Inspection·March 16, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm 7. In room [ROOM NUMBER], the call light for bed B was noted to be under the resident's mattress at the head of Resident #28's bed. 8. Throughout the corridor of the 400 unit, there were several stained ceiling tiles at the fire sprinklers and the air conditioning vents. Residents Affected - Some 9) On 03/13/22 at 11:33 AM, in room [ROOM NUMBER], the pull cord used to initiate the call light in restroom was wrapped around and tied to the grab bar. During an interview at the time of the observation, with Staff G, CNA (certified nursing assistant), when asked about the pull cord being wrapped around the grab bar, Staff G-CNA replied, I don't know, maybe she did that herself. 10. In room [ROOM NUMBER], the covering on the outside edge of the over bed table was detached exposing the particle board underneath. 11. In room [ROOM NUMBER], the molding at the floor and wall juncture was not secured to the wall. 12. In room [ROOM NUMBER], the paint on the inside of the door jamb at the entrance to the shared restroom was noted to be damaged and there was an accumulation of dust on a table inside the room. 13. In room [ROOM NUMBER], the fall mat was noted to be torn / damaged in several places. During the initial screening process, the pull cord to initiate the call light in the bathroom, was wrapped around and tied to the grab bar. On 03/16/22 at 10:07 AM, the cord was noted to be wrapped around the pull cord used to initiate the call light in the bathroom. During an interview with Staff H, RN (Registered Nurse) when asked about the resident being able to secure the pull cord in the described manner, Staff H-RN replied that the resident would not be able to use it. 14. In room [ROOM NUMBER], the paint on the inside of the door jamb at the entrance to the restroom was damaged and the fall mat for the door bed was noted to be dirty 15. In room [ROOM NUMBER], there was an area of unfinished and unpainted wall at head of window bed and there was a damaged picture frame behind the night stand 16. In room [ROOM NUMBER], there was an area of unfinished and unpainted wall at resident's head of bed B 17. In room [ROOM NUMBER], there were multiple areas of unfinished and unpainted walls in several areas of the room; and the wheelchair for the resident in Bed A (Resident #86) was noted to have tears in the padding of the arms. 18. In room [ROOM NUMBER], the paint on the inside of the door jamb at the entrance to the restroom was noted to be damaged. 19. In room [ROOM NUMBER], the paint on the inside of the door jamb at the entrance to the restroom was noted to be damaged. 20. In the Activity Room / Day Room on the 400 unit, there were several areas of the wall that were unfinished and not painted. 21. An area of floor outside of the 'Soiled Utility' room on the 400 unit was noted to be damaged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 2 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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 22. On the 500 unit, the floor at the nurse's station was noted to be worn Level of Harm - Minimal harm or potential for actual harm 23. In room [ROOM NUMBER], the floor showed signs of wear 24. In room [ROOM NUMBER], the floor showed signs of wear Residents Affected - Some 25. Throughout the 600 corridor, there were stained ceiling tiles at the fire sprinklers and the air conditioning vents. 26. In room [ROOM NUMBER], the walls were scuffed / damaged. 27. In room [ROOM NUMBER], the exterior of the door at the entrance to the room was damaged on the lower left side of the door. 28. In room [ROOM NUMBER], there were scuffs and paint peeling off of the walls, and the commode in the restroo was not sealed to the floor. 29. In room [ROOM NUMBER], the air conditioning unit was leaking water all over the floor by the ac and window. Resident #31 stated that it has 'been like this for months, no one knows how to fix it. The handles on siderails of Resident #31's bed were covered with a sticky material that also had areas that were black and discolored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 3 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an observation on 03/13/22 at 11:22 AM, Resident #100 was noted to have a possible contracture (a tightening and shortening of a muscle) to her right hand. A hand splint was noted on the resident's over-bed table. Residents Affected - Few Review of the current Quarterly MDS assessment, dated 02/22/22, documented Resident #100 received both passive range of motion (PROM) services and the application of a splint three days during the MDS seven-day look-back period of 02/16/22 through 02/22/22. During an interview on 03/14/22 at 11:01 AM, the Restorative Nurse was asked about Resident #100 related to her right hand contracture. The Restorative Nurse explained Resident #100 has had the right hand contracture for years, has a splint but refuses to wear it, and now is unable to do so, but will hold a towel in that hand at times. The Restorative Nurse stated she believed Resident #100 was receiving PROM. The Restorative Nurse was asked to provide documented evidence of the services. The Restorative Nurse reviewed the record under the Point of Care section in the electronic medical record, the section for documentation of services, and stated Resident #100 had not been receiving the PROM services. Review of the Point of Care History for Restorative Services from 02/16/22 through 02/22/22 documented each day either not performed / refused or unanswered. During an interview on 03/16/22 at 10:14 AM, the MDS Lead was asked about the MDS coding of 3 for both the PROM and splint assistance for the Quarterly MDS dated [DATE]. The MDS Lead provided a progress note from the Restorative Nurse that documented, 02/22/22 Restorative Nursing / Quarterly Review . Resident continues on Restorative Nursing Program daily for PROM and splinting / hand roll as