Health inspection·May 19, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed resident #17 was admitted to the facility on [DATE] from an inpatient psychiatric hospital with schizoaffective disorder, bipolar type, other schizophrenia, and mild cognitive impairment. The Minimum Data Set quarterly assessment with Assessment Reference Date 2/22/2023 showed the resident scored 10 out of 15 on the Brief Interview for Mental Status, which indicated the resident was cognitively impaired. The assessment noted the resident had received antipsychotic medications for 7 out of 7 days during the look back period. The comprehensive care plan included focuses for potential ADL self-performance deficits related to schizophrenia and anxiety, refusals of medications, mild cognitive impairment, and monitoring for adverse effects of antipsychotic medication use. The Order Summary Report noted active medication orders for Zyprexa 15 milligrams (MG) once daily at bedtime for delusions and paranoia, and Divalproex Sodium 500 MG twice daily for hallucinations and delusions. The level 1 PASARR form completed by the facility on 6/24/2020 noted the resident did not have nor was he suspected of having mental illness based on documented history. On 5/18/2023 at 3:14 PM, the DON said the PASARR dated 6/24/2020 was the only level 1 screen completed for resident #17. She stated the resident's mental illness diagnoses were correct, and the resident should have had a level 1 screen completed that included mental illness diagnoses to ensure further evaluation was not needed. The facility's policies and procedures titled, Preadmission Screening and Resident Review (PASRR) SS-402 dated 11/08/2021, read, Policy: The Center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Based on interview, and record review, the facility failed to refer a resident with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 2 of 4 resident reviewed for PASARR, out of a total sample of 42 residents, (#6, #17). Findings: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses including unspecified convulsions, bipolar disorder current episode depressed, seizures, chronic migraine without aura, anxiety disorder and unspecified atrial fibrillation. Review of the Minimum Data Set (MDS) annual assessment with assessment reference date (ARD) of 2/23/23 revealed resident #6 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. The document indicated her active diagnoses included non-Alzheimer's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 2 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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 0644 Dementia, seizure disorder, anxiety disorder, depression and bipolar disorder. Level of Harm - Minimal harm or potential for actual harm Review of resident #6's care plan revealed a behavior care plan initiated 9/18/18, revised 5/13/20 and a psychotropic medication use care plan initiated 12/27/22. The care plan interventions included administer medications as ordered; observe for symptoms/signs of bipolar disorder, depression and insomnia; and monitor/record occurrence of target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. Residents Affected - Few Review of resident #6's electronic medical record (EMR) revealed a diagnosis of bipolar disorder with an onset date of 3/06/15, anxiety disorder with an onset date of 8/23/22, depression with an onset date of 10/01/21 and mixed obsessional thoughts and acts with an onset date of 10/01/15. The record contained a Level I PASARR screening form dated 6/24/20 which did not indicate the resident had a mental illness (MI) or suspected MI. The record did not contain a Level II PASARR screening form. On 5/18/23 at 12:30 PM, the Director of Nursing (DON) explained she and the Assistant Director of Nursing (ADON) were responsible for the PASARR process due to the social worker not having a Master's degree. The DON reviewed the EMR for resident #6 and verified the Level I PASARR did not indicate the resident had a mental illness (MI) diagnosis. She stated the facility had been working on updating PASARRs but was unsure as to whether resident #6 had an updated Level I PASARR screen or had been referred for a Level II PASARR screening. On 5/18/23 at 3:09 PM, the DON stated she was unable to locate an updated Level I PASARR screening for resident #6. She explained resident #6 had not been referred for a Level II PASRR screening since she was not identified as having a MI on the Level I PASSAR. The facility's policy and procedure for Preadmission Screening and Resident Review [PASARR] dated 11/08/21 read, It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission. The document clarified, If it is learned after admission that a [PASARR] Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 3 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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** Based on interview, and record review, the facility failed to refer 1 resident for a level 2 Preadmission Screening and Resident Review (PASARR), (#4), and failed to submit a level 1 PASARR in accordance with the state process for 1 resident, (#77) out of 4 residents reviewed for PASARR from a total sample of 42 residents. Residents Affected - Few Findings: 1. Review of the medical record revealed resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital with diagnoses including schizophrenia, depression, anxiety, affective mood disorder, and stroke. The Minimum Data Set quarterly assessment with Assessment Reference Date 3/21/2023 showed the resident