Inspection·December 21, 2023

F 0561 Staffing Coordinator stated, We have a thing . We cover for each other. Level of Harm - Minimal harm or potential for actual harm On 12/20/23 the previous day, while doing a medication pass observation on the A1 hall between 4:00 and 4:30 PM, the red smoking cart was noted in the hallway near the nurses' station. The smoking area was located at the end of the A1 hall. Staff E, Restorative Aide, had been pulled to cover the A1 hall that morning for the 7 AM to 3 PM shift. When seen in the hallway at about 4:20 PM, the Restorative Aide stated she was staying over until 4:30 PM, and was then observed going into a resident's room. Residents Affected - Some On 12/21/23 at 9:07 AM, when Staff E was asked if she had covered for the Staffing Coordinator for the 4 PM smoking time the previous day, the Restorative aide confirmed she did not, further stating, You saw me in the hall. 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 12/21/2023 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 - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide housekeeping and maintenance services to provide a clean, comfortable and homelike environment on 2 of 2 units, the outside smoking patio and the common areas of the facility. The findings included: During a tour of the facility conducted on 12/21/23 at 10:09 AM, accompannied by the Maintenance Director and the Maintenance Assistant, the following was observed: a. On the patio outside of the Activity Room on the 100 Unit, which is the designated smoking area, there was an accumulation of cigarette butts in the planters, the ground around the planters, and the area just outside of the door that leads from the Activity Room to the patio. b. In the Main Dining Room, the metal frames around the air conditioning vents were noted to be rusted and damaged and there were several ceiling tiles that showed signs of water damage. c. In room [ROOM NUMBER], the baseboard was not secured under the air conditioning unit, the privacy curtain between beds was stained and the plug from bed B was damaged at the point where it plugs into the wall. d. In room [ROOM NUMBER], the surfaces of the overbed tables for both beds were damaged in such a manner that the particle board underneath was exposed. e. In room [ROOM NUMBER], the wall at the baseboard throughout the room was damaged and unfinished. f. In room [ROOM NUMBER], the surface of the overbed table of the 'B' bed was damaged in such a manner that the particle board underneath was exposed. g. In room [ROOM NUMBER], the foot board of the 'A' bed showed signs of wear. h. In room [ROOM NUMBER], the surface of the overbed table for the 'A' bed was damaged in such a manner that the particle board underneath was exposed, and the linens and pillowcases were stained. i. In room [ROOM NUMBER], the sheet on 'A' Bed was torn, the wall around the air conditioning unit was damaged / unfinished, and the splash board at the hand sink in the shared restroom was damaged and not properly sealed. The wall to the left of the toilet was damaged at the baseboard, the cover to the handle of the doorknob was not secured, and there was an accumulation of debris behind headboard and nightstand 'B'. j. In room [ROOM NUMBER], the wall to the left of the entrance to the shared restroom and the wall behind the head of the 'A' bed were damaged. The floor under the hand sink was stained. k. In room [ROOM NUMBER], the surface of the overbed table for bed B was damaged in a manner that exposed the particle board underneath, the armoire showed signs of wear and damaged, and the wall to the left of the air conditioning unit was damaged / unfinished. (continued on next page) 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 12/21/2023 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 - Some l. In room [ROOM NUMBER], the base board was missing from the floor and wall juncture to the left side of the toilet exposing a significant gap. m. In room [ROOM NUMBER], the surface of the overbed table was held together with scotch tape, the paint was peeling from the chair-rail that was installed throughout the perimeter of the room and there was a hole in the wall over the toilet. n. In room [ROOM NUMBER], the wall at the baseboard to the left of the bathroom and underneath the window were damaged. o. In room [ROOM NUMBER], there were holes in the walls where a chair-rail had been removed from the head of the beds and a sharps container was removed exposing an old paint surface. p. In room [ROOM NUMBER], there was a puddle on the floor from what seemed to be drainage from the tube-feeding supplement. q. In room [ROOM NUMBER], there was no pull cord on the overhead light of the 'A' bed. r. In room [ROOM NUMBER], the covering on the seat of the wheelchair for the 'A' bed was damaged in such a manner that the padding underneath was exposed. The drywall behind bed 'A' was marred with scratches and gouges and needed patching and repainting. s. In room [ROOM NUMBER], the edge of the overbed table to the 'A' bed was damaged in such a manner that the particle board underneath was exposed. t. In room [ROOM NUMBER], the wall behind the 'A' Bed was damaged at the baseboard. u. In room [ROOM NUMBER], there were unidentifiable spots on the floor, and the wall underneath the air conditioner looked like it had gotten wet and was rotting. The counter in the bathroom was separating around edges and underneath, and the laminate was chipped around the edges. The over-the-bed tables were missing edging around the table, exposing rough and jagged particle board. v. In room [ROOM NUMBER], the drawer at the sink was broken. Photographic Evidence Obtained. During an Environmental tour, on 12/21/23 at 10:09 AM, accompanied by the Maintenance Director and the Maintenance Assistant, they acknowledged their understanding of the concerns. The Maintenance Director stated that the facility had received several overbed tables and are in the process of assembling the tables. The Maintenance Director further stated that the walls were left unfinished due to the paint not being received until 12/18/23 (first day of the survey). 