell phone in the resident's room and staff are sleeping at night. On 6/9/21 at 4:26 p.m., after reviewing the 3/31/21, 4/28/2,1 and 5/26/21 Resident Council meeting minutes and her addition notes the AD confirmed the Resident Council group said in the 3/31/21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 3 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete meeting the residents would like to have the menus passed out daily to all the residents, they would like to have more food options like fresh fruit, the fish was tough, and the residents were receiving food items on their meal trays that were on their do not want list and their food allergy list routinely. She also confirmed, they told her the staff were noisy at night, and on their cell phones at night which was keeping the residents awake. She confirmed none of the concerns and recommendation voiced in the 3/31/21 were noted as being resolved by the facility and/or explained why the concerns and/or recommendation could not be resolved by the facility in the 4/28/21 and 5/26/21 Resident Council meetings as required. She confirmed the same concerns and recommendations noted in the 3/31/21 Resident Council meeting related to the nursing staff being loud at night, the dietary department not following the resident's diet choices and requesting dietary options were voiced again in the 5/26/21 Resident Council meeting. She confirmed there was no documentation the facility had addressed the Resident Council meeting concerns, grievances and group recommendations concerning resident care and life in the facility promptly and/or provide documentation of their response and their rationale for their response. Event ID: Facility ID: 105723 If continuation sheet Page 4 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident and staff interview, the facility failed to provide an ambulation program as per restorative and plan of care to maintain abilities and prevent decline in ambulation for 1 (Resident #70) of 1 resident reviewed for Activities of Daily Living (ADL). Residents Affected - Few The findings included: The facility's Restorative Nursing Guideline, dated 08/2019, primary focus was . Nursing interventions that help to maintain the patient's highest level of function and prevent unnecessary decline in function. On 6/7/21 at 2:15 p.m., Resident #70 was observed dressed and sitting in her wheelchair in the doorway of her room. Resident #70 said she used to be able to walk until they quit doing her physical therapy a few months ago. Resident #70 was asked if she had requested therapy to help her walk and Resident stated, Oh honey they know. When asked if she wanted to walk, she answered yes. On 6/8/21, during clinical record review, Resident #70's Physical Therapy Discharge summary dated [DATE] recorded Resident #70 ambulating 20 feet using a 2 wheeled walker. Assessment Summary discharge prognosis to maintain current level of function was good with consistent staff follow-through. Discharge recommendations for Resident #70 included Restorative ambulation program. The ambulation program said patient was currently able to walk in room but, balance was unsteady. With Restorative Nursing Program, patient would be able to walk in room with assist of one, and balance would require the physical support of one, by performing the following Restorative Nursing interventions: use walker. On 6/8/21, the Care Plan for Resident #70 was reviewed, and the interventions included to provide minimal assistance with walking from the bed to the wheelchair. Patient to use a 2 wheeled walker twice a day. The care plan initiation date was 12/18/20. These interventions were also listed on Resident #70's [NAME] (Quick summary of individual resident's needs) under heading of ADL's/Restorative Care. The ADL documentation records for Resident #70 were reviewed from 4/10/21 through 6/9/21. Under the area of walk-in room support provided, there were only 9 completed/documented out of 118 required during that time frame. There was no other documentation of the resident walking as per the Restorative Nursing program. On 6/9/21 at 10:00 a.m., in an interview, Certified Nursing Assistant (CNA) Staff E said Resident #70 used to walk in her room but couldn't remember when he last saw her walk. He said she only took 1 to 2 steps with assistance when transferring from wheelchair to toilet. CNA Staff E did not know if Resident #70 was on a restorative program and said he would ask the nurse to find out or get the information during report. On 6/9/21 at 10:15 a.m., in an interview Physical Therapist Staff F looked up Resident #70's record and the record stated functional status at discharge from Physical Therapy on 12/21/20 was walking 20 feet with a 2 wheeled walker. Resident was discharged to restorative with 1 assist. The restorative form was sent to Nurse Manager of unit, and they take over responsibilities of restorative program. Physical Therapist Staff F says there was no restorative CNA, that each CNA did their own assigned patients. