Inspection·October 26, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm orange splatters on the resident's floor. If she were to observe a mess in a resident's room, she would not walk past it, but clean it up. On 10/26/23 at 11:08 AM, Licensed Practical Nurse (LPN) G reported that she did not observe splatters of a red and orange substance while in the resident's room performing bedside blood glucose monitoring. Residents Affected - Few On 10/26/23 at 11:21 AM, Housekeeper I reported that she was assigned to Resident #85's room. She explained that she did not see splatters of the red and orange substance on the floor or bedrail in the resident's room. On 10/26/23 at 11:30 AM, CNA H reported that she was familiar with Resident #85 and said she noticed what appeared to be soup splattered in the resident's room on 10/23/23. She reported it to housekeeping that day. She said the resident did not complain of an upset stomach. The resident often put food on the bedroom floor with the intent to feed his cats and dogs, which were not in the facility. She also explained the resident had soup and a sandwich the night before (10/22/23), and housekeeping thought the spill on the floor was tomato soup. On 10/26/23 at 12:42 PM, the Director of Housekeeping and Laundry was interviewed and reported resident rooms and bathrooms had a regular daily clean, which included wiping down hard surfaces, sweeping and mopping to disinfect the floor. Bathroom supplies, such as hand soap and paper towels were replenished. Rooms were deep cleaned once a month or more frequently if needed. If a CNA or nurse saw a mess in a resident's room, they were expected to contact Housekeeping and request housekeeping services. If Housekeeping Services observed a mess on the floor, they were expected to clean it up. Housekeeping began cleaning resident rooms at 8:00 AM and finished at 3:00 PM. From 3:00 PM to 8:00 PM, someone from Housekeeping was available to do as needed cleaning. A review of the facility's Daily Resident/Patient Room Cleaning process noted required items to conduct cleaning services and a procedure. The room cleaning tasks should be performed in the following order: Straighten up the resident's room, dust all flat surfaces with a cloth and disinfectant, clean the air vent covers, and spot clean all necessary areas; dust mop the floor and sweep all trash and debris to the door and pick it up wit the dustpan . wet mop the room using disinfectant . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 2 of 10 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 10/26/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #52) of four residents reviewed for inability to carry out Activities of Daily Living (ADLs), from a total sample of 34 residents, received proper grooming. Residents Affected - Few The findings include: A review of Resident #52's medical record revealed that he was initially admitted to the facility on [DATE] and was re-admitted on [DATE]. His diagnoses included the following: orthopedic aftercare, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, unspecified fracture of the lower end of left radius, subsequent encounter for closed fracture with routine healing, and diabetes mellitus with unspecified diabetic retinopathy. A review of the quarterly minimum data set (MDS) assessment, dated 8/2/23, revealed a brief interview for mental status (BIMS) score of 10 out of 15 possible points, indicating moderate cognitive impairment. On 10/23/23 at 10:45 AM, Resident #52 was observed with facial hair on his chin, cheeks, and upper lip, which measured approximately one and three quarter inches long. The resident explained that the long facial hair bothered him, and he had requested that the staff trim his facial hair several months ago but no one responded. He also stated he disliked the long hair on his upper lip, which came into contact with his mouth while he spoke and ate. On 10/24/23 at 10:24 AM, Resident #52 was observed with five of ten fingernails extending approximately one half inch beyond his fingertips. (Photographic evidence obtained) Many of the long fingernails were jagged. The resident explained that he did not like his fingernails so long, and had asked facility staff multiple times to trim his nails. The resident also said he touched his face often and was fearful he would scratch his eye with such long, jagged nails. On 10/26/23 at 10:30 AM, Certified Nursing Assistant (CNA) E, assigned to provide care to the resident, reported that she was familiar with the resident and his activities of daily living needs. She explained that she did not notice the resident's long facial hair or long fingernails. She said she could not recall the resident asking to have his facial hair or nails trimmed. On 10/26/23 at 11:00 AM, Registered Nurse (RN) F, assigned to Resident #52's hallway, reported that she was familiar with the resident and his activities of daily living needs. She explained