Inspection·January 31, 2022

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident and staff interview, the facility failed to consistently ensure the call light was within residents' reach to request for assistance as needed for 3 (Resident #87, #91 and #60) of 35 sampled residents. Residents Affected - Few The findings included: 1. Review of the admission MDS assessment with a target date of 11/9/21 showed Resident #60 scored a 10 on the Brief Interview for Mental Status (BIMS), indicative of moderate cognitive impairment. The assessment noted the resident required limited physical assistance of one person to walk in room and locomotion on the unit, including how resident moves between locations in his room. On 1/11/22 at 11:00 a.m., Resident #60 observed in a wheelchair in his room. The call light was observed clipped to itself at the wall console, not accessible to the resident. At the time of the observation, in an interview Resident #60 was asked about his call light. The Resident looked around his room and said, I do not know what you're talking about. Resident #60 was shown the call light clipped to the wall. He said, Is that what that is? No one has shown that to me or told me to how to use it. On 1/12/22 at 4:10 p.m., Resident # 60's call light observed clipped to itself at the wall console in the same location as the previous day. 2. On 1/10/22 at 10:30 a.m., 1/11/22 at 10:30 a.m., and 1/12/22 at 9:25 a.m., Residents #87 and #91 were observed in bed. The call lights were on the floor behind the headboards and not accessible to the residents to request assistance as needed. Review of the quarterly Minimum Data Set (MDS) assessment with a target date of 11/27/21 revealed Resident #87 was totally dependent on staff for toilet use and personal hygiene. Resident #87 had no impairment of upper extremities. The Resident scored a 00 on the Brief Interview for Mental Status (BIMS), indicating of severe cognitive impairment. The assessment noted the resident was able to complete the interview. Review of the quarterly Minimum Data Set (MDS) assessment with a target date of 11/26/21 revealed Resident #91 required extensive physical assistance of staff for bed mobility, transfer, and personal hygiene, and had no functional limitation in range of motion of the upper extremities. The Resident scored a 00 on the BIMS but the resident was able to complete the interview. On 1/13/22 at 4:00 p.m., interviewed unit manager Registered Nurse (RN), Staff DD, about call lights. RN, Staff DD said, The resident should have the call lights clipped to their top cover and if they are able to use the call bell it should be placed in their hand. RN, Staff DD, confirmed the call lights were on the floor, behind the headboard and clipped to the wall unit. RN, Staff DD, said, That shouldn't happen. RN Staff DD said, I see it is a safety issue for the residents. Even those who can't communicate if there was an emergency then the staff would need access to call for assistance. It shouldn't be on the floor. I am going to get some clips right now and go room to room. On 1/13/22 at 4:30 p.m., in an interview the Director of Nursing (DON) and RN Staff N confirmed the call lights should be within easy reach of the resident and not be on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 2 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. 6. On 1/10/22 at 10:45 a.m., in an interview Resident #86 said she has been at the facility for almost two months. She said since her admission to the facility, when the facility staff sent her dirty clothing to the laundry, the laundry did not always come back. She said she told multiple staff about her missing clothing and sometimes the staff had been able to find some of her missing clothing, but she was still missing several pair of shorts, shirts and nightgowns. 7. On 1/10/22 at 12:01 p.m., in an interview Resident #92's husband said his wife was admitted to the facility in August of 2019. Since her admission, the facility had lost multiple clothing items which they had not been able to find. Because the facility had lost a lot of his wife's clothing he told them he would do her laundry. Since posting a sign on his wife's closet door, stating he would be doing his wife's laundry the nursing staff still would send his wife's clothing to laundry and not return all of them as required. He said he had complained to multiple staff over the past year about his wife's missing clothing. Resident #92's husband said the staff would search for the missing clothes in the facility but were unable to find all her missing clothing. On 1/12/22 at 11:04 a.m. in an interview Registered Nurse (RN) Staff Z said when a resident is admitted to the facility, the resident's Certified Nursing Assistants (CNAs) are responsible to log the resident's belongings on the resident's inventory list form and update the inventory list form as needed. Staff Z said all clothing items were labeled with the resident's name and if a clothing item was missing, they were to search for the item. If they were unable to find the missing item, the staff were required to fill out a grievance form which would then be given to the social service department. He said Resident #86 has complained to him about missing clothing but didn't know if they were ever found and/or a grievance form was completed as required. On 1/12/22/21 at 11:18 a.m., in an interview CNA Staff II said and confirmed the CNAs were required to complete an inventory list form when a resident was admitted to the facility and updated when new items were brought in for the resident. She said Resident #86 had told the staff several times about missing clothing items. Staff II said she had been able to find some of them in laundry and others in other resident's rooms. She said Resident #86 was still missing several shorts, shirts, blouses, and nightgowns. She said she had not filled out grievance forms with Resident #86's missing clothing items. On 1/12/22 at 11:44 a.m., in an interview Licensed Practical Nurse (LPN) Staff JJ said she had been working at the facility for seven months. She said the facility's policy was when a resident was admitted to the facility, staff were required to fill out an inventory form for each resident and when new items were brought to the facility, the staff were required to update the inventory list form with the new items. If an item went missing, they were required to search for the item and if they were not able to find the missing item, they were required to fill out a grievance form and give the grievance form to the Social Service Director (SSD). Staff JJ said Resident #92's husband had a sign on the closet door stating he would be doing his wife's laundry. She said Resident #92's husband has told her multiple times the staff were sending his wife's dirty close to laundry, and they were now missing. She said they have searched for the clothes but were not able to find all of Resident #92's missing clothing. She said she had not filled out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 3 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a grievance form for Resident #92's missing clothing. She further said she had heard multiple residents and family members say when clothing went to the laundry they did not always come back. On 1/13/22 at 3:49 p.m., in an interview the SSD said the facility staff were required to fill out the inventory list form for all residents upon admission. When new items were brought in for the resident, the staff were required to update the resident's inventory list form with the new items. If the items went missing and the staff were unable to find the missing item, they were required to fill out a grievance form and submit the form to the social service department and inform the Administrator of the missing item so it can be determined what to do to replace the resident's missing item. He said he was unable to find documentation the facility staff had written a grievance form for Resident #86's and Resident #92's missing clothing. He said the facility staff did not always complete the grievance form as required for missing resident belongings, resulting in administration not knowing of the missing items and not being able to resolve the grievance as required per their policy. Based on observation, record review, and interview, the facility failed to make prompt efforts to initiate and/or resolve grievances and keep resident appropriately apprised of progress towards resolution for 8 (Resident #32, #131, #145, #79, #72, #86, #92, and #129) of 8 residents for Residents' grievances and grievances filed through resident council meetings. The findings included: Facility policy titled Grievances last revised 5/2018 indicated, . Upon receipt of a written Grievance/Concern Form, the Grievance Official or designee will forward the Concern Form to the appropriate department for investigation. The investigating department will submit a written report of findings and resolutions to the Grievance Official. If the concern has not been resolved to the satisfaction of the resident/resident representative, within 5 days the Administrator will review the findings with the person who completed the investigation in order to determine what corrective action, if any, needs to be taken . The social worker or designee will follow up within one week to ensure that the resident/resident representative remains satisfied with the initial resolution and that there were no further occurrences . 