Inspection·June 16, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER]-B: A blanket on floor had a very large stain and was noted to be wet from leaking AC wall unit. An oxygen concentrator along with cereal boxes sitting on the blanket. 109-A: The wood at the foot of bed was chipped and had a large scratch going across it. room [ROOM NUMBER]-A: Resident complained that the floors were dirty, and the sheets had not been changed in a week. room [ROOM NUMBER]-B: dead cockroach was observed on the windowsill that remained on windowsill for 4 days, wipes were on the floor. Photographic evidence obtained. During an interview on 06/13/22 at 4:55 PM, with Resident #45's Power of Attorney, she complained of bugs and that the facility smells. 2. room [ROOM NUMBER]-B: During a family interview on 06/13/22 at 2:40 PM, the family member stated the toilet bowl was dirty from weekend and the toilet seat was broken; Ghost ants were on the windowsill, I told an aide who stated nothing can be done because maintenance is not here on the weekend. room [ROOM NUMBER]-A: Shares bathroom with room [ROOM NUMBER] the resident complained that the toilet bowl was dirty for 4 days per Resident#1, and the toilet had overflowed after someone put paper towels in toilet over the weekend. Nurse advised resident she was going to get maintenance to come and unclog toilet, but no one came. He had to use the shower room bathroom and did not like it. The toilet seat had been broken for 3 weeks. room [ROOM NUMBER]-B: foot of bed will not go in up position when pushing electronics for it to go up. Photographic evidence obtained. 3. Rug at exit door in activities room was dirty and not vacuumed, floor has multiple black substance and red rust looking substance on floor -The floor in hallway to kitchen was stained and has scuff marks -Hallway floors leading to 200 unit and on 200 unit were stained and dirty. -Live roach ran across conference room table when surveyors arrived. -A dead cockroach was found by resident in food after being delivered from kitchen. -Public bathrooms floors were filthy and stained and the grout around toilet was black and very dirty. -Mopping floors with dirty water. Photographic evidence obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 2 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 During a tour on 06/16/22 at 9:25 AM, with the Director of Operations & Regional Director of Facilities Management Region 3, the Director of Operations, stated he has only been with the company for 3 weeks, he does not have any help and is head of housekeeping as well. He stated that every discharge they do a deep clean plus one room a day is deep cleaned, this consists of maintenance going in to paint, housekeeping cleaning drawers, wiping everything down. The scrub machine is in shop right now and using a machine from one of their sister facilities across the street, they have used it three times. We currently have three housekeepers; the lead housekeeper starts next week as well as a floor tech. Each housekeeper is assigned a hallway. One housekeeper works 6:00 AM-2:30 PM and two housekeepers work 8:00 AM-4:00 PM. one person that we just hired will work from 11:00 AM-7:00 PM. We have a CNA (Certified Nursing Assistant) who is temporarily responsible for cleaning the COVID unit. She is just filling in. The Director of Operations stated he was not aware of any problems with the roaches until we came in. Maintenance work orders go in computer, the CNA's and nurses have access to it. Bug concerns go into pest control binder. During an interview on 06/16/22 at 10:35 AM, with Staff A, housekeeping, she stated her routine is to first clean the bathrooms, then clean the rooms, sweep, and then mop the floors. She denied seeing any insects when she cleans but then stated I saw some dead cockroaches yesterday. During an interview on 06/16/22 at 10:42 AM with Staff B, Housekeeping Aide, I am responsible for main hall and low 200's. I clean rooms every day, I wipe mirrors, counters sink, tissue box, soap, drawers and by window. I sweep and mop the floors and wipe toilets. We deep clean rooms when someone is discharged . She denied seeing any insects in any room but if she did, she would tell maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 3 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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. During an electronic record review revealed Resident #253 was admitted to the facility on [DATE] with diagnoses to include Nicotine Dependence, Fracture of Neck of Right Femur, Chronic Obstructive Pulmonary Disease, Osteopathic, Anxiety Disorder, Major Depressive Disorder, Fibromyalgia, Dorsalgia, Muscle Wasting and Atrophy, Anemia, and Essential Tremors. Resident #253 has been observed smoking outside on multiple occasions between 06/13/22 - 06/16/22 during the survey. Further review of the medical records revealed Resident #253 did not have a care plan for smoking and that the resident was being non-compliant, until 06/14/22 which was the second day of the survey. 3. An electronic record review for Resident #29 revealed he was admitted to the facility on [DATE], with diagnoses to include Intervertebral Disc Degeneration Thoracic Region, Emphysema, Chronic Obstructive Pulmonary Disease, Respiratory Failure with Hypoxia, Centrilobular Degenerative Disease of Nervous System, Peripheral Vascular Disease, Muscle Wasting, Heart Failure, Hyperlipidemia, Alcohol Dependence, Major Depressive Disorder, and Dependence on Supplemental Oxygen. Resident #29 had been observed smoking outside on multiple occasions between 06/13/22-06/16/22 during the survey. The resident's MDS Medicare 5 day dated 04/26/22 documented he had a BIMS (Brief Interview for Mental Status) of 14, which indicated his cognition was intact. Review of the Resident's Care Plan on 06/13/22, revealed he did not have a care plan for smoking. Further review on 06/16/22 revealed one was put in place on 06/14/22. During an interview on 06/16/22 at 8:41 AM, with the MDS Coordinator, she acknowledged this resident did not have a smoking care plan in place and that it was just completed on 06/14/22. She stated she was told in a morning meeting about this. Based on record review and interview, the facility failed to develop care plans with interventions for 3 of 23 sampled residents reviewed for care plans (Resident #25, Resident #29 and Resident #253): Resident #25 related to diagnosis of Pneumonia; and Resident #253 related to non-compliance with smoking; and Resident #29 related to smoking. The findings included: 1. On 06/06/22 Resident #25 was diagnosed with bilateral Pneumonia. An antibiotic (Amoxicillin Clavulanate Potassium 875-125 mg) was ordered to be given every 12 hours, for 10 days for the bilateral Pneumonia diagnosis. The resident's record was reviewed, and no care plan was located in the resident's record for the Pneumonia and the interventions (care he needed to receive) for the diagnosis. On 06/15/22 at 2:00 PM, an interview was conducted with the MDS (Minimum Data Set) Coordinator. She was unable to locate in the record, a care plan for the resident's diagnosis of Pneumonia. She stated there was not one in the resident's record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 4 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to revise care plans for smoking for 3 of 5 sampled residents (Residents #47, #55, and #7); and failure to update care plans related to transferring device for 1 of 1 sampled resident (Resident #16). The findings included: Observations were made throughout the survey of Resident #47 and Resident #253 smoking in front of the building. 