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 12/21/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #151 was admitted to the facility on [DATE] with diagnoses that included Acute and Chronic Respiratory Failure with Hypercapnia, Cellulitis, Metabolic Encephalopathy, Major Depressive Disorder, Anxiety, Essential Tremor, Restless Leg Syndrome, Polyneuropathy, Muscle Weakness, and Difficulty walking. On 12/18/23 at 9:38 AM, during initial interview and observation, observation revealed a left bed rail attached to Resident #151's bed. At this time, the surveyor witnessed the resident reach over and grab the left bed rail, and the surveyor saw that the resident was able to freely move the left handrail back and forth several inches. There was no right hand rail in place at this time. On 12/20/23 at 9:15 AM, an observation by another surveyor found the left side bed rail was still attached to the bed, and the rail was loose and could be moved freely back and forth several inches. Resident #151's 'admission readmission Nursing Evaluation', dated 11/17/23, contained the following information related to the resident's Side Rail Evaluation: The resident is cognitively intact. The resident is independent for transfers/bed mobility. It is determined that the resident needs side rails as an enabler to promote independence and no other appropriate alternative exists. Resident has bilateral side rails on their bed. The resident utilizes a 1/4 side rail. Review of Resident #151's 5-day MDS assessment completed on 11/24/23, documented the resident was assessed as having a BIMS score of 04 out of 15, indicating severe cognitive impairment. There was no functional limitation in range of motion, and the MDS documented that bed rails were not used. Review of Resident #151's care plans which had been completed on 11/30/23 showed no development or implementation of a care plan for the use of bed rails. There were also no consent form or physician orders found for the provision of bed rails for this resident. Based on observations, interviews and record reviews, the facility failed to implement care plans for the use of bed rails for 2 of 2 sampled residents reviewed for bed rails, Resident #20 and Resident #151. The findings included: The facility's policy, titled, Proper Use of Side Rails, revised December 2016, documented, in part, under the section for General Guidelines: 4. The use of side rails as an assistive device will be addressed in the resident care plan 1. Resident #20 was admitted on [DATE]. Review of the resident's most recent complete Medicare 5-Day Minimum Data Set (MDS) assessment, dated 11/07/23, documented Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition was intact. The assessment documented the resident had no impairments to the upper extremity and was frequently incontinent of bowel and bladder with no incontinent devices in use. Resident #20's diagnoses at the time of the assessment included: Acidosis, Hypertension, Malnutrition, Depression, Chronic Lung Disease, Weakness, Chronic Atrial Fibrillation, Hearing loss, Shortness Of Breath, Chest pain, Edema, Hypothyroidism, and Obesity. The MDS documented the bed rails were not used as a restraint. (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 12/21/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An admission readmission Nursing Evaluation, date 10/03/23 at 20:30 (8:30 PM), documented, Side Rail Evaluation; The resident is cognitively intact. The resident is independent for transfers / bed mobility. The resident would benefit from the use of a side rail to increase independence for transfers and bed mobility. The resident and/or the Resident's representative understands the risk and benefits of side rail use and consents to the use of it. It is determined that the resident needs side rails as an enabler to promote independence and no other appropriate alternative exists. Resident has bilateral side rails on their bed. The resident utilizes a 1/4 side rail. A 'Side Rail Consent Form' signed by Resident #20 and dated 10/03/23, documented the following: B. Comparison of Potential Benefits and Risks 1. Potential benefits of bed rails/side rails: a. Aid in turning and repositioning. b. Provide a handhold for getting into or out of bed. c. Provide a feeling of comfort and security. 2. Potential risks of side rails: c. Skin bruising, cuts, scrapes A review of the resident's electronic and paper-based health records revealed that there was no care plan for the use of side rails as an enabler. On 12/19/23 at 10:08 AM, Resident #20 was observed in bed sleeping with side rails in the raised position on both sides of the resident's bed, that extended from the resident's head of the bed to the resident's mid-section. During an interview with Resident #20, on 12/19/23 at 2:21 PM, when asked about the side rails, Resident #20 replied, I use them to turn so that they can clean me after a bowel movement. They are very useful. During an interview, on 12/21/23 at 8:38 AM, with Staff A, Licensed Practical Nurse (LPN), when asked about Resident #20 benefiting from the use of side rails, Staff A replied, she would use the bed rail for turning and repositioning. Staff A confirmed that the resident has had the side rails since admission [DATE]). During an interview, on 12/21/23 at 12:20 PM, with the MDS Coordinator, she confirmed that she was responsible for implementing care plans. When asked about Resident #20 not having a care plan for side rails, the MDS Coordinator replied, when I did her care plan, the consent wasn't signed yet, so I didn't do a care plan. I need the consent and I need the order. The Unit Managers and the nurses are responsible for obtaining the orders for the bed rails. 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 12/21/2023 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 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, record review, and interview, the facility failed to ensure clean and trimmed fingernails for 1 of 1 sampled resident reviewed for Activities of Daily Living (ADLs), Resident #13. Residents Affected - Few The findings included: Record review revealed Resident #13 was admitted to the facility on [DATE], and moved to her current room on 08/14/21. Review of the current Minimum Data Set (MDS) assessment, dated 11/12/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of 01, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This same MDS documented the resident needed substantial to maximum assistance for personal hygiene. The current care plans, dated 02/03/23, documented Resident #13 had an ADL (Activities of Daily Living) self-care deficit and needed assistance with all ADLs. A second care plan initiated on 02/03/23 documented the resident was resistive to care/refusing care related to dementia. Review of the recent progress notes for the past 30 days lacked any documented refusal of care. During observations on 12/18/23 at 9:29 AM, 12/18/23 at 12:12 PM while in the main dining room being fed by staff, and on 12/18/23 at 3:04 PM, the fingernails on Resident #13's left hand were long with brownish / black substance noted under the nails. The right hand fingernails were not readily visible as the resident maintained that hand in a closed fist. On 12/20/23 at 10:07 AM, Resident #13 was in bed, and the resident's left hand fingernails were in the same condition. Staff