Health inspection·March 16, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 03/15/22 at 10:40 AM, the Housekeeping Manager explained, No one on the C Wing had notified me that resident #107 was missing his privacy curtain. Review of the Facility's Federal Rights of Resident/Guest(s), dated November 1, 2001, read, . (e) Respect and dignity. The resident/guest has a right to be treated with respect and dignity . (a) (1) Resident/Guest Rights. A facility must treat each resident/guest with respect and dignity and care for each resident/guest in a manner and environment that promotes maintenance or enhancement of his or her quality of life . Event ID: Facility ID: 105376 If continuation sheet Page 2 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 ensure a clean, comfortable and homelike environment in 7 resident rooms, (A-109, A-110, A-120, B-202, B-223, C-309, C-324), on 3 of 3 units, (A, B and C Wings). Findings: 1. On 3/14/22 at 10:32 AM, the bottom portion of the walls near the closets in rooms 110 and room [ROOM NUMBER] were noted to be damaged. The walls were gashed and dented and sheet rock was exposed. 4. On 3/14/22 at 10:35 AM, room B223 was observed. There were multiple paint scuffs on the lower portion of the bathroom door, behind bed B, and on the wall left of the bathroom door. The paint scuffs measured approximately 3 to 5 inches in length and 1/4 to 1/2 inch in width. Observation of B223's bathroom revealed a gray and brown residue on the floor which was more noticeable along the seams. There was a brownish black residue that surrounded the base of the toilet. Observation of the square vinyl flooring between bed B and the room's package terminal air condition unit (PTAC) revealed three uneven and warped floor tiles. These tiles were located near the wall beneath the left side of the PTAC unit. 5. On 3/14/22 at 11:15 AM, room C324 was observed. There were three gouges located in the sheet rock wall behind bed A's headboard. The gouges were located at the level of the metal bedframe and connecting headboard. They measured approximately one to one and a-half feet in length, about two to four inches in width, and about 1/8 to 1/4 inches in depth. The wall paint was not visible where the gouges were located. 6. Observations conducted on in room C309 at 03/13/22 at 12:48 PM, 03/15/22 at 9:34 AM, 1:08 PM and on 03/16/22 at 11:45 AM noted white patches on the wall adjacent to the closet, behind 309-A's television, on the wall behind the head of A bed, and on the wall to the left and right of the window by the B bed. On 03/16/22 at 4:45 PM-5:30 PM observations of resident rooms were conducted with the Maintenance Supervisor, Maintenance Assistant and Senior [NAME] President of Operations. The Maintenance Supervisor explained he was responsible for the maintenance of the facility and conducted facility rounds Monday-Friday. He explained as part of his rounds he stopped at each of the three nursing stations to identify any issues to be addressed. He noted resident rooms were checked but there was no schedule for the resident room rounds. He stated the facility had a program called Angel Rounds and staff were assigned to each resident rooms and completed a form to document any maintenance issues. He added the form was then given to the Director of Nursing (DON) and any maintenance issues were forwarded to maintenance. He said the facility used an electronic system for maintenance issues. Resident room observations revealed the following: 109-A: baseboard coming off the wall and large brown stain on the privacy curtain 110-A: baseboard adjacent to the closet was damaged and needs repair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 3 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 120-A: 2 holes in the baseboard adjacent to the closet Level of Harm - Minimal harm or potential for actual harm 202-B air conditioner vent contained gray wet dust and a soaking wet towel was found under the air conditioner Residents Affected - Some 223-A: floor covered with dark substance (soiled) 309-A: walls with multiple white patches 309-B: walls with multiple white patches 324-A multiple large gouge marks on the wall behind the head of the bed The Maintenance Supervisor and Maintenance Assistant acknowledged the findings. Review of the Angel Rounds form revealed Room Observations: Cubical curtain is clean, free of stains, Floor is clean and free of debris. Structural Observations: Floor tiles in good repair, Walls are free of stains, gouges, marks and holes, and Baseboards are clean and adhering to the wall. Review of the Facility's Preventive Maintenance Strategy Policy,dated March 1, 2010, read, Purpose: The Facilities Maintenance Department's major goal is to schedule and perform preventive maintenance for all equipment, and the facility physical plant, so that breakdown or failure is avoided . Preventive maintenance should be performed by the facility maintenance department . 1. Preventive Maintenance - maintenance done on a scheduled routine basis with emphasis on preventing maintenance problems . Process: Maintenance schedules should be developed in order to prevent system failures or service interruptions . 2. On 3/13/22 at 12:44 PM, the air conditioning (AC) unit in room [ROOM NUMBER] was noted to have a large amount of thick dust inside the vents and along the length of the filter. There was a saturated, soiled white blanket on the floor that extended from under the AC unit towards the nearby bed. Photographic evidence was obtained. On 3/14/22 at 8:28 AM, the dirty, wet blanket remained on the floor under the AC unit, and the vents and filter were still coated with gray dust. On 3/15/22 at 11:02 AM, the blanket on the floor had been removed but the condition of the AC vents and filter was unchanged. On 3/16/22 at 11:40 AM, a large puddle of water was noted on the floor in room [ROOM NUMBER]. The puddle spread from underneath the right side of the AC unit to an area under the footboard of the bed, a distance of approximately two feet. On 3/16/22 at 11:43 AM, Certified Nursing Assistant (CNA) M confirmed there was a blanket under the AC unit earlier that morning. She explained the blanket