Inspection·May 22, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm On 5/22/25 at 11:13 a.m., RN Staff E said she was responsible for the comprehensive assessment data and resident care planning. She said if a resident has a pacemaker, they send them to the cardiologist for regular follow ups to ensure proper functioning and battery life. RN Staff E said the facility monitors for dizziness, shortness of breath, and vital signs. She said there should be a care plan in the record with that information. She verified there was no care plan for pacemaker in the record. Residents Affected - Few On 5/22/25 at 11:39 a.m., RN Staff D said the pacemaker was not on the hospital transfer form (Agency for Health Care Administration form 3008), and it was not listed in the diagnoses. She said they have limited information from the hospital. 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 05/22/2025 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to follow physician's orders and provided skilled therapy services for 1 (Residents #89) of 4 residents reviewed for following physician's orders. Residents Affected - Few The findings included: Review of the clinical record for Resident #89 revealed an admission date of 3/31/25. Diagnoses included debility and sarcopenia (age related loss of muscle mass and strength). Review of the Minimum Data Set (MDS) admission assessment with a target date of 4/6/25 revealed Resident #89 scored 14 on the Brief Interview for Mental Status (BIMS), indicative of intact cognition. Resident #89 required supervision or touching assistance to stand from sitting in a chair or on the side of the bed. The resident required supervision or touching assistance to walk 10 feet and partial to moderate assistance to walk at least 50 feet and make two turns. Review of the care plan initiated on 4/1/25 revealed Resident #89 was at risk for falls due to recent fall with pelvic fracture, Alzheimer's, weakness, low endurance, and decreased mobility as a result of acute and/or chronic health conditions requiring admission for care. The goal was for the resident to have decreased risk of falls utilizing assessment of the interdisciplinary team and appropriate interventions. The interventions included Physical Therapy (PT) and Occupational Therapy (OT) screen/evaluation. Review of the progress notes revealed Resident #89 sustained multiple falls since admission to the facility, on 4/8/25, 4/10/25, 4/26/25, and 4/28/25. Review of the Therapy notes revealed Resident #89 received Physical and Occupational Therapy. Resident #89 was discharged from Physical Therapy on 5/7/25 and was discharged from Occupational Therapy on 4/27/25. Further review of the clinical record revealed on 5/14/25 the Advanced Practice Registered Nurse (APRN) wrote a new order for PT, OT and Speech Therapy (ST) evaluation and treatment for weakness and sarcopenia. On 5/19/25 at 5:17 p.m., observed Resident #89 in a chair in his room. In an interview, Resident #89 said he sits in the chair all day. He said he thought he should be getting more therapy. He said, My legs buckle sometimes when I walk and I lower myself to the ground. The facility calls them falls. On 5/21/25 review of the clinical record, and therapy progress notes failed to reveal documentation Resident #89 received PT, OT and ST as per the APRN order dated 5/14/25. On 5/21/25 at 10:40 a.m., in an interview the Director of Rehabilitation (DOR) said he did not know Resident #89 had new orders for a therapy evaluation and treatment on 5/14/25. The DOR said he did not know the fracture follow-up included orders to continue PT. The DOR said the orders were not executed and Resident #89 did not receive PT, OT or ST services as ordered. (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 05/22/2025 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/21/25 at 1:40 p.m., in an interview the Director of Nursing (DON) said the therapy orders from the APRN dated 5/14/25 should have been carried out. On 5/21/25 at 1:48 p.m., in an interview Registered Nurse (RN) Staff E said on 5/14/25 she added the order for therapy services to the resident's orders. Staff E said the order for therapy was discussed in the morning meeting, and the DOR should have known about it. She said she did not know why Resident #89 was not receiving therapy services. On 5/21/25 at 3:48 p.m., in an interview the Nursing Home Administrator (NHA) said there should have been a follow-up from the therapy orders dated 5/14/25 before 5/21/25. FORM CMS-2567 (02/99) Previous Versions Obsolete 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 05/22/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on records review, observation and staff interviews the facility failed to accurately document physician ordered treatments for 2 (Residents #82 and Resident #93) of 2 resident's reviewed with feeding tubes. The findings included: Review of the facility's Charting and Documentation Policy revealed the facility, is committed to ensuring that all services provided to the resident, progress towards the care plan goals . is documented in the resident's medical record . The following information is to be documented in the resident medical record: . Treatments or services performed . Documentation in the medical record will be objective . complete, and accurate . documentation of procedures and treatments will include care-specific details, including: . The date and time the procedure/treatment was provided; The name and title of the individual(s) who provided the care . The signature and title of the individual documenting . Review of the facility's Gastrostomy Enteral Nutrition Via Gravity policy (last revised 9/2022) revealed states under the steps in the procedure section to check the order to verify the type, amount, method, and rate of administration. This section also notes to flush tubing with at least 30 mL warm water (or prescribed amount). Under the Initiate Feeding section, the policy states unless otherwise ordered, follow the feeding with 30-60 mL (milliliters) of warm water. Under the Documentation section, the policy states the person performing the procedure should document amount of feeding and amount of water administered in the resident's medical record. 