Inspection·January 18, 2024

F 0640 transmitted as of 1/17/24, which was 54 days late. Level of Harm - Minimal harm or potential for actual harm Record review for Resident #35's MDS assessments revealed a Quarterly MDS dated [DATE] was export ready but not transmitted from the facility as of 1/17/24, which was 56 days late. Residents Affected - Some Record review for Resident #37's MDS assessments revealed a Quarterly MDS dated [DATE] was transmitted on 1/16/24, which was 47 days late. Record review for Resident #39's MDS assessments revealed an Annual MDS dated [DATE] was transmitted on 1/16/24, which was 32 days late. Record review for Resident #40's MDS assessments revealed a Quarterly MDS dated [DATE] was export ready but not transmitted as of 1/17/24, which was 55 days late. Record review for Resident #43's MDS assessments revealed a Quarterly MDS dated [DATE] was transmitted on 1/9/24, which was 33 days late. Record review for Resident #44's MDS assessments revealed an admission MDS dated [DATE] was transmitted on 10/3/23, which was 19 days late. The Discharge MDS dated [DATE] was not transmitted and accepted until 1/9/24, which was 25 days late. On 1/17/24 at 1:11 p.m., in an interview MDS coordinator Staff L stated she started her position as MDS coordinator in July of 2023 and was still learning the regulations related to MDS assessments. On 1/17/24 at 1:36 p.m., in an interview the Director of Nursing verified the MDS assessments for Residents #1, #2, #3. #6, #12, #17, #19, #20, #26, #29, #35, #37, #39, #40, #43 and #44 had not been transmitted within the specified time frame in accordance with the Resident Assessment Instrument (RAI) manual. On 1/17/24 at 4:14 p.m., the Executive Director stated he expected MDS assessments to be completed and transmitted within the specified time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 2 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop and implement an individualized care plan to prevent decline in range of motion for 1 (Resident #29) of 2 residents reviewed with limited range of motion. The findings included: The facility policy, Plan of Care revised July 2023 noted, It is the policy of Cypress Cove to develop and implement a comprehensive person-centered care plan for each resident . that are identified in the resident's comprehensive assessment . Review of the clinical record for Resident #29 revealed an admission date of 8/3/22 with diagnoses including Dementia and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 00. The Quarterly MDS assessment with a target date of 11/10/23 noted Resident #29 had functional limitation of upper extremities on both sides. Resident #29 had contractures (chronic loss of joint mobility), multiple sites. The care plan with an effective date of 12/6/2020 and revised on 12/8/22 noted the resident had limited physical mobility related to contractures in the upper and lower extremities. The interventions with an effective date of 12/6/20 included monitoring, documenting, and reporting as needed any signs or symptoms of immobility, contractures forming or worsening. The care plan did not list interventions to prevent further decline in range of motion. On 1/16/24 at 10:48 a.m., Resident #29 was observed in bed. Both hands were contracted, closed in a fist. Resident #29 was not wearing any splints or hand rolls to prevent further decline in range of motion of the resident's hands. On 1/16/24 at 11:54 a.m., Resident #29 was observed sitting up in her Broda (specialized positioning) chair with both hands closed in a fist. There were no splints, positioning devices or hand rolls visible in the room. On 1/17/24 at 9:08 a.m., Resident #29 was observed in bed with her hands tightly closed. In an interview, Certified Nursing Assistant (CNA) Staff F said, we used to put wash clothes in her hands. On 1/17/24 at 10:03 a.m., and 12:01 p.m., Resident #29 was observed with Licensed Practical Nurse (LPN) Staff C. Resident #29's hands remained in a closed fist. The resident had no rolls or splints in either hand. Staff C said, sometimes we roll towels for her hands. On 1/18/24 at 8:22 a.m., CNA Staff M said, We roll wash clothes to put in her hands whenever we remember. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 3 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/18/24 at 9:00 a.m., Staff L, Registered Nurse (RN) said the specific care plan interventions for Resident #29 related to the contractures were resident is dependent on staff for feeding, dressing, and transfers. Therapy will reassess quarterly and as needed if there is a change or weakness. On 1/18/24 at 12:00 p.m., the MDS coordinator said the care plan says all they were doing was monitoring for worsening skin breakdown and notify staff she has upper and lower extremity contractures. Hoping there are no complications like skin breakdown, thrombus and reporting to the doctor. On 1/18/24 at 12:24 p.m., the Director of Nursing (DON) said she would expect to see hand strengthening exercise, massage, wash cloth rolls in the comprehensive care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 4 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide care and