Inspection·November 3, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 11/3/22 at 9:57 a.m., in an interview, the Social Services Director (SSD) said he doesn't think it is OK for residents to go to therapy in a gown. The SSD said he was not made aware Resident #91 had no clothes to wear, adding It is a dignity issue. On 11/3/22 at 6:51 p.m., in an interview, the Director of Nursing said the expectation was for residents to be dressed in clothes during the day to maintain their dignity. Event ID: Facility ID: 105882 If continuation sheet Page 2 of 25 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 11/03/2022 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident interviews, the facility failed to document, investigate and communicate resolution of a grievance voiced by the spouse of 1(Resident #91) of 4 residents reviewed for grievances. Residents Affected - Few The findings included: Review of the facility's Grievance/Concern Management Policy and Procedure (Effective February 2021) indicated: Social Services #5. will monitor and document resident/family satisfaction upon completion of the investigation and the summary of the findings/conclusion #12. Complete a concern report investigation with summary and conclusion On 10/31/22 at 11:02 a.m., record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses which included pleural effusion, diabetes, assistance with personal care, and chronic kidney disease. The admission Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact and required total dependence of 2 staff members toileting. On 10/31/22 at 11:58 a.m., Resident #91 said he had been left in feces and urine. The Resident indicated he could not get a hold of the staff and ended up calling his wife at home. On 11/03/22 at 7:47 a.m., review of progress note dated 10/27/2022 at 5:32 a.m., revealed the following: Call received from resident's wife this a.m., saying that her husband called her voicing need for his brief to be changed as he had a bowel movement. Resident's wife was assured that as soon as the CNA assigned to his care was finished caring for another resident that she will be in to care for him. Wife asked How long? Informed that according to the CNA approximately 10 minutes. Resident informed as to CNA approximate arrival time to change his brief. Resident continues to display agitation as CNA unable to attend to his needs immediately. Review of the grievance log revealed no evidence of a grievance from the wife of Resident #91. Further review failed to find the grievance was documented, investigated, and resolved to the satisfaction of Resident #91 and his wife. On 11/03/22 at 9:57 a.m., in an interview, the Social Service Director (SSD) reviewed the progress notes dated 10/27/22 documenting Resident #91's wife's call to the facility regarding Resident #91's soiled brief. The SSD said it should have been put on a grievance form and investigated. The SSD stated: Our grievance process was not followed. Part of the process is to fill out a grievance, investigate, and come to a resolution with the complainer. This was not done regarding Resident #91's concern because I was not made aware of that grievance. She said this definitely should have been put on the grievance log. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 3 of 25 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 11/03/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide the necessary repairs to maintain the building in a safe and comfortable environment for residents and visitors. The findings included: On 10/31/22 at 7:30 a.m., during initial tour of the Memory Care Unit, the following observations were made: A pungent smell of urine and other odors was noted immediately upon entering the unit. Bathroom trash cans were full of garbage and overflowing onto the floor in several bathrooms. room [ROOM NUMBER] there was an uncovered toothbrush resting on the bottom of the hand soap dispenser in a shared bathroom. room [ROOM NUMBER] had a broken nightstand with the top drawer missing for bed A. The blinds in the room were broken, missing sections and in disrepair. There were air-conditioning parts on the floor in the corner of the room. On 10/31/22 at 9:45 a.m., observed in the Memory Care Unit dining room were small flying insects flying over the food as the residents were eating. The flying pests were landing in the food and flying toward resident's faces. The residents were swatting the insects away with their hands. On 11/1/22 at 10:40 a.m., observed a large hole in the wall behind door of small dining room on the [NAME] Unit. On 11/1/22 at 1:13 p.m., in an interview, the Maintenance Director (MD) said he made the repairs to the air-conditioning unit and the blinds in room [ROOM NUMBER] today but did not know how long the room was in disrepair. He said he does rounds at least monthly conducting audits of the needed repairs including on the Memory Care Unit. He said the facility staff put repair concerns in a book. On 11/1/22 at 2:30 p.m., the Maintenance Director provided an undated resident room list that he signed at the bottom indicating he inspected all the blinds on the Memory Care Unit and replaced the blinds that were in disrepair. He said he completed the audit today and confirmed he had no additional documentation of his audits. The Maintenance Director said he was not aware the nightstand in room [ROOM NUMBER] A bed was broken and missing the top drawer. On 11/2/22 at 8:24 a.m., in an interview, Housekeeper Staff AA on the Memory Care Unit said she mops the floors daily and cleans the rooms including emptying the garbage cans. The Housekeeper said the CNAs were responsible to empty the garbage at the end of their shifts. She said she uses air freshener daily on the unit after cleaning rooms. She confirmed the unit often had a strong odor of urine. On 11/3/22 at 8:20 a.m., in an interview, the MD said he was not made aware of the hole in the wall on the [NAME] Unit needing repair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 4 of 25 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 11/03/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/31/22 at 8:45 a.m., observed in room [ROOM NUMBER] chipped paint and exposed plaster on the wall next to the head of the beds and the wall between the bed and the bathroom corner. On 11/2/22 at 11:45 a.m., in an interview, Resident #46 said that she had seen crawling bugs in her room. She confirmed that she told facility staff about the sightings. Resident #46 had environment grievances filed on 6/10/22, 7/6/22, and 7/28/22. On 11/2/22 at 3:06 p.m., during a tour of the laundry room with Director of Housekeeping, observed lights in dryer room broken and the room was warm. The Housekeeping Director said the AC is broken but they are working on it. The Housekeeping Director said the big washer and one of the driers are broken and are going