F, Certified Nursing Assistant (CNA), was in the room across the hall, saw the surveyor, and stated the resident was ready to get up and she would be doing so next. At 10:39 AM, Staff F was wheeling Resident #13 down the hall toward the Activity Room. An observation of the resident's fingernails at this time revealed they were still dirty and long. When shown to the CNA, Staff F stated, Oh, they need trimming. Usually the activity staff do the nails, but if they don't I am supposed to. During an observation on 12/20/23 at 10:42 AM with Staff G, Registered Nurse (RN), the nurse agreed and stated, Oh, they need cleaned and trimmed. The RN agreed the CNAs were to maintain the resident's nails short and clean. During an interview on 12/20/23 at 11:00 AM, Staff H, Activity Assistant, confirmed she does nail care for the residents. Staff H explained that it is a scheduled activity, they make an announcement at the time of the activity, and whoever wants will come and is welcome. Staff H further stated she goes to the room of those that do not like to get out of bed. When asked specifically about Resident #13, the Activity Assistant stated, I saw her nails really needed to be done yesterday, but got busy and didn't have time. When asked about documentation for nail care, Staff H stated she would document the provision of nail care in the computer when completed. Review of the Activity Participation in the electronic medical record for the past 30 days lacked any provision of nail care for Resident #13. 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 12/21/2023 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 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, interviews and record review, the facility failed to ensure a safe and secure bedrail which resulted in an injury for 1 of 2 sampled residents reviewed for siderails, Resident #151, which included failure to: a. Identify the hazard and risk; b. Evaluate and analyze the hazard(s) and risk(s) after an incident occurred; and c. Implement interventions after the incident occurred. The findings included: Review of Resident #151's admission readmission Nursing Evaluation, dated 11/17/23, documented the following information related to the resident's Side Rail Evaluation: The resident is cognitively intact. The resident is independent for transfers/bed mobility. It is determined that the resident needs side rails as an enabler to promote independence and no other appropriate alternative exists. Resident has bilateral side rails on their bed. The resident utilizes a ¼ side rail. Review of Resident #151's 5-day Minimum Data Set (MDS) assessment completed on 11/24/23, assessed this resident as having a Brief Interview for Mental Status (BIMS) Score of 04 out of 15, indicating severe cognitive impairment. There was no functional limitation in range of motion, and the MDS documented that bed rail was not used. Review of Resident #151's care plan which had been completed on 11/30/23 had no plan of care for the use of bed rails, nor was any physician orders found for the provision of bed rails. On 12/07/23 at 16:06, a Nursing Note documented, At approximately 10am, I was made aware by CNA [Certified Nursing Assistant] that pt's [patient's] arm was lodged underneath the side rail of the bed. Upon entering pt's room pt was noted to be lying on her back with her Lt. [left] arm lodged underneath the side rail of the bed. Removing her arm caused a skin tear to her Lt. upper arm. Lt. upper arm was cleansed with normal saline, skin prepped. TABO [Triple Antibiotic Ointment] applied followed by island dressing. Resident denies having any pain to her Lt. arm. MD [Medical Doctor] and Family made aware, order entered in computer. Resident resting no distress call light and table in reach. On 12/18/23 at 9:38 AM, during initial interview and observation, observation revealed a left bedrail attached to Resident #151's bed. At this time, the surveyor witnessed the resident reach over and grab the left bed rail, and the surveyor saw that the resident was able to freely move the left hand rail back and forth several inches. There was no right handrail in place at this time. On 12/20/23 at 9:15 AM, an observation by another surveyor found that the left side bedrail was still attached to the bed, and the rail was loose and could be moved freely back and forth several inches. On 12/20/23 at approximately 3:05 PM, the Maintenance Assistant was informed and shown the loose bed rail. The Maintenance Assistant decided at this time to remove the bed rail, as the resident did not require it for bed mobility. On 12/21/23 at 9:34 AM, the Maintenance Director, when asked about the 'audits' conducted on the residents' beds and bed rails, replied, I in-service the maintenance staff to check mattresses and rails . When asked for documentation of audits that had been done, the Maintenance Director provided a (continued on next page) 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 12/21/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 'Work History Report that documented that audits were done monthly. This Log documented that the last audit of rails was completed on 12/12/23. Resident #151's bed rail was observed to still be noticeably loose on 12/18/23 at 9:38 AM and on 12/20/23 at 9:15 AM. Review of the facility Report for the 12/07/23 incident involving the bed rail lacked any evidence that an evaluation was done analyzing the hazard/risk of the bedrail after the incident. It did not contain any interventions put into place to reduce the risk of this incident occurring again until the surveyor intervened during survey. The note on the facility Report documented: 12/21/23 Upon further investigation her bed rail was removed. 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 12/21/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide tube feedings in accordance with physician's orders, and failed to ensure weights were monitored as ordered for 1 of 2 sampled residents reviewed for tube feeding, Resident #89. The findings included: Record review revealed Resident #89 was admitted to the facility on [DATE] with a diagnosis that included malnutrition. The admission Minimum Data Set (MDS) assessment, reference date 10/31/23, indicated Resident #89 had cognition impairment, and she was rarely / never understood. Review of physician order dated 10/26/23 indicated the facility was to weigh Resident (#89) daily times 3, then weekly times 4, and then monthly. It also documented to enter the weights in the weights and vitals section in the computer system. Additional review of physician order, dated 11/06/23, revealed, an order for enteral feeding two times a day with Jevity 1.2 at 70ml/hour for 20 hours. Review of care plans with revision date 11/01/23 