Inspection·March 6, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm dermatologist he was told he did not have active health insurance. She said she knew his Medicaid was still pending in status in January 2025 because she said the facility paid for the dermatology group who provided services within the facility to see resident #25 for care. She verified it had been 2 months since that appointment when a referral was requested by the inhouse visiting dermatology group until a follow-up ophthalmology appointment was scheduled. Residents Affected - Some In a telephone interview on 3/06/25 at 11:53 AM, the Business Office Manager's contact #1 at the Florida Department of Children and Families stated that the October 2024 application to continue resident #25's Medicaid was never received. He verified that the submission done on 1/30/25 was considered a late recertification and a recertification that was sent in August 2024 was too early a submission. In a telephone interview on 3/06/25 at 3:40 PM, contact #1 at Assisted Living Facility #1 said she was the Admissions Coordinator for Assisted Living Facility #1. She recalled that resident #25 had been on their wait list since August 2024. She said it was due to the facility not obtaining resident #25's appropriate Medicaid that had delayed the process in his transferring to Assisted Living Facility #1. She said he was currently on their waitlist and April or May 2025 she thought he would potentially be able to move in if the facility did their part regarding supporting resident #25 with his Medicaid. The facility's policy entitled Resident Right- Exercise of Rights dated 4/01/22, stated all activities and interactions with residents shall focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preferences, and choices. Based on observation, interview, and record review, the facility failed to honor resident's with dignity by using labels when referring to residents, such as feeders, and failed to timely protect and promote the rights of a resident who requested support with insurance, for 1 of 1 residents reviewed for healthcare coordination support, (# 25), of a total sample of 42 residents. Findings include: 1. On 3/03/25 at 12:24 PM, residents were observed in the dining room for the lunch meal service. A few minutes later at 12:36 PM, two staff members moved several residents to a large table in the dining room when the Activities Director stated to Certified Nursing Assistant (CNA) E to leave spaces between the residents for staff to help the feeders. On 3/03/25 at 4:39 PM, Licensed Practical Nurse (LPN) F stated the nurses took turns to assist the residents with dining and rotated through dining room. LPN F described helping in the dining room earlier in the day and referred to the dependent diners, as you could see, we had a lot of feeders. On 3/06/25 at 10:24 AM, the Administrator acknowledged staff should not label dependent diners as feeders. The Administrator stated staff had been educated on the importance of dignity of all residents including not using labels, such as feeders for them. The facility's policy entitled Quality of Life-Dignity dated November 2010 indicated staff should not label or refer to residents by their room number, diagnosis or care needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 2 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 2 of 2 residents reviewed for self-administration of medications, of a total sample of 62 residents, (#44, and #92). Residents Affected - Few Findings: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, emphysema, and general anxiety disorder. A review of the Minimum Data Set (MDS) admission assessment, with an assessment reference date of 12/09/24, revealed resident #44 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating she was cognitively intact. On 3/03/25 at 4:12 PM, resident #44 was observed with an Albuterol Tartrate HFA inhaler on her overbed table. The resident stated she took it as needed. On 3/3/25 at 4:33 PM, primary care nurse, License Practical Nurse (LPN) C observed and acknowledged the resident's inhaler at her bedside. LPN C stated the resident had physician orders that she may have the inhaler at the bedside. Review of the Electronic medical record (EMR) revealed a physician order dated 1/16/25 for Levalbuterol Tartrate inhalation Aerosol 45 micrograms/actuation (MCG/ACT) 2 packet inhale orally every 6 hours as needed for shortness of breath. There was no order to keep the medicine at bedside or for the resident to self-administer the medication. 