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 5 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/9/21 at 10:30 a.m., in an interview, the Assistant Director of Nursing (ADON) stated she was over the Restorative Program. She was unable to produce any documentation of training for staff or restorative programs for residents. She stated she was working on it. She also stated she was the one who got the form from Physical Therapy and input it into the care plan program that went on the CNA [NAME]. Reviewed Resident #70's care plan with ADON and then daily task for the last 30 days. The ADON confirmed there was no documentation of the resident walking as per the restorative program. On 6/9/21 at 11:30 a.m., in an interview, Director of Nursing confirmed there was no restorative program but only restorative maintenance programs that each CNA was supposed to do. She was unable to provide a list of residents on restorative care. She said the CNAs were to use the [NAME] for that information. On 6/9/21 at 12:10 p.m., in a follow up interview with Resident #70, she stated it made her feel left out that she was unable to walk. She stated she definitely wants to walk. She said she used to enjoy going walking in the hall and outside. On 6/9/21 at 12:35 p.m., in an interview, ADON confirmed there was no list of residents on restorative programs. She did say there was a policy for restorative program, but the program for Resident #70 was not set up right. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 6 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 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, interview and record review, the facility to ensure the medication error rate was below 5.00%. Three licensed nurses on two different wings with 26 opportunities were observed. Three medication errors were identified resulting in a 11.54% error rate. Residents Affected - Few The facility policy, Medication and Treatment Administration Guidelines (Updated 3/2018) specified, Medications are administered in accordance with standards of practice and state specific and federal guidelines . 1. On 6/9/21 at 8:15 a.m., Registered Nurse (RN) Staff A was observed to prepare 6 different medications for Resident #7 including 1 tablet of multiple vitamin and Polyethylene Glycol 3350 Powder 17 grams (gm). RN Staff A measured and poured the dose of Polyethylene Glycol 3350 Powder in a cup and mixed it with water. RN Staff A left the cup with Polyethylene Glycol 3350 Powder on top of the cart and administered the other medications to Resident #7. RN Staff A returned to the cart and poured the polyethylene Glycol in the sink. On 6/9/21 at 11:20 a.m., upon reconciliation with the clinical record revealed a physician's order specifying to administer 1 tablet of multiple vitamins with minerals. On 6/9/21 at 1:02 p.m., in an interview RN Staff A confirmed she administered a multiple vitamin without minerals to Resident #7 instead of the ordered multiple vitamins with minerals. She also verified she did not administer the Polyethylene Glycol 3350 Powder as ordered. 2. On 6/9/21 at 8:25 a.m., Registered Nurse (RN) Staff A was observed to prepare and administer a tablet of plain multiple vitamins to Resident #5. On 6/9/21 at 11:30 a.m., upon reconciliation with the clinical record revealed a physician's order specifying to administer 1 tablet of multiple vitamins with minerals. On 6/9/21 at 1:06 p.m., during an interview, RN Staff A verified she administered a tablet of multiple vitamins to Resident #5 instead of the multiple vitamins with minerals as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 7 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 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, staff interview, and review of facility policy and procedure, the facility failed to identify and dispose of expired medications to prevent use in 2 (100 and 400 hall) of 3 medication carts and 1 (North wing) of 2 medication rooms. The facility failed to properly store and label medications for 3 (Residents #31, #89 and #349,) in 2 of 3 medication carts reviewed for proper storage and labeling of medications. This has the potential for expired medications to be administered to residents. The findings included: The facility policy, 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles (revised 10/31/16) documented, .Facility should ensure that medications and biological that (1) have an expiration date on the label; (2) have been retained longer than recommended by the manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated are stored separate from other medications until destroyed or returned to the pharmacy or supplier. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened .Medications with a manufacturer's expiration date expressed in month and year will expire on the last day of the month .Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels, or cautionary instructions. On 6/9/21 at 8:35 a.m., observation of the North Wing 100-hall medication cart with Registered Nurse (RN) Staff A revealed the following: 1) An opened, undated vial of Humalog insulin for Resident #31. Without a date opened, there was no ability to know when the medication had expired. 2) Two boxes of Clonidine 0.2 milligram Transdermal Patch with an expiration date of 1/2021. RN Staff A confirmed the medication was expired and said she would discard it. **Photographic Evidence Obtained** On 6/9/21 at 10:16 a.m., observation of the South Wing 400 hall medication cart with Licensed Practical Nurse (LPN) Staff D revealed the following: 3) Two opened, undated Humalog insulin KwikPens for Resident #89. LPN Staff D confirmed the two Humalog insulin KwikPens belonged to Resident #89 were opened but not dated. She said she would discard them. Without a date opened, there was no ability to know when the medication had expired. 4) An opened, undated Basaglar insulin KwikPen for Resident #89. LPN Staff D confirmed the Basaglar insulin pen was opened but not dated. She said she would discard it. Without a date opened, there was no ability to know when medication had expired. 5) An opened, undated Lantus Solostar insulin pen for Resident #349. LPN Staff D confirmed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 8 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 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 Lantus Solostar insulin pen was opened, not labeled with the date it was first opened. She said she would discard it. Without a date opened, there was no ability to know when medication had expired. 6. On 6/9/21 at 8:47 a.m., observation of the North Wing medication room showed a bottle of Magnesium Citrate with an expiration date of 3/2021. LPN Staff C confirmed the medication was expired and said it would be discarded. **Photographic Evidence Obtained** 7. On 6/9/21 at 8:58 a.m., observation of the North Wing 300 hall medication cart revealed a bottle of multiple vitamins with an expiration date of 5/2021. LPN Staff C confirmed the medication was expired and said it would be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 9 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 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 and staff interview, the facility failed to maintain the kitchen and nourishment rooms in a clean, safe, and sanitary manner that is in good repair by not having clean surfaces in food preparation and storage areas, and not maintaining the ice machine in a manner to prevent potential contamination. The findings included: 1. On 6/7/21 at 10:45 a.m., and 6/8/21 at 9:20 a.m., during tours of the kitchen, the following was observed: The entrance door was gouged with exposed wood on the bottom portion of the door inside the kitchen. There was a 6-inch by 2-inch hole in the wall on left side of the door. The panel on the wall facing the door was partially detached. The dry storage room had dust and biological growth (bio growth) on the air vent in the ceiling, a storage bin below had the lid open, and an opened bag of light brown sugar was exposed to potential contamination from above. The dish washing area had bio growth along the top of the wall over the hanging clean pots and along the tile underneath the pots. The food disposal unit under the dish machine was covered in rust and debris. The area around the ceiling vent had loose drywall paper hanging and was soiled. Dust and debris were noted on the top of the dishwasher. The wall and ceiling above the ice machine was torn and detached. A metal pole fan was heavily soiled with dust and the plate cover storage rack was heavily soiled with debris. The right-hand corner and metal sill to the walk-in refrigerator was rusted and heavily soiled with debris. The grills in the ceiling were coated with brown substance and the floor was heavily soiled. The wall across from steam table was in disrepair. The door frame of the door to the dining room was stained and had chipped paint. The floor was stained/soiled. The bread carts were coated with rust. The shelves in the plate cover storage rack were heavily coated with debris. There was a sign on the front of the ice machine indicating it had been out of order since 5/27/21. On 6/7/21 at 11:00 a.m., in an interview, Certified Dietary Manager (CDM) said the dietary department was getting ice from the nourishment room on the nursing unit. 2. On 6/7/21 at 11:18 a.m., the North Wing (NW) nourishment room was observed. The ice machine was soiled, and the water dispenser spout had bio growth on the inside of the rubber tube; the area around the ice chute was rusted and heavily soiled/stained; the grill underneath the ice dispenser had several areas of rust. The refrigerator next to the ice machine was observed to have food debris on the back shelf and was soiled. An unlabeled, undated, partially empty can of peanuts was being stored in a cabinet under the sink. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 10 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 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 On 6/7/21 at 12:35 p.m., the NW nourishment room was observed along with the CDM. The soiled ice machine was observed and per the CDM, it was the responsibility of the maintenance department to clean the ice machines. In regard to the can of peanuts, she said those did not come from the kitchen and discarded them. On 6/7/21 at 11:31 a.m., the South Wing Pantry was observed. The ice machine had the top panel off and was not in use; and the inside of the refrigerator was soiled. 3. On 6/8/21 at 11:45 a.m., during observation of tray line, the large pole fan was directed towards the open food on the steam table and was still heavily coated with dust. On 6/10/21 at 8:55 a.m., a tour of the kitchen was conducted with the CDM. All above concerns were again identified with exception of the bin in the dry storage room was now closed. Reviewed the bin had been observed opened on 6/7/21 and 6/8/21. The CDM said she would dispose of the bag of sugar. The CDM acknowledged rusted items were uncleanable surfaces and it was difficult for staff to reach all the floor in the walk-in refrigerator. She confirmed the ceiling looked like bio growth around the vents and needed to be cleaned and the wall damage above the ice machine was from a water leak. ** Photographic Evidence Obtained ** FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 11 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to maintain laundry room equipment, in safe operating condition. Residents Affected - Many The findings included: The facts about home clothes dryer fires as outlined in the U.S. Fire Administration website at https://www.usfa.fema.gov/prevention/outreach/clothes_dryers.html notes Facts about home clothes dryer fires . Failure to clean the dryer (34 percent) is the leading cause of home clothes dryer fires. Review of the facility's laundry room cleaning policy dated 6/25/20 revealed, Dryer Cleaning and Dusting or Vacuuming . Clean lint screen every two hours . On 6/9/21 at 6:55 a.m., during a tour of the laundry room with the Director of Nursing (DON), Laundry Room Attendant Staff M was observed putting wet clothes in the dryers. The lint filters of the two dryers were bulging and overflowing with lint. **Photograph Evidence Obtained** Laundry Room Attendant Staff M and the DON verified the lint filters were overflowing with lint. Laundry Room Attendant Staff M said, They should have been cleaned last night, I have not started the dryers this morning. Review of the dryer lint screen cleaning log revealed documentation the dryers' lint screens were last cleaned on 6/8/21 at 7:00 p.m. On 6/10/21 at 12:17 p.m., the DON provided a single page document titled Hood & Duct Cleaning which she said was from the facility's life safety manual that read Dryer Filter Cleaning; Frequency: After every hour on run time, at minimum . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 12 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident, family, and staff interview, the facility failed to maintain a safe, sanitary, and comfortable environment, free from biological growth (bio growth) for residents, staff, and the public, by not having clean surfaces; not repairing damaged walls in resident rooms and bathrooms; and not storing resident personal care items in a sanitary manner. Not maintaining a sanitary environment has the potential for cross contamination and promotes bio growth. The findings included: 1. On 6/7/21 at 12:00 p.m., mold was identified in the South Wing nourishment room by the Life Safety surveyor. The cabinet under the sink was in disrepair from extensive water damage with a large area of mold along the floor and walls. On 6/7/21 at 12:05 p.m., the Director of Maintenance and Administrator Consultant said the room would be closed until the cabinet was removed and the room cleaned. On 6/8/21 at 3:23 p.m., the Life Safety surveyor also identified mold in the open ceiling on the 100 unit outside resident rooms [ROOM NUMBER]. The ceiling tile was missing with the mold exposed to the hall below. On 6/7/21 at 3:23 p.m., in an interview, Licensed Practical Nurse (LPN)Staff H said there had been a leak outside room [ROOM NUMBER] and the ceiling tile had been missing for about 2 months with the area above exposed. She said the facility was aware as Certified Nursing Assistant (CNA) Staff J did write a maintenance request about it. On 6/7/21 at 3:33 p.m., in