Health inspection·December 14, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete that time for any resident who transferred to the hospital. She explained there had been a change in Social Service Directors during that time and the forms had not been completed since May. The facility's policy and procedure for Transfer, Discharge and Therapeutic Leaves dated 6/26/19 read, A copy of resident/guest bed hold and admission policies/transfer to hospital notice should be provided upon transfer by assigned nurse to resident and or representative of resident. Event ID: Facility ID: 105376 If continuation sheet Page 2 of 24 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 12/14/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 1 of 1 resident reviewed for pain management of a total sample of 52 residents, (#199). Findings: Resident #199 was admitted to the facility on [DATE]. Her diagnoses included encephalopathy, stage IV pressure ulcer, Klebsiella pneumonia, and resistance to multiple antibiotics. Review of the resident's physician orders revealed entries dated 12/08/23, 12/09/23, and on 12/12/23 for pain management/ medications. Review of the resident's clinical record revealed care plan potential for pain with start date of 12/11/23. A baseline care plan developed within 48 hours of the resident's admission could not be identified. On 12/14/23 at 4:10 PM, the Regional Case Manager stated baseline care plans were developed within 48 hours of admission and were revised when the comprehensive care plan was developed. On 12/14/23 at 4:30 PM, the Registered Nurse/ Minimum Data Set Coordinator (RN/MDS) stated the facility's process was that a baseline care plan should be developed on admission. A baseline care plan summary would then be printed, and a meeting would be held with the resident and family for review of the baseline care plan within 48 hours of the resident's admission. A signature indicating understanding and receipt of the baseline care plan would be obtained at that time. The RN/MDS Coordinator confirmed the resident was admitted on [DATE] but stated a baseline care plan was not developed for the resident within the relevant timeframe. The facility's policy, Person Centered Care Plan with effective date of August 15, 2018, read, According to federal regulations, the facility develops and implements a baseline plan of care within 48 hours of admission that includes the minimum healthcare information necessary to properly care for the immediate needs of the resident .Baseline Plan of Care- should be initiated by MDSC (Minimum Data Set Coordinator)/designee based on referral information, dietary observation, resident/guest and/or representative and staff input within 48 hours of admission. Baseline care plan summary provided to resident/resident representative, by MDSC, after baseline care plan established and prior to completion of comprehensive care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 3 of 24 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 12/14/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents were involved in developing the comprehensive person-centered plan of care for 1 of 3 residents reviewed for participation in care plan, of a total sample of 52 residents, (#52). Findings Resident #52, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic systolic (congestive) heart failure, diabetes type II, mild intermittent asthma, other chronic pain, and shortness of breath. Review of the resident's annual Minimum Data Set (MDS) assessment, with Assessment Reference Date of 9/20/23 revealed the resident's cognition was intact, with a Brief Interview for Mental Status score of 15 out of 15. On 12/11/23 at 4:04 PM, resident #52 stated she did not get invited to her care plan meetings. On 12/13/23 at 10:42 AM, the Registered Nurse/ Unit Manager (RN/UM) for the 200 Hall stated resident/family were invited to their care plan meeting by the Social Service Director (SSD), or the UM The UM explained the SSD sent a letter to the family with the scheduled date of the care plan meeting, and if the resident/family could not attend the meeting in person, they could participate via telephone, or the meeting could be held in the resident's room. She verbalized she had recently assumed the position as UM and had not participated in a care plan meeting with the resident yet. On 12/14/23 at 9:43 AM, an interview was conducted with the Regional Case Manager, and the Registered Nurse (RN)/ MDS Coordinator. The RN/MDS Coordinator explained the process for scheduling a care plan meeting included running a roster for the next month's care plans /assessments due, mapping the meetings on the calendar, providing a list of the residents that had care plan meeting coming up to the receptionist, who would send the letter to the resident/family. She noted if any responses were obtained either verbal or via telephone, the response would be documented. If there was no response, the facility would attempt to call the resident or family. The RN/MDS Coordinator stated care plan meetings were held with the Interdisciplinary team (IDT), and a care plan summary was completed in the resident's electronic medical record, and documentation would be done regarding all persons/representative who attended the meeting. She stated that if the resident did not want to come to the MDS office, the IDT would go to the resident's room, and have the care plan meeting at the resident's bedside. The RN/MDS Coordinator stated documentation of the last care plan meeting held on 8/03/21 for resident #52, indicated the resident's daughter participated via telephone. When asked if resident #52 was invited/participated in the care plan meeting, the RN/MDS Coordinator said the resident should have received a letter. The Regional Case Manager stated review of the resident's clinical records, revealed the resident was not listed as her own responsible party. When asked if that would prevent her from being invited to the care plan meeting, the RN/MDS Coordinator said, we normally invite the resident. On 12/14/23 at 11:46 AM, the Social Services Assistant Staff E, stated that between September 2022 to May 2023 she sent invitation letters for care plan meetings to residents and family members. She explained she placed the invitation letters in envelopes, and gave them to the Receptionist, who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 4 of 24 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 12/14/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm would deliver letters to the resident/family. When the resident or family responded, a copy of the letter with the response was placed in the residents' physical chart. The resident's physical chart was reviewed with Staff E. A letter dated August 3, with no year documented was addressed to the resident's daughter, and to the resident. Two options were listed, I will attend, I will not attend neither of the options were selected. No other invitation letter was found in the resident's chart. Residents Affected - Few On 12/14/23 at 11:56 AM, resident # 52 was resting in bed. She stated she did not receive any invitation to her care plan meetings. A copy of the letter found in the resident's chart was reviewed with the resident. She explained she had not received any letter and recalled her daughter told her the facility had called her, but she never received an invitation. Resident #52 said she wanted to participate in her care plan meeting. On 12/14/23 at 1:58 PM, the RN/MDS Coordinator provided a copy of the Care Conference Summary dated 8/03/23. Review of the document with the RN/ MDS Coordinator revealed the resident's daughter's name was documented in the area for Family/Resident Attendance- name of person invited. The resident's name was not included. The document indicated the resident's next care conference was on 10/03/2023, however, a Care Conference Summary could not be identified for this meeting. On 12/14/23 at 2:17 PM, the RN/MDS Coordinator stated a care conference was scheduled for the resident on 10/05/23 at 1:30 PM but was not held. The facility's policy Person Centered Care Plan with effective date of August 15, 2018, read, Conducting the Interdisciplinary Person-Centered Care Plan Meeting a) the team, including the resident/guest and their desired representatives when possible should present findings from assessment .discuss suggested new goals or approaches . Any input gained from the resident/guest should be recorded in the plan of care and the resident/guest participation should be recorded in the EMR (Electronic Medical Record). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 5 of 24 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 12/14/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 fingernail care for a dependent resident, for 1 of 3 residents reviewed for Activities of Daily Living (ADL) care of a total sample of 52 residents, (#7). Residents Affected - Few Finding: Clinical record review revealed resident #7 was admitted to the facility on [DATE]. Her diagnoses included major depressive disorder, chronic kidney disease, pain, sarcoma, and psychotic disorder with hallucinations. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 10/11/23 revealed the resident's cognition was severely impaired, and the resident was dependent on staff assistance for toileting, shower/bathe, and personal hygiene. On 12/11/23 at 10:29 AM, 12/12/23 at 9:40 AM, resident #7 was lying in bed on her back with her eyes closed. She did not respond when spoken to. The resident's fingernails to both hands were untrimmed, with a dark substance under the fingernails of her left hand. On 12/13/23 at 9:00 AM, resident #7 was sitting up in bed, with her over bed table positioned in front of her. The resident's breakfast tray was on the table, and the resident was feeding herself, using her hands and fingers to eat her oatmeal. The fingernails of her bilateral hands were untrimmed, with a dark substance under the nails. On 12/13/23 at 9:39 AM, the Registered Nurse/Unit Manager of the 300 Hall stated nail care was done by the Certified Nursing Assistants (CNA) as needed, and the facility had a nail care spa day provided by the Activities Department. On 12/13/23 at 10:05 AM, CNA F stated nail care was provided during morning ADL care. She acknowledged resident #7 was on her assignment on 12/11/23, and 12/13/23. During observation of the resident's fingernails with CNA F, she confirmed the resident's fingernails were untrimmed, with a dark substance under the nails. CNA F acknowledged the resident ate by using her hands and fingers. She explained the resident sometimes refused care, but there was no place on the Electronic Medical Record (EMR) for her to document the resident's refusal. On 12/13/23 at 10:12 AM, observation of the resident's fingernails was conducted with the Unit Manager. She confirmed the resident's fingernails to both hands were untrimmed and needed cleaning. Review of the resident's care plan with start date of 2/02/23 indicated the resident required assistance to complete daily activities of care safely, and an intervention was to provide nail care with showers, and ADLs as needed. The facility's policy Nail Care with effective date of October 1, 2010, read, Routine nail care helps reduce the potential for infection .prevents possible injuries .Nail care is a routine part of grooming each day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 6 of 24 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 12/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure nurses followed physician's Leave of Absence (LOA) orders and failed to provide necessary monitoring and supervision to mitigate the risk of serious injury for 1 of 7 residents reviewed for Accidents, of a total sample of 52 residents, (#77). Finding: Review of the medical record revealed resident #77 was admitted to the facility from an acute care hospital on 5/29/23 with diagnoses that included substance use disorder, ETOH (alcohol) and opiate (narcotic pain medication) dependence with recent recurrent episode, history of falls, impaired gait, neuropathy (nerve impairment/damage), chronic pain, and shortness of breath. On 12/03/23, the resident was transferred to an acute care hospital and readmitted from an inpatient psychiatric facility on 12/06/23 with diagnoses that included alcohol use disorder, severe, and major depressive disorder, with severe recurrent episode. The MDS Quarterly Assessment with ARD 11/28/23 noted the resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated he was cognitively intact. The assessment indicated verbal behavioral symptoms directed towards others and physical behaviors not directed towards others occurred 1 to 3 days, there were no rejections of evaluation or care, the resident did not require staff assistance for mobility or to complete ADLs, and he received high risk antidepressant, anticoagulant, hypoglycemic, and opioid medications during the look back period. On 12/12/23 at 9:50 AM, resident #77 was observed in his room sitting in a chair beside his bed. He recalled on 12/03/23, his roommate left clutter on the floor, and they had a verbal argument that led to him hitting the other resident. He explained he had to be admitted to the psychiatric facility after it happened and he desperately wanted to transfer to another facility, but he was unable to be placed. Review of the Comprehensive Care Plan focus areas included, substance use disorder related to history of alcohol and opiate dependence; recent recurrent episode, with interventions that nurses were to observe for signs and symptoms of substance use and/or overdose, notify the doctor immediately for signs and symptoms of substance use, increase monitoring to maintain the health and safety of the resident and others, assess the resident upon return from outings and/or Leave of Absence, monitoring for potential adverse drug reactions from antidepressant, antianxiety, hypnotic, and anticoagulant medication use. The interventions directed nurses to observe for sedation, agitation, psychotic manifestations, and abnormal bleeding, with a goal that the resident would not sustain an injury related to medication usage/side effects. A care plan for behaviors noted the resident hit another resident, and admitted he had been drinking with interventions for nurses to identify causes for behaviors and reduce factors that may provoke behaviors, place resident in area where frequent observation is possible, identify causes for behaviors and reduce factors that may provoke behaviors, with a goal that the resident would not injure himself or others. The December 2023 Medication Administration Record (MAR) documented physician ordered medications were administered to the resident that included, Percocet (narcotic pain reliever) 5-325 Milligram (MG) every 6 hours as needed for pain, Trazodone (anti-depressant) 100 MG once daily for depression, Xanax (anti-anxiety) 0.5 MG twice daily for anxiety, Temazepam (hypnotic) 7.5 MG once daily as needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 7 of 24 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 12/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for sleep, Methocarbamol (skeletal muscle relaxant) for muscle ache, Neurontin (anti-seizure) 200 MG three times daily for neuropathy, Eliquis (blood thinner) 5 MG twice daily for blood clot prevention, and Valsartan 160 MG once daily for high blood pressure. On 12/13/23 at 8:36 AM, Licensed Practical Nurse, (LPN) B said residents who were competent to go on LOA signed out on forms located in a binder kept at the nurse's station. She stated a physician's order was required for a resident to go outside. She explained nurses were required to note any LOAs in the Electronic Health Record (EHR) under the resident availability section to indicate in and out times. She noted upon their return, nurses assessed the resident for substance abuse impairment and notified the doctor and supervisor of their concerns, and added the LOA may be removed from the resident if they did not comply. She said the assessment was needed because, there's a liquor store across the street. Review of the progress notes contained in the EHR documented from 