services to prevent the decline in range of motion for 1 (Resident #29) of 2 sampled residents with functional limitation in range of motion. The findings included: A review of the Restorative Nursing Programs health care policy (R-12) revised June 2018 provided by the facility stated, Cypress Cove strives to provide maintenance and restorative services designed to maintain or improve a resident's ability to the highest practicable level. The procedure documented, Nursing personnel are training on basic, maintenance or restorative nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include maintaining proper positioning and body alignment, assisting residents with range of motion exercises, performing passive range of motion for residents unable to actively participate. Review of the clinical record for Resident #29 revealed an admission date of 8/3/22. Diagnoses included Dementia, and muscle weakness. The admission minimum data set (MDS) assessment dated [DATE] noted the resident scored 00 on the Brief Interview for Mental Status, which indicated severe cognitive impairment. Resident #29 required the extensive assistance of two for bed mobility and was totally dependent on 2 persons for transferring, dressing, and bathing. Resident #29 had no impairment of upper extremities including shoulder, elbow, wrist, and hand. The Quarterly MDS assessment with a target date of 11/10/23 noted Resident #29 had impaired range of motion on both upper extremities (shoulder, elbow, wrist, hand). The care plan initiated on 12/6/20 and revised on 1/3/24 noted the resident had limited physical mobility related to contractures (chronic loss of joint mobility) in the upper and lower extremities. The interventions initiated on 12/6/20 included monitoring, documenting, and reporting as needed any signs and symptoms of immobility; contractures forming or worsening. A Social Service Progress note dated 4/26/2023 documented family in agreement for Occupational Therapy to evaluate for wheelchair positioning and contracture management. Team in agreement with plan of care. On 1/16/24 at 10:48 a.m., Resident #29 was observed in bed. Resident #29's right and left hands were closed in a fist. Resident #29 was not able to respond to attempt to interview. Resident #29 was not wearing any hand splints or devices. On 1/16/24 at 11:54 a.m., Resident #29 was observed sitting up in her Broda (specialized positioning) chair. Resident #29's left, and right hands remained closed in a fist. Resident #29 was not wearing any splints or devices to the hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 5 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/17/24 at 9:08 a.m., Certified Nursing Assistant (CNA) Staff F said, We used to put wash clothes in her hands. Resident #29 was observed in bed with her left and right hands closed in a fist. On 1/17/24 at 10:03 a.m., Resident #29 was observed with Licensed Practical Nurse (LPN) Staff C. Resident #29's left, and right hands were closed in a fist. The resident was not wearing any splint or devices to the hands. Staff C said, sometimes we roll towels for her hands. On 1/17/24 12:01 p.m., Resident #29 was observed with her right and left hands closed in a fist. The resident was not wearing hand splints or rolled towels in her hands. On 1/18/24 at 8:22 a.m., CNA Staff M said, We roll the wash clothes to put in her hands whenever we remember. On 1/18/24 at 9:00 a.m., Registered Nurse (RN) Staff L said the specific care plan interventions for Resident #29 related to the contractures were resident is dependent on staff for feeding, dressing, and transfers. Therapy will reassess quarterly and as needed if there is a change or weakness. On 1/18/24 at 9:14 a.m., the Director of Rehab (DOR) said all residents are screened quarterly or more often if there is a referral from nursing. Residents will remain on the restorative program as long as needed. Once discharged they are monitored weekly for functional changes. All quarterly screenings are documented in the screening book. On 1/18/24 at 9:30 a.m., review of the screening book provided by the DOR failed to reveal quarterly therapy screenings for Resident #29 for the year 2023 or 2024. On 1/18/24 at 10:11 a.m., the Director of Restorative Services said Resident #29 was not on a restorative program. She confirmed there were no interventions in place addressing the resident's contractures. She said nursing staff should do light range of motion and keep the resident's nails trimmed. She said, I would think there should be specific interventions. We have had others with foam rolls, cones, but I don't see anything in place in this care plan. On 1/18/24 at 11:04 a.m., the DOR verified the lack of screening for Resident #29. The DOR said the resident should have been screened in July 2023, October 2023, and January 2024. On 1/18/24 at 11:43 a.m., the Occupational Therapist said she had not seen Resident #29 for quarterly screenings or restorative programming, and the nurse should have sent a referral. The Occupational Therapist said Resident #29 would benefit from custom or prefabricated splints for her hands. On 1/18/24 at 12:00 p.m., the MDS coordinator verified there were