Inspection·January 27, 2026

K0324 Cooking Facilities K0324 The plan of correction is submitted as required under SS = D CFR(s): NFPA 101 Federal and State regulations and statutes applicable Cooking Facilities to long-term care providers. This plan of correction Cooking equipment is protected in accordance with NFPA does not constitute an admission of liability on the 96, Standard for Control and Fire part of the facility, and such liability is hereby Protection of Commercial Cooking Operations, unless: specifically denied. This plan of correction * residential cooking equipment (i.e., small appliances constitutes our written allegation of compliance. such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. 1. The (MUA) make-up air unit for the kitchen hood system has been repaired and is functioning correctly. 2. No facility residents were , by this deficient practice. 3. The Maintenance Department staff will be in-serviced by the Executive Director/designee on maintaining the commercial cooking fire extinguishing equipment in accordance with national Fire Protection Association (NFPA) 101. 4. The Maintenance Director/designee will complete a 106057 LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD, ESTERO, Florida, 33928 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

K0324 SS = D Continued from page 1 Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, This STANDARD is NOT MET as evidenced by: Based on observation, and staff interview, it was revealed that the facility failed to maintain the commercial cooking fire extinguishing equipment in accordance with National Fire Protection Association (NFPA) 101. The findings included: On at 2:20 p.m. while touring the kitchen with the (DOM) Director of Maintenance, the exhaust and (MUA) make-up air units for the kitchen hood system were nonfunctioning. When interviewed the DOM said there was a power disruption on which causes the unit to shut off and requires manual reset. After the DOM reset the system the hood exhaust engaged, however the MUA was still nonfunctional. When interviewed the DOM said the system did not have a make-up air unit. An interview was conducted with the Maintenance Director, concurrent with the observations acknowledging the findings. On at 4:15 p.m. while touring the roof with the (MA) Maintenance Assistant, the kitchen MUA was located. The MA removed the cover, verifying the unit was non-operational. The kitchen has 1 hood system composing of 1 exhaust and 1 make-up air. Failure of this unit affects all staff in that compartment. An interview was conducted with the Maintenance Assistant, concurrent with the observations acknowledging the findings. per NFPA 101 (2012 Edition) 19.3.2.5.1, 9.2.3 per NFPA 96 (2011 Edition) 4.1.2, 4.1.4, 8.3.1

K0324 Continued from page 1 weekly audit of the commercial cooking fire extinguishing equipment to ensure it is maintained in accordance with National Fire Protection Association (NFPA) 101. Results of the audits will be brought to the monthly Quality Assurance and Performance Improvement meeting for review and recommendations for a period of three months, or until sustained compliance is achieved.

K0345 SS = F Fire Alarm System - Testing and Maintenance

K0345 1. The Biennial Smoke Detector Sensitivity test was performed on the 40 Duct Detectors. /2026 106057 LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD, ESTERO, Florida, 33928 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

K0345 SS = F Continued from page 2 CFR(6); NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This STANDARD is NOT MET as evidenced by: Based on record review and staff interview, the facility failed to maintain the Fire Alarm System in accordance with National Fire Protection Association (NFPA) 101. Maintaining the Fire Alarm System ensures proper operation and lessens the chance of delayed alarm operation or failure under hazardous conditions. Injury or can result in a fire alarm failure. The findings included: On between 9:30 a.m. and 12:00 p.m., during record review with the Maintenance Director, it was observed that the biennial smoke detector sensitivity test performed on 76 smoke detectors did not include the 40 Duct Detectors. An interview was conducted with the Maintenance Director, concurrent with the observations acknowledging the findings. per NFPA 101 (2012 Edition) 19.3.4.1, 9.6.1.3 per NFPA 72 (2010 Edition) 14.4.5.3.2

K0908 SS = F Gas and Vacuum Piped Systems - Inspection and CFR(6); NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, 8.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)

K0345 Continued from page 2 2. No facility residents were , by this deficient practice. 3. Maintenance department staff will be in-serviced by the Executive Director/designee on the Testing and Maintenance of the Fire Alarm System in accordance with the National Fire Protection Association (NFPA) 101. 4. The Maintenance Director/designee will complete a monthly audit to ensure compliance that the fire alarm system is maintained and tested in accordance with National Fire Protection Association (NFPA) 101. Results of the audits will be brought to the monthly Quality Assurance and Performance Improvement meeting for review and recommendations for a period of three months, or until sustained compliance is achieved.

