Inspection·July 1, 2021

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, review of facility policy and procedure, record review, and staff and resident interview, the facility failed to follow Physician orders and Therapy recommendations to provide and document daily restorative nursing care ordered for 1 (Resident #3) of 1 resident observed for restorative care. The finding included: The facility policy titled, Restorative Nursing Services, revised 09/2020, states, The purpose is to provide services that will increase or maintain functional performance in activities of daily living, diminish the risk of psychological and physiological complications of inactivity and enhance the resident's dignity and quality of life in the skilled car setting. Procedure #3 states, After receiving and reviewing the forms, the Restorative Nurse will enter the new information into the AOD [Answers on Demand] charting system. The facility policy titled Point of Care Documentation, revised 09/2020, states, Minimum daily charting by nursing assistants on every shift for every resident shall include the following a. ADLS [Activities of Daily Living], b. Toileting, c. Meals/ Eating, d. Bed Mobility, e. Transfers, f. Locomotion, g. Restorative Nursing. On 6/28/21 at 10:57 a.m., Resident #3 said, I am not getting therapy right now, they switched me to restorative care, but I don't get it every day since there is only one person to do it. Resident #3 raised concerns that he would not continue to improve without more consistent restorative care or therapy. On 7/1/21 at 9:17 a.m., Resident #3's records reviewed, which showed referral to restorative care program since discharge from therapy dated 6/7/2021. Referral included instructions for restorative care 5 times a week for 90 days and recommendations for implementations of goals. Physician orders showed transfer to restorative care dated 6/7/21. Resident #3's current care plan was reviewed. No documentation or interventions for restorative care was in current care plan. On 7/1/21 at 10:00 a.m., interviewed clinical coordinator Minimum Data Set (MDS) Registered Nurse (RN) Staff D, who was unable to find any documentation in clinical record for restorative care for Resident #3. RN Staff D, said, The restorative Certified Nursing Assistant (CNA) is off today. The other one quit, so she is the only one who does restorative care. On 7/1/21 at 12:44 p.m., interviewed Unit Manager RN Staff C, who said she did not track which residents received restorative care on her unit. On 7/1/21 at 1:05 p.m., interviewed Director of Nursing (DON) confirmed Resident #3 did not have any documentation in the Electronic Medical Record (EMR) in point of care documentation or in his care plan addressing his restorative care since it was ordered on 6/7/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105966 If continuation sheet Page 2 of 7 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 105966 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larsen Health Center 13880 Shell Point Plaza Fort Myers, FL 33908 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, policy and record review, the facility failed to ensure proper weight management for a high-risk resident by not properly assessment and following facility policy for weight monitoring. Residents Affected - Few The finding include: A review of facility policy and procedure on Resident Weight Management, last revision on 8/20, records: 1. Each resident's weight is obtained upon admission or readmission within 24 hours, by the nursing staff. 2. Each admission/re-admission is then weighed weekly for 4 weeks by designated nursing staff 6. Residents who are identified at risk for weight loss/gain will be reviewed with appropriate intervention and a plan of care at the weekly Risk Management committee meeting. On 6/28/21 at 12:12 p.m., Resident #480 was observed sitting in her chair at the bedside. Resident appeared significantly underweight and cachectic (extreme weight loss and muscle wasting). Her face was thin and her collar bones, wrist bone and hip bone were markedly visible even through her loose-fitting clothing. Her temples were sunk in. The resident room was observed to have 2 bags of multiple snacks of various kinds and several bottles of nutritional drinks. On 6/28/21 at 12:15 p.m., Resident #480 stated that she had lost a large amount of weight and weighed 76 pounds while in the hospital. She said that she felt she was trying to eat but the some of the food she liked had been taken from her because of her potassium level being slightly elevated. A review of Resident #480's medical record revealed she was admitted to the facility on [DATE], with the following diagnosis: left