Inspection·January 6, 2022

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few worked the 100 hall before when I first started here. I know [Resident 38]. I don't ever remember her saying that her BIPAP machine was not working. In that situation, when a BIPAP is not working, I would report it to my nurse, and I guess the nurse will go with her procedures. I have worked night shifts before, and I have seen [Resident #38] with her BIPAP on before, but that was a long time ago. During a 01/06/22 interview with CNA H at 1:46 PM, she stated, I'm familiar with [Resident #38], but I haven't worked with her in a while. She hasn't told me her BIPAP wasn't working. It's been a while, but I haven't seen her with her BIPAP on. If a machine is not working, I go tell the nurse. If a resident tells me a machine is not working, I'll go and look and then go tell the nurse. When asked whether she had been provided any training about what to do if she found a device that was not operating properly, she replied, No, I haven't had any training on what to do if machines are not working. During a 01/06/22 interview with LPN G/Unit Manager at 2:02 PM, she stated, The BIPAP is inspected on a daily/weekly basis. The CNAs and the resident will inform you if there is something wrong. I would go to the Central Supply person to have something ordered. In regard to [Resident #38], I've asked several times for the replacement of the BIPAP. According to the Central Supply person, the supply company would not send another machine until the resident saw a pulmonologist. I don't know if the former Central Supply person made notes as to the request. I did the chain of command. (I was informed by a CNA that the BIPAP wasn't working. I informed my Unit Manager and I let Central Supply know.) This happened in 2021 but I am unsure when this took place. A new machine was received yesterday (01/05/2022) evening in operable condition. It was ordered by the Regional Nurse. A review of the resident's medical record revealed diagnoses including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. A review of the physician's orders revealed a 02/02/2021 order for a follow-up appointment to be made with the pulmonologist and a 01/05/2020 order for BIPAP per programmed settings (every evening and night shift). No documented evidence was found since 02/02/2021 to indicate that an appointment was made with or that the resident was seen by a pulmonologist. No documented evidence was found since 02/02/2921 to indicate that the resident's physician was made aware that the resident's BIPAP was not working, and she was therefore, not utilizing the device as per physician's orders. A review of the resident's care plan, initiated on 11/12/2021, revealed a focus area for Altered Respiratory Status/Difficulty Breathing related to COPD, CHF, and sleep apnea with BIPAP as ordered. Elevate head of bed as needed (PRN) to facilitate breathing, encourage sustained deep breathing, monitor/document changes in orientation, increased restlessness, anxiety, and air hunger. Monitor for signs and symptoms of respiratory distress and report to physician. Monitor/document/report abnormal breathing patterns. Oxygen as ordered, Respiratory Treatment, Equipment Cleaning and Functioning. A review of the Treatment Administration Record (TAR) revealed that the BIPAP usage monitoring was being performed every day from 10/01/2021 to 01/04/2022 despite conflicting interviews with Resident #38 and staff members as noted above. (Photographic evidence obtained) A review of the facility's Environmental Equipment Care Policy (Implemented on 01/15/2021) revealed: - Paragraphs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 2 of 14 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 105468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Therapy Care Center and Rehab, The 1999 Old Moultrie Road Saint Augustine, FL 32086 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 (8) Mechanical, electrical, and patient care equipment shall be maintained in safe operating condition Level of Harm - Minimal harm or potential for actual harm (9) Equipment or other maintenance related needs should be communicated with the Supervisor, Maintenance Director or Executive Director. Communication may be done verbally if the appropriate personnel are present and able to remedy the concern. A communication system and/or maintenance tracking log can be utilized to communicate maintenance or repair needs for off shift or other desired needs. Residents Affected - Few According to British Journal of Anaesthesia (M. [NAME], U. Freo, A. S. BaHammam, D. Dellweg, F. [NAME], R. Cosentini, P. Feltracco, A. Vianello, C. [NAME], A. Esquinas, Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials, BJA: British Journal of Anaesthesia, Volume 110, Issue 6, June 2013, Pages 896-914, https://doi.org/10.1093/bja/aet070) the utilization of a BIPap Non-Invasive Ventilator can greatly reduce the overall distress for patients, practical complications, and mortality with proper settings and diligent monitoring. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 3 of 14 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 105468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Therapy Care Center and Rehab, The 1999 Old Moultrie Road Saint Augustine, FL 32086 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 observations, interviews, and record review, the facility failed to treat a resident's pain to the extent possible, by failing to identify and treat pain that persisted beyond the resident's current pain regimen for one (Resident #85) of three residents reviewed for pain management from a total of 38 sampled residents. Residents Affected - Few The findings include: A review of Resident #85's medical record revealed an admission date of 5/19/2021. His primary medical diagnosis was cerebral infarction. Secondary diagnoses included liver disease and unspecified pain. A Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating intact cognition. Resident #85 required extensive assistance from staff for activities of daily living. On 1/4/2022 at 8:39 a.m., an interview was conducted with Resident #85. He stated his left knee had been hurting really bad for about three days. He stated he had chronic pain, but this pain started during a transfer in which his left knee was twisted. He stated he had received tramadol (narcotic pain medication for moderate to severe pain) but that it was not working. A review of Resident #85's comprehensive care plan revealed a focus area for Actual Pain that was related to diabetic neuropathy and impaired mobility. The first intervention directed staff to anticipate the resident's needs for pain relief and respond immediately to any complaint of pain. The second intervention directed staff to evaluate the effectiveness of pain interventions and to review for compliance, symptom alleviation, dosing schedules, resident satisfaction with results, and impacts on functional ability and cognition. The third intervention directed staff to monitor and document the probable cause of each pain episode and remove or limit causes where possible. The seventh intervention directed staff to notify the physician if interventions were unsuccessful or if the current complaint was a significant change from the resident's past experience of pain. (Photographic Evidence Obtained) On 01/05/2022 at 1:35 p.m., a second interview was conducted with Resident #85. He rated his current pain as an 8 on a 0-10 verbal scale, with zero equaling no pain and 10 equaling the most severe pain. He described the pain as sharp, stabbing, and constant. He stated he didn't feel like doing much of anything because of the pain. Resident #85 was asked what the facility was doing to treat his pain. He stated he was receiving pain medication, but that it did not work at all and his knee had been hurting constantly since the incident. On 01/05/2022 at 3:16 p.m., an interview was conducted with Licensed Practical Nurse (LPN) B. She confirmed that she was assigned to Resident #85. She stated she had just come on shift and she was not aware of any pain concerns related to Resident #85's left knee. The nurse confirmed that she had not received any information about Resident #85's pain during the change-of-shift report. The nurse then explained that Resident #85 did not often verbally complain of pain, but He uses the call light a lot and asks for repositioning all the time. Sometimes I think that is his way of complaining of pain. The nurse added that the resident did receive tramadol every eight hours, but that she did not think it was effective. A review of Resident #85's physician's orders revealed an order dated 8/30/2021 for tramadol 50 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 4 of 14 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 105468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Therapy Care Center and Rehab, The 1999 Old Moultrie Road Saint Augustine, FL 32086 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few milligrams (mg) to be given orally three times daily for moderate to severe pain. A second order was noted for acetaminophen two tablets to be given orally every four hours as needed for pain or fever. The order did not include a dosage. A review of the medication administration records (MARs) for November 2021 through January 2022 revealed documentation of administration of the tramadol but no documentation of its efficacy. (Photographic Evidence Obtained) Continued review of the physician's orders revealed an order dated 11/18/2021 for a consultation with neurology for neuropathic pain and twitching. (Photographic Evidence Obtained) Further review of the medical record revealed no documentation that the consultation had been scheduled or that the resident had attended it. On 01/06/2022 at 1:07 p.m., an interview was