K0908 The wall and vacuum systems are disconnected and no longer in use. /2026 No facility residents were , by this deficient practice. No further measures needed to be put in place or systematic changes due to the facility no longer using the system. No further monitoring needed as the wall and vacuum systems are no longer in use. 106057 LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD, ESTERO, Florida, 33928 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

K0908 SS = F Continued from page 3 This STANDARD is NOT MET as evidenced by: Based on observations and staff interview, the facility failed to maintain medical gas systems in accordance with National Fire Protection Association (NFPA) 101. Improper use and management of medical gas systems could result in the failure of the system to perform as designed. The findings included: On between 9:30 a.m. and 12:00 p.m. during record review with the Maintenance Director, documentation for the Annual med gas inspection could not be produced. The system includes bulk and vacuum. Failure to perform the required inspections would affect all residents using wall and vacuum systems. An interview was conducted with the Maintenance Director, concurrent with the observations acknowledging the findings. Per NFPA 101 (2012 Edition) 19.3.2.4 per NFPA 99 (2012 Edition) 5.1.12.3.5.2, 5.1.14.2.3, 5.1.14.4.5, 5.1.14.4.9.5.1.15

K0908

K0918 SS = F Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored

K0918 The generator is maintained and tested in accordance with the National Fire Protection Association (NFPA) 101 as it pertains to the monthly conductance testing and the load testing. No current residents were by this deficient practice. Maintenance department staff will be in-serviced by the Executive Director/designee on the Testing and Maintenance of the generator as it pertains to the monthly conductance testing and the load testing. The Maintenance Director/designee will complete a monthly audit to ensure compliance that the generator is maintained and tested in accordance with the national Fire Protection Association (NFPA) 101 as it pertains to the conductance testing and load testing. /2026 3850 WILLIAMS ROAD, ESTERO, Florida, 33928 CROSS-REFERENCED TO THE COMPLETION DATE

K0918 Continued from page 4 SS = F energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically inspecting the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This STANDARD is NOT MET as evidenced by: Based on record review and staff interview, the facility failed to provide evidence of generator maintenance and testing in accordance with National Fire Protection Association (NFPA) 101. Failure to maintain the prime mover will result in a loss of power to the facility thus endangering all the residents and occupants of the facility. The findings included: On between 9:30 a.m. and 12:00 p.m., during record review with the Maintenance Director, the facility failed to show evidence of monthly specific gravity, or conductance testing of the generators' 2 maintenance free batteries. When interviewed, the Maintenance Director said the facility does not have a conductance tester weekly voltage testing of the generators' 2 maintenance free batteries. Monthly load testing of the facility life safety generator. When interviewed, the Maintenance Director said he did not transfer power to load the generator during the monthly test. The facility has 1 250 KW diesel powered, level 1 generator. An interview was conducted with the Maintenance Director, concurrent with the observations acknowledging the findings. Per NFPA 101 (2012 Edition) 19.5.1.1, 9.1.3.1 per NFPA 110 (2010 Edition) 8.1.1, 8.3.4, 8.3.7, 8.3.7.1, 8.4.1, 8.4.2, 8.4.3, 8.4.6 K0918 Continued from page 4 Results of the audits will be brought to the monthly Quality Assurance and Performance Improvement meeting for review and recommendations for a period of three months, or until sustained compliance is achieved. LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD, ESTERO, Florida, 33928 CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

