Inspection·August 25, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Patient will be reassessed later in the week as to performance. Will refer to Nursing and Administration for further guidelines to care plan possible replacement of rails. Currently therapist is unable to replace rails per facility stance. Resident refused EOB (end of bed) or OOB (out of bed) activities until she has bed rails to assist with transfers.' During an initial interview with Resident #78 on 08/22/22 at 11:55 AM, the resident stated when she was admitted , she had side rails on her bed, they took them off the bed stating that it was against the law to have them. She has wounds and cannot move around without them. She is very upset over this and has told so many staff about this, but nothing has been done. Observations were made during survey on 08/22/22 through 08/25/22 of this resident's bed revealed no bed rails / enablers on her bed. During an interview on 08/24/22 at 11:44 AM with Staff E, Director of MDS (Minimum Data Set), she stated therapy would have to access the resident or see if there is an alternative to side rails / enablers. She then stated that side rails are a restraint or entrapment. During an interview on 08/24/22 at 11:50 AM with the DON (Director of Nursing), she was asked what the policy was on the use of side rails / enablers. The DON stated that if a resident wants enablers, therapy is the one that decides if they get an enabler; Therapy has to evaluate them might need a trapeze or something different; and we are not involved in that. During an interview on 08/24/22 at 11:53 AM with the Director of Rehab, she stated that based on a resident's therapy assessment, if recommended, we get with nursing. She was asked if the resident requests siderails / enablers, then what. She stated that they should get them. She was asked to show the surveyor the assessment completed for Resident #78. During an interview on 08/25/22 at 9:23 AM with Staff F, Physical Therapist, he stated the evaluation was done for use of side rails and they were taken off the bed because they are considered a restraint. The physical therapy evaluation was completed on 07/13/22. He stated she had side rails when evaluation was completed. She did not mention it to me but did bring it to another therapist's attention that she wanted them. During an interview on 08/25/22 at 9:32 AM, with a staff member, the staff stated we just got a new policy on enablers and I know they are supposed to be evaluated by PT. The sataff member stated that prior to two weeks ago, corporate had us remove all the side rails; I remember she (the resident) was more dependent with the side rails and less dependent without them; and Therapy has to write an order for the enablers. During a secondary interview on 08/25/22 at 10:25 AM, with Resident #78, she stated she had told so many staff that included therapy and even the Psychiatrist or Psychologist (not sure what she was). The answer I always got was someone will come in to talk to me. She stated that it was so much easier for her to pull to the side when they were cleaning her up. She says now I have to literally put my knuckle/fist to the ground, so I don't fall. While talking to resident, a physical therapy assistant (PTA) walked in to work with her. During an interview on 08/25/22 at 10:30 AM, with Staff G, PTA (Physical Therapy Assistant), she was asked if this resident ever asked her about getting side rails / enablers. She stated Yes; the resident used to have a bed that this company wanted to send back to the rental company they were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 2 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few renting it from and it had enablers on them. When they brought in another bed, they did not have any. Corporate decided to be a 'siderail free' facility. She said that this resident was doing good without them. The resident then interrupted and said, that is not true; Have you seen me put my knuckles / fist to the ground to make sure I don't fall out of the bed. The PTA stated that it is not up to them to get the siderails to the patient. The surveyor asked if they are required to evaluate them prior to getting the siderails. She said the Director of Rehab told us that if the resident wants them, they should get them. During an interview on 08/25/22 at 2:20 PM with the Director of Rehab, she stated that we have been up in the air with evaluating the residents to use enablers because of Corporate not wanting to use side rails. We got an updated policy, but they have been wishy washy in using it, unsure what they [corporate] want us to do. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 3 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 - Few 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, record review and interview, the facility failed to provide a safe, clean comfortable homelike environment for the residents. The findings included: During tour of the facility, including resident rooms on 08/22/22 and through 08/25/22, and a secondary tour completed on 08/24/22 at 8:21 AM, with the Director of Maintenance & Housekeeping, and the Administrator, the following concerns were noted, observed, and acknowledged during tour: 1. 100 unit: a. room [ROOM NUMBER]A - Floors were dirty with debris. There were clothes piled up in the corner of the room. The resident stated he cannot get anyone to hang his clothes up for him. During the secondary tour on 08/24/22 (Thursday), two dead cockroaches were observed in the room, with one under the bed along with a dirty razor, which has been there since Monday. b. room [ROOM NUMBER]A - There was clothes piled next to bed. A sampled resident complained that staff say they don't have time to put away her clothes. Her closet was observed behind the door, labeled A. There were no clothes observed hanging in her closet, only briefs on the bottom floor of closet. During an interview on 08/24/22 at 9:20 AM with Staff I, Certified Nursing Assistant (CNA), she was brought into room [ROOM NUMBER]A, and was asked about the clothes on floor in corner. She stated she floats and does not have time to do put them away; I do not get to finish my assignment; and there is not enough staff. 2. 200 unit: a. Hallway leading to nurse's station A had vinyl baseboard peeling away from wall. b. Hallway ceiling vent by room [ROOM NUMBER] had dirty vents with black and green soot-like substance on vents and ceiling tiles. b. Hallway by room by 211 had vinyl baseboards pulling away from the wall. c. Hallway by room [ROOM NUMBER] had the vinyl baseboard pulling away from the wall. d. room [ROOM NUMBER] - the A/C (air conditioner) unit had black and green soot on and in the unit. The sampled resident's wheelchair's (W/C) left arm rest had a tear in it. e. room [ROOM NUMBER] - The floors were filthy with debris. The sampled resident's wheelchair seat and back cushion were torn. f. room [ROOM NUMBER]-A - the sampled resident's wheelchair back and seat were torn. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 4 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 g. room [ROOM NUMBER] - the faucet in room was corroded. Level of Harm - Minimal harm or potential for actual harm h. room [ROOM NUMBER] - the resident stated on 08/22/22 at 11:29 AM that the bathroom was disgusting, so gross to use the sink, and the A/C leaks. Observations made, during the resident interview, revealed concerns that the light over toilet was not working, the sink was dripping, the faucet at sink was corroded and had a black and green soot-like substance around it. The main door to the room was warped and did not close, a dead roach was observed under the resident's wheelchair. The floors in bathroom were stained, metal around ceiling tiles were rusted, metal fan cover was coming away from ceiling tile, vinyl baseboard was peeling away from wall, and the A/C had a blanket underneath it. Residents Affected - Few i. room [ROOM NUMBER] had plastic pipes lying under sink. j. room [ROOM NUMBER] - A-resident stated on 08/22/22 at 11:33 AM that the air conditioner did not work on somedays and it leaks; said he has his own fan under bed to use. Observed: a blanket under the A/C unit, bathroom caulking around toilet was missing in places and very dirty, toilet paper was all over floor, the floor was stained; two bed pans were sitting on sink countertop not labeled or bagged, along with a urinal sitting in bed pan, and the caulking on back of sink and wall was discolored. k. room [ROOM NUMBER]-B - On 08/22/2 at 9:36 AM, the sampled resident stated the covering of the toilet sit cannot stay up, and once put up, it automatically goes down. The resident voiced the toilet covering seat hurt her back 2-3 times, she told nurse on first shift yesterday and the day before, they haven't done anything about it. There was an unlabeled bedpan and basin stored directly on the sink in the bathroom, without any protective barrier, and this room was shared by 4 residents. l. room [ROOM NUMBER]-B - On 08/22/22 at 10:04 AM in bathroom that is shared by rooms 220 & 221, the inside of the toilet was dirty, stained with brown substance, 2 small live roach and 1 live cockroach were noted in the bathroom. On 08/24/22, during subsequent tour, the toilet continued to be dirty with brown substance. The resident's family in bed A stated she just killed a cockroach. It was observed on floor dead. Photographic Evidence Obtained. 3. During the secondary tour with the Director of Maintenance, he stated that housekeeping works 7:00 AM-3:00 PM and 8:00 AM-4:00 PM, and he does not have staff in the evenings. He stated that the wheelchairs are the responsibility of the rehab unit to let us know if a wheelchair needs to be replaced. We use an app called Tals and everyone has it and they input the information into the app. He stated the exhaust fans in the hallway were not working and were replaced last week. We had about 6 that were out. They had condensation on them and acknowledged that what we see on them is dust and can be mold. He was asked about the clothes on floor and stated that it is the CNA's responsibility to hang clothes up. During an interview on 08/25/22 at 1:58 PM with Staff U, CNA, when asked if a wheelchair is torn, Staff U stated, 'I tell therapy, I don't write it down I just tell them when I see them. I do not have the Tals app.' During an interview on 08/25/22 at 2:20 PM with the Director of Rehab she stated she does wheelchair audits once a month. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 5 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 4. a. Throughout the COVID unit, Rooms 100 - 110, the handrails were noted to be stained and encrusted with an unidentifiable matter. The walls on the COVID unit were noted to be damaged just above the rubber baseboard that covers the floor and wall juncture. Residents Affected - Few b. In the Activities room at the end of the COVID unit, the A/C units had been removed and left large holes in the walls that were not covered. The holes in the walls allowed for heat from the outside to be pulled into the room. The door of the Activities Room was held open by staff placing amounts of paper between the door and the door jamb, which created an opening that allowed the heat and humidity to get into the corridor of the COVID unit. The outside temperature during the survey time period ranged from 81 degrees Fahrenheit (F) to 94 degrees F. During an interview with Resident #11, with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, the resident commented that the room was 'very uncomfortable' due to feeling 'hot'. During interviews with Staff A, CNA, and Staff B, CNA, they both stated that the corridor and unit felt warm and were only made worse by having to don Personal Protective Equipment (PPE), in the form of N95 mask, gown, gloves and face shields. c. In room [ROOM NUMBER], the plate that covered the tumbler mechanisms of the door handle, on the inside of the door, was not secured, in a manner that residents could have the potential for skin tears. The over rubber side of the over bed table of the door bed was noted to be falling away from the table exposing the particle board underneath. The padding on the back of the resident's wheelchair in the door bed was noted to be torn, damaged, and the padding on the arms of the same wheelchair were noted to be not secured. d. In room [ROOM NUMBER], the surface of the over bed table for the door bed was noted to be worn. e. In room [ROOM NUMBER], the cushion of the sampled resident's wheelchair was torn in a manner that exposed the foam padding underneath, the back of the wheelchair and the arm rests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 6 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for 2 of 22 sampled residents, as evidenced by Resident #94 was inaccurately coded as having wandering behaviors and an indwelling urinary catheter; and Resident #207 was admitted to the facility and continued to utilize oxygen, while the MDS lacked any documentation of the oxygen use. Residents Affected - Few The findings included: 1. Review of the record revealed Resident #94 was admitted to the facility on [DATE], with a readmission on [DATE]. Review of the order summary report, that included discontinued orders, lacked any evidence of an indwelling urinary catheter (Foley). Review of the current Minimum Data Set (MDS) assessment, dated 08/01/22, documented Resident #94 had an indwelling urinary catheter. Observation of Resident #94 on both 08/23/22 at 2:51 PM and on 08/24/22 at 9:13 AM lacked any noted urinary catheter appliance. During an interview on 08/25/22 at 10:31 AM, the A Hall Unit Manager was asked if Resident #94 had had an indwelling urinary catheter at any point since the re-admission date of 07/25/22. The Unit Manager stated she had not. During an interview on 08/25/22 at 2:09 PM, Staff E, the MDS Director, was asked why Resident #94 was coded as having an indwelling urinary catheter on the 08/01/22 MDS assessment. The MDS Director pulled up the assessment in the electronic medical record (EMR), and upon review of the look back tool associated with the MDS question, the MDS Director identified one of the four Certified Nursing Assistants (CNAs) who documented on Resident #94 on 08/01/22, check marked that Resident #94 had an indwelling urinary catheter. The MDS Director then reviewed the orders for Resident #94 and agreed to the lack of an indwelling urinary catheter. 2. Review of the record revealed Resident #94 was admitted to the facility on [DATE], with a readmission on [DATE]. Review of the current MDS assessment, dated 08/01/22, documented Resident #94 had had a wandering behavior for 4 to 6 days during the look back period. The record lacked any care plan related to wandering or any recent documentation of a wandering behavior. Observations on 08/23/22 at 2:51 PM revealed Resident #94 in the main dining room participating in a BINGO type game. Observations on 08/24/22 at 9:13 AM revealed Resident #94 sitting in her wheelchair at the sink, washing her face. Resident #94 was not observed wandering throughout the building during the survey. During an interview on 08/25/22 at 10:31 AM, when asked about any wandering behaviors for Resident #94, the A-Hall Unit Manager (UM) stated when the resident was admitted in February of 2021, she had a couple months where she was continually wandering up and down the halls and did have some exit seeking behaviors. The Unit Manager stated that behavior only lasted for a couple of months as she was getting used to the facility. The Unit Manager explained Resident #94 will now self-propel in the hallway to go to an activity, but otherwise does not move about the facility. During an interview on 08/25/22 at 2:09 PM, the MDS Director was asked why Resident #94 was coded as having the behavior of wandering on 4 to 6 days, as documented on the current MDS assessment. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 7 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDS Director clicked on the look back tool in the EMR (electronic medical record) and revealed the CNAs, mainly on the evening shift, had documented the wandering behavior. During an interview on 08/25/22 at 3:37 PM, Staff C, another MDS Coordinator, stated Resident #94 was not currently wandering, there was no documented nursing notes for wandering at the time of the assessment, nor any wandering behavior documented on a behavior monitoring sheet. Staff C agreed the resident should not have been coded as having a wandering behavior on the 08/01/22 MDS assessment. During a supplemental interview on 08/25/22 at approximately 4:00 PM, the MDS Director stated she had spoken to the evening shift CNAs who stated Resident #94 goes to visit her friends in other rooms during the evenings at times, and that is why they coded their CNA documentation as 'wandering.' 3. Review of Resident #207's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses to include Pulmonary Hypertension due to lung disease and Hypoxia, Heart Failure, Nonrheumatic Tricuspid Valve Insufficiency, Hypertension, Emphysema, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure. Review of the admission / Medicare 5-day MDS, dated [DATE], under section O, does not document that Resident #207 is on oxygen while not a resident and while a resident. Review of the admission Assessment completed on 08/10/22 at 3:34 PM documented the resident on O2 nasal cannula 4 lpm (liters per minute). Further review of the progress notes documented the resident was on O2 therapy via nasal cannula. Observations of Resident #207 made throughout the survey on 08/22/22 through 08/25/22 revealed resident is on oxygen nasal cannula 3 lpm (liters per minute). During an interview on 08/25/22 at 3:21 PM with Staff E, Director of MDS Coordinator, Staff E stated, she had a 7-day look back from the hospital. She stated the ARD (assessment reference date) was 08/17/22 and the look-back is 14 days from that date which would have been 08/04/22; the resident was in the hospital on this date; and there were no notes on 08/04/22 or later, so she could not code it that he was on oxygen. She then came into the conference room and stated that she had not submitted the MDS yet and acknowledged it is late. Staff E then documented on the MDS for the next ARD, 08/23/22, 2 days overdue; and for the next Medicare, due 08/17/22, and was now 8 days overdue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 8 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 - Some 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** 4. During an interview on 08/23/22 at 1:58 PM, Resident #3 voiced concerns regarding bathing and lack of showering by the Certified Nursing Assistant (CNA) staff. Review of the record revealed Resident #3 was admitted to the facility on [DATE]. The record revealed the Minimum Data Set (MDS) assessment, dated 05/10/22, indicated Resident #3 needed extensive to total assistance from staff for personal hygiene and bathing. Review of the documented Care Plan Participation Attendance Record, dated 05/10/22, lacked any documented evidence of CNA participation in the care planning process. During an interview on 08/24/22 at 11:06 AM, when asked about CNA participation in the care planning process, Staff E, MDS Director, stated they generally don't attend the meetings. When asked again how they participate in the quarterly care planning process, the MDS Director stated they talk to the CNAs all the time. When asked if that is documented in anyway, the MDS Director did not have any answer. 5. Review of the record revealed Resident #5 was admitted to the facility on [DATE]. The record revealed the current MDS assessment was dated 08/09/22 and indicated Resident #5 needed extensive to total assistance with her care. Review of the documented Care Plan Participation Attendance Record, dated 08/09/22, lacked any documented evidence of CNA participation in the care planning process. 6. Review of the record revealed Resident #36 was admitted to the facility on [DATE]. The record revealed the current MDS assessment was dated 06/22/22. A progress note in the electronic medical record documented a care plan meeting was held on 06/23/22. Review of the documented Care Plan Participation Attendance Record lacked any documented evidence of CNA participation. 7. Review of the record revealed Resident #41 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] indicated the resident had lost weight. A progress note in the electronic medical record documented a care plan meeting was held on 07/07/22. The supplemental Care Plan Participation Attendance Record lacked any documented evidence of CNA participation. 8. Review of the record revealed Resident #73 was admitted to the facility on [DATE]. Record review revealed the current MDS was dated 07/22/22. A care plan meeting was held on 07/21/22 and the supplemental Care Plan Participation Attendance Record lacked any documented evidence of CNA participation. 9. Review of the record revealed Resident #94 was admitted to the facility on [DATE]. Review of the Care Plan Participation Attendance Record, supplemental to the completion of the 05/24/22 MDS assessment, lacked any documented evidence of CNA participation. 10. Review of Resident #78's records revealed the Care Plan Participation Attendance Record was held on 07/20/22 that included the MDS Coordinator, Social Services, Dietary, Activities and Therapy. There was no evidence of a CNA and Nursing participation in this care plan review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 9 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 - Some 11. Review of Resident #54's records revealed the Care Plan Participation Attendance Record was held on 06/27/22 that included the MDS Coordinator, Social Services, Dietary, Activities, Therapy and a Physician. There is a note attached from nursing. There was no evidence of a CNA participation in this care plan review. 12. Review of Resident #45's records revealed the Care Plan Participation Attendance Record was held on 07/07/22 that included the MDS Coordinator, Social Services, Dietary, Activities, Therapy and a Physician. There is a note attached from nursing. There was no evidence of a CNA participation in this care plan review. During an interview on 08/25/22 at 1:49 PM with Staff T, CNA she stated we do not go to any care plan meetings but have been asked about two residents. During an interview on 08/25/22 at 1:58 PM with Staff U, CNA she stated she has been here 1 year, and never attended a Care Plan Meeting, nor have they come up to me and asked about a resident. Based on record review and interview, the facility failed to ensure required interdisciplinary team (IDT) members participation in care planning process for 12 of 22 sampled residents reviewed for care plan, Residents #73, #94, #47, #41, #36, #5, #27, #78, #54, #35, #45, and #3. The findings included: 1. Record review for Resident #27 revealed the quarterly care plan review was held on 06/10/22 with interdisciplinary team (IDT) participation that included: the minimum data set coordinator (MDS), activity staff, license practical nurse (LPN), therapy and physician. There was no evidence of certified nursing assistance (CNA) and Dietitian participation in this care plan review. 2. Record review for Resident #35 revealed the quarterly care plan review was held on 04/22/22 with IDT participation that included: MDS, LPN, therapy, social services and physician. There was no evidence of CNA and Dietitian participation in this care plan review. 3. Record review for Resident #47 revealed the admission care plan review was held on 06/14/22 with IDT participation that included: MDS, social services, dietitian, activity, therapy and Physician. There was no evidence of CNAs and Direct Care Nurse participation in this review. On 08/25/22 at 10:32 AM during an interview with Staff C, MDS coordinator, she acknowledged the findings, and stated the facility had a hard time getting CNAs to participate in the care plan review. She revealed for the review on 04/22/22 and 06/10/22, the Dietitian did not participate as she was not in the building at the time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 10 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure care and services for Foley catheter for 1 of 2 residents, Resident #206, reviewed for indwelling catheters. The findings included: A review of the Policy and Procedures for 'Urinary Catheter Care', documented under general guidelines 1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. 2. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. Review of Resident#206's records revealed the resident was admitted to the facility on [DATE] with diagnoses to include Retention of Urine, Chronic Kidney Disease, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Hemiplegia and Hemiparesis following a Cerebral Infarction. A review of the Physician's Orders revealed that there was no physician order for a Foley catheter. A review of the Nursing admission Assessment on 08/16/22 documented under Bladder that the resident had an indwelling Foley catheter, 16 Fr (French), with a diagnosis of urinary retention. Observations on 08/22/22 at 2:08 PM, and throughout the survey to 08/25/22 revealed Resident#206 has a Foley catheter. On 08/24/22 at 12:10 PM, the surveyor entered the resident's room and observed the resident's Foley catheter tubing (drainage tube) disconnected from resident and remained attached to the bag and lying on the floor of the resident's room. Photographic Evidence Obtained. During an interview on 08/24/22 at 12:15 PM, with Staff H, LPN (Licensed Practical Nurse), the surveyor requested her to review the orders for a Foley catheter for this resident. She then stated I do not see any orders for a Foley catheter in PCC (Point Click Care). She acknowledged the resident did not have a Foley catheter order. The surveyor asked Staff H to go to the resident's room to observe the catheter. The Foley catheter tubing was no longer noted on the floor. The nurse stated don't step over there it is wet with urine, (where the catheter had been on the floor). She was asked if she used new tubing / set up for the Foley. She stated I took alcohol wipes and wiped the end of the tube and reinserted it. She then left to get the DON (Director of Nursing). During an interview on 08/24/22 at 12:54 PM with DON, she was shown the picture of the Foley catheter tubing on floor. She was asked what the process was for replacing it. She says we would need to reference the physician's order, which she acknowledged there was not a physician's order for a Foley catheter. She then took the surveyor to Resident #206's room and stated that the part that was pulled out did not go directly into the resident urethra and showed the surveyor where it was attached to the catheter. She then acknowledged that it is still a sterile technique, and the nurse should have replaced the whole Foley rather than using alcohol to wipe the tubing off. During a second interview on 08/25/22 9:50 AM, the DON stated that we reviewed the 3008-step down documents from hospital. She stated we get a prescription from hospital and put in the order, the discharge orders with medications, but there was nothing about the catheter, but every hospital is different. What we do is read the patient summary from the hospital on [DATE]. She stated that based on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 11 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0690 Level of Harm - Minimal harm or potential for actual harm what we see in here, the resident has a catheter in, the hospital did not put an order in and that order was missed. She said if patient has catheter, we continue it but someone should have caught it and I got distracted. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 12 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the record revealed Resident #41 was admitted to the facility on [DATE] with a re-admission on [DATE]. Review of the current Minimum Data Set (MDS) assessment, dated 07/07/22, documented Resident #41 had a weight loss and was not on a weight loss regimen. A current physician order, dated 02/15/22, documented Resident #41 was on a no added salt, renal diet (specific for residents who receive dialysis services), with double portions for nutritional therapy. Residents Affected - Few Review of the current care plan, initiated on 01/04/22 and revised on 02/11/22, documented the resident had nutritional problems or potential nutritional problems. The goal, revised on 06/27/22, included the resident will have improved nutritional status as evidenced by maintaining weight with no significant weight changes. Interventions included to monitor weights, to monitor/record/report to the physician as needed signs of malnutrition, to include a significant weight loss of 3 pounds in one week, more than 5% in one month, more than 7.5% in 3 months, or more than 10% in six months. An additional intervention included for the Registered Dietician (RD) to evaluate and make diet change recommendations as needed. Review of the electronic medical record (EMR) revealed the following weights for Resident #41: On 01/04/22, the resident weighed 115.2 pounds. On 02/11/22, the resident weighed 127.8 pounds. There was no documented weight for March 2022 in the EMR. On 04/07/22, the resident weighed 128.4 pounds. There was no documented weight for May 2022 in the EMR. On 06/19/22, the resident weighed 113.2 pounds. On 07/13/22, the resident weighed 112.4 pounds. There was no documented weight for August 2022. The most current nutritional note or assessment in the record was dated 04/07/22. This progress note documented a weight gain from 01/04/22 through 04/07/22, which was a desired weight gain. This note documented the resident was on a diuretic that had the potential to cause a weight fluctuation. The goal for Resident #41 was to have no significant weight changes with an intake of greater than 75%, and no skin integrity issues. One of the interventions included was to monitor weights. During an interview on 08/25/22 at 11:31 AM, Staff K, the restorative CNA, confirmed she was responsible for the residents' weights. When asked the process for obtaining weights, the CNA provided a Weight Book and stated she normally completes all the residents' weights the first two weeks of each month. When asked why there were no weights for August 2022, the CNA stated their scale was not working. When asked if she reported this to anyone, the CNA stated she told the Maintenance Director, who told her they were going to replace the scale. When asked if she was the staff who enters the weights into the EMR, she stated she was not. The CNA was asked if she had any weights for Resident #41 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 13 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0692 for the months of March and or May 2022, and the CNA provided the following from her weight book: Level of Harm - Minimal harm or potential for actual harm For the month of March 2022, the paper record documented a weight of 179.0 pounds. The CNA immediately stated that had to be an error and that another CNA was helping her that month. Residents Affected - Few For the month of May 2022, the paper record documented a weight of 114.4 pounds for Resident #41. On 04/07/22, Resident #41 weighed 128.4 pounds. Sometime during the month of May 2022, the resident weighed 114.4 pounds. This indicated a significant weight loss of 10.90 % in approximately one month. On 06/19/22, the resident weighed 113.2 pounds which indicated a weight loss of 11.84 % for a two-month period. On 07/13/22, the resident weighed 112.4 pounds which indicated a 12.46% loss for a three-month period. The record lacked any RD assessment since the 04/07/22 note. The record lacked any evidence of physician notification of weight loss and or any changes to diet or additions of nutritional supplements since the 04/07/22 assessment. During an interview on 08/25/22 at 11:38 AM, the Registered Dietician (RD) was asked the facility's procedure for obtaining resident weights. The RD stated the weights should be obtained at least monthly, but the scale was broken. The RD stated they were trying