no specific interventions in the care plan related to Resident #29's contractures other than basic skin care. On 1/18/24 at 12:24 p.m., The DON said she would expect to see care plan interventions such as hand strengthening exercise, massage and wash cloth rolls for Resident #29. On 1/18/24 at 12:42 p.m., the Occupational Therapist verified Resident #29 was not receiving services for the hand contractures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 6 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** Based on observation, record review, review of facility's policies and procedures, residents, resident's representatives and staff interviews, the facility failed to ensure adequate supervision to ensure safety and prevent falls for 3 (Residents #42, #8 and #206) of 3 residents reviewed for falls. The findings included: The facility policy Fall Review Program (revised 7/23) documented the facility strives to identify those residents at risk for falls, to provide a system of evaluation, reevaluation, and implementation of measures to reduce the potential for falls/additional falls. All residents will be reviewed for fall risk on admission/readmission and after an actual fall, and quarterly thereafter. For residents with 2 or more falls within the past 30 days will be placed on the Falling Star Program: A white round magnet with a red star will be placed on the residents door frame. The resident must not be left alone during toileting, grooming and bathing. Resident placement on the Falling Star program will be incorporated on the resident's care plan. Review of the clinical record for Resident #42 revealed an admission date of 9/20/23. Diagnoses included Parkinson's disease, muscle weakness and difficulty walking. The admission MDS (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 10/3/23 showed resident #42 had a Brief Interview for Mental Status score of 12 out of 15 which indicated moderate cognitive impairment. The care plan initiated on 9/25/23 showed Resident #42 was a high risk for falls related to gait/balance problems and a history of falls. The interventions included: encourage resident to rest in recliner before dinner initiated 1/15/24. Physical therapy (PT) eval: modify wheelchair (dropped) to promote safety, initiated 1/9/24. Clear indication made on remote to identify which button reclines initiated 10/23/2023. Encourage staff to communicate with resident when they are going to provide care initiated 10/25/2023. PT to treat as ordered initiated 11/6/2023. Dycem (non-slip mat) provided for wheelchair (w/c) placement to prevent sliding and promote safety initiated 11/29/2023. Dycem provided to recliner for placement to prevent sliding and promote safety initiated 12/28/2023. Therapy to assess w/c and cushion for recommendations to ensure safety initiated 1/4/2024. Call Don't Fall signs in resident room and bathroom as reminder to use call bell initiated 9/25/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 7 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 0689 Anticipate and meet the resident's needs initiated 9/25/2023. Level of Harm - Minimal harm or potential for actual harm Ensure that the resident is wearing appropriate footwear i.e. brown leather shoes, non-skid socks etc.) when ambulating or mobilizing in w/c. Date initiated: 9/25/23. Residents Affected - Some Falling Star Program initiated 10/23/2023. Keep bed in low position initiated 9/25/2023. Keep call light within reach-instruct on its use and remind/re-educate to use call light as needed initiated 9/25/2023. Resident should not be left alone during toileting, grooming, bathing. Staff should remain in the vicinity but do not have to be within arm's reach. On 1/17/24 at 12:18 p.m., in an interview Resident #42's wife said he falls all the time that is why he is here. He has Parkinson's and poor balance and in his mind he thinks he is still independent, but he is not. He also started sliding out of the wheelchair. He likes to be in the wheelchair so he can get around on his own. I have asked for therapy to try and work with him again and see if they can help him. Fall #1. Review of the facility Incident Report showed Resident #42 had a fall on 9/22/23 at 2:00 a.m. The incident report showed the resident was observed on the floor next to the wheelchair (w/c). The resident sustained a skin tear to the left elbow. The report documented the steps taken to prevent recurrence was increased rounding. Fall #2. Review of the facility Incident Report showed Resident #42 had a fall on 10/23/23 at 9:00 a.m. The incident report showed the resident was observed on the floor next to the wheelchair. The report documented the steps taken to prevent recurrence was increased rounding. Fall #3. Review of the facility Incident Report showed Resident #42 had a fall on 10/28/23 at 10:00 a.m. The incident report showed the resident was observed sitting on the floor next to his bed and wheelchair. The report documented the steps taken to prevent recurrence, was resident education. Fall #4. Review of the facility incident report showed Resident #42 had a fall on 11/28/23 at 6:00 p.m. The incident report showed the resident was found sitting on