Inspection·October 26, 2023

F 0806 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 9/28/23 at 1:37 p.m., the Registered Dietitian, (RD) documented in an admission assessment, Visited with patient . and he disputed the allergy to black pepper stating he only has a problem with it if too much is added. Message left for wife to attempt to clarify what he is able to receive . On 9/29/23 the RD documented in a Nutrition Assessment note, Food Allergies: Peppers, peanuts . On 10/1/23 at 1:00 p.m., the nurse documented in a progress note, Called to pt (patient) room with crash cart for possible stroke. Upon arrival to room CNA (Certified Nursing Assistant) present along with wife. Pt is alert. Pt is vomiting currently. His hand grasps are present but weak . Wife states an allergy to peppers, and states he ate dressing at lunch that has peppers . ready for EMS (Emergency Medical Services) transport to ER (Emergency Room). On 10/1/23 at 2:50 p.m., the Emergency Department encounter report noted, Patient was eating lunch when he began vomiting and choking. Patient also noted to have eaten red peppers on a salad today with an allergy to peppers and had a truncal rash on arrival. Patient was medicated for his allergy with IM (Intramuscular) epinephrine, Pepcid, Solu-Medrol, and Benadryl. Patient was not unable [sic] to maintain his airway and he was intubated in the emergency department . Allergen Capsicum Annuum Extract & Derivative (Bell Pepper) [Capsicum Oleo Resin]. Reaction: Hives and itching . Per patient and daughter report on 3/14/22 . Patient is NOT allergic to black pepper seasoning. Only allergic to the fruit (bell, jalapeno etc.) . Peanut- Derived Hives, Rash and Swelling . Allergic reaction, assessment, and plan. Patient had an allergic reaction during lunch today with red pepper being consumed with his salad. Patient arrived to ED with truncal rash . On 10/23/23 at 11:30 a.m., in a telephone interview Resident #1's wife said Resident #1 previously determined he was allergic to peppers when he developed a rash after eating peppers. She said approximately a year ago, he ate something with pepper, and became unresponsive. The spouse said on 10/1/23, when he ate the salad with the Italian dressing, it was like Déja [NAME]. He became in a trance like state and went unresponsive. She ran and got the CNA. Seven or eight staff members responded within minutes. After approximately three minutes, her husband started vomiting. She said that's when she read the ingredients on the packet of the salad dressing the facility provided and realized it contained red peppers. She said her husband ate the salad with the dressing. She immediately told a nurse who was in the room that he ate red pepper, and he was allergic to them. She requested an epi-pen, and the nurse told her they did not know what was going on with her husband. On 10/23/23 at 2:00 p.m., met with the Registered Dietitian, and the Director of Clinical Nutritional Operation to discuss the facility's process to ensure residents receive food that accommodate allergies. The Registered Dietitian said, the Registered Dietitian enters the allergies and preferences in Computrition, the facility's electronic system. The system contains all the recipes the facility utilizes through the outside food provider and the recipes used by the facility. The system is designed to not allow the dietary staff to print out a meal ticket with anything the resident is allergic to. The facility provided a Recipe Likes, Dislikes, Allergy report which listed food items the system will automatically not print on a meal ticket based on the allergies. The list included Italian dressing as an item not to provide with pepper allergy. (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 10/26/2023 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 0806 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The facility provided Resident #1's meal tickets printed from the Computrition system for all three meals from 9/27/23 through 10/1/23. The meal tickets listed allergies of peppers, and peanuts. Review of the facility's investigation revealed Resident #1 had a documented allergy to Capsicum Annuum Extract and derivative (Bell pepper). On 10/1/23 Resident #1 declined his original meal option and requested a chef salad and chicken noodle soup as an alternative. The nurse called the kitchen and left the resident's request on a voicemail. The voicemail did not include a request for salad dressing. Food and Nutrition Service Assistant Staff A prepared the requested meal and placed an Italian salad dressing on the tray to accompany the salad. Staff A did not review Resident #1's allergies in the computer prior to preparing the meal tray. The tray was delivered to the floor by another employee and handed over to a Certified Nursing Assistant (CNA). The CNA delivered the meal. Resident #1's spouse accepted the tray from the CNA, prepared the salad with the Italian dressing and assisted Resident #1 with his lunch. The facility concluded there was a process in place to ensure the residents' needs were met. The facility had adequate, qualified staff