to be replaced. The Housekeeping Director said there are towels stuffed under the functioning washing machine because it has been leaking for over a week. Laundry Aide Staff Y said she was told the lights in the laundry room are being replaced but keep going out because of the heat in this room. On 11/2/22 at 3:31 p.m., in an interview, the Maintenance Director said he was not aware of the laundry room lights being broken or the one washing machine leaking. The MD confirmed the broken dryer was being replaced, washing machine being replaced and the air conditioning unit waiting for a part. On 11/3/22 at 9:47 a.m., in an interview, the Regional District Manager for Housekeeping acknowledged the laundry aides had not been documenting the cleaning of the lint traps and the laundry area. The District Manager said the staff are being reeducated and the expectation is to have daily, weekly, monthly cleaning schedule documented day and night. On 11/3/22 at 1:15 p.m., observed room [ROOM NUMBER] with the Maintenance Director. The Maintenance Director confirmed the exposed plaster and chipped paint on walls and said he did not know it was like that. He said it is expected that maintenance issues would be reported by the Certified Nursing Assistants (CNA) and a work order generated. He said he doesn't have any work orders for the damaged walls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 5 of 25 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 11/03/2022 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility policy and resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Resident #7, and #49) of 3 residents reviewed for activities of daily living. Residents Affected - Few The findings included: The facility policy 5.5.1 ADL: Assistance, effective July 2022, documented Each resident will be encouraged to be as independent as possible with activities of daily living (ADL's). Staff will provide assistance with ADLs per plan of care. 1. A review of Resident #7's clinical record showed a significant change minimum data set (MDS) (a tool used to gather resident information) with assessment reference date (ARD) 7/28/22. The MDS documented Resident #7 required limited assistance of 1 for dressing, personal hygiene, and toileting. The Minimum Data Set (MDS) assessment showed a brief interview for mental status (BIMS) score of 7, indicating moderate cognitive impairment. The care plan documented the Resident has an ADL self-care performance deficit, cannot complete ADL tasks independently and requires individualized interventions to improve function because of weakness. The care plan interventions instructed the CNA to provide assistance with oral care, personal hygiene, toileting and dressing. On 10/31/22 at 9:01 a.m., Resident #7 was observed sitting in the dining room. Her hair was short, greasy and was uncombed. Her clothing was miss matched and she had a pungent body odor. Resident alternated her speech between English and Spanish and did not answer most questions. On 11/1/22 at 9:03 a.m., in an interview, Certified Nursing Assistant (CNA) Staff Z said Resident #7 could be agitated when care is provided, and she will yell at you when she does not want to do something. She said Resident #7 will try and do things for herself. On 11/1/22 at 9:10 a.m., Resident #7 was in her room dressed in a blue striped shirt with white long shorts. On 11/2/22 at 8:55 a.m., Resident #7 was observed in her room dressed in the same clothing as the previous day. She was sitting on the side of the bed, eating her morning meal. The resident's hair was short, greasy, and matted. The room had a pungent odor. There was a trail of liquid on the floor from the residents' bed to the bathroom. The same observation was made at 11:41 a.m. On 11/2/22 at 11:55 a.m., in an interview, CNA Staff C said Resident #7 can be resistive to care and often changes her clothing during the day. The CNA said, if we dress her, she will change her own clothing. The CNA said when she changes a resident the soiled clothing is bagged and places in the soiled utility room for the laundry. Review of the CNA documentation for September 2022 showed Resident #7 received no toileting, personal hygiene or dressing assistance on: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 6 of 25 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 11/03/2022 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 0677 Day shift - 9/11/22, 9/13/22, 9/19/22, 9/25/22. Level of Harm - Minimal harm or potential for actual harm Evening Shift - 9/13/22, 9/20/22, 9/27/22. Residents Affected - Few Night shift- 9/3/22, 9/6/22, 9/9/22, 9/10/22, 9/12/22, 9/13/22, 9/14/22, 9/19/22, 9/20/22, 9/24/22, 9/27/22 and 9/29/22. The documentation showed Resident #7 did not receive a scheduled shower on 9/17/22. Review of the CNA documentation for October 2022 showed Resident #7 received no toileting, personal hygiene or dressing assistance on: Day shift - 10/4/22, 10/5/22, 10/9/22, 10/19/22, 10/23/22. Evening shift- 10/4/22, 10/11/22. Night shift- 10/1/22, 10/3/22, 10/5/22, 10/6/22, 10/8/22, 10/11/22, 10/14/22, 10/16/22, 10/22/22, 10/25/22, 10/29/22 and 10/30/22. The documentation showed Resident #7 did not receive 4 of her scheduled showers. 2. A review of Resident #49's clinical record showed diagnosis of muscle weakness, vascular dementia, glaucoma, anxiety, and depressive disorder. The quarterly MDS with ARD 9/8/22 documented the resident required limited assistance of 1 with transfers, bed mobility, dressing, toileting and personal hygiene. The care plan identified Resident #49 had an ADL self-care performance deficit. Interventions included: Resident can help with some ADL's but needs physical help from staff to complete. Encourage resident to participate at highest level. Provide assistance required to complete task and document. On 10/31/22 at 10:00 a.m., Resident #49 was observed in bed without a sheet and wearing a gray sweater with no pants or undergarment on. Resident #49 was using a washcloth to cover her private area. At 11:27 a.m., the same observation was made with Resident #49. The resident said she did not know where her pants were. Resident #49 was using a cloth to cover her private area and said, I have to keep covered this is all I have. The call light was on the back of the headboard and not in the reach of the resident. The room had a pungent odor. At 12:19 p.m., and 2:47 p.m., the same observation was made with Resident #49. On 11/1/22 at 8:48 a.m., Resident #49 was observed in her room in bed sitting on the side of the bed and was dressed in the same gray sweater. Resident #49 did have a pair of pants on that were pulled up to her knees. She said she was trying to get them on but her legs did not work. At 2:45 p.m., Resident #49 was observed in the dining room dressed in a blue shirt with sequins on the front and blue pants. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 7 of 25 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 11/03/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/2/22 at 8:58 a.m., Resident #49 was observed in her bed eating the breakfast meal, she was dressed in the same blue sequined shirt from the previous day and had no pants or undergarments on. At 1:29 p.m., Resident #49 was observed in the same condition as the morning observation. Resident #49 said she was not able to get herself dressed because her leg was bad, and she could not stand. Resident #49 said she needs help to get dressed. Review of the CNA documentation for September 2022 shows Resident #49 did not receive assistance with dressing and personal hygiene on the following shifts: Day shift- 9/11/22, 9/13/22 and 9/19/22. Evening shift- 9/13/22, 9/20/22 and 9/27/22. Night shift- 9/3/22, 9/4/22, 9/6/22, 9/7/22, 9/11/22, 9/13/22, 9/24/22, 9/26/22 and 9/29/22. The CNA documentation showed Resident #49 did not receive her scheduled showers on 9/13/22, 9/20/22 and 9/27/22. Review of the CNA documentation for October 2022 showed Resident #49 received no assistance with hygiene and dressing on: Day shift - 10/3/22, 10/5/22, 10/9/22 and 10/23/22. Evening shift- 10/4/22, and 10/11/22. Night shift - 10/1/22, 10/2/22, 10/5/22, 10/6/22, 10/7/22, 10/8/22, 10/9/22, 10/14/22, 10/15/22, 10/16/22, 10/23/22, 10/24/22, 10/29/22 and 10/30/22. The CNA documentation showed, Resident #49 was scheduled for showers on Tuesdays and Fridays on the evening shift. Resident #49 did not receive her scheduled showers on 10/4/22, and 10/11/22. On 11/2/22 9:06 a.m., in an interview, CNA Staff C said the evening shift was responsible to assist the residents to get ready for bed. CNA Staff C said Resident #49 did require assistance with hygiene and dressing tasks. On 11/2/22 at 10:56 a.m., in an interview, the Director of Nursing (DON) said there was one nurse assigned to cover the [NAME] Unit and Memory Care Unit. She said the nurse was responsible to oversee the CNAs on the Memory Care Unit. The DON said the CNAs were responsible to provide the ADL care to the residents including personal hygiene, dressing, and bathing. She confirmed the nurse was not on the locked secured unit for the entire shift and was separated by double doors with small window panels, obscuring the nurse's vision when she was on the [NAME] Unit. On 11/2/22 at 11:05 a.m., in an interview, LPN Staff I said she was assigned the split assignment of the [NAME] and Secured Memory Care Unit. LPN Staff I said she goes first to the memory care unit for rounds and is there later to administer medications. The LPN said she was responsible to oversee the care the CNAs were providing to the residents on the Memory Care Unit and said she was not able to spend more time on the unit because she was also responsible to provide care to residents on the [NAME] Unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 8 of 25 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 11/03/2022 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** Based on observation, review of facility policy, clinical record review, and staff interviews, the facility failed to implement meaningful activity programs for 2 (Resident #48 and #302) of 2 residents reviewed with dementia on the secured Memory Care Unit. A lack of structured activities has the potential to cause boredom, agitation, and anxiety. Residents Affected - Few The findings included: The facility policy 6.1.1, Dementia Related Programs, 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.Review interdisciplinary data. Interview resident or representative to determine which activities interest the resident. Provide specialized activities based on the resident population with dementia and the various functional abilities of the residents. The activity calendar must include activities appropriate for dementia residents. 1. A review of Resident #48's clinical record showed a diagnosis of Alzheimer's disease, dementia with mood disorder, and Parkinson's disease. The quarterly Minimum Data Set (MDS) (a tool used to gather resident information) with an Assessment Reference Date of 8/6/22 documented a Brief Interview for Mental Status (BIMS) documented a score of 00 indicated severe cognitive loss. The activities care plan documented Resident #48 requires staff assistance with involvement of activities related to his cognitive deficits. He will listen to music and be around others daily. The interventions included, encourage to participate with activities of choice. prefers and would benefit from general activities program. preferred activity times are morning and afternoon. On 10/31/22 at 12:22 p.m., and 2:45 p.m., Resident #48 were observed sitting in the dining room on the Memory Care Unit. Certified Nursing Assistant (CNA) Staff H was sitting at his side and was not engaged with Resident #48. A review of the October activity calendar documented on 10/31/22 at 11:00 a.m., 1950's music memories and at 2:30 p.m., manicures. There was no structured activity observed in progress and the radio in the dining room was not turned on. On 11/1/22 on the Memory Care Unit, the following observations were made: At 10:08 a.m., there were 10 residents seated in the dining room including Resident #48, each with a magazine in front of them on the table, and the radio was playing contemporary rock hits. There were 2 CNAs seated in the dining room charting and there was no meaningful activity in progress. The activity calendar specified at 10:00 a.m., sit and get fit. At 12:10 p.m., on the Memory Care Unit, residents Including Resident #302 were in the dining room at tables seated with magazines in front of them on the table. Resident #48 was observed standing in front of the nurse's desk, slowly ambulating without staff intervention. The activity at calendar specified at 11:00, 1950's Music Memories. The radio was on playing contemporary rock hits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 9 of 25 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 11/03/2022 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 At 2:30 p.m., the Memory Care Unit activity calendar specified manicures at 2:30 p.m. The music on the radio had not changed. No manicures were provided to the residents. At 3:30 p.m., the activity scheduled for the residents was bodies in motion. There was no structured activity in progress. Residents Affected - Few On 11/1/22 at 2:35 p.m., in an interview, CNA Staff C was in the dining room talking with a resident. The CNA said the activity person was responsible to do the scheduled manicures for the residents. 