Health inspection·August 21, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to provide housekeeping and maintenance services to ensure a clean environment for 7 (rooms 135, 139, 138, 126, 205, 203 and 207) of 20 rooms observed on the Memory care and the North unit. The findings included:Review of the facility's Environmental General Cleaning policy (last updated 01/2024) revealed, it is the policy of this facility to provide a clean, safe, orderly, comfortable and attractive homelike environment . Accepted practices and procedures are used to keep the facility free from odors, accumulations of dirt, dust and safety hazards. On 8/17/2025 at 10:14 a.m., observation of room [ROOM NUMBER] revealed the front air conditioning vents were coated with multiple spots of a black substance. Photographic evidence obtained. On 8/17/2025 at 11:55 a.m., the front air conditioning vents of room [ROOM NUMBER] were observed coated with multiple spots of a black substance. On 8/18/2025 at 10:45 a.m., the air conditioning vents in room [ROOM NUMBER] were observed coated with multiple spots of a black substance. Photographic evidence obtained. On 8/20/25 at 9:27 a.m., the observation of the multiple spots of black substance on the air conditioning vents of rooms 203, 204 and 207 was shared with the Director of Environmental Services. In an interview he said he was the one responsible to clean the air conditioning vents. On 8/20/25 at approximately 9:35 a.m., the Director of Environmental Services observed the black substance on the air conditioning vents of room [ROOM NUMBER] and said it should not look like that. On 8/17/25 between 10:00 a.m., and 11:00 a.m., the following observations were made during a tour of the memory care unit: room [ROOM NUMBER]: Floor tile missing. The caulking around the toilet was cracked and discolored. Photographic evidence obtained. room [ROOM NUMBER]: Peeling wallpaper with orange discoloration on the wall under the wallpaper, water damage to the wall, molding and floor in the bathroom. Page 1 of 4 106020 106020 08/21/2025 Eagleridge Health and Rehabilitation Center 13881 Eagle Ridge Drive Fort Myers, FL 33912

F 0584 Photographic evidence obtained. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: Bathroom floor tiles stained and cracked. The caulk around the toilet was discolored and cracked. Residents Affected - Some Photographic evidence obtained. room [ROOM NUMBER]: Large gap in tiles, the wall by the air conditioning was cracked, embedded dirt in tiles, cracked, discolored caulking around the toilet. Photographic evidence obtained. On 8/20/25 at 2:30 p.m., the observations, and photographic evidence of the environmental concerns in the memory care unit were shared with the Director of Environmental Services. The Director of Environmental Services said he was aware of the concerns, and they have been slowly trying to work their way through the unit to address identified environmental issues. 106020 Page 2 of 4 106020 08/21/2025 Eagleridge Health and Rehabilitation Center 13881 Eagle Ridge Drive Fort Myers, FL 33912

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a Comprehensive Minimum Data Set (MDS) Assessment within 14 calendar days of admission for 1 (Resident #70) of 45 reviewed.The findings included:Review of medical records revealed Resident #70 was admitted to the facility on [DATE]. Diagnoses muscle wasting and atrophy, Type II Diabetes Mellitus and pulmonary disease.Review of the admission.On 8/20/2025 at 4:33 p.m., in an interview MDS coordinators, Registered Nurse (RN) Staff C and Licensed Practical Nurse (LPN) Staff D verified Resident #70 was admitted to the facility on [DATE] and the MDS admission Assessment was not completed until 3/27/25, 21 days after admission. LPN Staff D said the MDS admission Assessment should have been completed by 3/20/25 and was not sure why the admission MDS assessment was not completed within 14 days of admission as required. LPN Staff D said they follow the instructions on the Resident Assessment Instrument (RAI) manual specifying that the admission MDS assessment must be completed within 14 days of admission. 106020 Page 3 of 4 106020 08/21/2025 Eagleridge Health and Rehabilitation Center 13881 Eagle Ridge Drive Fort Myers, FL 33912

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 Based on record review and staff interviews, the facility failed to provide care and services in accordance with professional standards of practice by failing to communicate a significant weight loss to the physician for 1 (Resident #10) of 2 residents reviewed for nutrition.The findings included:On 8/18/25, review of the clinical record for Resident #10 experienced a significant weight loss. The documented weights were:2/10/25: 185.0 pounds (lbs.)3/05/25: 187.8 lbs.4/04/25: 186.0 lbs.4/24/25: 182.5 lbs.4/29/25: 183.0 lbs.5/06/25: 185.6 lbs.6/03/25: 181.0 lbs.7/03/25: 171.4 lbs.8/05/25: 168.0 lbs.8/13/25: 161.4 lbs.Review of the physician's orders revealed a dietary order dated 5/6/25 for Regular diet, large portions for weight loss.On 7/31/25, a Registered Dietitian progress note documented the resident's weight was 171.4 lbs. negative 5% change over 30 days.On 8/17/25 a Dietary progress note indicated Resident #10 was having an evaluation for significant weight change. Resident #10's usual body weight was in the 180s with a 13% weight loss (24 lbs.) over 180 days. Resident #10 was not receiving supplements. Dietary interventions were large portions. The resident's usual meals intake were 51% to 75%, 76% to 100%. The resident was tolerating oral diet with good appetite. Recent medication changes: Donepezil and Memantine (medications to treat Alzheimer's/dementia) associated with weight change may be contributing factor.The progress note specified: Defer to MD (physician). The clinical record lacked documentation the physician/provider was notified of the resident's significant weight loss.Review of the progress notes revealed on 7/2/25, 7/8/25, 7/10/25, 7/15/25, 7/17/25, 7/22/25, 7/24/25, 7/29/25, 7/31/25, 8/5/25, 8/8/25, 8/12/25, 8/15/25 and 8/18/25, the provider documented, His weight is stable. Review of System: Constitutional: (-) weight loss.On 8/19/25 at 3:07 p.m., in an interview the Regional Dietitian (RD) said when a dietary progress note is entered, there is a box that is checked for a physician/nursing communication report, and the doctor would have to review it. The Regional Dietitian reviewed the dietary progress notes. She said the box was checked on dietary progress note for 7/31/25 but had not been checked on the dietary progress note for 8/17/25. The RD said she could not explain why the physician's progress notes continued to say negative for weight loss.On 8/20/25 at 9:30 a.m., in an interview Licensed Practical Nurse (LPN) Staff E said she was Resident #10's nurse. She said the resident ate and did not refuse food.On 8/20/25 at 11:15 a.m., in an interview the Advanced Practice Registered Nurse (APRN) said she had been off for a week. She said she was looking through the system this morning and noticed the weight difference. She noticed a 10.0 lbs., then a 3.0 lbs. weight loss., then another weight. She said she asked staff to reweigh the resident as one of the weight was obtained standing and others were sitting.On 8/20/25 at 3:51 p.m., in a follow up interview the RD said there was no way to verify that the physician reviewed the communication reports. There was no place to sign off or acknowledge the physician had seen the communication report. The RD said she was not aware of any policy addressing the communication reports. Residents Affected - Some 106020 Page 4 of 4