Inspection·April 8, 2021

F 0585 water cup but her ginger ale. Level of Harm - Minimal harm or potential for actual harm The CNA was cocky and had an attitude/argumentative, when talking to her. Resident#202 said there was also a nurse outside her door that had witnessed the whole conversation. The next day a staff member came and talked with her about the incident then told her later CNA Staff Q would not be taking care of her anymore. Residents Affected - Few On 4/6/21 record review of the facility's Grievance/Concern log showed no grievance was recorded for Resident #202 and the incident that happened shortly after admission. The Risk Manager Staff S came with a completed form dated 4/4/21 with the concern being Resident #202 did not want CNA Staff Q to come in her room. The form did not indicate why the resident felt this way or what happened. Conclusion/Summary of findings stated CNA Staff Q was passing ice to unit and went to refill the resident's cup of ice water. The grievance form did not show a complete and thorough investigation. But the resolution was to take CNA Staff Q off the assignment. The training to the CNAs on customer service was done on 4/2/21, two days before the grievance was written. 2. Review of the clinical record revealed Resident #19 was admitted to the facility on [DATE] with the following diagnosis: history of femur fracture, heart disease, chronic respiratory problems, hypertension, anxiety, depression, insomnia, and macular degeneration. Resident was legally blind. Resident was assessed to be alert and oriented. On 4/5/21 at 12:08 p.m., in an interview Resident #19 said his main concern was about the way the certified nursing assistants (CNAs) talked to him and treated him. He said that it took very long on the evening and night shift to get the call light answered. He said when they did come in, they scolded him about turning on his light too much. He said they had told him they would take the call light away if he turned it on so much. Resident #19 said that they had taken it away in the past and he had had to yell out to get someone to come into his room. Then when they did come in, they said if he didn't stop yelling, they would put him over there. He said he was blind, so he didn't know what they meant by over there. Resident #19 said the kind of behavior from the CNA staff made him afraid. He also said the night CNA would not empty his urinal and he ended up spilling it when he tried to use it again. He said he was helpless in the bed and he couldn't do much for himself. He said that he had reported this to the nursing management and his wife. On 4/5/21 at 1:40 p.m., in an interview Resident #19's wife said her husband had told her that when he put his light on the staff did not come for a long time. She said that he had told her about the incident of a male CNA on nights telling him not to put on his call light or he would take it away from him. She said her husband was blind and when he had to use his urinal, he did not know how full it was. She said that the CNA told him that he would not empty it until it was ½ full. So, when the resident tried to use it he spilt it on the bed and then had to lay in a wet bed until someone came and changed it. She said her husband reported this could be hours sometimes. She said she reported this to nursing management to investigate but did not feel it had been resolved yet. On 4/6/21 record review of the facility's Grievance/Concern log showed 3 grievances (1/28/21, 2/17/21 and 3/3/21) reported by Resident #19 and his wife. The grievance form for 1/28/21 was filled out vaguely about resident concern over CNA Staff Q's approach and poor customer service. The form did not contain a description of the resident's concern however the CNA was educated on customer service and removed from the resident's assignment. 3. On 4/6/21 at 11:29 a.m., in an interview Resident #64 said when she turned on the call light on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 2 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 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 - Few the evening shift and night shifts, she felt the staff came in and scolded her and said to stop putting on the light. She felt that she needed help and needed to use her call light if she needed to be changed. She said she felt the CNA could use more education on being kinder and customer service. She said the night male CNA Staff O told her roommate to stay in bed when she asked to go to the bathroom. He said it so loud too, that it scared both her and her roommate. She said they both reported the incident after it happened to nursing management and they said they would look into it. 4. On 4/6/21 at 11:45 a.m., in an interview Resident #34 said she felt the CNAs on the evening and night shift needed more training in customer service. She said her and her roommate had to wait sometime an hour or more for the call light to be answered and then when a staff member came in and said, what do you want now. Resident #34 said last week the male night CNA staff O came in and she asked to go to the bathroom, and he said, stay in bed, do not get up. She said she had to go to the bathroom, and he said loudly, stay in