tolerated secondary to contractures . The MDS Lead stated she saw that Quarterly Review progress note and coded her as receiving the services. When asked why she coded it a 3 when the note documented daily, the MDS Lead stated because the restorative services are normally three times weekly. Based on record review and interview, the facility failed to ensure comprehensive assessments were accurate for 4 of 29 sampled residents (Resident #32, #37, #100 and #246), as evidenced by failure to capture all accurate diagnoses for Resident #32, failure to accurately document skin conditions for Resident #37, failure to accurately document specialized services for Resident #100 and failure to accurately document the use of physical restraints for Resident #246. The findings included: 1. Clinical record review conducted on 03/14/22 revealed Resident #32 has a Minimum Data Set (MDS), quarterly assessment with reference date of 01/01/22. The diagnosis section did not indicate the resident had an infection during the seven days look back period. Physician's order, dated 12/29/21, documented, Azithromycin tablet; 250 mg daily. Review of the Medication Administration Record (MAR) validated the resident received the prescribed antibiotic from 12/29/21 thru 01/01/22. Review of the Progress Notes dated 12/29/21 documented 'patient on ABT (antibiotic) for right ear infection'. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 4 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Review of the Progress Notes dated 12/30/21 documented the resident continues on ABT for an ear infection, no complaints of ear pain noted. Review of the Progress Notes dated 12/31/21 documented the resident continues on ABT for an ear infection, no complaints of ear pain or discomfort noted to ears. Residents Affected - Few Review of the Progress Notes dated 01/01/22 documented the 'resident continues on ABT for ear infection. No adverse reaction noted.' Interview with the MDS Coordinator conducted on 03/16/22 at approximately 8:18 AM revealed she will research the concern. A follow up interview with the Coordinator and the Corporate MDS Consultant at approximately 10:35 AM revealed the resident was receiving antibiotic for ear infection and confirmed the diagnoses was not included. 2. Clinical record review of Resident #37 conducted on 03/14/22 revealed the following: a. Progress Notes dated 12/28/22 documented, Seen on rounds with wound MD (physician). Had healing burn to right upper thigh covered with scab. Resident was taking off shorts and loosened scab and then he manually removed the scabbing. Now has full thickness wound, measures 5.5, 3.5, 0.1, with red non granular wound tissue and moderate serous drainage without odor. Surrounding skin is pink and normal, no erythema. Cleansed with NS, calcium alginate applied as primary dressing for autolytic debridement and covered with silicone bordered foam as secondary dressing. Rash to axilla is resolving with treatment, continue until completion of treatment order. Change daily and follow up with wound MD. b. Progress Notes dated 01/04/22 documented, Seen on rounds with wound MD. Right hip healing full thickness second degree burn evaluated. Measures 4.5, 2.5, 0.1, pink moist tissue with moderate serous drainage, no odor, and improving pain. Has surrounding blanchable erythema to wound. Area cleansed with NS, calcium alginate applied for autolytic debridement, and covered with island gauze dressing. c. Physician's orders dated 01/12/22 for right hip wound, documented 'cleanse with normal saline, apply calcium alginate with island gauze dressing every other day.' The treatment was discontinued on 01/18/22. d. Progress Notes dated 01/12/22 documented, Seen on rounds with wound MD (Medical Doctor) on 1-11-22. Right hip healing, now partial thickness second degree burn. Measures 2.5 inches length and 1.5 inches in width, pink moist tissue with moderate serous drainage, no odor, and improving pain. Has surrounding blanchable erythema to wound. Area cleansed with normal saline, calcium alginate applied for autolytic debridement, and covered with island gauze dressing. Change every other day and as needed. Follow up next week with wound MD. The record documented the wound healed on 01/18/22. Review of The Treatment Administration Record (TAR) dated 01/2022 validated that Resident #37 received the wound care treatment on 01/12/22, 01/14/22 and 01/16/22. Review of the MDS, quarterly assessment with reference date 01/17/22 failed to document Resident #37 had a burn. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 5 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Director of MDS conducted on 03/16/22 at 9:30 AM revealed she did not code the burn on the assessment because it healed before the reference date. The Director confirmed the resident was receiving treatment for the wound during the seven days look back period and confirmed there is documentation the burn healed on 01/18/22, a day after the assessment reference date. 3. On 03/13/22 during review of the New admission Matrix, it was noted that Resident #246 was coded as having use of physical restraints. During observation of resident on 03/13/22 at 12:30 PM, no restraints were seen being used at this time. On 03/14/22 at approximately 9:30 AM, the Director of Nursing (DON) was asked about the use of physical restraints for Resident #246. She stated that it was the policy of this facility to not use physical restraints on any of its residents. She stated that she would investigate why Resident #246 was coded as having physical restraints on the Matrix. On 03/14/22 at approximately 11:45 AM, the DON provided documentation that the MDS Coordinator confirmed that an error had been made during data entry and has since made a correction to Resident #246's MDS report. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 6 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the nursing staff failed to provide necessary care and services to restore skin integrity, by failing to assess and treat skin conditions in a timely manner, for 2 of 5 sampled residents, Resident #32 and #95. Residents Affected - Few The findings included: 1. Observation of Resident #95's care conducted on 03/14/22 at approximately 10:40 AM revealed Staff B, a Certified Nursing Assistant (CNA), performing catheter care. When finishing the task, Staff B-CNA repositioned the resident's left leg on a cushion. It was noted the posterior aspect of the leg had redness and an open area mid-calf. Staff B-CNA was made aware of the open skin and proceeded to place the cushion under the resident's leg. Observation of care conducted on 03/15/22 at approximately 10:20 AM revealed the hospice aide was assisting the resident with morning care. It was noted the wound to the left leg was open to air. At this time, the surveyor called in the Restorative Nurse, who was sitting at the nurses station and went in the resident's room to evaluate the wound. The Restorative Nurse was made aware the wound was present the day before and that the aide was aware of the open area, but there are no assessments or orders to treat the wound. The Nurse stated she will call the wound doctor who is rounding today to evaluate the resident. Clinical record review conducted on 03/13/22 revealed Resident #95 had the last documented weekly skin assessment on 03/09/22, the assessment noted no open areas. Review of the Minimum Data Set (MDS), significant change assessment with reference date 01/19/22, documented the resident was assessed as independent for skills of daily decision making, requires extensive assistance with activity of daily living, has no pressure wounds and is receiving oxygen therapy and hospice care. Review of the Care Plan, last revised 03/15/22, documented resident developed a venous ulcer to the left lower extremity, and the approaches included observe skin during care and apply barrier cream as ordered. Review of the Wound Note assessment completed on 03/15/22 documented the leg wound measures 1.5 cm in length and 1.5 cm in width. Review of the Physician's orders dated 03/15/22 documented: 'Change dressing to left lower leg. Cleanse with normal saline, pat dry, apply triple antibiotic ointment, apply Opti foam to open area twice a day'. The facility CNA failed to report the open area to the nurse immediately and subsequent staff who cared for the resident failed to identify and report the open wound on 03/14/22. Surveyor intervention was required to obtain an assessment of the wound and appropriate treatment. 2. Observation of care conducted on 03/13/22 at 10:54 AM revealed Resident #32, lying in bed. A dressing to the left upper extremity was noted with a date of 03/10/22 and initials SM. The resident was asked when the bandage was last changed and stated a couple of days ago, she was not sure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 7 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Clinical record review conducted on 03/13/22 revealed an Minimum Data Set, quarterly assessment with reference date 01/01/22. The resident was assessed as independent for skills of daily decision making, requires extensive assistance with activity of daily living and has no pressure ulcers. Review of the Progress Notes, dated 03/03/22, documented, Resident has skin tear on right arm measure 4 cm by 2 cm that was lightly bleeding. Pressure applied, area cleansed with normal saline and pat dry with gauze. Xeroform applied with gauze sponge and wrapped with gauze roll. Res denies pain. Change every other day and as needed. Review of the Care Plan, dated 03/04/22, documented the resident is at risk for skin breakdown related to decreased functional mobility and sustained skin tear to the left arm on 03/03/22. The goal noted the skin tear to left arm will be healed in the next 14 days without any infection. The approaches for care included: Observe for any signs of infections and report to physician and treatment as ordered. Review of the Physician's order, dated 03/03/22, documented: 'cleanse left arm skin tear with normal saline and pat dry with gauze. Apply Xeroform with gauze sponge and wrap with gauze roll. every other day'. Subsequent observation conducted on 03/14/22 at 10:59 AM revealed Resident #32's dressing to the left arm, remained the same, dated 03/10/22. Review of the Treatment Administration Record (TAR), dated 03/2022, failed to provide evidence the treatment was provided as ordered. There are no nurses initials to validate the provision of care. Interview with Staff A, a Licensed Practical Nurse (LPN), was conducted on 03/14/22 at 11:01 AM. Staff A-LPN was made aware of the overdue dressing change and verified the dressing was dated 03/10/22 and that the physician's order was to be change it every other day. Staff A-LPN explained most likely there was no wound care nurse over the weekend. Based on the review, the nursing staff failed to follow physician's order for the care of the resident's skin tear and failed to document the provision of the prescribed treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 8 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure restorative services were implemented for 1 of 1 sampled resident, Resident #74. The findings included: During observations on 03/13/22 at 10:36 AM and 03/15/22 at 9:17 AM, Resident #74 was noted in bed with both legs bent up at the knees. Review of the record revealed Resident #74 was admitted to the facility on [DATE]. Further review of the record revealed two orders related to restorative services as follows: 02/11/22, Active Range of Motion (AROM) exercises with two-pound weights to upper and lower extremities three times weekly, as tolerated, on Tuesday, Thursday, and Saturday. 