indicated Resident #89 required tube feedings relating to difficulty eating, and that the resident had a pressure ulcer. The subsequent record review in the computer system under the weights and vitals section revealed a lack of weekly weights for the following two weeks: 11/05/23 through 11/11/23, and 11/19/23 through 11/25/23. The record lacked any evidence of a reason for not obtaining the weights. Observations were conducted on Resident #89 on the following dates: 12/18/23 at 9:05 AM, 12/19/23 at 8:26 AM, and 12/20/23 at 8:27 AM. During these observations, Resident #89 was noted receiving Jevity 1.2 at 65ml/hour, which was not as ordered by the physician. On 12/20/23 at 8:32 AM, an interview was conducted with the Speech Therapist (ST) who revealed Resident #89's primary source of nutrition was via enteral feeding. On 12/20/23 at 8:34 AM, a subsequent observation was conducted of Resident #89 accompanied with the Director Of Nursing (DON). The DON acknowledged the feeding was running at 65cc/hour. She reviewed the enteral feeding order and agreed the ordered rate was documented for 70ml/hour. On 12/20/23 at 8:52 AM, an interview was held with the Dietitian and a side-by-side review of Resident #89 records was conducted with the dietitian. She confirmed the order was for Jevity 1.2 at 70ml/hour. During this time, the dietitian was made aware that there have been three observations of the feeding rate at 65 ml/hour. At this time, an inquiry was made regarding Resident #89's weights. She confirmed the weights should have been monitored daily times 3, weekly times 4, then monthly. The dietitian reviewed the weights in the computer system and agreed with the lack of weekly weights for two weeks. On 12/20/23 at 8:57 AM, an interview was held with Staff E, Restorative Aide, who obtains the weights for residents in the facility. When asked about Resident #89's weights, she voiced she would look for them. At 10:24 AM, Staff E returned and said she couldn't find them. The weekly weights were (continued on next page) 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 12/21/2023 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 0693 never provided for review. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 12/21/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to timely manage pain for 1 of 3 sampled residents reviewed for pain, as evidence by Nursing staff failed to properly assess for the effectiveness of as needed pain medication, failed to notify the physician of the ineffective pain medication, and failed to timely update the change in frequency of pain medication once received from the physician for Resident #152. Residents Affected - Few The findings included: Review of the policy, titled, Pain Evaluation and Management, revised 2/2023, documented, Guideline: Pain Management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: . g. Monitoring for the effectiveness of interventions. Acute pain should be evaluated 30 to 60 minutes after the onset and re-evaluated as indicated until relief is obtained. Monitoring and Modifying Approaches: . Monitor the following factors to determine if the resident's pain is being adequately controlled: a. the resident's response to interventions and level of comfort over time. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Reporting: Report the following information to the physician or practitioner: . Prolonged, unrelieved pain despite care plan interventions. Review of the record revealed Resident #152 was admitted to the facility on [DATE], and moved to her current room on 12/05/23. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed it was still in progress but the section for cognitive status had been completed. This assessment documented Resident #152 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the admission Nursing Evaluation completed 12/02/23 documented Resident #152 had had pain over the past 5 days, almost constantly present, and that it had impacted her day-to-day activities. The resident rated her worst pain at a 10, and the pain had made it difficult to sleep. This evaluation documented the pain increased with movement and was relieved with medications. Review of the record lacked any order for a pain management consult. The resident's current pain medication of Oxycodone 5 milligrams was ordered for every 6 hours as needed. Review of the corresponding Medication Administration Record (MAR) documented when pain medication was requested, the resident's pain levels ranged mostly from a 5 to 9. On four occurrences, the nurses documented the resident's initial pain level upon request of the pain medication was between 0 and 3, which was inaccurate as compared to the resident's description of her pain levels. Review of the corresponding progress notes documented of the 48 times that the Oxycodone was administered between 12/03/23 and 12/19/23, the following was noted: On three occasions, the assessed pain level prior to administration was documented at a 0 to 3. On 34 occasions, the assessed pain level after administration was documented as a 0 and effective. During an interview on 12/18/23 at 19:41 AM, Resident #152 stated she had been at the facility for (continued on next page) 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 12/21/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 16 days and wanted to see the pain management physician. The resident explained her pain tolerance is not good, her pain level starts at a 5 (on a 0 to 10 scale), and the current medications are only lasting three to three and one-half hours, but she can only have the medication every 6 hours. Resident #152 explained that she suffered with multiple painful compression fractures. Resident #152 stated she was told she would be seen by a pain management physician, but has not been seen. Resident #152 further stated, when she requests the pain medication, by the time the nurse gets to her, 30 minutes or more have passed, making her time between pain medication doses up to 7 hours. During an interview on 12/19/23 at 2:01 PM, when asked about Resident #152's pain, Staff I, Licensed Practical Nurse (LPN), stated she had been documenting in the eMAR notes that the pain medication was ineffective. The LPN stated the pain management physician usually was at the facility on Tuesdays and Thursdays, and that Staff K, A-Wing Unit Manager, would usually come to them to see if there were any residents who needed to be seen by the physician. The LPN stated she spoke with the Unit Manger that same day about Resident #152's pain, and the Unit Manager told her the physician would be in the building and she could ask the physician to see Resident #152. The LPN stated normally they would tell the physician and he would note the