was wet and dirty, and she used it to dry a puddle of water on the floor. CNA M stated she told the housekeeper who was about to clean the room, but did not report the issue to maintenance staff. On 3/16/22 at 11:48 AM, the Maintenance Assistant and Maintenance Supervisor confirmed the puddle of water on the floor in room [ROOM NUMBER] was from the AC unit. They stated facility staff should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 4 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 have reported the concern either verbally or through the electronic maintenance software. They acknowledged the vents and filter of the AC unit were dirty and explained cleaning the unit was the responsibility of both maintenance and housekeeping staff. The Maintenance Assistant then placed a dry towel on the floor to absorb the water that continued to drip from the AC. On 3/16/22 at 5:38 PM, the Business Office Manager (BOM) stated she was responsible for doing regular room rounds for designated rooms on the B Wing, including room [ROOM NUMBER]. The BOM was informed of the dusty, leaking AC unit and the dirty, wet blanket observed on the floor beneath it on 3/13/22 and 3/14/22. She stated she did room rounds recently and did not note anything wrong with the AC unit nor see a blanket on the floor. The BOM provided an Angel Rounds form dated 3/14/22 which showed no documentation related to concerns in the category Floor is clean and free of debris. Review of the policy and procedure Cleaning - Patient Room - Occupied (undated) revealed all rooms would be cleaned daily. Housekeeping staff were directed to dust mop floors, and damp mop floors and baseboards. 3. On 03/13/22 12:15 PM, while completing initial tour of the facility, the privacy curtain in room [ROOM NUMBER] had brown stains and the base cover was torn away from the wall and lying on the floor next to bed A. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 5 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review, the facility failed to ensure Annual and Significant Change in Status Minimum Data Set (MDS) assessments were completed within 14 days of the assessment reference date (ARD) for 5 of 16 residents reviewed for Resident Assessment, of a total sample of 56 residents, ( #1, #2, #4, #7 & #12). Findings: 1. Review of resident #1's Annual MDS assessment with ARD of 1/25/22 revealed Section Z0500 was signed by the Registered Nurse (RN) Assessment Coordinator on 3/09/22 to indicate completion of the assessment, 43 days after the ARD. 2. Review of resident #2's Annual MDS assessment with ARD of 1/24/22 revealed Section Z0500 was signed by the RN Assessment Coordinator on 2/25/22, 32 days after the ARD. 3. Review of resident #4's Significant Change in Status MDS assessment with ARD of 1/26/22 revealed Section Z0500 was signed by the RN Assessment Coordinator on 3/02/22, 35 days after the ARD. 4. Review of resident #7's Annual MDS assessment with ARD of 1/30/22 revealed Section Z0500 was signed by the RN Assessment Coordinator on 3/10/22, 39 days after the ARD. 5. Review of resident #12's Annual MDS assessment with ARD of 2/14/22 revealed Section Z0500 was signed by the RN Assessment Coordinator on 3/11/22, 25 days after the ARD. On 3/16/22 at 3:56 PM, during review of MDS Assessment Detail forms, the Regional MDS Manager confirmed the Annual MDS assessments for residents #1, #2, #7 and #12, and the Significant Change in Status assessment for resident #4 were not completed and signed within 14 days of the ARD as required. On 3/16/22 at 5:27 PM, the Director of Nursing (DON) explained the facility's Lead MDS Coordinator resigned in December 2021 and the department was short-staffed until another Lead MDS Coordinator was hired three weeks ago. The DON stated she was not aware of how far behind schedule the MDS assessments were until the new Lead MDS Coordinator completed an audit on 3/14/22. Review of the job description for MDS Care Plan Coordinator - RN dated 9/01/09 revealed the MDS/Care Plan Coordinator was responsible for completing the Resident Assessment Instrument (RAI) under the direction of the DON. Standard requirements included complying with all Quality Assurance, regulatory requirements, and Medicare and RAI guidelines. The job description read, Ensure that MDS documentation is placed in the resident's medical record and that documentation is completed, including dates, signatures, and sections completed in a timely manner by all members of the Interdisciplinary Team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 6 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident #40 was admitted on [DATE]. Her diagnoses included a cerebral vascular accident (CVA) with right sided weakness, peripheral vascular disease (PVD), and an infected vascular toe wound. Residents Affected - Some On 3/15/22, a review of resident #40's three OBRA (Omnibus Budget Reconciliation Act) MDS assessments was conducted. The assessment reference dates (ARD) for those assessments revealed the following: The admission MDS' ARD was timely dated 8/10/21. The following MDS was a Quarterly assessment with a timely ARD of 11/20/21. The third and most recent MDS was a Quarterly assessment. It's ARD was dated 3/17/22, 117 days past the previous Quarterly assessment's ARD of 11/20/21. On 3/16/22 at 10:48 AM, interview with the facility's LPN MDS Coordinator and Regional MDS Case Manager confirmed that resident #40's quarterly MDS' ARD date of 3/17/22 was overdue according to MDS timing requirements. The Regional MDS Case Manager verbalized that in order for the quarterly MDS assessment's ARD to have been timely, the ARD would have needed to be dated 3/2/22, 15 days sooner than the current ARD date of 3/17/22. She explained that a Quarterly ARD was required to be within at least 92 days after the previous OBRA assessment's ARD. Both stated there had been turnovers in their MDS Coordinators in the past few months. The LPN MDS Coordinator stated they had identified a problem back in August or September of last year, 2021, in regards to the timeliness of their OBRA assessments. The Director of Nursing (DON) and Administrator had been informed by the team that