02/11/22, Sit-to-stand transfers (times 10) with rolling walker and/or handrails in hallway with maximum assistance on Tuesday, Thursday, and Saturday. Review of the current care plan, dated 02/11/22, documented Resident #74 had the potential for alteration in range of movement, related to decreased mobility and weakness. The care plan Approaches included to encourage the resident to partake as actively as possible in the exercise programs, and to encourage the resident to perform active ROM. Review of the Point of Care History for restorative services from 02/12/22 through 03/15/22 revealed two areas for documentation as follows: Related to the number of minutes for active range of motion (AROM), on 02/24/22, 03/03/22, and 03/10/22 the documentation was unanswered, indicating Resident #74 did not receive the services 3 of 14 scheduled restorative service days. Related to the number of minutes transferring, the only documented completion of the task was on 02/15/22, indicating the provision of services one of the 14 scheduled restorative service days. Two of the 14 days were documented as deferred due to condition, seven days were documented as unanswered, and four days were documented as refused. During an interview on 03/16/22 at 10:34 AM, the Director of Rehabilitation (DOR) services was asked about Resident #74. The DOR explained Resident #74 was admitted to the facility on [DATE], had her evaluation for therapy on 01/27/22, and received therapy until 02/04/22. The DOR stated she was then referred to the restorative service for active ROM and sit-to-stand exercises. The DOR explained as per the family, Resident #74 was walking at home before the hospitalization and subsequent admission to the facility. When asked if the resident's legs were contracted, the DOR stated she had some hamstring tightness, but no contractures. The DOR stated the restorative services were to keep Resident #74 from becoming contracted and to improve her strength. The DOR stated if the restorative aides or nurse notices a decline, Resident #74 would be referred back for additional therapy. The DOR reviewed the Point of Care History for Resident #74 and agreed with the lack of services on the above stated dates. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 9 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/16/22 at 12:53 PM, the Restorative Nurse was shown the Point of Care History for Resident #74. The Restorative Nurse stated she believed her restorative staff was pulled to work the floor on two Thursdays recently. When asked what the deferred due to condition documentation on 02/22/22 and 03/03/22 means, the Restorative Nurse was not sure. The Restorative Nurse stated one of the Restorative Aides who documented that was in the building, and she would get her for an interview. When shown the lack of documentation related to the transferring, the Restorative Nurse stated, I know my staff wasn't pulled to the floor all those days. During an interview on 03/16/22 at 1:13 PM, Staff K, a Restorative Aide (RA), along with the Restorative Nurse, confirmed they were only pulled to work as a direct care aide on one of the scheduled restorative services days. During this interview, Staff K-RA explained the documented deferred due to condition was because Resident #74 was unable to do the exercise. When asked if she told anyone, Staff K-RA stated she informed the direct care nurse. The Restorative Nurse stated she was not informed of the inability to do the sit-to-stand exercises and explained the process would have been to either refer Resident #74 back to therapy or to discontinue the intervention if no longer appropriate. The Restorative Nurse agreed with the lack of the provision of restorative services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 10 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility staff failed to provide necessary care and services, including interventions to restore continence status for 1 of 1 sampled resident, who had a documented decline in bowel functioning, Resident #88. The findings included: Observations of Resident #88 conducted on 03/13/22 at 11:38 AM and on 03/14/22 at 9:40 AM revealed the resident moving herself around while sitting in the wheelchair. The resident had disposable briefs on the back of the chair in a plastic bag. Clinical record review conducted on 03/14/22 revealed Resident #88 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS), quarterly assessment with reference date of 02/16/22, documented the resident was assessed as moderately impaired for skills of daily decision making, is frequently incontinent of bowel and no toileting program has been implemented. Review of a previous assessment with reference date of 11/29/21 documentsed the resident was always continent of bowel. The assessments indicated Resident #88 had a decline in bowel continence. Review of the care plan, last revised 12/07/21, documented the resident requires assistance with daily needs for hygiene, grooming, dressing, toileting, bed mobility, transfer, eating, ambulating / locomotion; and the ADL (Activity of Daily Living) participation may fluctuate at times related to cognition. The goal noted in the care plan documented the resident will maintain highest level of function and will receive the assistance needed to maintain/achieve appropriate goals daily. The approaches included: Provide needed physical assistance with Toileting / Bed Pan, give praise and encouragement for participation in ADL care and promote Dignity by Ensuring Privacy with ADL Care. Review of the Point of Care documentation revealed Resident #88 had two episodes of bowel incontinence from 02/10/22 thru 02/16/22. The seven days look back period, used to complete the MDS assessment. Review of the Restorative notes, dated 02/15/22, documented the resident was continent of bowel; Resident has occasional episodes of dribbling; and she is able to make her toileting needs known and toilets self. Interview with Restorative Nurse conducted on 03/16/22 at 9:15 AM revealed Resident #88 is not incontinent of bowel. The Nurse interviewed the resident the day before the reference date for the