resident who needed to be seen, but further stated she did not see him today. The LPN stated the pain management physician was usually on the other side of the building, where the skilled residents resided. During an interview on 12/19/23 at 2:41 PM, when asked if the pain management physician had been in the facility that day, Staff C, B-Wing (skilled) Unit Manager, confirmed he was there earlier that morning. When asked how the pain physician gets new referrals, Staff C stated she would print out the face sheet and any narcotic information she had on a resident, and would hand the information to the physician each Tuesday and Thursday. When asked about the A-side residents, residing in the long term care unit, the B-Wing Unit Manager stated the A-Wing Unit Manager should print out a face sheet of any resident who he need to be seen by the physician, and she would give the resident information to the physician. The B-Wing Unit Manager confirmed she did not receive any long term care resident face sheets for today's visit, nor had any knowledge of any long term care residents that needed to be seen. During an interview on 12/19/23 at 2:48 PM, Staff K, A-Wing Unit Manager, confirmed the pain management physician was at the facility every Tuesday and Thursday. When asked how she would make him aware of the need to see one of the residents on the A-Wing, the Unit Manager stated she would usually send him a text or call him to let him know. When asked about Resident #152, the A-Wing Unit Manager stated she was told early that morning that the resident would like to see him, so she told the nurse that he would be there that morning, and she could go tell him. When told the physician did not see Resident #152 that morning because the nurse did not see him since he was over on the B-Wing, the A-Wing Unit Manager stated, Oh, if she (the nurse) would have circled back to me, I could have caught him. During a side-by-side review of the record, the A-Wing Unit Manager agreed Resident #152 had not been seen by the pain management physician during her stay at the facility. A tele-conference was completed between the pain management physician and Resident #152 on 12/19/23 at 3:55 PM regarding the resident's pain medication. The pain management physician agreed to change the pain medication from every 6 hours to every 4 hours, as needed. During an interview on 12/20/23 at 8:43 AM, when asked about her pain medication, Resident #152 confirmed the pain medication was changed to every four hours, But it didn't kick in last night. Resident #152 stated it was started that morning. (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 12/21/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the record revealed the new order was not entered into the electronic medical record until 12/19/23 at 9:45 PM. During an interview on 12/20/23 at 11:54 AM, the Director of Nursing (DON) agreed the pain management physician stated he would change the frequency of the pain medication during the tele-conference visit on 12/19/23 at about 4:00 PM. When told the order was not entered until nearly 10 PM, the DON stated the Unit Manager was waiting on the hard copy script and that she finally just changed the order in the Electronic Medical Record last night, as per his verbal order. The DON stated the pharmacy never received the script for the frequency change, and she was following up that morning. During a follow-up interview on 12/20/23 at 12:15 PM, Resident #152 again stated her pain level starts at a 5, and that she had never had pain rated less than that. When asked how long she had been telling the nurses the medication was only lasting 3 hours or so, the resident stated about a week. Resident #152 volunteered that Staff I, LPN, was the only nurse that ever asked her if she felt the medication was effective. When asked if the nurses returned to assess her pain level after receiving the medication, Resident #152 stated only Staff I had done that, and she had only taken care of her the past couple of days. Resident #152 again stated she had never verbalized a pain level of 0 to any nurse. 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 12/21/2023 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 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, record review and policy review, the facility failed to ensure competent nurse staffing related to medication administration for 2 of 6 sampled residents observed, as evidenced by: Staff C, Registered Nurse (RN)/B Wing Unit Manager, failed to ensure the proper dose of insulin for Resident #57; and Staff B, RN, failed to properly administer medications via enteral (tube) for Resident #80. The findings included: 1. A medication pass observation was made on 12/20/23 at 5:39 PM with Staff C, Registered Nurse (RN), for Resident #57. The RN stated she needed to check the resident's blood sugar level and administer some medications. The RN obtained the Lantus insulin pen from the cart, placed the pen on a clean disposable tray, and stated, If his blood sugar is OK, he will get 20 units. The RN obtained the items to check the resident's blood sugar, and took those items and the insulin pen into the resident's room. After obtaining the blood sugar for Resident #57, the RN took the Lantus insulin pen and stated, I'm going to give you your 30 units of insulin. Resident #57 stated, I get 20. The RN verbalized out loud, Was it 20 units or 30 units? The RN went back out to the medication cart and reviewed the eMAR (electronic Medication Administration Record), returned to the room and administered the 20 units. After the medication pass observation, Staff C, RN, stated, That's what I get for working since 7:30 this morning without lunch or any fluids. The RN agreed to her near miss and that if the resident would not have been alert and oriented, she would have administered the wrong dose of insulin. The RN also agreed the process for medication administration was to check the order and medication three times prior to administration. 2. Record review revealed Resident #80 was initially admitted to the facility on [DATE] with a re-admission on [DATE]. Review of Physician order dated 08/25/23 indicated to verify tube placement before each use, and if unable to verify placement notify the physician. On 12/18/23 at 10:05 AM, an observation of medication administration was conducted with Staff B, RN, for Resident #80. Staff B was administering medications via enteral tubing. Before the administration, Staff B was noted to have been 'pulled for gastric content' and subsequently administered the medications. Staff B did not use a stethoscope and a syringe to determine the tube placement. At 10:35 AM after the administration, an interview was conducted with Staff B, and an inquiry made regarding checking the for placement, Staff B voiced she had a stethoscope in the medication cart, but she was taught to pull for gastric content as a way to determine the tube placement. She added she can check for placement both ways, either by using a stethoscope to listen to bowel sound as she pushes a small amount of air in the syringe or by pulling for gastric content. An interview was conducted with the Regional Nurse Consultant. She was made aware of how Staff B lacked checking for the tube placement and had conducted the medication administration. 