they were behind with the MDS assessments. The LPN MDS Coordinator said the MDS team caught up and then one of the two full-time MDS coordinator's resigned in December 2021 leaving only one full-time MDS coordinator for the 180 bed facility. She said they got behind again. The DON and Administrator aware of her concerns in getting all the MDS' done timely. A Registered Nurse had been added part-time to the MDS team to assist. They indicated that another full-time RN MDS coordinator had started about three weeks ago. Another MDS audit was begun on 3/15/22, two days after the start date of the recertification survey. Currently there were 2 full-time coordinators, one for the Prospective Payment System (PPS) resident assessments and one for OBRA nonpayment resident assessments. Review of the Long Term Care Facilities (LTCF) Resident Assessment Instrument (RAI) User's Manual, MDS 3.0 included the following: A Quarterly assessment is considered timely if: The Assessment Reference Date (ARD) of the Quarterly MDS is within 92 days (ARD of most recent OBRA assessment +92 days) after the ARD of the previous OBRA assessment (Quarterly, Admission, Annual, Significant Change in Status, Significant Correction to Prior Comprehensive or Quarterly assessment) If the resident has experienced a significant change in status, the next quarterly review is due no later than 3 months after the ARD of the Significant Change in Status Assessment The facility's job description, MDS Care Plan Coordinator - RN dated 9/01/09, included: MDS Care Plan Coordinator is responsible for completing the RAI to identify needs and concerns of residents and determine the plan of care. Comply with all QA and regulatory requirements, coordinate interdisciplinary assessments, comply with OBRA, Medicare and RAI guidelines, Ensure that MDS documentation is placed in the resident's medical record and that documentation is completed, including dates, signatures, and sections completed in a timely manner by all members of the Interdisciplinary Team. Based on interview and record review, the facility failed to ensure Quarterly Minimum Data Set (MDS) assessments were completed within 14 days of the assessment reference date (ARD) for 7 of 16 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 7 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents reviewed for Resident Assessment, of a total sample of 56 residents, ( #3, #6, #10, #11, #14, #16 & #40). Findings: 1. Review of resident #16's Quarterly MDS assessment with ARD of 2/02/22 revealed Section Z0500 was signed by the Registered Nurse (RN) Assessment Coordinator on 2/24/22 to indicate completion of the assessment, 22 days after the ARD. 2. Review of resident #3's Quarterly MDS assessment with ARD of 1/24/22 revealed Section Z0500 was signed by the RN Assessment Coordinator on 2/24/22, 31 days after the ARD. 3. Review of resident #10's Quarterly MDS assessment with ARD of 1/25/22 reveled Section Z0500 was signed by the RN Assessment Coordinator on 2/25/22, 31 days after the ARD. 4. Review of resident #11's Quarterly MDS assessment with ARD of 2/14/22 revealed Section Z0500 was signed by the RN Assessment Coordinator on 3/10/22, 24 days after the ARD. 5. Review of resident #6's Quarterly MDS assessment with ARD of 1/17/22 revealed Section Z0500 was signed by the RN Assessment Coordinator on 2/22/22, 36 days after the ARD. 6. Review of resident #14's Quarterly MDS assessment with ARD of 2/15/22 revealed Section Z0500 was signed by the RN Assessment Coordinator on 3/11/22, 24 days after the ARD. On 3/16/22 at 3:56 PM, during review of MDS Assessment Detail forms, the Regional MDS Manager confirmed the Quarterly MDS assessments for residents #3, #6, #10, #11, #14, #16 & #40 were not completed and signed within 14 days of the ARD as required. On 3/16/22 at 5:27 PM, the Director of Nursing (DON) explained the facility's Lead MDS Coordinator resigned in December 2021 and the department was short-staffed until another Lead MDS Coordinator was hired three weeks ago. The DON stated she was not aware of how far behind schedule the MDS assessments were until the new Lead MDS Coordinator completed an audit on 3/14/22. Review of the job description for MDS Care Plan Coordinator - RN dated 9/01/09 revealed the MDS/Care Plan Coordinator was responsible for completing the Resident Assessment Instrument (RAI) under the direction of the DON. Standard requirements included complying with all Quality Assurance, regulatory requirements, and Medicare and RAI guidelines. The job description read, Ensure that MDS documentation is placed in the resident's medical record and that documentation is completed, including dates, signatures, and sections completed in a timely manner by all members of the Interdisciplinary Team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 8 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion, for 1 of 16 residents reviewed for Resident Assessment, of a total sample of 56 residents, (#6). Residents Affected - Few Findings: Review of resident #6's Quarterly MDS assessment with ARD of 1/17/22 revealed Section Z0500 was signed by the Registered Nurse (RN) Assessment Coordinator on 2/22/22 to indicate completion of the assessment. The document was transmitted to CMS on 3/09/22, 15 days after completion. On 3/16/22 at 3:56 PM, during review of MDS Assessment Detail forms, the Regional MDS Manager confirmed the Quarterly MDS assessment for resident #6 was not transmitted to CMS within 14 days of completion as required. On 3/16/22 at 5:27 PM, the Director of Nursing (DON) explained the facility's Lead MDS Coordinator resigned in December 2021 and the department was short-staffed until another Lead MDS Coordinator was hired three weeks ago. The DON stated she was not aware of how far behind schedule the MDS assessments were until the new Lead MDS Coordinator completed an audit on 3/14/22. Review of the job description for MDS Care Plan Coordinator - RN dated 9/01/09 revealed the MDS/Care Plan Coordinator was responsible for completing the Resident Assessment Instrument (RAI) under the direction of the DON. Standard requirements included complying with all Quality Assurance, regulatory requirements, and Medicare and RAI guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 9 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 0679 Provide activities to meet all resident's needs. 