2. Resident #92 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, major depression, and emphysema. A review of the MDS Quarterly assessment, with an assessment reference date of 1/29/25, revealed resident #44 had a BIMS score of 15/15, indicating she was cognitively intact. On 3/03/25 at 4:41 PM, LPN C, the primary nurse, acknowledged resident #92 with her inhaler in her jacket pocket. LPN C stated that resident #92 had a physician order that allowed her to keep her inhaler at the bedside. A review of the EMR reflected a physician order dated 4/30/24: Proventil HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA) 1 puff inhale orally every 4 hours as needed for SOB. The resident may have at the bedside. On 3/02/25 at 5:10 PM, the Assistant Director of Nursing searched the EMR for orders for self administration for residents #44 and #92. The ADON confirmed there was a physician order for resident #92 to keep the inhaler at bedside, but resident #44 did not. On 3/06/25 at 10:45 AM, the Director of Nursing (DON) explained before a resident could keep medications at the bedside, an assessment for self-administration should be performed by nursing staff. The DON continued, that if a resident wanted to self-administer medications, they needed to have a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 3 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete physician's order for self-administration, a self-administration evaluation was completed and a care plan for self-administration of drugs was initiated. The DON acknowledged that staff had not followed the facility's policy and procedures to ensure resident self-administration safety for resident #44 and #92. Review of the facility's policy and procedure for administering medication dated 2/21/23 revealed, residents may self -administer their medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, had determined that they had the decision-making capacity to do so. Event ID: Facility ID: 105207 If continuation sheet Page 4 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a homelike environment by failing to de-emphasize the institutional character of the dining room for one of one dining room reviewed for dining and failed to maintain a sanitary and comfortable interior of the resident rooms for 3 of 3 residents rooms reviewed for cleanliness, (#13, #20, and #62). Findings: 1. On 3/03/25 at 12:24 PM, in the main dining room, 36 residents were observed eating lunch. There were no table cloths, no centerpieces on the tables and there was no music playing to create a homelike atmosphere for dining. At 12:33 PM, loud country music was started. On 3/05/25 between 10:25 AM and 12:00 PM, residents were observed eating morning snacks at the dining tables in the dining room. A short time later a couple of tables were moved so residents could exercise in an open area of the dining room. Later, the tables were moved back so residents could eat lunch, but no dining room table additions such as tablecloths or centerpieces were added to create a homelike environment for the residents. On 3/06/25 at 9:31 AM, the Director of Activities, acknowledged the lack of tablecloths or centerpieces to create a homelike environment. She stated they used to have centerpieces for the dining tables and had tablecloths, but no longer did. The Director of Activities stated she could not say why the tablecloths or centerpieces were not being utilized for the residents. She added she believed the facility still had some of the seasonal centerpieces. 2. On 3/03/25 at 1:00 PM, upon entrance to residents #13's room the floor had dirty shoe marks and gray smudge lines about 6 to 8 inches long in the middle of the floor. The area outside the bathroom floor was brown and dingy with dirt the whole length of the doorway. The bedroom and bathroom floors were very sticky and dirty, and stuck to the bottom of any shoes. A large patched area of a wall was seen that had not been repainted. Resident #13 agreed the room floors and baseboards looked dirty and stated housekeeping had already come to clean the room that day, (photographic evidence obtained). On 3/04/25 at 8:30 AM, the floors resident #13's room had more grime and dirty shoe marks than seen the previous day. Resident #13 acknowledged the dirty floors. Certified Nursing Assistant (CNA) E who came in the room, stated a cup of juice had been spilled and tracked through the room which made the floors sticky. He added, he had told housekeeping to use two mop heads instead of just one because the floor was so dirty, (photographic evidence obtained). On 3/05/25 at 10:11 AM, Housekeeping staff G was observed deep cleaning room [ROOM NUMBER]. She explained resident rooms were cleaned between 7 AM to 3 PM. She stated she mopped the floor with premeasured soap and water, but if other staff used too much soap, the floor got sticky. She stated she used one mop head per room but did not change the mop water throughout the course of her shift and added that no one did. She stated that for floor edges, she sprayed with a cleaner and then wiped or mopped to see if the dirt came out. She demonstrated on the wall and baseboards of the room but stated the areas were not able to come clean. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 5 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/05/25 at 2:53 PM, the Environment Director stated four rooms were deep cleaned daily, which included cleaning the air conditioner filter, the blinds, dusting the furniture, moving furniture, and cleaning beds after blankets were removed. When observing the room that was deep cleaned today by Staff G, he acknowledged it looked like the baseboards were missed. The Environment Director stated he expected housekeeping staff to use fresh floor cleaning water first thing in the morning and get fresh water again when the food carts arrived on the resident units around lunch time. The Environmental Director provided a Deep Cleaning Schedule for February and March 2025, which indicated four resident rooms at the facility were deep cleaned that day by the staff during their usual cleaning shift. He also provided instructions from the Housekeeping Operations manual which stated each housekeeper was responsible for one complete room cleaning per day which required cleaning of corners and edges using a scrubbing pad (doodlebug pad), wall washing, and floor buffing and burnishing (which is assigned to the porter assigned to that section). 