his bottom in the bedroom. He stated he fell off his wheelchair trying to pick up his remote off the floor with a grabber. The report documented the steps taken to prevent recurrence, was resident education. Fall #5. Review of the facility incident report showed Resident #42 had a fall on 12/23/23 at 11:00 a.m. The incident report showed the resident was in the lift chair and the chair started to raise/tilt forward, and he slid out of the chair and onto the floor. The report documented the steps taken to prevent recurrence, Assist with ambulation. Fall #6. Review of the facility incident report showed Resident #42 had a fall on 12/30/23 at 1:00 p.m. The incident report documented Resident was found on the floor while talking to his daughter. Resident stated he slid off his wheelchair because the cushion was pushed back due to him moving around. No injuries, no complaints of pain. The report documented the steps taken to prevent recurrence, resident education. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 8 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 0689 Level of Harm - Minimal harm or potential for actual harm Fall #7. Review of the facility incident report showed Resident #42 had a fall on 1/2/24 at 9:00 a.m. The incident report documented Resident was sitting on the floor by his bed, unlocked wheelchair close by him, alert, able to explain what happened, according with him he was trying to reposition himself in wheelchair, cushion was too far forward, ended up sitting on the floor. The report documented the steps taken to prevent recurrence, resident education. Residents Affected - Some Fall #8. Review of the facility Incident Report showed Resident #42 had a fall on 1/4/24 at 4:00 p.m. The incident report documented Resident had a fall. Unwitnessed fall. Resident found sitting on floor next to wheelchair, said he slid out of wheelchair onto floor. The report documented the steps taken to prevent recurrence, resident education. Fall #9. Review of the facility incident report showed Resident #42 had a fall on 1/11/24 at 5:00 p.m. The incident report documented Resident found sitting on his bottom near the wheelchair. The resident stated, I was dozing and fell out of the chair. The report documented the steps taken to prevent recurrence, assist to recliner for naps. Fall #10. Review of the facility incident report showed Resident #42 had a fall on 1/14/24 at 2:00 a.m. The incident report documented Resident found on bathroom floor. The report documented the steps taken to prevent recurrence, assist with ambulation. On 1/16/24 at 3:14 p.m., the door to Resident #42's room was closed, there was a white circle with a red star on the door frame. On 1/16/24 at 3:45 p.m., in an interview Registered Nurse (RN) Supervisor Staff H said the red star on the door frame indicated the falling star program. Staff H said the Falling Star program meant the resident was not to be left alone in the bathroom. When asked what frequent rounding meant as a fall intervention she said, we round all the time, and we look in the rooms as we walk by but there was no documentation of the rounds. The RN said there was no schedule for the frequent rounding. On 1/17/24 at 9:04 a.m., in an interview RN Staff E said the star on the door frame indicated the falling Star program. Staff E said it meant the resident was a fall risk. She said, I do round all the time, and on the night shift the residents are checked every hour. On 1/17/24 at 9:22 a.m., in an interview Certified Nursing Assistant (CNA) Staff F said the falling star program meant a resident was a fall risk and you don't leave the resident alone in the bathroom. On 1/17/24 at 2:24 p.m., in an interview the Assistant Skilled Nursing Facility Administrator Risk Manager said, The process when a resident had a fall is we review the documentation, speak to the staff who may have seen or heard anything, and talk to the resident. We find the most applicable intervention and update the care plan, we put a new intervention in place. The Falling Star Program is used when someone has had more than 3 falls in 30 days. It means the resident is not to be left alone in the bathroom, that is the main part of the Falling Star program. When asked what else the staff are expected to do for someone on the falling star program, she said, I don't know. I will have to check on that. On 1/18/24 at 9:22 a.m., in an interview the Director of Nursing (DON), said the Falling Star program was initiated if the resident has had two or more falls within 30 days. It alerts the staff the resident is a fall risk. It alerts staff that the resident should not be left alone on the toilet or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 9 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in an unsafe area alone. The staff are not to leave the resident alone when grooming, bathing, or sitting on the side of the bed. The DON said increased rounding meant the CNAs do every two-hour rounding and the nurses are encouraged to do every two hours rounds so someone is laying eyes on the resident every hour. The DON said there was no documentation of the increased rounding and no way of knowing if the increased