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 12/21/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review and interview, the facility failed to ensure accurate documentation between the medication administration records (MARs) and the medication monitoring control record for 2 of 4 sampled residents, Resident #152 and #23. The findings included: 1. On 12/21/23 at 11:51 AM during the medication storage review process at Unit A2, two residents records were selected for review. Resident #152 had an order of Alprazolam 1 mg 1 tablet by mouth every 8 hours as needed. The medication monitoring control record was compared against the December 2023 MARs. There was a discrepancy in between the records. It was revealed that the Alprazolam was documented for removal in the medication monitoring control record on the following days 12/18 at 5:25, 12/18 1:40, and 12/18 at 9:55, however the removal was not recorded in the December MARs. 2. Resident #23 had an order of Tramadol 50 mg 1 tablet by mouth every 8 hours as needed. The medication monitoring control record was compared against the December 2023 MARs. There was a discrepancy in between the records. It was revealed that the medication was documented for removal in the medication monitoring control record on the following dates: 12/10 at 09:33, and 12/10 8:39. The December 2023 MARs did not have documentation for the removal on 12/10 at 09:33. It also revealed that the Tramadol was removed on 12/13/23 at 10:19 and 9:19. There was no documented evidence for the removal on 12/13 at 10:19. On 12/21/23 at 12:55 PM, an interview was conducted with the Director Of Nursing (DON) and a side-by-side review of Resident #23 and Resident #152's records was conducted. She agreed with the findings. 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 12/21/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that nursing staff administered insulin as per routine physician's orders and as per physician orders with set parameters for 1 of 5 sampled residents, Resident #45. Residents Affected - Few The findings included: Resident #45 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses that included Bipolar Disorder and Diabetes Mellitus (DM), Type II. Resident #45's initial Minimum Data Set (MDS) assessment completed on 09/18/23 shows the resident having a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating cognition was intact. During the look-back period for the MDS, it was documented that Resident #45 received insulin injections for 6 of the days. Review of the physician medication orders for Resident #45 showed orders as follows: a. Novolog Injection Solution Inject as per sliding scale: if 120 - 140 = 2 units; 141 - 160 = 4 units; 161 - 180 = 6 units; 181 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units greater than 400 give 12 units and call provider; subcutaneously every 12 hours for management of diabetes b. Lantus Subcutaneous Solution 100 unit/ml, Inject 20 unit subcutaneously in the morning for DM Review of the December 2023 electronic Medication Administration Record (eMAR) showed the following concerns: a. On 12/01/23, the Novolog Injection Solution per sliding scale was not given on 12/01/23. It was noted on the eMAR that the insulin was not provided due to blood sugar (BS) reading of 137 being 'outside of parameters'. According to sliding scale order, with a BS of 137, the resident should have received 2 units. b. On 12/18/23/ and 12/19/23, the Lantus Subcutaneous Solution, 20 units in AM, was not provided to Resident #45. On both days, it is noted the insulin was not provided due to being 'outside of parameters'. The order for the Lantus Subcutaneous Solution was a routine order for 20 units injected in the AM (morning). There were no parameters set for this routine dose of insulin. On 12/21/23 at approximately 12:30 PM, during an interview with the Director of Nursing (DON), the documentation on the eMAR and the concerns regarding nursing staff not following physician's orders (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 12/21/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm as it related to the insulin administration were reviewed with the DON. The DON acknowledged there were concerns with the documentation on the eMAR. She stated she would follow up and further investigate these concerns. Residents Affected - Few 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 12/21/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to properly store medications during for 1 of 6 sampled residents observed during the medication pass observation, Resident #57; and failed to properly store the extra supply of OTC (over the counter) medications in the Central Supply storage room. The facility had independently ambulatory residents in the facility at the time of the survey. The findings included: 1. A medication pass observation was made on 12/20/23 at 5:39 PM with Staff C, Registered Nurse (RN)/B Wing Unit Manager, for Resident #57. The RN stated she needed to check the resident's blood sugar level and administer some medications. The RN obtained the Lantus insulin pen from the cart, placed the pen on a clean disposable tray, and stated, If his blood sugar is OK, he will get 20 units. The RN obtained the items to check the resident's blood sugar, and took those items and the insulin pen into the resident's room. After administration of the insulin, the RN took the insulin pen and placed it on top of the medication cart. Photographic Evidence Obtained. During the continued observation on 12/20/23 at 5:48 PM, the nurse left the insulin pen on top of the medication cart and went to the medication room to look for eye drops. Staff C then went to the medication storage room on the opposite side of the building to obtain a pill. Upon return to the medication cart on 12/20/23 at 6:11 PM, the RN agreed she had left the insulin pen unattended on top of the cart on the B Wing, which was the Long Term Care unit. 2. During an observation on 12/19/23 at 11:41 AM, the Central Supply room door was closed but unlocked. Upon entering the room, there was a tall cabinet noted straight into the room, with the two doors slightly ajar and a broken