Health inspection·October 30, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few back to bed around the end of the shift. CNA A stated she was not aware of resident's transfer status or where to find the information but resident #1 told her that staff usually got her up with a 2-person pivot. CNA A explained she looked outside the room and asked another staff member to help her. CNA A stated she did not know the name of the other CNA she asked for assistance. She recalled that resident #1 said she had a little pain during the transfer and they lowered her to the floor, gave her a few minutes to rest and then lifted her and transferred her to bed. CNA A acknowledged she did not report the complaint of pain to the nurse. She explained it was the end of the shift and she had already given report and was about to leave when resident #1 asked for help. A witness statement from CNA B given on 10/17/25 revealed she clocked in for work at approximately 2:36 PM on 10/16/25 and went to her assigned unit. She reported that while she was on her way, CNA A opened the room door, saw her and asked her how strong she was. CNA A indicated she needed help with resident #1. CNA B recalled she recognized resident #1 but was not aware she required a mechanical lift for transfer. She documented that CNA A told her she would normally use the mechanical lift for resident #1's transfer but would just have the resident stand and pivot to put her in bed. CNA B noted she was hesitant as she observed a mechanical lift sling already under resident #1 in the wheelchair but agreed to help. Her statement indicated the wheelchair was positioned next to the bed with the left side of the wheelchair turned slightly toward the bed with the wheels locked. The statement indicated CNA B and CNA A stood on either side of resident and lifted her under her arms. CNA B reported the resident felt like dead weight. The statement indicated resident #1 started yelling about her leg hurting during the transfer. CNA B looked down and saw resident #1's left foot was turned in slightly. She reported they lowered resident #1 to the floor and her left leg was bent backwards at the knee out to her left side. CNA B stated that resident #1 complained that her leg hurt really badly and she was in a lot of pain. Resident #1 asked if they would get the mechanical lift and CNA A responded if they did that they were going to see her on the floor, and they would get in trouble. CNA B expressed she thought they should have gotten the mechanical lift, but CNA A told her she did not want to get her in trouble. She reported that after about 30-40 seconds, they lifted the resident from the floor under her arms and quickly placed her in a sitting position on the side of the bed. She was then positioned in bed with her feet on the bed. CNA B noted resident #1 was breathing heavily, said her leg hurt really badly and was in a lot of pain. CNA B recalled she told CNA A that this was a transfer gone very wrong. The statement revealed CNA A agreed and said that was the first and last time; adding they would use the mechanical lift next time. CNA B indicated she asked CNA A if she needed anything else, then left the room and went to her assignment. CNA B reported she did not have any further interaction with CNA A or resident #1 for the remainder of her shift. CNA B explained she did not inform the nurse of the fall or resident #1's complaint of pain because she thought CNA A would have reported it. On 10/27/25 at 10:15 AM, resident #1 was observed in bed with the head of bed elevated and a leg immobilizer on her left leg that extended from her thigh to her ankle. She confirmed two CNAs transferred her without the use of a mechanical lift on 10/16/25. She stated her foot slipped and hit the floor. Resident #1 explained the pain was immediately 10 out of 10 and continued throughout the night. Resident #1 recalled she told the assigned evening shift (3:00-11:00 PM) CNA C that her leg hurt. She stated CNA C reported it to the nurse, who did not do anything. In a follow up interview on 10/28/25 at 8:50 AM, resident #1 clarified the two CNAs lifted her under her arms from the wheelchair when she hit her foot on the floor and yelled out in pain. She stated the CNAs lowered her to the floor and lifted her again under her arms to put her back in bed. Resident #1's roommate verified her account and added that CNA A asked the residents not to say anything to anyone because they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105250 If continuation sheet Page 2 of 9 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 105250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (the two CNAs) would get in trouble. In a meeting with the Administrator, Director of Nursing (DON) and Regional Nurse Consultant (RNC) on 10/28/25 at 11:17 AM, the Administrator stated the facility investigation showed resident #1 was transferred inappropriately using a stand and pivot technique rather than a mechanical lift as directed in her plan of care. The Administrator, DON and RNS reported during the transfer, resident #1 complained of pain and was lowered to the floor. She was then lifted from the floor and placed in bed. They confirmed neither CNA reported the incident to the nurse. The Administrator explained resident #1 complained of pain to CNA C (her assigned 