bed, do not get up. Resident #34 said it made her feel like she was not being taken care of. Resident #34 said she and her roommate reported the incident to management. Someone came in and told them, they would look into the incident, but no one had come back and talked with them yet. 4/7/21 2:40 p.m., in an interview the Risk Manager Staff S said she had not heard of these issues before hearing it from the surveyor. On review of CNA Staff O and Q personnel files revealed each of the CNAs involved in the above incidents had 3 to 7 disciplinary actions on file, including suspensions and discharge warning. On 4/7/21 at 10:25 a.m., in an interview the Administrator acknowledged CNA Staff O and Q had multiple disciplinary actions in their files which included customer service issues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 3 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's abuse and neglect policy, residents and staff interviews, the facility failed to implement their policy and procedure and document thorough investigation of resident complaints of staff treatment for 4 (Resident #19, #34, #64, and #202) of 4 residents with documented grievances reported to management. Residents Affected - Few The findings included: The facility's policy and procedure titled Abuse Prevention Program, From Risk Management Manual last updated 1/2020, specified: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Definitions: Abuse Willful infliction of injury Unreasonable confinement/involuntary seclusion, Intimidation with resulting physical harm, pain, or mental anguish Punishment with resulting physical harm, pain, or mental anguish Deprivation by an individual, including a caretaker, of goods, or services that are necessary to attain or maintain physical, mental, or psychosocial wellbeing. Verbal AbuseOral, written, or gestured language that includes disparaging and derogatory terms to the residents within their hearing, regardless of their ability to comprehend or disability. Mental/Emotional AbuseIncludes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Whether mental abuse has occurred is determined by a reasonable person standard and does not require a specific response from the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 4 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 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 0607 Neglect- Level of Harm - Minimal harm or potential for actual harm Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Procedure- Residents Affected - Few The administrator, Director of Nursing and Risk Manager are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. They are also responsible for ongoing monitoring and tracking and trending such events. Facility leadership will identify situations in which abuse, neglect or mistreatment may be more likely to occur, such as: Residents with needs/behaviors which might lead to conflict or abuse/neglect. Staff burnout. IdentificationAn event report is initiated upon identification of actual, suspected, or alleged abuse. Should the issue be reported initially on a concern/Grievance report and later identified as actual, suspected, or alleged abuse, neglect, or mistreatment, the Concern/Grievance Report and Grievance Log will be notated Referred to Risk Management. Event Report and Resident Concern/Grievance Reports are reviewed, tracked and trended for indicator suspicious for abuse, neglect or mistreatment. InvestigationAn Event Report is initiated. Nursing Home Administrator or designee is notified and in collaboration with Risk Manager will initiate and conclude a complete and thorough investigation within the specified timeframe. Investigation will include, but not limited to: Resident statements/interviews Employee statements/interviews Documents review i.e., chart reviews, policy review, education programs, etc . Re-enactment of event when indicated. (review of employee employment file for past disciplinary actions) Review of the clinical record revealed Resident #202 was admitted to the facility on [DATE] with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 5 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the following diagnosis: muscle wasting & atrophy, degenerative joint disease, diabetes, chronic pulmonary obstructive disease (COPD), cirrhosis, chronic ulcer of the foot, bipolar disorder, anxiety, and convulsion. Resident #202 was assessed to be alert and oriented and had no impaired cognition. 