8/08/23 to 10/03/23 staff documented resident #77 had eight incidents of behavioral outbursts described as, verbal, yelling, and aggressiveness towards staff. The notes indicated on 7/18/23, the resident required 1 to 1 supervision for 10 days. The Incident Log for November 2023 noted the resident had a fall on 11/04/23. The Physician's Orders Report from 5/29/23 until 8/21/23 noted there were not any physician's orders for the resident to exit the facility for a Leave of Absence (LOA), and on 8/21/23, an order was entered that read, LOA for 1 hour. On 12/13/23 at 3:13 PM, resident #77 explained prior to the incident on 12/03/23, he was allowed to independently exit the facility on LOAs and often times, he walked to the convenience store down the street (0.3 miles) to get beer. He said typically, he was away, for a couple hours. On 12/13/23 at 9:18 AM, LPN K demonstrated the EHR's function where nurses were required to enter residents' LOAs. She explained, in addition, residents were required to sign out on a paper form located in binders at the nurses' stations, and inform the nurse upon return. She stated nurses were responsible for following the LOA directions specified in the physician's orders, but was not aware of any checks required for substance impairment when residents returned from leave. On 12/14/23 at 12:22 PM, the 200 Hall Unit Manager explained LOA orders were specific to the resident and restrictions were for the resident's safety. She said nurses were expected to check the orders for directions, monitor the sign in/out books to ensure timeliness, verify returns were recorded, and they also entered times in the EHR. She stated any overstays required a report to management and notification to the physician. She recalled there had been no reports of concerns or issues about resident #77 during the daily clinical meetings she attended. She stated mixing alcohol with controlled medications, is not good; he could get hurt. On 12/14/23 at 8:59 AM, the Director of Nursing (DON) recalled on 12/03/23, she received a phone call from the Weekend Supervisor who reported resident #77 was intoxicated, had assaulted his roommate, and he required an Emergency Medical Services (EMS) and Law Enforcement transfer to the hospital. Review of the psychiatric facility's Inpatient Hospital Care Psychiatric Evaluation dated 12/04/23 showed on 12/04/23, the resident was transferred by EMS from an acute care hospital under involuntary orders. The report noted, on 12/03/23 in the hospital emergency room, the resident's Blood Alcohol Level (BAL) was measured at 0.1065, and he required emergency medication and 4-point restraint interventions for management of violent behaviors towards EMS personnel. The document read, provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 8 of 24 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 12/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few background documentation, which indicated that client has a history of opioid dependency, alcohol abuse, and tobacco use .client has a history of . disorderly intoxication, possessing open containers of alcohol . Client reportedly became aggressive and assaultive towards staff, patients, and EMS at his nursing home after becoming intoxicated. Most Recent Diagnosis Prior to Current Visit Updates: Major depressive disorder, Recurrent episode, With psychotic features, Alcohol use disorder, severe . (In patient's own words): Chief Complaint: I was drinking. The acute care hospital's Patient Results report showed on 12/03/23 at 3:03 PM, an Ethanol (Alcohol) blood test was conducted with results that read, Ethanol 106.5 H (High) . Normal < (less than) or = (equal to) 10.1 mg (milligrams) / (per) dL (deciliter). The Patient Sign Out Roster forms from 8/15/23 through 12/03/23 noted resident #77 signed out on LOA forty-two times. Thirty-five entries did not show a return time. Seven LOAs documented four return times when the resident was gone from 1.5 to 3 hours. On 12/03/23, the day the resident was transferred to the hospital, the sign out time was recorded at 8:45 AM without a return time. The Resident Availability Status History report showed from 8/16/23 to 12/03/23, nurses entered a total of three instances the resident was out on pass, from 2 to 5.5 hours. On 12/03/23, the day the resident was transferred to the hospital, he was out of the facility unsupervised for 2.5 hours. On 12/14/23 at 9:09 AM, the DON said she expected nurses to follow the facility's LOA procedure and ensure residents or their family member signed them in and out on the paper forms at the nurses' station, and nurses documented LOAs in the availability section of the EHR. She did not provide an explanation for how nurses ensured resident #77's physician's order for a 1 hour time limit was followed, and she explained they relied upon the resident to report his returns. After she checked the resident's sign out forms and the EHR availability report, she acknowledged there were multiple missing return entries and LOAs well over one hour. She stated, the nurses weren't doing the monitoring. On 12/13/23 at 11:31 AM, in a joint review of the facility's investigation of resident #77's 12/03/23 incident, the Nursing Home Administrator (NHA) stated their investigation revealed the resident admitted to the responding Law Enforcement Officer he had consumed alcohol while on LOA prior to returning to the facility. In a telephone interview on 12/14/23 at 12:51 PM, resident #77's Primary Care Physician said he was very familiar with the resident and acknowledged he provided the LOA order placed in August 2023 with a 1 hour time limit. He stated he was aware the resident received opiate medications and was at a higher risk for injuries or accidents if he was intoxicated. He stated, it potentiates the alcohol and added, not at all a good combination. He said he was not aware nurses had not been following the order to monitor the specified time. He said if nurses had made him aware the resident was out of the facility for longer periods of time, he may have revisited the order. He said the timeframe was placed because he wanted to allow the resident to get some air and stated, I didn't want him to get drunk and come back. Review of the facilities standards and guidelines titled, Nursing Management Manual, Documentation and Medical Records revised 4/24/19 read, . V. Leaves of Absence Documentation pertaining to a resident's leave of absence . a) Date and time resident left the facility b) Mode of transportation (car, ambulance, wheelchair, stretcher) c) Condition of resident d) Name of person signing resident out of facility (form NM.IV-10b) e) Reason for resident leaving facility f) Date and time resident returned g) Condition of resident upon return . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 9 of 24 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 12/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the Facility Assessment Annual Review February 2023, reviewed 3/03/23 read, Resident support/care needs 2.0 There are certain care interventions and services that are necessary across all customer diseases and conditions. These include user defined assessments, care planning, careful education of care plans, monitoring of care plan interventions for effectiveness, changing of ineffective care plan interventions, following physician orders for medications, treatments and labels, physician and family notification of any significant changes in customer condition, ADL assistance, and risk assessments . Implementation of systems to maximize customer safety and minimize customer abuse and neglect are a constant. All these assessments, interventions and services are monitored by our Unit Managers, Nurses, Nurse supervisors and management staff . Event ID: Facility ID: 105376 If continuation sheet Page 10 of 24 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 12/14/2023 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 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 ensure a Midline dressing was changed in accordance with professional standards to prevent the potential for infection for 1 of 1 resident reviewed for antibiotic use of a total sample of 52 residents, (#198). Residents Affected - Few Findings: Resident #198 was admitted to the facility on [DATE] with diagnoses which included peripheral autonomic neuropathy, spinal stenosis, lumbar region, urinary tract infection, multiple myeloma, and bacteremia. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 12/08/23 indicated the resident's cognition was moderately impaired with a Brief Interview For Mental Status score of 12/15. The assessment revealed the resident received intravenous medications on admission. Review of the resident's physician orders showed an order dated 12/07/23 with start date of 12/12/23 for Midline dressing change every 7 days. An order dated 12/09/23 noted antibiotic, Ceftriaxone 2 grams every day at 8 PM, documented last day for administration was 12/10/23. On 12/11/23 at 10:40 AM, resident #198's wife stated the resident was admitted to the facility approximately five days ago, had two infections, and was on antibiotic therapy. A Midline was noted to the resident's left antecubital area, and the dressing was dated 12/04. A midline . is a long, thin, flexible tube that is inserted into a large vein in the upper arm. It is used to safely administer medication into the bloodstream. (retrieved on 12/15/23 from www.uhs.nhs.uk). On 12/12/23 at 11:10 AM, resident #198 was lying in bed on his back, with a midline dressing to his left antecubital area dated 12/04. The resident's primary nurse Licensed Practical Nurse (LPN) G was in the resident's room, and confirmed date on the midline dressing was 12/04. LPN G stated resident #198 completed antibiotic therapy on 12/10/23. She said the midline dressing should be changed every three days and was changed by a Registered Nurse (RN). On 12/12/23 at 11:25 AM, the RN admission nurse, stated resident #198 was admitted with the midline dressing, and it should be changed every 3 days and acknowledged the dressing should have been changed. On 12/12/23 at 11:56 AM, the Director of Nursing (DON) confirmed resident #198 was admitted to the facility on [DATE] and explained the midline dressings should be changed every 7 days. The DON said the facility was counting the days from when the resident was admitted to the facility, and not from the date of 12/04 documented on the dressing. She provided a physician order dated 12 07/23 for midline dressing change every 7 days with start date of 12/12/23. The order was discussed with the DON, who stated it was reviewed, and placed the day after the resident was admitted to the facility. The DON acknowledged that professional standard directs midline dressing should be changed every 5-7 days. The DON acknowledged the date of the last dressing change was 12/4, that indicated the resident's dressing should have been changed on 12/11/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 11 of 24 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 12/14/2023 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 0694 Level of Harm - Minimal harm or potential for actual harm The facility's policy Dressing Change and site care for PIV (peripheral intravenous line), Midline, CVAD (Central venous access device) and PICC (peripheral inserted central catheter) lines read, Central vascular access device site care and dressing/injection cap changes will be performed at established intervals .Transparent film dressings are changed every 7 days. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 12 of 24 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 12/14/2023 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** 2. Resident #52, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of chronic systolic (congestive) heart failure, diabetes type II, mild intermittent asthma, other chronic pain, and shortness of breath. Residents Affected - Few Review of the resident's annual Minimum Data Set (MDS) assessment, with Assessment Reference Date of 9/20/23 revealed the resident's cognition was intact, with a Brief Interview for Mental Status score of 15/15. On 12/11/23 at 3:55 PM, and at 4:08 PM, resident #52 was lying in bed with O2 via nasal cannula being administered at 5 liters per minute (LPM). On 12/12/23 at 2:49 PM, resident # 52 was lying in bed, watching television with O2 via nasal cannula at 5 LPM. The resident stated she was supposed to be on O2 at 4 LPM. On 12/12/23 at 2:52 PM, Licensed Practical Nurse (LPN) H stated resident #52 had physician orders for O2 at 4 LPM. Review of the resident's physician orders with LPN H revealed an order dated 3/31/23 for O2 at 4 LPM via nasal cannula for diagnosis of chronic obstructive pulmonary disease (COPD). The resident's O2 flow rate was observed with LPN H. She confirmed the flow rate was at 5 LPM, and the order was for 4 LPM. LPN H stated she usually checked O2 therapy after she received shift report, and when administering medications. She explained only nurses were supposed to adjust O2 flow rate, and O2 therapy should be administered as ordered. On 12/12/23 at 2:58 PM, the RN/Unit Manager for the 200 Hall stated O2 therapy required a physician order and was monitored every shift. She stated nurses were responsible to check and sign off on the resident's O2 therapy, and the flow rate should be as per physician's order. Review of the resident's care plan for Oxygen Therapy dated 1/31/23 included interventions to administer oxygen therapy as ordered. The facility's policy for Oxygen Concentrator with effective date of April 6, 2009, read, Oxygen should be administered only under orders of the attending physician. The process included: obtain physician's orders for the rate of flow and route of administration of oxygen .Turn the unit on to the desired flow rate and assess for proper functioning. Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice pertaining to tracheostomy care and suctioning for 1 of 4 residents (#40), and failed to ensure Oxygen (O2) therapy was administered per physician's order for 1 of 2 residents reviewed for O2 therapy, (#52) of a total sample of 52 residents. Findings: 1. Resident #40 was admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE] with diagnoses including chronic respiratory failure, dependence on supplemental oxygen, attention to tracheostomy, anoxic brain damage, cerebral infarction, and seizures. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 13 of 24 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 12/14/2023 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 the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and to remove secretions from the lungs (retrieved on 12/21/23 from www.hopkinsmedicine.org). The Minimum Data Set (MDS) assessment dated [DATE] showed resident #40 required oxygen therapy, suctioning and tracheostomy care. Review of the physician orders for December 2023 included enhanced barrier precautions related to trach (tracheostomy), trach collar to be changed daily, suction prn (as needed), trach care every shift and prn. The orders did not include the actual size of the current trach tube or one size smaller to be kept at bedside along with bag valve mask (ambu bag) for emergencies. To ensure patient safety, a replacement tracheostomy tube, an obturator, a bag valve mask (Ambu bag), and suction catheter kit must always be available in the room (retrieved on 12/21/23 from www.ncbi.nlm.nih.gov). Review of the Treatment Administration Record (TAR) for December 2023 showed no evidence the nurses verified a replacement tracheostomy tube or bag valve mask were at bedside in the event of an emergency. The most recent note by the Respiratory Therapist (RT) dated 12/4/23 revealed resident #40's Trach size was 6. Resident #40's care plan dated 1/31/23 for chronic respiratory failure with SOB (shortness of breath), included altered respiratory function related to chronic respiratory failure. The interventions included to suction trach as ordered, trach care related to secretions as per physician orders and observe for audible congestion, tenacious/colored sputum, cough, and abnormal breath sounds. The goal was for the resident not