3-11 shift CNA) during ADL care. The investigation showed CNA C reported resident #1's complaint to Licensed Practical Nurse (LPN D, an agency nurse, at 4:00 PM, 6:00 PM and 8:00 PM. CNA C then went to another nurse for assistance with resident #1's pain. Per the investigation, LPN D did not go to assess resident #1 until approximately 10:50 PM, almost seven hours after it was initially reported to her. LPN D then contacted the provider and received an order for a STAT (immediate) X-ray. Per the Administrator, the X-ray was not performed until 10/17/25 at 9:30 AM, (19 hours after the incident). The facility received the X-ray results on 10/17/25 at 11:13 AM, which showed a proximal tibia (lower leg) fracture with mild displacement. The Administrator reported that a Quality Assurance and Performance Improvement (QAPI) meeting was held on 10/19/25 to review the investigation and a root cause analysis was conducted. He reported the committee determined the staff willingly chose to ignore previous training and chose not to follow the resident's plan of care for safe transfers. He explained the agency nurse also failed to respond to resident #1's complaints timely and was no longer allowed to return to work at the facility. Per the facility's investigation, an allegation of neglect was substantiated due to the actions of CNA A, CNA B and LPN D. Review of the facility's policy and procedure for Abuse, Neglect and Exploitation revised 11/16/23 revealed neglect was identified as failure of the facility, its employees, or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of corrective measures to remove Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/16/25 at 4:00 PM, resident #1 reported to her CNA that she had pain in her left leg. The CNA reported the complaint to the nurse at 4:00 PM, 6:00 PM and again at 8:00 PM. *On 10/16/25 at 10:50 PM, resident #1 was assessed by the nurse due to her complaint of pain in left lower extremity, provider was notified and order received for diagnostic imaging. *On 10/17/25 at 9:30 AM, X-ray was performed and results were received at 11:13 AM which showed a proximal tibia fracture with mild displacement. *On 10/17/25 at 11:13 AM, resident's physician was notified of the abnormal X-ray results and orders were received for a leg immobilizer and an outpatient orthopedic physician consult. *On 10/17/25 at 2:26 PM, a knee immobilizer was placed to resident's left leg as ordered. *On 10/17/25 resident #1 and roommate were interviewed by the former DON and reported that resident #1 was transferred without the use of the mechanical lift by two CNAs on 10-16-25. *On 10/17/25, the facility initiated an investigation. *On 10/17/25, the ADON began education on identifying resident's transfer status, safe transfers and skills validation. *On 10/17/25 an Ad Hoc QAPI meeting was held with the facility Administrator, Director of Nursing and Medical Director to review the incident including physician orders obtained related to the resident's fracture. Resident #1's individualized plan of care including outpatient orthopedic consult and leg immobilizer deemed appropriate by the Medical Director. Discussed staff training to be conducted as a result of incident on 10/16/25. *On 10/18/25, the CNA who assisted the assigned CNA performed a reenactment of the incident and provided a statement which included information that the two CNAs had knowledge of resident #1's transfer status and subsequent disregard by performing a stand and pivot transfer. Resident #1's care plan and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105250 If continuation sheet Page 3 of 9 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 105250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Kardex indicated she required two person assistance with the use of mechanical lift for transfers. *On 10/18/25 through 10-19-25, each resident's care plan and Kardex were reviewed to ensure accurate transfer status was reflected. *On 10/19/25 as part of the investigation process, residents were interviewed by the Social Services Director to determine if there were additional concerns of abuse or neglect with no findings. *On 10/19/25, the facility held an ad hoc QAPI meeting to review the progress of education and competency completion as well as quality reviews. The committee conducted a root cause analysis which determined the assigned CNA made an independent decision, chose to ignore her prior education and did not follow the resident's plan of care for safe transfers. The ad hoc QAPI committee including the Medical Director approved the recommendations. *On 10/20/25, resident #1 was seen by the provider. Her pain regime was reviewed and adjusted. The facility scheduled an orthopedic appointment for 10/24/25 as per the physician order. *On 10/20/25, the former DON discussed transfer options to the hospital with resident #1. *On 10/21/25, the former DON spoke to the resident and resident voiced wanting to go to the hospital. *On 10/21/25, resident #1 was sent to the emergency room for evaluation due to uncontrolled pain related to the fracture. The resident returned to the facility. *On 10/21/25, resident #1's provider was contacted, and pain regimen was reviewed and adjusted. *On 10/17/25 through 10/21/25, the nursing staff were educated on change in condition to include but not