conducted with the Nurse Practitioner. She confirmed that she was familiar with Resident #85. She stated she was very familiar with the resident's complaints of pain. She added that the resident was receiving tramadol every eight hours, but that the pain seems unrelieved. The Nurse Practitioner stated she had requested the resident be evaluated by neurology for neuropathic pain and twitching because she wasn't sure what was causing the pain. When asked about the original order for a neurology consult on 11/18/2021, the Nurse Practitioner stated she had asked the facility why the appointment had not been scheduled but never could get a definite answer. She added that she reordered the consultation on 01/05/2022. When asked whether the resident had been considered for evaluation by a pain management physician, the Nurse Practitioner stated she thought that would be a good idea, because she was unable to determine the cause of the resident's pain and the resident had not been seen by a pain management physician that she was aware of. On 01/06/2022 at 1:45 p.m., an interview was conducted with Certified Nursing Assistant (CNA) D. She stated she had worked in the facility since August 2021 and was employed by a staffing agency. She confirmed that she was assigned to Resident #85 and was familiar with his care. When asked whether the resident ever complained of pain, she stated, He complains of pain to his abdomen area a lot. When asked whether the resident ever complained of knee pain, the CNA stated, sometimes he does. The CNA added that she had reported the resident's complaints of pain to the nurses several times. On 01/06/2022 at 1:52 p.m., an interview was conducted with the Unit Manager. He confirmed that he was familiar with Resident #85. He identified the resident as having a lot of concerns and requiring a lot of attention. The Unit Manager confirmed that the resident had chronic pain concerns. When asked to describe the facility's interventions to manage the resident's chronic pain, he stated, On different days he complains of different types of pain all over his body. I know he gets tramadol every eight hours. When asked how the pain management interventions were monitored for effectiveness, the Unit Manager stated, Well, we go back in and check to see if it worked. If it didn't work, we call the nurse practitioner. I know the nurse practitioner just ordered a neurology consult to see if we can figure out where the pain is coming from. When asked whether he was aware that an order for a neurology consult had already been ordered for that same purpose in November 2021, the Unit Manager reviewed Resident #85's physician's orders and stated, To be honest, this is the first time I am seeing the order. I will call the office and schedule an appointment. On 01/06/2022 at 5:55 p.m., an interview was conducted with the Director of Nursing (DON). He stated he was not very familiar with Resident #85, as he had just started working at the facility a few weeks ago. The DON stated he had not reviewed Resident #85's pain regimen prior to the survey. Regarding the monitoring of pain medication effectiveness, the DON explained that nurses would be expected (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 5 of 14 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 105468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Therapy Care Center and Rehab, The 1999 Old Moultrie Road Saint Augustine, FL 32086 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm to monitor the efficacy of the medication and document the findings. He stated for as-needed (PRN) medications, the electronic record system prompted the nurses to enter the effectiveness after a specific time frame, but he was unsure of whether the system had the same function for medications scheduled to be given routinely. Regarding Resident #85's neurology appointment, the DON explained that Someone outside of the facility schedules the appointments. He stated, It doesn't work that good. Residents Affected - Few The facility's Pain Management policy, titled Pain Screening and Management directed staff to monitor residents receiving ongoing pain management interventions and to document those findings to include observation of intensity and location of pain, frequency of as-needed analgesic use, effectiveness of pain medications, and potential need for review by the physician for potential medication regimen review. The policy also directed staff to consider the resident's goals and preferences when developing the pain management regimen. (Photographic Evidence Obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 6 of 14 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 105468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Therapy Care Center and Rehab, The 1999 Old Moultrie Road Saint Augustine, FL 32086 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff and resident interviews, the facility failed to meet