1. Review of Resident #47's electronic records revealed he was admitted to the facility on [DATE] with diagnoses to include Nicotine Dependence-Cigarettes, Orthopedic Aftercare, Gangrene, Cellulitis, Type II Diabetes, Muscle Wasting, Congestive Heart Failure, Hyperlipidemia, Opioid Dependence, Depression, Peripheral Vascular Disease and Cardiomyopathy. The resident's MDS (Minimum Data Set) Medicare 5 day dated 04/26/22 documented he had a BIMS (Brief Interview for Mental Status) of 14, which indicated his cognition was intact. On 06/13/22, a review of the resident's care plan for smoking revealed it was initiated on 05/02/22 to include: Resident likes to smoke and potential for injury. His interventions included to ensure that there is no lighter/cigarettes at bedside; staff will provide such during smoking time in the smoking room. Further review of Resident #47 care plan revealed it was revised on 06/14/22 (the second day of the survey) adding that resident is non-compliant, by not allowing staff to keep his cigarettes and lighter at the nurse's station. During an interview on 06/15/22 at 9:00 AM, the resident stated that he is going home tomorrow and had run out of cigarettes today but acknowledged that he did keep his cigarettes and lighter on him in his room. He stated that when you go to the front desk to ask for them, they would not give them, so he keeps them on him. During an interview on 06/16/22 at 8:41 AM with the MDS Coordinator, she acknowledged that Resident #47's smoking care plans were just updated for non-compliance after being advised in a morning meeting. 2. Review of Resident #55's electronic records revealed he was admitted to the facility on [DATE] with diagnoses to include Tobacco Use, Metabolic Encephalopathy, Acute Respiratory Failure with Hypercapnia & Hypoxia, Chronic Obstructive Pulmonary Disease, Type II Diabetes, Morbid Obesity, Lymphedema, Chronic Kidney Disease, Peripheral Vascular Disease, Dependence on Oxygen, Atrial Fibrillation, Congestive Heart Failure, Short Of Breath, Major Depressive Disorder, non-Hodgkin lymphoma, Dysphagia, Obstructive Sleep Apnea, Chronic Pain, Insomnia, Persistent Mood Disorder, and Acute Kidney Disease. Resident #55's MDS (Minimum Data Set) documented he had a BIMS of 14, which indicated his cognition was intact. On 06/16/22, a review of the resident's care plans for smoking revealed it was initiated on 05/05/22 with a revision on 06/14/22 (the second day of the survey) to include: Resident #55 likes to smoke (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 5 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a vape pen, potential for injury: He is non-compliant with smoking policy-refuses to allow staff to keep his vape pen at the nurse's station. Interventions included ensure that there is no lighter/cigarettes at bedside; and staff will provide such during smoking time in the smoking room. During an interview on 06/16/22 at 9:14 AM with Resident #55, the resident stated that he vapes, and he was keeping his vape pen in his room until they took it from him this week. During an interview on 06/16/22 at 8:41 AM with the MDS Coordinator, she acknowledged that Resident #55's smoking care plans were just updated for non-compliance after being advised in a morning meeting. 3. Review of Resident #7's electronic records revealed he was admitted to the facility on [DATE] with diagnoses to include Tobacco Use, Chronic Obstructive Pulmonary Disease, Type II Diabetes, Major Depressive Disorder, Schizophrenia, Pleural Effusion, Anxiety Disorder, Gangrene, and Benign Prostatic Hyperplasia. Resident #7's MDS quarterly assessment dated [DATE] documented he had a BIMS score of 15, which indicated his cognition was intact. On 06/16/22, a review of Resident #7 smoking care plan revealed the initial smoking care plan dated 12/20/21 with a revision date of 06/14/22 to include: Resident likes to smoke, potential for injury; he is non-compliant by not allowing staff to keep his cigarettes and lighter at the nurse's station. Interventions included to ensure that there is no lighter/cigarettes at bedside; and staff will provide such during smoking time in the smoking room. During an interview on 06/16/22 at 8:41 AM with the MDS Coordinator, she acknowledged that Resident #7's smoking care plans were just updated for non-compliance after being advised in a morning meeting 4. During an interview on 06/14/22 at 8:41 AM with Resident #16, he stated he wanted to go to bed and rather than using the sit to stand lift using 2 people to transfer him, a CNA (Certified Nursing Assistant) picked him up and put him in bed hurting his shoulder. Review of Resident#16's electronic records revealed he was admitted to the facility on [DATE] with diagnoses to include Pneumonia, Pleural Effusion, Hypokalemia, Chronic Obstructive Pulmonary Disease, Type II Diabetes, Peripheral Vascular Disease, Insulin, Hypertension, Obstructive Sleep Apnea, Major Depressive Disorder, Muscle Wasting & Atrophy, Age related Osteoporosis, Muscle Weakness, Cellulitis of right & Left Leg, and Chronic Pain. Resident #16's MDS Medicare 5 day dated 03/29/22 documented he had a BIMS score of 14, which indicated his cognition was intact. He was extensive assist 2 person for Bed Mobility and Dressing and total dependence 2 person for transfers. Review of the Activities of Daily Living (ADL) care plan on 06/15/22 and 06/16/22 revealed Resident #16 required assistance with ADL functions. The interventions included Transfers with two-person assist with transfers using a mechanical lift with transfers (Hoyer lift). Further review of physical therapy documentation revealed a therapy progress note dated 05/05/22 that the resident continues to require maximum assist squat pivot transfers due to weakness; however, staff initiated the use of standing lift versus Hoyer lift. During an interview on 06/16/22 at 1:50 PM, with the Rehab Director, he acknowledged that this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 6 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 Resident #16 uses a 'sit to stand lift'. They used to notify MDS when there was a change in transfer status, so the care plan can be updated but now they don't. He stated that the corporate office does not want them to get into the computer system to do that, they notify verbally but do not have any evidence who they notify. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 7 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement their smoking policy to prevent potential accidents for 5 of 5 sampled residents who smoke (Residents #29, #253, #47, #55 and #7). The findings included: On 06/14/22, the surveyor requested to see the smoking policy. The surveyor was given multiple smoking policies that documented and included the following: Tobacco-Free Environment Policy Acknowledgement documents facility is committed to providing a healthy and safe environment for our employees, Residents, and all others. Facility is a tobacco free facility. A copy of the Tobacco-Free Facility Policy is attached here to as attachment D1 (See doc). I understand and agree to enter a tobacco free Facility where I will not be allowed to use smoking or any other tobacco products as defined in the Tobacco-Free Facility In witness whereof, the parties have signed their names, symbols, or initials, on the dates indicated. Policy. Attachment D1 documents facility premises: Property leased or owned by the Facility including all buildings, sheds, and other structures on Facility owned or leased property parking lots, including vehicles parked on Facility owned or leased parking lots or property. There will be no designated smoking area on facility premises unless specifically identified for the use of Resident admitted to the facility before the implementation of the Tobacco-Free Environment Policy. Attachment D2 Tobacco-Restrictive Policy Acknowledgment SMOKING CONTRACT AGREEMENT: updated 06/02/22 Purpose: to provide residents the privilege of smoking while maintaining their safety and the safety of others. Facility Policy: 1. resident smoking is permitted only in the designated smoking area; all other areas are smoke free. 2. All smokers will be assessed upon admission or start of smoking and as their cognitive and/or physical status mandates. 3. Residents who require supervision will only use tobacco products with supervision at the appointed smoking times (this includes electronic cigarettes) 4. Residents who use tobacco products will have a care plan 5. If determined resident is unsafe when smoking, their smoking periods to be supervised 6. Residents to smoke only products purchased for them. No borrowing or sharing tobacco products between residents and staff. If resident does not have tobacco products, they cannot smoke. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 8 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7. Tobacco products will be dispensed one at a time per resident request, with limit of two cigarettes per supervised smoking break. 8. Absolutely no tobacco paraphernalia and/or tobacco products are to be kept in resident rooms. 9. If at any time, a resident is found with tobacco materials (including lighters, matches, electronic cigarettes etc.) in his/her room or is found smoking in the room or inside the facility, such articles will be removed, smoking privilege's will be revoked and could result in Resident discharge from facility. 10. If any policy/contract is violated, smoking/and or tobacco usage privileges will be revoked. 11. privileges maybe revoked at discretion of administration 12. no smoking while on oxygen 13. Smoking paraphernalia for all residents will be secured by staff and labeled with individual resident names. 14. E-cigarettes considered same as cigarettes and are subject to the same policies. 15.Any resident witnessed using/obtaining/storing illegal smoking materials and/or paraphernalia on facility property is subject to a 30- day discharge notice. Law enforcement to be notified. SMOKING-UNSUPERVISED Updated 06/02/22 The facility shall observe the resident's right to smoke unsupervised if the resident presents no safety risk to him/herself or other residents. Residents who have the cognitive ability to smoke (in the designated area on facility grounds) without supervision are not permitted to maintain their own cigarettes/cigars, lighters/matches, and/or electronic cigarettes to ensure the safety of all residents. Procedure: 1. applicable residents will be required to review, sign, and therefore agree to the terms of the facility Smoking Contract. 2. applicable residents shall request smoking from nursing personnel when desired, thus alerting nursing personnel of their intention to smoke at that time. 3. following use, lighters/matches, unused cigarettes, electronic cigarettes etc. shall be returned to nursing personnel for safe storage. 4. residents who smoke independently shall be evaluated on a quarterly basis in coordination with his/her care plan review to ensure the resident continues to safely manipulate smoking materials. 5. residents identified as safe independent smokers will be offered and encouraged to use a smoking apron. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 9 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 Observations on 06/13/22 at 8:30 AM revealed a sign posted at the front door that documented the facility is a smoke-free facility. 1. Observations were made throughout the survey from 06/13/22 through 06/16/22 of Resident #47, smoking outside in front of the building. Residents Affected - Some During an interview on 06/13/22 at 10:46 AM, Resident #47 stated they moved us to the front of the building to smoke because the smoking area is where the COVID residents are. They tell us we have to have a staff member with us, but you cannot find anyone to go out. We didn't need anyone before when we were smoking in the fenced in area. He acknowledged that he holds on to his cigarettes and lighter because they don't give them to me when asked to smoke. During an interview on 06/15/22 at 9:00 AM, the resident stated that he is going home tomorrow, he ran out of cigarettes today but acknowledged that the Administrator came around on 06/15/22 to take his cigarettes and lighter, he did not have any cigarettes left but they took his lighter. Review of Resident #47's electronic records revealed he was admitted to the facility on [DATE] with diagnoses to include Nicotine Dependence-Cigarettes, Orthopedic Aftercare, Gangrene, Cellulitis, Type II Diabetes, Muscle Wasting, Congestive Heart Failure, Hyperlipidemia, Opioid Dependence, Depression, Peripheral Vascular Disease and Cardiomyopathy. The resident's MDS (Minimum Data Set) Medicare 5 day dated 04/26/22 documented he has a BIMS (Brief Interview for Mental Status) of 14, which means his cognition is intact. He is supervision set up only for locomotion on and off unit. Review of his Smoking Assessment document dated 04/20/22 documented a score of 4 which indicated he needed no supervision to smoke. A second smoking assessment completed on 06/13/22 documented a score of a 1. A score between 0-9 means the resident does not need supervision when smoking. On 06/13/22 a review of the resident's care plan for smoking revealed it was initiated on 05/02/22 to include: 'Resident likes to smoke and potential for injury. His interventions included to ensure that there is no lighter/cigarettes at bedside; staff will provide such during smoking time in the smoking room. Monitor