3. On 3/03/25 at 12:13 PM, observation of resident #20's room revealed shoes stuck to the floor as one walked around the bilateral sides and foot of resident #20's bed. On 3/04/25 at 12:31 PM, shoes stuck to the floor of resident #20's room as one walked around the bilateral sides and foot of the bed. On 3/04/25 at 4:49 PM, resident #20's family member said they or their significant other visited resident #20 almost daily. Resident #20's family member confirmed the brown hue within the abraded surface of the toilet seat and the notable sewer-like odor within the bathroom itself. Resident #20's family member and their significant other noted the stickiness of the floor on both sides of the bed and at the foot of the bed as well. They said they often experienced the floor being sticky when they visited resident #20. On 3/05/25 at 10:31 AM, shoes stuck to floor as one walked around both sides and the foot of resident #20's bed. On 3/05/25 at 10:32 AM, numerous white splatters were observed on the wall area below the light switch in resident #20's room. Multiple scraped, dented areas of plaster and missing paint were noted below the light switch area and above the baseboard. A notable damaged area, that was irregularly shaped and of irregular depth to the plaster was observed to be approximately 1 foot by 1 foot. 4. On 3/03/25 at 12:24 PM, black and gray colored debris was observed on the floor at the head of resident #62's bed and to the floor on the window side of bed. On 3/03/25 at 3:51 PM, resident #62's family member said they visited often, and felt her room was dirty. Gray and black colored debris was observed on the floor at the base of resident #62's feeding pump pole. Scratched, peeling paint was observed at the head of resident #62's bed. On 3/05/25 at 10:44 AM, the Environmental Director verified there was stickiness on both sides and at the foot of resident #20's bed. He also verified the notable sewer odor in resident #20's bathroom-he was not sure of the source of the odor. He noted the brown hue within the abraded toilet seat. He was unclear what caused the brown hue. Next he observed and confirmed the gray black debris on the floor at the head of resident #62's bed. The Environmental Director explained staff should clean the floor under the beds, as well as under the small furniture like the three drawer chest of drawers. He said he spot checked the cleanliness of the rooms on Monday through Friday. He said he did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 6 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some keep a record of environmental concerns expressed to him. The Environmental Director said he tried to address concerns as they arose. Scratched peeling paint was observed behind resident #62's bed. He removed resident #62's air conditioning filter and noted what he described as more than a week's worth of debris on the filter. He said the air conditioning filter cleaning should be done Monday, Wednesday, and Friday of each week. He acknowledged he needed to review the work of his staff more to ensure they cleaned sufficiently. On 3/05/25 at 11:39 AM, the Maintenance Director observed the wall area under the light switch in resident #20's room. He said he was not sure what caused the numerous white splatters between the light switch and the baseboard. He stated he was not aware of the plaster damaged area, that was irregularly shaped and of irregular depth that was approximately 1 foot by 1 foot. The facility's policy entitled Resident Rights-Safe, Clean, Comfortable Homelike Environment dated 4/01/22, indicated the resident had a right to a safe, clean, comfortable and homelike environment, and the facility should provide the housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 7 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #26 was initially admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy. She was discharged from the facility on 4/26/24 and readmitted on [DATE] following a right hip fracture. The admission Record or face sheet listed diagnoses including dementia with behavioral disturbances, insomnia, depression, and psychotic disorder with delusions due to known physiological condition, and anxiety. Residents Affected - Few A psychiatry consult from 6/26/24 revealed that resident #26 was admitted with medications for diagnoses of dementia and insomnia. Resident #26 was started on Depakote sprinkles 250 milligrams (mg) two times a day for psychotic disorder on 1/02/24. Resident #26's care plan initiated on 7/12/24 indicated the resident had impaired cognition which affected communication, functional abilities, decision making, and judgement related to psychosis and dementia. The resident's PASARR forms dated 11/03/23 and 6/24/24 