1. On 1/11/22 at 10:00 a.m., during a group meeting Resident #32 said she has seen cockroaches both day and night. Resident #145 said she also has seen cockroaches mostly in the bathroom and some in her bedroom. She said she also has a problem right now with a lot of little bugs. Resident #131 said she has seen roaches coming in and out her window and climbing on the walls. Resident #72 said there have been problems with dining. She said what is on the menu is not what you get. 2. Review of the grievance log showed on 7/16/21 Resident #145 filed a grievance about bugs. The grievance documented the room was treated and marked as resolved. On 1/11/22 at 1:30 p.m., in an interview Resident #145 said after filing grievances, the Activities person talked about it in the next resident council meeting, but a director or anyone like that never followed up with her. She said the bugs continue to be an issue. 3. On 1/11/22 at 10:00 a.m., during a group meeting Resident #79 said the ceiling fans on both patios have been broken about for about a year and it gets very hot out there. The grievance log contained documentation on 5/6/21 Resident #79 requested to please get the fans on the smoking lanai fixed. The lanai was too hot to enjoy. The action/investigation portion of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 4 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0585 form indicated the issue was resolved and two fans had been ordered/requested. Level of Harm - Minimal harm or potential for actual harm Observation of the smoking lanai on 1/12/22 at 9:45 a.m. showed both fans were not working. Residents Affected - Some On 1/12/22 9:45 a.m., the Social Services Director said he thought the fans had been fixed and working, but maybe they broke again. The Social Services Director admitted he did not do a follow up with Resident #79 to ensure she remained satisfied with the initial resolution. The grievance log also showed on 8/14/21 Resident #79 filed a grievance related to cockroaches in the room, ants in the sink and dietary issues. The grievance was marked as resolved. On 1/11/22 1:25 p.m., in an interview Resident #79 said she had filed several grievances. She said no one ever followed up with her about her concerns and the issues were still occurring. 4. The grievance log revealed on 12/23/21 Resident #72 had filed a grievance regarding food. The grievance was marked as issue resolved. On 1/11/22 at 4:20 p.m., in an interview Resident #72 said she had been at the facility for five years and had made multiple complaints. She said nothing gets done. She said the former dining person used to try, but the new people had been there about a month or so and the food isn't fit for anyone. She said no one follows up with anything there. On 1/12/22 at 9:45 a.m., the Social Services Director said the facility called a pest control company to come in and treat for pests and a new dining service had taken over. The Social Services Director admitted he did not follow up with Resident #145, Resident #72, or Resident #79 to ensure they remained satisfied with the initial resolution. On 1/12/22 at 10:08 a.m., the Director of Maintenance (DOM) said new fans were received in December 2021. He said they have not been fixed yet as they were short staffed. The DOM said the fans had been broken since October 2021 when he started employment at the facility. Since he arrived, one had been working only intermittently. The DOM said he did not know when they ordered the fans or anything else as he has no documentation from the previous Maintenance person. He said there is a pest control company they call. When someone reports an issue, the pest control company will come in and treat the area where they were seen. On 1/12/22 at 1:11 p.m., the Executive Director (ED) said he was aware the fans were not working and said they have not worked for quite a while. He was aware the new fans arrived last month, but they would not be putting them up. He said they switched the area for smoking to that lanai due to COVID and as long as there was smoking, he would not fix the fans because it will blow ash all around. The ED said he did not know if this was ever explained to the person who filed the grievance, but he said it was not a grievance, it was a complaint. On 1/12/22 1:30 p.m., the Activities Director agreed call light, dietary and pest concerns have been brought up by the resident council for months. She said she completed the grievance/concern forms and gave them to the Social Services Director (SSD) following the meetings. She said the SSD handed them out to the managers, but she doesn't hear anything back after that. She said when she writes resolved on the Resident Council minutes, it means she asked the resident at the next meeting if they are still having the problem. If they say no, she says it is resolved, but if another resident raises the concern, she will list it again as a new concern. The Activity Director said no one from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 5 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0585 management attends or asks to address the Resident Council concerns. Level of Harm - Minimal harm or potential for actual harm On 1/12/22 at 9:45 a.m., the Social Services Director (SSD) said he was the grievance officer. He said he received the Resident Council Minutes and concerns. He said he forwards these concerns to the unit managers to investigate. He said he does not receive documentation of the investigation, findings, or resolutions from the unit managers. He said he does not go to the Resident Council meetings as he has not been invited to go. He admitted he did not do post-resolution follow up with residents to monitor satisfaction with reported resolved concerns. Residents Affected - Some 5. On 1/10/22 at 11:39 a.m., in an interview Resident #129 said a while ago she lost her dentures in the courtyard. She said the facility knew she lost her dentures, but she did not know if they were doing something about it. On 1/11/22 at 01:04 p.m., review of the grievance log showed on 5/8/21 Resident #129 filed a grievance for missing top dentures and room change. The grievance report form noted additional actions was required and [ Organization Name] was to set up an appointment for new dentures. On 1/12/22 at 11:31 a.m., in an interview the Social Service Assistant verified the lack of resolution to Resident #129's grievance related to her missing dentures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 6 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to complete, encode, and transmit Discharge Minimum Data Set (MDS) assessments for 3 (Resident #3, #4 and #6) of 4 residents reviewed for resident assessments. Residents Affected - Some The findings included: The facility's policy titled MDS Assessment Completion Process revised 11/1/2019 stated, RAI (Resident Assessment Instrument) guidelines are to be followed for appropriate time frames (scheduling and completion). Per RAI manual (October 2019), MDS discharge assessments, return not anticipated should be completed by the discharge date , plus 14 calendar days and should be transmitted to the Center for Medicare and Medicaid Services (CMS) 14 calendar days after the MDS completion date. On 1/13/22 at 11:01 a.m., clinical record review showed Resident #3, and Resident #6 were discharged return not anticipated from the facility on 8/9/21. The facility failed to complete and submit an MDS discharge assessment. The MDS discharge assessments were 143 days overdue. On 1/13/22 11:15 a.m., clinical record review showed Resident #4 was discharged , return not anticipated from the facility on 8/16/2021. The facility failed to complete and submit an MDS discharge assessment. The MDS