was unable to complete the Brief Interview for Mental Status and noted he was severely cognitively impaired. The assessment noted the resident was dependent on staff to complete Activities of Daily Living (ADL), and received opioid medication for 3 out of 7 days during the look back period. The comprehensive care plan included focus for dependence on staff to meet emotional, intellectual, physical, and social needs related to schizophrenia and physical limitations, refusal of care and treatments, physical aggression, combativeness, ADL self-performance deficits related to schizophrenia, depression, pain, and limited mobility, impaired cognition, and monitoring for adverse effects of psychoactive medication use. The Order Summary Report noted active medication orders for Valproic Acid 250 milligrams (MG) every 6 hours for anxiety, hydrocodone-acetaminophen 5-325 MGs every 6 hours for pain, and oxycodone 7.5-325 MGs as needed every 6 hours for pain. The medical record showed a level 1 PASARR screening was completed by an acute care hospital on [DATE], and noted a level 2 evaluation was required for further evaluation of serious mental illness before admittance to a nursing home. The form did not document a level 2 evaluation was requested. On 5/18/2023 at 3:14 PM, the Director of Nursing said the level 1 PASARR from 10/29/2020 was the only screen completed for resident #4. She explained there was no record of a level 2 evaluation request or evaluation for the resident. She stated a level 2 evaluation should have been requested to ensure appropriate placement for the resident, and she could not explain why it was not done. 2. Review of the medical record revealed resident #77 was admitted to the facility on [DATE] from the community and had diagnoses including bipolar disorder, epilepsy, lack of coordination, need for assistance with personal care, malnutrition, and Parkinson's disease. The Minimum Data Set admission assessment with Assessment Reference Date 4/2/2023 showed the resident scored 15 out of 15 on the Brief Interview for Mental Status, which indicated the resident was cognitively intact. The assessment noted the resident required staff assistance to complete ADL, and had received antipsychotic medication 3 out of 7 days, and antidepressant medication for 4 out of 7 days during the look back period. The comprehensive care plan included focus for dependence on staff to meet emotional, intellectual, physical, and social needs related to cognitive deficits and physical limitations, ADL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 4 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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 self-performance deficits related to activity intolerance, Parkinson's disease, rheumatoid arthritis, limited physical mobility, and monitoring for adverse effects of antipsychotic, antidepressant, and anxiolytic medication use. The Order Summary Report noted active medication orders for Austedo 9 MGs twice daily for bipolar disorder, Vraylar 3 MGs once daily for delusions and paranoia, and Venlafaxine 225 MGs for bipolar disorder, sadness, and crying. The medical record did not include a level 1 PASARR screening. On 5/18/2023 at 3:14 PM, the Director of Nursing said the level 1 PASARR was not submitted for resident #77 because she could not remember her password to access the electronic portal. She explained a level 1 screen should have been completed in compliance with the state process to ensure further evaluation was not needed. The facility's policies and procedures titled, Preadmission Screening and Resident Review (PASRR) SS-402 dated 11/08/2021, read, Policy: The Center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 5 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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 - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident hazards and each resident received adequate supervision to prevent accidents for 4 of 4 residents reviewed for smoking out of a total sample of 42 residents, (#17, #29, #42, and #74). Findings: 1. Review of resident #17's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, mild cognitive impairment, and glaucoma. Review of the quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/22/23 revealed resident #17's Brief Interview for Mental Status (BIMS) score was 10 out of 15, which indicated moderate cognitive impairment. He required supervision for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. The annual MDS assessment with ARD of 8/24/22 noted resident #17 used tobacco. Review of a care plan dated 4/16/20 revealed resident #17 was to be supervised while smoking. Interventions included Staff only to light cigarettes and The resident's smoking supplies are stored in the smoke box. The Smoking Evaluation form dated 3/12/23 indicated resident #17 was assessed by a nurse and deemed to require supervision with smoking. Question #3, Resident is able to light cigarette safely with a lighter . was unanswered. 2. Review of resident #29's medical record revealed he was readmitted to the facility on [DATE] with diagnoses that included paraplegia, non-pressure ulcer of the left lower leg and anxiety. Review of the quarterly MDS assessment with ARD of 3/29/23 revealed resident #29's BIMS score of 15 out of 15, which indicated intact cognition. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and supervision for locomotion. The annual MDS assessment with ARD of 12/27/22 noted resident #29 used tobacco. Review of a care plan revised on 9/10/22 revealed resident #29 was a smoker and had the tendency to go across the street to smoke. Interventions included Educate and remind resident to turn in lighter. May keep cigarettes (only) in room. Staff to light cigarettes. requires supervision while smoking. A care plan with a focus for refusal of care revised on 9/5/22 showed interventions for Staff to distribute cigarettes to resident and Staff to keep smoking paraphernalia locked up. The Smoking Evaluation form dated 3/12/23 indicated resident #29 was assessed by a nurse and deemed to require supervision with smoking. The original evaluation noted resident #29 was not able to light cigarettes safely with a lighter. Review of a Nursing Progress Note dated 1/27/23 read, .notified by CNA that resident (#29) and/or roommate was smoking in room. went to evaluate. The bathroom appeared to smell of smoke. Resident denied smoking in room. This writer informed Administrator of situation. Additional nursing progress notes dated 1/31/23, 2/14/23, 3/1/23 and 5/5/23 revealed resident #29 was discussed in Standards of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 6 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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 - Minimal harm or potential for actual harm Residents Affected - Some Care meeting with the Interdisciplinary Team for smoking and the care plan and [NAME] were reviewed and current. 3. Review of resident #42's medical record revealed he was readmitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting his right dominant side and schizophrenia. Review of the annual MDS assessment with ARD of 2/16/23 revealed resident #42's BIMS score was 6 out of 15, which indicated severe cognitive impairment. He required limited assistance for bed mobility, transfers, and personal hygiene. The annual MDS assessment with ARD of 12/27/22 noted resident #42 used tobacco. Review of a care plan for smoking dated 6/15/20 revealed interventions included, Staff only to light cigarettes and The resident's smoking supplies are stored at Nurses station. The Smoking Evaluation form dated 3/12/23 indicated resident #42 was assessed by a nurse and deemed to require supervision while smoking. Question #2, . able to communicate the risks associated with smoking and #3, . able to light cigarette safely with a lighter . were answered No. 4. Review of resident #74's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included hemiplegia affecting the right dominant side, contracture of the right shoulder, right elbow, and right hand. Review of the quarterly MDS assessment with ARD of 3/02/23 revealed resident #74's BIMS score was 10 out of 15, which indicated moderate cognitive impairment. She required extensive assistance with bed mobility, transfers, dressing and personal hygiene and was totally dependent on staff for toileting and locomotion. A significant change in status MDS assessment with ARD of 11/30/22 noted resident #74 used tobacco. Review of a care plan for smoking dated 9/29/22 revealed interventions included Smoking supplies to be kept with Nursing department. The Smoking Evaluation form dated 4/04/23 indicated resident #74 was assessed by a nurse and did not require supervision while smoking. On 5/15/23 at 11:08 AM, resident #74 stated she was allowed to smoke three times a day. She explained staff kept cigarettes and lighters. She indicated staff did not keep count of how many cigarettes were used each break and were less strict with some residents by allowing them to smoke more than 2 cigarettes per break. Later on 5/19/23 at 11:21 AM, resident #74 indicated she kept her own cigarettes and some residents kept their cigarettes and lighters but technically is not supposed to be. She said, many times there is no lighter and cigarettes go missing. On 5/15/23 at 4:13 PM, during a tour of the designated smoking area, resident #29 was observed smoking a cigarette and a lighter could be seen inside his fanny pack bag. At 4:20 PM, he lit a second cigarette by himself. At 4:18 PM, Certified Nursing Assistant (CNA) I sat down in the smoking patio and looked down at a cell phone for approximately a few minutes while 14 residents were smoking. On 5/15/23 at 4:42 PM, CNA I stated there were smoking breaks at 9 AM, 1 PM, 4 PM, and 7 PM which lasted approximately 15 minutes and different CNAs were assigned each time. She indicated cigarettes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 7 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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 - Minimal harm or potential for actual harm and lighters were kept by staff but there were some residents who were deemed competent to keep their lighters. She stated there were 2 residents who kept their cigarettes but could not recall their names. She stated if you tried to get the lighter or cigarettes from them, 'It will get ugly and she tried not to get confrontational with them. She indicated there was no documentation required during the smoking task and no list or specific information about each resident. Residents Affected - Some On 5/16/23 at 5:05 PM, CNA C stated residents who smoked were not supposed to keep lighters or their cigarettes with them because some liked to smoke in their bathrooms. She indicated whoever was assigned the smoking task should ensure residents did not keep the lighter or cigarettes. She stated the staff were supposed to light cigarettes for the residents. On 5/17/23 at 4:00 PM, during a second tour of the designated smoking area, resident #29 was observed smoking