rounding was effective or ineffective. She said on the incident report the nurse puts an intervention in place and then the Interdisciplinary Team goes over it and we see if the intervention is effective for the resident or needs to be changed. The DON said Resident #42 had not come to the realization that he needs help. It is very hard for him to come to us and ask for help. She said I would encourage him to watch TV in the day room, but he refuses. I spoke with his wife a week or so ago about having a companion to sit with him, but she won't pay for it. The DON said the resident's wife has a schedule for her visits and she can't come and sit with him more frequently. She said We just asked his wife to remind him over and over not to get up without using the call light. Our next intervention would have to be a 1-1 sitter at specific times. The DON agreed the current interventions were not effective in preventing falls for Resident #42. Review of the facility Falling Star Program revised June 2018 revealed After a resident sustains a second fall within a 30-day period, a red star will be placed on the doorframe of the resident's room. Interventions included: Not to be left unattended during toileting, grooming, bathing, sitting on the edge of the bed, and dressing; will be assisted with all transfers and ambulation. Review of the Caution and Fall Program revised February 2020, Residents at risk for falls will be identified to all staff members through a yellow dot on the doorframe. Residents should not be left completely unattended during toileting, grooming, bathing, and dressing. Staff should remain in the vicinity but do not have to be within arm's reach or within view of resident. Review of the medical record for Resident #206 revealed a fall and hospitalization prior to admission to the facility. Review of the hospital record revealed resident #206 suffered from dizziness for one year and multiple falls. His hemoglobin in the hospital was low and the resident suffered from delirium (episodes of confusion). The resident was admitted to the facility for rehabilitation. The facility's comprehensive assessment with a reference date of 12/1/23 revealed an elderly resident, admitted on [DATE] who required assistance for walking. The diagnoses included anemia (low red blood levels) and orthostatic hypotension (low blood pressure during position changes.) Review of the facility progress notes revealed Resident #206 fell 3 times at the facility: 11/18/23, 12/11/23, and 1/2/24. Review of the fall incident on 11/18/23 at 9:00 a.m. revealed the resident was alone in the bedroom when he fell. The resident tried to make a phone call and fell. The facility steps to prevent recurrence were apply lotion for skin hydration and place a Call Don't Fall sign in the bedroom and bathroom to remind the resident to use the call bell for assistance. Other interventions initiated on 11/20/23 to prevent falls were anticipating and meeting needs; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 10 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some caution program; ensure appropriate footwear while walking or using wheelchair; keep bed in low position; keep call light in reach, instruct on use and remind resident to use it; safe environment; slide personal items within reach; update fall risk review quarterly; assist resident with toileting and transfer using the wheelchair and walker. Review of the fall incident on 12/11/23 at 6:00 a.m. revealed the resident was alone in the bedroom when he fell. The resident lost his balance. The facility step to prevent recurrence was increased rounding. The care plan was updated to include placing a sign to remember to position foley bag (drainage bag from catheter inserted in the bladder) accordingly prior to ambulation. Review of the fall incident on 1/2/24 at 5:00 p.m. revealed the resident was alone in the bedroom when he fell. The resident stated he wanted to sit on the floor. After staff got him sitting on the bed, he started to slouch forward, so they laid him down quickly. After the resident returned to baseline, he started saying he fell off the bed. The staff noted this was switching stories. The steps taken to prevent a recurrence: assist with ambulation, which the resident was previously care planned for and labs ordered to rule out a urinary tract infection (UTI). Review of the facility progress notes from November 2023 - January 2024 revealed Resident #206 suffered periods of confusion and pulled out his urinary catheter twice while at the facility. The psychiatrist noted the resident suffered from dementia, impaired ability to remember, think or make decisions that interfere with doing everyday activities. Review of the care plans did not include increased supervision for the resident. Review of the facility progress notes from November 2023 - January 2024 revealed the resident suffered gait, balance, and wandering issues, sometimes wandering into the bedroom of others. The staff were to assist the resident as necessary for transferring. There were no directions for increased supervision of the resident. Review of the Standard of Care Agenda dated 1/4/2024 revealed the facility