discharge assessment was 136 days overdue. On 1/13/22, at 1:26 p.m., in an interview the Minimum Data Set Coordinator Staff A verified Residents #3, #6 and #4 were discharged but the MDS discharge assessments were not completed. The MDS coordinator said MDS discharge assessments should be completed 14 days after the discharge date . On 1/13/22 at 4:27 p.m., the Assistant Director of Nursing (ADON) confirmed MDS Staff A was responsible for MDS completion. The ADON said she would expect all required MDS assessments to be completed, including the Discharge, Return not anticipated MDS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 7 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the clinical record showed Resident #115 was admitted to the facility on [DATE]. The clinical record lacked documentation Resident #115 received a copy of the baseline care plan. On 1/13/22 at 8:08 a.m., in an interview Resident #115 said he did not receive a copy of the Baseline Care Plan or list of medications when he was admitted to the facility. On 1/13/22 at 10:42 a.m., The Minimum Data Set Coordinator said since the facility began using electronic clinical records (Point Click Care), the nurses did the baseline care plan. The MDS coordinator said he did not know who explained the baseline care plan and medications to the residents. On 1/13/22 at 10:48 a.m., the Director of Nursing said she could not find documentation Resident #115 was given a copy of the baseline care plan including services and goals for admission and a list of medications. Based on records reviewed and staff interviews the facility failed to develop and implement a baseline care plan for each resident admitted that included the instruction needed to provide effective and person-centered care for 5 (Residents # 12, # 41, #115, #116, and #132) of 5 residents reviewed for baseline care plan. The findings included: The facility's policy titled Care Planning revised 07/2017, stated, . An interdisciplinary baseline care plan will be initiated upon admission by the admitting nurse using the baseline care plan template and completed within 48 hours. A copy (summary) of the baseline care plan will be provided to the resident and/ or resident representative. Facility will maintain evidence baseline care plan was provided . 1. On 1/13/22 at 9:24 a.m., reviewed clinical record including baseline care plan for Resident #41 with an admission date of 11/5/21 and Resident #116 with an admission date of 12/2/21. The baseline care plans noted to be incomplete evidenced by missing signatures. There was no documentation in the clinical record the residents or representatives received a copy of the baseline care plan. On 1/13/22 at 10:05 a.m., in an interview MDS Coordinator Staff O confirmed a copy of the baseline care plans were not given to Resident #41, #116 or their representatives. MDS Coordinator Staff O said, Nope we don't do that. On 1/13/22 at 10:30 a.m., in an interview the Social Services Director (SSD) verified a copy of the baseline care plan were not provided to the residents. He said, No we switched to PCC (Point Click Care an Electronic Health Record) a few years ago. We used to do them on paper, and we would give copies then; but no, we haven't given them since being put on PCC. 2. On 1/10/2022 at 3:21 p.m., record review revealed Resident #12 was admitted to the facility on [DATE]. The clinical record lacked evidence of a baseline care plan which included initial goals, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 8 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some summary of current medications and dietary instructions. There was no documentation Resident #12 was provided a copy of the baseline care plan. On 1/13/2022 at 3:26 p.m., in an interview Minimum Data set (MDS) Coordinator Staff O verified the baseline care plan summary for Resident #12 was incomplete, unsigned and the facility did not review baseline care plan with resident. 3. On 1/10/22 at 4:10 p.m., Resident #132 said he did not receive a copy of a list of his medication, or any other document related to her care when she was admitted on [DATE]. On 1/13/2022 at 3:30 p.m., record review revealed no evidence Resident #132 received a summary of the baseline care plan, including initial goals, and a summary of current medications. On 1/13/2021 at 3:35 p.m., (MDS) coordinator Staff O verified the baseline for resident #132 was incomplete. On 1/13/22 at 4:03 p.m., in an interview the Unit Manager, said the admitting nurse must initiate the interim/admission baseline Care Plan. The Unit Manager agreed the respective admitting nurses for Residents #12 and #132 did not complete the base line care plan and did not review it with the families or resident as required. On 1/13/22 at 4:15 p.m., in an interview MDS coordinator Staff O stated residents admitted at facility in the past 2 years would not have a signed baseline care plan. The facility started using Point Click Care and did not update their process for ensuring compliance with baseline care plans. On 1/13/22 at 4:43 p.m., in an interview the Director of Nursing (DON) verified the facility failed to develop a baseline care plan for Residents #12, #41, #115, #116 and #132. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 9 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure appropriate storage of residents' medications in 3 of 3 medication carts reviewed. The facility also failed to ensure 1 ([NAME] unit) of 2 medication rooms was free from expired medications. The findings included: The facility's Medication Storage policy CM-11 revised 3/2021 stated, The facility should not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed . Antiseptics, disinfectants and germicides shall be stored separately from regular medication. 1. On 1/11/22 at 8:35 a.m., observation of medication cart #A of [NAME] Unit cart with Licensed Practical Nurse Staff S revealed several loose pills and pill fragments in the drawer. A bottle of scented odor eliminator was also observed stored with residents' medications. A pink zipped bag was stored in the bottom drawer with residents' medications. Licensed Practical Nurse (LPN) Staff S said the zipped bag was hers and acknowledged the loose pills in the drawers. She said those items are not permitted in the medication cart, including the bottle of odor eliminator. Photographic evidence obtained 2. On 1/11/22 at 9:06 a.m., observation of the medication refrigerator of the [NAME] Unit with Licensed Practical Nurse (LPN) Staff S revealed an Aplisol injection with an expiration date of 12/3/21. LPN Staff S verified the Aplisol injection was expired. Photographic evidence obtained 3. On 1/11/22 at 11:53 a.m., observation of medication cart B of [NAME] Unit showed a can of soda stored at the bottom of the cart with a blood pressure machine. LPN Staff GG said the soda did not belong to him or the residents. LPN Staff GG said he did not know how long the soda had been in the medication cart and acknowledged those items are not permitted in medication cart. Photographic evidence obtained 4. On 1/11/22 at 12:23 p.m., observation of the medication cart B on the Ford unit with LPN Staff M revealed six loose pills and pill fragments at the bottom of the second drawer. LPN Staff M verified the pills were unlabeled and loose. Photographic evidence obtained On 1/12/22 at 9:43 a.m., in an interview the Director of Nursing verified personal items and food products should not be stored in the medication cart with residents medications. She also verified the loose pills should be removed from the drawers and expired medications should be removed from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 10 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 refrigerator. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 11 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview the facility failed to promptly arrange services following the loss of dentures for one (Resident #129) of one resident reviewed for dental care out of 35 sampled residents. Residents Affected - Few The findings included: On 1/10/22 at 11:39 a.m., in an interview Resident #129 said a while ago she lost her dentures in the courtyard. The Resident said it was difficult for her to chew and needed to see a dentist. She said the facility knew she lost her dentures, but she did not know if they were doing something about it. On 1/11/22 at 01:04 p.m., review of the Resident/Family Grievance Report showed on 5/8/21 Resident #129 filed a grievance for missing top dentures that read, Top dentures missing. Placed in cup @ HS [At bedtime]. The form noted additional actions was required and [Organization Name] was to set up an appointment for new dentures. The Social Service note dated 12/21/21 contained documentation Resident #129's sister voiced concerns about the pureed diet and felt the resident's diet could be upgraded. The Social Worker documented, Dentures are in progress, and she should be getting them in January 2022. Review of the care plan failed to show documentation to address the resident's dental status and the lost dentures. On 1/12/22 at 11:06 a.m., in an interview the Minimum Data Set (MDS) coordinator said he was not aware Resident #129 had lost her dentures. He said he participated in daily clinical meetings but did not recall mention of the lost dentures. The MDS coordinator confirmed the lack of care plan addressing Resident #129's dental status and the missing dentures. On 1/12/22 at 11:31 a.m., in an interview the Social Service Assistant said Resident #129 was forgetful and went around so she could have lost or misplaced her dentures. She said it took four visits before dentures can be done because of the process. The Social Service Assistant said Resident #129 has been under the care of [Organization name] (Program of all-inclusive care for the elderly) for a while. She said she was not sure if [Organization name] was notified. The Social Service Director present and participating in the interview said he oversaw grievances. He said he did not recall calling or notifying [Organization name] about the lost dentures. On 1/12/22 at 1:35 p.m., the Social Service assistant wrote a note that read, Phone call attempted to [Organization name] to follow up on replacement dentures for [Resident #129]. Phone call kept being disconnected on their end, unable to reach the Social Worker . An email has ben sent to [name] as another form of communication. Follow up pending . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 12 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm 9. On 1/31/22 11:02 a.m., the serving line for the lunch meal had begun. Three trays prepared and placed in the transport cart. No temperature checks of the food on the steam table were observed. The kitchen manager, when asked if the temperature of the food on the tray line is checked, said no temperatures were checked today. A review of the food temperature logs for the past week found temperatures recorded for the dinner meal on Tuesday 1/25/22 with the entrée at 185° Fahrenheit (F). All other hot food items' temperature were listed as 170°F. No temperature was documented for cold food and milk. The logs for breakfast, lunch, and dinner for 1/26/22 were not filled out. There were no logs available for food temperatures on 1/27/22. The food temperature logs for 1/28/22 recorded breakfast as 185°F for hot cereal and 170°F for all other hot items. There were no temperatures for the chilled items. Lunch temperature for the hot entrée was 180°F and 170°F for all other hot items. The chilled item recorded at 40°F. Dinner, all hot items were documented as 170°F. No temperature was recorded for the chilled items. There were no temperature logs for 1/29/22, 1/30/22 or 1/31/22. Residents Affected - Some 3. On 1/10/22 at 10:47 a.m., Resident #115 said he was admitted to the facility a couple of months ago. Resident #115 said the food is always cold when it should be hot. He said this morning he was served cold scrambled eggs and cold potatoes chunks. Resident #115 said for some reason, by the time the food gets to him it's always cold. Resident #115 said the previous day the ravioli was cold and it did not look attractive or taste good. 4. On 1/10/22 at 11:50 a.m., Resident #30 said the food that should be hot arrives cold. She said she's been here since 1/8/21, and the hot food has always been served cold. She said she doesn't want to eat reheated food from the microwave, and besides the hot food should arrive hot the first time. Resident #30 said the food is neither attractive or palatable and lacks proper seasoning with salt or pepper. On 1/11/22 at 4:50 p.m., Resident #30 had been served dinner. Resident #30 said the dish was some kind of cheese with eggs (quiche). She said she does not like cheese with eggs (quiche) and did not order it. She said she took a few bites, did not like the taste, and it did not agree with her. She said the food was not attractive or palatable and she did not want to ask for a meal replacement. Photographic evidence obtained 5. On 1/10/22 at 11:01 a.m., in an interview Resident #32 said, The food is always late, and we sometimes are not getting what we order. She said I had requested pizza and they brought ravioli. A lot of the time the food is cold, and doesn't look good, burnt grilled cheese or like slop. They lost a lot of staff in the kitchen, and I can tell since it happened it has gotten worse. Resident #32 said she has told staff about the food concerns. She said, Of course I told the staff, but they don't do anything about it. 6. On 1/10/22 at 1:13 p.m., in an interview Resident #60 said, I know farmers who feed their pigs better than what we get here. I am waiting for lunch, now it is late and will be cold. It will look terrible be cold and taste terrible. On 1/10/22 at 1:20 p.m., observed staff delivering the lunch meal to Resident #60. He said, The sweet potato is warm, but the chicken is cold. The iced tea is ok but not the way I like it. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 13 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0804 #60 said he tells staff when the food is cold, but they don't care and don't do anything about it. Level of Harm - Minimal harm or potential for actual harm Review of the schedule of mealtimes showed lunch was scheduled to arrive on the Ford unit at 12:15 p.m. Residents Affected - Some 7. On 1/10/22 at 3:21 p.m., in an interview Resident #116 said, The food is cold a lot of the time, often you do not get items requested. Resident #116 said she sometimes tells the staff about it, but not much changes. On 1/11/2022 at 1030 a.m., in an interview, Resident #116 said, Food is better this week while you are here but still not good. I would describe it as cafeteria or institutional type food. On 1/11/2022 at 9:35 a.m., in an interview, Resident #60 said, The food is awful. You can tell it is a little better since you are here. It is like a jail. On 1/13/2022 at 9:00 a.m., in an interview Resident #60 said, Breakfast was terrible. All I had was a waffle with some berry stuff. No milk. On 1/12/2022 at 12:45 p.m., in an interview Registered Nurse (RN) Staff B, said, Residents complain about the food and we have had trouble staffing the kitchen. Sometimes it takes a long time for meals to get from the kitchen to the units. On 1/12/22 at 4:15 p.m., in an interview Certified Nursing Assistant (CNA) Staff Q said residents complain about quality of food. CNA, Staff Q said, Yes, they complain. We need better food. The food looks terrible. If a resident doesn't want to eat the meal and we go to the kitchen to get them something else the kitchen people are rude to the CNAs and accuse them of taking food for themselves. CNA Staff Q said it happens often that a resident does not like a meal. 8. On 1/10/22 at 9:46 a.m. in an interview, Resident #120 said the food was awful and sometimes he couldn't eat because it was so bad. On 1/13/2022 at 1:35 p.m., in an interview Resident #120 said the food tastes terrible, and he never gets what he wants or orders. He said today he ordered a ham sandwich for lunch and didn't get it so he didn't eat lunch. 9. On 1/10/22 at 10:03 a.m., in an interview, Resident #151 said she has been here for 2 months and the food was bad. On 1/13/22 at 1:45 p.m., Resident # 151 said the food tastes bad, and she never gets what she orders. Based on observation, policy review, resident and staff interviews, the facility failed to ensure residents receive food and drink that are palatable, attractive and at a safe and appetizing temperature for 9 (Resident #30, #151, #115, #17, #120, #12, #32, #60, #116) of 9 residents reviewed. The findings included: The facility's policy titled Philosophy of Diet and Nutrition Therapy for Skilled Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 14 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Communities (Publication date July 2019) reviewed on 1/12/22 at 2:19 p.m., read, . Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . 1. On 1/10/22 at 3:31 p.m., in an interview Resident #12 reported the food is bad and served cold. She said the Vegetables are very soggy, no taste, and meat is dried and hard to chew. Resident #12 added, Cardboard would have tasted better than breakfast this morning. 