current MDS assessment and the resident had no issues with bowel incontinence. The Restorative Nurse explained the MDS coordinator coded the section by using the aides documentation and proceeded to explained that the aide who documented the resident was incontinent, is fairly new and that her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 11 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 documentation is incorrect. If in fact there is a decline, the MDS staff would notify her, but they never did. Level of Harm - Minimal harm or potential for actual harm A follow up interview with the Restorative Nurse was conducted on 03/16/22 at 9:28 AM. The surveyor shared the Point of Care documentation dated from 02/16/22 through present, showing Resident #88 had multiple episodes of bowel incontinence and documented by different aides. The Restorative Nurse stated in the last couple of weeks, the resident had something happening with access to cigarettes and maybe that situation is affecting her. Residents Affected - Few Interview with the Director of MDS conducted on 03/16/22 at 9:30 AM revealed the section for bowel incontinence was coded strictly by the aide documentation. The Director was just informed that if there is a change in resident's functioning, she was to refer the resident to the restorative program and confirmed Resident #88 was not referred for restorative services. Interview with Resident #88 conducted on 03/16/22 at 1:25 PM revealed at times she has incontinence accidents, both urine and bowel; it does not happen very often and she does not need incontinence briefs. The resident was not able to explain why there was a brief hanging from the back of her wheelchair. Based on the review, Resident #88 experienced a decline in her bowel continence status. The facility identified the decline and no interventions were implemented to restore the resident's level of functioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 12 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to follow through with ordered speech therapy evaluations for 1 of 5 sampled residents who sustained weight loss, Resident #63; and failed to consistently document the meal intake for Resident #63, in order to accurately assess the resident's meal consumption on 24 of 28 days reviewed. Residents Affected - Few The findings included: During an observation on 03/13/22 at 1:36 PM, Resident #63 was sitting up in bed with her eyes closed, appeared to be sleeping, and her untouched lunch tray was in front of her. On 03/13/22 at 2:13 PM, Resident #63 began eating with the help of Staff Q, a Certified Nursing Assistant (CNA). The record lacked documented of the amount of food eaten by Resident #63 for that meal. On 03/14/22 at 9:26 AM, Staff R-CNA, stated Resident #63 did not eat any breakfast. Staff R-CNA stated the resident's daughter usually brings in food for Resident #63 for lunch. The record lacked any documented intake for the breakfast meal. During an interview on 03/14/22 at 11:53 AM, the daughter of Resident #63 explained she visits on Monday, Wednesday, and Friday, and brings in food for her mother to eat. When asked why she brings in food, the daughter stated, because she (Resident #63) won't eat their food. She doesn't like the pureed food. It looks different and tastes different. When asked if her lack of eating had been addressed by the facility, the daughter stated they were going to speak with the nutritionist or someone about the pureed food (for a possible upgrade in texture). When asked if the resident has had a swallowing study, the daughter was unsure. Additional observations on 03/15/22 at 8:54 AM revealed Resident #63 ate only 50% of the sausage and a few bites of eggs, with the rest of the breakfast untouched. When asked about her breakfast, Resident #63 stated I'm just not hungry. On 03/15/22 at 1:30 PM, the lunch tray for Resident #63 was barely touched, having only eaten a few bites. Resident #63 refused the facility food at this time. The record lacked any documented lunch intake for Resident #63. Review of the record revealed Resident #63 was admitted to the 07/08/19. Review of the current Quarterly Minimum Data Set (MDS) assessment documented Resident #63 had a Brief Interview for Mental Status (BIMS) score of 03, on a 00 to 15 scale, indicating cognitive impairment. This same MDS documented Resident #63 had an unanticipated weight loss. Further review of the record revealed on 09/13/21 Resident #63 weighed 94.8 pounds, and on 03/03/22 Resident #62 weighed 89.2 pounds, which indicated a weight loss of 5.91% over 6 months. On 07/09/21, Resident #63 weighed 101.2 pounds. Review of the Point of Care History for the breakfast, lunch, and dinner meal intake from 02/16/22 through 03/15/22 revealed the following: Fifteen (15) of the 28 days had incomplete intake information, lacking one or two meals. Nine (9) of the 28 days lacked any documented meal consumption. A Quarterly Nutritional Assessment, dated 02/02/22, documented Resident #63 was on a pureed diet with numerous supplements. The goal was to maintain an ideal body weight of 98 pounds (plus or minus 10%) as able while on palliative care. A supplemental progress note written by the Registered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 13 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Dietician (RD) on 02/24/22 documented the Advanced Practice Registered Nurse (APRN) requested a nutritional consult reporting Resident #63 does not like puree texture / family would like mechanical soft foods. This note further documented a referral was made to Speech Therapy for potential diet upgrade. Review of the current orders included an order, dated 11/04/19, for puree texture diet. Review of two inactive orders documented the following: 02/24/22, Nutrition consult. Patient does not like puree. Family requesting soft mechanical diet. Patient down to 87 lbs (pounds). 