2. A review of Resident #302's clinical record showed a diagnosis of dementia and anxiety disorder. The MDS documented a BIMS score of 10, indicating moderate cognitive impairment. The activities care plan documented Resident #302 was independent of pursuing her own activities without facility intervention. The interventions included, encourage to participate with activities of choice. prefers/would benefit from general activity program. no cognitive impairment, requires physical assistance to & from activities. On 10/31/22 at 10:36 a.m., Resident #302 was observed in a wheelchair in the hallway of the Memory Care Unit and was repeatedly calling out Help. I want to go to school. There was no nurse on the unit. The staff walked past her and did not acknowledge her. There was no activity program in progress. On 11/1/22 at 10:08 a.m., Resident #302 was observed in her room in bed. The television (TV) was not turned on. Resident #302 had her eyes open and was talking to herself. She said she liked music and to watch the TV. On 11/2/22 at 9:11 a.m., Resident #302 was observed in her room in bed, the door to her room had been closed. There was no radio or TV on in the room. There was orange juice spilt on the bed linen from the morning meal tray on the bedside table in front of the resident. Resident #302 was repeatedly calling out, help. She was not able to state what she needed. On 11/1/22 at 10:39 a.m., in an interview, the Activity Director said he had a specialized calendar of activities for the Memory Care Unit. He said he had an assistant who worked 20 hours a week and does the activities on the weekend and on Wednesday in the Memory Care Unit. The Activity Director said he does activities on Monday's and throughout the week for the residents on the Memory Care Unit. He said the CNAs were responsible to follow the activity calendar and provide the activities. He confirmed he did not do activities on the Memory Care Unit on 10/31/22 and said placing a magazine in front of the dementia residents may not be appropriate due to vision and cognitive loss. On 11/2/22 at 8:42 a.m., in an interview, CNA Staff C said the activity department was responsible to do the scheduled activities but they are not always on the unit to do it. CNA Staff C said we put music on for the residents and we give them books and magazines to look at; they like to look at them. [NAME] music was heard playing on the radio for the residents seated at the tables. CNA Staff C said the CNAs are in the dining room doing charting, so we are with the residents. CNA Staff C confirmed she did not do the scheduled activities with the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 10 of 25 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 11/03/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Facility failed to provide appropriate supervision to prevent falls for 1 resident (Resident #57) of four surveyed for falls. Residents Affected - Few The findings included: Resident #57 was admitted to the facility on [DATE] with a history of displaced fracture of the right tibia. The resident has a history of chronic kidney disease, anemia and arrhythmia. The Minimum Data Set assessment completed on 9/11/22 shows the resident had a brief mental interview score of 12 indicating mild cognitive loss. On 8/31/26 at 2:26 p.m., Resident #57 said a staff member had rolled her out of the bed when she was changing her sheets. Resident #57 stated she had hit her head and she was still having headaches due to the fall. Review of the fall investigation completed on 10/18/22 shows Registered Nurse Staff V documented, Observed Resident lying on the floor on her left side Resident states she was turned to be changed and she rolled too far off the bed and fell to the floor. Resident stated she hit her head. On 10/18/22 Certified Nursing Assistant (CNA) Staff T was interviewed and reported she was changing the resident's bed sheets and the resident rolled out of bed. Staff T is documented as stating, I was asking her to roll like I always do, and she reached too far and fell. Review of the facility investigation shows the action taken by the facility was to educate the CNA regarding positioning of the resident. An Interdisciplinary Resident/Patient Teaching Record shows Staff T was educated on turning and positioning the resident towards the middle of the bed rather than far to the side. On 11/2/22 at 11:35 a.m., Staff V verified Resident #57 rolled out of bed when Staff T was providing care. Staff V was asked if Resident #57 needed the assist of two staff members with bed mobility and Staff V said, No, she is a one person assist. Staff V verified Resident #57 was placed back in bed with a Hoyer lift after she fell. Review of the MDS dated [DATE] shows Resident #57 is a two-person extensive assist with bed mobility. Review of Resident #57's ADL care plan shows the resident is a two person assist with bed mobility and that this is documented on the CNA [NAME]. On 11/2/22 at 3:30 p.m., the DON verified she was not aware Resident #57 was a two person assist with bed mobility. On 11/3/22 at 9:00 a.m., the DON said she had in-serviced Staff T on 11/2/22 regarding insuring a two person assist when turning the resident in the bed. The DON said Staff T had told her she felt the resident was doing better and could now be a one person assist. The DON said she had spoken with the CNA on day shift (Staff EE) and she also felt Resident #57 was a one person assist with bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 11 of 25 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 11/03/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete mobility at this time. The DON at that time verified that she did not want CNAs making the decision of making a two person assist a one person assist. On 11/3/22 at 9:00 a.m., Staff EE said Resident #57 was a one person assist with bed mobility. Staff EE was asked where she got the information from, and she said from the Resident's [NAME] on her computer. Staff EE was observed to pull up the resident's [NAME] on her mobile device. Staff EE said she could not read the device without her glasses. At that time, it was observed the [NAME] on the staff member's mobile device said Resident #57 was a two person assist with bed mobility. Staff EE stated, Well sometimes she is a one person assist and sometimes she is a two person assist. Event ID: Facility ID: 105882 If continuation sheet Page 12 of 25 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 11/03/2022 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure a process was in place to assess parameters of nutritional status by not monitoring resident's weights on admission and thereafter for 6 ( Residents #91, #94, #96, #253, #351, and #402) admitted in past 30 days of 6 residents reviewed. This had the potential to affect all 84 residents residing in the facility. Residents Affected - Some The findings include, Review of facility policy and procedure (Effective October 2021) - Topic: Weight management - states, weights are completed on admission and re-admissions, then weekly for 4 weeks and then monthly unless physicians' orders