to have complications such as unrelieved SOB, and congestion. The care plans did not include approaches regarding checking for an ambu bag and tracheostomy replacement tube at beside every shift in the event of an emergency. On 12/12/23 at 5:10 PM, an interview and observation was conducted with Licensed Practical Nurse (LPN) A who was assigned to resident #40 on the 3 PM to 11 PM shift. The resident's neck dressing around trach tube was saturated with white mucous. LPN A said he usually suctioned her at least 3 times during his shift because she had a lot of mucous. He was able to show a size 6 trach tube and ambu bag in the top drawer of the resident's dresser for emergencies. The suction canister at the bedside was noted to be ¾ full of pale white colored fluid. On 12/12/23 at 11:32 AM, the assigned LPN B who worked the 7 AM to 3 PM shift said she already suctioned the resident 4 times today. She noted the resident had a lot of secretions. On 12/12/23 at 11:45 AM, trach care and suctioning was observed with LPN B, the Unit Manager (UM) B Wing and Staff Development nurse. There was a sign on resident #40's door that read Enhanced Precautions with instructions to use hand sanitizer and were gloves and gown for high contact resident activities which included tracheostomy. Prior to entering the room, LPN D stated the only PPE (personal protective equipment) that should be worn was a gown and gloves for the procedure. The LPN donned a gown, gloves, and face mask. The UM and Staff Development nurse also wore gown and gloves but did not wear face mask. All 3 staff did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 14 of 24 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 12/14/2023 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 not wear face shield. Level of Harm - Minimal harm or potential for actual harm The facility's policy for Guidance for Implementing Enhanced Barrier Precautions in the Nursing Home, updated 7/12/22, read, Enhanced Barrier Precautions expand the use of PPE PPE use for these situations: Device care or use .Tracheostomy/ventilator .Face protection may also be needed if performing activity with risk of splash or spray . Residents Affected - Few Prior to trach care, none of the staff could locate the ambu bag and repeatedly looked in the clear plastic storage unit. They were informed by the surveyor that the nurse located it yesterday in the dresser across from the resident's bed. Neither LPN B, the UM nor Staff Development nurse was only able to find a size 6 trach tube at bedside and could not locate any other size or smaller tube for an emergency. The LPN washed her hands and set up her supplies on the bedside table. The suction canister remained ¾ full and non of the staff attempted to empty prior to procedure. Resident #40 was lying in bed with her head and upper body elevated approximately 45 degrees. LPN B turned on the suction machine and attempted to check if it was working properly by putting the tip of suction catheter into a cup of sterile saline. She did not know it was working until prompted by the UM to place her finger over the catheter suction port. The UM put resident #40's oxygen trach collar to the side of her neck and the LPN proceeded to suction the resident. The LPN put her finger over the catheter suction port and suctioned while entering the catheter into the trach tubing approx. 4-5 centimeters (cm) and suctioned on the way out as well. She did not rotate the catheter. The LPN proceeded to suction 2 more times using this same technique and then was instructed by the UM that she should only apply suction when pushing the catheter down the tube. The UM then donned sterile gloves and took over suctioning procedure and was able to put the tubing down into the trach tube approximately 10-12 cm and suctioned up large amounts of thick white mucous. The UM repeatedly suctioned approximately 4-5 times and the resident had strong cough reflex and expectorated large amount of mucous from the trach tube herself. While changing the trach ties, resident #40 coughed/sprayed mucous directly into the UM's face who was not wearing face mask or eye shield. By the end of the procedure, the suction canister was 90% full and the LPN was observed emptying the canister then placed it back at bedside. The canister still had remnants of thick white secretions stuck to the interior side wall. Resident #40 stopped coughing post procedure and none of the staff attempted to assess breath sounds or pulse oximetry pre/post or during the procedure. Only when prompted by surveyor approximately 5 minutes post procedure did the LPN check the pulse oximetry which read 97% and heart rate of 120 beat a minute. Pulse oximetry is a test used to measure the oxygen level (oxygen saturation) of the blood. It is an easy, painless measure of how well oxygen is being sent to parts of your body furthest from your heart, such as the arms and legs. A clip-like device called a probe is placed on a body part, such as a finger or ear lobe. The probe uses light to measure how much oxygen is in the blood. This information helps the healthcare provider decide if a person needs extra oxygen. (retrieved on 12/21/23 from www.hopkinsmedicine.org). On 12/14/23 at 12 PM, an interview was conducted with the Director of Nursing (DON) and the Assistant DON (ADON) who was in training to be the Infection Preventionist (IP). Currently the DON was the IP nurse. The DON and ADON both acknowledged that all the nurses caring for resident #40 should be able to readily locate the ambu bag at bedside in the event of emergent situation with her breathing and that the nurses should have emptied the suction canister when ¾ full prior to trach care and suctioning procedures. They both verified the proper procedure when suctioning a trach was not to apply suction upon advancing the catheter and should be done upon withdrawing catheter, as well as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 15 of 24 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 12/14/2023 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 spiral technique per facility policy. Level of Harm - Minimal harm or potential for actual harm The DON and ADON validated the staff should have checked resident's lung sounds and pulse oximetry pre and post trach care and suctioning process. They agreed the staff should have anticipated a high likelihood of splash/spray due to resident #40's history of having strong cough reflex during care and should have donned face masks and eye protection. Residents Affected - Few On 12/14/23 at 2:04 PM, the ADON verified that no competency for Trach Suctioning or care was ever completed for LPN B or the Staff Development nurse who were both present during observation of care. The competency for Trach-Suctioning dated 12/1/17 read, Insert cath into trach tube opening until resistance is felt. Do not apply suction while inserting. Withdraw catheter approximately 1/2 inch. Place finger over cath suctioning port for approximately 10-12 seconds. Rotate and withdraw catheter smoothly . On 12/14/23 at 2:11 PM, a telephone interview was conducted with the RT who verified she saw resident #40 every 2-3 weeks. The RT said resident #40 coughed constantly during trach care and can expectorate her own sections. She stated she did not suction her often. The RT explained the resident will spasm when being suctioned and she did not recommend suctioning her too often. The RT said she wore a face mask and eye shield when providing care due to secretions being sprayed. She said she would expect the nursing staff to wear appropriate PPE as well. The RT verbalized the nursing staff should be aware of the location of the ambu bag in case something went wrong and they would be able to provide ventilation. She explained the suction canister should be emptied pre procedure if ¾ full and that suction should only be applied when withdrawing the catheter. The RT added, the nurses should be checking lung sounds pre/post suctioning to determine if suctioning was effective. She said she left the pulse oximeter on the resident throughout care to ensure the resident's oxygen level was not dropping too low and that she was tolerating the procedure. The RT stated, the oxygen level is important because we do not want to endanger the resident while doing procedure and checking lung sounds to know that you have done effective job. The RT explained that as well as an ambu bag there should be size 6 trach and a smaller size 4 at bedside in the event of extubation it would be easier to put smaller tube back in. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 16 of 24 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 12/14/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nursing staff were competent to care for residents with tracheostomy for 1 of 4 residents reviewed for respiratory care of a total of 52 residents, (#40). Findings: Resident #40 was admitted to the facility on [DATE] and readmitted from acute care hospital on [DATE] with diagnoses including chronic respiratory failure, dependence on supplemental oxygen, attention to tracheostomy, anoxic brain damage, cerebral infarction, and seizures. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and to remove secretions from the lungs (retrieved on 12/21/23 from www.hopkinsmedicine.org). The Minimum Data Set (MDS) assessment dated [DATE] showed resident #40 required oxygen therapy, suctioning and tracheostomy care. Review of the physician orders for December 2023 included enhanced barrier precautions related to trach (tracheostomy), trach collar to be changed daily, suction prn (as needed), trach care every shift and prn. The orders did not include the actual size of current trach tube or one size smaller to be kept at bedside along with bag valve mask (ambu bag) for emergencies. To ensure patient safety, a replacement tracheostomy tube, an obturator, a bag valve mask (Ambu bag), and suction catheter kit must always be available in the room (retrieved on 12/21/23 from www.ncbi.nlm.nih.gov). Review of the Treatment Administration Record (TAR) for December 2023 showed no evidence the nurses verified a replacement tracheostomy tube or bag valve mask were at bedside in the event of an emergency. The most recent note by the Respiratory Therapist (RT) dated 12/4/23 revealed resident #40's Trach size was 6. Resident #40's care plan dated 1/31/23 for chronic respiratory failure with SOB (shortness of breath), included altered respiratory function related to chronic respiratory failure. The interventions included to suction trach as ordered, trach care related to secretions as per physician orders and observe for audible congestion, tenacious/colored sputum, cough, and abnormal breath sounds. The goal was for the resident not to have complications such as unrelieved SOB, and congestion. The care plans did not include approaches regarding checking for an ambu bag and tracheostomy replacement tube at beside every shift in the event of an emergency. On 12/12/23 at 5:10 PM, an interview and observation was conducted with Licensed Practical Nurse (LPN) A who was assigned to resident #40 on the 3 PM to 11 PM shift. The resident's neck dressing around trach tube was saturated with white mucous. LPN A said he usually suctioned her at least 3 times (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 17 of 24 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 12/14/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few during his shift because she had a lot of mucous. He was able to show a size 6 trach tube and ambu bag in the top drawer of the resident's dresser for emergencies. The suction canister at the bedside was noted to be ¾ full of pale white colored fluid. On 12/12/23 at 11:32 AM, the assigned LPN B who worked the 7 AM to 3 PM shift said she already suctioned the resident 4 times today. She noted the resident had a lot of secretions. On 12/12/23 at 11:45 AM, trach care and suctioning was observed with LPN B, the Unit Manager (UM) B Wing and Staff Development nurse. There was a sign on resident #40's door that read Enhanced Precautions with instructions to use hand sanitizer and were gloves and gown for high contact resident activities which included tracheostomy. Prior to entering the room, LPN D stated the only PPE (personal protective equipment) that should be worn was a gown and gloves for the procedure. The LPN donned a gown, gloves, and face mask. The UM and Staff Development nurse also wore gown and gloves but did not wear face mask. All 3 staff did not wear face shield. The facility's policy for Guidance for Implementing Enhanced Barrier Precautions in the Nursing Home, updated 7/12/22, read, Enhanced Barrier Precautions expand the use of PPE PPE use for these situations: Device care or use .Tracheostomy/ventilator .Face protection may also be needed if performing activity with risk of splash or spray . Prior to trach care, none of the staff could locate the ambu bag and repeatedly looked in the clear plastic storage unit. They were informed by the surveyor that the nurse located it yesterday in the dresser across from the resident's bed. Neither LPN B, the UM nor Staff Development nurse was only able to find a size 6 trach tube at bedside and could not locate any other size or smaller tube for an emergency. The LPN washed her hands and set up her supplies on the bedside table. The suction canister remained ¾ full and non of the staff attempted to empty prior to procedure. Resident #40 was lying in bed with her head and upper body elevated approximately 45 degrees. LPN B turned on the suction machine and attempted to check if it was working properly by putting the tip of suction catheter into a cup of sterile saline. She did not know it was working until prompted by the UM to place her finger over the catheter suction port. The UM put resident #40's oxygen trach collar to the side of her neck and the LPN proceeded to suction the resident. The LPN put her finger over the catheter suction port and suctioned while entering the catheter into the trach tubing approx. 4-5 centimeters (cm) and suctioned on the way out as well. She did not rotate the catheter. The LPN proceeded to suction 2 more times using this same technique and then was instructed by the UM that she should only apply suction when pushing the catheter down the tube. The UM then donned sterile gloves and took over suctioning procedure and was able to put the tubing down into the trach tube approximately 10-12 cm and suctioned up large amounts of thick white mucous. The UM repeatedly suctioned approximately 4-5 times and the resident had strong cough reflex and expectorated large amount of mucous from the trach tube herself. While changing the trach ties, resident #40 coughed/sprayed mucous directly into the UM's face who was not wearing face mask or eye shield. By the end of the procedure, the suction canister was 90% full and the LPN was observed emptying the canister then placed it back at bedside. The canister still had remnants of thick white secretions stuck to the interior side wall. Resident #40 stopped coughing post procedure and none of the staff attempted to assess breath sounds or pulse oximetry pre/post or during the procedure. Only when prompted by surveyor approximately 5 minutes post procedure did the LPN check the pulse oximetry which read 97% and heart rate of 120 beat a minute. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 18 of 24 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 12/14/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Pulse oximetry is a test used to measure the oxygen level (oxygen saturation) of the blood. It is an easy, painless measure of how well oxygen is being sent to parts of your body furthest from your heart, such as the arms and legs. A clip-like device called a probe is placed on a body part, such as a finger or ear lobe. The probe uses light to measure how much oxygen is in the blood. This information helps the healthcare provider decide if a person needs extra oxygen. (retrieved on 12/21/23 from www.hopkinsmedicine.org). Residents Affected - Few On 12/14/23 at 12 PM, an interview was conducted with the Director of Nursing (DON) and the Assistant DON (ADON) who was in training to be the Infection Preventionist (IP). Currently the DON was the IP nurse. The DON and ADON both acknowledged that all the nurses caring for resident #40 should be able to readily locate the ambu bag at bedside in the event of emergent situation with her breathing and that the nurses should have emptied the suction canister when ¾ full prior to trach care and suctioning procedures. They both verified the proper procedure when suctioning a trach was not to apply suction upon advancing the catheter and should be done upon withdrawing catheter, as well as spiral technique per facility policy. The DON and ADON validated the staff should have checked resident's lung sounds and pulse oximetry pre and post trach care and suctioning process. They agreed the staff should have anticipated a high likelihood of splash/spray due to resident #40's history of having strong cough reflex during care and should have donned face masks and eye protection. On 12/14/23 at 2:04 PM, the ADON verified that no competency for Trach Suctioning or care was ever completed for LPN B or the Staff Development nurse who were both present during observation of care. The competency for Trach-Suctioning dated 12/1/17 read, Insert cath into trach tube opening until resistance is felt. Do not apply suction while inserting. Withdraw catheter approximately ½ inch. Place finger over cath suctioning port for approximately 10-12 seconds. Rotate and withdraw catheter smoothly . On 12/14/23 at 2:11 PM, a telephone interview was conducted with the RT who verified she saw resident #40 every 2-3 weeks. The RT said resident #40 coughed constantly during trach care and can expectorate her own sections. She stated she did not suction her often. The RT explained the resident will spasm when being suctioned and she did not recommend suctioning her too often. The RT said she wore a face mask and eye shield when providing care due to secretions being sprayed. She said she would expect the nursing staff to wear appropriate PPE as well. The RT verbalized the nursing staff should be aware of the location of the ambu bag in case something went wrong and they would be able to provide ventilation. She explained the suction canister should be emptied pre procedure if ¾ full and that suction should only be applied when withdrawing the catheter. The RT added, the nurses should be checking lung sounds pre/post suctioning to determine if suctioning was effective. She said she left the pulse oximeter on the resident throughout care to ensure the resident's oxygen level was not dropping too low and that she was tolerating the procedure. The RT stated, the oxygen level is important because we do not want to endanger the resident while doing procedure and checking lung sounds to know that you have done effective job. The RT explained that as well as an ambu bag there should be size 6 trach and a smaller size 4 at bedside in the event of extubation it would be easier to put smaller tube back in. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 19 of 24 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 12/14/2023 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 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, interview, and record review, the facility failed to ensure dishes were washed at the appropriate temperature, with regard to the dish machine's data plate and manufacturer's instructions. Residents Affected - Some Findings: On 12/11/23 at 11:06 AM, during kitchen observation, the Dietary Manager started the dish machine and put a couple of empty dish racks through the machine. The temperature dial on the dish machine showed temperature to be 156 degrees Fahrenheit (F). The Data Plate, on the machine, noted the wash temperature should be 160 degrees F. The dish machine temperature log dated 12/11/23 noted the morning wash temperature was 155 degrees F. The Dietary Manager identified the initials next to the recorded temperature as Dietary Aide L. On 12/11/23 at approximately 11:15 AM, Dietary Aide L verified he recorded the temperatures that morning. He stated he had continued to wash dishes. Dietary Aide L explained that was the first temperature and the water got hotter as he ran the machine but acknowledged he did not record any of those temperatures. Dietary Aide L stated he did not report the low temperature to the Dietary Manager. On 12/14/23 at 11:13 AM, the Dietary Manager provided a work order which showed the dish machine had been serviced on 12/12/23 at 11:43 AM. She reported the facility had continued to serve on regular dishes and flatware as the rinse cycle reached the appropriate temperature to sanitize the dishes. She acknowledged the dishes were not washed at the temperature listed on the machine's data plate and the manufacturer's guidelines. On 12/14/23 at 2:13 PM, Dietary Aide L was observed running dish racks through the dish machine. The temperature dial on the dish machine did not reach 160 degrees F on the wash cycle as four racks of dishes passed through the machine. Dietary Aide L stated he checked the wash temperature earlier but did not check temperatures on every rack that went through. Dietary Aide L stated the wash temperature did reach the correct temperature in the morning. The Dietary Manger came into the dish room and verified the wash temperature was lower than 160 degrees F. The dish machine temperature log dated 12/14/23 did not have any recorded temperatures for the current cycle. The Food and Drug Administration 2017 Food Code notes in section 4-501.15A, that a warewashing machine and its auxiliary components shall be operated in accordance with the machines data plate and other manufacturer's instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 20 of 24 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 12/14/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #109 was admitted to the facility on [DATE] with diagnosis that included Corona Virus Disease 2019 (COVID-19). Residents Affected - Some Review of the resident's clinical record revealed a physician order dated 12/08/23 with a stop date of 12/18/23 for droplet precautions. On 12/11/23 at 11:50 AM, a sign posted on the resident's door in English and Spanish read, special droplet/contact precautions. The sign directed that everyone must: clean hands when entering and leaving room, wear an approved N95 or equivalent or higher-level respirator at all times, wear eye protection, and gown and glove at door. A three-drawer container at the entrance of the resident's room in the hallway contained the appropriate PPE. On 12/11/23 at 11:52 AM, Certified Nursing Assistant (CNA) I entered the resident's room, without the appropriate PPE. The CNA did not perform hand hygiene prior to entry, nor wear a gown, or eye protection. CNA I wore a KN95 mask. When she exited from the room, the CNA stated she did not get report, and was not sure what type of isolation the resident was on. She stated she did not read the sign that was posted on the resident's door. On 12/11/23 at 11:57 AM, the 300 Hall Registered Nurse/Unit Manager (RN/UM) stated resident #109 was on droplet precautions, and signage on the resident's room door instructed staff must clean their hands when entering/ leaving room, wear an N95 equivalent/higher mask, wear eye protection, don gown and gloves at the door/on entry to the room. The UM stated CNA I, did not have a regular floor assignment as she was the concierge, and did not get a shift-to-shift report. The UM said the CNA should have read the sign posted on the resident's door. On 12/11/23 at approximately 12 PM, CNA I stated she did not wear the appropriate PPE to enter the resident's room, and only had on a KN95 mask. She verbalized she should have read the sign. On 12/12/23 at 10:45 AM, the Infection Preventionist stated resident #109 was on droplet precautions and staff were required to wear an N95 mask, gown, gloves, and eye protection when entering the room. Observation of CNA I on 12/11/23 at 11:52 AM, was shared with the Infection preventionist. She stated she was made aware, and staff should have worn the appropriate PPE prior to entering the room. The facility's policy titled, Droplet Precautions with effective date of September 1, 2017 read, Signage should be placed on door .to notify staff, residents and visitors to follow indicated precautions. 