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 incorporate expressed choices for preferred activities into the plan of care, and failed to ensure access to a television provided by family to promote the highest practicable well-being for 1 of 2 residents reviewed for activities, of a total sample of 56 residents, (#8). Residents Affected - Few Findings: Resident #8 was admitted to the facility on [DATE] with diagnoses including gastrostomy tube, tracheostomy, stroke, seizures, brain damage due to lack of oxygen, respiratory failure, dependence on supplemental oxygen. A tracheostomy is a hole that is created surgically through the front of the neck and into the windpipe. A tube is inserted into the hole to keep it open for breathing and to maintain a permanent or temporary airway as indicated. A gastrostomy tube is inserted directly into the stomach through a surgically created opening in the abdominal wall. It is used to provide nutrition and hydration for patients who cannot swallow normally (retrieved on 3/25/22 from www.mayoclinic.org). Review of the Minimum Data Set (MDS) Annual assessment with assessment reference date (ARD) of 8/01/21 revealed resident #1 enjoyed activities that included listening to music. The assessment showed participating in her favorite activities was somewhat important to her, and religious practices were not very important. The Quarterly MDS assessment with ARD of 1/26/22 revealed resident #8 had short and long term memory problems, severely impaired cognitive skills for daily decision making and limitation in range of motion of all extremities. On 3/13/22 at 1:39 PM, resident #8 was in bed. Her eyes were partially open, she was non-verbal and did not show a response to her name being called. The privacy curtain in the middle of the room was drawn to separate the resident's bed from her roommate and the hallway outside the room. The blinds at the window beside the resident were closed, and the room was silent. There was no radio or television in the resident's room to provide sensory simulation. On 3/13/22 at 2:59 PM, in a telephone interview with resident #8's mother, she stated her daughter was bedbound and could not communicate verbally. She explained she bought a 32-inch television as her daughter was always in bed and did not participate in activities outside her room. Resident #8's mother stated she placed the large television on a shelf in front of the bed. The mother described the resident's favorite activities which included watching soap operas and listening to music from the Rhythm and Blues (R&B) genre. The mother was informed resident #8 did not have a television, radio or any other audio equipment in her room. She explained she had not visited the facility for a while, instead she had been participating in video calls with her daughter. The mother recalled when she used to visit in person, she often found the room dark, with the window blinds closed and the television off. Resident #8's mother stated she used to get very upset that staff would just leave her daughter in a silent, dimly lit or dark room. On 3/14/22 at 11:25 AM, resident #8 was in bed. Her eyes were closed and the room remained silent with no television or radio noted. The blinds at the window were closed and harsh, bright light above (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 10 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 0679 the head of the bed shone on her face. Level of Harm - Minimal harm or potential for actual harm On 3/15/22 at 10:58 AM, resident #8 was in bed and her eyes moved back and forth from the closed privacy curtain on the right side of her bed to the window on the left side of her bed. The blinds were partially open, but the room remained quiet. Residents Affected - Few On 3/15/22 at 1:33 PM, the resident's room remained silent, the privacy curtain was drawn around her bed, and her eyes were closed. On 3/15/22 at 5:23 PM, the Activity Director stated activities department staff conducted 1:1 visits with resident #8 in her room two to four times weekly. She explained these 30-minute visits included playing audio books, listening to religious music, and rubbing her hands. She explained although the resident was non-verbal, she made eye contact and responded well to voices and sounds. The Activity Director acknowledged the resident should therefore not be left in her room in silence, without sensory stimulation. She confirmed resident #8 had a television in her room in the past, and recalled turning it on for her. She could not remember when she last noticed the television and explained the facility did not offer radios or compact disc players for residents who were not able to leave their rooms. On 3/15/22 at 5:53 PM, Certified Nursing Assistant K recalled there used to be a big television in the resident's room, but she was unsure if it belonged to the resident or her previous roommate. On 3/15/22 at 6:09 PM, the Staff Development Coordinator verified resident #8 had a television in her room which she last saw about one year ago. On 3/15/22 at 6:20 PM, a small television had been placed on resident #8's dresser and a religious program played. On 3/16/22 at 11:38 AM, resident #8 was in bed and a speaker on her bedside table played loud religious music. On 3/16/22 at 1:16 PM, the Activity Director explained she conducted annual and quarterly assessments with residents and/or their representatives to ensure the plan of care reflected their activities of interest. She confirmed the last Annual MDS assessment indicated religious practices were not very important to her. She reviewed resident #8's care plan and confirmed it did not include watching television, especially soap operas, as indicated by the resident's mother. The Activity Director stated she spoke with the resident's mother regularly but never received this information. She was asked to call the resident's mother to conduct a joint interview. During the telephone interview, resident #8's mother informed the Activity Director her daughter had a 32-inch television on admission to the facility. The mother reiterated she had been interviewed by facility staff and informed them her daughter enjoyed soap operas, crime, mystery, action, and religious programs on television, and preferred R&B music. The Activity Director reviewed her activity notes dated 12/28/21 and 1/24/22 and validated she wrote that resident #8 enjoyed . inspirational scriptures, poems, gospel/spiritual music per family . She acknowledged the medical record did not include documentation regarding the resident's television or her preferences. Resident #8 had an activity care plan initiated on 7/31/21. The care plan goal was for the resident to participate in an activity for at least 30 minutes. Interventions dated 7/31/21 included provide activities per capability of resident, assess activity preferences and help plan, assist to get (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 11 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few activities chosen and allow rest breaks between activities. The care plan did not include specific interventions to ensure the resident's preferred activities were provided. The document indicated the resident's mother was contacted by telephone on 12/28/21 at 2:39 PM to review the care plan, but there were no new or updated interventions on that date. On 3/16/22 at 2:50 PM, the Licensed Practical Nurse MDS Coordinator explained the Activity Director would update the care plan with appropriate interventions based on interviews with residents and family. She confirmed resident #8's activities care plan did not previously include interventions regarding watching television, preferred programs and music genres. She verified the individualized interventions were added that morning, on 3/16/22. Review of the policy and procedure for Federal Rights of Resident/Guest(s) effective 11/28/16 revealed all residents had the right to chose activities consistent with their interests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 12 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 oxygen was administered as ordered by the physician for 1 of 5 residents reviewed for respiratory care, of a total sample of 56 residents, (#8). Residents Affected - Few Findings: Resident #8 was admitted to the facility on [DATE] with diagnoses including tracheostomy, dependence on supplemental oxygen, convulsions, stroke, brain damage due to lack of oxygen, shortness of breath, and respiratory failure. A tracheostomy is a hole that is created surgically through the front of the neck and into the windpipe. A tube is inserted into the hole to keep it open for breathing and to maintain a permanent or temporary airway as indicated (retrieved on 3/25/22 from www.mayoclinic.org). Review of the Quarterly Minimum Data Set assessment with assessment reference date of 1/26/22 revealed resident #8 had short and long term memory problems and severely impaired cognitive skills for daily decision making. The assessment indicated she received oxygen therapy, tracheostomy care, and respiratory therapy during the lookback period. Review of Physician Orders for March 2022 revealed resident #8 had a physician's order dated 12/27/21 for continuous oxygen at 6 liters per minute (L/min) via tracheotomy collar. The resident had a care plan for altered respiratory function related to tracheostomy with oxygen, initiated on 10/27/20. The interventions included administration of oxygen as ordered. On 3/14/22 at 9:30 AM, resident #8's oxygen tubing and the mask that provided her with oxygen through the tracheotomy tube were connected to the oxygen concentrator machine at her bedside. The concentrator's flow meter was set at 10 L/min. On 3/14/22 at 9:31 AM, the B Wing Unit Manger (UM) validated the resident's oxygen concentrator was set to administer oxygen at 10 L/min. She was unsure of the physician's orders and stated she would review the medical record to obtain the information. On 3/14/22 at 9:36 AM, the B Wing UM returned to resident #8's room and explained the physician's order was to administer oxygen at a flow rate of 6 L/min. She said, It is way high at 10 liters. She explained the resident's assigned nurses were responsible for ensuring oxygen settings were accurate. The B Wing UM stated nurses should verify each resident's oxygen flow rate at the start of the shift. On 3/16/22 at 3:00 PM, Licensed Practical Nurse (LPN) L stated she was assigned to resident #8 on Monday, 3/14/22 during the day shift. She was informed the flow meter on the oxygen concentrator was discovered at 10 L/min at 9:30 AM, almost three hours after the start of the day shift. LPN L stated she was not aware of the concern as she was passing medications to other residents and had not yet been to resident #8's room at that time. She said, It must have been set that way since the night shift. On 3/16/22 at 3:46 PM, the facility's contracted Respiratory Therapist (RT) stated she visited the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 13 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 facility to assess residents with complex respiratory issues including tracheostomies. The RT explained she saw residents either every two weeks or once monthly. She stated the facility's nursing staff were responsible for daily monitoring of these residents, and could contact her by telephone if they had questions or concerns. The RT stated she checked oxygen concentrators during her visits but never changed oxygen flow rates since they were prescribed by a physician based on clinical status. She recalled the last time she assessed resident #8, her oxygen flow rate order was 6 L/min. The RT recalled occasions in the past when she found resident #8's oxygen flow rate set at a higher level than ordered and she had to lower it. She said, I have actually said to the nurses that they should keep it at the ordered level. The RT stated nurses should ensure oxygen was administered at the correct rate and call the physician for an order rather than adjust it themselves if resident #8 required additional supplemental oxygen. Review of the policy and procedure for