more frequently. On 11/1/22 during initial review of admission weights of sample residents, weights were not found for Residents #91, #94, #96, #253, #351, and #402 admitted in past 30 days. On 11/1/22 at 2:47 p.m., in an interview, the RN MDS Coordinator stated, We don't get the weight upon admission. I use the hospital weight as the admission weight. The MDS coordinator said the Restorative Certified Nursing Assistant (CNA) used to do the weights but as of March, we don't have a restorative CNA. She believes all of the CNAs are supposed to do the resident weights. On 11/1/22 at 3:39 p.m., Licensed practical nurse (LPN) Staff W indicated the nursing staff should complete the weight on admission; but is not sure how often weight should be done after the admission weight. Staff W said the problem is that we don't have a weight schedule to follow. On 11/3/22 at 3:50 p.m., in an interview, CNA Staff L said the CNAs takes the residents' weight when they are admitted but didn't know how often after admission. She said she thinks the nurse tell you if someone needs to be weighed. On 11/3/22 at 2:58 p.m., the Registered Dietician (RD) confirmed the facility must weight residents upon admission, weekly for four weeks and then monthly. The RD said after staffing regulation changes last march, the facility got rid of the restorative program. This change affected the system we had in place for completing weights. This task became the admitting CNA's responsibility. The RD said the trend of missing weights started immediately after the change. The RD said she brings it up at meetings constantly. The RD said she feels she doesn't have current data. The RD said it is concerning that she can't compare weights and, therefore, she is not sure the interventions are appropriate. She said she doesn't know how many resident are losing or gaining weight. She said it is not clear how she is supposed to request weights. On 11/3/22 at 3:56 p.m. Registered Nurse (RN) Staff V said management is aware of the weight issue because, it is brought up almost daily in morning meeting since March 2022. Staff V said she was not sure if the nursing staff had been educated after this task was assigned to them. RN said we haven't had someone in charge of education for a while and there is a lack of evidence the nursing staff was in-serviced. On 11/3/22 at 4:04 p.m., a review of the matrix indicated only 1 resident identified as excessive weight loss. In a follow up interview, the RD said that is not accurate, but I can't give you a number because she is lacking the necessary data to flag changes in weight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 13 of 25 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 11/03/2022 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 11/3/22 at 4:17 p.m., the Administrator stated, It was never made clear to me that there is an issue. I knew we were missing some weights but not as consistent and as steady. The Administrator said the resident weight task was assigned to the nursing staff back in March of this year. The Administrator said nursing was told they would be doing the weights but could not confirm staff had been educated on weighing residents. Administrator said she doesn't have a quality assurance plan improvement (QAPI) for the weight. Event ID: Facility ID: 105882 If continuation sheet Page 14 of 25 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 11/03/2022 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on staff interview and record review the facility failed to ensure competency and performance reviews are completed every 12 months for 2 (Staff B and Staff BB) of 6 staff sampled for performance review and competencies. Residents Affected - Few The findings included: 1. Record review revealed Certified Nursing Assistant (CNA) Staff B's permanent date of hire was listed on the facility rooster as 7/10/12. Review of the competency review record provided by the Director of Nursing (DON) revealed Staff B's last competency/performance review was completed on 5/12/21. On 11/2/22 at approximately 3:30 p.m., the DON verified Staff B's competency/performance review had not been completed within the last 12 months. 2. Record review revealed CNA Staff BB's permanent date of hire was listed on the facility rooster as 2/23/10. Review of the facility provided documentation revealed Staff BB had not had a competency/performance review completed since 2/16/18. On 11/2/22 at approximately 3:30 p.m., the DON verified Staff BB had not had a competency/performance review completed within the last 12 months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 15 of 25 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 11/03/2022 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to post hours for licensed and unlicensed nursing staff on a daily basis as required by regulation. Residents Affected - Some The findings included: Review of the facility postings from 10/10/22 to 10/31/22 revealed: There was no documentation of any licensed and unlicensed nursing staff hours posted on 10/11/22. There was no documentation of any licensed and unlicensed nursing staff hours posted on the 3 to 11 shift on 10/14/22. There was no documentation of any licensed and unlicensed nursing staff hours posted on the 7 to 3 and the 3 to 11 shift on 10/15/22. There was no documentation of any licensed and unlicensed nursing staff hours posted on the 7 to 3 and the 3 to 11 shift on 10/16/22. There was no documentation of any licensed and unlicensed nursing staff hours posted on 10/19/22. There was no documentation of any licensed and unlicensed nursing staff hours posted on the 3 to 11 shift on 10/20/22. There was no documentation of any licensed and unlicensed nursing staff hours posted on the 3 to 11 and the 3 to 11 shift on 10/21/22. There was no documentation of any licensed and unlicensed nursing staff hours posted on 10/22/22 There was no documentation of any licensed and unlicensed nursing staff hours posted on 10/23/22. There was no documentation of any licensed and unlicensed nursing staff hours posted on 10/24/22. There was no documentation of any licensed and unlicensed nursing staff hours posted on the 3 to 11 shift on 10/25/22. There was no documentation of any licensed and unlicensed nursing staff hours posted on the 7 to 3 and the 3 to 11 shift on 10/26/22. There was no documentation of any licensed and unlicensed nursing staff hours posted on the 7 to 3 and the 3 to 11 shift on 10/30/22. On 11/2/22 at approximately 3:30 p.m., in an interview, the Director of Nursing verified the federal hours were not posted as required from 10/10/22 to 10/30/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 16 of 25 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 11/03/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, the facility failed to secure medications in a locked storage area consistent with state or federal requirements and professional standards of practice for 2 (Resident #6 and #65) of 2 residents reviewed for medication storage. The findings included: Review of facility policy 7.1 Medication Administration General Guidelines policy dated 9/18 noted: Medications are administered in accordance with written orders of the prescriber. 