1. On 4/5/21 at 11:20 a.m., in interview Resident #202 said a few days after she was admitted there was an incident were a Certified Nursing Assistant (CNA) had come into her room and grabbed her foam cup from off her bedside table and walked off towards the door. She called out to her and said, where are you going with my ginger ale?. The CNA did not respond, or answer and it made her feel that she was being ignored. When she came back, she asked her again what she was doing with her cup. The CNA got an attitude and said she was putting more ice water in the cup. Resident #202 told the CNA it was not her water cup but her ginger ale. The CNA was cocky and had an attitude/argumentative, when talking to her. Resident#202 said there was also a nurse outside her door that had witnessed the whole conversation. The next day a staff member came and talked with her about the incident then told her later that CNA Staff Q would not be taking care of her anymore. Resident #202 said before CNA Staff Q was removed from caring for her, she had heard CNA Staff Q arguing with a male resident in the hall near her room. She asked her what was going on and CNA Staff Q told her it was none of her business. She said she was just concerned about the other resident getting yelled at. On 4/6/21 at 3:25 p.m., Resident #202 was observed in her room and forcefully telling CNA Staff R she did not want to be there anymore. CNA Staff R yelled at the resident, Don't yell at me. Then the CNA slammed the door shut and walked away. After surveyor intervention Unit Manager Staff I attended the resident to defuse the situation. On 4/6/21 at 3:30 p.m., in an interview Unit Manager Staff I said this was a known behavior for the resident. The remedy to calm the resident was to sit in a chair next to the bed and let the resident talk. This satisfied the resident and calmed the event. She said this resident was recently moved to this room from another area in the facility. She said the staff attending this room was not trained in the method for diffusing the resident's anxiety according to the unit manager. On 4/6/21 at 3:41 p. m., CAN Staff R remained on the unit. She was observed walking down the hallway. On 4/7/21 at 12:30 p.m., observed resident #202 sitting at her bedside finishing her lunch. Resident #202 was tearful. She stated in an interview she was upset about the incident that happened the previous. She said it was the second time a CAN had spoken to her that way. She said she felt very stressed and needed something for her anxiety. She became tearful again as she recounted the experiences. 2. Review of the clinical record revealed Resident #19 was admitted to the facility on [DATE] with the following diagnosis: History of femur fracture, heart disease, chronic respiratory problems, hypertension, anxiety, depression, insomnia, and macular degeneration. Resident was legally blind. Resident was assessed to be alert and oriented. On 4/5/21 at 12:08 p.m., in an interview Resident #19 said his main concern was about the way the certified nursing assistants (CNAs) talked to him and treated him. He said it took very long on the evening and night shift to get the call light answered. He said when they did come in, they scolded him about turning on his light too much. He said they had told him they would take the call light away if he turned it on so much. Resident #19 said they had taken it away in the past and he had had to yell out to get someone to come into his room. When they did come in, they said if he didn't stop (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 6 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 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 0607 Level of Harm - Minimal harm or potential for actual harm yelling, they would put him over there. He said he was blind, so he didn't know what they meant by over there. Resident #19 said the kind of behavior from the CAN staff made him afraid. He also said the night CAN Staff O would not empty his urinal and he ended up spilling it when he tried to use it again. He said he was helpless in the bed and he couldn't do much for himself. He said he had reported this to the nursing management and his wife. Residents Affected - Few On 4/5/21 at 1:40 p.m., in an interview Resident #19's Wife said her husband had told her when he put his light on the staff did not come for a long time. She said he had told her about the incident of a male CAN on nights telling him not to put on his call light or he would take it away from him. She said her husband was blind and when he had to use his urinal, he did not know how full it was. She said CAN Staff O told him he would not empty it until it was ½ full. So, when the resident tried to use it he spilt it on the bed and had to lay in a wet bed until someone came and changed it. She said her husband reported this could be hours sometimes. She said she had reported this to nursing management to investigate but did not feel it had been resolved yet. 3. On 4/6/21 at 11:29 a.m., in an interview Resident #64 said when she turned on the call light on the evening shift and night shifts, she felt the staff came in and scolded her and said to stop putting on the light. She felt she needed help and needed to use her call light if she needed to be changed. She said she felt the CAN could use more education on being kinder and customer service. She said the night male CAN Staff O told her roommate to stay in bed when she asked to go to the bathroom. He said it so loud it scared both her and her roommate. She said they both reported the incident after it happened to nursing management and they said they would look into it. 4. On 4/6/21 at 11:45 a.m., in an interview Resident #34 said she felt the CNAs on the evening and night shift needed more training in customer service. She said she and her roommate had to wait sometimes an hour or more for the call light to be answered and then a staff member came in and said, what do you