to fix the scale or rent one, but that had been difficult. When asked about the lack of a nutritional assessment since April of 2022, even though Resident #41 had had a significant weight loss, the RD stated there was some problem with the EMR (electronic medical record) and it was not triggering them of the weight loss. The RD stated they identified it yesterday (08/24/22) and pulled a list in a different manner. When asked about the nutritional assessment completed on 08/24/22 for Resident #41, the Consultant RD stated she completed that assessment. The RD stated she added a bedtime snack to start tonight. Neither the RD or the Consultant RD were aware of the incorrect weight obtained in March, or the May weight of 114.4 pounds, which was when they should have identified the significant weight loss. When asked who was responsible for putting the weights into the EMR, the RD stated it varies between the nursing staff, the RD, and the restorative aide. During an interview on 08/25/22 at 12:05 PM, the Maintenance Director explained some men were working in the facility a while back and tore the wires out of the back of the scale (exact date unknown). The Maintenance Director stated he tried to order one through Amazon, but it was denied by corporate. The Maintenance Director explained he called his medical equipment repair man this past Monday, 08/22/22, to have him come to the facility to possibly fix their broken scale. During an interview on 08/25/22 at 12:07 PM, the Nursing Home Administrator (NHA) explained they did try to purchase a new scale, but it went through the wrong processes and was denied by corporate. The Administrator stated now corporate wants them to try to fix the one they have. They have reached out to the medical equipment repair service out of Jacksonville, used by the facility, and was told they would be put on a list, but would not provide a date for service. When asked about renting a scale, the Administrator said he reached out to a couple of places via Google and was unable to locate one. A Regional Nurse Consultant, who was sitting in the office during this interview, suggested reaching out to a sister facility who might have an extra scale. The Administrator stated he had not thought about that. On 08/25/22 at 2:38 PM, the survey team was informed they now had two scales on the way, and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 14 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0692 weights would be done by the end of day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure timely nutritional assessment for 2 of 4 sampled residents, Resident #27 who had a facility acquired pressure ulcer of Stage 4, and failed to ensure timely nutritional assessment for a resident who had a significant weight loss and to ensure weights were obtained, Resident #41. Residents Affected - Few The findings included: 1. On 08/24/22, beginning at 12:00 PM, clinical record review started for Resident #27. There was a physician order, dated 07/28/22, for wound care treatment as follows: Stage 4 pressure of the Sacrum / cleanse with normal saline, pat dry, apply acetic acid solution, wet to moist covered with island gauze with border dressing once daily. Additional record review showed documented evidence of a nutritional assessment, dated 03/10/22. Further record review indicated a quarterly minimum date set (MDS) assessment, reference date 06/10/22. There was no documented evidence of a quarterly nutritional assessment with this quarterly MDS assessment. On 08/23/22 at 10:39 AM, wound care observation was conducted on Resident #27. Observations revealed Resident #27 had an open wound to the sacrum area. On 08/25/22 at 9:34 AM, an interview was held with Staff D, Dietitian. She stated she tries to do the nutritional assessments quarterly with the MDS, but she is only at the facility two days a week for the long-term care. The Dietitian voiced she conducted a nutritional assessment yesterday (08/24/22) and had updated Resident #27's care plan yesterday (08/24/22) as well. The dietitian agreed the nutritional assessment was three months late. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 15 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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, record review and interview, the facility failed to obtain a physician's order for oxygen and ensure proper maintenance was done for 1 of 1 sampled resident reviewed, Resident #207. Residents Affected - Few The findings included: Review of the Policy & Procedures for Oxygen Administration documented, in part, to verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of Resident#207 medical records reveal resident was admitted to the facility on [DATE] with diagnoses to include Pulmonary Hypertension due to lung disease and Hypoxia, Heart Failure, Nonrheumatic Tricuspid Valve Insufficiency, Hypertension, Emphysema, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure. Review of the Admission/Medicare 5-day MDS (Minimum Data Set) dated 08/17/22 documents resident has a BIMS (Brief Interview for Mental Status) of 8, indicating mildly impaired cognition. Review of the physician orders revealed there was no order for oxygen (O2). Review of the admission Assessment completed on 08/10/22 at 3:34 PM documented the resident was on O2 via nasal cannula at 4 lpm (liters per minute). Review of the nurse's progress notes beginning 08/10/22 to 08/23/22 documented the resident was on O2 therapy via nasal cannula with different dates documenting a range of 4 lpm to 2 lpm. Observations were made on 08/22/22 at 2:15 PM of Resident#207 wearing oxygen via nasal cannula at 3 lpm. The resident stated that his oxygen was not working, as he could not feel air coming out of the nasal cannula. The DON (Director of Nursing) was brought into room and acknowledged that the oxygen concentrator was not working. She had a nurse bring in another oxygen tank. On 08/23/22 at 8:35 AM, the surveyor observed an oxygen concentrator in the room again and asked the resident if it is working? He stated No, it is not working. Staff V, LPN, was brought into the room and was asked if she checks the resident's O2 on her rounds in the morning. Staff V stated yes. She also stated she checked the resident's pulse oximetry and his oxygen concentrator. She acknowledged it was not working. She then left the room to exchange it. During an interview on 08/25/22 at 10:00 AM with the DON (Director of Nursing), the DON acknowledged that there was not a physician order for the O2 until 08/23/22 at 11:00 PM. She stated the admission nurse uses what they see from the hospital. This resident was on O2 in the hospital and came to us on O2. The admissions nurse is not going to get an order if she sees he is on oxygen, as she doesn't have time. We have a team of clinical personnel that meet and review charts after they come in. If it is the weekend, we will review the chart on Monday. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 16 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0698 Provide safe, appropriate dialysis care/services 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, record review, interview and policy review, the facility failed to ensure appropriate coordination of care for 1 of 1 sampled resident, Resident #73, reviewed for dialysis care, as evidenced by the resident was scheduled for a procedure to the dialysis fistula (access) and the facility staff did not ensure NPO (nothing by mouth) status; and failed to ensure pre and post dialysis assessments were completed for Resident #73. Residents Affected - Few The findings included: Review of the policy, Hemodialysis Access Care, revised September 2010, documented, in part, Care of AVFs (arteriovenous fistula for dialysis access) . 4. To prevent infection and/or clotting: . d. Check for signs of infection at the access site when performing routine care and at regular intervals. g. Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals. Review of the record revealed Resident #73 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) dated [DATE] documented Resident #73 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating he was cognitively intact. Review of the current orders revealed the following: A physician order dated 08/23/22 indicated Resident #73 was NPO for surgery scheduled for 08/24/22. A physician order dated 08/24/22 that documented the resident's surgery was scheduled for 12:00 PM on 08/24/22, with a pick-up time at 10:30 AM via the facility's transportation services. A physician order dated 06/03/22 that indicated Resident #73 received dialysis every Monday, Wednesday, and Friday, at 9:30 AM, with a pick-up time of 9:00 AM and a return/pick-up time of 3:00 PM. A physician order dated 08/17/21 that instructed the nurse to complete a pre and post dialysis progress note every Monday, Wednesday, and Friday. A physician order dated 01/12/21 that instructed the nurse to monitor a right subclavian (chest area) dialysis port for signs and symptoms of bleeding, infection, and pain, every shift. On 08/24/22 at 8:34 AM, Resident #73 was noted sitting up on the edge of his bed eating breakfast. Resident #73 stated he was ready to go to dialysis. When asked how he received the dialysis treatment, Resident #73 showed the surveyor his right arm fistula. During this observation, Resident #73 had eaten half of the double portion eggs and all of the double portion grits. Photographic Evidence Obtained. On 08/24/22 at 9:01 AM, Resident #73 was in the facility lobby area awaiting his ride to the dialysis facility. The A-Hall Unit Manager (UM) said something quietly to the resident, who responded, I'm not having any procedure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 17 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/24/22 at 9:06 AM, Resident #73 self-ambulated out of the facility to wait on the front patio area, stating he was going to dialysis. On 08/24/22 at 9:46 AM, Resident #73 was back sitting in the facility lobby. When asked what was going on, Resident #73 stated transportation had not come to take him to dialysis. When asked if he was having some kind of procedure or surgery that day, Resident #73 stated, Not that I know of. When asked if he was told not to eat breakfast that morning, the resident stated, No. During an interview on 08/24/22 at 9:48 AM, the A-Hall UM was asked what was going on with Resident #73 that morning. The UM explained that Resident #73 was NPO (nothing by mouth) for a scheduled procedure / surgery on his fistula. The UM stated she put a sign on his table and took his breakfast tray out of his room. When told the surveyor observed him eating breakfast earlier, the UM went to his room and found his totally eaten breakfast tray sitting on top of the NPO sign. The UM stated, I don't know who gave him his tray. The UM further stated she told his CNA, (Certified Nursing Assistant, Staff L), to give the resident a shower, using the special soap, because he was having a procedure that morning. The UM also stated she told the CNA that the resident could not eat breakfast. During an interview on 08/24/22 at 10:00 AM in the presence of the A-Hall Unit Manager, Staff L-CNA for Resident #73, stated she was told to give the resident a shower. Staff L stated she was not told he was NPO. The CNA explained when they returned to the resident's room from the shower, Resident #73 asked for his breakfast. When asked if she saw the NPO sign on his table, the CNA explained that his clothes were on the table, and probably over the sign. When shown the NPO sign, the CNA stated she did not see that sign, but if she would have seen it, she would not have given the resident his breakfast tray. During a subsequent interview on 08/24/22 at 10:02 AM, Resident #73 again stated he did not know about the procedure that day. When shown the NPO sign, that also documented Nothing By Mouth and dated 08/24/22, the resident stated he did not know what that meant. During an interview on 08/24/22 at 10:24 AM, when asked where in the record was the documented pre and post dialysis progress notes, the A-Hall UM stated in their EMR (electronic medical record) under progress notes tab. Review of the progress notes in the EMR from 07/01/22 through 08/22/22 lacked evidence of all pre and post dialysis notes during the month of July 2022, except on 07/06/22 and 07/11/22. During the month of August 2022, the only documented pre and post dialysis note was on 08/08/22. Review of the July and August 2022 Medication Administration Records (MARs) documented the nurses had completed a pre and post dialysis progress note every dialysis day, as indicated by a check mark. On 08/24/22 at 10:31 AM, when asked if he had a port in his chest for dialysis, Resident #73 stated he did not think so, and showed the surveyor his upper chest. There was no right subclavian dialysis port noted. On 08/24/22 at 3:02 PM, Staff J, Licensed Practical Nurse (LPN), stated she usually worked the A-Hall. Staff J confirmed Resident #73 has dialysis every Monday, Wednesday, and Friday, and that there should be a pre and post dialysis progress note with each visit. When asked about a right subclavian dialysis port, Staff J thought the resident had that port. During an interview on 08/24/22 at 3:59 PM, the Kitchen Manager was not aware that Resident #73 was NPO this morning for surgery. The Kitchen Manager stated they were not made aware. When asked how (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 18 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that communication was usually made, the Kitchen Manager stated he does not get notification via the EMR but would usually get a piece of paper with the information. During a subsequent interview on 08/24/22 at 4:10 PM, the A-Hall UM explained she received the order related to surgery for Resident #73 from the surgery center late last night (referring to 08/23/22). The Unit Manager explained she told the early morning shower aide to let the kitchen know that Resident #73 was NPO. The UM stated she had since spoken with that early morning shower aide and was told she gave the message to the kitchen. The UM agreed the kitchen obviously did not get the message as a tray was delivered to the unit for Resident #73. When asked about the right subclavian port for Resident #73, the UM was unsure, and stated it may be an old order. During an observation on 08/24/22 at 5:00 PM, the A-Hall UM identified old scars to the resident's right chest and agreed that may have been an old dialysis access location. Review of the July and August 2022 Treatment Administration Records (TARs) documented the nurses had been monitoring a right subclavian dialysis port every shift, although the resident did not have that port. It was unknown when the right subclavian port was discontinued. During an interview on 08/25/22 at 10:02 AM, when asked the scheduled surgery from the previous day, the UM was unsure. The UM made a call to the surgery center which revealed the surgery was a right arm fistioplasty, a procedure to open up the fistula with a balloon to allow more blood flow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 19 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the record revealed Resident #3 was admitted to the facility on [DATE]. Review of the current orders revealed a physician order dated 05/16/22 for a Lipid Profile (a specific laboratory test to measure the amount of cholesterol and triglycerides in the blood), monthly on the 17th of each month. Residents Affected - Few Review of the laboratory results in the electronic medical record (EMR) for Resident #3 lacked any evidence of or documentation of the Lipid Profile for 08/17/22. Review of the August 2022 Medication Administration Record (MAR) documented the Lipid Profile was completed on 08/17/22, as indicated by a check mark and nurse's initials. During an interview on 08/25/22 at 10:59 AM, when asked the process for obtaining ordered laboratory tests, the A-Hall Unit Manager (UM) explained the order comes up in the EMR and the nurse who signed it off was to ensure a laboratory requisition was completed in the laboratory