and had a pack of cigarettes and a lighter in his fanny pack bag. Resident #42 had a pack of cigarettes and a lighter with him. Resident #42 lit a cigarette by himself while CNA H distributed smoking paraphernalia to waiting residents. There were 10 residents in the smoking patio, and one was observed assisting other residents to light their cigarette with his cigarette. At 4:13 PM, resident #17 gave his lighter to another resident who lit his own cigarette unaware by CNA H. At 4:20 PM, resident #29 left the smoking patio with his cigarettes and lighter. On 5/17/23 at 4:24 PM, CNA H stated residents on the smokers list could come out to smoke, but she did not have the list. She explained boxes with cigarettes were labeled with the residents' names in the cart. She explained she was supposed to watch everyone while they smoked and make sure they were safe. She added she was supposed to light the cigarettes. She stated she was told residents were not supposed to keep their lighters, but some could keep them. She stated whoever had a lighter could keep them in their rooms. She indicated she had not confirmed if this was correct or which residents could keep their lighters. She noted some names were not in the boxes where they kept cigarettes, which meant those residents kept their cigarettes and lighters. She confirmed she meant whoever she saw with their cigarettes and lighters could keep them. She stated she believed smoking details for each resident who smoked could be found in their [NAME] (Care Plan used by CNAs). At 4:43 PM, CNA H reviewed the [NAME] for resident #29. She stated it included, staff to light cigarettes and he required supervision while smoking, doesn't mention keeping the lighter. She stated she could have used the [NAME] to verify the information. She looked in the cart with smoking paraphernalia and stated there were no cigarettes or lighter for resident #29. On 5/17/23 at 5:08 PM, the B-Wing Unit Manager (UM) explained smoking occurred on the B-wing patio. She stated she kept a list of approved smokers in her office and a binder located by the nurses station. She indicated smokers were identified upon admission to the facility. She noted they performed assessment and determined if they were a safe smoker or not. She stated according to the policy, residents were not supposed to keep cigarettes or lighters but when she started working, she saw residents who kept their cigarettes and lighters. She indicated the former Administrator said it was okay for the residents to have their own lighters and cigarettes. She explained smoking assessments were performed quarterly. She recalled a staff member informed her there were 2 residents smoking in their room, not sure if staff saw it or smelled smoke. She indicated she went to resident #29's room and she smelled the smoke. She noted resident #29 rolled his cigarettes and kept his lighter in his room. She stated in the time she had been the UM he always kept his lighter. She indicated she brought this issue up with the new Administrator and he said he was going to speak with resident #29 but she didn't know what happened. Staff acknowledged staff were to light the residents' cigarette. She explained lighters and cigarettes kept by residents posed a risk for accidents because there were residents who wandered into rooms and some residents used oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 8 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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 - Minimal harm or potential for actual harm Residents Affected - Some On 5/18/23 at 1:51 PM, the Administrator stated he met with resident #29 and removed the lighter and explained it needed to be locked up. He indicated he reviewed the smoking policy with resident #29 and confirmed resident could roll his own cigarettes, he just can't have the lighter on him. He indicated he explained to resident #29 this was a safety concern. He stated he did not recall any staff addressing concerns regarding smoking or he would have discussed it with the Quality Assurance and Performance Improvement Committee and put a Performance Improvement Plan in place to correct it. He stated every time staff brought him the name of a resident they saw with smoking paraphernalia, he addressed it and he put the lighter in the cart. He stated he told residents why they could not keep lighters with them. He indicated smoking agreements were updated, re-signed and smoking privileges explained to the residents. Review of the facility's policy and procedure (P&P) Smoking - Supervised effective 11/30/14 and revised on 2/07/20 read, For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. The P&P included, If a resident is identified during the smoking evaluation to require assistance of supervision with smoking, the Center will include the appropriate information in the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 9 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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 0694 Provide for the safe, appropriate administration of IV fluids 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 provide intravenous (IV) care and services according to standards of practice and plan of care for 1 of 1 resident reviewed for IV care out of 42 total sampled residents, (#68). Residents Affected - Few Findings: Resident #68's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include femur fracture, dementia, and cystitis. Review of the Minimum Data Set (MDS) Modification of admission assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 05 out of 15 which indicated resident #68 had severe cognitive impairment. Review of the medical record for resident #68 revealed physician orders dated 4/17/23 that read, Insert Peripherally Inserted Central Catheter (PICC) for long term IV antibiotic administration. PICC line is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart . A PICC line gives your doctor access to the large central veins near the heart. It's generally used to give medications . A PICC line requires careful care and monitoring for complications, including infection and blood clots (retrieved on 6/09/23 from www.mayoclinic.org). The physician orders also included an order to evaluate site for leakage/bleeding/signs of infection every shift, and change dressing to PICC once weekly and as needed. On 5/15/23 at 2:30 PM, resident #68 was observed lying in bed with her eyes closed. An IV infusion pump was noted next to her bed. The resident was wearing a long-sleeved shirt covering both arms. Licensed Practical Nurse (LPN) L stated the resident does have an IV. She removed resident #68's left arm from the shirt sleeve and there was an occlusive dressing (not dated) on the residents upper arm. LPN L removed the occlusive dressing and the PICC dressing was dated 5/01/23. The nurse stated she did not know the resident because she worked on the other unit. On 05/17/23 at 2:42 PM, the A wing Unit Manager (UM) stated she was aware that resident #68 had a dressing dated 5/01/23 covering her PICC line on 5/15/25. She said, I expect the dressing to be changed as ordered by the physician. The UM explained the resident pulled the PICC line out in the past, so it was covered with an occlusive dressing so resident #68 would not see it. When asked how the staff could assess the site, she said the occlusive dressing could be removed and replaced easily after rechecking the site. She could not explain how the site was assessed every shift and no one noticed the date on the dressing. On 05/18/23 at 3:38 PM, the DON acknowledged she was made aware that resident #68 had not had her PICC dressing changed as ordered. She said, It is my expectation that if a resident has a PICC line or an IV, the dressing would be changed every seven days and as needed (PRN). She stated the staff should not be using occlusive dressings to cover an IV. They could use mesh or long sleeves to cover it. She added, the dressing needs to be changed every 7 days and as needed to prevent infection. The dressing cannot be covered with an occlusive material because the staff need to be able to assess the site. On 5/19/23 at 12:48 PM, during a telephone interview, LPN K stated she thought she changed resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 10 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #68's dressing on 5/01/23 and documented in the record on 5/03/23. She said the resident would sometimes play with the dressing causing it to become loose and that is why she changed it on 5/01/23. She did not explain why she did not document the dressing change until 5/03/23. Review of the facility policy and procedure, Guidelines for Preventing Intravenous Catheter-Related Infections, dated revised August 2014, revealed: Change transparent, semi permeable membrane dressings on Central Venous Access Devices every 5-7 days or PRN if damp, loosened, or visibly soiled. This does not require a physician's order. Event ID: Facility ID: 105325 If continuation sheet Page 11 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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 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 safely to prevent foodborne illness for residents residing in the facility. Residents Affected - Some Finding: On 5/15/23 at 10:05 AM, the initial kitchen inspection was conducted with the Certified Dietary Manager (CDM). The walk in refrigerator contained food items that were either previously opened or cooked that were not labeled to identify the food item and or the open/discard date. In the walk-in refrigerator there was a box on the bottom shelf that had sausage links in a hermetically sealed plastic bag that had been opened with no open/discard date. There was also a bag of chicken in a metal pan that was thawing and it did not have a label to indicate when the chicken was placed in the refrigerator for thawing, the intended date of use or discard date. There was a dinner plate with an egg sandwich covered with plastic wrap. There was no indication as to when the sandwich had been made or a discard date. There was also a small bowl of mandarin oranges, a small container filled with what looked like gelatin, two containers with salad, two small containers filled with fruit, which were all topped with plastic lids that were not labeled with contents, or open/discard dates. The dry storage shelf contained a half empty bag of potato chips that were folded over and sealed with plastic wrap which covered the expiration date and had no open/discard date. There was also a box with an opened bag of rice on the shelf undated. The CDM was unable to explain why nothing was labeled or dated. The scoop for the ice machine was lying uncovered on top of the ice machine next to a bag of soap (used for the soap dispenser). Review of the Healthcare Services Group, Labeling and Dating Inservice revealed the following: Food labels must include: The food item name, the date of preparation/receipt/removal from freezer The use by date. Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate use by date. The facility was responsible for ensuring that all food was stored and distributed in a safe sanitary and ensure the potentially hazardous foods that are subject to time/temperature are maintained or discarded to prevent the growth of pathogens that are capable of causing disease of toxin formation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 12 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, and interview, the facility failed to maintain the area surrounding the dumpster in a clean and sanitary manner. Residents Affected - Some Findings: On 5/15/23 at approximately 10:05 AM, the dumpster area was observed with the Certified Dietary Manager (CDM). There were two dumpsters with doors closed but refuse and debris were noted on the ground around the dumpsters. There were clear plastic cups, Styrofoam cups, cup lids, surgical face mask and disposable gloves on the ground. The CDM stated he usually checked every morning to ensure the area around the dumpsters was clean. He acknowledged the facility staff needed to ensure the dumpsters and the proximal area were maintained in a sanitary manner to prevent the harborage and feeding of pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 13 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Based on observation, and interview, the facility's Governing Body failed to implement policies regarding the management and operation of the facility to ensure the building's hot water was maintained to ensure residents comfort for bathing and hygiene in 32 resident bathrooms on 1 of 2 units, (Unit B). During a complaint, and recertification and relicensure survey that began on 5/15/2023, it was identified that 32 resident room bathrooms on 1 of 2 units were not supplied with hot water. Facility staff stated the problem started in late January 2023 due to plumbing damage that caused an outage to the entire B unit. The facility's governing body approved funding that allowed the facility to partially complete repairs in March 2023 which provided hot water to the Unit B shower room only. Findings: On 5/15/2023 between 10:56 AM and 2:09 PM, it was identified there was no hot water in any resident room bathrooms on Unit B of the facility. On 5/18/2023 at 1:35 PM, the facility's Administrator explained the former Maintenance Director reported to him that per the Regional Plant Operations Director, the fix for partial repairs for hot water on Unit B was done because there was underground pipe damage that required major repairs involving destruction and restoration of the Unit B floor to restore hot water in resident rooms. The Administrator acknowledged hot water was expected to be provided to residents in their room for bathing and hygiene as this was their home. He said, it took a very long time to get hot water. On 5/17/2023 at 3:06 PM , the Maintenance Assistant said the hot water outage on Unit B started in late January 2023 when a leak in the floor was identified. He said no hot water was available in resident rooms on Unit B since late January and it took until 3/17/2023 to restore hot water to the Unit B shower room. He recalled he had communicated this to the Administrator and it was discussed during morning meetings since then that residents frequently asked him when the issue would be fixed. He said he knew there were additional costs for repairs for installing a copper line in the ground and recalled he had been told by the former Maintenance Director that Corporate didn't want to pay for that. He stated Corporate Operations were responsible for approval of major work orders and the Administrator told him corporate management staff were aware and were working on it. On 5/19/2023 at 1:43 PM, the Administrator explained he had been in frequent contact over the past 6 months with the former Regional Corporate Plant Operations Director and Chief Executive Officer about restoring the hot water to resident rooms and didn't receive responses or was told it was a work in progress. He said he had completed all the requests to the Executive team, and there's nothing else I can do. The facility's policies and procedures titled, Governing Body, dated 5/03/2022 read, The Governing Body shall be . actively engaged with the management of the facility . conduct meeting with the Administrator, Director of Nursing, and Medical Director weekly to. discuss any operational or clinical issues facing the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 14 of 15 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain the walk-in refrigerator in a safe and clean operating condition. Residents Affected - Some Findings: On 5/15/23 at 10:15 AM an observation of the walk-in refrigerator (milk cooler) revealed a 48 inch x 1 inch separation along in the entire width of the metal floor in the center of the refrigerator. Various areas of the floor separation had water seeping through the gaps. Along the separation were gaping holes measuring 6 inches x 7 inches, 3 inches x 1/12 inches, and 1/1/2 inch x 2 inches. Two gaps in the metal floor had adjoining areas with a 3/8 inch rise on the floor. A water stain measuring 48 1/4 inches long x 2 inches wide was noted along the north side of the walk-in refrigerator. The Certified Dietary Manager (CDM) acknowledged the holes in the floor and the water seepage into the holes. Review of work orders dated 12/28/22, 3/31/23, and 4/20/23 were submitted with high priority for a floor in milk cooler but the repairs had not been done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105325 If continuation sheet Page 15 of 15