Health inspection·May 31, 2023

F 0684 topically in the morning was also noted. Level of Harm - Minimal harm or potential for actual harm On 4/28/23 the wound care orders were updated for Gentamicin Sulfate external ointment 0.1% apply topically in the morning for infection, cleanse with normal saline (NS), then apply Gentamicin and mupirocin to wound bed, cover with Adaptic then ABD (abdominal) pad, and wrap with kerlix; and Mupirocin external ointment 2% apply topically in the morning for infection to right and left lower leg, cleanse with NS then apply Gentamicin and mupirocin to wound bed, cover with Adaptic then ABD pad, and wrap with kerlix then ace wraps. Residents Affected - Few Review of the Physician progress notes dated 4/25/23 at 10:38 a.m. noted Resident #10 underwent excisional debridement of left leg and left leg excisional debridement into the bone, with graft application of myriad wound graft application of myriad morsels to left leg for a large hematoma of right lower extremity (RLE) and laceration of left lower extremity (LLE) with (name of physician) (surgical wound care physician) on 4/13/23. On 4/26/23, Resident #10 had during an appointment at the wound care clinic, the surgical wound care physician wrote good uptake of the right lower extremity graft myriad, skin with good uptake myriad xenograft right lower extremity left knee medial superficial abrasion laceration mild necrosis to the wound bed. Under the Assessment/Plan section of the progress note, the wound care physician wrote: 1) hematoma of right lower leg, status post myriad graft 12 days ago. Staples removed in the office. Good uptake of graft. Bactroban, gentamicin, Adaptic gauze, and Ace. 2) abrasion of skin of left lower leg Bactroban, gentamicin, Adaptic, Ace. Return to clinic on 5/17/23. Review of the Nursing Weekly Skin Check form dated 4/28/23 by the Assistant Director of Nursing (ADON) documented: left knee abrasion 6 x 2.5 x 0.1 cm (centimeters) with epithelial and granulation tissue with scant serosanguinous drainage. The right lower leg wound was described as 10.5 x 8.5 x N/A cm with graft that was intact, well approximated, and pink in color with bruising in the surrounding area. The right ankle was described as 6.5 x 1 x N/A cm with dried fibrinous scab with no drainage. Review of the Nursing Weekly Skin Check form dated 5/3/23 by Staff H License Practical Nurse (LPN) documented Resident #10 had a skin graft to right lower leg, skin graft was intact, pink in color and well approximated with no sign of infection. Treatment was in place and a dressing was applied. A dry scab was observed to the right outer ankle. An abrasion to left knee with no sign or symptom of infection, but with slight serosanguineous drainage. Epithelial and granulation tissue were present. Treatment in place and covered with ABD pad and wrapped with kerlix then ace wrap. Nursing Weekly Skin Check form dated 5/11/23 by Staff H LPN documented Resident #10's wound to right leg was pink in color and the dermis layer was exposed. There were no signs or symptoms of infection noted. A treatment was in place and a dressing was applied. A dry scab to right outer ankle was observed and an abrasion to left knee with no signs or symptoms of infection, slight serosanguineous drainage noted. Epithelial and granulation tissue were present. A treatment was in place and covered with ABD pad and wrapped with kerlix then Ace wrap. On 5/17/23 Resident #10 had an appointment at the wound care clinic. The wound care physician wrote status post myriad graft to right medial leg approximately 1 month ago. She currently resides in the nursing home with dressings. Bactroban, gentamicin, Adaptic daily. Currently there is no evidence of graft and bone is exposed, and the patient is very tender there. The daughter is concerned about the change in the patient's mentation as well. Direct admit to (name of hospital). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106137 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 106137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Preserve 14750 Hope Center Loop 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 Residents Affected - Few On 5/26/23 at 10:40 a.m., the ADON said she was the Wound Care Nurse for the facility until the newly hired Wound Care Nurse became fully trained. She confirmed she had conducted Resident #10's weekly body audit and had written on the Nursing Weekly Skin Check form Resident #10 right lower leg skin graft was intact, well approximated and pink in color. The ADON said she was unaware Resident #10's right lower leg skin graft was missing until 5/17/23 when Resident #10's wound care physician discovered the skin graft was missing during the wound care appointment. She said the Director of Nursing (DON) started an investigation to determine when Resident #10's skin graft went missing. On 5/26/23 at 12:32 p.m., in an interview with Staff I RN (Registered Nurse), she said Resident #10's daily lower legs dressing changes were scheduled for 6:00 a.m. in the morning. She said Resident #10 wound refuse the dressing change to right leg, so she never observed the surgical wound to the right leg for a long time. She said she didn't remember when she first observed Resident #10's right leg surgical wound, but she remembered, it did not look good. She said when Resident #10 allowed her to do the dressing change to the right leg she didn't remember seeing a