Health inspection·July 13, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 07/10/23 at 3:12 PM, Resident #22 stated the CNAs can be very bossy and dictatorial, further explaining that one CNA stated to him, You will do it my way during a shower. Resident #22 further stated, The thing that bothers me the most is when I'm sitting out there (pointing to the common area), and I need and ask for help to the bathroom, and they just walk by and ignore me. Then I can't wait, and I have accidents. The spouse of Resident #22 stated the resident doesn't ask just one CNA to get help to the bathroom, but asks two or three and gets ignored, and then he will have an accident. Resident #22 confirmed he knows when he needs to go to the bathroom. During an interview on 07/13/23 at 3:05 PM, while explaining to the SSD about the voiced concerns of Resident #22, to determine if they had done a grievance of the concerns, the SSD stated Resident #22 never sits in the common area, and continued to tell the surveyor all she had done for the resident and the family, but would not speak to the dignity concern except, I got it. On 07/13/23 at 3:23 PM, four nursing staff, to include Staff G, Licensed Practical Nurse (LPN), were at the nurses' station. When asked if Resident #22 is up and about in his wheelchair, Staff G confirmed, explaining the resident self-propels throughout the unit several times during her shift, and that he also sits in the common area of the unit. The other three staff agreed. 3. Review of the record revealed Resident #41 was admitted to the facility on [DATE]. Resident #41 fell and fractured her ankle on 04/27/23. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS documented the resident had no behaviors and that she needed the extensive assist of one staff for toileting. Review of the quarterly MDS dated [DATE], which was prior to her fall, documented Resident #41 was independent for all care and was continent. During an interview on 07/10/23 at 11:26 AM, Resident #41 stated she fell and broke her ankle about four months ago, and ever since then staff won't take me to the bathroom because it takes too long. Resident #41 further stated, They ignore me when I ask to go to the bathroom, then they come back with a diaper, so I know I'm being diapered. Resident #41 stated that one of the staff told her, You are gonna have to go in your diaper. Resident #41 further stated, I have been waiting all morning to have my sheet fixed on my bed. I've asked three different staff and they just walk on. Resident #41 was observed at that time, sitting up in her bed with the head of the bed elevated. The bottom fitted sheet was halfway down the top half of bed, exposing the mattress. Resident #41 stated the attitude of the staff is nonchalant. When asked why they don't take her to the bathroom, Resident #41 stated, because it takes time, and they are lazy. During an interview on 07/12/23 at 4:19 PM, Staff H, CNA, confirmed Resident #41 was independent and continent prior to her ankle fracture, and remains continent if taken to the bathroom before her shower. During an interview on 07/13/23 at 3:08 PM, the SSD stated Resident #41 has been mad about her Medicaid pending status since August of last year, but had no comment about the concern related to dignity. 4. Review of the record revealed Resident #109 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented the resident had a BIMS score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS documented the resident did not exhibit any behaviors and that he needed the extensive to total assistance of one or two staff for all ADLs except eating and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 2 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 07/10/23 at 9:22 AM, Resident #109 explained that his normal routine in the facility was to get up out of bed mid to late afternoons and stay up for a while. Resident #109 stated many of the CNAs don't speak English, and they speak Haitian to each other in front of him, while providing care. When asked how he feels about that, Resident #109 stated, I don't like it. I don't want them speaking in another language in front of me. It's absolutely rude. And if you tell them, then they won't help you or they have attitudes. Resident #109 further stated in the afternoon or evening, he has seen all the staff sitting around the nurses' station playing solitaire games on the computers. The resident stated he has also watched the CNAs taking all the snacks and stuffing them into their backpacks, not leaving any for the residents. Resident #109 then volunteered that there was a resident with dementia on the unit near his room, who was constantly yelling out help me, help me over and over again. Instead of going over to the resident to console her, Resident #109 stated he heard staff just laughing at her and saying, yea yea . we are helping you. During an interview on 07/13/23 at 3:10 PM, when told of the voiced concerns, the SSD stated that Resident #109 doesn't get out of bed that often. On 07/13/23 at 3:15 PM, upon arrival to the unit were Resident #109 resided, the resident was not in his room. Upon further observation, the resident was in the therapy gym. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 3 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure baths and showers for 2 of 5 sampled residents were provided as per facility schedule and resident request, Resident #22 and #100. The findings included: 1. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE], documented the resident had a BIMS score of 10, on a 0 to 15 scale, indicating he had some cognitive impairment. This MDS documented the resident had no behaviors, and that he needed the total assistance of one person for bathing. This MDS also documented it was very important for the resident to choose between a bath and a shower. During an interview on 07/10/23 at 3:12 PM, Resident #22 and his wife were discussing their concerns with the slow or no response by staff, resulting in the resident having incontinent episodes. The resident's wife stated, They don't like giving showers. You have to beg for them. You always get the yes, yes, yes, but nothing happens. The wife further stated the previous weekend, (unsure of day but thought it was Sunday), she arrived to the facility at 11 AM, her husband was still in bed, and there was poop all over the bed. The wife stated the resident had told her he had the accident overnight. The resident's wife stated she asked staff to give the resident a shower, and they told her later, but it did not happen during her visit at the facility. Review of Certified Nursing Assistant's (CNA) [NAME] (plan of care) documented Resident #22 preferred showers twice weekly and was scheduled on the 7 AM to 3 PM shift each Tuesday, Saturday, and PRN (as needed). Review of the CNA documentation revealed showers were only provided on two occasions since his admission, on Thursday 06/15/23 and Friday 06/23/23. 2. Review of the record revealed Resident #100 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had not rejected any care, and needed the total assistance of one staff for bathing. Review of the CNA [NAME] documented the resident was scheduled a shower / bath on the 7 AM to 3 PM shift on Wednesday, Thursday, and PRN. Review of the CNA documentation revealed bathing was provided only on 06/17/23 and 07/05/23 during the past 30 days. During an interview on 07/10/23 at 1:55 PM, Resident #100 stated she had not been washed up in a week. When asked if she had been provided incontinence care, the resident stated she had but that was all. The room had a slight odor. During a subsequent interview on 07/11/23 at 9:35 AM, Resident #100 again stated she wanted to be washed up. When asked if she wanted a shower, Resident #100 stated she did not, but just wanted a full bed bath and bed linen change, as it had been over a week. Resident #100 again stated they just clean her private area, and nothing else. A slight odor was again noted in the room. On 07/11/23 at 3:26 PM, when asked if she received a bed bath today, Resident #100 stated, She told me I'd get one on Friday. When asked who said that to her, she did not know her name. Resident #100 was wearing the same [NAME] colored top that she had on earlier that day and the prior day. Resident #100 stated, I didn't want to ask anymore because I don't want to make trouble for myself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 4 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 07/11/23 at 3:27 PM, when asked if any of her residents refused a bed bath or shower today, Staff I, Licensed Practical Nurse (LPN) for Resident #100, stated that none of the residents refused bathing that day. During an interview on 07/11/23 at 3:33 PM, Staff P, evening LPN, stated the residents should get a bed bath and or shower daily, unless they refuse. On 07/11/23 at 4:06 PM, when asked how much assistance is needed to care for Resident #100, Staff N, CNA, stated the resident could help a little with turning, but was like a total (was totally dependent upon staff for care). When asked how Resident #100 was that day and if she refused anything, the CNA stated she was ok and did not refuse care. When asked if she provided Resident #100 with a full bed bath, Staff N stated she did not, because I told her tomorrow I would give her a full shower and change her bed. When asked the last time she gave Resident #100 a full bath, the CNA stated it was last Friday (07/07/23). During an interview on 07/12/23 at 1:26 PM, when asked if she got a bed bath today, Resident #100 stated, That girl you were just talking to (Staff Q, CNA, while at the doorway) just wiped off my chest. When asked if she received a full bed bath, the resident again stated she did not. On 07/12/23 at 2:06 PM, Staff Q, CNA, confirmed she just washed the top half of Resident #100, because that's what she asked for. The CNA stated the resident did not ask for a full bed bath. The CNA explained that on her shower days, if she refused a shower, she would get a full bed bath. (Of note, Wednesday 07/12/23 was a documented shower day for Resident #100). Staff I, LPN, joined the conversation and stated Resident #100 will voice when she wants care and often refuses it. The LPN stated she will often say come back later, and it will be passed on to the next shift. The LPN confirmed the CNAs should be documenting in the electronic record when a shower or bed bath was given. The LPN also looked in a new shower book, as the previous one was lost in the construction, and Resident #100 was not in the book as having received or refused a shower. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 5 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services to maintain a clean, comfortable and homelike environment for 3 of 5 units (Units 100, 200, and 500); and failed to maintain the residents' call lights to be accessible to the residents, for 4 of 53 sampled residents reviewed, Residents #64, #46, #4 and #85. The findings included: 1. Observations on 07/13/23 at approximately 1:00 PM, accompanied with the Director of Maintenance, revealed the following: In room [ROOM NUMBER], the room floors were dirty, the bed linens on the window-bed were stained, there was no toilet seat on the commode, there was an accumulation of trash on the floor, and the commode was not in proper working order. As reported by the residents, the toilet would 'fill up with water and then go down really slow'. In room [ROOM NUMBER], the privacy curtain between the beds was stained, there was an accumulation of residue and debris on the floor and the sink in the shared restroom was not secured to the wall. In room [ROOM NUMBER], it was noted that the corner of the over bed table was heavily taped. Resident #6, with a Brief Interview for Mental Status score of 15, stated that she had been trying to get a new one and that she talked to a woman about it (the resident was unable to recall who she talked to about the table). Resident #6 further stated that she put the tape on the tablet because the top was broken and she did not want to get 'cut'. In room [ROOM NUMBER], there was a large stain on the ceiling at the sprinkler over the privacy curtain of the door bed, indicative of the ceiling being previously wet, the floor at the air conditioning unit was damaged and there was an accumulation of residue on the floor at the air conditioning unit. In room [ROOM NUMBER], there was a strong odor of urine noted in the room, the shower stall in the shared bathroom was filled with bags of recyclable refuse and trash, the over-commode toilet seat was rusted, there was a substantial amount of clutter generated by the resident's personal items and food items, the door jamb at the entrance to the shared bathroom was damaged, and the floor was dirty. In room [ROOM NUMBER], the room floor was dirty, the door to the shared bathroom was damaged and the wall by the entrance to the bathroom was damaged, and there was an accumulation of debris and residue on the room floor. In room [ROOM NUMBER], the overbed table for the window-bed was damaged, exposing the particle board underneath the covering, there was an accumulation of residues and debris on the base of the over bed table and the air conditioning unit. In room [ROOM NUMBER], there was an accumulation of debris and residue on the floor and the sink in the shared restroom was not properly sealed to the wall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 6 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In room [ROOM NUMBER], the room entry door latch did not latch completely to secure the door closed. The surveyor was able to open the door without initiating the locking mechanism and with minimal force and effort. During an environmental tour, on 07/13/23 at approximately 1:07 PM, the Director of Maintenance acknowledged the findings. 2. a. On 07/10/23 at 09:02 AM Resident #64 who had difficulty communicating verbally was observed signaling towards the call light (requested it), the call light was observed on the floor, away from him. The surveyor picked it up and provided him the call light as requested. b. On 07/10/23 at 9:19 AM Resident #46 complained that she did not have the call light to call staff for assistance with her breakfast. She stated, I don't have a call light, I have to yell, I have to wait all the time. Resident #46 had only the right eye. She voiced she has problem eating her food because she couldn't see. Resident #46 kept yelling, help, help me, no call light. The call light was observed on the floor, not at the resident reach. The call light was located behind the head of the bed. c. On 07/10/23 at 9:27 AM Resident #4 was observed sitting at the edge of the bed, she was eating breakfast, she dropped the food tray on her, as she fell backward on the bed, she yelled help. When the surveyor asked her to press the call light to call the facility's staff for assistance, she voiced she was not able to reach the call light, evidently, the call light was noted on the floor away from Resident #4. The surveyor picked up the call light and assisted Resident #4. d. On 07/10/23 at 9:59 AM Resident #85 was observed lying in bed, the call light was away from the resident, it was located on the wheelchair, when asked how would he reach the staff if he needs them? He did not answer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 7 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure interdisciplinary team (IDT) participation in care planning process for 7 of 32 sampled residents, to include food and nutrition services, activities, and therapy, as applicable involving Residents #6, #22, #41, #106, #111, #5, and #8. The findings included: On 07/13/23 during the afternoon, Staff B, Minimum Data Set (MDS) Coordinator, provided requested evidence of interdisciplinary team (IDT) participation in the care planning process for numerous resident's in the survey sample, as the electronic medical record lacked current participation records. An overview of the provided Quality Resident Review Worksheet & Attendance Records, the forms utilized by the facility to document participation in the care planning process, revealed numerous blanks where the signatures of dietary, activities and therapy staff were to be recorded. The MDS Coordinator confirmed the Registered Dietician was only in the building once weekly, and also agreed someone from activities and therapy as indicated, should be part of the IDT and care planning process. 1. Review of the record revealed Resident #6 was admitted to the facility on [DATE], and was receiving long term care. The current MDS assessment was dated 07/03/23, with a subsequent Care Plan meeting on 07/06/23. Review of this attendance record lacked documented participation by food and nutrition services. Resident #6 was receiving dialysis services. This attendance record also lacked participation by activities staff. During an interview on 07/11/23 at 9:55 AM, Resident #6 voiced concerns with food choices and services, and this most recent care plan meeting lacked participation by food and nutrition services. 2. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. The current MDS assessment was dated 06/16/23, with a subsequent Care Plan meeting held on 06/27/23. Review of the attendance record lacked participation from the food and nutrition services. During an interview on 07/10/23 at 3:12 PM, Resident #22 voiced complaints about the quality of the facility food. 3. Review of the record revealed Resident #41 was admitted to the facility on [DATE]. Resident #41 had fallen and sustained an ankle fracture on 04/27/23, and was receiving therapy services. The current MDS was dated 05/12/23, with a subsequent change in condition care plan meeting held on 05/23/23. Review of the attendance record lacked participation from food and nutrition services and therapy. 4. Review of the record revealed Resident #106 was admitted to the facility on [DATE], and was currently receiving long term care. The current MDS was dated 06/02/22, with a subsequent care plan meeting on 06/27/23. The attendance record for this meeting lacked participation by the activity staff. 5. Review of the record revealed Resident #111 was admitted to the facility on [DATE]. Resident #111 had a significant weight loss as of 06/10/23. The most recent Care Plan meeting provided by Staff B, MDS Coordinator, was dated 07/05/23. This meeting documented participation by the resident's son and concerns about the resident's weight and oral intake. Food and nutrition services were not involved in this meeting. The provision of occupational therapy was observed during the survey, but therapy was not involved in the recent care plan meeting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 8 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6. Resident #5 was admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Type-2 Diabetes, Anemia, PVD, Hyperlipidemia, Malignant Neoplasm of Part of Right Bronchus or Lung, Heart Failure, Hypertension, Chronic Kidney Disease Stage 3, Muscle Weakness, History of Falling, Mood Disorder, Major Depressive Disorder, and Adjustment Disorder. Review of the Dietary Note on 07/11/23 noted weight changes of 11.3 % weight loss within 180 days. It was noted the resident has a history of edema and diuretic use, so weight changes can be expected. Review of the Care Plan Meeting with the Interdisciplinary Team held on 05/09/23 documents that the Team reviewed: Therapy Services and Activities for Resident #5, yet failed to have a representative from Therapy Services or Activities present during the Care Plan meeting. 