3. Resident #199 was admitted to the facility on [DATE]. Her diagnoses included encephalopathy, stage IV pressure ulcer, Klebsiella pneumonia, and resistance to multiple antibiotics. Review of the resident's clinical record revealed a physician order dated 12/13/23 for Contact Isolation. On 12/13/23 at 9:16 AM, a Physical Therapist D was in the resident's room working with the resident. Signage posted on the resident's room door indicated the resident was on contact isolation precautions, and directed that in addition to cleaning hands before entering and leaving the room, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 21 of 24 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 12/14/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some providers and staff must also put on gloves and gown before room entry, and discard gloves and gown before room exit. An overdoor container with an adequate amount of the required PPE was in place. The Therapist had on gloves, but did not have on a gown, and was at the resident's bedside physically touching the resident, working on her lower extremities. On 12/13/23 at 9:31 AM, Physical Therapist D stated she was working with resident #199 for strengthening of her bilateral lower extremities. She acknowledged the resident was on contact isolation precautions, and stated she had gloves on and a mask, but did not have on a gown even though she was in contact with the resident. The Therapist stated she read the posted sign prior to entry to the resident's room, went in to say hello, but then continued with her therapy session. She said she realized she should have worn a gown along with her gloves since she was in contact with the resident. She stated there was the potential for cross contamination. The Center for Disease Control advised that Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. (Retrieved from www.cdc.gov/infection control on 12/15/23). Based on observation, interview, and record review, the facility failed to maintain proper infection control practices to prevent contamination during tracheostomy care for 1 of 4 residents reviewed for respiratory care, (#40) and failed to ensure the appropriate personal protective equipment (PPE) was donned prior to entry to transmission-based precaution rooms to prevent the potential for cross contamination for 2 of 2 residents reviewed for transmission-based precautions, (#109, #199) of a total sample of 52 residents. Findings: 1. Resident #40 was admitted to the facility on [DATE] and readmitted from acute care hospital on [DATE] with diagnoses including chronic respiratory failure, dependence on supplemental oxygen, attention to tracheostomy, anoxic brain damage, cerebral infarction, and seizures. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and to remove secretions from the lungs (retrieved on 12/21/23 from www.hopkinsmedicine.org). Review of the physician orders for December 2023 included enhanced barrier precautions related to trach (tracheostomy), oxygen at 2 liters continuous via trach for SOB (shortness of breath), and tracheostomy care. Resident #40's care plan started on 1/31/23 for chronic respiratory failure with SOB (shortness of breath), included approaches to suction trach as ordered. On 12/11/23 at 10:45 AM resident #40 was observed lying in bed on her right side with oxygen via trach collar and she was audibly congested. She had white to clear mucous draining from her mouth down her right cheek. On 12/12/23 at 5:10 PM, an interview and observation was conducted with Licensed Practical Nurse (LPN) A who was assigned to resident #40 on the 3 PM to 11 PM shift. The resident was in bed with her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 22 of 24 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 12/14/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm neck dressing around trach tube was saturated with white mucous. The suction canister at the bedside was noted to be ¾ full of pale white colored fluid. On 12/12/23 at 11:32 AM, the assigned LPN B who worked the 7 AM to 3 PM shift said she already suctioned resident #40 4 times today because the resident had a lot of secretions. Residents Affected - Some On 12/12/23 at 11:45 AM, an observation of trach care and suctioning was observed with LPN B. The Unit Manager (UM) B Wing and Staff Development nurse were present in the room and assisted with care. There was a sign on resident #40's door that read enhanced precautions with instructions to use hand sanitizer, wear gloves and gown for high contact resident activities which included tracheostomy. Prior to entry into the room LPN D stated the only PPE (personal protective equipment) that should be worn was a gown and gloves for trach care and suctioning procedure. The LPN wore a gown, gloves, and face mask. The UM and Staff Development nurse also wore gown and gloves but did not wear face mask. All 3 staff did not wear face shield. The facility's policy for Guidance for Implementing Enhanced Barrier Precautions in the Nursing Home, updated 7/12/22, read, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs [Multi Drug Resistant Organisms] to staff hands and clothing The use of gown and gloves for high contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home resident with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection .Table: Summary of Personal Protective Equipment [PPE] Use and Room Restriction When Caring for Resident in Nursing Homes: Standard Precautions: Applies to All resident with an of the following .Tracheostomy/ventilator regardless of MDRO colonization status. PPE use for these situations: Device care or use .Tracheostomy/ventilator .Face protection may also be needed if performing activity with risk of splash or spray . Observation of PPE supplies outside resident #40's room only included gowns and gloves. There was a box of facemasks noted at the nurses' station, but no face shields were available on the unit. Resident #40 was lying in bed with her head and upper body elevated approximately 45 degrees. The suction canister remained 3/4 full of white thick fluid. The UM put resident #40's oxygen trach collar to the side of her neck and the LPN proceeded to attempt to suction the resident. The LPN put her finger over the catheter suction port and suctioned while she introduced the catheter into the trach. The UM then donned sterile gloves and took over suctioning procedure and suctioned large amount of thick white mucous. The UM repeatedly suctioned approximately 4-5 times and the resident had strong cough reflex and expectorated large amount of mucous from the trach tube herself. While changing the trach ties resident #40 coughed/sprayed mucous directly into the UM's face who was not wearing face mask or eye shield. By the end of the procedure the suction canister was 90% full. On 12/14/23 at 12 PM, an interview was conducted with the Director of Nursing (DON) and the Assistant DON (ADON) who was in training to be the Infection Preventionist (IP). Currently the DON was the IP nurse. The DON and ADON verified the nurses should have emptied the suction canister when ¾ full prior to doing trach care and suctioning procedures. They both acknowledged the staff should have anticipated a high likelihood of splash/spray due to resident #40's history of having strong cough reflex during care and should have donned face masks and eye protection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 23 of 24 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 12/14/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm On 12/14/23 at 2:11 PM a telephone interview was conducted with the Respiratory Therapist (RT). The RT said she always wore face mask and eye shield when providing care because the resident's secretions splatter everywhere, and she would expect the nursing staff to wear appropriate PPE as well. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105376 If continuation sheet Page 24 of 24