02/24/22, Patient continues to lose weight, dislikes puree. Has no teeth but eats soft food well per patient and daughter. Thanks. Special Instructions: Please have nutrition see the patient for diet change to soft mechanical diet. During an interview on 03/15/22 at 4:11 PM, the Speech Therapist was asked if she had seen Resident #63. The Speech Therapist stated she had not seen Resident #63 lately, but she is on my people to check list. When asked why she was on her list, the Speech Therapist stated she believed nursing had told her she was not happy with her diet, a week or so ago. When asked why she had not seen Resident #63 related to the 02/24/22 request, the Speech Therapist stated she was behind and that ideally a resident should be seen within 24 hours of the request. The Speech Therapist stated she was very busy. During an interview on 03/15/22 at 4:17 PM, the Director of Rehabilitation (DOR) services was asked the process for a Speech Therapy referral. The DOR stated the RD usually speaks with the Speech Therapist and a nurse would have to get and write an order for the Speech Therapy evaluation. When asked specifically about Resident #63, the DOR stated she was unaware of the recent request for a Speech Therapy evaluation for a possible upgrade in diet, requested on 02/24/22, related to the resident's dislike in pureed texture, the daughter bringing in food from home, and the resident's weight loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 14 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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 ensure that the administration of enteral nutrition, via PEG tube, for 1 of 1 sampled resident was consistent with and followed doctor's orders (Resident #236). The findings included: On 03/13/22 at 11:08 AM, Resident #236 was observed lying in bed. Resident #236 had a PEG tube (Percutaneous Endoscopic Gastrostomy). He was not receiving an enteral feeding at this time. Resident #236 is an alert and oriented resident with a BIMS of 15, indicating intact cognition. Resident #236 stated that he is to receive his feedings 5 times a day: 6:00 AM, 11:00 AM, 3:00 PM, 6:00 PM and 10:00 PM. Resident #236 said that on 03/12/22 his 11:00 AM tube feeding was done at 11:30 AM, and he did not receive another feeding until approximately 7:15 PM. He stated that staff had also missed another feeding on a previous day but couldn't recall the exact date. He said there were times when the feedings came later than scheduled. A review of resident weight record shows no weight loss since admission. A review of the physician's order for the enteral feedings, dated 03/02/22, documented the following: Enteral Feeding: Jevity 1.5 240 ml 5X a day. 50 ml fluid flush before and after every TF bolus 6 AM, 11 AM, 3 PM, 6 PM, 10 PM. A review of the March 2022 electronic Medication Administration Record (eMAR) for 03/12/22 documented the following (copy of supporting documents obtained): On 03/03/22 for 6 AM feeding, no nurse initials, amounts, or comments were recorded. On 03/03/22 for 6 PM feeding, LPN (Staff I) initialed and recorded 0 amount. No comment was recorded as to why resident did not receive any feeding. On 03/03/22 for 10 PM feeding, Staff I-LPN initialed and recorded 0 amount. On 03/04/22 at 00:10 AM, nurse added comment, Previously refused. On 03/04/22 for 6 AM feeding, Staff I-LPN recorded, 0 amount, but no comment was recorded as to why resident did not receive any feeding. On 03/05/22 for 6 AM feeding, no staff initials, amount, or comment was recorded On 03/05/22 for 11 AM feeding, no amount is recorded. Comments added at 12:01 PM, Resident refused feeding, patient stated he just got fed around 8 AM. However, nothing was recorded on the eMAR documenting an earlier feeding. On 03/09/22 for 6 PM feeding, no staff initials, amounts or comments recorded. On 03/12/22 for 3 PM feeding, Staff J-LPN initialed and recorded amount as 100%. Comment by Staff J-LPN was added at 6:48 PM, Charted late; completed on time. [*It should be noted that this is the feeding time that Resident #236 states was missed on 03/12/22]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 15 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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 On 03/12/22 for 6 PM feeding, Staff J-LPN initialed and recorded amount as 100%, but no comment was recorded for this feeding time. On 03/12/22 for 10 PM feeding, staff initialed and recorded 240 ml. Comment was added at 11:31 PM, Charted late; done on time. Residents Affected - Few On 03/15/22 at 12:07 PM, a second interview was conducted with Resident #236. This resident confirmed, again, that he received no feeding on 03/12/22 between 11:30 PM and approximately 7:15 PM. The resident stated, My 3:00 PM feeding was missed on this day. The resident stated that he does not recall missing any 6 AM feedings, but some have come late. He stated he has missed a couple 10 PM feedings. He also confirmed there were times when he refused a feeding because the previous feeding had been late and there wasn't enough time between the next feeding to empty his stomach. The resident added, This issue is now a [NAME] point because the nurse told me today that they are going to be setting up a continuous feed. On 03/16/22 at approximately 2:00 PM, the DON was informed of the issues regarding Resident #236's administration and documentation of physician ordered tube feedings. No additional documentation was provided at the time of the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 16 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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 ensure pain medication was administered in a timely manner for 1 of 1 sampled resident, reviewed for pain, Resident #381. Residents Affected - Few The findings included: The facility policy, titled, Pain Assessment and Management (revised March 2015), documented in part: 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the residents' pain to the