Oxygen Administration effective 12/08/05 revealed oxygen should be administered under orders of the attending physician. The procedure directed nurses to obtain an order for oxygen flow rate and route of administration, and to check the flowmeter to verify the correct liter flow. The Facility Assessment Annual Review 2021-2022 indicated the facility had all necessary equipment and competent staff to provide necessary care and services for residents who had tracheostomies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 14 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 pain management was provided consistent with professional standards of practice for 1 of 2 sampled residents, of a total sample of 56 residents, (#637). Residents Affected - Few Findings: Resident #637 was admitted to the facility on [DATE] with diagnoses including polyneuropathy, gout, anxiety and chronic pain. Review of the New admission documentation dated 3/9/22 showed resident #637 was alert and oriented to person place and time. The pain management regimen review indicated the resident verbalized pain and his pain would be measured on a 0-10 scale. The resident was not experiencing any pain at the time of the assessment. Review of the facility policy and procedures dated 12/18/19 for Pain Management and Assessment read, Purpose: The detection of the presence of pain, determining the frequency and intensity of pain, and identification of effective pain management interventions and with evidence of new or worsening pain .On-going Pain Assessment: The alert resident/guest should be asked to describe their pain on a scale of 1-10; with zero being no pain and 10 being the most severe pain the resident/guest can imagine .Document Pain (1-10) .documentation on MAR [Medication Administration Record] Review of the resident's care plan for potential for pain dated 3/11/22, included goal that he will not have unrelieved pain. The interventions read, observe for effectiveness of medications and attempt to measure resident pain level using pain scale 0-10. On 3/13/22 at 12:49 PM, resident #637 was observed lying in bed alert and oriented. The resident explained he came to the facility after being hospitalized for fall at home and was at the facility for therapy. The resident complained of pain in his back/hip and groin areas and said it was a 5 on a 0-10 scale at the present time. The resident's assigned Licensed Practical Nurse (LPN) B came into the room and offered pain medication to the resident who indicated to her yes he needed some. The nurse did not ask or assess the resident regarding the pain intensity or location. She then exited the room and within a few minutes returned to administer the pain medication by mouth (PO). The nurse did not inform the resident what type of pain medication she had given. The nurse then exited the room and the resident said he thought he was getting either Oxycontin or Hydrocodone for pain. On 3/14/22 at 11:10 AM, the resident was observed sitting up in bed brushing his teeth and said he received pain medication earlier this morning but still had pain level of 7. Per the resident's request, surveyor informed the assigned LPN D and Unit Manager (UM) of the resident's complaint of pain at level 7. The staff checked the electronic medical record (EMR) and said his last pain medication, Norco 5-325 milligrams (mg) was given at 3:34 AM. They explained the current order for pain medication was for every 12 hours, and they would need to call the physician to see what could be done. Norco contains a combination of acetaminophen (Tylenol) and hydrocodone. Hydrocodone is an opioid pain medication (www.drugs.com). Review of the resident's medical record revealed physician order dated 3/10/22 for nurses to check pain by scale of 0-10 at the end of each shift. An order dated 3/12/22 read, Norco 5-325 mg give 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 15 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tablet twice a day prn (as needed) for pain. On 3/14/22, the Norco order was increased to every 8 hours prn for pain. Review of the MAR revealed the nurses from 3/10/22 to the morning of 3/15/22 initialed they assessed the resident's pain level every shift but there was no documentation of the pain level. This included a total of 15 times, 3 shifts and 9 nurses who failed to document pain scale of 0-10. Review of the nursing progress notes from 3/11/22 to 3/15/22 did not include the resident's level of pain. On 3/15/22 at 1:23 PM, LPN D and the UM acknowledged physician orders since 3/10/22 were for pain assessment to be done at the end of each nursing shift and included use of pain scale 0-10. LPN D said she was assigned to resident #637's care on 3/10, 3/11, 3/14 and today and could not recall if she had documented his pain level. LPN D and the UM reviewed the MAR and reported the nurses from 3/10 to present had not assessed the resident's pain level as per physician orders. LPN D explained she had not documented the pain scale as it did not appear on the electronic MAR so she only checked the box but did not note the pain scale. The UM indicated the nurse who entered the original order did not enter it properly. She said the nurse would have had to click special requirements to add pain scale of 0-10. LPN D acknowledged she gave prn Norco for pain to the resident yesterday and could not recall what his pain level was pre/post administration. The LPN and UM conveyed it was important to document pain level to assess if the resident received adequate pain management. On 3/15/22 at 4:36 PM, Registered Nurse (RN) C verified she was assigned to resident # 637 on 3/12/22 the 7-3 and 3-11 shifts. She acknowledged only checking and not utilizing pain scale per physician orders on the MAR. She said she would need help with putting in the orders correctly and did not document pain scale in her nursing notes either. RN C acknowledged the importance of assessing resident utilizing pain scale to ensure assigned nurses would know if the resident's pain was improved or worsening. On 3/16/22 at 11:08 AM, LPN B verified she was assigned to resident # 637's care on 3/13/22 the 7-3 shift. She said, I think