that routine care of residents should include daily observations of resident appearance and grooming needs. When a resident's nails were excessively long and had grown past the top of the fingers, they should be trimmed because long nails could potentially cause a resident to scratch themself. The process to trim nails was to clean the nail, soak the nail and either file down or clip the nail tip to shorten the length. She stated that when a resident's facial hair was long, or grew over the lip, the facial hair should be trimmed. She explained that shaving facial hair should be part of the daily routine while providing residents with activities of daily living care. On 10/26/23 at 11:08 AM, Licensed Practical Nurse (LPN) G reported that she was assigned to care for Resident #52. She explained that when she encountered the resident, the resident did not request her to shorten his nails or facial hair. LPN G expressed that she performed blood glucose monitoring for the resident and did not notice the length of his nails while checking his blood glucose level. She explained that she used to work as a certified nursing assistant and was well familiar with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 3 of 10 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 10/26/2023 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 0677 providing activities of daily living and grooming care. Level of Harm - Minimal harm or potential for actual harm On 10/26/23 at 11:25 AM, LPN D reported that she worked at the facility on an as needed basis and provided the names of staff assigned to care for the resident. Residents Affected - Few On 10/26/23 at 11:30 AM, CNA H explained that she was assigned to provide care to Resident #52 during the day shift and was familiar with the care the resident required. She expressed that she did not notice the resident had excessively long fingernails. She reported that the resident did not request that his nails or facial hair be trimmed. If she noticed the resident's nails or facial hair was long, she would have trimmed the facial hair and nails. A review of the resident's medical record revealed no documented evidence that the resident refused care or assistance in activities of daily living. A review of the facility's Standards and Guidelines: Activity Care and Assistance Manual - Nursing (Implemented on 01/15/21 and Reviewed/Revised on 1/15/21), documented Personal Hygiene: How resident maintains personal hygiene, including combing hair, brushing teeth, shaving . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 4 of 10 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 10/26/2023 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 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 observations, staff, resident and family interviews, record review, and facility policy review, the facility failed to ensure that one (Resident #36) of two residents reviewed for skin conditions, from a total of 34 residents sampled, received wound treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Residents Affected - Few The findings include: On 10/23/23 at 12:30 pm, Resident #36 was observed sitting up in a wheelchair in his room, next to his bed, dressed in day clothes. Both of his lower extremities were observed with a dressing on each leg. The dressings were dated as follows: 10/18/23 on the right lower leg, and 10/22/23 on the left lower leg. Observation of the left lower leg dressing revealed reddened skin with a small black area at the furthest end visible outside of the dressing area. The dressing had a small amount of drainage visible on the top and bottom of the dressing. The dressing on the right lower leg was dated 10/18 and had a second (undated) dressing on top of it with one spot of drainage noted on the right side of the second dressing. The resident was asked how often his leg dressings were changed, and he replied that he wasn't sure. On 10/24/23 at 3:15 pm, Resident #36 was observed lying in bed. His wife was visiting at bedside. She was asked if she knew how often wound care was provided to the resident's legs. She stated, I think it's every other day. Dressings were still dated 10/18/23 on the right lower leg and 10/22/23 on the left lower leg. The left lower leg dressing observation revealed reddened skin with a black area at furthest end visible outside of the dressing area. The dressing had drainage visible on the top and bottom of the dressing. The dressing on the right lower leg, dated 10/18, was observed with a second (undated) dressing on top of it with one spot of drainage noted on the right side of second dressing. (Photographic evidence obtained) On 10/24/23 at 3:25 pm, Licensed Practical Nurse (LPN) A/Wound Care Nurse was observed in the 100 hallway at a treatment cart. She was asked if she was the wound care nurse. She stated yes. She was asked if she had any other wound treatments or assessments on this hallway to