the needs of residents in accordance with established national guidelines for five (Residents #83, #79, #2, #139, and #145) from a total of 38 sampled residents. Specifically, the facility failed to ensure that with reasonable efforts, the residents' allergies, food preferences, and therapeutic diets were honored/followed. The findings include: A review of the Resident Council Minutes dated 10/21/2021, documented that residents had a new concern with the dietary department. Residents stated the kitchen was out of items often or they weren't getting items on their trays. This concern was noted to have been submitted to the dietary department for resolution. A review of the Resident Council Minutes dated 11/18/2021, documented that residents had a new concern with the dietary department. Residents stated, The meat (pork, beef, and occasionally chicken) is tough and hard to cut with a knife. This concern was noted to have been submitted to the dietary department for resolution. There was no documentation indicating a resolution to the dietary concern from 10/21/2021. 1. A review of Resident #83's medical record revealed that she was admitted on [DATE] with diagnoses including cerebral infarction, type 2 diabetes mellitus, recurrent depressive disorder, anxiety disorder, hypertension, gastrointestinal reflux disease, protein malnutrition, dysphasia, dementia with behavioral disturbances, and anemia. A review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #83 had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 points, indicating moderate cognitive impairment. She was documented with a consistent carbohydrate diet of a mechanical soft texture and a regular liquid consistency, as well as medications including Levemir (insulin) and Metformin (antidiabetic medication) for diabetes. Resident #83's care plan included a food allergy to strawberries, a need for a specialized diet to address glucose levels due to type 2 diabetes mellitus (low concentrated sweets/mechanical soft/thin liquids). During an interview with Resident #83 on 01/03/2022 at 12:40 PM, she reported she had a food allergy to strawberries but had been given strawberry jelly at breakfast several times and strawberry short cake on her food tray. 2. During an interview with Resident #79 on 01/03/2022 at 2:22 PM, she complained that her breakfast was always wrong. She confirmed she had an allergy to egg yolk and pineapple, but received fruit cocktail with pineapple mixed on her food tray. She further stated she was allergic to the runny yolk of the egg but could have scrambled eggs, and had explained that to the kitchen staff. She stated she had only seen the choice menu twice in order to circle the items she wanted at mealtimes. During an interview with Certified Nursing Assistant (CNA) M on 01/06/2022 at 9:49 AM, she was asked whether she was familiar with Resident #79. She confirmed that she was familiar with this resident. She is a picky eater. CNA M stated the resident's egg allergy was on her food ticket, but she wanted scrambled eggs. She mostly drinks her own protein shakes. CNA M was asked to explain the process (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 7 of 14 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 105468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Therapy Care Center and Rehab, The 1999 Old Moultrie Road Saint Augustine, FL 32086 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for how resident menu items were selected. She stated the menu came out on Sunday for the coming week, and the everyday menu came out during the 3-11 shift each day for the following day and was kept at the nurse's desk. Menus were also available hanging on the wall outside of the dining room. CNA M stated she was not sure if the everyday menus were provided to all residents or only to certain residents who requested them. She confirmed that it was the CNA's responsibility to provide the everyday menus to all residents. When asked to explain when and how the everyday menus were submitted to kitchen, CNA M stated any staff member could take the menu back to the kitchen. Once the resident selected and circled the items they wanted, the staff member could return the slip to the kitchen. All meal tickets should be returned before the kitchen closed. During an interview with Resident #79 on 01/06/2022 at 10:14 AM, she was asked which food items she was eating for breakfast most of the time. She replied, My own Premier Protein (protein drink). When asked whether she had spoken with the physician or registered dietitian (RD) regarding her egg preference, she stated she had spoken with them 4-5 times. I received a hard boiled egg today. I can have scrambled eggs or an omelet. I told them I'm allergic to egg yolks only when they are runny. Why not give me egg whites? When asked whether she had completed the everyday menu for today, Resident #79 replied that she had not received an everyday menu this