lock. This cabinet was full of OTC creams and pills on the shelves. There were also OTC ointments and solutions stored on thee open shelves in the room. 2. On 12/21/23 at 9:18 AM, an observation was made of the supply storage room. The room was noted unlocked and unattended. In the supply storage room, there was a medication cabinet which was opened and unattended. Inside the cabinet, there were numerous bottles of over-the-counter medications, that included: MiraLAX, acidophilus, oral pain relieve gel, multivitamin, sodium chloride, senna, calcium, vitamin D, elder tonic, antacid, Tylenol, gas relieve and other medications and supplements. There were also pain patches, Dakin's solution bottles, hydrocortisone creams, artificial tears, nasal sprays, earwax drops, enemas, suppositories and others. At 9:25 AM, one of the Regional Nurse Consultants and the Nursing Home Administrator were called to the room. They were made aware that the door had been unlocked and unattended for two days now. They acknowledged the storage room, and the medication cabinet was open and not locked. On 12/21/23 at 9:50 AM, an interview was held with Staff D, from central supply. She voiced the storage room was supposed to be always locked, and the facility uses a key to lock and unlock the storage room manually. Staff D and the B wing-1 nurse have the key, so when she leaves the facility, after-hours, the nurse can open the door for the Certified Nursing Assistant for when they need supplies. Staff D revealed about a week ago she had reported to the maintenance assistant that the lock system to the over-the-counter cabinet was broken and needed repair. Staff D was made aware that on Tuesday the storage room was unlocked and unattended. She voiced that she was out of the building (continued on next page) 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 12/21/2023 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 0761 Tuesday at about 11:40 AM transporting residents to dialysis. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 12/21/2023 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** Based on record review and interview, the facility failed to ensure laboratory services for 1 of 7 sampled residents, Resident #37. Residents Affected - Few The findings included: Review of the record revealed Resident #37 was admitted to the facility on [DATE], and moved to her current on 02/23/22. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 0, on a 0 to 15 scaled, indicating the resident was severely cognitively impaired. This MDS also lacked any documented behaviors. Review of the physician orders revealed an HbA1C (blood level to determine the overall blood sugar control) was to be drawn on 09/14/23 and then every three months thereafter. The record lacked any results for 09/14/23 or 12/14/23. Further review of the orders revealed a comprehensive metabolic panel (CMP/a variety of laboratory values) was to be drawn on 09/14/23 and then every six months thereafter. The record lacked the results for the 09/14/23 CMP. During a side-by-side record review, when asked the process to obtain ordered laboratory draws, Staff L, Licensed Practical Nurse (LPN), explained the direct care nurse at the time of the order would enter the order and print out a requisition to draw the ordered lab. The requisition would be put into the lab manual and logged into the daily sheet for the technician's use. If the resident refused the lab for some reason, the technician would let the nurse know and put a hand-written note of the refusal next to the resident's name. Review of the lab manual lacked any laboratory draws for Resident #37 for 12/14/23. Further review of the electronic medical record and the laboratory software program for results lacked any results for Resident #37 since 09/13/23, the date the above mentioned labs were ordered. The LPN had no explanation, stating the orders were entered correctly. 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 12/21/2023 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the inspection of bed mattresses and bedrails to identify potential hazards, for 2 of 2 sampled residents reviewed for bedrails, Residents #20 and #151. The findings included: The facility's policy, 'Proper Use of Side Rails, revised December 2016, documented in the section titled 'General Guidance': 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting a potential benefits and risks. 13. when side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used. 1. Resident #151's admission readmission Nursing Evaluation, dated 11/17/23, contained the following information related to the resident's Side Rail Evaluation: The resident is cognitively intact. The resident is independent for transfers / bed mobility. It is determined that the resident needs side rails as an enabler to promote independence and no other appropriate alternative exists. Resident has bilateral side rails on their bed. The resident utilizes a 1/4 side rail. Per facility report dated 12/07/23, Resident #151 had gotten her left arm lodged underneath her left bedrail. The removal of her arm resulted in a skin tear to her left upper arm. On 12/18/23 at 9:38 AM, during initial interview and observation, a surveyor observed a left bedrail attached to Resident #151's bed. At this time, the surveyor witnessed the resident reach over and grab the left bedrail, and the surveyor saw that the resident was able to freely move the left handrail back and forth several inches. There was no right handrail in place at this time. On 12/20/23 at 9:15 AM, an observation by another surveyor found that the left side bedrail was still attached to the bed, and the rail was loose and could be moved freely back and forth several inches. On 12/20/23 at approximately 3:05 PM, the Maintenance Assistant was informed and shown the loose bedrail. The Maintenance Assistant decided at this time to remove the bedrail, as the resident did not (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 12/21/2023 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 0909 have a care plan or consent form for the bedrails and did not require it for bed mobility. Level of Harm - Minimal harm or potential for actual harm On 12/21/23 at 9:34 AM, the Maintenance Director, when asked about the 'audits' conducted on the residents' beds and bedrails, the Maintenance Director replied, I in-service the Maintenance staff to check mattresses and rails . When asked for documentation of audits that had been done, the Maintenance Director provided a 'Work History Report that documented that audits were done monthly. This Log documented that the last audit of rails was completed on 12/12/23; however Resident #151's bedrail was observed to still be noticeably loose on 12/18/23 at 9:38 AM and also on 12/20/23 at 9:15 AM. Residents Affected - Few Photographic Evidence Obtained. 