an interview, CNA Staff J said he worked on the 100 unit routinely and the ceiling near 107 had been weak for a while due to water leaks. The ceiling gave way a couple months prior when dripping during a heavy rain. CNA Staff J said he made out a maintenance request in the computer, at the time the tile came down. On 6/8/21 at 10:50 a.m., in an interview, Director of Maintenance said he was not aware of the ceiling issue on the 100 hall or any maintenance request but would check the computer. At 2:11 p.m., the Director of Maintenance said he found one work order in regard to a hole in the ceiling near room [ROOM NUMBER]. The work order was reviewed and indicated, The ceiling has a hole, looks bad. The note was dated 4/15/21. On 6/8/21 at 1:13 p.m., in an interview, Administrator Consultant said a remediation company would be there to mitigate the mold and put a plan in place. He said the facility started acting on this as soon as they became aware. Reviewed that staff reported the tile had been missing for 2 months from water damage and maintenance had been notified. There was no evidence the facility had taken action to ensure residents and staff were not exposed to mold spores prior to surveyor intervention on 6/7/21. The Life Safety surveyor requested the residents be moved from the proximity as the presence of mold, especially high concentrations, can exacerbate immune suppression, respiratory compromise, and allergies in residents, staff, and visitors. 2. On 6/7/21, 6/8/21, and 6/9/21, during a tour of the facility, the following was observed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 13 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many South Wing nourishment room- the walls were marred and stained; the floor was stained and soiled with debris; the vent in the ceiling was coated with dust; bio growth was present along the top of the backslash, behind the sink; there was a section of detached cove base along the left wall; the front of the cabinets were soiled and stained with spillage; the floor behind and next to the ice machine was heavily soiled with debris; the floor in front of the trash receptacle was stained black with a large hole in the wall next to it; and the inside of the cabinet, where paper products and food items were being stored, was heavily soiled/stained with bio growth along the back wall. On 6/7/21 at 12:00 p.m., the Director of Maintenance also observed the South Wing nourishment room and confirmed this finding. North Wing nourishment room- walls were marred and stained; the floor was soiled; debris was present behind the ice machine; the wall of the cabinet, next to the ice machine was partially detached and heavily soiled; the inside of the cabinet was soiled/stained with paper products being stored; and the area under the sink was stained/soiled with bio growth present on the back wall. 500 hall shower room- the inside of the cabinet under the sink was heavily soiled/stained with bio growth present; personal care items, resident briefs, and other items were being stored in the cabinet; an unlabeled wash basin was being stored inside a commode receptacle on the floor of the shower stall; unlabeled personal care items were being stored in the wall cabinet; the mirror above the sink was discolored along the base; the faucet and handles were corroded; and the base of the toilet was heavily stained. 400 hall shower room- the entrance door was delaminated with gouged/exposed wood; the corners of the floor were stained/soiled; unlabeled personal care items were being stored in the wall cabinet and on top of the paper towel dispenser; the mirror above the sink was discolored along the base; the floor around the base of the toilet was stained/soiled; and the air vent, surrounding ceiling, and shower curtain track was heavily soiled/stained with bio growth. 100 hall shower room- floor and wall around the sink were stained; the faucet was corroded and bio growth was present along the back of the sink; the base of the toilet was stained/soiled; resident equipment along with a bag of linen was being stored inside the bathtub; the air vent was soiled with bio growth present; the tract of the shower curtain was soiled; and unmarked personal care items, along with a wrist watch, were being stored inside the wall cabinet. [NAME] Unit shower room- the vent in the ceiling was heavily soiled with dust; the base of the toilet was soiled/stained; the floor inside the shower stall was missing a section of tile and was heavily soiled with debris; the ceiling was discolored above the shower; and the wall under the sink had a hole around the plumbing and was stained/soiled. [NAME] Unit- a 12 inch by 3 inch hole in the wall, with exposed wires, was present below the handrail in the corridor across from the door to the courtyard; several ceiling tiles were stained around unit; and the ceiling vent in the hallway, across from the nursing station, was heavily soiled with ducting debris coming out of the ceiling. North Wing nursing station- there was missing laminate along the edges with exposed wood; the fabric chair was soiled/stained; the floor was soiled, and the back of the desk was stained and discolored. Family room/Cafe- the fabric chairs were soiled/stained with gouged wood on the legs; and the 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 14 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 wall air conditioners were detached from the wall with heavy dust accumulation. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]- the floor was stained/discolored in the bathroom along the base of the toilet; the air conditioning wall unit was detached from the wall; and the floor was heavily soiled with debris. Residents Affected - Many room [ROOM NUMBER]- the floor around the toilet was heavily soiled/stained. On 6/8/21 at 12:25 p.m., in an interview, Resident #86's family member said the facility was filthy, the floors and bathrooms were dirty. room [ROOM NUMBER]- the floor was soiled with debris throughout the room with a build-up of dust under the bed; the edges of the floor were heavily soiled with dust and debris; the bathroom floor was soiled and discolored around the toilet; and the walls were in disrepair in the bathroom with peeling paint. room [ROOM NUMBER]- the ceiling was stained and in disrepair; wall was gouged; and the floor in the bathroom was heavily stained/soiled. room [ROOM NUMBER]- the floor was heavily stained and soiled. room [ROOM NUMBER]- the wall was in disrepair to left of door; the vent was dusty in the bathroom; there was a hole in the door to bathroom; and the wall was gouged wall to right of bathroom. room [ROOM NUMBER]- there was a large, 1 inch gap to outside at the top of wall air conditioner unit with a heavy accumulation of dust; bio growth was present along edge of sink backslash; edge of bathroom door was missing the laminate covering and bare wood was exposed; there was a hole in bottom of door; top of the wall/ceiling in bathroom was stained/discolored; and the closet door was missing laminate strip on half of the door. room [ROOM NUMBER]-bathroom had stained, cracked, detached cove base; stained wall and floor; rusted water valve; stained counter and detached laminate to left of sink; the base of the mirror was discolored; and holes were present in the walls of the room. room [ROOM NUMBER]-wall was damaged under the clock and behind the chair and bed; dresser was in disrepair and missing handles; and the base of toilet was soiled/stained. On 6/7/21 at 2:35 p.m., in an interview, Resident #54 said the hot water hardly worked. When they took him to the shower room, the water was cold or no pressure. He said the wallpaper had been peeling on the wall since he moved into the room. room [ROOM NUMBER]- wall was damaged next to the entrance to the bathroom with peeling, detached, drywall, and rusted metal. In an interview on 6/7/21 at 11:11 a.m., Resident #43 said the damage to the wall had been there since he was admitted to this room. room [ROOM NUMBER]- the wall next to the resident's bed was in disrepair. In an interview on 6/7/21 at 12:32 p.m., Resident #63 said the damage to the walls in his room had been like that since being admitted to the room. He said no one had told him when they would be fixing the wall damage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 15 of 16 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 105723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Health and Rehabilitation Center 1600 Matthew Drive Fort Myers, FL 33907 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]- the wallpaper was detached from the wall and the base of the toilet was stained/soiled. In an interview on 6/7/21 at 1:01 p.m., Resident #398 said the bathroom light and toilet didn't work all the time; he told the staff several days ago, but no one had come to address those problems. He said the wallpaper next to the bathroom had been like that since moving into the room. Residents Affected - Many room [ROOM NUMBER]- the base of the toilet was heavily stained/discolored. **Photographic Evidence Obtained** On 6/10/21 at 11:43 a.m., a tour of environment was conducted with the Administrator, Director of Maintenance, and Housekeeping Supervisor. The above areas identified were again observed with exception of area that was sealed off. The Housekeeping Supervisor said the wall cabinets in the shower rooms were for cleaning chemicals only and confirmed personal care items were being stored along with the cleaning product. The Director of Maintenance said he would be addressing the doors and acknowledged the areas that needed to be repaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105723 If continuation sheet Page 16 of 16