K0918 SS = F Continued from page 5 Class III

K0918

K0920 SS = F Bldg. 02 Electrical Equipment - Power and Extens

K0920 The two front desk RPTs (relocatable power taps) have been reduced to 1, the extension were removed from Resident , the staff break room vending machine, the Medical Records office, and the Doctors' lounge. The refrigerators and microwaves in the care and MDS offices are plugged directly into a wall outlet. /2026 CFR(s); NFPA 101 Electrical Equipment - Power and Extension Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assemblies that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity shall not be used for non-patient care personal electronics, except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension are not used as a substitute for fixed wiring of a structure. Extension used temporarily are removed immediately upon completion of the purpose of which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70). This STANDARD is NOT MET as evidenced by: The findings included: On between 12:00 p.m. and 4:30 p.m., while touring the facility with the Maintenance Director the following was observed: 1. Front desk, 2 RPT observed daisy chained, plugged into an outlet. 2. Resident , extension cord in use. 3. Staff break room, vending machine observed plugged into an extension cord. 4. Medical records office, extension cord in use. 5. care office, refrigerator and microwave observed plugged into a RPT. 6. Doctors lounge, extension cord in use. Weekly rounds have been added to the tasks in TELS for the maintenance director to complete to ensure that relocatable power tabs (RPT) and extension are used and maintained in accordance with National Fire Protection Association (NFPA) 101. Maintenance department staff will be in-serviced by the Executive Director/designee to ensure that relocatable power tabs (RPT) and extension are used and maintained in accordance with National Fire Protection Association (NFPA) 101. The Maintenance Director/designee will complete a weekly audit to ensure compliance that relocatable power tabs (RPT) and extension are used and maintained in accordance with National Fire Protection Association (NFPA) 101. Results of the audits will be brought to the monthly Quality Assurance and Performance Improvement meeting for review and recommendations for a period of three months, or until sustained compliance is achieved. 106057 LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD, ESTERO, Florida, 33928 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

K0920 SS = F Bldg. 02 Continued from page 6 7. MDS office, refrigerator and microwave observed plugged into a RPT. An interview was conducted with the Maintenance Director, concurrent with the observations acknowledging the findings. Per NFPA 99 (2012 Edition) 10.2.3.6 Per NFPA 101 (2012 Edition) 19.5.1.1, 9.1.2 Per NFPA 70 (2011 Edition) Article 400.8

K0920 106057 LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD, ESTERO, Florida, 33928 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

E0000 Initial Comments

E0000 /2026 During the Fire & Life Safety recertification survey conducted on nursing home, Emergency Preparedness was reviewed. Life Care Center of Estero is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 483.73, Requirement for Long-Term Care Facilities. 01/27/2026 LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD, ESTERO, Florida, 33928 CROSS-REFERENCED TO THE COMPLETION DATE

K0000 INITIAL COMMENTS K0000 /2026 An unannounced Fire & Life Safety re-licensure survey was conducted on at Life Care Center of Estero, a nursing home in Estero, Florida in accordance with National Fire Protection Association (NFPA) 1 and 101 (2021 Edition) and applicable requirements of Florida State Fire Marshal's Rules and Regulations, Florida Administrative Code (F.A.C. 69A-3, F.A.C. 69A-53, F.A.C. 59A-4, and Florida Statutes (F.S.) 400.11, and F.S. 633.0215, adopting National Fire Protection Association (NFPA) 1 and 101 (2021 Edition) known as the Florida Fire Prevention Code and all NFPA referenced standards and requirements adopted per NFPA 101, Chapter 2. The following is description of the deficiencies found at the time of the visit.