level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Review of the Resident #381's clinical record revealed Resident #381 was admitted on [DATE], with a BIMS score ( brief interview for mental status) of 15, indicating the resident is cognitively intact. The resident has diagnoses to include Fibromyalgia, age related Osteoporosis, Tinnitus, and Urinary Tract Infection. Review of the physician's orders for pain included: Start date of 03/03/22 and discontinued date of 03/10/22 for Hydrocodone-Acetaminophen 5-325 mg 3 times a day PRN (as needed) for pain level of 7-10. Start date of 03/10/22 for Hydrocodone-Acetaminophen tablets 5-325 mg to be given every 6 hours (PRN) for pain level 7-10. Start date of 03/03/22 for Tylenol 325 mg every 8 hours for pain scale of 1-3. The plan of care for Resident #381 revealed the goal was for the resident to be as comfortable as possible. The intervention for the goal included: Medications as ordered, observe for effectiveness and side effects. In an interview on 03/13/22 at 4:37 PM with Resident #381, she stated, I need more pain medication or something that works for my pain. She stated she is aware that she is receiving Hydrocodone 5-325 mg every 6 hours as needed. She stated she calls when it is time for another dose, and she still doesn't receive her pain medication as needed. On 03/15/22 at 9:50 AM, the surveyor entered Resident #381's room. Resident is moving back and forth on her bed and stated she is having rib pain and it is equal to a 9 out of a pain scale of 1-10. She stated that she called 3 times for her pain medication, Hydrocodone 5-325 mg. She stated they answered her calls and stated they would tell her nurse. The resident's nurse, Staff D, a Registered Nurse, (RN) was located at 9:57 AM and informed that resident had called for pain medication 3 times. Staff D-RN stated she was unaware of patient's call for pain medication. At 10:01 AM, Staff E-RN arrived at Resident #381 room and medicated the resident. A review of the record revealed that Resident #381's last dose of Hydrocodone 5-325 mg was given (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 17 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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 on 03/15/22 at 2:40 AM and resident was eligible to receive it at 8:40 AM. Level of Harm - Minimal harm or potential for actual harm On 03/15/22 at 1:40 PM, an interview was conducted with Resident #381 and her husband. The resident's husband stated the nurse told them they would be meeting with someone yesterday (03/14/22) to discuss Resident #381's pain management. He stated no one ever came to speak with them. The husband stated that he was told by a nurse, the DON (Director of Nurses) was going to speak with him. Residents Affected - Few Resident #381 and her spouse both stated that on Saturday afternoon, 03/12/22, they called 5 times for her Hydrocodone 5-325 mg, and no one came until her husband went to the nurses station to request it. Review of the MAR (Medication Administration Record) revealed Hydrocodone 5-325 mg was given at 12:45 PM and at 9:24 PM. Resident #381 and her husband stated they are aware of the 'prn' status of her pain medication and the 6-hour intervals. They called when the resident was eligible to receive it. On 03/15/22 at 1:45 PM, an interview was conducted with the DON concerning Resident's #381 pain management. The DON stated she would speak with Resident #381 and her husband. On 03/16/22 at 9:05 AM, Resident #381 stated she and her husband told Staff C, MDS (minimum Data Set) Coordinator, yesterday (03/15/22) they would like to see a Pain Management doctor. Resident #381 stated, I am still having pain and I shouldn't have to beg for pain medication. Review of the record on 03/16/22 at 2:40 PM revealed the facility had not ordered a consult with a Pain Management Physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 18 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to send order of physician-prescribed medication for 1 of 5 sampled resident and follow through with the appropriate action when the resident's medication was not available for administration, Resident #101. The findings included: Review of Policy and Procedures for ORDERING AND RECEIVING NON-CONTROLLED MEDICATIONS FROM THE DISPENSING PHARMACY (April 2017) documented: Policy Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. Procedures A. Ordering medications from the Dispensing Pharmacy, and B. Receiving Medications from the Pharmacy. (Full Policy and Procedure details obtained). Record review revealed Resident #101 was admitted to the facility on [DATE], with a BIMS of 13, indicating the resident is cognitively intact. Review of the resident's electronic March 2022 Medication Observation Record (eMAR) documented a physician order, dated 02/28/22, for Combivent Respimat mist (Ipratropium-albuterol) 20-100 mcg/actuation, to be given 4 times per day, 1 puff, via inhalation, for shortness of breath/wheezing. When reviewing the March 2022 eMAR, it was documented from 02/28/22 at 1:00 PM through 03/12/22 at 9:00 AM that this medication was not available. On the following dates and times, the staff initialed signifying administration: 03/03/22 at 9 AM, 1 PM and 5 PM, Licensed Practical Nurse (LPN), Staff S-LPN initialed medication was administered. 03/06/22 at 9 PM, Staff I -LPN initialed and commented that resident refused medication. 03/08/22 at 9 AM, Staff T-LPN initialed medication was administered; no additional comments were added. 03/09/22 at 9 AM and 5 PM, Staff L-LPN initialed medication was administered and commented that it was charted late at both times. 03/09/22 at 9 PM, Staff M-RN (Registered Nurse)) initialed medication was administered; no additional comments were added. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 19 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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 03/10/22 at 9 AM, Staff U-RN initialed medication was administered; no additional comments were added. Level of Harm - Minimal harm or potential for actual harm 03/12/22 at 1 PM and 5 PM, Staff J-LPN initialed medication was administered and added comment, charted late .completed on time. Residents Affected - Few 03/12/22 at 9 PM, Staff N-LPN initialed medication was administered; no additional comments were added. 03/13/22 at 9 AM, 1 PM, and 5 PM, Staff J-LPN initialed medication was administered and added for 1 PM, Charted late .completed on time, and for 5 PM, Charted late. 03/13/22 at 9 PM, Staff O-LPN initialed medication was administered and added comment, charted late. 03/14/22 at 9 AM, Staff P-LPN initialed medication was administered; no additional comments were added. At 1 PM, Staff P-LPN initialed medication was administered and added comment, charted late .completed on time. At 5 PM, Staff P-LPN initialed medication was administered and added comment, charted late .given. On 03/14/22 at 9 PM , Staff M-RN noted that Drug item was not available. On 03/16/22 at 12:41 PM, the Director Of Nursing (DON) was interviewed regarding the unavailability of Resident #101's Combivent Respimat, according to the eMAR from 02/28/22 to 03/12/22. She stated she would find out when the order was faxed to the pharmacy and when the medication was actually received at the facility. On 03/16/22 at 2:40 PM, a copy of an email from the facility pharmacy, dated 03/16/22 at 1:40 PM, was provided by the ADON. This email confirmed receipt of the order for Combivent AER 20-100 mcg (30 day supply) on 03/16/22 at 1:40 PM. The pharmacy flagged the order as a high-cost medication and was requesting prompt follow-up as to the possibility of a limited supply of 14 days for Medicare A / Managed Care or 5 days for insurance, per non-covered facility rules. There were no additional documents provided which showed evidence that this medication was sent to the pharmacy on 02/28/22, or any time prior to the date of this survey, nor were there documents provided showing receipt of this medication. On 03/16/22 at 1:48 PM, a Progress Note was added to Resident #101's electronic record documenting, Pharmacy never sent Combivent Respimat due to high cost. Orders from Dr. [name] to DC [discontinue] Combivent inhaler. Resident states she does not need medication and that she does not have a breathing problem. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 20 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to prepare, store and serve food in accordance with professional standards and in a manner to prevent the possible growth of pathogens that cause foodborne illness. The findings included: 1. During the initial kitchen tour, on 03/13/22 at 9:21 AM, accompanied by the Kitchen Manager / Certified Dietary Manager (CDM), the following were noted: a. A portion of the wall to the left of the coffee station and underneath water filters for the ice machine was noted to be damaged and missing tiles. b. A staff member's purse was kept on a shelf with food (bread) and single use and disposable napkins. c. Cutting boards were scored and stained and appeared to be uncleanable. d. The handle of a knife that was stored was noted to be melted in one area, creating an uncleanable surface. e. The exterior of the door and wall of the w/i cooler was stained. f. The gasket on the interior of the door to the walk in cooler was noted to be torn in a manner that creates an uncleanable surfaces. g. In the walk-in freezer, the facility was using plastic milk crates that are not designed to be easily cleanable for shelving. h. There was an accumulation of ice on the inside of a top loading chest freezer containing pre-portioned individual servings of ice cream. i. The 'wash' basin of the three-compartment sink used for manual ware washing contained dirty water with food particles floating in the basin. j. The 'wash' basin of the three-compartment sink used for manual ware washing, was being used for rinsing cleaned items. When asked why the sink was not set up to wash, rinse and sanitized in the proper order, the Kitchen Manager stated that the 'wash' basin did not hold water and that the plug did not work. 2. During the follow up tour of the kitchen, on 03/15/22 at 11:14 AM, accompanied by the Kitchen Manager, the following were noted: a. Staff F, Dietary Aide, was observed handling residents' open and uncovered foods while wearing a watch. b. Personal items, including a charging cable for a cellular device, insulated personal cup and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 21 of 22 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port St Lucie Rehabilitation and Healthcare 7300 Oleander Ave Port Saint Lucie, FL 34952 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 Residents Affected - Many opened bottle of water were stored on a shelf that contained a container with breads and single use and disposable napkins c. The internal temperature of meatloaf that was in the process of cooling after being cooked the previous day, according to the Kitchen Manager, was 46 degrees Fahrenheit (F), 44 degrees F and 49 degrees F. The meatloaf was discarded by the Kitchen Manager, who stated that the meal would be replaced with Salisbury steak, with the approval of the Dietitian. 3. During a tour of the unit pantries, on 03/15/22 at 1:19 PM, accompanied by the Dietitian, the following were noted: a. In the unit pantry for the 500 and 600 units, the inside of the cabinet underneath the hand sink was damaged, there was an accumulation of a black mold-like substance inside of the cabinet underneath the hand wink, and there was an accumulation of debris on the counter underneath the microwave oven. b. In the unit pantry for the 300 and 400 unit, the cabinet underneath the hand sink was damaged and there was an accumulation of a mold-like substance inside of the cabinet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105410 If continuation sheet Page 22 of 22