7.1 (#3) notes that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access Section 7.1 (#15) notes residents are allowed to self-administer medications when specifically authorized by the prescriber, the nurse care centers interdisciplinary team (IDT), and in accordance with procedures for self-administration of medications and state regulations. 1. On 10/31/2022 at 10:27 a.m., during a tour of the facility, one bottle of family care nasal relief nasal spray was observed on Resident #6's nightstand. The resident said he had used it one to two times a day depending on his nasal/sinus stuffiness. The nasal spray medication bottle did not have a pharmacy label noting the residents name, the name of the medication with directions for use, and/or any other pertinent information. Resident said he had not been told he was not allowed to keep the medication at bedside. On 11/1/22 at 2:00 p.m., observed two bottles of nasal spray sitting on Resident #6 nightstand. He said one was running low, so his wife brought a second one in to use. On 11/03/22, a review of Resident #6 medical record revealed he was admitted to the facility on [DATE]. A review of Resident #6's physician orders revealed no order for any nasal sprays. 2. On 10/31/22 at 2:04 p.m., during a tour of the facility, one bottle of advanced moisturizer lubricant drops (artificial tears) was observed on Resident #64 bedside table. The box did not have a pharmacy label, the directions for use or any other pertinent information. Resident #64 said the nurse left them in here. *Photographic evidence obtained* On 11/03/22 a review of Resident #64's medical record revealed she was admitted to the facility on [DATE]. A review of Resident #64's physician orders showed a physician order dated 3/28/22 for Refresh Tears Solution 0.5 % (Carboxymethylcellulose Sodium) with directions to instill 1 drop in both eyes. Further review of Resident #64 medical records revealed no documentation the facility had conducted a self-administration of medication assessment prior to leaving the medication with Resident #64. Further review of Resident #64 medical records revealed no documentation the facility had conducted a self-administration of medication assessment prior to allowing resident to have medication at the bedside On 11/03/22 at 2:42 p.m., in an interview, the Director of Nursing, (DON) said medications are to be locked up. The DON stated, No residents are authorized to self admin medication including Resident #6 and Resident #64 and no consent or assessments have been done for evaluation for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 17 of 25 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 11/03/2022 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 0761 self-administration of medication for any current resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 18 of 25 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 11/03/2022 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, the facility failed to accommodate residents with food allergies/intolerances for 1 (Resident #65) of 1 resident reviewed. The findings included: On 10/31/22 at 12:18 p.m., during a tour of the facility Resident #65 was observed eating lunch. Resident #65 said she needs a gluten free diet but was given soggy toast and pasta for lunch. Resident #65 said she has reported this issue to multiple staff and during several care conferences. The dietary admission note dated 3/15/22 noted Resident #65 had a food allergy/intolerance to gluten. On 11/2/22 at 8:13 a.m., Resident #65 was observed in her wheelchair trying to eat breakfast in the dark. The blinds were closed, and lights were off. Resident #65 stated she can't eat most of what was sent for breakfast: white toast, potatoes, scrambled eggs. The meal ticket did not list toast, or scrambled eggs but baked omelet with cheese. Resident #65 stated Last night I sent my tray back, everything was covered in gravy. She stated: I can't eat gravy; it gives me stomach cramps and straight to the bathroom I go. Resident #65 said her dinner ticket dated 11/1/22 had chicken on a croissant, spiral pasta. No beets, and no tomato juice were on tray, which I like. When I eat bread, pasta, gravy, I go straight to the bathroom with stomach cramps. *Photographic evidence obtained* On 11/02/22 at 3:31 p.m., in an interview with the Registered Dietitian (RD) and the Certified Dietary Manager (CDM), the RD said Resident #65 has no food allergies and is on a mechanical soft diet with regular thin liquids. The RD said the gravy is used in mechanical soft diets to moisten food like meat to make it easier for swallowing. The CDM stated Resident #65 has numerous dislikes and confirmed bread and gravy as dislikes. Both the RD and CDM said they have no knowledge of Resident #65's need for gluten free diet. The RD said that all mechanically soft food is softened with gravy. The menu was reviewed and confirmed by the RD and CDM that these items are on Resident #65's dislike list. Resident #65 had been provided with garlic bread, toast, spaghetti noodles, chicken salad on a croissant, and an alternative meal choice of macaroni and cheese. Bread, gravy, and pasta are not gluten free unless specifically labeled as such. On 11/02/22 at 4:01 p.m., an interview, the RD reviewed the comprehensive assessment dated [DATE] and confirmed she completed the assessment which documented Resident #65 had a gluten allergy/intolerance. She said that gluten was listed as an allergy at the time of admission. She does not know who or why it was removed from residents list of allergies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 19 of 25 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 11/03/2022 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 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** Based on observation, record review, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to effect 105 residents who resided in the facility. Review of Food and Nutrition Services Manual - Topic: Storage (Effective January 2021. Refrigerator storage: 1. store perishable foods in refrigerator and/or foods marked keep refrigerated: by the manufacturer 7. Discard leftovers per use by date. 8. Discard refrigerated leftovers after 72 hours. Maintain food temperature at 41 degrees Fahrenheit (F) or less Review of policy and procedure for Dish Machine Temperature Log. Policy: To monitor dish machine temperatures and chemical saturation for both high and low temperature machines at each meal prior