for compliance with smoking policy. Notify charge nurse immediately if resident is suspected to violate facility smoking policy.' Further review of Resident #47's care plan documented it was revised on 06/14/22 (the second day of survey) adding that resident is non-compliant by not allowing staff to keep his cigarettes and lighter at the nurse's station. Review of the documents / policy that provided by the Admissions Director documented it's a Tobacco-Free Policy Acknowledgement. Further review revealed that Resident #47 had verbalized the smoking policy and had refused to sign and had verbalized understanding. The document had been completed by the facility authorized agent which was dated on 04/25/22 at 8:40 AM. 2. Observations were made throughout the survey from 06/13/22 through 06/16/22 of Resident #253 smoking outside in front of the building. An electronic record review for Resident #253 revealed the resident was admitted to the facility on [DATE] with diagnoses to include Nicotine Dependence, Fracture of Neck of Right Femur, Chronic Obstructive Pulmonary Disease, Osteopathic, Anxiety Disorder, Major Depressive Disorder, Fibromyalgia, Dorsalgia, Muscle Wasting and Atrophy, Anemia, and Essential Tremors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 10 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Further review of the medical records revealed Resident #253 did not have a care plan related to smoking and for non-compliance until 06/14/22 (the date the care plan was initiated was the second day of the survey). Her care plan interventions included: close monitoring while smoking in smoking area, ensure that there is no lighter/cigarettes at bedside; staff will provide such during smoking time in the smoking room; explain facility smoking policy monitor for compliance with smoking policy, and notify the nurse immediately if resident is suspected to violate facility smoking policy. Her smoking assessment dated [DATE] documented a score of 1. A score between 0-9 means the resident does not need supervision when smoking. The resident had been observed smoking outside on multiple occasions during the 4-day survey During an interview on 06/14/22 at 9:00 AM, the resident was asked if she smoked. She stated yes, I hold onto them, do not ruin that for me. During an interview on 06/15/22 at 2:05 PM with Resident #253, she was asked where are her cigarettes were kept and does she turn them in to staff after she is done smoking. She stated that she usually kept them until this morning when the Administrator came by and took them. She was asked if she signed a policy related to smoking. She stated that she did. The surveyor stated that she saw one document that she had refused. The resident stated she had never refused to sign anything. She then went into a folder where she had paperwork and pulled out a document called Resident/Patient and Family/Visitor Education Smoking Safety Policy. The resident had signed it on 06/02/19. She stated it didn't matter she is going home tomorrow. Review of the documents / policy provided by the Admissions Director documented it's a Tobacco-Free Policy Acknowledgement. Further review revealed that Resident #253 had verbalized the smoking policy, refused to sign; and verbalized understanding. The document had been completed by the facility authorized agent, was electronically signed and dated on 06/02/22 at 11:31 AM. 3. Observations were made throughout the survey from 06/13/22 through 06/16/22 of Resident #29 smoking outside in front of the building. An electronic record review for Resident #29 revealed he was admitted to the facility on [DATE], with diagnoses to include Intervertebral Disc Degeneration Thoracic Region, Emphysema, Chronic Obstructive Pulmonary Disease, Respiratory Failure with Hypoxia, Centrilobular Degenerative Disease of Nervous System, Peripheral Vascular Disease, Muscle Wasting, Heart Failure, Hyperlipidemia, Alcohol Dependence, Major Depressive Disorder, and Dependence on Supplemental Oxygen. Resident #29's MDS Medicare 5 day dated 04/26/22 documented he had a BIMS score of 14, which indicated his cognition was intact. Review of the resident's care plan on 06/13/22, revealed he did not have a care plan for smoking. Further review on 06/16/22 revealed a care plan had been put in place on 06/14/22 to include: Resident likes to smoke, potential for injury, he is non-compliant by not allowing staff to keep his cigarettes and lighter at the nurse's station. His interventions included close monitoring while smoking in the smoking area, ensure that there is no lighter/cigarettes at bedside; staff will provide such during smoking time in the smoking room, explain facility's smoking policy, monitor for noncompliance with smoking policy, notify charge nurse immediately if resident is suspected to violate facility smoking policy. A review of his smoking assessment dated [DATE] documented the resident's score is a 2. A score between 0-9 means the resident does not need supervision when smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 11 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the documents /policy that was provided by the Admissions Director documented it's a Tobacco-Free Policy Acknowledgement. Further review revealed Resident #29 electronically signed his Tobacco-Free Policy Agreement on 04/18/22 at 11:31 AM with authorized agent. 4. Review of Resident #55's electronic records revealed he was admitted to the facility on [DATE] with a diagnoses to include Tobacco Use, Metabolic Encephalopathy, Acute Respiratory Failure with Hypercapnia & Hypoxia, Chronic Obstructive Pulmonary Disease, Type II Diabetes, Morbid Obesity, Lymphedema, Chronic Kidney Disease, Peripheral Vascular Disease, Dependence on Oxygen, Atrial Fibrillation, Congestive Heart Failure, Short Of Breath, Major Depressive Disorder, Non-Hodkins Lymphoma, Dysphagia, Obstructive Sleep Apnea, Chronic Pain, Insomnia, Persistent Mood Disorder, and Acute Kidney Disease. The resident's MDS documented he had a BIMS (Brief Interview for Mental Status) of 14, which indicated his cognition was intact. On 06/16/22, a review of the resident's care plan for smoking revealed it was initiated on 05/05/22 with a revision on 06/14/22 (the second day of the survey) to reflect: Resident likes to smoke a vape pen, potential for injury; and he is non-compliant with smoking policy-refuses to allow staff to keep his vape pen at the nurse's station. Interventions included to ensure that there is no lighter/cigarettes at bedside; staff will provide such during smoking time in the smoking room, close monitoring while smoking in the smoking area, monitor for noncompliance with smoking policy, notify charge nurse immediately if resident is suspected to violate facility smoking policy. Review of resident's Smoking Assessment documented under annual nursing evaluation a score of 1, indicating no supervision to smoke was required. It documented he smokes cigarettes, not electronic cigarettes, and under additional comments that the facility policy that smokers