knee sprain after fall at home, chronic kidney disease, muscle weakness, acute and chronic respiration failure, bronchiectasis, atrial-fib, hypertension and moderate protein-calorie malnutrition and history of eating disorder. admission weight was done on 6/21/20 at 2:56 p.m., (3 days after admission) and was 83.80 pounds. Resident #480 next weight was on 6/22/21 and was 84.40 pounds. On 6/30/21, Resident #480's weight was 81.2 pounds. This was 8 days after the last weight and a 3.2 pound weight loss. On 6/30/21 at 12:33 p.m., in an interview, the Director of Nursing (DON) said that the resident was weighed, and she was 81 pounds. (a loss of 3 pounds in 8 days). The DON said that the residents were to be weighed within the first 24 hours after admission, per policy, and weekly thereafter for 4 weeks. She acknowledged that the resident was not weighed according to policy. On 6/30/21 at 2:24 p.m., in an interview, the Dietitian said Resident #480 was first seen by her on 6/21/21, 3 days after her admission. She said when she did her first assessment, she did not have an admission weight and went on what the resident had stated to her which was 71 pounds. She said because the resident's potassium level was elevated on admission, she took some of the food that the resident liked, and she felt that was why she lost the 3 pounds over the 8 days. She said she did not do a calorie count or personally review what resident was taking for meals. The Dietitian said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105966 If continuation sheet Page 3 of 7 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 105966 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larsen Health Center 13880 Shell Point Plaza Fort Myers, FL 33908 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident was eating 50-100% of her meals and 50-100% of supplements. The Dietitian could not explain how resident lost 3.2 pounds over the 8 days with eating the above amounts. On 7/1/21 at 11:30 a.m., in an interview, RN Staff M said that all residents were supposed to be weighed within 24 hours of admission and then weekly after that. She said that Resident #480 should have been weighed on admission because she had a history of weight loss and was a high risk. She said she also did not know why she was not weighed within the week. She said the policy was not followed. Event ID: Facility ID: 105966 If continuation sheet Page 4 of 7 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 105966 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larsen Health Center 13880 Shell Point Plaza Fort Myers, FL 33908 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to provide sufficient and consistent nursing staff to meet the needs of 6 residents (Resident #25, #34, #60, # 65, #111, and #482) of 6 residents sampled. The failure to maintain sufficient and consistent staffing, resulted in the inability of nursing staff to respond to call lights and provide nursing related services to the residents in order to maintain the highest practicable physical, mental, and psychosocial well-being. The findings included: On 6/28/21 at 11:48 a.m. Observation of Resident #482's room revealed the call light was illuminated from 11:48 a.m. to 12:13 p.m. when a Certified Nursing Assistant (CNA) Staff N from another hall came to answer the light, she then turned off the light and left the room, she came back 4 minutes later (12:17 p.m.). On 6/28/21 at 12:17 p.m., in an interview, CNA Staff N said she did not know how to transfer the resident so she could not get her up. CNA Staff N said she would just get her up because she did not have time to look at the [NAME] because the resident had been waiting long already. On 6/29/21 at 2:15 p.m., in an interview, Director of Nursing (DON) said the facility was staffed based on PAR numbers, meaning they set a number they would like to meet each day and on resident census and acuity of residents. DON said occasionally if the facility was short staffed, they would pull a Certified Nursing Assistant (CNA) from activities or restorative program and give them an assignment on the nursing unit. On 6/29/21 at 2:30 p.m., in an interview with Activities Assistant CNA, said she very rarely got pulled form activities to work an assignment on the floor, but said it did happen. On 6/29/21 at 10:00 a.m., in an interview, Licensed Practical Nurse (LPN) Staff I, said the 3rd floor nursing unit was short 1 nurse that day. LPN Staff I said there were usually 3 nurses assigned to the unit daily, but there were only 2 nurses assigned that day. LPN Staff I said she was responsible for 2 halls on the unit and was required to administer medications, answer call lights and do wound care. On 