1. Record review of Resident #82 showed a diagnosis of dysphagia (difficulty swallowing), nutritional anemia and iron deficiency anemia. Resident #82's orders dated April 4, 2025, revealed the resident's diet as nothing by mouth NPO. Resident #82's Care Plan (4/7/2025) noted resident is at potential risk for dehydration d/t (due to) dysphagia with PEG tube feeding and hydration. The Care Plan also noted resident will not show any sign/symptoms of dehydration: i.e. dry skin, cracked concentrated urine, noted or increased confusion, abnormal lab values that may indicate dehydration. The Care Plan also listed to give tube feeding and flushes as ordered. Resident #82's orders dated April 24, 2025, revealed Feeding tube (tube inserted directly into the stomach through the abdominal wall) flushes - 60 milliliters (ml) Feeding tube 3 times a day before and after medications. Total volume 360 ml. Resident #82's medications were scheduled at 6:30 a.m., 9:00 a.m., and 9:00 p.m. Review of the Medication Administration Record (MAR) tube feeding flushes before and after medications during May 2025 revealed: On 18 occasions at 6:30 a.m., the MAR showed documentation that the resident's feeding tube was flushed with 60 mL of water (5/1/2025 through 5/14/2025, 5/17/2025 through 5/19/2025 and 5/21/2025). (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 05/22/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm On 19 occasions at 9:00 a.m., the MAR showed documentation that the resident's feeding tube was flushed with 60 mL of water (5/1/2025 through 5/16/2025, 5/19/2025 through 5/21/2025). On 17 occasions at 9:00 p.m., the MAR showed documentation that the resident's feeding tube was flushed with 60 mL of water (5/1/2025 through 5/13/2025, 5/16/2025 through 5/18/2025, 5/20/2025). Residents Affected - Few Resident #82's orders dated April 23, 2025, revealed Feeding tube flushes - 30 mL Feeding tube 4 times per day before and after bolus (single, large dose) feedings, total volume 240 mL. Resident #82's bolus tube feedings were scheduled for 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. Review of the MAR for tube feeding flushes before and after bolus feedings during May 2025 revealed: On 21 occasions at 9:00 a.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (5/1/2025 through 5/15/2025, 5/17/2025 through 5/21/2025). On 19 occasions at 1:00 p.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (5/1/2025 through 5/17/2025, 5/19/2025, 5/20/2025). On 19 occasions at 5:00 p.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (5/1/2025 through 5/17/2025, 5/19/2025, 5/20/2025). On 18 occasions at 9:00 p.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (5/1/2025 through 5/13/2025, 5/16/2025 through 5/20/2025). On 5/21/2025 at 1:36 p.m., Registered Nurse (RN) Staff B was observed providing tube feeding for Resident #82. RN Staff B followed physician orders by flushing 30 mL of water before and after tube feed administration. RN Staff B said Resident #82 receives hydration through water flushes because they cannot have anything by mouth. Resident #82's MAR was reviewed and noted the resident received only 30 mL of water when they actually received 60 mL of water. RN Staff B was unable to identify the incorrect documentation in the MAR for Resident #82's water flushes until the error was explained. RN Staff B said the documentation was not correct and it makes it look like water flushes are not being given per physician orders. On 5/21/2025 at 1:58 p.m., RN Staff A said when a resident is NPO they will have water flushes to maintain proper hydration. RN Staff A was unable to identify the incorrect documentation in the MAR for Resident #82's water flushes until the errors were explained. RN Staff A said the documentation was not correct and it looks like water flushes are not being given per physician orders. On 5/21/2025 at 2:12 p.m., the Director of Nursing (DON) said when a resident is NPO and has tube feeds, the dietitian will evaluate and put in for hydration. The DON said water flushes would be hydration. The DON was unable to identify the incorrect documentation in the MAR for Resident #82's water flushes until the errors were explained. The DON said the documentation is incorrect and it looks like the resident in not receiving proper hydration per the physician orders. On 5/22/2025 at 10:08 a.m., the Nursing Home Administrator said when a physician puts in orders, staff are expected to follow those orders. The Nursing Home Administrator was unable to identify the (continued on next page) 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 05/22/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incorrect documentation in the MAR for Resident #82's water flushes until the errors were explained. The Nursing Home Administrator said the documentation makes it look like the resident is not receiving enough water flushes per physician orders. Records review of Resident #93 showed a diagnosis of dysphagia, unspecified protein-calorie malnutrition and Vitamin B-12 deficiency. 2, Resident #93's Care Plan listed Resident is at potential risk for dehydration. The resident's care plan also noted to administer tube feed flushes as ordered. Resident #93's orders dated September 6, 2024, revealed 30 mL H2O (water) via feeding tube 3 times a day before and after bolus feedings, total volume: 180 mL. Resident #93's bolus tube feeds were scheduled for 8:00 a.m., 1:00 p.m., and 6:00 p.m. Review of the MAR for tube feeding flushes before and after bolus feedings during April 2025 revealed: On 28 occasions at 8:00 a.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (4/1/2025 through 4/21/2025, 4/23/2025 through 4/26/2025, 4/28/2025 through 4/30/2025). On 28 occasions at 1:00 p.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (4/1/2025 through 4/21/2025, 4/23/2025 through 4/26/2025, 4/28/2025 through 4/30/2025) On 29 occasions at 6:00 p.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (4/1/2025 through 4/26/2025, 4/28/2025 through 4/30/2025). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105966 If continuation sheet Page 7 of 7