be supervised regardless of BIM or BIMS score. During an interview on 06/16/22 at 9:14 AM with Resident #55, the resident stated that he vapes, and he was keeping his vape pen in his room until they took it from him this week. 5. Review of Resident #7's electronic records revealed he was initially admitted [DATE] and readmitted to the facility on [DATE] with diagnoses to include Tobacco Use, Chronic Obstructive Pulmonary Disease, Type II Diabetes, Major Depressive Disorder, Schizophrenia, Pleural Effusion, Anxiety Disorder, Gangrene, and Benign Prostatic Hyperplasia. Resident #7's MDS quarterly assessment dated [DATE] documented he had a BIMS of 15, which indicated his cognition was intact. On 06/16/22, a review of Resident #7's smoking care plan revealed an initial smoking care plan dated 12/20/21 with a revision date of 06/14/22, to include: Resident likes to smoke, potential for injury; he is non-compliant by not allowing staff to keep his cigarettes and lighter at the nurse's station. Interventions included to ensure that there is no lighter/cigarettes at bedside; staff will provide such during smoking time in the smoking room, continue to inform resident where the smoking area is and encourage compliance, monitor for noncompliance with smoking policy. Review of resident's Smoking Assessment that was under his annual nursing evaluations dated 03/10/22 documented the resident does not use smoking / tobacco / nicotine products. He had a Smoking Assessment that is dated 10/15/19 with a score of 2. A score between 0-9 does not need supervision when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 12 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 smoking. Level of Harm - Minimal harm or potential for actual harm On 06/15/22 at 1:15 PM, the surveyor spoke with Admissions Director and requested the policy that the residents signed related to smoking per their policy. After review of the documents, the surveyor went to Admissions Director and asked if this was the only policy for smoking and what she provides to the resident to sign for smoking. She stated yes. The Regional Business Development was also present and stated they recently changed the policy which came out this past Monday 06/13/22, but that is all she knew. Residents Affected - Some During an interview on 06/15/22 at 2:00 PM with the Director of Nursing (DON), she was asked about the smoking policy. She was shown a policy on smoking and began to read it and stated that this one had been in effect and updated a couple of months ago, and no one was given directions on the smoking policy. The DON stated a new policy came out Monday. She was shown the tobacco free policy that the resident's signed and stated she is not aware of this document. She stated it was her job to make sure that the residents are safe, and to make sure they are not taking products into room. She stated we check the rooms, and the residents will put it in their briefs [under-garments] and no we did not check their brief. If resident is non-compliant, it is out of my hand, and the Administrator and social service are notified. The DON stated that right now, no resident is non-compliant, they all turn their cigarettes in to the nurse's station and when they want a tobacco product, they go to the nurse's station. The surveyor asked the DON to take her to the nurse's station to show her the residents' cigarettes. The Unit Manager then pulled a plastic baggy out of a drawer with 3 packs of cigarettes and stated these are for resident [Resident #253]. On 06/15/22 at 3:17 PM, the DON and Administrator requested to talk to the surveyor. The Administrator stated the company changed to a different policy starting 06/11/22. When questioned they said the company changed it so that all the facilities were the same. They stated the last Administrator changed the policy to allow the residents to smoke. The new policy stated they cannot keep material in room. The DON then stated she was concerned with the non-compliant resident who refused to give smoking products back and would hide them. The DON stated that one resident (Resident #29) was on O2 (oxygen). The DON verbalized the need for support and told the acting Administrator. The policy initiated was supposed to give residents a couple cigarettes and lighter and then they would give them back, but the residents would do take cigarettes and keep their lighter and not give them to us. During an interview on 06/16/22 at 8:41 AM, with the MDS Coordinator, she acknowledged that smoking care plans were just updated for non-compliance after being advised in a morning meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 13 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 record review and interview, the nursing staff failed to ensure medications and dialysis treatment times were coordinated to promote medication regimen adherence for 1 of 1 sampled resident (Resident #56). Residents Affected - Few The findings included: Clinical record review conducted revealed Resident #56 was readmitted to the facility on [DATE] with diagnosis of End Stage Renal Disease (ESRD). Review of the Minimum Data Set, significant change assessment, with reference date 05/02/22, revealed the resident was assessed as independent for skills of daily decision making; requires extensive assistance with activity of daily living and is receiving dialysis treatments. Physician's order, dated 04/07/22, documented Hemodialysis on Monday, Wednesday and Fridays, chair time is 1:00 PM and transported by facility via wheelchair with pick up time of 12 noon. Care plan, dated 04/19/22, documented the resident is at risk for complication related to receiving dialysis for diagnosis of ESRD. The interventions included observe for hypotension: Dizzy or lightheaded with a feeling of passing out. Instruct me to lie down with my head lower than my arms and legs, if possible. Notify my MD if symptoms persist. Physician's order, dated 03/25/22, Midodrine 5 milligrams, give one tablet by mouth three times a day for Hypotension. Medication Administration Record (MAR), dated 06/2022, indicated Resident #56 had missed multiple doses of the Midodrine due to the dialysis schedule. The administration record (MAR) and nurses' notes validated the nurses did not administer the medication on 06/01/22, 06/06/22, 06/08/22, 06/10/22, and 06/15/22 (1:00 PM dose) as the patient was in dialysis. It was also noted the medication, Spironolactone Tablet 25 milligrams, was held on 06/10/22 for the 9:00 AM dose because the patient was going to dialysis. There are no parameters to hold this medication. Interview with the Director of Nursing (DON) conducted on 06/16/22 at 1:32 PM after review of the administration records and nurses' notes, confirmed Resident #56 had missed multiple doses of the medications to treat her Hypotension. (A condition that is likely exacerbated during dialysis treatment). The DON confirmed that some nurses are giving the medication and some are not and acknowledged the medication times can be adjusted to minimize missing