want now. Resident #34 said last week the male night CAN Staff O came in and she asked to go to the bathroom. The CNA said, stay in bed, do not get up. She said she had to go to the bathroom, and he said loudly, stay in bed, do not get up. Resident #34 said it made her feel like she was not being taken care of. Resident #34 said she and her roommate reported the incident to management. Someone came in and told them, they would look into the incident, but no one had come back and talked with them yet. 4/7/21 2:40 p.m., in an interview the Risk Manager Staff S said she had not heard of this issue before hearing it from the surveyor. On 4/6/21 record review of the facility's Grievance/Concern log showed no grievance was recorded for Resident #202 and the incident that happened shortly after admission. Then the facility Risk Manager Staff S came with a form dated 4/4/21 with the concern being Resident #202 did not want CNA Staff Q to come into her room. The form did not describe the incident explaining why the resident felt this way. Conclusion/Summary of findings stated CNA Staff Q was passing ice to unit and went to refill the resident's cup of ice water. The grievance form did not show a complete and thorough investigation. The resolution was to take CNA Staff Q off the assignment. The training to the CNAs on customer service was done on 4/2/21, two days before the grievance was written. On 4/6/21 record review of the facility's Grievance/Concern log showed 3 grievances for Resident #19 and his wife. Each of the 3 grievances forms were filled out vaguely about resident concern over CNA approach and poor customer service. When Resident #19's wife filled out the grievance it had much more detail. CNA educated on customer service and removed from the resident's assignment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 7 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 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 0607 Level of Harm - Minimal harm or potential for actual harm On review of CNA Staff O, Q, and R personnel files revealed each of the CNAs involved in the above incidents had 3-7 disciplinary actions on file, including suspensions and discharge warning. On 4/7/21 at 10:25 a.m., in an interview the Administrator acknowledged that all the CNAs reviewed had multiple disciplinary actions in their files which included customer service issues. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 8 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 4/6/21 at 9:10 a.m., Resident #39 observed sitting in in a wheelchair next to her bed. Resident #39 said she would participate in activities if the facility offered them. Resident #39 said staff did not bring her books or magazines. Residents Affected - Some Review of the Minimum Data Set, dated [DATE], showed Resident #39 liked books, newspapers, and magazines. She liked to listen to music. Resident #39 liked to keep up with the news. Resident #39 liked to go out and get fresh air. Resident #39's activity care plan goal stated, The resident will participate in activities of choice to meet their needs while maintaining COVID-19 protocols. Interventions included to encourage alternative activities to be done in her room and provide supplies to be kept in room for room activities. On 4/7/21 at 11:30 a.m., Resident #39 was observed sitting in a wheelchair next to her bed. The resident was awake and alert, no books or magazines were observed in her room. 4/8/21 at 8:30 a.m., in review of documentation provided by the Activities Director, showed Resident #39 had not attended any activities over the last two months. There was no documentation the resident was offered books or magazines, or word puzzles. There was no documentation the resident went outside for fresh air. The Activities Director said she had failed to document providing word puzzles for the resident. The Activities Director verified she had not been encouraging the resident to attend activities. 4/8/21 at 8:40 a.m., Resident #39 was observed being assisted in eating her breakfast. There were no magazines, books, or word puzzles observed in the resident's room at that time. 6. On 4/6/21 at 11:29 a.m., Resident #41 was observed to be independent and able to propel himself in his room, to shave himself, and complete activities of daily living. Resident was alert and oriented to person, time, and place. He was able to make his likes and dislikes known. Resident #41 stated he was not aware he could go outside to get fresh air. Resident #41 said there had been no activities in the facility since the pandemic started last year. On 4/6/21 at 3:01 p.m., in an interview Resident #41 said before COVID-19 they played bingo. The resident stated again there had been no activities at the facility since COVID-19. The Annual Minimum Data Set activities preference assessment dated [DATE] showed Resident #41 liked books, newspapers, and magazines to read. He liked to listen to music. He liked to keep up with the news. Resident #41 liked to go outside and get fresh air. Activities care plan goal was for resident to participate in activities of choice to meet their needs while maintaining COVID-19 protocol/precautions. Interventions included to