were completed by prior to admission to the facility. The form had no diagnosis listed under Section IA Mental Illness or suspected Mental Illness. On 3/05/25 a new Level I PASARR, completed by the Lead MDS Coordinator, was added to the Resident's clinical record. Under Section 1: Mental Illness or Suspected Mental Illness the following diagnoses were listed: anxiety disorder, depressive disorder and insomnia. The Lead MDS Coordinator on 3/05/25 at 10:44 AM, stated the facility had been reviewing and updating PASARRS of residents within the facility. She reviewed resident #26's PASARR from 3/05/25 and confirmed that the diagnosis of anxiety disorder, depressive disorder and insomnia were listed under Section 1 on the PASARR. The Lead MDS Coordinator confirmed that the PASARR she had just completed was incomplete as it did not have psychotic disorder with delusions listed. She then stated, I'm old and miss things sometimes. On 3/05/25 at 1:2 PM, the Lead MDS Coordinator revealed that the facility initiated a Performance Improvement Project following a discussion with the Psychologist Consultant and a subsequent email on 2/26/25. The email revealed, here is the info for the PASRRs from today's patients followed by a 25 resident names with diagnoses next to them. Resident #26 was listed with the diagnoses of depression, insomnia and dementia next to her name. When asked if the diagnoses next to the resident's names were current diagnoses or instead what was listed on the PASARR at the present time, she replied I'm not sure. But I think they are either missing or need to be added to the PASARR. On 3/05/25 at 1:45 PM, the Social Service Director revealed that the diagnosis listed in the email was the same diagnoses that should be listed on the PASARR. The Social Service Director was unable to answer whether if a diagnosis was not listed next to a resident's name, it meant that the diagnosis was no longer current and thus did not need to be on the PASARR. She stated the facility was performing daily audits but was unable to clarify how she was able to complete these audits herself every day. The facility policy titled Social Services - PASARR indicated, the facility shall ensure each resident in a nursing facility is screened for a mental disorder or intellectual disability prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 8 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admission and that individuals identified with a mental disorder or intellectual disability are evaluated and receive care and services in the most integrated setting appropriate to their needs. Based on interview, and record review, the facility failed to rensure an accurate Preadmission Screening and Resident Review (PASARR) level I and level II evaluation was completed for 2 of 2 residents reviewed for PASARRs, of a total sample of 62 residents, (#55, and #26). 1. Review of the medical record revealed resident #55 was admitted to the facility on [DATE] from an acute care hospital. Some of her diagnoses included type 2 diabetes, morbid obesity, hypothyroidism, pain, major depressive disorder, panic disorder, anxiety disorder and Post-Traumatic Distress Disorder (PTSD). Resident # 55's Quarterly Minimum Data Set (MDS) assessment with assessment reference date of 11/30/24 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status which indicated she had no cognitive impairment. Her active diagnoses listed under Psychiatric Disorders included anxiety, depression and PTSD. On 3/04/25, upon further review of resident #55's electronic medical records, the PASARR dated 2/22/24 Level I screen was found to have not been updated since anxiety disorder was the only Mental Illness diagnosis listed in Section 1A of the form. The diagnoses included on the Level I screen did not include major depressive disorder, panic disorder or PTSD. On 3/05/25 at 1:45 PM, the Lead MDS coordinator acknowledged resident # 55's Level I PASARR was missing the diagnoses and was inaccurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 9 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 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, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents reviewed for choices, of a total sample of 62 residents, (#93). Residents Affected - Few Findings: Resident # 93 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of Parkinsonism, anemia, syncope and collapse, and hypertensive heart disease without heart failure. Her most recent Minimum Data Set (MDS) showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which meant she had no impairment in cognition. On 3/03/25 at 4:47 PM, resident #93 explained she and facility staff were very careful with her blood pressure because she passed out a few times and so she spent most of the day at the therapy gym. Review of the physician orders included Vital signs every shift and Midodrine HCL oral tablet 10 milligrams (mg). Give one tablet via G-Tube three times a day for hypotension. Parameters included Hold for Systolic Blood Pressure greater than 120 millimeters of mercury. A review of resident # 93's Care Plan initiated on 12/17/24 revealed a focus on the potential for alterations in blood pressure had interventions which included administer medication as