skin graft to the right leg wound site. She said she did not document Resident #10 had refused the daily wound care dressing to the right leg wound surgical site. On 5/26/23 at 3:37 p.m., in an interview with the DON and ADON, they said Staff H had completed Resident #10's Weekly Skin Check on 5/3/23 and 5/11/23. They confirmed the Weekly Skin Check dated 5/3/23 stated the skin graft was intact to the right lower leg, pink in color and well approximated. They also confirmed on the 5/11/23 note, Staff H wrote Resident #10's wound to right leg is pink in color and the dermis layer was exposed. On 5/26/23 at 4:19 p.m., in an interview with Staff H, she confirmed she had completed Resident #10's Weekly Skin Check on 5/3/23 and 5/11/23. She said when she did the skin audit on 5/3/23 and daily wound care treatments Resident #10's right leg skin graft was intact. Staff H also stated when she did the weekly skin check audit on 5/11/23, she noted the right leg skin graft was missing and she informed the day shift nurse of the missing skin graft and to inform the ADON of the missing skin graft, because the day shift nurse was the Wound Care Nurse. She said she remembered Resident #10 telling her one of the nursing staff did not change the dressing to her legs but didn't remember the dates. On 5/30/23 at 1:38 p.m., in an interview with the DON and ADON, they confirmed Resident #10 was admitted to the facility on [DATE] with a wound to her both lower legs and a skin graft to the right lower leg. They both said they observed the right lower leg skin graft on 4/28/23 and it was intact, well approximated, and was pink in color. They confirmed Staff H documented on 5/3/23 the right lower leg skin graft was present during the weekly skin audit but documented on 5/11/23 the right leg skin graft was not present. During the interview, the DON said the facility was unaware until 5/17/23 when Resident #10's daughter told them, when the wound care clinic physician had removed the dressing to Resident #10's right leg dressing the skin graft was missing. The daughter reported to the facility due to the skin graft being missing and other complications, Resident #10 was sent to the hospital for evaluation and treatment. The DON said after talking with Resident #10's daughter she started the investigation into when Resident #10's skin graft went missing and to determine which staff were involved. She said as of the time of the interview, she had not completed the investigation to determine who was involved or when the skin graft went missing. On 5/31/23 at 10:25 a.m., in an interview with the facility's Medical Director said, he said when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106137 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 106137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Preserve 14750 Hope Center Loop 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 Residents Affected - Few there was a change in a resident's condition which would have included wound observation, the nursing staff were required to call the resident's primary care physician and document their findings and any new physician order(s). He said if the nursing staff were unable to follow a physician order for any reason, they were required to inform administration and the resident's primary care physician to determine what interventions needed to be taken. He said he did not become aware of Resident #10's missing skin graft until 5/17/23 but would expect when the skin graft was first observed missing the nursing staff would have informed the resident's physician of the missing skin graft to determine the next course of action. On 5/31/23 at 2:11 p.m., in an interview with the DON, she said after a review of Resident #10's medical record, the right leg skin graft went missing sometime after 5/8/23. She said she was unable to find documentation the nursing staff had informed Resident #10's primary care physician and/or administration when Resident #10's had refused her lower legs dressing changes and when Resident #10's skin graft was observed not attached to the right leg surgical site. She said the nursing staff did not inform the Interdisciplinary Team, Physician/PA/CNP and resident representative of any changes in skin integrity as noted in the facility's policies and standard of care as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106137 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 106137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Preserve 14750 Hope Center Loop 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policies and procedures, and interview the facility failed to ensure ongoing skin assessment and implementation of necessary preventive measures to prevent the development of pressure ulcers for 1 (Resident #1) of 4 sampled residents who developed a pressure ulcer at the facility. Residents Affected - Few The findings included: The facility's policy and procedure for prevention and treatment of skin breakdown with a revised date of 7/2018 noted, It is the policy of Volunteers of America to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide the appropriate treatment modalities for wounds according to industry standards of care . If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: Notify Physician/PA (Physician Assistant)/CNP (Certified Nurse Practitioner) and Resident and/or Resident Representative . Notify Supervisor/Designee as assigned . Re-evaluate