7. Resident #8 was admitted to the facility on [DATE] with diagnoses that included Intervertebral Disc Degeneration, Thoracolumbar region, Chronic Kidney Disease Stage 4, Dementia, Anxiety, Cyst of Kidney, Hyperlipidemia, Obstructive and Reflux uropathy, Insomnia, Osteoarthritis, Muscle Weakness, Malignant Melanoma of skin, Depression, Constipation, and Diffuse Mastopathy of Breast. Review of the Care Plan Meeting with the Interdisciplinary Team held on 05/09/23 documented that the Team reviewed: Therapy Services and Dietary Orders for Resident #8, yet failed to have a representative from Therapy Services or Dietary present during the Care Plan meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 9 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the record revealed Resident #6 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the resident needed limiting assistance for personal hygiene and extensive assistance for incontinence care. This MDS lacked any documented behaviors. Residents Affected - Few During an interview on 07/11/23 at 9:53 AM, while speaking, observation revealed food was noted in the teeth and gum line of Resident #6. When asked if she was able to brush her teeth, Resident #6 stated she could not as her left hand shakes when she tries to brush her teeth, and she is left-handed. When asked if staff help her with oral care, Resident #6 stated, No, they just put the stuff in front of me and leave, so it just sits there. When asked how her teeth feel, Resident #6 said, Nasty. Long facial hair was also noted on the chin of Resident #6. When asked if it bothers her to have facial hair, she did not directly answer but stated, It was really long and sticking to my blanket before. During an interview on 07/13/23 at 1:41 PM, Staff I, Licensed Practical Nurse (LPN), for Resident #6, stated she was dependent upon staff for her grooming as she had tremors. On 07/13/23 at 2:31 PM, when asked if her teeth had been brushed today, Resident #6 opened her mouth and food particles were again observed. Resident #6 stated, They haven't brushed my teeth because they haven't been in here today. When asked if she had been changed or washed up today, the resident again confirmed she had not. Resident #6 put on her call light. The restorative aide answered the call light, Resident #6 requested that her adult brief be changed, and the aide went to get supplies. An observation of the assignment board at the nurses' station revealed Staff J, CNA, was assigned to care for Resident #6. During an interview on 07/13/23 at 2:35 PM, Staff J was asked what she had done for Resident #6 that day. Staff J stated, she's not on my assignment. Staff J explained she had the middle part of the hall, and that they (the CNAs) had divided the hall so that she had the middle 10 residents, ending on the room just before Resident #6. Staff J was told the assignment board had her name as CNA for Resident #6, and she again explained how they had divided up the hall that morning, and that Staff K, CNA, had Resident #6. During an interview on 07/13/23 at approximately 2:40 PM, Staff K, CNA for the back part of the hall, was asked what care she had provided to Resident #6 that day. Staff K stated, I didn't have Resident #6 today. Look at the assignment board. On 07/13/23 at 2:55 PM, Staff I, LPN, and the DON explained the night shift does the assignments and puts them up on the white board. When asked what happened this morning, Staff I, LPN, stated when she came in that morning the CNAs told her they had their assignments, front, middle, and back, and the LPN thought everything was fine. Staff I, LPN, stated she did not have any complaints from Resident #6 today when she passed medications, so she was unaware of any problems. On 07/13/23 at approximately 3:15 PM, Resident #6 was provided incontinence care by two CNAs. Resident #6 was wet and had had an incontinent bowel movement, but was not saturated as she does not void much, as she was receiving dialysis services. The buttock of Resident #6 was pink, but no open areas were noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 10 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Actual harm 3. Review of the record revealed Resident #16 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15, on a 0 to 15 score, indicating the resident was alert and oriented. This MDS also documented the resident needed the extensive assistance of one person for incontinence care. Residents Affected - Few Review of the current care plans completed on 06/22/23 documented Resident #16 was at risk for complications related to bowel and/or bladder incontinence. Interventions included to offer and assist with toileting tasks as needed, and to provide incontinence care with each incontinence episode, as tolerated. A second care plan documented Resident #16 had moisture associated skin damage (MASD) to the right and left buttocks. Interventions included to provide incontinence care promptly should any episodes of incontinence occur. Review of the weekly skin assessments documented the MASD was noted on 06/24/23. During an interview on 07/11/23 at 12:30 PM, Resident #16 stated, My bottom is really raw; I am not being changed or cleaned as much I should be. They are not putting any cream on me either. During a subsequent interview on 07/13/23 at 1:29 PM, when asked why her bottom hurts, Resident #16 stated, Because I'm laying in peepee. When asked if she could tell when she is wet, the resident confirmed she could. When asked if she uses the call light to ask to be changed when she is wet, Resident #16 confirmed she did, but further stated it can take from 2 to 4 hours to get changed. During an observation on 07/13/23 at 2:09 PM, the buttock of Resident #16 was noted with a large area of excoriation from moisture on both buttock. When asked how long she had the excoriation, Staff L, CNA who usually cared for Resident #16 on the 7 AM to 3 PM shift, stated, basically for a long time. When asked if the resident was dry when she arrived at 7 AM, the CNA stated, No! and further added, Or she will have on a dry brief, but the entire bed will be wet! What good is that. 4. Review of the record revealed Resident #106 was admitted to the facility on [DATE]. The current MDS dated [DATE] documented the resident had a BIMS score of 6, on a 0 to 15 scale, indicating the resident had some cognitive impairment, and needed the extensive assistance of one staff for personal hygiene. A progress note written by the Director of Rehab indicated she provided nail care while working with the resident's right-hand splint on 03/30/23. Review of the current care plan initiated on 11/02/22, and revised on 03/16/23 documented Resident #106 had an ADL self-care deficit and staff were to encourage and assist with all ADL tasks, including personal hygiene. During an observation on 07/10/23 at 10:40 AM, the fingernails to both hands of Resident #106 were noted to be long with a black substance under the nails. The left thumb nail was broken with a jagged corner. On 07/11/23 at 9:25 AM, the fingernails of Resident #106 remained long and dirty. On 07/13/23 at 3:03 PM, the Assistant Director of Nursing (ADON) was asked if the CNAs were allowed to clean and trim fingernail, and she confirmed that was part of their personal hygiene tasks. The ADON observed the resident's fingernails and agreed they needed to be cleaned and trimmed. The ADON was informed the resident's fingernails had been observed long and dirty since 07/10/23. 