working in the kitchen to meet the residents' needs. Sufficient alternative options were immediately available. Resident #1's allergy was appropriately documented in the electronic medical record and the nutritional computer application. Dietary Staff A preparing the tray admitted the normal process she was trained for would be to confirm the patient's diet and allergies in the computer system prior to preparing the tray. She admitted to an error in not checking the allergies for the requested alternative meal. The facility provided an undated handwritten statement from Staff A that read, Prepared the salad tray for RM (room) 214 and gave patient Italian dressing. I failed to check patient's allergies before doing so. The facility provided a packet of Italian dressing which they said was the same brand they provided to Resident #1 on 10/1/23 with his lunch meal. The ingredients listed, Less than 2% of . Red Bell Pepper . On 10/23/23 at 5:30 p.m., in a telephone interview, Dietary Staff A said the nurse called and asked for a chef salad for Resident #1. She said she made the salad and provided the Italian dressing with the meal. She said she was in a hurry, was not paying attention and did not check the system for Resident #1's allergies or preference before preparing the salad. She said she should have printed a meal ticket. The system would not have allowed her to print a meal ticket with Italian dressing due to the resident's allergy to pepper. Review of the dietary staff meetings revealed Dietary Staff A attended a staff meeting the week of September 4, 2023. The content of the meeting included, Check diets in Computrition BEFORE agreeing to give a patient/therapy/nursing etc. any food . On 10/25/23 at 12:15 p.m., the Director of Nursing said prior to the incident involving Resident #1, the nursing staff did not check the meal tickets before taking a tray to the residents. After the incident, the facility implemented a new process which includes nursing to check the meal ticket for the right diet, including food allergies prior to delivering the meal to the resident. On 10/25/23 at 12:34 p.m., the Administrator said prior the incident involving Resident #1, the dietary staff was responsible to check for food allergies in their system. They did not always print out meal tickets when a resident requested an alternate meal. She said at this time all staff are (continued on next page) 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 10/26/2023 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 0806 required to make sure they have a meal ticket and check for allergies before delivering the meal to the resident. Level of Harm - Immediate jeopardy to resident health or safety The immediate actions implemented by the facility and verified by the surveyor on 10/25/23 and 10/26/23 included: Residents Affected - Few Resident #1's symptoms immediately attended. The surveyor verified through review of the clinical record. Staff interviews, regulatory notifications, investigation, and root cause analysis initiated immediately. The surveyor verified through review of the investigation and root cause analysis completed. Residents allergies and preferences reviewed by the Dietitian on 10/2/23 and verified for current residents, including EPIC (Computer system) and Computrition (Dietary computer system) are matching. The surveyor verified through review of the audits completed. Administrator, Director of Nursing, Risk Manager and Director of Clinical Nutrition reviewed process for alternate tray requests to be provided to residents on 10/2/23. On 10/2/23 the new process was initiated, and all facility staff completed education on re-printing ticket for additional tray requests for all food items leaving the kitchen. The education was completed at 100% by 10/3/23. The surveyor verified through review of the education, review of the new facility's policy and procedure and interview with dietary and nursing staff. Surveyor verified through observation of meals. Each meal tray had a meal ticket and residents with documented allergies did not receive any food they were allergic to. On 10/2/23 the Administrator, Director of Nursing, Risk Manager and Director of Clinical Nutrition reviewed and educated all facility staff on process for acknowledging food allergens on tray before leaving kitchen and upon receipt on units, prior to delivery to resident or family member requesting to assist resident. This education was completed at 100% on 10/3/23. The surveyor verified through review of the education, random nursing and dietary staff interview, and observation of meal delivery. Audits began on 10/2/23 and are being completed ongoing to ensure tray accuracy related to allergies for all meals. These audits are being completed by nursing and dietary staff. Audit completed on 10/2/23 by the Registered Dietitian to ensure allergies in EPIC and Computrition were correct. The surveyor verified through review of audits, interview with the Registered Dietitian, the Administrator, and the Director of Nursing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106122 If continuation sheet Page 4 of 4