week. During an interview with Licensed Practical Nurse (LPN) F on 01/06/2022 at 10:24 AM, she was asked whether she was familiar with Resident #79. LPN F stated she was and explained that the resident was alert, oriented and vocal. She fractured her left hip, had surgery and is here for rehab. She is progressing well. LPN F stated the resident had weight loss surgery a few years ago and had select items she would eat. She picks what she wants. When asked to explain the process for how the resident menu items were selected, LPN F stated, Sometimes [Resident #79] will request a sandwich in the morning, or if she doesn't want what is on her food tray, she will ask for something else. There is a meal ticket that comes on the tray for the residents to select their next meal, or the CNA will take the meal ticket to the resident for them to circle the items they want. I've seen it both ways. We have changed kitchen staff and it depends on who is working in the kitchen. LPN F stated most of the time, the everyday menus were provided only when a resident asked for them. A menu was provided for them to circle food items, then the staff member would take the menu right back to the kitchen. Menus should be returned before the kitchen closed. One copy of the everyday menu was observed on the desk at the nurse's station. LPN F was unsure of whether menus had been provided to residents for the next meal service. On 01/06/2022 at 11:51 AM, the Activities Director (AD) stated the facility's Food Committee met during the same time as Resident Council, every third Thursday at 10:30 AM. When asked who participated in the meeting, the AD replied, The DON (Director of Nursing), Regional Nurse, and the Kitchen Manager or Cook. On 01/06/2022 at 12:22 PM, a review of Resident #79's meal ticket revealed known food allergies to pineapple, egg, and citrus fruit. There was no choice meal ticket completed for the resident. On 01/06/2022 at 12:25 PM, a review of the Resident Council Minutes sign-in sheets and meeting notes revealed that the Regional Kitchen Staff was present during the September and December 2021 meetings. The October and November 2021 minutes identified concerns that the kitchen was often out of items or residents weren't getting items on their trays. (Photographic Evidence Obtained) A review of Resident #79's hospital Facesheet and discharge instructions, dated [DATE] at 5:48 PM before her facility admission, revealed allergies to egg yolk and pineapple. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 8 of 14 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 105468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Therapy Care Center and Rehab, The 1999 Old Moultrie Road Saint Augustine, FL 32086 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with CNA J (Agency) on 01/06/2022 at 5:00 PM, she stated she had worked in this facility since October 2021, usually on the 3-11 shift. When asked whether she asked residents what they wanted on the menu, she replied No, I don't ask residents about their meals. I think the 7-3 shift does. When asked if she worked with any diabetic residents receiving special diabetic diets, she replied that there were no residents on the unit that were receiving diabetic diets. I check with the nurse to see if there are any diet concerns. I don't ask about diets. I expect it to be what they wanted. I serve whatever is on the tray. If the resident asks for a certain item when dinner arrives and they want a change, the CNAs will go to the kitchen and get what is requested. CNA J confirmed resident allergies were listed on the meal tickets. During an interview with Certified Dietary Manager (CDM) K on 01/06/2022 at 5:02 PM, she stated she was a full-time next level staff member and had been here at the facility 3-4 days per week since October 2021. When asked to describe the process for determining what residents wanted on the menu, she stated that upon admission, residents were interviewed by the RD or CDM. Residents and/or family members were provided menus to complete. A review of the facility's Diet Requisition Form revealed diet ordered nutrient content choices. CDM K stated it was up to the physician and RD regarding what diet to provide. Menus were updated as needed. Snacks were stocked in the pantry. We follow a CCHO (consistent carbohydrate diet for diabetes) diet. We don't carry sugar-free snacks. When asked how the facility would respond if a resident requested sugar-free Jell-O, CDM K stated, I would have to provide it. It would have to be up to the physician and RD. I can't change diets. When asked if a resident had requested a diet they had previously received, how their choice was honored, CDM K replied, I can honor preferences. I would turn it over to the RD and do a follow-up call to the physician. I can replace food items; whole milk to skim, sugar to sugar free. CDM K stated the choice menus went out with the dinner meal during the 