K0324 CFR(s): NFPA 101 K0324 /2026 SS = D Cooking Facilities Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4. Commercial cooking operations shall be protected in accordance with NFPA 96 unless such installations are approved existing installations, which shall be permitted to be continued in service. 18.3.2.5.1 through 18.3.2.5.5, 19.3.2.5.1 through 19.3.2.5.2, 9.2.3. This LICENSURE REQUIREMENT IS NOT MET as evidenced by: Based on observation, and staff interview, it was revealed that the facility failed to maintain the commercial cooking fire extinguishing equipment in accordance with National Fire Protection Association (NFPA) 101. On at 2:20 p.m. while touring the kitchen with the (DOM) Director of Maintenance, the exhaust and The plan of correction is submitted as required under Federal and State regulations and statutes applicable to long-term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. This plan of correction constitutes this written allegation of compliance. 1. The (MUA) make-up air unit for the kitchen hood system has been repaired and is functioning correctly. 2. No facility residents were deficient practices. by this 3. The Maintenance Department staff will be in-serviced by the Executive Director/designee on maintaining the commercial cooking fire extinguishing equipment in accordance with national Fire Protection Association (NFPA) 101. 4. The Maintenance Director/designee will complete a weekly audit of the commercial cooking fire extinguishing equipment to ensure it is maintained in accordance with National Fire Protection Association (NFPA) 101. Results of the audits will be brought to the monthly Quality Assurance and Performance Improvement meeting Office of Primary Care and Health Systems Management Florida Department of Health 01/27/2026 LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD, ESTERO, Florida, 33928 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

K0324 SS = D Continued from page 1 (MUA) make-up air units for the kitchen hood system were nonfunctioning. When interviewed the DOM said there was a power disruption which causes the unit to shut off and requires manual reset. After the DOM reset the system the hood exhaust engaged, however the MUA was still nonfunctional. When interviewed the DOM said the system did not have a make-up air unit. An interview was conducted with the Maintenance Director, concurrent with the observations acknowledging the findings. On at 4:15 p.m. while touring the roof with the (MA) Maintenance Assistant, the kitchen MUA was located. The MA removed the cover, verifying the unit was non-operational. The kitchen has 1 hood system composing of 1 exhaust and 1 make-up air. Failure of this unit affects all staff in that compartment. An interview was conducted with the Maintenance Assistant, concurrent with the observations acknowledging the findings. per NFPA 101 (2021 Edition) 19.3.2.5.1, 9.2.3 per NFPA 96 (2021 Edition) 4.1.2, 4.1.4, 8.3.1 Class III

K0324 Continued from page 1 for review and recommendations for a period of three months, or until sustained compliance is achieved.

K0345 SS = F Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance Detection systems, where required, shall be in accordance with Section 9.6. Fire alarm systems required by this Code shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA70 and NFPA72 unless otherwise permitted by 9.6.1.4. 18.3.4.1, 19.3.4.1, 9.6, and NFPA 70, and NFPA 72 This LICENSURE REQUIREMENT IS NOT MET as evidenced by: Based on record review and staff interview, the facility failed to maintain the Fire Alarm System in accordance with National Fire Protection Association

K0345 1. The Biennial Smoke Detector Sensitivity test was performed on the 40 Duct Detectors. 2. No facility residents were by this deficient practices. 3. Maintenance department staff will be in-serviced by the Executive Director/designee on the Testing and Maintenance of the Fire Alarm System in accordance with the National Fire Protection Association (NFPA) 101. 4. The Maintenance Director/designee will complete a monthly audit to ensure compliance that the fire alarm system is maintained and tested in accordance with National Fire Protection Association (NFPA) 101. Results of the audits will be brought to the monthly Quality Assurance and Performance Improvement meeting for review and recommendations for a period of three months, or until sustained compliance is achieved. /2026 STATE FORM Florida Department of Health PRINTED: 02/19/2026 3850 WILLIAMS ROAD, ESTERO, Florida, 33928