doses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 14 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 record reviews and interviews, the facility failed to ensure licensed nurses were able to demonstrate competency related to the provision of medication administration, ordering medications timely and performing accurate documentation. The failure affected 1 of 5 sampled residents (Resident #37). The findings included: Clinical record review conducted on 06/15/22 revealed Resident #37 was admitted to the facility on [DATE] for short term rehabilitation. Minimum Data Set, admission assessment with reference date of 04/11/22, documented the resident was assessed as independent for skills of daily decision making; requires extensive assistance with activity of daily living and received antianxiety, antidepressant, anticoagulant, antibiotic and opioid medications. Care plans initiated for the resident included: Resident is admitted for short-term placement, Resident would like to complete therapy, get stronger and go home, dated 04/05/22. The plan documented interventions as administer medications per physician's order and administer treatment as ordered. Resident at risk for dehydration related to use of diuretic medication (spironolactone) related to Congestive Heart Failure [CHF], dated 04/22/22. The interventions included provide additional fluids at medication pass and other times and give medications as per physician's orders. The resident has shortness of breath status post-surgery, dated 04/27/22. The interventions included assist resident / family / caregiver in learning signs of respiratory compromise. Review of the Medication and Treatment Administration Records (MARs), dated 06/2022, disclosed the following medication and treatment omissions, without an appropriate clinical rationale: a. On 06/13/22, Mupirocin Ointment 2% ointment, apply to face and neck topically three times a day for impetigo for 14 Days, was not administered; explanation noted as did not occur at this time. Bactrim DS Tablet 800-160 MG, give 1 tablet by mouth every 12 hours for Urinary Tract Infection for 14 days, was not administered; explanation noted as did not occur during this shift. Diclofenac Sodium Gel 1 % ointment, apply to right knee topically four times a day for right knee pain, was not administered, explanation noted as patient did not receive this during this time. Budesonide Suspension 0.5 Milligrams MG/2 Milliliters ML, inhale orally every 12 hours for shortness of breath [SOB], was not administered; explanation noted as patient oxygen saturation is within normal limits. Arformoterol Tartrate Nebulization Solution 15 Microgram MCG/2 ML inhale orally via nebulizer two times a day for Chronic Obstructive Pulmonary Disease (COPD), was not administered; explanation noted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 15 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 as the patient oxygen saturation is adequate at this time. Level of Harm - Minimal harm or potential for actual harm b. On 06/10/22, Arformoterol Tartrate Nebulization Solution 15 MCG/2 ML, inhale orally via nebulizer two times a day for COPD, was not administered, explanation noted as did not occur patient breathing well. Residents Affected - Few Zinc Oxide Ointment 10 % ointment, apply to per additional directions topically two times a day for skin condition Apply to sacrum and perineal area, was not administered, explanation noted as DNO. Diclofenac Sodium Gel 1 %, apply to right knee topically four times a day for right knee pain, was not administered, explanation noted as DNO. Diclofenac Sodium Gel 1 % apply to right knee topically four times a day for right knee pain, was not administered, explanation noted as DNO. Arformoterol Tartrate Nebulization Solution 15 MCG/2 ML, inhale orally via nebulizer two times a day for COPD, was not administered, explanation noted as patient breathing is adequate move this order to prn, request. Budesonide Suspension 0.5 MG/2 ML inhale orally every 12 hours for SOB, was not administered, explanation noted as patient breathing is within normal limits. c. On 06/8/22, Zinc Oxide Ointment 10%, apply to per additional directions topically two times a day for skin condition apply to sacrum and perineal area, was not administered, explanation noted as did not occur during this shift. Biofreeze Gel 4% apply to neck/upper back/shoulder topically every shift for chronic pain, was not administered, explanation noted as did not occur during this shift. Diclofenac Sodium Gel 1% apply to right knee topically four times a day for right knee pain, was not administered, explanation noted as did not occur during this shift. Biofreeze Gel 4 % apply to neck/upper back/shoulder topically every shift for chronic pain, was not administered, explanation noted as did not occur during this shift. Diclofenac Sodium Gel 1% apply to right knee topically four times a day for right knee pain, was not administered, explanation noted as did not occur during this shift. Bactrim DS Tablet 800-160 MG, give 1 tablet by mouth every 12 hours for Urinary Tract Infection, for 14 days, was not administered, explanation noted ordered medication, awaiting arrival. d. On 06/07/22, Zinc Oxide Ointment 10% apply to per additional directions topically two times a day for skin condition apply to sacrum and perineal area, was not administered, explanation noted as DNO [possibly: Did Not Occur]. Diclofenac Sodium Gel 1% apply to right knee topically four times a day for right knee pain, was not administered, explanation noted as DNO. Zinc Oxide Ointment 10 % apply to per additional directions topically two times a day for skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 16 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 condition apply to sacrum and perineal area, was not administered, explanation noted as did not occur during this shift. Biofreeze Gel 4% apply to neck/upper back / shoulder topically every shift for chronic pain, was not administered, explanation noted as not needed during this shift. Residents Affected - Few e. On 06/05/22, Arformoterol Tartrate Nebulization Solution 15 MCG/2 ML, inhale orally via nebulizer two times a day for COPD, was not administered, explanation noted as patient oxygen status is within normal limits. f. On 06/04/22, Diclofenac Sodium Gel 1%, apply to right knee topically four times a day for right knee pain, was not administered, explanation noted as did not apply during this shift. Entresto Tablet 49-51 MG, Give 1 tablet by mouth two times a day for Chronic Heart Failure, was not administered, explanation noted as the patient had low blood pressure. Arformoterol Tartrate Nebulization Solution 15 MCG/2 ML inhale orally via nebulizer two times a day for COPD, was not administered, explanation noted as patient oxygen is within normal limits. g. On 06/03/22, Arformoterol Tartrate Nebulization Solution 15 MCG/2 ML inhale orally via nebulizer two times a day for COPD, re-ordered pharmacy notified. Entresto Tablet 49-51 MG give 1 tablet by mouth two