complete. She stated just one at the end of the hallway. She and the wound care physician were observed entering the room at the end of the hallway. They were not observed entering Resident #36's room. On 10/25/23 at 6:55 am, Resident #36 was observed lying in bed. He was asked if his leg dressings had been changed. He stated I don't think so. Look and see. Observation of both lower extremities revealed a dressing on the right lower leg dated 10/18, and a left lower leg dressing dated 10/22. The left lower leg dressing observation revealed reddened skin with a black area at the furthest end visible outside of the dressing area. The dressing had drainage visible on the top and bottom of the dressing. The right lower leg dressing had a second (undated) dressing on top of the dressing dated 10/18, with one spot of drainage noted on the right side of second dressing. (Photographic evidence obtained) A review of Resident #36's medical record revealed a physician's order dated 10/9/2023, which read: Cleanse denuded area on right lower extremity with normal saline, pay dry. Apply Xeroform, cover with border gauze every day shift, every 3 days for wound care. The medical record review did not reveal a wound care order for the resident's left lower extremity. Further review of the record revealed an electronic treatment administration record (eTAR), which showed that the treatment for the right lower leg had been signed off by nursing as though care had been provided as ordered on October 10, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 5 of 10 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 10/26/2023 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 0684 13, 19, and 22 (2023). Level of Harm - Minimal harm or potential for actual harm A review of the person-centered care plan for Resident #36 revealed: Focus (7/10/23) The resident has potential/actual impairment to skin integrity related to history cellulitis. Residents Affected - Few Goal: The resident will be free from injury through the review date. The resident will maintain or develop clean and intact skin by the review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Monitor/document location, size, and treatment of skin injury. Record abnormalities. In an interview with LPN A/Wound Care Nurse on 10/26/23 at 10:50 am, she was asked about Resident #36's lower extremity wounds. She stated, Yes, he bumped his right lower leg. It was about a month ago. His wife came and told me, and I observed a skin tear and the area was denuded. His left lower leg, when I went in to see him yesterday I saw someone had placed a dressing, but no one had told me about it, so I wasn't aware. It looks like a skin tear area. He has a history of Peripheral Vascular Disease (PVD) and edema, and he does get skin tears easily. He also has a history of vascular wounds, but those are all completely healed at this time. She was asked what the treatments for each lower leg wound were. She stated, Both wounds are cleansed with normal saline and Xeroform is applied and then covered with a border gauze. She was asked how often the dressings were changed. She stated, Every three days. She was asked who changed the dressings. She stated, I do if it falls on a weekday. If it falls on the weekend, the floor nurse assigned to the resident changes the dressings. She was asked why the dressing for the right lower extremity hadn't been changed from 10/18/23 until 10/25/23. She stated, I don't know. I think it was due to be changed on the weekend. The nurse must not have changed it. I changed it yesterday. She was asked if she knew why the treatment was signed off as having been completed on 10/22/23. She stated, No, I don't know why it was signed off if it wasn't completed. She was asked to confirm that the dressing on the resident's right lower extremity had not been changed as ordered for seven days. She stated, That's correct. She was asked to clarify whether the left lower extremity had any wound care due when she discovered the dressing on that area yesterday. She stated, No, he didn't have any wound care due for his left lower leg. I found the dressing dated 10/22 yesterday and no one had told me anything about it. I called the doctor and got an order. A review of the facility's policy titled Wound Care (revised 1/15/21) revealed: Standard: It will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds, and the treatment of skin impairment. Guidelines: 6. Wound care procedures and treatments should be performed according to physicians' orders. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 6 of 10 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 10/26/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for one (Resident #1) of 34 residents sampled. Resident #1's room was observed over a period of three days with several razors left lying on the resident's sink. This practice could result in injury to this resident or any other resident who entered this room and had access to the razors. The findings include: On 10/23/23 at 11:11 am, three disposable razors were observed in the bathroom belonging to Resident #1. The razors were positioned behind the water faucet on the sink. Two of the razors were covered by a clear plastic cap. The third was uncovered and appeared to have been used. (Photographic evidence obtained) A second observation of the razors was made on 10/24/23 at 3:46 pm. The razors remained in the same location in the resident's bathroom positioned behind the water faucet. A third observation of the razors was made on 10/25/23 at 10:17 am. The razors remained in the same location. The resident was present in the room outside of the bathroom. He was asked about the use of the razors. He stated the aides used the razors to shave him when he got his showers. He did not know who provided the razors or how long they had been there. A review of the medical record revealed that Resident #1 was admitted to the facility on [DATE]. His diagnoses included cerebral palsy, chronic obstructive pulmonary disease (COPD), hypertension, anxiety disorder, and major depressive disorder. A review of the quarterly minimum data set (MDS) assessment, dated 8/25/23, revealed that Resident #1 had a brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. He required supervision with locomotion on and off the unit and for eating. During an interview conducted on 10/25/2023 at 10:22 am with Licensed Practical Nurse (LPN) D, she stated sharps were not permitted in resident rooms. She stated they were stored in the nurses' bin. It was the responsibility of all staff to monitor the residents' rooms. She stated they did rounds daily and checked the residents' rooms. On 10/25/2023 at 10:39 am, a tour was conducted of Resident #1's room with LPN D. Three disposable razors remained positioned behind the water faucet on the sink in the resident's bathroom. Upon observing the razors, LPN D gathered all of the razors in her hand. She removed them from the resident's bathroom and exited the resident's room. She confirmed that the razors should not have been left in the resident's bathroom. During an interview conducted on 10/25/23 at 3:25 pm with the Assistant Director of Nursing (ADON), she stated there was a list of items not permitted in resident rooms. She stated the residents had to sign it and it was uploaded in the electronic medical system. She stated residents were discouraged from bringing the disposable razors, adding that they were provided by the facility. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 7 of 10 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 10/26/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the were kept in a box in the shower room, not in the residents' rooms. She stated the facility staff conducted rounds to check resident rooms for prohibited items i.e., razors. She stated the Guardian Angels and Department Heads went around and checked the resident rooms and their belongings, adding that they had to ask the residents first, but they check for anything that they might sneak in. She stated the rounds were conducted Monday through Friday during the morning shift, however, if they were unable to do it before the clinical meeting, they did it after the meeting. She stated a second round was performed during the afternoon. This was done because some of the residents' families would sneak things in. She stated the razors found in the bathroom of Resident #1 were brought in by a family member the previous day. She was advised that the razors had been present in the resident's bathroom for three days. She stated she had not been made aware of that information. She confirmed that the razors should not have remained in the resident's bathroom. A review of the facility's Items Not Allowed in the Residents' Rooms list revealed the following: Under Federal Law, these items are prohibited in residents' rooms and may present a hazard to the health of the residents. Included in the list of items not allowed were knives and shart objects. These items are prohibited in residents' rooms for the safety of your loved ones and our other residents. If management finds these items in a resident's room, they will be removed. You may retrieve these items when you discharge. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 8 of 10 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 10/26/2023 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 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff, resident and family interviews, medical record review, and facility policy review, the facility failed to ensure that one (Resident #36) of two residents reviewed who required respiratory care, from a total of 34 residents sampled, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan. Residents Affected - Few The findings include: On 10/23/23 at 12:30 pm, Resident #36 was observed sitting up in a wheelchair in his room, next to his bed, dressed in day clothes. He was receiving oxygen via a nasal cannula. The oxygen concentrator was set at 1 liter per minute (LPM). The resident requested to go back to bed. Two certified nursing assistants (CNAs) assisted the resident back to bed via a mechanical lift. One CNA was observed removing the resident's nasal cannula in order to complete the transfer. When she was finished, she asked the resident if he would like to have his oxygen back on. She stated, Do you want your oxygen back on? It's as needed, so it's up to you. The resident stated yes. The concentrator was set at 1 LPM after the CNA left the room. On 10/24/23 at 10:45 am, Resident #36 was observed lying in bed, awake. His nasal cannula was in place on his face. The oxygen concentrator was set at 1 LPM. (Photographic evidence obtained) On 10/24/23 at 3:15 pm, Resident #36 was observed lying in bed. His spouse was visiting. His oxygen flow rate was set at 1 LPM on the concentrator. (Photographic evidence obtained) His spouse was asked if she knew at what rate the resident's oxygen should be set. She stated, The last I knew, it was 2 LPM. I'm not sure. On 10/25/23 at 6:55 am, Resident #36 was observed lying in bed, awake. His oxygen cannula was observed on his bedside table. (Photographic evidence obtained) The oxygen concentrator was set at 1 LPM. (Photographic evidence obtained) He was asked why his nasal cannula was not on his face. He stated, I don't know, it's around here somewhere. On 10/25/23 at 10:25 am, Resident #36 was observed lying in bed, awake and watching TV. His oxygen concentrator was set at 4 LPM. The nasal cannula was in the resident's bed. On 10/25/23 at 10:27 am, Licensed Practical Nurse (LPN) B was asked if he was caring for Resident #36 today. He stated yes. He was asked what the resident's oxygen flow rate should be set at. He stated, I was told at report that it's 3 LPM. I haven't checked it yet today. He was asked what time he started his shift today. He stated 7:00 am. He was asked to observe the resident's oxygen flow rate. Upon entering the resident's room, he stated, It's up above 4 LPM. He was asked if the order was for continuous oxygen or oxygen as needed. He stated, I'm not sure. I need to go check the order. He returned and stated, I just checked. His order is continuous. He was asked if he had observed this morning that the resident was not using his oxygen. He stated, No, I'm just getting to this room. On 10/25/23 at 1:30 pm, Certified Nursing Assistant (CNA) C was asked if she was caring for Resident #36 today. She stated, No, but I have cared for him on other days and I do assist his assigned aide with him. She was asked what her role as a CNA was regarding his oxygen. She stated, Well the nurse monitors it. If I see he doesn't have it on, I'll let the nurse know. I will let the nurse know if anyone has their oxygen off, but as the CNA, I don't put it back on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 9 of 10 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 10/26/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She was asked if she was aware of what setting the residents' oxygen should be set on. She stated, No, not generally. I usually know my own residents' settings just from caring for them and knowing them, but I don't know the settings for all the residents on the floor. On 10/25/23 at 1:35 pm, Resident #36 was observed lying in bed with the head of the bed elevated and eating lunch. His wife was sitting next to him. He was observed not wearing his oxygen. He was asked why his oxygen was off. He stated, I take it off when I'm eating. His wife stated he did remove it while he was eating. He was asked if he was able to put it back on when he was finished eating. He stated, Sometimes I can. He was asked if staff assisted him with putting it back on. He stated, Sometimes they do, sometimes they don't. A review of Resident #36's medical record, revealed a physician's order dated 7/3/23, which stated: Oxygen at 3 liters/minute via nasal cannula with humidification. Further medical record review revealed a person-centered care plan which revealed: Focus (7/10/2023) The resident has altered respiratory status/difficulty breathing related to chronic obstructive pulmonary disease (COPD). Goals: The resident will have no complications related to shortness of breath through the review date. The resident will have no signs/symptoms of poor oxygen absorption through the review date. Interventions: Oxygen settings: Oxygen per MD orders. A review of the facility's policy titled Respiratory Care and Oxygen Administration (revised 1/15/21) revealed: Standard: It is the standard of this facility to provide guidelines for respiratory care and safe oxygen administration. Guidelines: 1. Verify there is a physician's order for oxygen use. Review the physician's order for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105468 If continuation sheet Page 10 of 10