encourage alternative activities that can be done in room. Provide supplies to be kept in room for in room activities. On 4/8/21 at 8:20 a.m., the Activities Director was asked to provide documentation of Resident #41's activities over the last two months. The documentation showed the Activities Staff visiting the resident to bring him his mail. There was no documentation the resident participated or refused to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 9 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some participate in activities. The Activities Director verified she had not encouraged the resident to participate in activities over the last two months. The Activities Director verified Resident #41 was allowed to go outside for fresh air. 7. On 4/6/21 at 9:10 a.m., Resident #19 was observed laying in his bed. Resident #19 said he would participate in activities if the facility offered them. Resident #19 said all he had to do was lay in bed all day and often his television (TV) did not work. Resident said he was legally blind. On 4/6/21 at 10:40 a.m., in an interview the Activity Director said she did visit the resident from time to time and changed his channel on the TV for him and would open his mail if needed. Review of the Minimum Data Set, dated [DATE] showed, Resident #19 was alert and oriented and liked books, newspapers, and magazines. He liked to listen to music. Resident #19 liked to keep up with the news. Resident #19 liked to go out and get fresh air. Resident #19's activity care plan goal noted the resident required staff assistance with involvement of Activities related to requires physical assistance to & from activities. Interventions included to provide activities calendar monthly. On 4/7/21 at 1:30 p.m., Resident #19 was observed laying in his bed on his back in bed with the drapes closed and TV on. The resident was awake and alert, no books or magazines were observed in the room. Resident #19 said, in interview, that there were no activities, not even books on tape, like he had at home. He said there was nothing to do and he would like to get up in his wheelchair and get out of the room. On 4/8/21 at 12:30 p.m., observed Resident #19 in bed on his back with TV on. 8. On 4/6/21 at 11:10 a.m., Resident #64 was observed laying in her bed. Resident #64 said she would participate in activities if the facility offered them. Resident #64 said all she had to do was lay in bed all day. She said she would like to get up and get out of the room for a while. She said she could not sit up for more than an hour at a time, but she would like something to do. Review of the Minimum Data Set, dated [DATE], showed Resident #64 was alert and oriented and liked books, newspapers, and magazines. She liked to listen to music. Resident #64 liked to keep up with the news. Resident #64 liked to go out and get fresh air. Assessment records showed that Resident #64 needed extensive assist of 2 staff to be able to get up and move about. Resident #64's activity care plan goal noted the resident was independently capable of pursuing her own activities without facility intervention. The interventions included: encouraging resident to participate with activities of choice, give monthly calendar. On 4/7/21 at 1:30 p.m., Resident #64 was observed laying in her bed on her back in bed, no TV was on. The resident was awake and alert, no books or magazines were observed in her room. Resident #64 said in interview that there were no activities. She said there was nothing to do so her and her roommate just ended up talking. On 4/8/21 at 12:30 p.m., Resident #64 was observed in bed laying on her side with no TV on. Based on observation, record review, review of policies and procedures, and staff interview, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 10 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm facility failed to implement meaningful and empowerment activity programs to meet the assessed needs of 8 (Resident #5, #19, #39, #41, #58, #60, #62, and #64) of 8 residents identified with emotional and psychological needs. The lack of an individualized activity program has the potential to cause social isolation, boredom, agitation, and frustration. Residents Affected - Some The findings included: The facility policy 6.1.1, Dementia Related Programs (1/2021) documented: Specialized support, maintenance and empowerment activity programs are provided for residents with cognitive impairments. The activities are based on the level of dementia and functional ability .Dementia related programming should be activities that can be broken down into small segments. The activity calendar must include activities appropriate for dementia residents. The facility policy 1.1.1 Activities Overview documented: Activities department employees will provide activities that include sensitivity and an understanding of each individual resident's needs and requirements including medical, emotional, spiritual, therapeutic and recreational needs. 