3-11 shift. Sometimes the menus came back on the food tray, and some were placed in the dietary box on the door. CDM K stated she interacted with residents daily, and no concerns from Resident #79 had been brought to her attention. She confirmed she had no meeting with the resident regarding her meal requests. (Photographic Evidence Obtained) 3. A review of the medical record revealed that Resident #2 was admitted on [DATE] with diagnoses including unspecified calorie malnutrition, diabetes type 2, vitamin deficiency, and acute kidney failure. A review of the Physician's Order Sheets for December 2021 and January 2022 revealed current physician's orders for insulin and blood glucose monitoring. Resident #2 was documented as receiving a regular, NAS (no added salt) diet and double all entrees. Resident #2 was interviewed on 01/03/2022 at 9:45 AM regarding his dietary needs and choices. He said the meat, especially the pork chops, were too tough to eat. He also stated he was not being provided a diabetic meal as requested. Resident #2 was interviewed again on 01/03/2022 at 1:30 PM. He said he had just completed his lunch. He stated it was good but was not a diabetic diet. He had asked for a diabetic meal but stated the RD told him diabetic diets were not available. He was aware of the always available food choices, but stated they were mostly sandwiches. He said he liked the BLT (bacon, lettuce, tomato), but it was too much bread. The breakfast meal was powdered eggs. He said he loses weight when he is here. Resident #2 was interviewed on 01/04/2022 at 1:00 PM. He said he had ham, potatoes, two cups of pudding and apple pie. He was unaware that he did not have a physician's order for a diabetic meal. Resident #2 was observed on 01/05/2022 at 11:00 AM requesting a diabetic meal for lunch. The nurse stated she would make note of his request. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 9 of 14 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 105468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Therapy Care Center and Rehab, The 1999 Old Moultrie Road Saint Augustine, FL 32086 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 0803 Level of Harm - Minimal harm or potential for actual harm A record review on 01/06/2022 at 12:25 PM, revealed the resident's meal ticket for 01/06/2022. He was not offered a diabetic diet as requested. Resident #2 was interviewed on 01/06/2022 at 2:35 PM with his spouse. The spouse said her husband had informed her that he was not getting a diabetic diet, but he should be. Residents Affected - Few During an interview with CNA J on 01/06/2022 at 5:00 PM, she said the staff on the 7:00 a.m. to 3:00 p.m. shift managed the residents' meal choice tickets each day. She said she worked on the 3:00 p.m. to 11:00 p.m. shift. She discusses with the nurse each day whether there have been any resident care or dietary changes. She was unaware of any residents on her shift that had a diagnosis of diabetes. She said there were no sugar-free snacks, and she would normally not suggest any snack items. The residents would usually come up with the choice themselves, often a grilled cheese sandwich. She said Resident #2 often received food from family, and she was unaware of his need for a diabetic diet. She said he had not asked her for diabetic diet. An interview was conducted with CDM K on 01/06/2022 at 5:15 PM. She said the residents were given the diet that was established by the registered dietitian (RD) and physician. She was not able to adjust a resident's diet. They offered a carbohydrate diet for some residents, but did not have sugar-free or low-sugar menu items to offer. She said she did not always receive all of the menu choice forms each day. The menu choice forms were sent out with the dinner meal for the next day's options. She said the 3:00 p.m. to 11:00 p.m. shift was responsible for this. She said the facility had options that should be offered to the residents, but they did not have sugar-free snacks. She said there might be a need to do additional education with the CNAs so that when they offered the food choices to the residents each day, they were sure they knew what to offer. She said this would be especially true of any items the resident may want that were not on the food lists. She said she was aware that Resident #139 was a vegetarian. The facility had soy patties or other alternate protein choices. She said mashed potatoes did get offered a lot, but if the CNAs were not offering other vegetarian options, they probably just needed more education. She said that not all daily meal choice forms were turned back in to the dietary department each day. An interview with the Director of Nursing (DON) was conducted on 01/06/2022 at 5:45 PM. He said a restricted sugar and carbohydrate (RSC) diet was available to residents with diabetes. The diet did not include no sugar items, but some foods such as unsweetened tea were available. The DON said he was not aware of any concerns with Resident #2 or his diet choices. 