Inspection·July 18, 2023

F 0584 Photographic evidence obtained. Level of Harm - Minimal harm or potential for actual harm 5. room [ROOM NUMBER] in the nightstand drawer were dead bugs and small black pellet shaped droppings, in the dresser drawers. Residents Affected - Some Photographic evidence obtained. 6. room [ROOM NUMBER] rolls of toilet paper were stored on the bathroom rail and on the top of the toilet Photographic evidence obtained. 7. room [ROOM NUMBER] in the shared bathroom was a pair of glasses and a half filled cup of liquid stored on top of the paper towel dispenser. There was an unlabeled stick deodorant on the sink. In the dresser drawer there were small black droppings. Photographic evidence obtained. 8. room [ROOM NUMBER] there was toilet paper and a hanger stored on the pipe extending from the wall in the shared bathroom. Photographic evidence obtained. 9. In the shower room in the shower stall on the floor was dirt and debris and the grout was stained brown. Photographic evidence obtained. 10. room [ROOM NUMBER] in the nightstand drawer there were small black, pellet shaped droppings. Photographic evidence obtained. 11. In the dining room there was a drawer missing from the dining room cabinet. There was a dead bug in one of the cabinet drawers. Photographic evidence obtained. The findings in the 300 hall (secured dementia unit). and main dining room were verified by Licensed Practical Nurse Staff B. Staff B said the drawer for the cabinet had been missing for some time. On 7/18/23 at 3:08 p.m., the Director of Nursing and the Housekeeping supervisor verified the findings on the 300 hall. On 7/18/23 at 12:30 p.m., during a tour of the B wing (200 hall) nursing unit the following was observed: 12. room [ROOM NUMBER] in a shared bathroom, a urinal was stored on the handrail. There was a small basin on the back of the sink with a tube of toothpaste, a cup and a brush that were not labeled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106000 If continuation sheet Page 2 of 8 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 106000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aspire at Evans 3735 Evans Ave Fort Myers, FL 33901 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 Photographic evidence obtained. Level of Harm - Minimal harm or potential for actual harm The findings were verified by Registered Nurse Staff A. Photographic evidence obtained. Residents Affected - Some 13. room [ROOM NUMBER] in the shared bathroom there were unlabeled personal items including two toothbrushes, toilet paper and a canister used for measuring liquids on the back of the toilet. There was toilet paper, Vaseline and toothpaste stored on the bathroom handrail. An unlabeled wash basin was on the floor under the sink and mouthwash and a small basin were on the back of the sink. Photographic evidence obtained. 14. room [ROOM NUMBER] in the shared bathroom was a cup and small basin on the paper towel dispenser. On the back of the toilet was a cup and personal hygiene items not labeled. There was a wash basin with mouthwash on the floor under the sink. Photographic evidence obtained. Certified Nursing Assistant Staff C verified the findings in room [ROOM NUMBER] and 211. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106000 If continuation sheet Page 3 of 8 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 106000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aspire at Evans 3735 Evans Ave Fort Myers, FL 33901 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 staff interviews, the facility failed to provide ongoing monitoring of impaired skin, including signs and/or symptoms of infection, so healing could be evaluated for 1 (Resident #1) of 3 sampled residents with skin concerns. Residents Affected - Few Ongoing monitoring and documentation of skin status of affected area allows clinical staff to detect complications and implement new interventions as necessary to prevent worsening of the skin condition. The findings included: Review of the clinical record for Resident #1 revealed an admission date of 2/11/23. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 7. The resident required limited physical assistance of one staff member for activities of daily living, including dressing, and bed mobility. Resident's diagnoses included Diabetes Mellitus, and Dementia. Review of the progress notes revealed on 6/28/23 at 10:12 p.m., the nurse documented the resident's right foot was noted to be red, swollen, warm and painful to touch. The Advanced Practice Registered Nurse (APRN) was notified and ordered an X-ray. On 6/29/23 the APRN assessed the resident's right foot and documented the resident was seen for complaints of right foot noted with edema (swelling) and pain. The X-ray to rule out possible fracture or dislocation resulted negative. The APRN documented, We will continue to monitor. On 6/30/23 Licensed Practical Nurse (LPN) Staff B documented in a skin integrity review form, tx [treatment] as indicated for ble [bilateral lower extremities] tears. There was no documentation the nurse evaluated the resident's right foot for signs of complications. There was no care plan developed on 6/29/23 for the change of condition to the resident's right foot with goal and interventions to prevent the worsening and promote healing of the area. Review of the progress notes, Medication Administration Record, Treatment Administration Record for 6/30/23 through 7/3/23 (four days) failed to reveal documentation of an evaluation of the resident's right foot for signs and/or symptoms of complications, including signs