K0345 SS = F Continued from page 2 (NFPA) 101: Maintaining the Fire Alarm System ensures proper operation and lessens the chance of delayed alarm activation or failure under hazardous conditions. Injury or can result in a fire alarm failure. The findings included: On between 9:30 a.m. and 12:00 p.m., during record review with the Maintenance Director, it was observed that the biennial smoke detector sensitivity test performed on 76 smoke detectors did not include the 4D Duct Detectors. An interview was conducted with the Maintenance Director, concurrent with the observations acknowledging the findings. per NFPA 101 (2021 Edition) 19.3.4.1, 9.6.1.3 per NFPA 72 (2019 Edition) 14.4.4.3.2 Class III

K0908 SS = F Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 99 Gas and Vacuum Piped Systems - Inspection and Testing Operations A maintenance program should be developed and implemented to ensure that the medical gas and vacuum system (MGVS) continues to operate as designed and intended. Some of the key elements of an MGVS maintenance program are as follows: Evaluate equipment status. Develop policy and procedures. Develop schedules for work. Document and evaluate results. Educate all personnel that will work on and use the MGVS. This testing and inspection does not replace the installer and verification testing that must be conducted following any new construction or modification.

K0345

K0908 The wall .. and vacuum systems are disconnected and no longer in use. /2026 No facility residents were .. by this deficient practice. No further measures needed to be put in place or systematic changes due to the facility no longer using the system. No further monitoring needed as the wall .. and vacuum systems are no longer in use. Florida Department of Health LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD, ESTERO, Florida, 33928 --- | --- | --- | --- | ---

K0908 SS = F | Continued from page 3 5.1.14.4.3, 5.1.14.7, 5.2.13, 5.3.13 (NFPA 99) This LICENSURE REQUIREMENT IS NOT MET as evidenced by: Based on observations and staff interview, the facility failed to maintain medical gas systems in accordance with National Fire Protection Association (NFPA) 101. Improper use and management of medical gas systems could result in the failure of the system to perform as designed. The findings included: On between 9:30 a.m. and 12:00 p.m. during record review with the Maintenance Director, documentation for the Annual med gas inspection could not be produced. The system includes bulk and vacuum. Failure to perform the required inspections would affect all residents using wall and vacuum systems. An interview was conducted with the Maintenance Director, concurrent with the observations acknowledging the findings. Per NFPA 101 (2021 Edition) 19.3.2.4 Per NFPA 99 (2021 Edition) 5.1.14.4.1, 5.1.14.4.3, 5.1.14.7 Class III | K0908 | |

K0918 SS = F | Electrical Systems - Essential Electric Syste CFR(s): NFPA 99 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times in a year in 20-40-day intervals, and exercised once every 36 months for four continuous | K0918 | The generator is maintained and tested in accordance with the National Fire Protection Association (NFPA) 101 as it pertains to the monthly conductance testing and the load testing. No current residents were by this deficient practice. Maintenance department staff will be in-serviced by the Executive Director/designee on the Testing and Maintenance of the generator as it pertains to the monthly conductance testing and the load testing. The Maintenance Director/designee will complete a monthly audit to ensure compliance that the generator is maintained and tested in accordance | /2026 STATE FORM Florida Department of Health LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD, ESTERO, Florida, 33928

K0918 SS = F Continued from page 4 hours. Scheduled test under load conditions includes a transfer simulated start and automatic or manual transfer of all EES loads and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.9.1, 6.9.2, 6.9.3, 6.9.4, 6.10.18, 6.11 through 6.11.4.4 (NFPA 99), NFPA 110, NFPA 111, NFPA 70 This LICENSURE REQUIREMENT is NOT MET as evidenced by: Based on record review and staff interview, the facility failed to provide evidence of generator maintenance and testing in accordance with National Fire Protection Association (NFPA) 101. Failure to maintain the prime mover will result in a loss of power to the facility thus endangering all the residents and occupants of the facility. The findings included: On between 9:30 a.m. and 12:00 p.m., during record review with the Maintenance Director, the facility failed to show evidence of monthly specific gravity, or conductance testing of generators' 2 maintenance free batteries. When interviewed, the Maintenance Director said the facility does not have a conductance tester/weekly voltage testing of the generators' 2 maintenance free batteries. Monthly load testing of the facility life safety generator. When interviewed, the Maintenance Director said he did not transfer power to load the generator during the monthly generator. The facility has 1 250 KW diesel powered, level 1 generator. An interview was conducted with the Maintenance Director, concurrent with the observations acknowledging the findings. Per NFPA 101 (2021 Edition) 19.5.1.1, 9.1.3.1 Per NFPA 110 (2019 Edition) 8.1.1, 8.3.6, 8.3.6.1,

