Inspection·October 28, 2021

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 observation, record review, resident and staff interview the facility failed to follow through and provide timely care and treatment for wound after written communication from dialysis unit for 1 (Resident #37) of 2 dialysis resident reviewed. Residents Affected - Few The findings included: Review of Dialysis Patient Management, Policy #165 last revised on 5/2021. Policy noted Lee Skilled Nursing staff will ensure coordinated care with involvement from resident/patient . attending physician and related medical providers, dialysis provider . and facility's interdisciplinary team . Communication book will be created for resident/patient to allow for communication between facility staff and dialysis staff before and after dialysis treatment Primary nurse is also required to verify and transcribe any new orders that were communicated via Dialysis Center faxed documentation . On 10/27/21, review of Resident #37's clinical record, revealed the resident was an [AGE] year-old male with a history of end-stage renal disease, receiving hemodialysis on Monday, Wednesday and Friday. On 10/27/21, review of the dialysis communication record dated 10/22/21 revealed a recommendation from the dialysis center to change the resident's dressing to the right groin. The note indicated a physician had assessed the site. The clinical record lacked documentation the facility assessed or changed the dressing to the right groin on 10/22/21. On 10/26/21 a weekly skin evaluation noted Resident #37 had a puncture site to the right groin measuring 1.0 centimeter by 0.6 centimeter by 0.1 centimeter with red, fragile skin and scant serosanguinous drainage. On 10/26/21 Registered Nurse (RN) Staff B documented in a progress note Resident #37 had a puncture site to the right groin with the wound bed fragile, red, bleeding with scant serosanguinous drainage. On 10/27/21 at 1:38 p.m., in an interview Registered Nurse (RN) Staff B, second floor Charge nurse said she did not have any documentation on 10/22/21 RN Staff A assessed Resident #37's right groin or had done any follow up with what was written by the dialysis nurse about the dressing. RN Staff B said her expectation was for the nurse receiving the resident back from dialysis to do an assessment and review anything the dialysis wrote on the dialysis communication form. She said she was not there on 10/22/21, but on 10/26/21 she saw the communication note from the dialysis center, assessed the area, and obtained orders. On 10/27/21 at 1:44 p.m., in an interview the Director of Nursing (DON) said her expectation was for the nurse on duty to review the dialysis communication book upon the resident's return and address any recommendation, take off or write orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106122 If continuation sheet Page 2 of 4 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 106122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Medical Center Skilled Nursing Unit 13960 Plantation Road Fort Myers, FL 33912 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 On 10/28/21 the Advanced Practice Registered Nurse (APRN) documented Resident #37 had a small circular area of excoriation to the right groin around the puncture site from a femoral arterial line that was placed on 10/14/21 while the resident was hospitalized . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106122 If continuation sheet Page 3 of 4 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 106122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Coast Medical Center Skilled Nursing Unit 13960 Plantation Road Fort Myers, FL 33912 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility policy and resident and staff interviews, the facility failed to provide the necessary care and services to monitor and maintain a continuous positive airway pressure (CPAP) machine for 1 (Resident #157) of 1 resident reviewed with a CPAP machine (machine used to deliver constant and steady air pressure to help breathe while sleeping). Residents Affected - Few The findings included: The facility policy #381 Respiratory Equipment with a review date of 2/21 documented, To maintain nebulizers and oxygen equipment and positive airway pressure machines (to include CPAP and BIPAP) and accessories in a sanitary manner .Respiratory equipment will be cleaned, maintained and or changed in a timely manner within predictable intervals and as needed for soiling/replacement .CPAP masks will be sanitized daily using manufacturer recommendations . Nursing staff will document completion of respiratory equipment maintenance in the medical record . On 10/26/21 at 1:40 p.m., during an observation, Resident #157 had a CPAP machine on the nightstand. The nasal mask was stored in the drawer uncovered. Photographic evidence obtained. On 10/26/21 at 2:01 p.m., a review of the clinical record revealed Resident #157 had diagnoses including obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops). The clinical record showed no documentation of a physician order or a care plan to indicate the settings or use of the CPAP machine. On 10/27/21 at 9:51 a.m., in an interview, Resident #157 said his wife brought the CPAP machine to him on 10/24/21 and said he takes care of his CPAP machine. Resident #157 said he was able to apply and remove the CPAP mask. On 10/28/21 at 10:33 a.m., in an interview Registered Nurse Supervisor Staff C said the procedure for CPAP machines was to obtain a physician order for use with the machine settings. The order is then placed on the medication administration record. The night shift nurse was responsible to assist the resident to put the CPAP mask on and to remove it in the morning. Staff C said the CPAP machine would be care planned so staff knew how to assist the resident and maintain the machine. Staff C reviewed Resident #157's clinical record and confirmed there was not a physician order for the CPAP machine and no care plan was initiated. Staff C confirmed the clinical record provided no documentation for the use and care of Resident #157's CPAP machine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106122 If continuation sheet Page 4 of 4