1. A review of the clinical record showed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 99. The BIMS score (scale used to assess cognitive status in elderly patients) indicated the resident was not able to participate in the interview. Resident #5 had a diagnosis of vascular dementia with behavioral disturbance and major depression. The clinical record showed an Activity Assessment with a date of 3/10/21, documented Resident # 5 loved to sing and talk to people. The activity plan review was not completed. On 4/5/21 at 9:45 a.m., during observations on the Memory Care Unit, Resident #5 was seated in her wheelchair at a table in the dining room. A radio was on loudly playing rock and roll music. Resident #5 said, it's loud in here. No facility staff was present in the dining room. At 12:26 p.m., Resident # 5 was at the table in the dining room with a book opened in front of her. Resident #5 was not looking at the book and said, I am not looking at it. The radio was on playing a rock and roll station. Certified Nursing Assistant (CNA) Staff G was seated in the dining room but was not interacting with the residents. On 4/6/21 at 10:33 a.m., Resident #5 was observed in the dining room seated at the table. The radio was on playing Spanish music. The resident was not responding to the music and was not meaningfully engaged. 2. Review of the clinical record showed Resident #58 had a BIMS score of 3, indicating a severe cognitive impairment. Resident #58 had a diagnosis of Alzheimer's disease, dementia, and major depressive disorder. On 4/5/21 at 3:15 p.m., during observation on the Memory Care Unit, Resident #58 was in her room, sitting on the bed. There was no television or radio on, and no group activity was in progress on the unit. On 4/6/21 at 2:51 p.m., Resident #58 was in the Memory Care dining room seated at a table, a radio was on. Resident #58 was sleeping at the table and there was no activity in progress. 3. A review of the clinical record showed Resident #60 had a BIMS score of 0, indicating severe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 11 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cognitive impairment. Resident #60 had a diagnosis of Alzheimer's disease, insomnia, major depressive disorder, Parkinson's, and psychosis. The clinical record indicated Resident #60's primary language was Spanish. During random observations on 4/5/21 at 9:57 a.m., 1:58 p.m., and 3:59 p.m., Resident #60 was in her room in bed, her eyes were open, and she was staring at the wall. There was no television or radio on for the resident. On 4/6/21 at 9:00 a.m., Resident #60 was in bed sleeping. The television was on but there was no volume. The clinical record showed an activity progress note with a date of 1/28/21 documented a catalog order was completed for Resident #60. On 4/6/21 at 3:24 p.m., during an interview the Activity Director said she did a catalog order for Resident #60 on 1/28/21. The Activity Director confirmed there was no documentation of any other activities provided by the Activity Department for Resident #60 since 1/28/21. 4. Review of the clinical record showed Resident #62 had a BIMS score of 1, indicating severe cognitive impairment. Resident #62 had a diagnosis of Alzheimer's disease, glaucoma and dementia without behaviors. The clinical record showed a care plan (provides details on the type of nursing care a patient requires) initiated on 2/16/21, specified the resident appeared more comfortable in bed and did not transfer to a wheelchair during the day. The care plan documented Resident #62 had impaired vision related to glaucoma. On 4/5/21 during random observations at 9:30 a.m., and 12:00 p.m., Resident #62 was in her room in bed, lying on her back and looking up at the ceiling. There was no television or radio on. Resident #62 said, I'm looking up at a white ceiling. Resident #62 confirmed she was not able to see. A review of the care plan showed activities initiated 12/19/17, identified Resident #62 required staff assistance with involvement of activities. The care plan specified that Resident #62 would benefit from a general activity program. The activity progress note on 3/1/21 documented, sat and gave a hand massage today. On 3/11/21 the activity progress note documented, sat and talked to Resident #62 about the weather and her bed sheets. The clinical record showed no activity progress notes for Resident #62 for the month of February 2021. The activity progress note for January 2021 documented, did a catalog order for Resident #62 today. On 4/6/21 at 3:22 p.m., in an interview the Activity Director confirmed she knew Resident #62 was visually impaired and said, when I get time, I give her a hand massage. The Activity Director confirmed she provided only four documented activities since 1/28/21 for Resident #62. The Activity Director said she held the position at the facility for 1 year. The Activity Director said she did not have a special calendar for the Memory Care, and specified she modified the calendar used for the general population of the facility. The Activity Director was not able to explain how the activities were modified for the cognitively impaired residents on the Memory Care Unit. The Activity Director said she had made the first Memory Care Unit activity calendar for April 2021 but said no one was assigned to provide the activities on the calendar. The Activity Director said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 