limited to accidents resulting in injury, offering resident to be transferred to higher level of care for further evaluation if serious injury, escalation to chain of command via nurse supervisor and/or DON if resident concern is not addressed, following resident care plan/Kardex, safe resident handing, mechanical lift usage and competencies. As of 10/21/25, 77 out of 92 nursing staff received education, (84%), The remaining 15 total nursing staff members to receive education prior to next shift worked. *On 10/17/25 through 10/21/25, facility staff were educated on abuse, neglect and exploitation by the Administrator, Staff Development Coordinator and Nurse Managers. As of 10/21/25, 111 out of 128 staff members received education, (86%). The remaining 17 total staff members to receive education prior to next shift worked. *Ad Hoc QAPI meetings were completed 10/20/25 and 10/21/25 with Medical Director, Administrator, and former DON where incident, abuse and neglect, use of mechanical lifts, transfer competencies, updating care plans/Kardex, change in condition, pain management and following care plans/Kardex were discussed. No recommended changes were made to the performance improvement plan. From 10/29/25 to 10/30/25, interviews were conducted with 18 staff members representing all shifts (1 Registered Nurse, 4 LPNs, 9 CNAs, 1 dietary, 2 environmental services and 1 activity aide/CNA). Staff interviews revealed they were knowledgeable of identifying abuse and neglect, following a resident's plan of care, safe handling of resident and who to report any violations or suspected violation. The resident sample was expanded during the survey to include five additional residents. Observations, interviews, and record reviews conducted revealed no concerns related to abuse and neglect, care plans and transfer status for residents #6 through #10. Event ID: Facility ID: 105250 If continuation sheet Page 4 of 9 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 105250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a safe environment to prevent an accident resulting in leg fracture during resident transfer, for 1 of 9 residents reviewed for use of mechanical lifts, of a total sample of 10 residents, (#1).On 10/16/25 at approximately 2:40 PM, the facility failed to ensure nursing staff followed resident #1's plan of care for safe transfers resulting in serious injury and avoidable pain of a physically impaired resident during a transfer from wheelchair to bed. Two certified nursing assistants (CNAs) failed to follow resident #1's care plan which required her to be transferred using a mechanical lift with assistance of two staff. The two CNAs transferred the resident from her wheelchair by manually lifting her to an upright position and pivoting her to the bed. Resident #1 immediately complained of pain in her left leg during the transfer and was lowered to the floor. The two CNAs then manually lifted her from the floor and placed her in bed. Resident #1 continued to complain of extreme pain to her left leg. An X-ray performed on 10/17/25 of resident #1's left leg indicated she had sustained a fractured tibia (lower leg). Record review revealed a total of 23 residents were identified who required a mechanical lift for transfers. The facility's failure to ensure staff transferred residents according to their transfer status and care plan contributed to the injury of resident #1 and placed her and all other residents who required mechanical lifts for transfer at risk for serious impairment and/or death.This failure resulted in Immediate Jeopardy which started on 10/16/25 and was removed on 10/21/25 after verification of the immediate actions implemented by the facility. The scope and severity was decreased to a D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.Findings: Cross reference F600 Resident #1, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis (one-sided paralysis and weakness) following stroke affecting left non-dominant side, obesity, chronic back pain and muscle weakness. Review of resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated she was cognitively intact. The assessment indicated resident #1 was dependent on staff for transfers. It was noted that due to her medical conditions and/or safety concerns, evaluations of resident's ability to sit to stand, transfer to the toilet or walk ten feet were not attempted. Review of the Significant Change MDS assessment dated [DATE], after resident #1 sustained the tibia fracture, revealed a decline in mood from the previous assessment. Resident reported feeling down, depressed or hopeless and had a poor appetite for 7 to 11 of the previous 14 days; and reported trouble falling or staying asleep or sleeping too much and feeling tired or having little energy for 12 to 14 of the previous 14 days. The assessment also showed a decline in resident #1's functional status and documented she became dependent on staff for sit to lying, lying to sitting on side of bed. Resident #1 reported an increase in pain frequency which occasionally made it hard for her to sleep at night. Her worst pain over the last five days increased from a pain intensity of 5/10 on the Quarterly assessment to a pain intensity of 7/10 on the Significant Change assessment after the incident. Review of the resident's electronic medical record (EMR) revealed an Activities of Daily Living (ADL) self-care performance deficit care plan initiated 5/30/23 and revised 10/18/25. The care plan indicated resident #1 had a recent fracture of left tibia. The interventions identified resident #1 as dependent for transfers and required the assistance of two staff using a total mechanical lift. The ADL task history showed resident #1 was first identified as requiring the use of a mechanical lift on 5/16/24. Review of physician orders revealed an order dated 10/17/25 for non-weight bearing pending orthopedic appointment and to apply brace to left knee (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105250 If continuation sheet Page 5 of 9 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 105250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few for immobilization. An order dated 10/21/25 read, Transfer to ER [Emergency Room] for evaluation of left tibia fx [fracture]. The EMR contained a radiology results report from 10/17/25 which revealed resident #1 sustained a left proximal (closer to the body) tibia fracture with mild displacement. Review of resident #1's Medication Administration Record (MAR) for October 2025 revealed between 10/01/25 to 10/16/25 resident #1 had complaints of pain on 6 days. Her complaints of pain increased to daily, after the incident from 10/17/25 through 10/28/25. In a phone interview on 10/27/25 at 12:08 PM, CNA A confirmed she was resident #1's assigned CNA on 10/16/25. She recalled resident #1 put on her call light and asked to go back to bed around the end of the shift. CNA A stated she was not aware of the resident's transfer status or where to find the information but resident #1 told her that staff usually got her up with a two-person pivot. CNA A explained she looked outside the room and asked another staff member to help her. CNA A stated she did not know the name of the other CNA she asked for assistance. She recalled that resident #1 said she had a little pain during the transfer and they lowered her to the floor, gave her a few minutes to rest and then lifted her and transferred her to bed. CNA A acknowledged she did not report the complaint of pain to the nurse. She explained it was the end of the shift; she had already given report to the oncoming CNA and was about to leave when resident #1 asked for help. She stated she was not aware resident #1 was injured until she was notified the next day by the (former) Director of Nursing (DON). Review of CNA B's witness statement given on 10/17/25 revealed she clocked in for work at approximately 2:36 PM on 10/16/25 and went to her assigned unit. She reported that while she was on her way, CNA A opened the room door, saw her and asked her how strong she was. CNA A asked her to help transfer the resident back to bed. CNA B recalled she recognized resident #1 but was not aware she required a mechanical lift for transfer. She documented that CNA A told her she would normally use the mechanical lift to transfer resident #1 but now would just have the resident stand and pivot to put her in bed. CNA B noted she was hesitant as she observed a mechanical lift sling already under resident #1 in the wheelchair but agreed to help. Her statement indicated they positioned the wheelchair next to the bed with the left side of the wheelchair turned slightly toward the bed and locked the wheels. CNA B and CNA A stood on either side of resident and lifted her under her arms. CNA B indicated in her statement the resident felt like dead weight. CNA B recalled resident #1 started yelling about her leg hurting during the transfer. CNA B looked down and saw resident #1's left foot was turned in slightly. She reported they lowered resident #1 to the floor and her left leg was bent backwards at the knee out to her left side. CNA B stated that resident #1 complained that her leg hurt really badly and she was in a lot of pain. Resident #1 asked if they could get the mechanical lift and CNA A responded if they got the lift that they were going to see her on the floor and would get in trouble. CNA B stated she thought they should have gotten the mechanical lift, but CNA A told her she did not want to get her in trouble. She reported that after about 30-40 seconds, they lifted the resident from the floor under her arms and quickly placed her in a sitting position on the side of the bed. She was then positioned in bed with her feet on the bed. CNA B noted resident #1 was breathing heavily and said her leg hurt really badly. She stated the resident was in a lot of pain. CNA B recalled she told CNA A that this was a transfer gone very wrong. CNA B reported that CNA A agreed and said that it was the first and last time, as they would use the mechanical lift next time. CNA B indicated she asked CNA A if she needed anything else, then left the room and went to her assignment. She stated she did not have any further interaction with CNA A or resident #1 for the remainder of her shift. CNA B explained she did not inform the nurse of the fall or resident #1's complaint of pain as she thought CNA A reported it. On 10/27/25 at 10:15 AM, resident #1 was observed in bed with the head of bed elevated and leg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105250 If continuation sheet Page 6 of 9 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 