4. An interview was conducted with Resident #139 on 01/04/2022 at 10:05 AM. She stated she was a vegetarian. She said that since her admission to the facility on [DATE], she had not spoken to anyone from the kitchen or the registered dietitian (RD) regarding her meal choices. She said she received mashed potatoes all the time with an additional rotating selection of carrots, peas, and green beans. She said it was over and over again. If she asked for something else to eat, they would give her a peanut butter sandwich. Sometimes they would offer her another item, but it she had requested on many occasions to receive something other than mashed potatoes. She said she did not eat meat, but she would like other options such as pasta or salad. She said no one had helped her resolve this problem. A record review revealed a 12/17/2021 physician's order for a vegetarian/vegan only, regular diet. An interview was conducted with LPN G on 01/06/2022 at 3:45 PM. She said the CNAs asked the residents what choices they wanted from the menu the day before that meal was scheduled. She said the CNAs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 10 of 14 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 105468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Therapy Care Center and Rehab, The 1999 Old Moultrie Road Saint Augustine, FL 32086 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not necessarily know, or were able to easily tell, how the menus met dietary restrictions, preferences, or the needs of the residents. She said none of the residents were on restricted or therapeutic diabetic diets. Instead, as an example, she said residents on diabetic diets would receive snacks that were high in protein, not necessarily low in sugar. An interview was conducted with CNA A on 01/06/2022 at 4:08 PM. She said the CNAs on the 3:00 p.m. to 11:00 p.m. shift took a full meal choice list to each of the residents on their unit. She said the staff member would then circle the residents' food choices for the next day. An interview was conducted with CNA J on 01/06/2022 at 4:48 PM. She said she did not ask residents about their meal choices. She said she believed the CNAs on the 7:00 a.m. to 3:00 p.m. shift asked the residents. She said she would always check with the nurse on duty to see whether there were any dietary concerns, or possible changes in full status. She said she did not ask about diets. She did review what was on the resident's meal tray, but she said she expected what the resident was being served was what they wanted from their choice selection. She said she and the dietary department both reviewed for any allergy concerns. An interview was conducted with CDM K on 01/06/2022 at 5:40 PM. She said the residents were given the diet that was established by the registered dietitian (RD) and physician. She said she was not able to adjust a resident's diet. She said they had options that should be offered to the residents. She said they did not have sugar-free snacks. She said there might be a need to do additional education with the CNAs so that when they offered the food choices to the residents each day, they are sure they knew what to offer. She said this would be especially true of any items the resident may want that were not on the food lists. She said she was aware that Resident #139 was a vegetarian. The facility had soy patties and other alternate protein choices. She said mashed potatoes did get offered a lot, but if the CNAs were not offering other vegetarian options, they probably just needed more education. She said that not all daily meal choice forms were turned back into the dietary department each day. 5. Resident #145 was observed in bed on 01/03/2022 at 12:36 PM. The resident verbalized concerns with nutrition he was provided being of poor quality. Upon review of the weekly menu, Resident #145 stated, What you see is what you get. When he was asked about food alternatives, he said alternatives were not readily available. The resident was not aware of the always available menu which was posted in the hallways. The resident was not able to ambulate and required total care. Further, the resident stated the kitchen/cafeteria usually closed early, and it was not possible to get a cup of coffee at 9:00 p.m. or at 9:00 a.m. The resident was interviewed on 01/04/2022 at 9:31 AM. He stated the morning's meal was same, same. An interview was conducted with CNA M on 01/05/2022 at 11:09 AM. She was unable to explain the process of ensuring each resident received the appropriate and preferred meal items. Her response was that she did not know what process was used to inform the residents of food choices because she was only agency staff. An interview was conducted with LPN G on 01/05/2022 at 11:12 AM. She displayed a menu slip that the night nurses and CNAs were handed each evening. The evening staff were then responsible for delivering the menu slips to each resident for completion. This menu slip would be filled out to identify which food items the resident wished to receive the following day. Staff were to assist residents who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 11 of 14 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 105468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Therapy Care Center and Rehab, The 1999 Old Moultrie Road Saint Augustine, FL 32086 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 0803 needed help completing the form. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 12 of 14 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 105468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Therapy Care Center and Rehab, The 1999 Old Moultrie Road Saint Augustine, FL 32086 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and staff interviews, the facility failed to maintain accurately documented resident medical records by failing to accurately document the use of a bilevel positive airway pressure (BIPAP) device during the evening and night shifts for one (Resident #38) of one resident reviewed, from a total of 38 sampled residents. Specifically, the nursing staff executed 137 Treatment Administration Record (TAR) entries indicating use of a BIPAP device when the resident's BIPAP device was inoperable. The findings include: During an interview conducted on 01/03/22 at 12:22 PM, Resident #38 stated, My BIPAP machine was inoperable for several months, and I haven't had an appointment with the pulmonologist. It's been about a year since I've used the BIPAP machine. During an interview on 01/04/22 at 12:00 PM, Licensed Practical Nurse (LPN) G/Unit Manager, stated, I'm very familiar with [Resident #38] and the BIPAP machine. It doesn't work. [Resident #38] has had four machines this year. I don't know how or why her machines keep breaking, but she finds a way to have a broken machine. On 01/05/22 at 11:55 AM, Resident #38's BIPAP device was checked to see whether it was operable, but the device did not come on. Resident #38 stated, It may be unplugged because it doesn't work. The device was observed to be unplugged. It was plugged into the receptacle, and it remained inoperable. A review of the Treatment Administration Records (TARs) for October, November and December 2021, revealed the nursing staff signed off the forms as having observed Resident #38 utilizing a BIPAP device when the device was inoperable: 12/31, 12/28, 12/27, 12/26, , 12/25, 12/24, 12/22, 12/21, 12/11, 12/10, 12/09, 12/08, 12/07, 12/05, 12/04, 12/03, 12/01, 11/27, 11/26, 11/22 (device unavailable), 11/21, 11/19, 11/16, 11/13, 11/12, 11/11, 11/10, 11/06, 11/05, 11/04, 11/03, 11/02, 10/29, 10/28, 10/27, 10/23, 10/22, 10/21, 10/20, 10/19, 10/16, 10/14, 10/09, 10/08, 10/07, 10/06, 10/04, and 10/02. On 01/06/2022 at 11:36 AM, progress notes in Resident #38's record were reviewed and were documented as follows: Effective date 01/05/2022 at 4:28 PM, authored by Licensed Practical Nurse (LPN)/Unit Manager G, Spoke to the Advanced Practice Registered Nurse (APRN) this shift in regards to the resident's BIPAP, and got an order to place on hold until she is seen by pulmonology. No adverse effects noted from the nonuse of the machine. will continue to monitor. Effective date 01/05/2022 at 5:30 PM, authored by LPN/Unit Manager G, Orders obtained for new BIPAP. Settings are 15/7. Provider and resident aware. Appointment with pulmonology will remain in place. Effective date 01/05/2022 at 10:43 PM, authored by LPN/Unit Manager G, BIPAP on and working properly. Resident noted to be resting in bed with eyes closed. During a 01/06/22 interview with LPN G/Unit Manager at 2:02 PM, she stated, The BIPAP is inspected on a daily/weekly basis. The CNAs and the resident will inform you if there is something wrong. I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 13 of 14 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 105468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Therapy Care Center and Rehab, The 1999 Old Moultrie Road Saint Augustine, FL 32086 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would go to the Central Supply person to have something ordered. In regard to [Resident #38], I've asked several times for the replacement of the BIPAP. According to the Central Supply person, the supply company would not send another machine until the resident saw a pulmonologist. I don't know if the former Central Supply person made notes as to the request. I did the chain of command. (I was informed by a CNA that the BIPAP wasn't working. I informed my Unit Manager and I let Central Supply know.) This happened in 2021 but I am unsure when this took place. A new machine was received yesterday (01/05/2022) evening in operable condition. It was ordered by the Regional Nurse. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 14 of 14