2. Resident #20 was admitted on [DATE]. According to the resident's most recent complete assessment, a Medicare 5-Day Minimum Data Set (MDS), dated [DATE], Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, indicating 'cognitively intact'. The assessment documented that the resident had no impairments to the upper extremity and was frequently incontinent of bowel and bladder with no incontinent devices in use. The MDS documented that the bed rails were not used as a restraint. Resident #20's diagnoses at the time of the assessment included: Acidosis, Hypertension, Malnutrition, Depression, Chronic lung disease, Weakness, Chronic Atrial Fibrillation, Hearing loss, SOB, Chest pain, Edema, Hypothyroidism, and Obesity. An admission / readmission Nursing Evaluation, date 10/03/23 at 20:30 (8:30 PM), documented, Side Rail Evaluation; The resident is cognitively intact. The resident is independent for transfers/bed mobility. The resident would benefit from the use of a side rail to increase independence for transfers and bed mobility. The resident and/or the Resident's representative understands the risk and benefits of side rail use and consents to the use of it. It is determined that the resident needs side rails as an enabler to promote independence and no other appropriate alternative exists. Resident has bilateral side rails on their bed. The resident utilizes a 1/4 side rail. A 'Side Rail Consent Form' signed by Resident #20 and dated 10/03/23, documented: B. Comparison of Potential Benefits and Risks 1. Potential benefits of bed rails/side rails: a. Aid in turning and repositioning. b. Provide a handhold for getting into or out of bed. c. Provide a feeling of comfort and security. 2. Potential risks of side rails: c. Skin bruising, cuts, scrapes On 12/19/23 at 10:08 AM, Resident #20 was observed in bed sleeping with side rails in the raised position to both sides of the resident's bed, that extended from the resident's head of the bed to the resident's mid-section. It was noted that there was a significant gap between the mattress and the raised side rails. (continued on next page) 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 12/21/2023 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation of Resident #20's bed, on 12/20/23 at 3:17 PM, accompanied by the Maintenance Director and the Maintenance Assistant, the Maintenance Assistant measured the space between the mattress and the bed frame with the bed rail attached and in a raised position with a tape measure. The space between measured six inches in width on the resident's right side of the bed. The Maintenance Director agreed that there should not be that much of a gap between the mattress and the bed frame and raised bed rail. During an interview, on 12/21/23 at 8:38 AM, with Staff A, Licensed Practical Nurse, when asked about Resident #20 benefiting from the use of side rails, Staff A replied, she would use the bed rail for turning and repositioning. Staff A confirmed that the resident has had the side rails since admission [DATE]). During an interview, on 12/21/23 at 9:34 AM, with the Maintenance Director, when asked about monitoring and checking the beds and bed rails for resident safety, the Maintenance Director replied, We check the mattresses and rails. They (referring to additional Maintenance staff) were in-serviced by me to check the bed itself, the mattress and the operations (making sure that the head and legs go up). The Maintenance Director provided the survey team with documentation of monthly audits completed on the residents' beds and bed rails, most recently on the 100 unit on 12/12/23. It was noted that the 'Work History Report' only documented that audits were done monthly. It did not document what observations were made of the beds and bed rails during the audits. When asked for documentation of the observations made and corrective actions taken during the observations, the Maintenance Director was not able to provide. 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 12/21/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 maintain an effective pest control program, as evidenced by pest sightings in the room of Resident #25, the main dining room / activities room, the 100 and 200 units' Clean Utility rooms, and documentation of pests in room [ROOM NUMBER]. Residents Affected - Some The findings included: During an interview, on 12/18/23 at 11:22 AM, with Resident #25, with a documented Brief Interview for Mental Status (BIMS) score of 14, indicating 'cognitively intact', when asked of the presence of pests, Resident #25 stated that she had seen roaches on the floor the previous day. During an observation at the conclusion of the interview, live roaches were observed in all stages of life and too numerous to count, behind the resident's nightstand. During an observation in the Main Dining Room / Activities Room, on 12/18/23 at 1:44 PM, two live and mature roaches were observed in a cabinet. During an observation of the 200 unit 'Clean Utility' room, which was used as a unit pantry, on 12/20/23 at 2:32 PM, accompanied by the Certified Dietary Manager (CDM), live roaches in all stages of life and too numerous to count were observed behind the upright refrigerator freezer. During an observation of the100 unit 'Clean Utility' room, which was used as a unit pantry, on 12/20/23 at 2:38 PM, live roaches in all stages of life and too numerous to count were observed under and behind upright refrigerator/freezer. A review of 'Pest Sightings Logs' that are kept on the units revealed that there had been sightings of roaches in room [ROOM NUMBER] on 11/10/23, 11/18/23, and on 11/29/23. The Logs did not document sightings of pests in the 'Clean Utility' Rooms on the units or in the Main Dining Room. On 12/20/23 at approximately 3:00 PM, the Nursing Home Administrator was made aware of the observations of pests made by the surveyor. During an interview, on 12/21/23 at 8:33 AM, with Staff A, Licensed Practical Nurse (LPN), when asked of the presence of pests, Staff A replied, We have come by a few in a room sometimes, we put it in the log (referring to the Pest Sighting Log). Staff A stated that there had been no recent sightings. During an Environmental tour, on 10/21/23 at 10:09 AM, accompanied by the Maintenance Director and the Maintenance Assistant, they acknowledged their understanding of the concerns. The Maintenance Director provided the survey team with pest control invoices that documented weekly visits by a Pest Control company. The invoices did not document what sightings were made by the Technician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105382 If continuation sheet Page 25 of 25