ordered, blood pressure as indicated or as ordered and to report signs and symptoms of complications related to alterations in blood pressure. Review of the blood pressure summary for resident # 93 since admission on [DATE] indicated that the resident's blood pressure had been measured only once after 2/26/25, on 3/03/25. There were no record of blood pressure measurements for 3/04/25 or 3/05/25. Upon further review, no blood pressure measurement was documented for 2/01/25 through 2/08/25 nor from 1/11/25 through 1/17/25. At 12:56 PM, the assigned nurse Registered Nurse (RN) A stated she administered the morning medication Midodrine and checked resident #93's blood pressure. She was unable to show where she documented the blood pressure in the resident's electronic medical record. RN A could not find documentation anywhere. RN A checked her report sheet but confirmed she did not record the blood pressure there either. She stated she would have held the Midodrine if the systolic blood pressure was greater than 120. RN A in reference to the documentation of resident #93's blood pressure reading, said there was something missing. On 3/05/25 at approximately 1:02 PM, the South Wing Unit Manager confirmed the findings that blood pressure was not documented and explained that it may have been when their electronic record system changed over. She acknowledged from the record, the blood pressure measurement was not done but medication was given. The South Wing Unit Manager did not know if the medication was administered within the prescribed parameters. On 3/05/25 at 1:17 PM, the Director of Nursing (DON) said that based on what was documented, the resident's blood pressure was not taken but the medication was administered. The DON acknowledged she was not here during that time and that supplemental orders for blood pressures to be recorded were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 10 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 now in the system. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy for Administering Medications with an effective date of 4/01/22 and revised on 2/21/23 revealed the purpose was to ensure that medications were administered in a safe and timely manner and as prescribed. Section 9 b. indicated that vital signs were checked, if necessary, for each resident prior to administering medications. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 11 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided in accordance with professional standards of practice, and per physician orders for 2 out of 2 residents reviewed for respiratory care, of a total sample of 62 residents, (#35, & #85). Residents Affected - Few Findings: 1. Resident #35 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety disorder, unspecified ulcerative colitis, celiac disease, pulmonary embolism (PE) and history of breast cancer. A review of the annual Minimum Data Set (MDS) assessment with reference date 2/12/25 revealed resident #35 had no cognitive impairment, no behaviors, no rejection nor refusal of care and required the use of oxygen. The physician orders for oxygen read continuous oxygen at 2 liters per minute (LPM) via nasal cannula. Resident #35 had a plan of care for shortness of breath related to COPD, recent pneumonia and PE with interventions that included oxygen as ordered and for staff to notify the physician if the resident refused oxygen therapy. On 3/03/25 at 3:51 PM, resident #35 was observed sitting up in bed and explained she was here for rehabilitation. The level of oxygen on the oxygen concentrator was set at 3 LPM and she stated it was at 3 LPM of oxygen because her oxygen levels kept dropping. On 3/04/25 at 12:48 PM, resident #35 was up in her wheelchair with a portable oxygen tank set at 3 LPM of oxygen. She said she was comfortable and had no complaints at the time. On 3/05/25 at 10:47 AM, the assigned nurse Licensed Practical Nurse (LPN) A confirmed the amount of oxygen resident #35's concentrator was set to as 3 LPM of oxygen. Resident #35 then told LPN A that the Pulmonologist had seen her and said that 3 LPM of oxygen was ok. LPN A confirmed the physician order was for 2 LPM. LPN A stated she knew to check the orders to ensure the resident was on the correct amount of oxygen. She confirmed she did not do it this morning. A few minutes late the Unit Manager for the South wing verified the resident was recently seen by the Pulmonologist but they had not written anything in the notes about increasing her oxygen to 3 LPM. She also indicated that the Pulmonologist does not enter orders by herself, instead, she would have written an order for facility staff to enter new orders. The Director of Nursing (DON) was also present at the nurses' station and along with the South Wing Unit Manager (UM) acknowledged that oxygen orders were not followed for resident #35. On 3/06/25 at 3:52 PM, the DON stated her expectation was that nurses would check the oxygen orders and verify the concentrator setting so that the resident received oxygen as ordered. The facility's Policy on Oxygen Administration dated 4/01/22 indicated The purpose of the procedure is to provide guideline for safe oxygen administration and the preparation in section 1. described, Verify