2. On 1/12/22 at 9:45 a.m., in an interview, Resident #17 said the food did not taste good and was served cold. Resident #17 said the food was not appetizing to the eyes and did not taste good. On 1/12/22 at 4:13 p.m., in an interview the Regional Dining Services Director Staff K said she had heard from the residents and family members and knew there were major concerns with the food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 15 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. 4. On 1/11/22 at 4:32 p.m., Resident #115 was observed eating dinner. Resident #115 said he did not know what it was but thought it was eggs and stewed tomatoes. He said there was no meal ticket with the food. He said he's never been issued a menu to select the food he would like to eat. He said he saw the food selections posted on the board. He said there are Cheerios on the list, and he likes Cheerios, but he did not know how to order them. Photographic evidence obtained Based on observation, resident and staff interview, the facility failed to honor food preferences for select menus for 4 (residents#50, #43, #311, and #115) of 4 residents reviewed. The findings included: The facility's policy titled Philosophy of Diet and Nutrition Therapy for Skilled Nursing Communities (Publication date July 2019) provided by the facility on 1/12/22 at 2:19 p.m., read, . Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . 1. On 1/10/22 at 8:40 a.m., observed Resident #50 in bed looking at her breakfast tray which included scrambled eggs, one hashbrown and one English muffin. The Resident stated they always serve her eggs even though her menu specifically stated she dislikes eggs, do not serve eggs. She said every morning for breakfast eggs was always included on her plate even though she had told staff multiple times she did not like eggs. Resident #50 said she never gets what she orders on her menu. Observation of the meal ticket showed scrambled eggs and hash brown potatoes listed under Dislike/DO NOT SERVE. Photographic evidence obtained On 1/11/22 at 9:17 a.m., Resident #50 said she was served English muffin, hashbrowns, which she didn't order, as she doesn't like either one. She said this has been a daily occurrence for a longtime. Resident # 50 stated, It makes me upset when they can't follow what I mark on my menu. Why bother with the menu if they are doing that? On 1/12/22 at 8:49 a.m., in an interview Resident # 50 said breakfast was the same issue again, she was served eggs, even though her ticket says no eggs. She said they keep giving her things she dislikes. On 1/12/22 at 12:22 p.m., in an interview Resident #50 said she ordered whole milk, and orange juice with her lunch but was served reduced fat milk and cranberry juice. Observation of resident #50 's lunch tray showed a cup of dark red juice which the resident said was cranberry juice, and an opened carton of reduced fat milk. The ticket for lunch meal confirmed whole milk and orange juice were checked on her order. Resident # 50 said she was tired of telling them as they never get her order correct. Photographic evidence obtained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 16 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/12/22 at 12:45 p.m., Dietary Staff E and Regional Dining Services Director Staff K both confirmed resident #50's dislikes included eggs. Staff E and Staff K confirmed Resident #50 was served eggs and should not have been served eggs as her ticket indicated no eggs. They also confirmed Resident #50 did not receive orange juice and whole milk as per her request documented on the meal ticket on 1/12/22. On 1/13/22 at 8:36 a.m., contracted Staff H said Resident #50 has complained multiple times about her meals as she almost never receives the items she orders and receives eggs for breakfast, even though her ticket specifies she dislikes eggs. She said she has informed the kitchen multiple times about Resident #50's concerns about her menu. On 1/13/22 at 8:42 a.m., Staff D said Resident #50 has complained multiple times about not receiving what she ordered on her menus and receiving eggs even though her menu ticket specifically states dislikes for eggs. Staff D said she has brought up the concerns of residents not receiving what is ordered on their menu tickets with kitchen staff multiple times and residents including Resident #50 are still having issues. On 1/13/22 at 8:55 a.m., Certified Nursing Assistant Staff I said she has observed Resident #50 being served eggs on her tray when her ticket states she dislikes eggs. Resident #50 has complained multiple times about never receiving what she orders on her menu. Staff I said she has informed the kitchen multiple times about residents complaining about not receiving what they have ordered, but the issues continue. On 1/13/22 at 8:16 a.m., review of the Resident Council minutes for 12/10/21 revealed residents voiced concerns of the food being cold, and not receiving what they selected. On 1/13/22 at 11:30 a.m., in an interview contracted Staff L said the facility does not have a food committee so the residents bring their food concerns to the Resident Council meeting. Staff L said the residents have brought up multiple food concerns at the Resident Council meeting for the last few months. There was no one in charge of the kitchen, so she never knew who to report the concerns to. Staff L acknowledged food concerns are ongoing and have not been resolved, including cold food, not getting what they order on the menu tickets, food not looking good and or not tasting good. 2. On 1/10/22 at 1:00 p.m., in an interview Resident #43 said she didn't have food on the tray that is on the ticket. She said the food delivered never matches what she orders. On 1/12/22 at 12:10 p.m., in an interview Resident #43 said she ordered lunch but did not receive the desert which was the ice cream and Cheetos she ordered. 3. On 1/10/22 at 1:07 p.m., in an interview Resident #311 said she asked for a toasted English muffin and was told they don't have a toaster at the facility, but they could warm it in the microwave. She stated the food was cold, and never what she orders. On 1/11/22 at 9:13 a.m., in an interview Resident #311 said she didn't eat the corned beef hash served for breakfast this morning as it looked like cat food. She said she never knows what she is getting for meals. On 1/12/22 at 12:15 p.m., in an interview Resident #311 said she never gets a choice of food, no one spoke to her about it. Resident #311 said she does not get a select menu to choose her meal, she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 17 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0806 is just served the meal. Level of Harm - Minimal harm or potential for actual harm On 1/12/22 at 12:37 p.m., in an interview Dietary Staff E and Regional Dining Services Director Staff K, Staff E said residents are given select menus weekly to make their meal choices for the week and that is what is used for their menus for their trays. Staff K confirmed there was no completed select menus and no preferences on file for resident #311, and said she was not sure why it was not done. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 18 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/31/22 at 9:15 a.m., toured the kitchen to determine if the dish washer was functioning properly. A review of the dishwasher machine temperature log found the log had been completed for the entire day. The new dietary manager (DM) stated the staff operating the dishwasher completes the log and is supposed to check the temperature each time prior to and or when using and not complete the log for the entire day at one time. On 1/31/22 at 9:20 a.m. in an interview, the dietary staff operating the dishwasher staff said, I am the only one who runs the machine, so I check the thermometer once in the morning and record the temperature on the log for the whole day. He said there was no method for verifying the rinse temperature. He said there were chlorine test strips and quat (quaternary ammonium) test strips in the rack above the sink, but not temperature change strips. On 1/31/22 at 9:30 a.m., toured the kitchen and found no improvement in cleanliness since the initial tour of the kitchen on 1/10/22 at 7:30 a.m. During the tour on 1/31/22, observation of the walk-in refrigerator found a pan of food not dated or labeled, two sheet cakes uncovered, glasses of drinks (juice) not covered. Photographic evidence obtained Food prepared for service were placed on carts dirty with food debris and grime. The