Inspection·August 19, 2021

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, staff interview, and review of facility policies and procedure, the facility failed to identify and dispose of expired medications to prevent use in 3 of 4 medication carts and 1 of 2 medication rooms reviewed for proper storage of medications. This has the potential for expired medications to be administered to residents. The facility failed to ensure 1 of 4 medication carts was locked when out of the direct supervision of the nurse. The findings included: The facility policy, Medication Storage in the Facility, Effective Date: March 2019 documented, Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date .The nurse will check the expiration date of each medication before administering it. No expired medication will be administered to a resident. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. On 8/16/21 at 9:40 a.m., during an observation on the second floor, the medication cart was not locked and was unattended. The medication cart remained unlocked and unattended for 4 minutes. **Photographic Evidence Obtained** On 8/16/21 at 9:45 a.m., Registered Nurse (RN) Staff C confirmed she had left the medication cart unlocked and unattended. On 8/16/21 at 10:01 a.m., observation of the 2nd floor medication cart #1 with Registered Nurse (RN) Staff A showed: One box of Mucinex 600 milligrams (mg) with the expiration date 5/2021. Two unidentified capsules in a pill card with no medication label. **Photographic Evidence Obtained** One bottle of pneumonia vaccine with a label indicating to keep refrigerated. **Photographic Evidence Obtained** One bottle of vitamin B12 with the expiration date 7/2021. **Photographic Evidence Obtained** One bottle of loratadine 10 mg tablets with the expiration date 6/2021. **Photographic Evidence Obtained** One bottle of zinc sulfate 50 mg with the expiration date 3/2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106108 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 106108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakton Place Health and Rehabilitation at the Arli 8000 Arlington Circle Naples, FL 34113 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 **Photographic Evidence Obtained** Level of Harm - Minimal harm or potential for actual harm The findings were verified by RN Staff A during the observation. **Photographic evidence obtained** Residents Affected - Few On 8/16/21 at 10:48 a.m., observation of the 2nd floor medication cart #2 with RN Staff C showed: One bottle of Aspirin 81 mg with the expiration date 3/2021. **Photographic Evidence Obtained** One bottle of Melatonin 10 mg with the expiration date 6/2021. The findings were verified with RN Staff C at the time of the observation. **Photographic evidence obtained** On 8/16/21 at 10:54 a.m., observation in the 2nd floor medication room with RN Staff C revealed: Two boxes of Mucinex 600 mg with the expiration date 6/2021. 12 bottles of Vitamin C 500 mg with the expiration date 6/2021. **Photographic Evidence Obtained** The findings were verified with RN Staff C during the observation. On 8/16/21 at 11:30 a.m., observation of the 3rd floor medication cart #1 with Licensed Practical Nurse (LPN) Staff B revealed: One bottle of Melatonin with the expiration date 6/2021. **Photographic Evidence Obtained** One bottle of vitamin B12 with the expiration date 7/2021. **Photographic Evidence Obtained** One bottle of Vitamin C with the expiration date 6/2021. **Photographic Evidence Obtained** The findings were verified with Licensed Practical Nurse Staff B during the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106108 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 106108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakton Place Health and Rehabilitation at the Arli 8000 Arlington Circle Naples, FL 34113 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record review, the facility failed to store and distribute food in a sanitary manner for 1 (3rd floor) of 2 floors observed. The facility also failed to ensure proper cleaning and sanitization and prevent cross contamination of dishes and cookware. This has the potential to result in foodborne illness and affect 28 of 28 residents residing at the facility who consume an oral diet. The findings included: 1. On 8/16/21 at 9:50 a.m., during an initial tour of the second-floor kitchen with Sous Chef Staff E the following was observed: The inscription on the dishmachine data plate specified the wash and rinse for a high temp machine should be respectively 150 F (degrees Fahrenheit) and 180 F. Kitchen Assistant Staff G donned a pair of gloves, placed a tray of dirty plastic lids into the dishwasher and started the machine. The temperature gauges read 140 degrees F for the wash and 156 degrees F for the final rinse. Staff G removed the tray from the dishwasher with his gloved hands. Staff G gathered the lids against his uniform, placed them in a tray and transported them to the kitchen to be used. The dishwasher operation instructions read, Warm-up cycles: For a typical daily start-up, it may be necessary to run the machine through 3 cycles to ensure that all of the cold water is out of the system and to verify that the unit is operating correctly . Review of the 24-5 Minute Weekly Training Script (December 2010) read, If you have a hot water sanitizing machine . the dishmachine's final rinse step kills germs on dish surfaces-this is the sanitizing step. In order for the water to sanitize properly it has to be 180 degrees as measured on the temperature gauge. Check the gauge at least once daily to make sure the water is hot enough. Be sure to log the temperature on the dishmachine temperature log. Review of the dishmachine temperature log for August 2021 failed to reveal documentation the temperature was checked on 8/16/21. The sprayer hose for the sink in front of the dishwasher was had a large accumulation of caked debris. **Photographic evidence obtained** The rinse agent bottle above the sink had large amount of black substance on the bottle and label. **Photographic evidence obtained** On 8/16/21 at 10:00 a.m., observation of the dry storage room in the second-floor main kitchen with Sous Chef Staff E revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106108 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 106108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakton Place Health and Rehabilitation at the Arli 8000 Arlington Circle Naples, FL 34113 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 0812 Six cardboard boxes containing foam cups, foam containers, and lids were stored on the floor. Level of Harm - Minimal harm or potential for actual harm **Photographic evidence obtained** A lunch box with a bottled water was stored on the shelf with the dry food supplies. Residents Affected - Many Staff E removed the lunch box which he said belonged to Staff G who was operating the dishwasher. He instructed Staff G to take his lunch box to the employee lounge. On 8/16/21 at 10:15 a.m., the walk-in refrigerator was observed with Sous Chef Staff E. An unlabeled container of thick, red sauce which Staff E identified as barbeque sauce was stored uncovered in the refrigerator. Staff E said it should never have been stored uncovered. A container of coffee cake extract had a label which read, use by 8/14/21. 2. On 8/16/21 from 12:00 p.m., to 1:00 p.m., observed the meal distribution on the 3rd floor. The food arrived from the second-floor kitchen in an electric hot box. Server Staff H kept containers of sweet potatoes, broccoli, cauliflower, and ground beef on the stove top au [NAME]-[NAME] (Pots of food placed in larger pot of hot water). He placed a packet of soft slices of cheese on the counter next to the stove. Staff H did not take the temperature of the food when it arrived from the kitchen. Staff H washed his hands and donned a pair of gloves. He was observed touching the handle of the hot box, the refrigerator, the microwave, resting his hands on the counter and returning to the line to serve lunch. Staff H used the same gloved hands to prepare 3 cheese steak sandwiches with the cheese on the counter and microwaved the sandwiches. He continued to plate food, rearrange steamed cauliflower and broccoli on the plates with his gloved hands. He removed the gloves, washed his hands for approximately 10 seconds and donned a clean pair of gloves. Staff H continued to go from the hot box to the refrigerator and the microwave, touch the counter, a dish rag and plate food with his gloved hands. He peeled sweet potatoes, continued to rearrange steamed broccoli and cauliflower on the plates and prepare sandwiches with his gloved hands. He did not change his gloves, wash, or sanitize his hands after touching work surfaces. Server Staff H was observed preparing a peanut butter sandwich with his gloved hands. A resident's private assistant walked into the meal preparation area, handed him a tray with leftover food from a resident's room. Server Staff H took the tray, placed it on a table. He did not remove the gloves, wash, or sanitize his hands and continued to prepare the peanut butter sandwich. On 8/16/21 at 12:25 p.m., in an interview, Server Staff H said he came in at 11:55 a.m., and did not get a chance to take the temperature of the food since he had to get ready to serve the food. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106108 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 106108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakton Place Health and Rehabilitation at the Arli 8000 Arlington Circle Naples, FL 34113 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 0812 Level of Harm - Minimal harm or potential for actual harm said he would take the temperature of the leftovers after all the residents had been served. Server Staff H verified he touched the food with the gloved hands after touching contaminated surfaces. He said, I understand. It's for bacteria and stuff. On 8/16/21 at 12:55 p.m., Staff H said now that everyone had been served, he would take the temperature. Residents Affected - Many The soft cheese on the counter was 70 F. Server Staff H said, It's not cold enough. On 8/16/21 at 1:30 p.m., in an interview, the Front House Supervisor Staff I said the expectation was for the server to take the food temperature once it reached the floor to make sure the food was still at the proper temperature. If not, the food needed to be reheated. He said the cheese should never be left out on the counter and needed to stay cold to avoid the danger zone. He explained cold food items need to be kept under 40 degrees F. He said the danger zone was from 41 F to 141 F when bacteria grew on the food. He said the cheese should have been kept on ice. He said the servers were expected to wear gloves when handling the food but needed to wash their hands and change the gloves when going from one item to the next. He said it was not acceptable for the servers to touch surfaces and not wash their hands or change their gloves. The Front House Supervisor Staff I said the servers were trained frequently on sanitation, food service, use of gloves, and handwashing but the facility did not keep a record of the training. Review of the meal temperature policy (date of issue January 1, 2021) noted, . When food is transported to a remote serving location such as a household, neighborhood, etc., final cook temperatures are taken and recorded in the kitchen; temperatures are taken and recorded again once transported to service location and prior to serving. If temperatures are not optimal at the receiving location, respond accordingly to correct. Record ending temperatures or at one hour intervals during service. Temperatures below or above standards may indicate procedural and/or equipment problems. Address any concerns noted . Review of the safety and sanitation glove usage policy with a revision date of February 2018 read, Disposable gloves shall be utilized as necessary during food service operations when handling ready to eat foods and when preparing food for use. To assure safe sanitary conditions in the preparations and service of the food for patients/residents and customers of the facility. To prevent contamination of food products from bacteria and to prevent the possibility of foodborne illness. Single use gloves shall be used for only one task, and then discarded. Single use gloves should always be changed when moving from one task to another. Remove gloves when: Moving to another new task or work area . Going into walk-in or reach in coolers. Touching soiled food contact areas . 