that there is a physician order for this procedure. Review the physician's orders or facility protocol for oxygen administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 12 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Resident #85 was admitted on [DATE] with diagnoses of type II diabetes mellitus, abnormal posture and unsteadiness of feet, muscle weakness, sepsis, hypertensive disease with heart failure, chronic kidney disease, and heart failure. The MDS assessment dated [DATE], revealed the resident was assessed with a BIMS of 15/15, which indicated he was cognitively intact. Section O of the MDS revealed the resident was not on oxygen at admission nor during this stay at the facility. On 3/03/25 at 1:32 PM, resident #85 was in his room with his sister. He was receiving 2 liters of oxygen from an oxygen concentrator, connected to a nasal cannula. The resident stated he arrived with oxygen from the hospital and used it daily, even when he received dialysis. He reported he had labored breathing and was short of breath without it. Resident #85 added nursing staff changed the oxygen tubing every Sunday night or early Monday morning, but they didn't do it this week. On 3/05/25 at 12:37 PM, LPN F confirmed there was no order for oxygen, nor an order for changing oxygen tubing, that was active or discontinued during the resident's current stay. LPN F verified resident #85 received oxygen and stated assigned nurses were supposed to ensure the tubing was changed weekly by checking the date on the tubing during their daily shift rounds. LPN F checked the date on resident #85's oxygen tubing and found it to be dated 2/24/25, 9 days prior. She removed the oxygen nasal cannula from the resident's nose and told him she needed to change the tubing. LPN F confirmed resident #85 had been receiving oxygen during his stay without a physician's order and the tubing had not been changed in the past 9 days. Review of the hospital discharge form indicated resident #85 received continuous oxygen at 2 LPM. The facility-admission NURSING Data collection form indicated the resident was admitted on [DATE] with an oxygen saturation rate of 96% from oxygen via nasal cannula. In error, the form indicated in the Respiratory Risk section; the resident did not have any issues which might create a risk for respiratory complication such as Congestive Heart Failure (CHF). Review of nine Nursing and APRN Progress Notes from between 2/13/25 to 2/18/25 revealed resident #85 received oxygen through a nasal cannula and the APRN's Note on 2/13/25 confirmed the resident did have CHF. On 3/06/25 at 10:24 AM, the Administrator stated it was her expectation for nursing to not provide patient care treatment without Physician orders. The Administrator confirmed in addition to nurses checking dates on tubing, staff were also to check oxygen tubing dates during angel rounds as a back-up for increased accuracy of compliance to infection control policies. The facility's policy entitled Nursing-Physician orders dated 4/01/22 and revised 3/10/23, stated its purpose was to ensure the plan of care is followed in accordance with the orders established by the physician or nurse practitioner. It added, medications and treatments would be administered only upon the written order of a person duly licensed to prescribe them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 13 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to post the nursing staffing hours daily, which identified the number of staff working in the facility on the form posted. Residents Affected - Some Findings: On 3/03/05 at 10:24 AM, 3/04/25 at 10:15 AM, 3/05/25 at 8:34 AM, and 3/06/25 at 8:37 AM, the daily Nurse Staffing Form located by the receptionist in the lobby failed to identify the number and type of nursing staff working in the facility on the form posted. On 3/06/25 at 9:53 AM, the Staffing coordinator stated she was responsible for posting the form. The Staffing Coordinator acknowledged that the facility name was not on the Nurse Staffing Form, and that the form did not identify the number and type of staff working. The Coordinator stated the company was undergoing changes, so she was not sure what company name to put on the sheet. ON 3/06/25 at 1:03 PM, the Administrator stated there was a staffing meeting at about 11:00 AM daily. The Administrator explained that last week, the facility received a call that their name was changing, so we stopped putting the facility name on the posted daily staffing sheet. The Administrator confirmed the posting was for public viewing, so it should reflect the facility's name. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 14 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Pharmacist recommendations were addressed by the physician for 1 of 5 resident reviewed for unnecessary medications, of a total sample of 62 residents, (#57). Findings: Resident #57 was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral brain hemorrhage, muscle weakness, abnormalities of gait and mobility, moderate protein-calorie malnutrition, anxiety, depression, and hypertension. The resident's Care Plan dated 12/16/24 stated the resident was at risk for falls due to weakness and adverse effects of psychotropic medications with intervention to watch for signs and symptoms such as gait disturbance, sedation, lightheadedness, dizziness and change in mental status, mentation, and mood. Review of the medical record revealed on 1/13/25, the pharmacist submitted a recommendation for the physician to evaluate the order for the antidepressant, Mirtazapine (Remeron), and to consider tapering the dose from 15 milligrams (mg) to 7.5 mg per night or implementing an alternative treatment due to resident's recent fall. The record revealed this recommendation was never addressed by the physician. On 1/13/25, the pharmacist recommended the physician evaluate possible causal relationship between resident receiving Gabapentin for neuropathy and anxiety at 200 mg, three times day and his recent fall. They also recommended to consider a trial to taper this medication to 200 mg, two times per day if appropriate. Review of the record revealed this recommendation was never addressed by the physician. On 3/06/25 at 9:30 AM, the Director of Nursing (DON) confirmed resident #57's Pharmacist drug regimen reviews and recommendations had not been addressed prior to her starting at the facility, nor had they been addressed yet by her. She stated she was trying to catch up on the incomplete work from the previous DON. On 3/06/25 at 10:24 AM, the Administrator started her expectation was for the DON to address pharmacist recommendations by notifying the physician and documenting their response in a timely manner. She added that she was not aware some of them from January had not been addressed, but that the new DON was trying to catch up. The facility's policy entitled Pharmacy Services-Drug Regimen Review dated 1/10/25 indicated the drug regimen of each resident should be evaluated at least monthly by a licensed pharmacist, and any irregularities reported to the attending physician, Medical Director, and DON. It continued, the attending physician shall document the recommendation that has been reviewed, and what, if any, action has been taken to change the medication and their rationale for doing so. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 15 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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. Based on observation, and interview, the facility failed to store food in accordance with professional standards for food service safety and failed to follow proper sanitation practices to prevent the outbreak of foodborne illness. This had the potential to affect all residents at the facility who eat food prepared in the kitchen. Findings: 1. On 3/03/25 at 10:00 AM, during the initial kitchen tour with the Assistant Dietary Manager I, observations in the walk-in found there were four, one-third steamtable pans of leftover food items including mechanical soft pork dated 3/1 and use by 3/07/25, sweet potatoes dated 3/2 and use by 3/08/25, corn dated 3/1 use by 3/07/25, and mashed potatoes dated 3/2 use by 3/08/25. Assistant Dietary Manager I stated their policy was to keep leftover fish, meat, and poultry for three days after prepared, and vegetables for five days. She could not explain why it was written to keep all these food items for six days each. There were two packages of hard-boiled eggs, unsealed and left open to the air, and undated; and a carton of whole eggs was open and did not have a date as to when it had been opened. There was a bag which contained approximately 20 pieces of tilapia fish inside the cardboard box, the bag was open to the air and undated. A bag of approximately 15 fried eggs was also left open to the air and undated in the cardboard box. Assistant Dietary Manager I threw away the eggs and fish. In a plastic bin with other cheese items, were two bags of what the Assistant Dietary Manager I thought was unlabeled and undated, rancid shredded mozzarella. Assistant Dietary Manager I eventually decided the unlabeled food was hash brown potatoes. In the same bin, there were two bags of shredded mozzarella cheese dated 2/11 (20 days ago) with a marker and 1/28/25 (33 days) indicated on a sticker label. Assistant Dietary Manager I was unsure which date was accurate and how long the bags of cheese should be kept. She threw the hash browns and cheese away. 2. In the walk-in freezer was a storage bag of leftover pork and a bag of salisbury steak. Both items had frost built up on the meat and were not dated. Assistant Dietary Manager I stated these items were old and should have been thrown away. There was also a bag of approximately 20 chicken tenders, undated as to when they were opened, which she threw away. 3. In the cook's reach-in refrigerator, in an unlabeled, round plastic bin, there were two stacks of approximately 15 American cheese slices wrapped in plastic wrap and two unwrapped stacks of approximately 35 slices of American cheese. There were no dates on any of this cheese. Assistant Dietary Manager I stated they were from sandwiches made yesterday and she meant to put them in storage bags and date them. She stated this cheese should not be kept for more than one week. There were also two covered plastic tubs, one with leftover peaches and the other with leftover fruit cocktail; both were unlabeled and undated and Assistant Dietary Manager I discarded them. 