105250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few immobilizer on her left leg that extended from her thigh to her ankle. She confirmed that two CNAs transferred her without the use of a mechanical lift on 10/16/25. Resident #1 stated her foot slipped and hit the floor. She reported the pain was immediately a 10 out of 10 and continued throughout the night. Resident #1 expressed she felt she should have been sent out to the hospital when it happened. She recalled the X-ray was not done until the next day and came back as a fracture of her leg. She stated she had still not been sent out to the hospital, but the former DON and Assistant Director of Nursing put a brace on her leg and told her they were going to schedule an orthopedic appointment for her. Recalled she went to a local hospital about a week ago for her pain but did not see an orthopedic doctor. She reported she was sent to an orthopedic doctor in another city approximately an hour away on 10/24/25 but they did not take her insurance, so she was sent back to the facility without being seen for the fracture. Resident #1 expressed that her leg still hurt and was painful during ADL care, especially with rolling and positioning in bed. On 10/27/25 at 11:00 AM, Registered Nurse (RN) E confirmed she was a provider with resident #1's insurance. She stated she was familiar with the resident and was aware of the tibia fracture. RN E verified resident #1 had not had an orthopedic follow-up since the incident on 10/16/25. She recalled the former DON made an appointment for resident #1 for one day last week and verified they accepted the resident's insurance. RN E stated when resident #1 arrived, she was told they did not take her insurance and sent her back to the facility. She explained they were having difficulty finding a provider that accepted her insurance. RN E acknowledged it had been 11 days since resident #1 sustained the fracture and she had not had her orthopedic physician consultation. RN E stated it had been too long and explained they were still working on getting the resident an appointment. In a follow up interview on 10/28/25 at 8:50 AM, resident #1 stated the facility had now set her an appointment this morning with an orthopedist approximately an hour away. She explained she was supposed to leave shortly. In a meeting with the Administrator, Director of Nursing (DON) and Regional Nurse Consultant (RNC) on 10/28/25 at 11:17 AM, the Administrator stated the facility investigation showed CNA A and CNA B transferred resident #1 inappropriately using a stand and pivot technique rather than a mechanical lift as directed in her plan of care. During the transfer, resident #1 complained of pain and an X-ray revealed she sustained a left tibia fracture. The physician was notified and ordered a leg immobilizer and an orthopedic consultation. The Administrator was unable to state why the physician did not order the resident to be sent to the hospital for evaluation of the fracture. He stated the resident had requested to go to the hospital a couple of days later and then changed her mind but then requested again the next day. The Administrator reported the resident went to the hospital for uncontrolled pain but refused to allow them to do additional imaging. He was unable to explain why she was sent to the hospital for uncontrolled pain instead of for the tibia fracture when the physician order in the EMR was for evaluation of left tibia fracture. He stated that an orthopedic appointment was scheduled for 10/24/25. He explained the facility verified resident #1's insurance would be accepted, but when she arrived, they refused to see her based on her insurance. The Administrator stated the facility offered to pay but the clinic declined and resident #1 returned to the facility without being evaluated. On 10/28/25 at 2:27 PM, resident #1 was in a reclined chair at bedside. She recounted it had been a long day, and she was in pain from her toes all the way up. She stated the orthopedic doctor had ordered STAT (immediate) imaging and she was now going to the hospital for the tests. At 3:00 PM, resident #1 was leaving out the front door of the facility for transportation to the hospital. Resident #1 remained in the hospital and did not return to the facility prior to the end of the survey. On 10/30/25 at approximately 1:27 PM, the RNC confirmed resident #1 was still in the hospital. She stated resident #1 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105250 If continuation sheet Page 7 of 9 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 105250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few been diagnosed with deep vein thrombosis in her left leg. Deep vein thrombosis (DVT) is a blood clot in a vein located deep within your body, usually in your leg. This occurs when a blood clot develops in veins deep in the body because the veins are injured or the blood flowing through them is too sluggish. The clots may partially or completely block the blood flow through the vein and may dislodge moving to the lungs which is a medical emergency. Conditions which increase the risk for DVT include not moving for long periods of time, being immobile after surgery or a serious injury including fractures, (retrieved from my.clevelandclinic.org on 10/30/25).In a phone interview on 10/30/25 at 5:04 PM, resident #1 stated