times a day for Chronic Heart Failure, was not administered, explanation noted as unavailable pharmacy notified. Diclofenac Sodium Gel 1% apply to right knee topically four times a day for right knee pain, was not administered, explanation noted as did not occur during this shift. h. On 06/02/22, Arformoterol Tartrate Nebulization Solution 15 MCG/2 ML inhale orally via nebulizer two times a day for COPD, was not administered, explanation noted as medication is not available. Entresto Tablet 49-51 MG give 1 tablet by mouth, two times a day for Chronic Heart Failure, was not administered, explanation noted as blood pressure 102/60. Interview with the Director of Nursing (DON) conducted on 06/17/22 at 1:48 PM after review of the administration records, confirmed the nursing staff should document if the resident refused the medication; also clarified DNO, is not an approved abbreviation, it could mean Did Not Occur. The facility is utilizing agency nurisng staff and it has been challenging. The DON acknowledged the staff should have contacted the provider to discuss the nebulizer treatments and to change the orders from scheduled to as needed basis; and confirmed there are no parameters to hold the Entresto, topical ointments and nebulizer treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 17 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive, and served at an appetizing temperature for 15 of 25 sampled residents interviewed (Residents #1, #19, #26, #37, #44, #45, #56, #59, #80, #83, #306, #13, #64, #48 and #3). Residents Affected - Some The findings included: 1. During interview on 06/13/22 at 12:07 PM, Resident #1 stated, The food is cold when it is supposed to be warm. For Breakfast, we got 1 scoop of egg and a pastry, which is not enough for breakfast. For Supper, we get a egg salad sandwich that hardly fills the bread. There is no menu. The girl said this morning, 'You have no meat. Then she went and got me some. 2. During interview on 06/13/22 at 10:42 AM, Resident #19 stated, The food is not good here, but it is better than it used to be; but it's still not good. 3. During interview on 06/13/22 at 10:12 AM, Resident #26 stated, I often eat peanut butter and jelly sandwiches because I don't like the food that is served. 4. During interview on 06/13/22 at 11:19 AM, Resident #37 stated, Saturday they served all of us a hot dog with no bun, and the food is always cold. On 06/11/22, Resident #37 completed a Grievance Form stating, Lunch was a hot dog no bun .Resident would like a complete meal. The Grievance Form was signed by Unit Manager, Social Services, Kitchen Staff; and the Administrator was assigned to follow up. It is documented that the Administrator spoke with the resident and educated the kitchen staff regarding following menu and making sure there were enough supplies on hand to follow the menu. Resident was offered white bread or a replacement meal. 5. During interview on 06/13/22 at 12:23 PM, Resident #44 stated, The food is always cold. I ask them to warm it up, but they say they don't have a microwave to use to heat it up. On Saturday, there was no bun for my hot dog. 6. During interview on 06/13/22 at 04:55 PM, Resident #45 stated she brings in food to eat when she can instead of having the meals served, I bought pizza and put three pieces in baggy with my name on it. I saw one of the nurses and asked to put in fridge, as there is a special fridge just for patients. I also brought a bagel yesterday (06/12/22) and asked staff to put it in the fridge. At the same time, I asked about my pizza, but no one knew what happened to it. 7. During interview on 06/13/22 at 10:08 AM, Resident #56 stated, I don't like peaches or mangoes, yet I seem to get them a lot. The kitchen often doesn't follow the menu 8. During interview on 06/14/22 at 10:21 AM, Resident #59 stated, I don't like the food. That's why I don't eat. 9. During interview on 06/13/22 10:08 AM, Resident #80 stated, The food here does not taste good. 10. During interview on 06/13/22 at 2:40 PM, Resident #83 stated, The quality of food is awful. I am extremely picky, but I put my choices down on the menu, and I never get it. I will also put alternates down for my choices, and I never seem to get them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 18 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 0804 Level of Harm - Minimal harm or potential for actual harm 11. During interview on 06/13/22 at 2:51 PM, Resident #306 stated, I found a roach in my breakfast food 2 days ago. When I pointed it out to staff when they picked up my tray, they just kind of laughed about it. 12. During a meeting with 4 resident council representatives on 06/15/22 at 2:00 PM, all 4 members agreed that the food served was not appetizing or warm when served (Residents #13, #64, #48 and #3). Residents Affected - Some a. Resident #13 stated, The spinach salad served today did not taste like spinach. The Potatoes are always watered down. The brownie served today was 1 inch x 1 inch; it wasn't even worth putting it in my mouth. When asked why there were no food complaints listed on the council meetings for May or June 2022 she replied, We stopped complaining much during the meetings because it doesn't seem to help. b. Resident #64 stated, The food is worse than ever! The food is usually half-cooked and cold. My family brings in food for me every day because I won't eat here. Review of past Resident Council Minutes revealed the following: Minutes for May and June 2022 had no food concerns noted. Minutes for April 2022 noted some cold food coming out warm. Minutes for March 2022 noted, food is too salty; food is coming out burnt. Minutes for February 2022 noted, need diabetic snacks. Minutes for January 2022 noted, Food portions are not consistent and food is cold. A review of the Grievance Log for January 2022 - June 2022 shows 13 separate food complaints within the past 6 months, 11 of which were in addition to the complaints voiced during this survey. On 06/16/22 at 11:40 AM, an observation was made of the Food Cart sitting in the Hall for rooms 221-231. Three (3) covered food plates were sitting on top of food cart (photo evidence obtained). Staff did not start serving food until 12:05 PM. A sample tray was taken from this food cart which was to be delivered to Resident #1, and a new tray was ordered for this resident. Three surveyors tested the palpability and temperature of the food served: Orange Chicken, Sugar Snap Peas, [NAME] Steamed Rice, Vegetable Egg Roll, Lemon Bar. The 3 surveyors agreed that the Sugar Snap Peas were barely warm and overcooked. The Orange Chicken was barely warm and tasted bland, but the meat was tender and moist. The egg roll was barely warm, soggy and bland; and the plain, white, steamed rice was barely warm. The Lemon Bar was to be served chilled, but it was at room temperature. An interview was conducted with the Dietary Manager on 06/16/22 at 1:25 PM. She stated that if residents had any complaints they could tell their Guardian Angels, the CNAs or their nurse. She stated