5. Review of the record revealed Resident #111 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented Resident #111 had a BIMS score of 3, on a 0 to 15 scale, indicating she was cognitively impaired. This MDS lacked any documented rejection of care, and revealed the resident needed the extensive assist of one person for personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 11 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Actual harm Residents Affected - Few Review of the current care plan initiated on 11/02/22, and revised on 03/17/23 documented Resident #106 had an ADL self-care deficit and staff were to encourage and assist with all ADL tasks, including personal hygiene. An observation on 07/10/23 at 10:57 AM revealed the fingernails of Resident #111 were excessively long with a black substance under the nails. On 07/11/23 at 9:44 AM, the resident's fingernails remained long and dirty. On 07/13/23 at 3:02 PM, Resident #111 was sitting in the common area. The ADON was asked to look at the resident's nails and was asked if they could be cleaned and trimmed, and she stated of course. Resident #111 stated she would let the staff clean and trim her nails and further stated, Oh yes, they need it. Based on observations, interviews and record reviews, the facility failed to provide ADL (Activities of Daily Living) care related to incontinence care, oral and personal hygiene, and personal grooming for 5 of 9 sampled residents, Residents #228, #6, #106, #16, #111. This failure in ADL assistance resulted in psychosocial harm for Resident #228. The findings included: 1. Review of clinical record revealed Resident #228 had been a previous resident who had been discharged home on [DATE] but had been re-admitted to the facility on [DATE] due to the inability to care for himself at home. Resident #228 had diagnoses that included: Idiopathic Peripheral Autonomic Neuropathy, Gastroesophageal Reflux Disease (GERD), Hypertensive Heart Disease without Heart Failure, Peripheral Vascular Disease, Hyperlipidemia, Type-2 Diabetes with Circulatory Complications, Absence of Right Leg above the Knee, Osteomyelitis, Muscle Weakness, and Dysphasia. The Discharge Minimum Data Set (MDS) assessment completed on 06/12/23 documented Resident #228 was assessed as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 of 15. The admission / readmission Nursing Evaluation Form completed on 07/08/23 documented the following: 'Functional status was unknown; uses wheelchair. Resident is alert and easily arousable, oriented to person, place, time and situation. Resident is able to communicate. Resident is to have upper and lower dentures, but they are missing (not provided by daughter) Resident is continent of bowel and bladder. Resident's safety awareness/cognition intact; Resident is impulsive, anxious/restless, and agitated. Resident needs assistance with toileting Urinal within reach (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 12 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Documented the resident is 'completely immobile: does not make even slight changes in body or extremity position without assistance.' Level of Harm - Actual harm Residents Affected - Few - Note: Resident observed independently sitting up on side of bed on 07/10/23 and 07/11/23. Also, independently self-propelling in wheelchair on 07/12/23 and 07/13/23 (see observations below). No Mental Health Concerns or Psychosocial Concerns noted. No Depression Screening Summary completed. Resident does not smoke. - Note: It was determined through the smoking evaluation review and resident interview, the resident is a smoker. Resident does have frequent pain. ADLs (Activities of Daily Living) require assistance, including toileting. Eating is documented as being dependent (total assistance) -Note: Based on observation and Nutritional Assessment effective 07/12/23, Resident is able to eat independently.' During initial observations on 07/10/23 at 9:26 AM, Resident #228 was sitting up on the side of his bed, dressed in a hospital gown. The resident was missing his right leg. His hair appeared a bit oily and unwashed. As soon as I introduced myself, Resident #228 stated, Please help me. Please! I have been treated terrible. I hate it here. It is a horrible place. They do nothing for me. They close the door at night and ignore me. They let me lay here in my pee and poop. I have no clothes. It makes me feel like I just want to kill myself. Can you just please give me my wheelchair, I can get myself out of bed if you will just move it over here close to my bed. Please, just give me my wheelchair so I can get up. Resident #228's wheelchair was located in the corner of the room, out of reach of the resident. When I told him I would notify the CNA that he wanted to get up, he stated, Please just get me my wheelchair. They won't do it. They don't do anything for me. I push my call light, but they don't come. I just want to die. An odor of feces was detected near the resident. It was noted that according to readmission assessment, Resident #228 was continent of bowel and bladder and should have a urinal within reach. The resident was to have assistance for toileting, not be placed in adult briefs and encouraged to go to the bathroom in these briefs / diapers. There was no urinal observed at bedside at this time. On 07/10/23 at approximately 9:35 AM, the Unit Manager, Staff R, was notified that the resident was requesting assistance with transfers and incontinence care. The Certified Nursing Assistant (CNA) stated she would assist the resident when she was finished with her current resident. On 07/10/23 at approximately 9:45 AM, the Unit Manger was observed entering Resident #228's room. On 07/10/23 at 1:00 PM, Resident #228 was observed in bed, dressed in hospital gown. His wheelchair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 13 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 was parked in the resident's bathroom. Once again, the resident stated that he gets no assistance from staff, and he just wanted to die because no human being should have to live like this. Level of Harm - Actual harm Residents Affected - Few On 07/10/23 at 4:30 PM, the Director of Nursing (DON) was made aware of the resident's observations and the DON admitted to his state of depression and hopelessness, and that the resident stated he felt like killing himself. She stated she was going to set up a tele-consult with a psychiatrist for the resident that evening. On 07/11/23 at 10:05 AM, Resident #228 was sitting on edge of his bed in his hospital gown. An odor of feces was again noted when approaching the resident. Resident #228 stated he needed help and wanted to get out of bed. He begged the surveyor to bring him his wheelchair. He stated, I can get out of bed myself, if I just had my wheelchair, please bring it to me. I told him I would check with the nurse to make sure he could transfer independently, and he responded, Please, please help me. They won't come. I have to sit here in my pee and poop because no one comes. I just want to die. They treat me like an animal, and I am not an animal. No one should have to live like this. On 07/11/23 at 10:10 AM, the Registered Nurse, Staff E, was asked if Resident #228 could transfer independently. She said she didn't think so but would check with the Unit Manager. She returned and stated that the Unit Manager said the resident needed assistance X 1 person for transfers. On 07/12/23 at 9:50 AM, Resident #228 was in his wheelchair coming out of the bathroom. The CNA was in his room changing the resident's bed. Resident #228 was dressed in a navy-blue sweatshirt and pull-on pants. He stated, The sores on my arm hurt. I don't know what they are from. I am not getting anything for it. They treat me like an animal here. No one cares. No one helps me. I just want to die. This isn't living. I just wish I knew how to end it. I haven't had a shower since I have been here. My hair is so dirty. The resident's hair appeared oily, as if it hasn't been washed recently. On 07/12/23 at 1:34 PM, Resident #228 was seen outside of his room. He again confirmed that he had not had a shower and would like one. he stated, My hair needs washed; there is dirt on my head. I just feel dirty. Why can't I just let me die. There is no reason to live anymore. No one needs me and no one cares about me. On 07/12/23 01:40 PM, the Unit Manager, Staff C, was informed that Resident #228 was requesting a shower for today. On 07/13/23 at 9:28 AM, Resident #228 was observed sitting in his wheelchair wearing the same clothes that he was wearing the previous day. He stated that he had received a shower, and he only had this one outfit. His daughter had not brought him any clothing or cigarettes. He stated again, My life is not worth living. My daughter just dumped me here and the staff don't care about me. I really don't want to be alive anymore. The Social Services Director walked by during this time and stopped and told the resident that she was going to try to contact his daughter again. Interview with CNA, Staff L on 07/13/23 at 2:09 PM confirmed that Staff L frequently finds residents soiled at the beginning of her shift. On 07/11/23 at 4:19 PM, Staff F, Licensed Practical Nurse (LPN) who was interviewed by another surveyor on the survey team, confirmed that she had heard from other nurses and CNAs that there have been times when only one CNA was on the unit, and she had followed when there has been just 1 CNA on the night shift. Staff F stated, The residents just get changed once overnight. The day CNAs are then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 14 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 'pissed' because they [the residents] are soaking wet and they have to change the whole bed . Some of the CNAs are saying they are too old, so I'm chasing them around making sure stuff gets done. Level of Harm - Actual harm Review of the Progress Notes and documentation showed the following: Residents Affected - Few 07/10/23 at 4:54 PM -Narrator informed by AHCA representative the resident expressed feelings of hopelessness - resident states r/t [related to] placement in a nursing home. Telemedicine done with the resident who verbalizes he has no plan but does not want to be isolated r/t not leaving the room (awaiting personal clothing from daughter who was contacted for his clothing). He is not at risk of harming himself after being interviewed by psych services. He has no plan. Clothing provided to the resident. Psych to follow up with the daughter. Emotional support provided. Primary nurse notified to provide additional support as needed r/t adjustment. Social services to reach out to the daughter. Review of the 07/10/23 at 5:02 PM Note documented: The ARNP [Advanced Registered Nurse Practitioner] was updated on the resident along with psych follow up and that the resident