book. The ordered laboratory test would also be documented on the Lab Monitoring Sheet for each day. The UM explained the laboratory technician (lab tech) comes to the facility in the morning and draws the blood for the ordered laboratory tests as per each requisition. The UM explained if there were no labs for that day, the lab tech writes on the daily laboratory record No Labs. Review of the daily record for 08/17/22 documented No Labs. The UM agreed the Lipid Profile for Resident #3 was not completed as per physician order. Based on record review and interview, the facility failed to ensure ordered labs were completed for 2 of 6 sampled residents reviewed, Residents #35 and #3. The findings included: 1. Clinical record review for Resident #35 revealed an admission to the facility on [DATE] with diagnoses that included: Hypertension and Anemia. Additional record review evidenced a care plan dated 08/05/22 that indicated Resident #35 had Anemia, and interventions included: obtain and monitor lab / diagnostic work as ordered. Report results to MD [medical doctor] and follow up as indicated. Further record review indicated a physician order, dated 08/02/22, for a laboratory test of glomerular filtration rate (GFR) which is a blood test that measures how much blood your kidneys filter each minute. Resident #35's record lacked evidence of this lab test result. Review of the August 2022 medication and treatment administration records lacked documentation of this ordered lab. The August 2022 lab requisition book lacked evidence of this ordered lab as well. Resident #35's progress notes lacked evidence of the reason for the lab omission. On 08/25/22 at 11:39 AM an interview was held with the Director of Nursing (DON) and the B-wing Unit Manager (UM) in training. They acknowledged the GFR was not completed. The UM voiced she was new and was still in the learning process of the computer system to input orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 20 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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** 3. A medication pass observation was made with Staff M, a Registered Nurse (RN), on 08/23/22 beginning at 4:00 PM. The RN stated she had several accu-checks (obtaining the blood sugar levels using a glucometer) to complete. The RN was instructed to do what she normally would do and the surveyor would observe. The RN obtained the blood sugar level for her first resident and then returned to the medication cart and placed the now 'used' glucometer on top of the cart to be able sanitize her hands. Residents Affected - Some On 08/23/22 at 4:02 PM, Staff M went to Resident #206, donned gloves, obtained a new strip to obtain the blood, and placed the glucometer directly on the resident's table. The RN obtained the blood sample, removed the strip, returned to the medication cart and placed the glucometer on top of the cart. On 08/23/22 at 4:04 PM, Staff M went to Resident #75, repeated the process of obtaining the blood sugar level but kept the glucometer in her gloved hands. The RN disposed of the used strip and returned to the medication cart, placed the glucometer on top of the cart to sanitize her hands and donned a new pair of gloves. On 08/23/22 at 4:06 PM, the RN repeated the same process for Resident #353. The RN used the same glucometer for each of these residents. During an interview on 08/23/22 at 4:09 PM, when asked if there was just the one glucometer for her use, the RN stated, They (the residents) are supposed to each have their own machine, but sometimes I don't know where they disappear to, so I just use the one for everyone. I know that I'm supposed to clean it between residents. The RN was then called to assist with a new admission. During a subsequent interview on 08/23/22 at 4:29 PM, when asked why she did not clean the glucometer between residents, the RN stated, I have no excuse, but I went and got the purple top wipes. A container of Super Sani-Cloth disinfectant wipes was now on top of her medication cart. Based on observations, record review and interviews, the facility failed to follow standards of practice for infection control practices related to PPE (Personal Protective Equipment) use and glucometer disinfecting. This has the potential to affect all residents in the facility. The census at the time of the survey was 99 residents. The findings included: Review of the policy COVID-19 (Florida) Guidance and Initiatives, revised 06/21/22, documented in part, Personal Protective Equipment and Hand Hygiene . 3. Transmission Based Precautions will be implemented and signage instructing the appropriate use of PPE's will be posted outside the resident's door. 5. As per CDC's protocol, for a resident with known or suspected COVID-19: employees providing care wear gloves, isolation gown, eye protection and an N95 or high-level respirator if available. A facemask is an acceptable alternative if an N95 or higher-level respirator is not available. 6. Hand Hygiene should be performed for at least 20 seconds with soap and water: a. Before donning and doffing PPE. b. When gloves are torn, visibly soiled, or removed. c. Before and after patient contact and/or contact with potentially infectious material. Review of the green Center for Disease Control and Prevention (CDC) 'Droplet Precaution' signs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 21 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 posted on numerous residents' doors documented, in part: Everyone must Clean hands, including before entering and when leaving the room; Make sure their eyes, nose and mouth are fully covered before room entry; Remove face protection before room exit. Review of the 2nd green CDC Sequence for Putting on Personnel Protective Equipment (PPE)' signs posted on numerous residents' doors documented, in part: 1. Gown . 2. Mask or Respirator . 3. Goggles or Face Shield . 4. Gloves . And Use Safework Practices to protect yourself and limit the spread of contamination . 1. Upon entrance to the facility on [DATE], there were eleven (11) COVID-19 positive residents. After completion of resident testing on 08/22/22, there were eighteen (18) COVID-19 positive residents. After resident testing on 08/24/22, there were an additional six positive residents (25 residents). a. During the initial tour of the rooms on 08/22/22, the following was observed: -Bathroom for rooms 216/217 had a bed pan observed on the bathroom sink that was unlabeled and not in a plastic bag. This bathroom was shared by 4 residents. Photographic Evidence Obtained. -Bathrooms for rooms 214/215, had two bed pans and urinal on top of one of the bed pans that were observed unlabeled and not contained in a bag. This bathroom is shared by 4 residents. Photographic Evidence Obtained. b. On 08/22/22 at 12:15 PM, during lunch observation, room [ROOM NUMBER] had a 'droplet precaution' notice on the door. Staff I, CNA (Certified Nursing Assistant) was observed passing drinks / beverages to room [ROOM NUMBER]. She had a shield and a mask on face. She did not wear a gown. She was asked why she didn't wear a gown and she stated no one told her to wear a gown. c. On 08/22/22 at 12:20 PM Staff W, Speech Therapist entered room [ROOM NUMBER] without a gown. The room has signs on the door for 'droplet precautions'. She was asked about not wearing a gown and she stated she was just helping, and she did not know she was supposed to wear a gown. The DON (Director of Nursing) was passing by the door and was asked about wearing a gown in the room. She stated one person is to gown up in the room and someone is supposed to pass them the trays. d. On 08/22/22 (unknown time), an ARNP (Advanced Registered Nurse) Psych nurse was observed in room [ROOM NUMBER] that had 'droplet precautions' on room door but was without PPE (Personal Protective Equipment). When she exited the room, the surveyor asked her about why she didn't have PPE on, and she stated she was not touching the patient. e. On 08/22/22 at 1:45 PM, Staff X, CNA was observed coming out of a room that had droplet precautions