his pain was around 3 but did not document his pain level on MAR because it did not pop up for her to do that. She acknowledged knowing how to go back and re-enter orders as special requirement bud did not pay attention due to being so busy that day. On 3/16/22 at 11:17 AM, during an interview the Director of Nursing (DON) and Regional RN A, the DON explained nurses should have entered orders for pain scale under special requirements on the MAR. The DON acknowledged nurses had not documented the resident's pain level every shift since 3/10/22 to the morning of 3/15/22. She also acknowledged nurses had not consistently documented the residents pain level pre/post administration of Norco. She added the nurses should have reached out for assistance with entering the orders correctly. She verbalized the purpose of documenting an actual number of 0-10 was to assess if resdient's pain was well controlled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 16 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow and serve therapeutic diets as per facility's menu and for 2 of 11 residents observed for dining/nutritional concerns, (#128 and #636). Findings: 1. Review of the facility's Diet Census revealed 13 residents had physician orders for pureed diets. Review of the facility's Cycle Menu for week #4 revealed meat lasagna was served for lunch on Sunday, 3/13/22. The other menu items for that meal included vegetable blend, garlic bread and frosted cake. The alternate meal for lunch on 3/13/22 included chicken tenders and french fries. Review of the facility's therapeutic menu revealed residents with physician ordered pureed diets were to receive 6 ounces of pureed meat lasagna and/or pureed chicken tenders. On Sunday, 3/13/22 at 10:35 AM, during the initial kitchen inspection at 10:50 AM, the lunch tray line was in progress. On the steam table were meat lasagna, vegetable blend, chicken tenders, puréed chicken tenders, pureed vegetable blend, corn chowder soup and gravy. The pureed meat lasagna and garlic bread were missing. [NAME] Y and Dietary Aide X reported the Certified Dietary Manager (CDM) had not ordered garlic bread nor enough frozen lasagna for pureed meals. They explained garlic bread came to the facility frozen and was reheated at the facility. They acknowledged they had bread, butter/margarine and garlic powder available but did not explain why garlic bread was not prepared despite having ingredients available. On 3/13/22 at 12:17 PM, the main dining room was observed. There were 3 staff and 4 residents in the dining room. The residents had just finished eating dessert. Certified Nursing Assistant W said the desert was red velvet cake but it was not frosted. On 3/13/22 at 12:28 PM, [NAME] Y and Dietary Aide X explained the facility did not have frosting for the cake. On 3/16/22 at 4:24 PM, the CDM indicated he was aware of issues with the lunch meal on 3/13/22. He stated there was enough frozen lasagna in the freezer for staff to prepare pureed lasagna. He explained frozen frosted chocolate cakes were also available in the freezer and should have been served for lunch on 3/13/22. He added the food vendor did not have frozen garlic bread but acknowledged kitchen staff had the ingredients to make it. 2. Review of resident #636's medical record revealed he was admitted to the facility on [DATE] with diagnoses of ketoacidosis, obesity, and diabetes mellitus type 2. Review of the 5-day minimum data set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with Brief Interview for Mental Status score (BIMS) score of 14/15. Review of the dietary communication form dated 2/18/22 indicated he was on mechanical soft, no added salt, carbohydrate consistent diet. On 3/13/22 at 12 PM, resident #636 stated, I never get what is on the meal ticket. Observation of the lunch plate revealed lasagna, vegetable blend, chocolate frosted cake and diet soda. Review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 17 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the dietary slip dated 3/13/22 on the lunch tray documented meat lasagna, vegetable blend, chocolate frosted cake, garlic bread and diet soda. Certified Nursing Assistant (CNA) E who was at resident's bedside identified he did not have any garlic bread on his tray as per the meal ticket. 3. Review of resident #128's medical record revealed she was admitted to the facility on [DATE] with diagnoses including dementia and anemia. Review of the annual MDS assessment dated [DATE] revealed she had severe cognitive impairment with BIMS score of 1/15. On 3/12/22 at 12:05 PM, observation of resident #128's lunch plate revealed lasagna, red velvet cake, mixed vegetables, chocolate shake and cranberry juice. The resident was sitting up in bed feeding herself and was not able to answer any questions. CNA E was present at the bed side and acknowledged there was no garlic bread on the resident's tray and should have been as per the meal ticket. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 18 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 ensure the garbage storage area was maintained in clean and sanitary condition. Residents Affected - Many Finding: During the initial kitchen inspection on 3/13/22, the garbage storage area was observed at 11:10 AM. There was a trash compactor and dumpster for recycling with one of the doors open. Debris was scattered on the ground including white/clear gloves, milk cartons and other refuse. [NAME] Z was in the area and said the dumpster doors should be closed at all times. He said the gloves were used by nursing staff as the kitchen staff used black gloves. He explained he did not know who was responsible for keeping the garbage storage area clean. On 3/16/22 the Certified Dietary Manager indicated he did daily inspections which included the garbage storage area. He explained he did not work on 3/13/22 and did not know who was responsible for inspecting the garbage storage area when he was off work. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 19 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, interview and record, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to physical environment and Minimum Data Set (MDS) assessments. Findings: Cross Reference F584, F636, F638 and F640 Review of the facility's survey history revealed repeat deficiencies and systemic concerns with the resident's physical environment over the past four years, and for the current recertification survey. Past deficiencies noted failures in maintaining comfortable resident rooms, resident equipment and furniture. Review of the facility's survey history also revealed repeat deficiency related to resident MDS assessments over the past year and systemic concerns for the current recertification survey with inaccurate assessments, delays in completing and transmitting MDS assessments. On 3/16/22 at 4:52 PM, an interview was conducted with the Administrator and Director of Nursing (DON) regarding the facility's QAPI program. Review of the facility's QAPI monthly meeting agenda revealed the facility's housekeeping and maintenance concerns were not listed as part of the agenda. The Administrator and DON acknowledged this and said the Housekeeping Department did not report to their monthly QAPI meetings. They explained the Environmental Director conducted safety committee meetings which included fire drills, safety drills, employee injuries, and occupational safety and health related activities, but did not report to the QAPI monthly meeting. They indicated the facility conducted weekly Angel Rounds, a program where administrative staff inspected assigned rooms and residents. They said the inspections included reports on environmental concerns that were brought to their morning and/or afternoon meetings. There was no documented evidence the environmental concerns from Angel Round Program was trended or brought to the QAPI meetings for possible action plans. The Administrator and DON acknowledged there was no current QAPI plan in place for housekeeping and environmental concerns. The DON revealed one of the two MDS Coordinators had left employment in middle of December with now only one MDS Coordinator for the 180 bed facility. They said after the MDS coordinator left, they were aware of assessments not being completed timely. The DON identified that during the current recertification survey, on 3/14/22, they initiated an audit of MDS assessments. The DON noted they knew there was a problem in December with late MDS assessments, but did not know how bad it was until this week. Review of the facility's Quality Assurance Performance Improvement Plan (QAPI) included the following: Our purpose is to provide excellent quality resident/guest services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the resident cost effectively while maintaining good resident outcomes and perceptions of resident care The QAPI Plan addresses: Monitor existing data available through annual . survey, resident/guest family satisfaction surveys the following data is monitored through QAPI survey findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 20 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure oxygen concentrator's external filter was maintained in a clean and sanitary manner to promote oxygen flow for 1 of 5 residents reviewed for respiratory care of a total sample of 56 residents, (#132). Residents Affected - Few Findings: Review of resident #132's medical record documented she was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of the Lung with Lobectomy in 2004, Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Bronchitis and Acute Upper Respiratory Infection. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident received oxygen therapy. Review of the resident's plan of care dated 01/14/22 noted intervention to administer oxygen therapy as ordered, Review of resident #132's physician orders dated 12/02/21 read, continuous oxygen at 2 Liters (L) via nasal cannula. On 03/14/22 at 9:57 AM, the resident's oxygen concentrator's external filter was missing and gray dust was noted at the filter opening. On 03/15/22 at 9:42 AM and 1:35 PM, the oxygen concentrator's external filter was now in place. The inner surface of the filter was covered with balls of gray dust which peeled off the filter. On 03/15/22 at 1:25 PM, the C Wing Unit Manager (UM) said oxygen tubing was changed by the licensed nurses on Wednesday nights on the 11 PM - 7 AM shift and Central Supply maintained the oxygen concentrator. She explained if the filters were blocked with dust the resident would not receive the proper oxygen flow. The UM removed the concentrator's external filter and acknowledged the filter's surface was covered with gray dust. She stated, The filter needs to be cleaned. On 03/16/22 at 10:00 AM, the Director of Nursing (DON) indicated she was unsure who was responsible for cleaning the filters. She reported if the filters were clogged, the oxygen concentrator would not work properly to provide the proper oxygen flow rate to the resident. We need to follow the manufacturer guide lines On 03/16/22 at 10:09 AM, Central Supply staff stated she checked the filters every 6 months and she noticed several residents with soiled oxygen filters. I just put the filter in resident #132's concentrator since it was missing. I did not check the to see if the space where the filter fits was clean. Review of the Facility's Cleaning Infection Control for Equipment, dated May 4, 2020, read, . 2. Implement Infection Control Cleaning of Equipment . c. All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and at Infection Control nurse's instruction . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 21 of 22 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 105376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904 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 Level of Harm - Minimal harm or potential for actual harm Review of the oxygen concentrator .Series User Manual not dated, read, Routine Maintenance, Cleaning of the Cabinet Filter. DO NOT operate the concentrator without the filter installed . 1. Remove the filter and clean as needed. 2. Clean the cabinet filter with a vacuum or wash in soapy water and rinse thoroughly. 3. Dry the filter thoroughly before reinstallation . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 22 of 22