has no plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 15 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to initiate a new wound care physician order in a timely manner for 1 of 3 sampled residents reviewed for facility-acquired pressure ulcers, Resident #33. Residents Affected - Few The findings included: The policy, titled, Prevention of Pressure Ulcers/ Injuries and revised on 07/17, documented, in part: Review the interventions and strategies for effectiveness on an ongoing basis. Resident #33 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Type 2 diabetes, history of falls, Atrial Fibrillation, Tremors, Glaucoma, Hyperlipidemia, and muscle wasting with atrophy. The record documented the resident had a BIMS (Brief Interview for Mental Status) score of 3 of 15, which indicated severe cognitive impairment. On 07/10/23 at 11:53 AM, a telephone interview was conducted with the spouse of Resident #33 to review his care at the facility. She stated her husband has a pressure ulcer on his left heel and she was the one who identified it. She stated she was changing his socks when she noticed the pressure ulcer. She stated she was upset because she had taken her husband to the see the Podiatrist on 07/05/23 and the physician had updated the order, for his left heel pressure ulcer dressing change. The new orders included the dressing on the left heel was to be changed every day; with the previous orders that included the dressing change was for every other day. She stated when she returned, she had given the orders to Staff A, Licensed Practical Nurse, (LPN). The spouse of the resident stated she was at the facility on 07/09/23 and Resident #33's left heel dressing was dated 07/07/23. She stated she asked why the dressing wasn't being changed every day. She stated the facility had told her there were no orders for his dressing to be changed every day, just changed every other day. On 07/11/23 at 12:20 PM, an interview was conducted with the Wound Care Nurse. She stated the new orders had been given to Staff A, upon returning from the physician's office. The orders were subsequently given to the Staff C, the Unit Manager, to process. The dressing change orders were never entered into the computer system by Staff C. She stated she went to Staff C after the spouse of Resident #33 contacted the facility about the new orders. She stated Staff C had the paperwork folded up and she thought it was just to set up Resident #33's next transportation to the physician's office. An interview was conducted with Staff C, who stated Resident #33's paperwork from the physician's office was given to and she was told the paperwork was for her to set up the residents next physician appointment transportation. She stated it was just a miscommunication. The paperwork from the physician's office was reviewed. On page 1 of 4, at the top of the page documents: Order placed today, Wound Dressing Change. Page 2 of the documents contained the resident's medication list and on page 3 are the step-by-step instructions to follow for the current left heel wound dressing. The new orders were reviewed. The new orders included the dressing change was to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 16 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 done every day and stated, 'Do not skip dressing change'. 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: 105474 If continuation sheet Page 17 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the record revealed Resident #111 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented the resident had a BIMS score of 3, on a 0 to 15 scale, indicating she was cognitively impaired. This MDS lacked any documented rejection of care, and indicated the resident needed limited assistance with eating. Further review of the record revealed Resident #111 weighed 110.3 pounds on 05/11/23, and weighed 91.0 pounds on 06/10/23, which was a 17.5% weight loss in one month. This was the most current weight in the record. Residents Affected - Few Review of the current orders documented as of 07/05/23, staff were to complete weekly weights for four weeks, then monthly weights. A progress note on 07/06/23 documented the resident refused to be weighed. An order dated 06/21/23 documented the addition of fortified foods with meals. A progress note by the Registered Dietician dated 06/29/23 documented Resident #111 was being reviewed for significant weight loss, with the recommendation for weekly weights to track trends. A progress note dated 07/05/23, documented during a care plan meeting, noted that the resident's son was concerned about his mother's weight. An observation of the lunch meal on 07/12/23 at 1:25 PM, lacked any fortified foods, which were either mashed potatoes or pudding, as per the kitchen staff. (Photographic Evidence Obtained). Observation of the dinner meal on 07/12/23 at 5:59 PM, lacked gravy on the mashed potatoes, as per documentation on the menu ticket. (Photographic Evidence Obtained). The resident was being fed by a staff member who confirmed the lack of gravy. During an interview on 07/13/23 at 1:06 PM, the Registered Dietician (RD) was asked when and how she identified the weight loss of Resident #111. Upon review of her notes, the RD originally stated on 06/22/23, she heard about it and implemented fortified foods and supplements. The RD explained she is at the facility every Monday, and reviews the 'weight exception report' in the electronic record. The RD was questioned about the gap between the 06/10/23 weight of 91.0 pounds and the implementation of fortified foods on 06/22/23. The RD found an email to the Director of Nursing (DON) and Assistant DON (ADON) dated 06/12/23 that confirmed she had increased the Med Pass protein supplement from 120 ml (milliliters) daily to 240 ml daily, requested large protein portions for meals, and a different scale was used for the resident's weight. This email also requested weekly weights for a month, which were not implemented by the facility. The RD was asked if she could obtain a current weight on the resident, and provide it to the surveyor. As of the exit conference, no weight had been provided. 2. Resident #123 was admitted to the facility on [DATE]. The resident's diagnosis included metabolic encephalopathy, Dementia, urinary tract infection, aphasia, adult failure to thrive, hyperlipidemia, hypothyroidism, pain, nutritional deficiency, anxiety disorder, acute cystitis, alcohol abuse, other psychoactive substance abuse, constipation, and depression. In review of the record, the resident was weighed on 04/25/23 and her weight was 119.8 pounds. On 06/12/23, the resident was weighed, and her weight was 108.6, indicating a 9.36 % (percent) weight loss in less than 2 months. The resident was admitted with an order for weekly weights for 4 weeks. The weekly weights were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 18 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 completed and only 2 weights were documented in the chart: the 04/25/23 weight and the 06/12/23 weight. Level of Harm - Minimal harm or potential for actual harm On 06/16/23, the dietician wrote in her notes that the weekly weights after admission were not completed. Residents Affected - Few On 07/13/23 at 9:30 AM, an interview was conducted with Staff D, Restorative CNA, who is responsible for weighing and documenting the residents' weights. She was asked about the weights for Resident #123. She stated she had just turned them into the MDS employee to place in the resident's record. On 07/13/23 at 9:45 AM, Staff B, MDS nurse, looked at the weights for the resident and stated she only has 2 recorded during her stay and the new record indicated she refused her being weighed on 07/11/23. Based on observation, interview and record review, the facility failed to follow physician dietary orders and recommendations for obtaining weights for 3 of 5 sampled residents reviewed for nutrition, Residents #120, #111 and #123, that resulted in significant weight loss for Residents #111 and #123. The findings included: The facility's policy, titled, 'Weight Assessment and Intervention', revised September 2022, documented, in part: Weight Assessment 1. The nursing staff will measure resident weight on admission. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Any weight change of 5% or more since the last weight assessment will be retaken as soon as practical usually within the next day for confirmation. If the weight is verified, nursing will communicate with the Dietitian. 3. The Dietitian will review the Weight Record to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 4. The threshold for significant unplanned and undesired weight loss will be used on the following criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100]. 5. If the weight change is desirable, this will be documented and no change in the care plan will be necessary. 