3. On 8/18/21 at 10:10 a.m., through 10:30 a.m., observed Kitchen Staff K operating the dishwasher and process loads of dishes. He donned a pair of gloves, scraped food from the dirty dishes, placed them in a rack and put them through the dishwasher. Staff K used the same gloves to remove the clean dishes from the machine. The wash temperature of the first and second load was respectively 130 F and 140 F. On 8/18/21 at 10:25 a.m., Kitchen Staff K said the facility used a high temp dishwasher and the heat was the sanitizing agent. He said the machine needed to reach 180 F to sanitize the dishes. He said they ensured the dishes reached the proper temperature by placing a heat strip on the surface of the dishes. Once sanitized properly, the heat strip turned black. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106108 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 106108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakton Place Health and Rehabilitation at the Arli 8000 Arlington Circle Naples, FL 34113 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 0812 Level of Harm - Minimal harm or potential for actual harm Staff K continued to scrape food from plates, put them through the dishwasher and remove the clean plates with the same gloves. On 8/18/21 at 10:30 a.m., Chef Staff L intervened and told Staff K he had just cross contaminated all the clean dishes. Residents Affected - Many On 8/18/21 at 10:35 a.m., the heat strip on a clean cup from a load of clean dishes remained clear, it did not turn black. Staff K said the machine may not be functioning properly even though the rinse temperature reached 180 F. He said the heat strip should have turned black. The label on the strip indicated it would turn black once the temperature reached 160 F. On 8/18/21 at 10:35 a.m., shared observation of the dishwasher conducted on 8/16/21 during the initial tour of the kitchen when the temperature gauge read 140 F for the wash and 156 F for the final rinse with Chef Staff L. He said he will have the dishwasher serviced. On 8/18/21 at 1:00 p.m., the Assistant Director of Dining Services said the vendor who supplied the chemical for the dishwasher was at the facility on 8/16/21 and checked the dishwasher. He provided a report which he said was from 8/16/21. The report noted the final rinse temperature was only reaching 171 F, however the thermal label turned black on first run. Review of the preventive maintenance instructions for the dishwasher read in part, . a common problem has to do with temperatures being too low. Verify that the water temperatures coming to your dishmachine match the requirements listed on the machine data plate. There can be a variety of reasons why your water temperature could be too low, and you should discuss it with a qualified service agency to determine what can be done . 4. On 8/18/21 at 10:40 a.m., observation of the three compartments (wash, rinse and sanitize) sink showed the facility used Quaternary as their sanitizing agent. The cleaning procedures posted on the wall above the sink read in part, Pre-scrape, wash, rinse, sanitize 1 minute, air dry. The Quaternary Sanitizer testing procedures posted on the wall above the sink read in part, . Testing must be done in sanitizer solution that is clean, fresh and at room temperature 75 F . Tear off a 1 ½ -2-inch strip of test paper . Hold the test strip in the solution for 10 seconds . Do not move the test paper around, as this will give a false high concentration reading. Remove test strip from solution . Hold test strip up against the color chart on the side of the test strip container. Always refer to the color range on the QT-10 Test Kit for accurate color matching of strips. The correct reading must be 200-400 ppm (part per million). If the solution test does not meet the 200-400 ppm requirements, test again. Take corrective action if the reading remains out of range. The policy and procedure Sanitizing food contact surfaces (F018) with a revision date of 1/18 read, . Pot sink: Immerse items in sanitizing solution (third sink) for a minimum of 60 seconds. complete Pot-sink Sanitizer concentration log daily at each meal period. On 8/18/21 at 10:45 a.m., Kitchen Staff F was observed using the three-compartments sink to wash cooking pots and pans. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106108 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 106108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakton Place Health and Rehabilitation at the Arli 8000 Arlington Circle Naples, FL 34113 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 0812 Level of Harm - Minimal harm or potential for actual harm She filled the third sink halfway with a sanitizing solution. She did not check the concentration of the sanitizing solution. She scrubbed pots and pans, rinsed, and placed them in the sanitizing solution. She did not completely submerge the pots and pans in the solution to ensure all surfaces were sanitized. Kitchen Staff F removed the pots and pans from the sanitizing solution and said they were clean and would now let them air dry. Residents Affected - Many On 8/18/21 at 10:57 a.m., in an interview Staff F said she measured the concentration of the sanitizer by measuring the water temperature. She took a digital thermometer, placed the probe in the water and immediately removed it. She held the thermometer in the air as the temperature was decreasing. She said she was waiting for screen to stop blinking to read the temperature of the water. When asked to test the sanitizing solution, she took a piece of the test strip and placed in the water that measured 134.6 F. She shook the strip in the water and placed it against the label and said it read 400 and was fine. On 8/18/21 at 11:35 a.m., in an interview Chef Staff L verified Staff F did not follow the proper procedure to test the concentration of the sanitizing agent of the three compartments sink. He said he was sure Staff F was trained but could not locate the training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106108 If continuation sheet Page 8 of 8