12 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Certified Nursing Assistants (CNAs) would do the activities on the Memory Care unit. The Activity Director said she did not always have time to chart her progress notes for the activities she provided and had no record of the residents who attended activities. On 4/6/21 at 2:45 p.m., in an interview CNA Staff E said the Activity Director put up the big calendar a few days ago for the resident activities on the Memory Care Unit. CNA Staff E said the Activity Director, or the Assistant did the activities for the residents on the Memory Care Unit. CNA Staff E said the residents did not do the activities listed on the calendar and the CNAs on the unit were not assigned to assist the residents with the scheduled activities. Event ID: Facility ID: 105882 If continuation sheet Page 13 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and staff interview, the facility failed to provide oxygen therapy, in accordance with physician orders, for 2 (Residents #24 and #60) of 2 residents sampled for oxygen administration. Failure to follow prescribed oxygen therapy may result in inadequate oxygen treatment or an increased risk of side effects and complications. Residents Affected - Few Findings included: Requested and received a copy of Oxygen Therapy Policy and Procedure. Received document titled: The Oxygen Therapy. (SMS O2 ED 2013). States: Definition of Oxygen 1) Oxygen is a drug which must be ordered by physician. Clinical Consideration: Clinical Consideration: 1) CO2 retainers- Some patients are sensitive to O2 and have the potential to stop breathing if their blood oxygen becomes elevated. These patients should be maintained with their O 2 saturations near 90% and monitor closely for sensorium change. 1. Observation on 4/5/21 at 12:05 a.m., found Resident #24 in bed receiving oxygen via a nasal cannula connected to an oxygen concentrator set on 3 liters per minute (LPM). Resident #24 was observed in bed, on 4/5/21 at 2:00 p.m., receiving oxygen via a nasal cannula connected to an oxygen concentrator set on 3 LPM. The nasal cannula was not inserted in the resident's nostrils and was hanging around the resident's neck. On 4/5/21 at 2:00 p.m., in an interview Resident #24 said if she wore the nasal cannula continuously her nose and throat became very dry. Record review for Resident #24 found a physician's order dated 2/1/21 for oxygen at 2 LPM via nasal cannula, as needed (PRN). During observation on 4/6/21 at 09:04 a.m., the oxygen concentrator was set at 3 LPM. Resident#24 did not have nasal cannula in nose, it was hanging from her neck. During observation on 4/7/21 at 11:17 a.m., the oxygen concentrator was set at 1.5 LPM. Resident#24 did not have nasal cannula in her nose, it was hanging from her neck. On 4/7/21 at 11:18 a.m., in an interview Certified Nursing Assistant (CNA) Staff A said they kept Resident #24's oxygen between 2 LPM and 3 LPM as needed and the nurses were the ones adjusting it. On 4/7/21 at 11:19 a.m., Licensed Practical Nurse (LPN) Staff B observed concentrator set at 1.5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 14 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LPM. At the time of observation, 4/7/21 11:19 a.m., LPN Staff B acknowledged the order was for 2 LPM. LPN Staff B said, when I came in the morning it was at 3 LPM. I knew the order was for 2 LPM so I changed it. I don't know why it's set at 1.5 now. LPN Staff B attempted to increase the dial to 2 LPM, but the dial was not functional. LPN Staff B stated she would replace the oxygen concentrator for Resident #24. On 4/7/21 at 2:30 p.m., in an interview, the Director of Nursing acknowledged the oxygen concentrator was not in working order and said LPN Staff B replaced the oxygen concentrator for Resident #24. **Photographic Evidence Obtained** 2. On 4/6/21 at 9:02 a.m., Resident #60 was observed with oxygen on at 2.5 LPM via nasal cannula. On 4/6/21 at 10:02 a.m., Resident #60's oxygen concentrator was set to 3.0 LPM via nasal cannula. On 4/7/21 at 8:41 a.m., Resident # 60 was observed in bed and her oxygen was on at 2.5 LPM via N/C. The physician's orders dated 3/29/21 showed an order for oxygen at 2 LPM as needed for dyspnea (difficulty breathing or shortness of breath). On 4/7/21 at 9:27 a.m., in an interview, Unit Manger Registered Nurse Staff C confirmed the oxygen concentrator for Resident #60 was set on 2.5 LPM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 15 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/7/21 at 8:25 a.m., in an observation on the [NAME] Unit, the medication cart was in the short hall, near the entrance to the Memory Care Unit and it was not locked. Unit Manager Registered Nurse (RN) Staff C confirmed the medication cart was not locked. There were 3 staff members walking past the unlocked cart to enter the Memory Care Unit. Based on observation, review of facility policy and procedures, and staff interviews the facility failed to ensure timely access to locked emergency-controlled substance medications located in 1 of 2 medication storage rooms. The facility also failed to have a system to audit and reconcile the disposition of discharged controlled substances and failed to ensure secured and locked medication carts for 1 of 6 carts at the facility. The findings included: Facility policy and procedure 4.2 Controlled Medication Storage dated 2007 item 6 states At each shift change or when keys surrendered, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurses per state regulation and is documented on the controlled substance accountability record or verifications of controlled substances count report. The nursing care center may elect to count all controlled medications at shift change. 