4. In the dry storage room, there was an unlabeled and undated bin with a bag of sugar inside and a bag of opened and resealed, but undated evaporated milk. There was also a dirty tray which held approximately 15 clean drinking glasses which Assistant Dietary Manager I stated the glasses were used for residents in the dining room. 5. Under the cook's food preparation table, there were three dry storage bins. All three were lined with a large plastic (garbage) bag. The lining bag was dirty on the outside of the bin labeled FLOUR and inside this bin were two paper (original shipping) bags of flour. One of the paper shipping (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 16 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 bags indicated the flour was manufactured on 1/07/24, but had no date that indicated when it was received or opened. There was a flying insect that hovered outside of the dirty flour bin. None of these three bins had a date for when these items were received, opened, and/or stored in these bins. In the kitchen was also a dirty sheet pan with approximately 16 glasses of juice that had been poured for today's upcoming lunch meal, sitting on the dirty tray (photo evidence acquired)). Residents Affected - Many 6. On 3/5/25 at 11:25 AM, during the follow-up visit to the kitchen, it was noted the kitchen floor tiles and grout had a build-up of a black substance which was also prevalent on and around the floor drains. (pictures taken). The facility's policy entitled Food Storage: Dry Goods dated 9/17 indicated all dry goods would be stored appropriately in accordance with the Food and Drug Administration (FDA) Food Code and would be date marked as appropriate. The policy entitled Food Storage: Cold Foods and dated 9/17 and revised 4/18, stated all foods would be stored wrapped or in covered containers, labeled, and dated. The provided Healthcare Services Group Labeling and Dating Inservice (undated) indicated all foods should be dated upon receipt before being stored with the food name, date of preparation, receipt, and/or removal from the freezer, and the use by date. It added, the manufacturer's expiration date may be used as the use by date for unopened items and the manufacturer's instructions for discarding of opened items may be used. If not available, the day of preparation or opening was considered as day one when establishing a use by date and all ready-to-eat and time/temperature controlled for safety food items would be labeled and dated with a prepared date (day one) and a use by date (day seven). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 17 of 18 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to establish a system for the prevention of communicable diseases by failing to ensure all residents were offered and encouraged to perform hand hygiene before meals for all residents eating meals in the dining room. Residents Affected - Some Findings: On 3/04/25 at 12:00 PM, in the main dining room, approximately 28 residents were observed eating lunch. Several of the residents stated they were not offered a way to clean their hands prior to meals while one resident stated he was only offered a napkin. On 3/05/25 at 10:25 AM, approximately ten residents were observed finishing a morning snack in the main dining room, after which they proceeded to move to the front of the dining room for morning exercise. A short time later at 11:00 AM, 12 residents were observed participating in exercises to music while sitting in their wheelchairs, after which most of these residents moved to the dining tables to eat lunch. None of these residents, nor others who joined the dining room afterwards, were offered a means to clean their hands before the meal was served. On 3/05/25 at 12:13 PM, Recreation Aide H stated many of the residents who participated in the morning snack then stayed in the dining room for lunch. She stated if they requested to wash their hands, they used the sink in the dining room that the staff used to wash their hands. Recreation Aide H explained if the residents' hands were very dirty, staff would take the resident back to their rooms for the CNA to clean them. She stated the residents were cleaned in the morning before they came to morning activities. Then after lunch, they would take them back to their room to be changed and cleaned again before Bingo at 2 PM. On 3/06/25 at 9:31 AM, Activities Director stated as an activity person, they sent the residents back to their room to be cleaned up and she expects that if a resident goes to their room, they will be changed and their hands washed. She acknowledged that some residents will go to therapy or somewhere else on their own, but it never occurred to her to wipe or disinfect their hands right before meals and she will discuss this with the Administrator. The facility' policy entitled Hand Hygiene and Resident Cleanliness Policy During Meal Times stressed the importance of hand hygiene to prevent the spread of infection and to maintain a safe, sanitary environment for both residents and staff. It included a Reminder to ensure staff clean resident's hands and face before and after eating and that wet wipes were to be available at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 18 of 18