removed Resident #206 from the falling star program. He has had 1-3 falls in the last 30 days. The Resident is ambulating independently. Delirium seems to have cleared. On 1/16/24 at 10:32 a.m., during an interview with Resident #206 in his bedroom, he said he fell at home but did not recall any falls at the facility. The resident's room was the very last room at the end of the hall farthest from the nursing station. The call bell was in reach and the Call Don't Fall sign was on the wall near the bed. On 1/17/24 at 8:33 a.m., Resident #206 said his memory is not too good and he cannot remember some things that are said. He said he lived with his wife and wants to go home. He said he always gets up and uses the bathroom by himself with the walker if he remembers. He said he only falls when he trips on something. During the interview, the resident was lying in bed wearing street clothes and shoes. The resident's walker was in the doorway of the bathroom approximately 5-10 feet from the resident. The resident said he left the walker in the bathroom doorway. The wheelchair was in the room next to the credenza, but not in reach of the resident. He said he did not remember falling at the facility. He said if he needed to go to the bathroom he would just get up and use the walker and go himself and would not call the staff to help him. He said they don't come in and check on him very often. On 1/17/24 at 9:36 a.m., observed yellow dot on the doorframe of the resident's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 11 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/17/24 at 9:44 a.m., CNA Staff R said the yellow dot means the resident is a frequent faller and pulled out her instruction sheet. The sheet did not indicate how many times staff needed to check the resident. On 1/17/24 at 11:58 a.m., the Director of Rehab the resident has safety awareness issues and is not aware of his limitations. He said it does not matter how many signs you place in the room; the resident will get up and walk without calling for assistance. The director said the resident is not getting therapy. On 1/17/24 12:40 p.m., Resident #207 observed walking down hallway with walker. There were no staff in the area. On 1/17/24 12:59 p.m. CNA Staff T said she knows the resident is a fall risk and she should check on him. She said there is no special time or routine for checking. On 1/17/24 1:28 p.m., Licensed Practical Nurse (LPN) Staff O said staff should be checking resident every hour, but that is not written anywhere. She said the resident uses the call bell for toileting assistance and staff cannot leave until he is finished. She said there are no special instructions for supervision. On 1/18/24 at 8:46 a.m., observed resident in his room awake in bed. The Call Don't Fall sign was on the wall near the bed. The resident said you should call them on the phone before you do something where you may fall. The resident said he does not use the call bell, almost always uses the walker for ambulation unless he forgets. He said staff do not check on him. On 1/18/24 at 8:52 a.m., observed resident up in room walking without the walker. There were no staff in the room or in the hallway near the room. On 1/18/24 at 10:08 a.m., the MDS (Minimum Data Set) Coordinator said criteria for the Falling Star Program was two falls in one month. She said the resident had two falls in one month but was removed from the Falling Star Program. On 1/18/24 at 11:59 a.m., the Director of Nursing (DON) said Resident #206 was confused and was tripping over the urinary catheter bag when he was first admitted . The Assistant Nursing Home Administrator said they have safety concerns about the resident tripping when he goes home and that is why he is still at the facility. The Transitions of Care Coordinator said Resident #206 has short term memory deficits. The DON said the Resident #206 has no safety awareness. The DON said there has been no increase in supervision for Resident #206. She said between the CNAs and nurses they should be checking the resident every hour, but there are no specific instructions for that. Review of the clinical record for Resident #8 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE]. The assessment noted Resident #8 had a Brief Interview for Mental Status (BIMS) score of 02, which indicated severe cognitive impairment. The resident needed substantial/maximal assistance with all activities of daily living (ADLs). Review of Resident #8 care plan with a revision on 1/15/2024 after the fall was Therapy to evaluate wheelchair safety. Other interventions to prevent a fall in place 06/22/2023 Place Call don't fall signs in room, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 12 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 0689 7/05/2023 Ensure call light is easily within resident's sight while he is in bed, Level of Harm - Minimal harm or potential for actual harm 2/17/2023 Keep call light within reach-instruct on its use and remind/re-educate to use call light as needed, and 8/10/2023 Falling Star program. Residents Affected - Some Review of incident reports: Resident #8 unwitnessed fall out of wheelchair on 1/13/2024. Note