floor underneath stove area remained dirty with food debris. The spill pan under the stove burners was dirty with grease and burned food debris. The food preparation tables and shelves above the tables were dirty with food debris and sticky residue. The clean flatware bins on the serving line had standing water at the bottom with floating food debris. Photographic evidence obtained The heater for the plate warming pellets was dirty with food debris and grime. Photographic evidence obtained Wet plate domes were stacked nesting with clean domes on a rack, dirty with grime, and debris, and used gloves. The Ice machine was soiled with grime, debris. The top of the machine was heavily corroded. Photographic evidence obtained On 1/31/22 at 1:49 p.m., The technician from the dishwasher maintenance company was interviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 19 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 about the functioning of the dishwasher. He said he recommends using a submersible max register temperature thermometer or color change temperature strips to verify that the dishwasher achieved the required wash and rinse temperatures. On 1/31/22 at 3:30 p.m., in an interview the Regional Manger acknowledged the kitchen needed cleaning and cooking equipment repaired. He said his biggest problem was staffing in the kitchen and was aware of the problems in the kitchen. Based on record review, observation and staff interview, the facility failed to maintain food preparation equipment in a clean and sanitary manner; failed to maintain a minimum wash temperature in the dishwasher to ensure effective sanitization of dinnerware. The facility failed to maintain nourishment room and equipment in a clean safe and sanitary manner to prevent contamination for 3 of 3 nourishment rooms. The lack of sanitation in the kitchen and nourishment rooms has a potential to affect all residents consuming an oral diet. The findings included: Page Rehab Policy and Procedure Manual, Dining services: Sanitation and Food Safety, Food Storage (Dry, Refrigerated and Frozen) Policy included: Food storage areas will be clean, dry and maintained at temperatures as required. The procedure included: Food storage areas shall have all products no less than eighteen (18) inches from the ceiling and no less than six (6) inches from the floor. 5. All open products (as able) will be sealed (rolled closed, wrapped closed, with lid closed) to ensure quality and prevent contamination against pests or rodents. Goods that have been opened with no date. Left on the floor, or not properly sealed will be discarded . On 1/10/22 at 7:34 a.m., during the initial kitchen tour the following was observed: The floor in the kitchen, dry storage room, and walk-in refrigerator was heavily soiled with food residue, grime, and debris. Photographic evidence obtained The wall at the entrance of the kitchen was heavily soiled with grime, with the patched area on the wall bulging. Photographic evidence obtained A box containing cartons of milk being used for breakfast service was sitting on a utility cart next to the cart of juice being served with used rolled tissue paper sitting on the top of the box. The service carts being used for the juices and milk for service were heavily soiled with grime and debris. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 20 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 Photographic evidence obtained Level of Harm - Minimal harm or potential for actual harm Shelves under the steam table were heavily soiled with grime and debris and dirty towels. Photographic evidence obtained Residents Affected - Many The hot holding critical control point unit holding the plates and English muffins being used for service was heavily soiled with grime and debris. Photographic evidence obtained The walk-in freezer contained two metal pans with raw meat sitting in water on a shelf, both half uncovered with aluminum foil, not labeled and or dated. Photographic evidence obtained The tilt skillet and stove were heavily soiled with grime and debris. Photographic evidence obtained An electric plug socket in the kitchen was broken and hanging from the wall. Photographic evidence obtained The kitchen ovens were all heavily soiled with grime and debris, The kitchen ovens that were being used to prepare food for the facility were heavily soiled with grime and debris, on the interior and exterior. Photographic evidence obtained The walk-in freezer contained boxes of food products being stored on the floor of the freezer, with products on the floor under the shelves soiled with grime and debris. Photographic evidence obtained The clean dish area and floor were observed to be heavily soiled with grime and debris, and the stacking shelf contained soiled towels stacked on the shelf. Photographic evidence obtained The wall under the hand washing area sink contained brown substance on the tiles and the pipe fittings were rusted. The sink was soiled with grime and the back of the sink contained black bio growth. Photographic evidence obtained The dishwasher area and floor were observed to be heavily soiled with grime and debris. Photographic evidence obtained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 21 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 The dishwasher was heavily soiled with grime, and a yellow substance on the front of the machine. The top of the dish washer machine was leaking with a plate cover sitting under the pipe to contain the water leaking from the machine. A bottle of water was stored on the top of the dish washing machine. The dish washing machine was leaking at the bottom with the pipe wrapped with a black cloth and sitting over a container to hold water from the leaking pipe. Residents Affected - Many Photographic evidence obtained The dish washing machine boost system was torn and in disrepair. Photographic evidence obtained The top of the ice machine was heavily corroded, and the interior was soiled with grime. Photographic evidence obtained The hot steam stove contained dirty water on the interior and the exterior was soiled with grime. The steam stove held a bucket under it that was catching water from the stove with cleaning chemicals on the shelf under the hot steam stove. Photographic evidence obtained On 1/10/22 at 7:57 a.m., in an interview Dietary Staff F confirmed the observation with the kitchen and equipment cleanliness. Staff F said she did not have enough staff to clean the kitchen. The [NAME] Nourishment room ice machine vents with grime, and debris, rust on the base on the ice machine, interior of refrigerator soiled with grime and debris, cabinets heavily soiled with grime, debris and roaches, food in refrigerator not labeled and or dated and half opened, ceiling with missing tiles with exposed wires. Photographic evidence obtained The Ford Nourishment room ice machine vents were soiled with grime and debris. The interior of refrigerator was soiled with grime, the cabinets heavily soiled with grime and debris, the sink soiled with grime, debris, and black bio growth. Photographic evidence obtained The Royal Palm nourishment room ice machine vents heavily soiled with grime and debris, interior of microwave with dead insect squished on the interior on the door. The microwave door was soiled with grime and rusted. The cookie oven interior was soiled with grime and debris. A cabinet door was broken with live crawling insect in the cabinet. The food in refrigerator was not labeled. Photographic evidence obtained On 1/10/22 at 10:40 a.m., A dietary aide was observed operating the high temperature dishwasher. The wash temperature rose to 140 F which is below the minimum of 160 F and the rinse temperature rose to 120 F which is below the required minimum of 180 F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 22 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 1/10/22 at 10:45 a.m., Dietary Staff E confirmed the dishwasher machine was not reaching the required temperature for the wash and rinse cycle to ensure sanitizing of dishware when in use. He said he will call the company and there was no temperature log maintained in the kitchen to indicate staff was monitoring the dishwasher temperature. On 1/10/22 at 10:50 a.m., observation of the chemical test for the 3-compartment sink with Dietary Staff E. The sanitizing sink contained no sanitizer for the rinse. Staff E confirms there was no sanitizer chemical for the 3-compartments sink. He said he has had multiple conferences with the facility maintenance for the kitchen machinery for a few weeks and nothing gets done. Staff E confirmed