on the door. The staff was observed exiting the room and not taking off the mask. f. On 08/22/22 at 3:30 PM, Staff Y, LPN (Licensed Practical Nurse) was observed going into room [ROOM NUMBER] that had droplet precautions on the room door without donning PPE. Staff Y then came out when she observed the surveyor watching her. e. During an interview on 08/25/22 at 1:49 PM with Staff T, CNA we are supposed to disinfect the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 22 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 urinal or bed pan. We then bag them, but other aides come in behind me and might not to that. They are rushing. We are supposed to write down with room # if it's bed A or bed B. Sometimes it is not done. 2. Upon arriving to the designated COVID unit, on 08/24/22 at 11:15 AM, when asked of the facility's protocols for donning Personal Protective Equipment (PPE) to enter the residents' rooms, Staff A, CNA, stated that one only needed to have a gown and a mask. It was noted that all of the room doors had green signs posted on them with instructions for 'Droplet Precautions', requiring anyone that entered a residents' room on the unit would be required to don an N95 mask, gown, gloves and eye protection in the form of a face shield or goggles, as well as additional signage regarding properly donning and doffing PPE. a. During an observation, on 08/24/22 at 11:15 AM, of lunch being served on the designated COVID Unit, rooms 100-110, Staff A, CNA, was observed removing her gloves in the doorway of room [ROOM NUMBER]. Staff A proceeded to remove her gown, by pulling the front of the gown by her bare hands and without performing any hand hygiene after removing the gloves. Staff A then proceeded to the cart in the hallway that contained residents' lunch meals. Staff A was then observed donning a new gown from a container that was in the corridor of the unit, still without performing hand hygiene at any point in the process of donning PPE. b. During the same observation, Staff B, CNA, was observed donning and doffing PPE in the same manner without performing any hand hygiene during the process. Staff A and Staff B were asked to stop passing lunch trays to the residents in their rooms and referred to the signage that was on the doors for appropriately donning and doffing PPE. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 23 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure COVID-19 testing was completed as per manufacturer's instructions for 6 of 6 observed staff tests (Staff N, Staff O, Staff P, Staff Q, Staff R, and Staff S); and for 4 of 4 observed sampled residents (Residents #210, #48, #78, and #102). Residents Affected - Some Upon entrance to the facility on [DATE], there were eleven (11) COVID-19 positive residents. After completion of resident testing on 08/22/22, there were eighteen (18) COVID-19 positive residents. After resident testing on 08/24/22, there were an additional six positive residents (25 positive residents). The nursing staff were not following manufacturer's instructions for COVID-19 testing, thus the actual number of COVID-19 positive residents and or staff may have been more. The findings included: Review of the manufacturer's instructions for the [NAME] BinaxNOW COVID-19 Antigen test documented, in part, the following, Sample Test Procedure: 1. Hold Extraction Reagent bottle vertically. Hovering 1/2 inch above the top hole, slowly add 6 drops to the top hole of the swab well. Do not touch the card with the dropper tip while dispensing. 4. Peel off adhesive liner from the right edge of the test card. Close and securely seal the card. Read result in the window 15 minutes after closing the card. In order to ensure proper test performance, it is important to read the result promptly at 15 minutes, and not before. Results should not be read after 30 minutes. Supplemental instructions on the Product Insert documented, Materials Required but not provided: Clock, timer or stopwatch. Specimen Collection and Handling: Anterior Nasal (Nares) Swab . To collect a nasal swab sample, carefully insert the entire absorbent tip of the swab into the nostril. Firmly sample the nasal wall by rotating the swab in a circular path against the nasal wall 5 times or more for a total of 15 seconds, then slowly remove from the nostril. Using the same swab, repeat sample collection in the other nostril. a. An observation of staff testing was made with the Director of Nursing (DON) beginning on 08/23/22 at 3:10 PM. Staff N, a Registered Nurse (RN) obtained the nasal sample herself. The DON placed the reagent drops on the card, inserted the Q-tip, closed the card, and read it as negative at 3:17 PM. b. Staff O, Certified Nursing Assistant (CNA), obtained the nasal sample herself. The DON placed the reagent drops on the card, turned the Q-tip, and closed the card and stated, Some of them read quickly, referring to test results. The DON read the results as negative at 3:23 PM, but kept the card on the table. The DON threw away the sample at 3:25 PM, still maintaining the negative result. c. Staff P, a Physical Therapy Assistant (PTA) obtained the sample herself, the DON repeated her process and closed the test card at 3:24 PM. The DON threw out the test card at 3:26 PM, stating the result was negative. d. Staff Q, a CNA, self-swabbed but only from one nostril. The DON added the reagent drops so quickly, the surveyor was unable to count the number of drops. The Q-tip was placed into the test card and closed at 3:26 PM. The DON read the test result at 3:30 PM as negative, and threw out the card. e. Staff R, a CNA, obtained the sample while the DON placed drops, inserted the Q-tip, and closed the cart at 3:28 PM. The DON read the test result as negative at 3:30 PM and threw out the card. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 24 of 25 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 105382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandgate Gardens Rehab and Nursing Center 703 S 29th St Fort Pierce, FL 34947 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 0886 f. Staff S, a CNA, only made three quick circles in each nostril to obtain the test sample. Level of Harm - Minimal harm or potential for actual harm g. A second COVID-19 testing observation was made on 08/24/22 beginning at 11:24 AM with the A-Hall Unit Manager. The Unit Manager (UM) donned appropriate PPE and went to the room of Resident #210. The RN obtained a sample form the resident's right nostril only. The Unit Manager closed the test sample at 11:30 AM. She read it as negative at 11:32 AM and threw the test card away. Residents Affected - Some h. A test sample was obtained by the UM from Resident #48 on 08/24/22 at 11:31 AM. The COVID-19 test card was read as negative and thrown away at 11:35 AM. i. The Unit Manager went to Resident #78, obtained the test sample on 08/24/22 at 11:41 AM. The test read COVID-19 positive and the Unit Manager did a second test to confirm the results. She had read both tests by 11:46 AM. When asked how long the test sample should sit before reading it, the Unit Manager stated, I thought these were the five minute rapid tests. When asked if the sample was collected from one or both nostril, the Unit Manager stated, I thought we could do either one or both. The instructions were reviewed by the Unit Manager. j. On 08/24/22 at 12:11 PM, the Unit Manager read the results for Resident #102, that were collected at 11:56 AM. The results came back positive, and the Unit Manager stated, That one did not pop up positive right away. During an interview on 08/24/22 at 12:48 PM, the DON was able to verbalize the number of reagent drops used for the COVID-19 tests. When asked how long to wait before reading the COVID-19 test results, the DON stated, I know there is a specific time, but you wait until it dries. The DON was unable to verbalize the time frame for reading the test results. The technique for obtaining the sample was reviewed with the DON, who had no comment at that time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 25 of 25