6/30/21 at 3:00 p.m., in an interview, Restorative CNA Staff B said she got pulled from her restorative duties to cover a floor shift approximately 2 times a week. Restorative CNA Staff B said when this occurred there would be no one to provide restorative nursing programs for the residents. Restorative CNA Staff B said the CNA's working on the units were not trained to provide the restorative nursing programs for the residents. Restorative CNA Staff B said there were currently 24 residents in the facility who were on restorative nursing programs. On 6/29/21 at 10:00 a.m., in an interview, Resident #34 said she was upset that it took so long for the call light to be answered when she needed assistance. Resident #34 said she could not wait very long for the staff to assist her to the toilet when she put the call light on. Resident #34 said when she had to wait for staff, she would often have incontinent episodes. On 6/29/21 at 11:00 a.m., in an interview, Resident #25 said it sometimes took longer than 15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105966 If continuation sheet Page 5 of 7 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 105966 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larsen Health Center 13880 Shell Point Plaza Fort Myers, FL 33908 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few minutes for the call light to be answered and said, sometimes it takes so long to answer the light I forget why I rang it. Resident #25 said there was no continuity with the staff and the resident care provided. On 6/29/21 at 11:00 a.m., in an interview, Resident #60 said he resided on the 4th floor but always went to the 3rd floor dining room for his noon meal. Resident #60 said it took a long time for anyone to help him back to his room after he was finished with the meal. Resident #60 said he put in a request to the nurse and CNAs for transportation back to his room for 12:30 to 1:00 p.m., but he often waited up to an hour for assistance. Resident #60 said the staff would arrive between 1:30 p.m. to 2:00 p.m. He stated he wanted to get back to his room because he enjoyed watching television and when staff were late, he would miss his favorite television programs. On 6/29/21 at 3:20 p.m., in an interview, Resident #111 said it took 15-20 minutes for staff to respond when she put on her call light. She said she had had accidents with her bowel and bladder when she waited for staff assistance and said it made her feel humiliated. On 6/29/21 at 3:25 p.m., in an interview, Resident #65 said it took 20 minutes or longer for staff to come answer the call light and assist her. Resident #65 said she was bedbound and called for staff assistance when she needed changed. On 6/30/21 at 3:30 p.m., in an interview, DON said the facility did not have a policy to direct staff on answering resident call lights in a timely manner. DON said the expectation was for staff to answer the resident call lights in 2-5 minutes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105966 If continuation sheet Page 6 of 7 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 105966 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larsen Health Center 13880 Shell Point Plaza Fort Myers, FL 33908 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 Based on medical record review, interview, and policy review, the facility failed to ensure residents, receiving continuous positive airway pressure (CPaP) oxygen therapy per a machine, implemented preventive measures to lessen the development of a respiratory infection and the transmission of communicable diseases for 1 (Residents #73) of 2 residents sampled using a CPaP machine. Residents Affected - Few The findings include: Initial observation on 6/28/21, at 10:45 a.m., revealed Resident #73 had a CPaP machine, with the mask not bagged. (photo evidence) On 6/28/21 at 10:45 a.m., during an interview Resident #73 said, I use the machine sometimes during the night when I am short of breath. The nurses clean it and put water in it when I tell them too. The CPaP mask was uncovered. On 6/30/21 at 9:15 a.m., observation of Resident #73's room revealed the CPaP mask was not bagged. On 6/30/21 at 9:21 a.m., in an interview, Director of Nursing said, The CPaP machine belongs to the resident, and Yes the mask portion should be in a bag when not used. On 6/30/21 at 3:45 p.m., observation of Resident #73's room revealed the CPaP mask was not bagged. Review of the facility's CPaP/BiPaP Support Policy and Procedure Manual, section (7) notes, Masks, nasal pillows and tubing: Will be changed weekly on Sundays. Mask to be stored in a bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105966 If continuation sheet Page 7 of 7