the staff was not cleaning the kitchen floors on each shift and they were short staffed. On 1/10/22 at 2:00 p.m., in an interview the Administrator said any food in the nourishment room refrigerator was to be labeled with names, room numbers, and food not labeled would be thrown out. The Administrator confirmed half opened food in the [NAME] nourishment room refrigerator looked like a Christmas meal served at the facility and will be thrown out as it was not dated. On 1/11/22 at 8:45 a.m., a follow up tour of kitchen revealed all concerns from initial tour remained the same, with no improvement. On 1/11/22 at 9:00 a.m., in an interview Staff E stated he was informed the dishwasher had a broken part which kept the water running but not coming to the required temperature to wash and sanitize when in use. The machine that carries the boost to the dishwasher was broken and a new one was needed. He acknowledged the kitchen has multiple issues with cleanliness. On 1/11/22 at 11:15 a.m., in an interview the Regional Dining Services Director Staff K confirmed the kitchen and equipment were not clean. She confirmed the observation of food in the walk-in freezer stored on the floor said food is to be stored 6 inches from the floor. Staff K verified the broken shelf being held up with plastic container, and walk-in freezer floors soiled with grime and debris. Staff K stated a dietary aide was responsible for cleaning the nourishment rooms and the equipment. Staff K also confirmed nourishment rooms and equipment were not clean. On 1/11/22 at 11:38 a.m., in an interview Dietary Staff J confirmed the nourishment rooms and equipment were not clean and the food in the refrigerator was not labeled and or dated. Staff J stated when she was not on duty no one kept them clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 23 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 - Some 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** On 1/10/22 a tour of the facility's locked memory care unit revealed rooms #110, #111, #112, #113, #114, #115 and #116's closet doors were broken and leaning against the wall. Rooms #113 and #116's bedside furniture were missing drawers and some drawers were taped together with electrical tape. Photographic evidence obtained In room [ROOM NUMBER], the wall behind the toilet was discolored and sections of the wall were held together with blue tape. Photographic evidence obtained Rooms #111, #113, #114 and #130 had broken toilet paper holders in the resident bathrooms. Photographic evidence obtained On 1/13/22 at 1:50 p.m., during an interview with the Maintenance Director, he said all facility staff were required to document in the TELS (Building management software platform) computer program all room damage and things which needed repair. He said every morning he reviewed and printed the areas of concern documented by facility staff in the TELS system. He used this information to prioritize which repairs needed to be completed first and insured all repairs were completed on a timely basis. On 1/13/22 at 2:00 p.m., a tour of the memory care unit was conducted with the Maintenance Director. The Maintenance Director confirmed the room damage and areas which needed repair identified on 1/10/22 for rooms #110, #111, #112, #113, #114, #115 and #116. He said he was unaware of the repairs identified in rooms #110, #111, #112, #113, #114, #115 and #116 because the facility staff had not entered the repairs into the TELS computer program as required. He said he had had many discussions with administration about the facility staff not entering needed repairs into the TELS system as required resulting in needed repairs not being completed in a timely manner. On 1/10/22 at 7:36 a.m., during a random tour, a Geri chair (medical recliner chair) was observed in room [ROOM NUMBER]. The seat was dirty with dried on spots. A dried streak of spill was observed on the side of the chair and crusty dried-up substances on the seat and handrails. The same observation was made on 1/11/22 at 12:00 p.m., and 1/12/22 at 9:40 a.m. On 1/10/22 at 8:02 a.m., a black and a blue wheelchair were observed stored in the bathroom of room [ROOM NUMBER]. The black wheelchair's cushion was stained and soiled with debris. On 1/12/22 at approximately 12:45 p.m., the wheelchairs remained in the bathroom with the black wheelchair cushion stained and soiled with debris. On 1/12/22 at 1:00 p.m., the Director of Rehab said the residents in room [ROOM NUMBER] did not use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 24 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 - Some a wheelchair and did not know why the chairs were in their bathroom. The Director of Rehab agreed the black wheelchair was soiled and in need of a cleaning. The Director of rehab said there was no way to know how long the wheelchair had been in the bathroom, which residents had used it or when it was last cleaned. On 1/11/22 at 10:00 a.m., Resident #79 said she began using a wheelchair provided to her by the facility in the last week. She said the wheelchair was brought to her dirty and disgusting and said if you lift the cushion, it is filthy. When the cushion was lifted the seat of the chair was dirty with staining, dried on substances and debris. She said as far as she knew no one cleans the chairs. A follow up observation of the chair was made on 1/12/22 at 9:39 a.m., and it remained stained and soiled with dried substances and debris. Photographic evidence obtained On 1/11/22 during a meeting at 10:00 a.m., Resident #145 said the wheelchairs were not regularly cleaned. She said her chair was cleaned before Christmas because she was expecting visitors and she asked the staff to clean it. The wheelchair was observed at this time to be dirty with a white substance encrusted on the wheels and frame of the chair. A follow up observation of the chair was made on 1/12/22 at 9:40 a.m., and it remained in the same condition. Photographic evidence obtained On 1/11/22 during a meeting at 10:00 a.m., Resident #72 said there was a sign on her unit that night shift will wash the chairs. She said her chair hasn't been cleaned in at least three months. Resident #72's wheelchair was observed at this time with staining to the seat and cushion and built-up debris in the seat area. Photographic evidence obtained On 1/11/22 during a meeting at 10:00 a.m., Resident #32 said no one cleans her wheelchair. She said she wiped it down herself. On 1/12/22 at 10:16 a.m., the Director of Nursing (DON) said the facility had a wheelchair wash machine and the midnight shift was supposed to clean them on a continuing basis. She said she was not aware of any log kept of when or which chair had been washed. On 1/12/22 at 12:37 p.m., the Executive Director said the facility has a wheelchair washer. He said they are supposed to be cleaned by the 10:00 p.m., to 6:00 a.m. shift as needed. The Executive Director said there was no schedule for cleaning the chairs, they should be cleaned as soiled. He said there no log was kept of when or which chairs have been cleaned and there would be no way to know the last time a chair was cleaned. On 1/12/22 at 12:45 p.m., the Regional Nurse said there was no official policy and procedure on cleaning the wheelchairs. She said no log is kept and nothing is done to follow up to ensure the wheelchairs are being cleaned. The Regional Nurse said it was like bringing fresh water to the resident rooms, it was just done. There was no log kept of when water was brought to the residents. On 1/12/22 at 3:00 p.m., the DON provided a form titled Wheelchair cleaning schedule that had been updated on 9/28/18. The form outlined a schedule for the rooms on the unit and the rooms whose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 25 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 - Some chairs were supposed to be cleaned on those evenings. The DON agreed there was no documentation the wheelchairs were cleaned per the schedule, or any follow up done to ensure the chairs are being cleaned. On 1/11/22 at 12:15 a.m., Resident #115 said the toilet paper holder in the bathroom was broken and had been that way since he was admitted to the facility. He said staff go into the bathroom to stock the toilet paper and should be aware of the broken holder. Photographic evidence obtained On 1/10/22 at 8:25 a.m., observed large gouges on wall in room [ROOM NUMBER]. the wheelchair had a torn arm rest in need of repair. On 1/10/22 at 9:06 a.m., observation of brown substance on ceiling wall in room [ROOM NUMBER]. On 1/10/22 at 9:32 a.m., observation of water damage on wall