of infections. On 7/4/23 LPN Staff B checked off Blister, Discoloration, Wound in the skin evaluation section of a change of condition form. The nurse wrote, BLE [Bilateral Lower Extremities] wound, heels. Resident #1 was transferred to an acute care hospital on 7/4/23 for evaluation and treatment of the right lower extremity. On 7/5/23 the APRN documented, Reason for visit (07/6/23): Received phone call yesterday from attending nurse with concerns of patient's right foot noted with darkish color/hematoma (collection of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106000 If continuation sheet Page 4 of 8 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 106000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aspire at Evans 3735 Evans Ave Fort Myers, FL 33901 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few blood outside of blood vessels) with edema and pain. Two toes noted with discoloration noted as well; ordered patient to be sent to ER [Emergency Room] for further diagnostic testing for possible blood flow issues. No injuries have been reported; Unsure how injury happened; negative x-ray reported. Review of the hospital records revealed the problems included sepsis (presence of harmful microorganisms in the blood), right foot cellulitis (bacterial skin infection). On 7/17/23 at 1:13 p.m., the APRN said she ordered the X-ray of the right foot on 6/29/23 because the top of the foot was red, swollen, with a raised area. The X-ray was negative. On 7/4/23 at 11:32 a.m., she received a text message and picture of Resident #1's right foot from LPN Staff B. She said Staff B told her the toes were black, so she instructed the nurse to send Resident #1 to the emergency room because the problem was urgent. The APRN said on 6/29/23, when she assessed the resident's feet, they were loosely wrapped in kerlix (bandage rolls). She remembers pulling it back and looking at the foot. On 7/7/23 Licensed Practical Nurse Staff B documented in a statement dated 7/7/23, a therapist called her to Resident #1's room on 7/4/23, telling her there were ants on the bed. She proceeded to change the dressing on the resident's right foot and check for ants bites, no ants noted on the wound. The nurse documented during wound care, the resident complained of pain and changes in condition on wound. She notified the APRN. The clinical record lacked documentation of a physician's order for wound care and dressing to the right foot. On 7/17/23 at 1:13 p.m., the APRN provided the surveyor with a picture of Resident #1's right lower leg which she said LPN Staff B sent to her on 7/4/23. Observation of the picture revealed a large dark discoloration of the dorsal area of the resident's foot with loose skin, and dark discoloration of the base of the second and third toe. The third toenail extended approximately half inch from base with dark discoloration. On 7/17/23 at 6:00 p.m., in a telephone interview, LPN Staff B said on 7/4/23 she opened the dressing on the resident's right foot after the therapist told her there were ants on the resident's bed. She saw the change in condition and notified the APRN. On 7/18/23 at 6:12 p.m., the DON said Staff B called her on 7/4/23 to tell her she was sending Resident #1 to the hospital. She said for any change in condition the standard of care would include the nurse checking on the area to ensure it is healing and not getting worse. She said the nurse should have asked the Nurse Practitioner for clarification of how often to monitor the foot. The nurse should have inquired as to the next step for Resident #1's foot after the negative X-ray, which may have included wound care, antibiotics, or sending the Resident to the hospital. She acknowledged the care plan for Resident #1 did not include interventions for the right foot on 6/28/23 after the redness, pain, swelling, and warmth was identified. She acknowledged there was no order for wound care for the right foot. The DON acknowledged the foot got worse at the facility from 6/28/23 through 7/4/23. She said she did not know what happened to the resident's foot. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106000 If continuation sheet Page 5 of 8 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 106000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aspire at Evans 3735 Evans Ave Fort Myers, FL 33901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 7/18/23 at 11:00 a.m., during a tour of the facility the following observations were made: Residents Affected - Some In the main dining room small ant-like bugs were observed crawling on the windowsill and on the table next to the window. The area behind the half wall in the main dining room was being used as storage. There were beds, mattresses, and other medical equipment in the area. Old food, trash and other items were observed on a table next to the storage area. Several ant-like bugs were observed crawling on the table. The findings in the main dining room were verified by the Director of Nursing (DON) and the Housekeeping Supervisor. On 7/18/23 at 11:30 a.m., a tour of the secured dementia unit revealed the following: Black pellet shaped droppings were observed on the wall mounted air conditioning unit. Photographic evidence obtained. room [ROOM NUMBER] in the nightstand drawer were dead bugs and small black pellet shaped droppings, in the dresser drawers. Photographic evidence obtained. room [ROOM NUMBER] dresser drawer had small black droppings. room [ROOM NUMBER] in the nightstand drawer there were small black, pellet shaped droppings. Photographic evidence obtained. In the dining