interventions per risk factors identified . Update the residents individualized care plan for Skin Integrity and nursing assistant [NAME] with any skin concern. Review of the clinical record for Resident #1 revealed an admission date of 10/18/22 with diagnoses including quadriplegia (paralysis of all four limbs). The admission Minimum Data Set (MDS) Assessment with an assessment reference date of 10/25/22 noted the resident's cognition was intact with a Brief Interview for Mental Status of 15. The resident's skin was intact. Resident #1 required the physical assistance of one person for activities of daily living. Review of the progress notes revealed on 4/6/23 at 8:00 a.m., Resident #1 complained of pain to the right thigh and was treated with Tylenol. The resident's right knee and both his feet were swollen. The resident stated two nights ago when the night shift Certified Nursing Assistant was getting him ready, his right knee bumped the right side of the bed. Review of the facility's investigation revealed an X-Ray obtained on 4/6/23 showed an acute appearing fracture of the distal femur (thigh bone). On 4/6/23 the physician issued an order to apply an immobilizer to the right knee. The order specified staff may remove the immobilizer for hygiene and skin check every day and night shift. On 4/8/23 Resident #1 was transferred to the local hospital for complaint of worsening of leg pain and right ankle swelling. The resident was diagnosed with an acute fracture of the right ankle. Resident #1 returned to the facility on 4/11/23 with orders for a right knee immobilizer and a Controlled Ankle Motion (CAM) boot to the right ankle (removable orthopedic boot prescribed for treatment and stabilization of fractures). The physician's orders dated 4/11/23 specified to apply the CAM boot and right knee immobilizer to the right lower extremity at all times and may remove to check skin integrity and for hygiene every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106137 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 106137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Preserve 14750 Hope Center Loop 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 0686 shift. Level of Harm - Actual harm On 4/19/23 Physical Therapist Staff A documented she performed a skin inspections of the resident's bilateral lower extremities and noted slight redness on the bony prominences. She documented she adjusted the knee immobilizer and boot for proper fit and to prevent increased pressure. She discussed the findings with the nursing staff. Residents Affected - Few The clinical record lacked documentation of a nursing assessment of the redness reported by Physical Therapist Staff E. There was no documentation in the clinical record the physician was notified of the redness to the bony prominences for additional interventions as necessary. Further review of documentation in the clinical record revealed on 4/24/23 Registered Nurse (RN) Staff B noted the CAM boot overlapped the immobilizer from the right knee (mid-thigh to lower leg). RN Staff B, the Assistant Director of Nursing and the evening supervisor completed a skin assessment of the resident's right leg which revealed a deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue) to the right shin measuring 11 centimeters (cm) in length by 1.2 cm (width), a deep tissue injury to the right lateral leg measuring 3.0 cm (length) by 7.0 cm (width), a deep tissue injury of the right great toe measuring 1.0 cm (length) by 1.0 cm (width), a deep tissue injury to the sole of the right foot measuring 1.2 cm (length) by 0.8 cm (width), a deep tissue injury of the right heel measuring 4.0 cm (length) by 5.0 cm (width). On 4/25/23 the wound care physician assessed the resident's right leg and documented in a progress note an unstageable deep tissue injury of the right shin, right calf, right plantar (sole of foot), right first toe, right heel, right dorsal second toe, right lateral knee, and the right thigh. The wound care physician documented, Multiple wounds. Wound details included multiple right leg pressure possible arterial wounds are noted. If wounds are pressure related from long extremity immobilizing brace or cam boot, the injuries can occur over a short time span (from 4 to 6 hours). The injuries can occur while asleep. Even with vigilant survey and evaluation of the skin under the brace it can rapidly cause injury between nurse evaluations. The only way to completely ensure that no pressure injuries occur is to remove the brace which is usually discouraged by the primary surgeon. This was discussed with the staff and also arterial studies will be recommended to determine if there may be an underlying disease that hastened this process. The Arterial Ultrasound of the right lower extremity dated 4/26/23 noted, Occlusion disease of the superficial femoral artery reconstitution of the popliteal artery occlusion distally. On 4/26/23 Resident #1's wounds were assessed by an orthopedic physician who issued an order to discontinue the CAM boot and immobilizer, and for the nurses to check the right leg to monitor for pressure sores twice a day. Review of the facility's investigation related to the new multiple pressure areas of the resident's right leg revealed: On 4/19/23 Licensed Practical Nurse Staff C who worked the night shift (7:00 p.m., to 7:00 a.m.) signed on the Medication Administration Record she completed a skin check