K0918 Continued from page 4 with the national Fire Protection Association (NFPA) 101 as it pertains to the conductance testing and load testing. Results of the audits will be brought to the monthly Quality Assurance and Performance Improvement meeting for review and recommendations for a period of three months, or until sustained compliance is achieved. STATE FORM

K0918 SS = F Continued from page 5 8.4.1, 8.4.2, 8.4.6, 8.4.6.1, 8.5.1 K0918 (blank) (blank)

K0920 SS = F Bldg. 06 Electrical Equipment - Power and Extens K0920 The two front desk RPTs (relocatable power taps) have been reduced to 1, the extension were removed from Resident , the staff break room vending machine, the Medical Records office, and the Doctors' lounge. The refrigerators and microwaves in the care and MDS offices are plugged directly into a wall outlet. /2026 Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assemblies that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension are not used as a substitute for fixed wiring of a structure. Extension used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6, 10.2.4, 10.5.2.3 (NFPA 99), NFPA 70 This LICENSURE REQUIREMENT is NOT met as evidenced by: Based on observations, and staff interview the facility failed to ensure that relocatable power taps (RPT), and extension are reusable and maintained in accordance with National Fire Protection Association (NFPA) 101. This condition could lead to electrical of staff and residents, or loss of power to the facility and a fire hazard affecting all residents as well as staff and visitors. The findings included: On between 12:00 p.m. and 4:30 p.m., while touring the facility with the Maintenance Director the following was observed: 1. Front desk, 2 RPT observed daisy chained, plugged into an outlet. Weekly rounds have been added to the tasks in TELS for the maintenance director to complete to ensure that relocatable power tabs (RPT) and extension are used and maintained in accordance with National Fire Protection Association (NFPA) 101. Maintenance department staff will be in-serviced by the Executive Director/designee to ensure that relocatable power tabs (RPT) and extension are used and maintained in accordance with National Fire Protection Association (NFPA) 101. The Maintenance Director/designee will complete a weekly audit to ensure compliance that relocatable power tabs (RPT) and extension are used and maintained in accordance with National Fire Protection Association (NFPA) 101. Results of the audits will be brought to the monthly Quality Assurance and Performance Improvement meeting for review and recommendations for a period of three months, or until sustained compliance is achieved. Florida Department of Health 130471026 01/27/2026 3850 WILLIAMS ROAD, ESTERO, Florida, 33928 PREFIX PREFIX CROSS-REFERENCED TO THE COMPLETION DATE

K0920 SS = F Bldg. 06 Continued from page 6 2. Resident , extension cord in use. K0920 3. Staff break room, vending machine observed plugged into an extension cord. 4. Medical records office, extension cord in use. 5. care office, refrigerator and microwave observed plugged into a RPT. 6. Doctors lounge, extension cord in use. 7. MDS office, refrigerator and microwave observed plugged into a RPT. An interview was conducted with the Maintenance Director, concurrent with the observations acknowledging the findings. Per NFPA 101 (2021 Edition) 19.5.1.1, 9.1.2 Per NFPA 99 (2021 Edition) 10.2.3.6 Per NFPA 70 (2020 Edition) Article 400.12 Per NFPA 1 (2021 Edition) 11.1.4.2 Class III