that Staff would notify us for a meal preference update, and we would put the information in PointClickCare as a progress note. If there is a complaint about food temperatures, we will watch the tray (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 19 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some delivery for 3 days, log the information, and note when the resident has no further concerns. We always temp the food before it comes out of the kitchen. We batch cook and serve for each unit to help keep the food warm. If there are numerous complaints about a certain meal/food, we will change out the meal for something that is comparable, and we notify the dietitian so that the particular item will be taken off the menu in the future. We do monthly meetings during Resident Council, and individual interviews to get feedback from residents. Upon admission, we give a menu for a week and an 'Always Available', we ask that residents request from the 'Always Available' in enough time to prepare it. On 06/16/22 at approximately 5:00 PM, the Administrator and the Dietary Manager were notified of numerous resident food concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 20 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and interviews, the facility failed to prepare and serve food in a safe and sanitary manner. Residents Affected - Some The findings included: During the initial tour of the kitchen on 06/13/22 at 9:14 AM with Dietary Manager, the following was observed: -Staff C, Dietary Aide not wearing hairnet in kitchen. -A service contractor doing maintenance on a sink in the kitchen is bald but has facial hair not covered by a mask. -Uncooked Macaroni noodles observed on floor. Within noodles and a pile of dirt was a dead cockroach. -The floors are filthy -The griddle has a thick layer of grease and the metal piece that covers wall behind griddle has grease and is dirty. -The utensils stored in a metal container, the bottom is not clean, has black specks of a substance. -Clean metal pans are stored under toaster that has crumbs observed on edges of metal lip. -Clean dishes stored in a rollator with bottom not clean and metal sides not clean. -A piece of tile on bottom of wall is broke. Photographic evidence obtained. On 06/15/22 at 11:00 AM, with Dietary Manager, a secondary tour was conducted. It was observed that the ice cooler scoop was in a metal container in a dirty sink and with wet spinach in the container and hanging over container. -a couple of flies flying around the kitchen. Photographic evidence obtained. The Dietary Manager stated that they were going to cook macaroni noodles for lunch and changed their mind. The griddle was used this morning to cook eggs for breakfast. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 21 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations, the facility failed to ensure garbage and refuse were disposed of properly. The findings included: Residents Affected - Few During a kitchen tour on 06/13/22 at 9:14 AM, with the Dietary Manager, it was observed around the outside of the dumpster scattered on the grass, the following items: plastic utensils, cardboard boxes, used gloves and other pieces of garbage that couldn not be identified. The Dietary Manager acknowledged this finding during the tour. Photographic evidence obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 22 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 so that the facility is free of pests for entire facility. Residents Affected - Some The findings included: Review of the facility's Policy & Procedures for Pest Control, dated 05/01/11, documented, to assure the facility's buildings and grounds are maintained free of pests and to promote a safe and healthful workplace. The facility will maintain an ongoing pest control program to assure that the facility is kept free of insects, rodents and other pests. Observations made between 06/13/22 through 06/16/22 revealed the following: -Upon surveyors' entrance to the facility conference room on 06/13/22 at 8:53 AM, a live cockroach ran across the conference room table. -room [ROOM NUMBER]-A, 15 dead cockroaches observed on floor on right side of wheel by head of bed. -room [ROOM NUMBER]-B, resident stated she has sugar ants in room. -room [ROOM NUMBER]-B, dead cockroach laying on windowsill. -room [ROOM NUMBER]-B, a family interview stated they have ghost ants on the windowsill. The family member stated, I told an aide and she said nothing can be done because maintenance is not available on the weekend. -Dead cockroach laying on kitchen floor. -Resident #306 stated to a surveyor that a dead cockroach was found in her breakfast food. Photographic evidence obtained. Review of the 'bug log' on the 100 unit revealed the last time it was filled out was in April 2022. The 'bug log' on the 200 unit documented concerns with bugs / cockroaches since 08/21. During an interview on 06/14/22 at 10:20 AM with Pest Control Service Manager who was in the facility spraying, he stated, I am here weekly every Tuesday. They have not had concerns recently with cockroaches though there was a problem in the kitchen, they had cockroaches in the walls in the kitchen, this was 6-8 months ago, the German roaches are hard to control, they are brought in from the outside they are not in the facility. What we do is control them once in facility. The roaches come in with the residents and with stuff they bring in. When asked how he knows where to spray, he stated, I go by the book at each nurses station and that is what we address. I cannot spray any rooms unless unoccupied, we have to have the patients removed from the room for an hour to spray. I will usually bait the rooms, I put a gel or powder down. During a tour of the facility on 06/16/22 at 9:25 AM with Director of Operations and Regional Director of Facilities Management Region 3, a live cockroach was observed running behind the bed in room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 23 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 Level of Harm - Minimal harm or potential for actual harm [ROOM NUMBER]-A. A smooched dead cockroach was seen on floor in hallway. They stated that if there is a pest control concern, they go in a binder at the nurse's station. The Director of Operations and Regional Director of Facilities Management 3 was shown all the pictures of evidence and they acknowledged the findings. They were not aware of any concerns with bugs until the surveyors came into the facility this week. Residents Affected - Some Photographic evidence obtained. During an interview on 06/16/22 at10:35 AM with Staff A, Housekeeping staff, she was asked if she has seen any insects in the rooms or hallways. She stated, I haven't seen any lately. During an interview on 06/16/22 at 10:42 AM with Staff B, Housekeeping Aide, she was asked if she has seen any insects in the resident rooms or hallways. She stated, I have not seen any bugs in room. if I saw one, I would tell maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 24 of 24