near the toilet in room [ROOM NUMBER]. On 1/10/22 at 9:41 a.m., observation of broken side cabinet door in room [ROOM NUMBER]. On 1/10/22 at 10:00 a.m., observation of room [ROOM NUMBER] with peeling, cracked baseboard and broken toilet paper holder in bathroom. On 1/10/22 at 12:32 p.m., the bathroom of room [ROOM NUMBER] had a broken toilet paper holder. The call light button was on the floor behind the bed, not accessible to the resident to call for assistance. Photographic evidence obtained On 1/10/22 at 12:37 p.m., Observation of room [ROOM NUMBER] A resident call light button behind the resident bed out of reach for resident to call for assistance, personal toiletries items on the sink with no name to identify which resident as bathroom is shared bathroom, broken toilet paper holder, gouges in the wall at the back of the bed. Photographic evidence obtained On 1/10/22 at 12:42 p.m., observation of room [ROOM NUMBER] with cracked and broken base tiles in the bathroom, broken toilet paper holder and sink leaking and continuously dripping, water damage on wall in bathroom, base of bed headboard peeling and gouges in wall next bed, personal toiletries on sink with no covers and or labels to identify resident as bathroom is shared bathroom. Photographic evidence obtained On 1/10/22 at 1:55 p.m., observation of room [ROOM NUMBER]'s shared bathroom with toiletries on sink and handrail in bathroom with no names to identify which resident own the toiletries, broken toilet paper holder and graduate sitting on the back of the toilet seat with no cover and no label to identify which resident it is being used for. Photographic evidence obtained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 26 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 - Some On 1/13/22 at 1:21 p.m., tour of facility with Maintenance Staff C, confirmed all environment concerns. He stated he would take care of the issues. On 1/13/22 at 1:40 p.m., Licensed Practical Nurse Staff D confirmed the residents' personal items in the bathroom of room [ROOM NUMBER], #127, #228 and #124 were not labeled. Staff D said the protocols for resident in a shared room was nothing on the sink, shower rail and or the back of the toilet, personal items were to be marked for the residents in a shared room. Staff D stated the graduate on the back of the toilet should be in a plastic bag when its changed and should be labeled. Based on observation, review of facility's policies, resident and staff interview, the facility failed to maintain a safe, sanitary, and comfortable environment for residents. The facility failed to ensure proper storage and cleaning of residents' equipment, failed to store resident personal care items in a sanitary manner, failed to repair damaged furniture in resident rooms and make necessary repairs in bathrooms. Not maintaining a sanitary environment has the potential for cross contamination. The findings included: On 1/10/22 at 1:00 p.m., in an interview Resident #25 said she was being treated for Pneumonia and received her last nebulizer treatment the day before. The nebulizer mask was observed uncovered on a tissue box on bedside table. Photographic Evidence Obtained The facility's policy for Handheld Nebulizer with a revised date of 3/2020 specified to, store nebulizer equipment in a storage bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 27 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/10/22 at 8:54 a.m., in an interview Resident #110 said there had been roaches in his room and crawling on his bed. Resident #110 said the room was treated for bugs, but he felt the facility was infested. Residents Affected - Some On 1/12/22 at 11:00 a.m., in a follow up interview Resident #110 said the previous evening he saw live cockroaches crawling on his bed. On 1/11/22 at 9:00 a.m., Resident #131 said she has seen big and little roaches in her room. Resident #131 pointed to a pink fly swatter on her nightstand. She said her sister gave her the fly swatter to kill them. On 1/10/22 at 8:15 a.m., observation of live crawling insects in the cabinets of the [NAME] Nourishment room. On 1/10/22 at 8:37 a.m., observed live crawling insects in room [ROOM NUMBER]'s bathroom. On 1/10/22 at 9:10 a.m., in an interview Certified Nursing Assistant Staff EE said there were roaches all over the residents' rooms and bathrooms. She said it has been an ongoing issue since she started employment at the facility in March 2021. On 1/10/22 at 9:25 a.m., a dead insect was observed squished on the interior surface of the microwave door in the Royal Palm nourishment room. Live brown crawling insects were observed in a cabinet. Photographic evidence obtained On 1/10/22 at 12:42 p.m., Resident #111 said she saw a couple of roaches in her room. On 1/10/22 at 12:47 p.m., Resident #59 said she sees roaches all over the place, she saw them the previous night. On 1/10/22 at 3:17 p.m., Resident # 55 said she saw roaches last night, one crawled on her foot. She said she saw roaches in the garbage can. Resident #55 said, we got roaches really bad. I see roaches every night and the nurse kills them at night. I was told by maintenance they don't have a license to take care of it. On 1/11/22 at 9:39 a.m., small brown live crawling insects were observed on the walls and in the cabinets of the Royal Palm nourishment room. Photographic evidence obtained On 1/10/22 at 9:39 a.m., in an interview Resident #60 said, They have roaches everywhere. I know they know about it. How could they not. On 1/11/2022 at 10:30 a.m., in an interview Resident #60 said, Yes they still have roaches. I know the staff knows about it. It's terrible. On 1/10/22 at 11:00 a.m., in an interview Resident #32 said she sees roaches of all sizes in her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 28 of 29 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 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Page Rehabilitation and Healthcare Center 2310 N Airport Road 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room. Resident #32 said, There was one crawling on the wall by my bed this morning. They come out of the drain in the bathroom, and I don't have anything that the roaches would want like open food or anything in my room. Resident #32 said, I have told them and brought it up in resident council. On 1/12/2022 at 09:20 a.m., in an interview Resident #32 regarding bugs in her room Resident #32 said, I have them in my bathroom right now. Two live brown crawling insects were observed in the bathroom at the time of the interview. Photographic evidence obtained On 1/10/22 at 3:17 p.m., in an interview, Resident #116 said I saw a roach crawling around my room this morning. I try to keep my room clean. I was in the military. I have seen roaches many times here. On 1/12/22 at 3:30 p.m., interviewed Director of Nursing (DON) and Registered Nurse (RN), Staff N, about pest control in facility. RN, Staff N, said they have had roaches and had the pest control company here again yesterday. RN Staff N said, We have had problems with families bringing food for the holidays. That can attract pests. Based on observation, staff and resident interviews, and record review, the facility failed to have an effective pest control program and ensure a pest free living environment for residents. The findings included: On 1/10/22 at 10:03 a.m., in an interview Resident #151 she said she has been here for two months. She said there are big roaches. She said one was in her bed the other night. On 1/10/22 at 9:46 a.m., in an interview, Resident #120 said there were roaches all over the place. He said they come from under the heater at night. On 1/10/22 at 8:05 a.m., in an interview Resident #109 said he saw a roach in his room two nights ago. On 1/10/22 at 1:00 p.m., in an interview Resident #25 said there were cockroaches everywhere. On 1/12/22 at 01:40 p.m., in an interview Registered Nurse (RN) Staff Z said he has seen roaches in the facility. Review of the grievance log from June 2021 through December 2021 revealed residents' grievances filed on 6/18/2021, 7/16/21, 8/14/21, 10/8/21, and 12/22/21 related to bugs seen in their rooms. All the complaints were listed as resolved. On 1/13/22 at 4:00 p.m., in an interview the facility's Executive Director agreed the facility had a roach problem and said the pest problem was much better now than it used to be. He said it was difficult with such a big building and so many residents to keep it bug free. He said the facility was making an effort to control the pest problem. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105864 If continuation sheet Page 29 of 29