for Resident #1. The nurse said she did not check the resident's right leg and interpreted the order as, If I need to check the skin for any reason, I may remove the immobilizer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106137 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 106137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Preserve 14750 Hope Center Loop 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 0686 Level of Harm - Actual harm On 4/20/23 agency LPN D worked the night shift (7:00 p.m., to 7:00 a.m.). She checked the order on the Treatment Administration Record (TAR) acknowledging the order that she may remove the immobilizer and CAM boot. She said she felt no reason to remove the immobilizer or CAM boot to check the resident's skin since the day shift nurse did not mention any issues and the resident was restful that night. Residents Affected - Few On 4/21/23 LPN Staff E who worked the day shift (7:00 a.m., to 7:00 p.m.) admitted she did not remove the immobilizer nor the CAM boot to check Resident #1's skin integrity. She said she signed the TAR with the understanding she may remove the immobilizer and CAM boot, but the resident was sound asleep, and she did not want to interfere with his sleep. She said she was not made aware of any skin issues to the resident's right leg. On 4/21/23 LPN Staff F who worked with Resident #1 said she received report from the outgoing agency nurse that day who told her the resident had a new reddened area on the back of his leg. She did not know if the agency nurse checked Resident #1 or not. She said she took off the CAM boot and noticed slight redness to the back of the leg, slight reddened area to the right shin. LPN staff F said she placed ordered powder to the back of the leg and rubbed powder to the reddened area to the right shin. The nurse documented a late entry that read, around 10-1030 am resident treatment was applied to both lower extremities . and resident stated to me that he has an area on the back side of his right leg, this nurse lift [sic] his right leg up as much as he can tolerate and observed small upper area, this nurse applied nystatin (antifungal) to the area. resident stated to me . can you take a picture from your phone and send it to my wife . The clinical record lacked documentation of an RN assessment of the areas of concern observed to the resident's right leg. There was no documentation the physician was notified of the abnormal skin findings. Review of the Resident Assessment Instrument (RAI) Manual instructions for unstageable pressure injuries related to deep tissue injury revealed, Planning for Care. Deep tissue injury requires vigilant monitoring because of the potential for rapid deterioration. Such monitoring should be reflected in the care plan . Clearly document assessment findings in the resident's medical record, and track and document appropriate wound care planning and management. On 5/31/23 at 2:45 p.m., the Director of Nursing said every effort was being made to ensure similar incidents don't happen. She provided documentation of an ad HOC Quality Assurance and Performance Improvement Plan held on 4/28/23. The facility opened a Performance Improvement Project for pressure related skin preventions on 4/25/23. She provided a copy of the immediate actions implemented by the facility related to Resident #1's pressure ulcers, including education to the nurses with a document titled, What are the Major Causes of Medical Device-Related Pressure Injury (MDRPI)? Cast and Splints. The document read, Casts and splints are major causes of medical device-related pressure injuries. There are 2 main factors for this: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106137 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 106137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Preserve 14750 Hope Center Loop 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 0686 When the order states that the device must not be removed, or MAY be removed. Level of Harm - Actual harm 2. Residents Affected - Few When clinicians are worried about their competency to remove a splint and replace it correctly. For a splint that can be removed fully, take care to note how it is placed before removing it (take a photograph if necessary). Knowing how the splint is meant to function will help to ascertain correct positioning. If a problem is identified, discuss with colleagues how to address the issue . Offloading boots need to be removed during repositioning, and the skin must be checked before replacing the boots after repositioning. Conclusion. The prevention of medical device-related pressure injuries is very much the responsibility of the whole health care team . staff need to feel competent and confident to manage devices needed for patient care and treatment. We need to protect the patient and the skin they are in. Devices that are removable must be removed and checked for skin concerns every shift. On 5/31/23 review of the in-service sign in sheet dated 4/26/23 for Skin assessment/skin issue reporting showed three of the 20 nurses, and nine of the 43 CNAs employed at the facility attended the in-service. The In-Service sign in sheet dated 4/25/23 for Reporting changes in skin condition during care. Wound care prevention protocol showed one nurse and 18 CNAs attended the in-service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106137 If continuation sheet Page 8 of 8