states fall was unwitnessed at approximately 3:00 p.m. after the family left him. He slipped out of his wheelchair. No complaints of pain, no skin tears or major injuries noted. He stated he did not hit his head. Interventions in place at time of incident 1:1 supervision. The new intervention in place is to increase rounding. Note text: new intervention is for therapy to evaluate wheelchair safety. No new interventions to educate the family to notify staff when leaving so they can check on the resident, since his fall happened after the family left. On 1/16/24 at 10:15 a.m., Resident #8 was observed in a wheelchair at end of the bed with the call light out of reach on the bed. Resident stated he is to call for help when he needs to get up. Resident #8 was not able to reach for the call light upon request. Photographic evidence obtained. On 1/16/24 at 1:00 p.m., Resident #8's spouse stated Resident #8 fell out of his chair on 1/13/2024 but did not sustain any injuries. She felt that a wedge should be put on his wheelchair so that he doesn't have to always try and push himself back into the wheelchair. On 1/16/24 at 2:57 p.m., Resident #8 was observed asleep in bed with call light on the floor. Photographic evidence obtained. On 1/16/24 at 3:00 p.m., Licensed Practical Nurse Staff B said the resident used two call lights. She verified one of the call lights was on the floor and not within sight or reach of the resident. She pointed to a call light under the resident's pillow. The call light was not within the resident's sight as per the care plan dated 7/5/23. On 1/16/24 at 3:13 p.m., CNA Staff G, Said the yellow dot is fall risk on door. She said fall risk usually sit in hallway to have a set of eyes on the resident. She doesn't know what pink dot is. On 1/16/24 at 3:29 p.m., Registered Nurse (RN) Staff H Supervisor said it is on trust that the staff is increasing rounds on a resident. On 1/17/24 at 9:27 a.m., LPN Staff C stated pink means dnr, red is alarm, yellow is don't know, falling star at risk for fall. When is time to check on them she makes rounds every hour and CNAs are up and down the hall. There is no documentation that they round. The purpose of signs are to identify the resident issue. On 1/17/24 at 10:00 a.m. CNA Staff F said falling star means fall risk, do not leave them by themselves and no walk by themselves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 13 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 0689 Level of Harm - Minimal harm or potential for actual harm On 1/18/24 at 9:22 a.m., in an interview the DON said increase rounding is: RN's and CNAs alternate rounds every two hours; they should increase to every 30 minutes. The DON confirmed there was no documentation of the increase rounds, they were just told to increase rounds Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 14 of 15 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 106019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodge at Cypress Cove, The 10500 Cypress Cove Dr 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 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. Based on observation, review of facility policy and staff interviews, the facility failed to ensure expired medications were not retained longer than the expiration date in 1 of 2 medication storage rooms observed and 1) medication cart of 3 medication carts observed. This has the potential for expired medications to be administered to residents. The findings included: The facility policy and procedure Medication Storage (revised 8/23) documented All medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdates, defective or deteriorated medications with worn, illegible or missing labels. On 1/16/24 at 10:09 a.m., during an observation of the 2nd floor medication room with Licensed Practical Nurse (LPN) Staff B revealed an emergency insulin box located in the locked compartment of the medication refrigerator. The emergency insulin box contained 1 Humulin insulin injectable pen with an expiration date of 12/11/23. LPN staff B confirmed the insulin had expired. Photographic evidence obtained. On 1/16/24 at 10:29 a.m., during an observation of 2nd floor [NAME] Hall medication cart with LPN Staff C revealed a plastic pharmacy medication bag with 2 Albuterol AER/HFA inhalers. The expiration date on the inhalers was 12/23. LPN Staff C confirmed the inhalers had expired. Photographic evidence obtained. On 1/18/24 at 8:52 a.m., in an interview, the Pharmacy Consultant said he was at the facility monthly and checks the emergency drug kits including the insulin. The Pharmacy Consultant said he checked the emergency drug kits at his last visit on 12/20/23 and was not aware the Humulin insulin had expired on 12/11/23. On 1/18/24 at 5:15 p.m., the Director of Nursing said she had contacted the pharmacy to replace the emergency insulin box on 1/16/24 because the Humulin insulin had expired. She said she checks the medication refrigerators and the medications including the emergency drug box every day. The Humulin insulin had an expiration date of 12/11/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106019 If continuation sheet Page 15 of 15