room of the secured unit there was a dead bug in one of the cabinet drawers and small brown ant-like bugs were crawling on the counter. The findings in the secured dementia unit main dining room were verified during the tour by Licensed Practical Nurse Staff B. On 7/18/23 at 3:08 p.m., the Director of Nursing and the Housekeeping supervisor verified the findings on the secured dementia unit. Based on observation, review of facility policies and procedures, resident and staff interviews, the facility failed to maintain an effective pest control program to ensure an environment free from pests for residents residing in the skilled nursing facility, for 3 (100, 200, and 300) of 3 halls observed. The findings included: The facility Policy and Procedure, HL-200 (11/30/14) specified the facility will maintain a pest (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106000 If continuation sheet Page 6 of 8 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 106000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aspire at Evans 3735 Evans Ave Fort Myers, FL 33901 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 control program which includes inspection, reporting and prevention. Level of Harm - Minimal harm or potential for actual harm Review of the facility's history revealed on 5/11/23 during a complaint survey it was determined the facility failed to maintain an effective pest control program and a sanitary environment free from pests for four of 111 residents. The facility alleged compliance as of 5/31/23. Residents Affected - Some Review of the facility Grievance Log June 2023 revealed a grievance dated 6/6/23 that read, Res. [Resident] Council. Insects still rampant. The resolution section noted the exterminator was contacted and sprayed inside and outside the facility. Review of the facility's investigations of incidents revealed on 7/4/23 staff observed ants on Resident #1's bandage to the right lower extremity. Licensed Practical Nurse (LPN) Staff B documented in a statement dated 7/7/23, a therapist called her to Resident #1's room on 7/4/23, telling her there were ants on the bed. The nurse documented Resident #1 was in bed at the time of the observation. The Administrator was notified of ants on the resident's bed, and ants coming through the window. On 7/17/23 at 1:13 p.m., the Advanced Practice Registered Nurse (APRN) provided the surveyor with a picture of Resident #1's right lower leg which she said LPN Staff B sent to her on 7/4/23. Observation of the picture provided by the APRN showed three ant-like crawling insects on the right third outer toe, and one ant-like crawling insect on the dorsal aspect of the right great toe. Review of the pest sighting log for the 300 (secured unit) hall revealed documentation of ants sighting in Resident #1's room on 7/4/23, and 7/18/23. The log noted on 7/18/23 the sighting of ants in Resident #1's room, dining room, air conditioner, small spider in the dining room, Resident #1's drawer (closet). Review of the maintenance request log for the 300 (secured unit) hall revealed ants were the problem on 7/9/23 in the day room and the bathroom of room [ROOM NUMBER]. On 7/17/23 at 9:57 a.m., Resident #4 said he saw live cockroaches recently in the therapy room and his bathroom. On 7/17/23 at 10:10 a.m., Agency LPN X said there were live and dead bugs in room [ROOM NUMBER]. On 7/17/23 at 10:15 a.m., several dead brown crawling insects were observed on the floor in room [ROOM NUMBER]. One brown insect was observed crawling under the nightstand. On 7/17/23 at 10:21 a.m., observed two brown insects crawling on the wall across from room [ROOM NUMBER], and the nurse's station. On 7/17/23 at 5:13 p.m., live ant-like insects were observed crawling on the windowsill of room [ROOM NUMBER]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106000 If continuation sheet Page 7 of 8 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 106000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aspire at Evans 3735 Evans Ave Fort Myers, FL 33901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 7/17/23 at 6:00 p.m., LPN Staff B said during a telephone interview, when she worked on 7/4/23 she observed ants on the floor and on Resident #1's bed. She said she saw a line of ants marching from the window down to the floor and onto Resident #1's bed. She notified the administrator. On 7/18/23 at 12:17 p.m., ant-like insects were observed in Resident #1's former room crawling on the wall next to the credenza, in the clothes closet, and inside the air conditioning vent. On 7/18/23 at 12:28 p.m., LPN Staff B confirmed the live ants in Resident #1's former room, on the wall next to the credenza, in the clothes closet, and in the air conditioning vent. On 7/18/23 at 3:20 p.m., a tour of the 300 hall was conducted with the Director of Nursing and Housekeeping supervisor. Live ant-like insects were observed crawling in the credenza drawers and windowsill of room [ROOM NUMBER]. Live ant-like insects were observed crawling on the top of the credenza and clothes drawer of room [ROOM NUMBER]-B. Live ant-like insects were observed crawling out of the air conditioning vents, the credenza top, and drawers of room [ROOM NUMBER]-A. Live ant-like insects were observed crawling in former Resident #1's room near the credenza, in the clothes closet, and air conditioning unit. The DON and housekeeping supervisor verified the observation of ant-like crawling insects in room [ROOM NUMBER]-A, 311-B, 312, and former Resident #1's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106000 If continuation sheet Page 8 of 8