to dishwashing to assure proper cleaning and sanitizing of dishes Procedure: 2. Send an empty dish rack through the dish machine prior to recording temperatures. On 10/31/22 at 7:16 a.m., during a kitchen observation with the Certified Dietary Manager (CDM), the following was observed in the walk-in freezer in the kitchen: Two large size cups and two medium size cups uncovered and unlabeled with a yellow liquid substance One container of [NAME] slow with use day by 10/19/22. One container with chicken salad dated 10/25/22. One container with rice dated 10/24/22. One container with cottage cheese with date opened 5/29 and best used date of 9/19/22. One unopened clear plastic container with contents that appeared to be patties. There was no expiration date and no clear indication of the type of meat. One container of cookies with date of 10/22/22. At the time of the observation, the Dietary Manager indicated the leftover food can only be stored for three days and the entire dietary staff is responsible for monitoring and discarding any expired food. On 10/31/22 at 7:19 a.m., inspection of dish machine log revealed wash, rinse, final rinse and sanitizer was filled out for 10/31/22 for all 3 meals (breakfast, lunch and dinner). CDM crossed it out and stated: This is not how it is supposed to be done. We have to check the dish machine and log the temperature when those tasks are done and none have been done yet, it is only 7:00 in the morning. On 10/31/22 at 7:23 a.m., Dietary Aide Staff R said she had initialed the dish machine log for the meals at the beginning of the shift. Staff R stated, This is how I do it. Staff R could not recall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 20 of 25 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 11/03/2022 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 0812 if she had been in-serviced regarding dish washing temperature recording. Level of Harm - Minimal harm or potential for actual harm On 10/31/22 at 9:11 a.m., the CDM said all staff have been educated on the use of chemical sanitizer. CDM failed to provide evidence dietary staff were educated regarding dish washing temperature over the past year. Residents Affected - Many On 11/02/22 at 11:45 a.m., observation during tray line revealed 3 chicken sandwiches were on a table to be served for lunch. Dietary staff failed to maintain chicken sandwiches at appropriate temperature. At 12:13 p.m., a sandwich was placed on a resident's tray. The temperature reading of the chicken sandwich was 47 degrees F. CDM stated, it should be below 40, adding, the sandwiches should be kept cold until served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 21 of 25 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 11/03/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. On 11/2/22 at 10:54 a.m., in an interview, the Assistant Director of Nursing (ADON) said, for the residents in the C. diff. rooms, she would expect the CNAs to have the mask and gloves on when entering the room and washing their hands with soap and water before coming out of the room. They must don full personal protective equipment when giving care. Residents Affected - Some On 11/2/22 at 1:04 p.m., observed CNA Staff L with no gloves on enter room of Resident #351 on isolation for C. diff. to pick up lunch tray. She sanitized but did not wash her hands prior to coming out of the room. On 11/2/22 at 1:06 p.m., observed CNA Staff L with no gloves on enter room of Resident #31, on isolation for C. diff. to pick up lunch tray . She sanitized but did not wash her hands prior to coming out of the room. On 11/3/22 at 8:19 a.m., observed CNA Staff J with no gloves on enter room of Resident #31, on isolation for C. diff. to deliver a meal tray. She then summoned CNA Staff O. CNA Staff O went into the room and assisted CNA Staff J to pull resident up in bed. No gloves were worn by either staff member, both came out of room use hand sanitizer, but neither one washed their hands. Based on observation, review of policy and procedure, review of the Center for Disease Control and staff interview, the facility failed to ensure all staff followed infection prevention measures to prevent the spread of disease-causing organism when caring for 3 (Resident #3, #31, and #351) of 3 sampled residents reviewed on contact precaution. The findings included: The facility's policy and procedure, titled Clostridium-difficile: Prevent Spread, effective October 2021 stated, Residents diagnosed with Clostridium-difficile whose stool is not contained shall be placed on Contact Precautions. The Centers for Disease Control and Prevention (Page last reviewed July 12, 2021) notes C. diff. is a germ that causes diarrhea and inflammation of the colon. C. diff. can be life-threatening. The steps to prevent spread include to wear gloves and a gown when treating patients with C. diff., even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff. and hand washing might not be sufficient alone to eliminate all C. diff. spores. https://www.cdc.gov/cdiff/clinicians/faq.html#prevent https://www.cdc.gov/cdiff/index.html On 11/1/2022 at 3:03 p.m., the Assistant Director of Nursing (ADON)/ Infection Preventionist (IP) said currently three residents were on contact precautions for C. diff. On 11/2/2022 at 9:20 a.m., observed CNA (Certified Nursing Assistant) Staff N don gown and gloves to enter Resident #3's room who was on contact precautions for C. diff. CNA Staff N walked into the resident's room, removed her gloves and used the bed controls to raise the head of the bed. She proceeded to assist the resident with her breakfast meal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 22 of 25 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 11/03/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/2/2022 at 9:36 a.m., CNA Staff N was observed without gloves, holding a cup with a straw in place. Resident was drinking from the straw and holding onto the cup. On 11/2/2022 at 9:39 a.m., CNA Staff N removed the isolation gown, walked out of the room with the breakfast tray, opened the meal cart in the hallway, and placed the tray into the cart. CNA Staff N did not wash her hands before leaving Resident #3's room. CNA Staff N sanitized her hands with hand sanitizer after placing the tray in the cart. On 11/2/2022 at 9:41 a.m., Staff N (CNA) verified she knew Resident #3 was on contact precautions for C. diff. She verified she did not keep her gloves on while assisting Resident #3 and did not wash her hands as required with soap and water before leaving the room. CNA Staff N said, I was taught to use soap and water and I did not use soap and water or wash my hands before leaving [Resident #3's room]. On 11/2/2022 at 10:32 a.m., the Infection Preventionist (IP) said it has been a while since the staff were in-serviced about C. diff. and hand washing before leaving the room of a resident on contact precautions for C. diff. The IP stated, The proper way to wash hands is to use soap and water before leaving the room. On 11/2/2022 at 4:48 p.m., interviewed Director of Nursing (DON) about isolation precautions at facility. DON informed of observations of staff member not following the contact isolation protocol for a resident with C. diff. after providing direct resident care. The DON was informed staff member left resident room after not using gloves in the room, did not wash hands with soap and water as required for C. diff. The DON said, that is concerning. I am going to complete targeted education, blast education, and direct kitchen and housekeeping to complete additional cleaning. I will inform the administrator and medical director. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 23 of 25 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 11/03/2022 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on staff interview and policy review the facility failed to maintain an antibiotic stewardship program that includes antibiotic use protocols and system to monitor antibiotic use. Residents Affected - Many The findings included: Reviewed policy and procedure titled, Antibiotic Stewardship, Tracking, Monitoring Antibiotic Prescribing, Use and Resistance, effective April 2017 which stated, Residents will have a complete clinical assessment documentation at the time of the antibiotic prescription. Audits of antibiotic prescriptions for completeness of documentation, regardless of whether the antibiotic was initiated in the facility or a transferring facility. Monthly prevalence studies regarding antibiotic usage will be presented to quality assurance and performance improvement committee (QAPI). This information can also be in the infection prevention and control monthly summary manuals. Reviewed policy and procedure, titled Infection Prevention and Control Program, effective October 2021 which stated, The Infection Prevention and Control Program is comprehensive program that addresses detection, prevention and control of infections and communicable diseases.will facilitate activities to improve antibiotic use to reduce adverse events, prevent emergence of antibiotic resistance, and promote better outcomes for residents.The Major Activities of the Program are . Antibiotic Stewardship- ongoing tracking of antibiotic prescribing , antibiotic use and developing antibiotic resistance patterns with documentation and education. Tracking of antibiotics will include antifungals, antivirals, and all formulations of the antibiotic used. On 11/1/2022 at 3:03 p.m., interviewed the Assistant Director of Nursing (ADON)/ Infection Preventionist (IP) for antibiotic stewardship process. The ADON/IP stated, I go through the charts and look for the antibiotic order and the labs, if I can find them. I place the information on a handwritten form. In regards to tracking and trending antibiotic use and patterns of infection, the ADON/ IP stated, I try, I talk about it in the morning meetings. I do not document the conversations. I have not tracked or confirmed the use of antibiotics in a while. I cannot remember the last time I completed the form. The ADON/ IP said to initiate staff education for infection control and antibiotic usage, she looks at the infections sheet and, if she finds the same infection for more than one resident , she will complete an in-service with the staff on hand washing. The ADON/ IP was unable to provide any documentation for tracking or trending incidents of infections, antibiotic use, identification of repeat organisms, or addressing potential outbreaks. On 11/2/2022 at 4:48 p.m., the Director of Nursing (DON) confirmed the expectation for infection control is to track and trend what is done in real time, to look at the signs and symptoms of infections, diagnosis, and review labs, then present the information at the monthly QAPI meeting. The ADON/ IP is responsible for the education and documentation of staff in-services. The DON stated, I am going to complete targeted education, blast education, and direct kitchen and housekeeping to complete additional cleaning. I will inform the administrator and medical director. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 24 of 25 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 11/03/2022 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 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** Based on observation, review of facility policies, and staff interviews, the facility failed to maintain an effective pest control program and failed to provide a sanitary environment free from pests. Residents Affected - Few The findings included: The facility policy 8.33.1 Pest Control documented, The facility strives to promote good sanitation practices to protect its residents and employees. The maintenance staff shall make every effort to inspect, identify, monitor, evaluate and control pests as their method of entry into the building. On 10/31/22 at 9:45 a.m., observation in the Memory Care Unit dining room revealed small flying insects flying over the food as the residents were eating. During random observations over 4 days on all units of the facility and in the conference room, small flying pests were noted daily. On 11/2/22 at 1:20 p.m., while in the office of the Director of Nursing, small flying pests were observed. The Care Plan Coordinator was in the office and began to swat at the insects with her hand and confirmed the observation of flying pests. A review of the Pest Control Service Summary documented the following: On 7/13/22, Installed three new Flying [NAME] Scones for monthly continuous service and upkeep and maintenance for flies issues. On 8/2/22 Inspected and treated unit 108 for reported American roaches. Inspected and changed the fly monitoring boards inside the fly light stations for continuing monitoring and service. On 10/18/11 Inspected the fly boards inside the fly light stations and observed moderate captures and will be changing out with new fly boards at the next bi-weekly service visit. On 11/1/22, Talked to faculty manager MD and reported no pest issues inside the building structure at this time. Inspected and changed fly boards inside the fly light stations for continuous monitoring and service. On 11/3/22 at 8:20 a.m., in an interview the Maintenance Director (MD) said he was a aware of problem in the facility with the small flying insects. The MD said the flying pests have been a problem since I have worked here. The MD said he has been employed at the facility for 4 years. I have put in blue bug lights in the kitchen, main dining room. The pest control comes twice a month and sprays down the sinks. I have just received approval for a blue bug light in the Memory Care Unit dining room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105882 If continuation sheet Page 25 of 25