she still had extreme pain in her leg. She said the consulting orthopedist on 10/28/25 sent her to the hospital right away because he could not make any recommendations without viewing the X-ray images, and the facility had not provided them. Resident #1 explained now the hospital informed her she had a blood clot in her leg. She said the facility should have sent her to the hospital right away when they knew of her injury from the transfer. Resident #1 said she never refused or declined to go to the hospital but recalled the former DON had told her on 10/20/25 the facility had made an appointment with the orthopedist for a consultation the next day, so she agreed not to go at that time. She said when she did go to the hospital ER for pain, the hospital didn't offer to do an X-ray or MRI, and she never refused any imaging. Resident #1 said she finally saw a surgeon at the hospital but was told they couldn't do surgery because of the DVT, so she has to wear the brace instead and she is in a lot of pain. Review of the facility's policy and procedure for Safe Resident Handling/Transfers revised 11/29/22 revealed it was the policy of the facility to ensure that residents were handled and transferred safely to prevent or minimize the risks for injury and provide and promote a safe, secure and comfortable experience for the resident. The guidelines instructed staff that resident lifting and transferring would be performed according to the resident's individual plan of care. Review of corrective measures to remove Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/16/25 at 10:50 PM, resident #1 was assessed by the nurse due to her complaint of pain in left lower extremity, provider was notified and order received for diagnostic imaging. *On 10/17/25 resident #1 and roommate were interviewed by former DON and reported that resident #1 was transferred without the use of the mechanical lift by two CNAs on 10-16-25. *On 10-17-25 the CNAs who were noted as failing to follow resident's plan of care correctly for use of mechanical lift were immediately suspended. *On 10/17/25, the ADON began education on identifying resident's transfer status, safe transfers and skills validation. *On 10/17/25 an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the facility Administrator, Director of Nursing and Medical Director to review the incident and training to be conducted as result of incident that occurred on 10/16/25. *On 10/18/25, the CNA who assisted the assigned CNA performed a reenactment of the incident and provided a statement which included information that the two CNAs had knowledge of resident #1's transfer status and subsequently disregarded this information by performing a stand and pivot transfer. Resident #1's care plan and Kardex indicated she required a two person assist with the use of mechanical lift for transfers. *On 10/18/25 through 10-19-25, each resident's care plan and Kardex were reviewed to ensure accurate transfer status was reflected. *On 10/19/25, the facility held an ad hoc QAPI meeting to review the progress of education and competency completion as well as quality reviews. The committee conducted a root cause analysis which determined the assigned CNA made an independent decision, chose to ignore her prior education/training and did not follow the resident's plan of care for safe transfers. The ad hoc QAPI committee including the Medical Director approved the recommendations. *On 10/17/25 through 10/21/25, the nursing staff were educated on change in condition to include but not limited to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105250 If continuation sheet Page 8 of 9 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 105250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete accidents resulting in injury, offering the resident to be transferred to higher level of care for further evaluation if serious injury, escalation to chain of command via nurse supervisor and/or DON if resident concern is not addressed, following resident care plan/Kardex, safe resident handing, mechanical lift usage and competencies. As of 10/21/25, 77 out of 92 nursing staff received education, (84%), The remaining 15 total nursing staff members would receive education prior to next shift worked. *Ad Hoc QAPI meetings were completed 10/20/25 and 10/21/25 with Medical Director, Administrator, and former DON where incident, abuse and neglect, use of mechanical lifts, transfer competencies, updating care plans/Kardex, change in condition, pain management and following care plans/Kardex were discussed. No recommended changes were made to the performance improvement plan. Interviews were conducted from 10/29/25 to 10/30/25 with 18 staff members representing all shifts (1 RN, 4 LPNs, 9 CNAs, 1 dietary, 2 environmental services and 1 activity aide/CNA). Staff interviews revealed they were knowledgeable of identifying abuse and neglect, following a resident's plan of care, safe handling of resident and who to report any violations or suspected violations. The resident sample was expanded during the survey to include five additional residents. Observations, interviews, and record reviews conducted revealed no concerns related to abuse and neglect, care plans and transfer status for residents #6 through #10. Event ID: Facility ID: 105250 If continuation sheet Page 9 of 9