1. On 4/6/21 at 4:27 p.m., during an observation of the medication room Ford Hall with Unit Manager, Registered Nurse (RN) Staff I, 2 refrigerators were located within the locked medication room. Unit Manager, RN Staff I said, The unlocked refrigerator is for emergency insulin and additional medications that are not controlled substances that require refrigeration. The locked refrigerator contains the emergency Ativan [controlled substance medication used to treat seizure disorders or anxiety]. Unit Manager RN Staff I opened the locked outer door of the controlled substance refrigerator and said she needed the other nurse to open the lockbox inside the refrigerator. Unit Manager RN Staff I had Licensed Practical Nurse (LPN) Staff H come to the medication room to open the inside lock box. LPN Staff H and Unit Manager RN Staff I attempted several keys and were unable to open. Unit Manager RN Staff I, called a second nurse working, LPN Staff K, to the medication room. LPN Staff K and Unit Manager RN Staff I continued to attempt to open the emergency medication box but were unsuccessful. Unit Manager RN Staff I said, I will go and get the evening supervisor. He will have a key. We exited the medication room. On 4/6/21 at 4:45 p.m., Unit Manager RN Staff I and RN Staff J returned to the medication room to attempt to open the locked refrigerated medication box for controlled substances. After attempting 5 keys, they were unable to find working key. We exited the medication room. On 4/6/21 at 4:51 p. m., in an interview, LPN Staff L said, Maintenance Director changed the box when he changed the refrigerator, 2 days ago or maybe yesterday. We exited the medication room. Unit Manager RN Staff I and RN Staff J went to get the Maintenance Director. On 4/6/21 at 4:55 p.m., Unit Manager RN Staff I and RN Staff J returned to the medication room with a key Unit Manager RN Staff I identified as, extra key I got from the [Director of Nursing] DON office. The refrigerator and the emergency drug box opened with both staff present. The Emergency Ativan medication box was locked inside the drug box as well as a plastic bag containing emergency (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 16 of 17 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 105882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winkler Court 3250 Winkler Avenue Extension Fort Myers, FL 33916 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 0755 Level of Harm - Minimal harm or potential for actual harm intramuscular (IM) Ativan for Resident #77. The medication for Resident #77 was issued 8/16/19. Unit Manager RN Staff I confirmed Resident #77 was not located on Ford Hall and was currently located on [NAME] Hall. Unit Manager RN Staff I said, that resident has been moved to the other side. **Photographic Evidence Obtained** Residents Affected - Few 2. On 4/7/21 at 11:20 a.m., during an interview the DON said the facility process for removing discontinued controlled medications was for the DON to go every few days to collect the discontinued medications from the medication carts. 2 nurses removed the medications and verified count of medications. The DON said she verified the medication count sheet was correct. The DON said she took the medications with count sheets wrapped around each medication to her office and locked them in a double locked wall cabinet. The DON said she was the only one with access to the double locked wall cabinet except when she was on vacation. During her vacation, the Assistant Director of Nursing had the keys for the double locked wall cabinet. The DON said she did not know what medications, or the amount of controlled medications were contained currently in wall cabinet. The DON confirmed she had no way to reconcile the controlled medications inside the locked wall cabinet. The DON said she completed monthly destruction of controlled medications with the Administrator or another RN. Then the DON scanned and logged the medication destruction in her logbook. On 4/8/21 10:49 a.m., in an interview the DON confirmed the practice communicated 4/7/21 for destruction of controlled medications. The DON confirmed she could not tell what was in the wall cabinet and did not have a process for periodic reconciliation of these medications. The DON was interviewed about the emergency Ativan medication in the Ford Hall locked medication refrigerator that was dispensed on 8/16/19. The DON confirmed there was an order for resident which had been discontinued 9/2019, the resident did not have a current order for IM Ativan and the medication was never collected for destruction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 17 of 17