1. Resident #120 was admitted on [DATE]. Review of the Medicare 5-day Minimum Data Set (MDS), dated [DATE], revealed Resident #120 had a Brief Interview for Mental Status (BIMS) score of 11 or 15, indicating that the resident had moderate cognitive impairment. The MDS documented Resident #120 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 19 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few independent for eating with no swallowing disorders and no dental concerns. Resident #120's diagnoses at the time of the assessment included: CAD (Coronary Artery Disease), Orthostatic Hypotension, Diabetes Mellitus (T2DM), Atrial Fibrillation (a-fib), syncope and collapse, Chronic Pancreatitis, and Dependence on renal dialysis (ESRD), Review of the care plan initiated on 06/12/23 and most recently updated on 07/03/23, revealed The resident is at risk for alteration nutrition / hydration r/t [related to] Fx [fracture] of orbital wall, chronic pancreatitis, syncope, chronic a-fib, hypotension, ESRD, CAD, T2DM, and per MNA [Monthly Nutrition Assessment] at risk for malnutrition. The goals of the care plan included: * No sig [significant] wt [weight] changes through NRD [next review date] - Resident will consume adequate meals / fluid from all sources to meet estimated needs through the review date - improve skin integrity. with a target date of 10/10/23. * The resident will tolerate current diet order through next review - with a target date of 10/10/23. Interventions to the care plan included: *Administer medications as ordered * Encourage and assist resident to be OOB as tolerated * Encourage and assist resident to eat in dining room as tolerated * Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. * Labs/diagnostics as ordered. Report to MD/IDT as indicated. * Provide, serve diet as ordered. Monitor intake and record q meal. * RD to evaluate and make diet change recommendations PRN. Resident #120's physician orders included: Weight weekly x 4 then monthly - 06/09/23. On 06/19/23, the resident weighed 168.2 lbs. On 06/30/23, the resident weighed 160.6 pounds which was a -4.52 % Loss. There were no weights documented in the resident's record after 06/30/23. During an interview, on 07/13/23 at 8:41 AM with the Assistant Director of Nursing (ADON), when asked about the resident's weight loss, the ADON replied, I did notice that he had some edema, I am not sure if that was a wet weight or a dry weight previously and I am not sure how much fluid they took off of him. I put in the dialysis weight. I would investigate it - check for possibility of fluid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 20 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shift, check on PO [oral] intake, I would check to see what was going on with the skin or if there are any new wounds. I have requested to have him re-weighed. During an interview, on 07/13/23 at 11:00 AM with the Dietitian, when asked about Resident #120's weights being monitored, the Dietitian replied, I had sent an email to request readmission weights multiple times for the resident. the reply was asking Staff B (MDS coordinator) if she would get the weights completed by Restorative. I replied that I called the dialysis center to get the dry weight on him. During an interview, on 07/13/23 at 11:08 AM, with Staff B, MDS Coordinator, when asked about Resident #120's weight being monitored, Staff B replied, 160.6 was the last weight that I have on him and that was a dry weight from dialysis. They just dumped the weights and restorative on me last week. The problem is that the Restorative CNA [Certified Nursing Assistant] is on the floor as a CNA most days. Today is the first day since I don't know when that she is not on the floor as a CNA. None of the lists that they have given to me are for SSU [500 unit] patients. During an interview, on 07/13/23 at 11:27 AM, with Staff D, Restorative CNA, when asked about Resident #120's weights being taken, Staff D replied, I have been here 3 months. I weighed him last Friday and gave it to Staff B. Because he is on dialysis, they don't do his weight as much. I know that I weighed him last week, his daughter was here, and she helped me get him in the chair. I do the weights and I give Staff B the paper and she puts it in. I usually do restorative as they are short most of the time, I am on the floor as a CNA. I do the splints, weights - those are what I do right now. When asked about any other restorative staff, Staff D replied, No, it is just me; most of the time, I am not getting the weights done on time - I am supposed to get them in by the 5th of the month, but there is no way, because I am always on the floor. The Therapy Director always helps with splints and braces when I am on the floor. After I do my rounds, I try to fit that in my schedule; we are always short. Staff D provided documentation of the resident's weight being 190 pounds on 07/03/23, with is a 30-pound weight gain, that had not been documented in the resident's record. At the conclusion of the interview, the surveyor requested that the resident be weighed. On 07/13/23 at 12:47 PM, the resident weighed 161 pounds which is a 30-pound loss from the previous weight. During an interview, on 07/13/23 at 3:17 PM with the DON, when asked about the restorative program, the DON stated that there were 2 restorative aides, Staff D is the main restorative aide and does the weights, another CNA indirectly assists with that. Corporate placed Restorative under the MDS, at the time we had 3 MDS Coordinators, it was assigned to them because it is a nursing and functional maintenance program. The care plans would be driven from a nurse, so it just made sense. When asked about Staff B being trained to oversee the Restorative program, the DON replied, Corporate training - they did online via Zoom, prior to that, she had been given the restorative booklet. The Therapy Director offered additional training and trains the restorative aides. Saff B should be overseeing it, and the other MDS Coordinator should be assisting. She asked for additional training, and they set up a Zoom and she never brought it up after that. During an interview, on 07/13/23 at 3:32 PM, with the Rehabilitation Director, when asked about staff B being trained to oversee the Restorative program, the Rehabilitation Director replied, she wanted more training than I could give her and felt that the corporate nurse should be training her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 21 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Basically, to be able to see if she could complete ROM [range of motion] she knew how to use the gait belt, but she was uncomfortable with using a walker, she wouldn't look at the paperwork for competencies for the ROM and the things that she would be evaluated for. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 22 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 record review and interview, the facility failed to respond to 1 of 1 sampled residents reviewed for vocalization of significant pain which resulted in harm, Resident #36. Residents Affected - Few The findings included: The facility policy, titled, Pain Assessment and Management, documents in part: 2) Pain management is defined as the process for alleviating the resident's pain to a level that is acceptable to the resident and is based on his or clinical condition and established treatment goals. 3)d address the underlying cause of the pain Resident #36 was admitted to the facility on [DATE] with documented diagnosis to include Dementia, unspecified severity with other behavioral disturbance, history of falling, Osteoarthritis, personal history of Covid 19, and Dysphagia. The resident had a BIMS (Brief Interview for Mental Status) score of 3 of 15, which indicates severe cognitive impairment. Record review of the nursing progress notes for Resident #36 documented on 03/10/23 at 1:03 PM that the resident 'has been in bed all day, was cued at mealtime to eat; cried and yelled in pain every time she was moved; X-rays were ordered and Will continue to monitor.' On 03/10/23, an x-ray was ordered for right lower extremities, right hip, bilateral shoulders, thoracic and lumbar spines. On 03/13/23 at 4:01 PM, the nursing progress notes documented the resident 'stayed in bed again today. Will continue to monitor.' On 03/13/23 at 5:13 PM, the progress notes documented, 'Difficulties with turning and positioning related to pain and discomfort.' An x-ray was completed on 03/13/23 at 7:45 PM. The findings of the x-ray indicated a right hip fracture. On 03/14/23 at 1:10 AM, an order was obtained to transfer the resident to the ER (Emergency Room) for evaluation of right hip fracture. On 03/14/23 at 5:59 AM, Resident #36 was transferred to the hospital and admitted . The Medication Administration Record (MAR) for the month of 03/2023 was reviewed. There was no pain medication documented as administered to the resident for pain on 03/10/23 or 03/13/23. On the pain monitoring tool, the day shift and the evening shift of 03/10/23 indicated the resident's pain level was an 8 out of 10. The resident's pain was also documented in the progress notes of 03/13/23, however, on the pain monitoring tool, zero was written in the record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 23 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/12/23 at approximately 3:00 PM, the Director Of Nursing (DON) was asked about Resident #36 and inquired if resident had an incident or a fall on 03/10/23. She stated she would check on it since she had not been employed at the facility during the time the resident had been discharged to the hospital. In an interview with the DON on 07/13/23 at 9:15 AM, she stated she was unable to locate any incident or any fall on the resident for 03/10/23. It was discussed with her the delay of the resident having her x-ray done 3 days after the order was obtained and lack of pain management from 03/10/23 until 03/14/23 when the resident was transferred to the hospital. During a record review on 07/13/23 at 4:00PM with Staff C, Minimum Date Set (MDS) nurse, she reviewed the record concerning the Resident #36 fracture. She had documentation the fracture was due to her bone disease. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 24 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure care and services for 1 of 1 sample resident receiving dialysis, as evidenced by a lack of consistent documentation of coordination between the nursing and dialysis facility; failure to ensure documented pre and post weights to monitor for fluid overload; and failure to inform the physician and/or family of the resident's refusal of dialysis services, Resident #6. Residents Affected - Few The findings included: Review of the record revealed Resident #6 was admitted to the facility on [DATE]. Resident #6 received dialysis services from an outside facility every Monday, Wednesday, and Friday. Dialysis treatment records were noted as part of the record to ensure communication between the two facilities. Review of the record lacked any communication documentation from the dialysis facility for the month of June 2023, and only included one note dated 07/10/23 for the month of July 2023. On 07/12/23 at 1:30 PM, Staff R, Unit Manager, explained the documented communication between the two facilities included a form filled out by the nursing home nurses to include vitals and weights, and the treatment record from the dialysis center. The Unit Manager agreed to the lack of consistent documented communication between the two facilities. Further review of the record revealed a physician order dated 04/10/23 to notify both the physician and family if the resident refuses to go to dialysis. A progress note dated 05/19/23 documented the resident refused to go to dialysis. This note lacked any notification to the physician or family. A second progress note dated 06/30/23 by Staff I, Licensed Practical Nurse (LPN), documented the resident's refusal of dialysis. This note documented notification to the physician, but lacked any notification to the family. During an interview on 07/12/23 at 1:41 PM, when asked the process should Resident #6 refuse to go to dialysis, Staff I stated she would text the physician's assistant (PA) and write a progress note. When asked if she was aware of the physician order to also notify the family, the LPN stated she was not. The physician order of 04/10/23 also documented pre and post dialysis weights must be entered. Review of the current care plan initiated on 03/06/23 documented Resident #6 was at risk for fluid overload with an intervention to monitor for weight changes. Review of the weight record in the electronic record and on the communication forms lacked consistent weights. The communication sheets dated 06/21/23 and 07/12/23 lacked any documented weights. Review of the weight record revealed only 19 of the 32 possible pre and post dialysis weights between the dates of 06/01/23 and 07/07/23, were documented. During the continued interview on 07/13/23 at 1:41 PM, when asked about weights for Resident #6, Staff I, LPN, explained the Certified Nursing Assistants (CNAs) weight Resident #6 with the Hoyer lift, when they get her up and ready for transport. The LPN stated, if there is a CNA who is not familiar with the resident, they may forget to do the weight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 25 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure sufficient staffing to ensure care and services to meet the needs of bathing and showering for 2 of 5 sampled residents (Resident #22 and #100); to provide incontinence care, oral and personal hygiene, and grooming for 5 of 32 sampled residents (Residents #6, #16, #106, #111, and #228); and to follow dietary recommendations and orders for obtaining weights for 3 of 5 sampled residents (Residents #111, #120, and #123). Interviews from random residents, families, and staff revealed voiced concerns of a lack of staff. Review of current residents with skin impairments revealed 7 of 9 current pressure injuries were facility acquired (Residents #33, #72, #51, #20, #64, #10, and #76). The facility utilized managers to supplement Certified Nursing Assistant (CNA) assignments on 2 of 13 days reviewed. The findings included: 1. Residents #22 and #100 voiced concerns with a lack of staff and indicated they were not being provided baths and showers as per facility scheduling or per their request. Refer to F561 for details. 2. Resident #228 was admitted to the facility on [DATE], complained of a lack of assistance to include a lack of incontinence care, and was not assisted out of bed until 07/12/23. The resident voiced concerns of distraught and wanting to kill himself. Resident #16 developed Moisture Associated Skin Damage (MASD) to both sides of her buttock due to a lack of timely and consistent incontinence care. Staff failed to assist Resident #6 with oral care and incontinence care as needed. Staff failed to keep the fingernails of Residents #106 and #111 clean and trimmed. Refer to F677 for details. 3. Residents #111 and #123 both had significant weight losses, and staff failed to obtain weekly weights as per Registered Dietician recommendation. Staff failed to obtain weekly weights for newly admitted Resident #120. Refer to F692 for details. 4. The following residents, families, and staff interviews were obtained by the survey team, that included voiced concerns of a lack of sufficient staff: During an interview on 07/10/23 at 9:19 AM, Resident #46 stated there was not enough staff to help with needs. When asked what makes her think that, the resident explained she has a problem eating her food because she can't see, and when she asked the staff for help they don't help. During an interview on 07/10/23 at 10:23 AM, Resident #70 stated there were very few people on the night shift, and she had to wait two hours one night for staff to answer her call light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 26 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Actual harm Residents Affected - Few During an interview on 07/10/23 at 10:36 AM, Resident #35 stated, You'll press the button, nobody comes. Sometimes I waited 2 hours. I press the call light for my roommate, because he couldn't reach his, and they didn't come. There's not enough staff. You don't get them when you want them. During an interview on 07/10/23 at 10:39 AM, Resident #51 stated, They take a long time to get here. I've waited 20 minutes for staff to answer call lights. During an interview on 07/10/23 at 11:03 AM, Resident #54 stated, It takes a long time when you push the bell. There's not enough of people here. I guess people just quit or get fired. I've had to wait half an hour or more for staff to answer call light. During an interview on 07/10/23 at 11:04 AM, Resident #21 stated it can take up to 45 minutes to get help around here. Stated she only calls when she needs to be changed. The resident stated sometimes the light will be on for that long; other times they come in and turn the light off and say they will get help, and never come back, so she has to put it back on again. During an interview on 07/10/23 at 11:26 AM, Resident #41 stated, They won't take me to the bathroom because it takes too long. They ignore me when I ask to go to the bathroom. They come back with a diaper, so I know I'm being diapered. They don't have the help. Sometimes it's just one aide and one nurse for our unit. I've been waiting all morning to have my sheet fixed. I've asked three different staff and they just walk on. An observation at that time revealed the fitted sheet was halfway down the top half of her bed. During a phone interview on 07/10/23 at 11:49 AM, the spouse of Resident #33 stated, They don't have enough staff during the weekends. The spouse stated she was always helping feed residents who reside on the [NAME] unit at lunch time as they never have enough help. The spouse stated they allow her to feed other residents. On 07/11/23 at 12:00 PM, the spouse of Resident #33 came into the conference room to introduce herself, and confirmed she was always assisting other residents on the [NAME] unit at mealtime. During an observation on 07/11/23 at 12:06 PM, the spouse of Resident #33 assisted two residents by pushing their wheelchairs up to the table in the dining room. The spouse stated, Today they have enough help, so everyone is being fed that I usually help feed. Later the spouse of Resident #33 peeked her head into the conference room and stated, You all need to be here every day so they would have enough help. During an interview on 07/10/23 at 1:53 PM, Resident #100 stated, It takes two or three hours to get changed when I have a BM [bowel movement]. They don't have enough staff. They always blame me for everything. The private companion stated, They work these girls to death, but there are not enough staff to keep them [residents] clean and dry timely. If there is a call out, they will have just one CNA for the entire hall. During an interview on 07/11/23 at 9:02 AM, Resident #87 stated the facility does not have enough staff. When asked what makes her think that, the resident explained when she needs to urinate, she will put the call light on and it can take up to a half hour for staff to answer the light. Resident #87 stated she has had accidents because of the lack of response and added, I am concern about that because I feel helpless, real helpless. During an interview on 07/11/23 at 9:20 AM, Resident #232 stated she was admitted on [DATE]. The resident explained the other night she had her call light on for over two hours waiting for her medication and to get help to the bathroom. The resident stated she ended up urinating in her brief. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 27 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Actual harm Residents Affected - Few During an interview on 07/11/23 at 9:29 AM, Resident #230 stated, There just isn't enough staffing. I know everywhere is experiencing the same issue. The ones that are here are great and do the best they can, but it results in long wait times when you need assistance. The daughter of Resident #39 voiced to two different surveyors during the survey, that when there was a call-out, they only have one CNA on the hall. The daughter stated her mother had a facility acquired pressure ulcer, that had since healed. The daughter stated she hired a private aide, and between the two of them they ensure her mother was taken care of. The daughter stated they don't have enough staff and have to pull from other halls for a few hours to help cover shifts. During an interview on 07/11/23 at 3:10 PM, Staff S, CNA, stated she usually works the [NAME] Unit, that has the capacity of 28 residents. The CNA stated there are usually just two CNAs working on that unit, but there has been just one on the weekends sometimes. The CNA stated when she is by herself or with just one other CNA, not everyone gets their scheduled shower. During an interview on 07/11/23 at 3:37 PM, Staff M, CNA stated he usually works the 11 PM to 7 AM shift on the [NAME] Unit. When asked if he had ever worked the unit as the only CNA, Staff M stated he had, with just one nurse, who may or may not help. The CNA stated it happened more often, before they were in their survey window. When asked what happens when he is the only CNA, Staff M stated he just has to speed through everything. When asked what he can't get done when there is only one aide on the unit, the CNA stated the residents who are supposed to get up before he leaves at 7 AM, he can usually get them cleaned up and dressed, but can't get them up out of bed, especially if they are a Hoyer lift, which needs two persons. At the time of the survey, one of five residents on the 11 PM - 7 AM Get Up list was a two person assist, Resident #74. During an interview on 07/11/23 at 4:19 PM, Staff F, Licensed Practical Nurse (LPN), stated she is part time, floats throughout the building and usually works the 7 AM to 3 PM shift. When asked if she had ever worked a unit with just one CNA, the LPN stated she had not, but had heard other nurses had. The LPN stated she has followed a shift when there was just one CNA on the unit during the previous shift. The LPN stated when that happens, my CNAs are pissed because the residents are soaking wet and then her CNAs have to change the whole bed. The LPN also stated the residents who are to be up early are not. The LPN stated it had not happened in a few weeks for her, but it has happened more than just once in a while. On 07/12/23 at 1:36 PM an interview was held with Staff O, CNA, who had been working at the facility for 21 years. The CNA complained of insufficient staffing, and stated, There's not enough staff and that affect the residents care really bad. When asked her to explain how the lack of staffing affects resident's care, Staff O stated, Because if I am feeding one resident, and two or three other residents are yelling and need help, I can't get to all of them. Staff O added she had worked the [NAME] Unit by herself, mostly on Sundays. During a supplemental interview on 07/12/23 at 2:59 PM, Staff O, CNA, stated this past Sunday (07/09/23) she was on the [NAME] unit as the only CNA. Staff O stated her coworker who was a CNA assigned to the [NAME] Unit came over to help her turn and clean the residents. When shown the Daily Staffing Assignment for 07/09/23, when asked whose name was listed with her name for the [NAME] Unit, Staff O stated, I might get fired for saying this, but I believe she is the weekend supervisor. When asked if the weekend supervisor worked the front half of the hall as assigned, Staff O stated, No, ma'am, I had the whole hall and a CNA, who had her own assignment on the [NAME] Unit, came and helped me when I needed a second person. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 28 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Actual harm Residents Affected - Few 3. On 07/12/23, the facility was asked to provide a list of all current residents with skin impairments. On 07/13/23 at approximately 3:30 PM, upon review of the provided list, the Wound Care Nurse confirmed there were currently seven residents with facility-acquired pressure injuries, including sampled Residents #10 and #33, along with additional Residents #72, #51, #20, #64, and #76. Upon further review of the provided list, the Wound Care Nurse stated Resident #229 had a facility acquired pressure injury that had healed during the survey week. The Wound Care Nurse also confirmed that Resident #39, who currently was listed on the list as having a blister to the top of her foot, had a facility acquired pressure injury to her buttock recently, that has since healed. 4. Review of the staffing assignments from 06/28/23 through 07/10/23, revealed management had CNA assignments on 2 of the 13 days reviewed. On 07/09/23, the Weekend Supervisor was listed as a CNA for the [NAME] Unit on the 7 AM to 3 PM shift. On 07/10/23, Staff R, Unit Manager, was listed as a CNA for the [NAME] Unit on the 7 AM to 3 PM shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 29 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to follow physician orders for 2 of 2 sampled residents with physician ordered fluid restrictions, Residents #22 and 120. The findings included: The facility's policy, titled, 'Fluid Restrictions' documented, in part: Policy Interpretation and Implementation 1). When a physician prescribes a fluid restriction, a communication form notifying the Fod and Nutrition Services department will be completed. 2). If the resident is receiving liquid nourishments for nutritional support. 3). If no clarification of liquid nourishment provided is obtained the liquid nourishment shall be included in the total fluids administered. 4). Water pitchers will be removed from the resident's room. Beverage preferences will be obtained by Food and Nutrition Services designee if possible and reflected on the resident's meal ticket/tray card. 5). Jell-O, ice cream, soup and anything at room temperature that becomes liquid, will be calculated and included in the diet as a fluid. Nursing & Food and Nutrition Services designee will explain fluid restrictions to resident. 6). Food and Nutrition Services will include on the Meal ticket/tray card utilized for the resident's meal, the total fluid restriction (in the diet field) and the total number of ccs administered with the meal (in the beverage field). 7). Nursing Services will maintain documentation of fluids accepted with meals, and with medications. Medications may be administered with applesauce or pudding (with an appropriate physician order) to [NAME] fluids utilized/offered with medications to later offer in absence of medications 8). Compliance or failure to follow physician orders shall be documented I the medical record as deemed necessary and communicated tot eh physician in a timely manner. 9). The fluid restriction will be reflected on the plan of care established for the resident and updated as necessary to retain validity. 1. record review revealed Resident #22 was admitted to the facility on [DATE]. According to an admission / Medicare 5-day Minimum Data Set (MDS) assessment, dated 06/16/23, Resident #22 had a Brief Interview for Mental Status (BIMS) score of 10 of 15, indicating the resident was moderately cognitively impaired. The MDS documented that Resident #22 required 'limited assistance' and 'one person physical assist for eating. The assessment documented the resident had swallowing disorders that included: coughing or choking during meals or when swallowing medications and the resident was edentulous. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 30 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Resident #22's diet physician orders included: Level of Harm - Minimal harm or potential for actual harm NAS (No Added Salt) CCHO (Carbohydrate Controlled) Renal diet, Regular texture, Nectar / mildly thick consistency - 07/09/23. Residents Affected - Few Fluid Restriction 1200 cc Dietary will provide 720 cc on tray with meals, Nursing will provide 480cc as follows: 7-3 may give 240cc, 3-11 may give 120cc, 11-7 may give 120cc - 06/13/23. During an observation of breakfast being served to the residents in their rooms, on 07/13/23 at 8:05 AM, Resident #22 was served breakfast that consisted of: hard boiled eggs, intact sausage patties, 4 ounces of thickened apple juice, 4 ounces of thickened milk, toast, crispy cereal in milk, and brown sugar to put on the cereal. It was also noted that the resident had a 20-ounce foam cup of water on his over bed table. The tray ticket that accompanied the meal documented: 8oz Fluid Restriction / Breakfast Standing orders: 4 fl oz Cran Apple Juice-Nectar 8 fl oz Milk Whole-Nectar 8 fl oz Water-Nectar Thick. During an interview, on 07/13/23 at 9:05 AM, with the Assistant Director of Nursing (ADON), when the observation was brought to her attention, the ADON stated, his wife wants him to be on thin liquids; he is a dialysis patient and has fluid restrictions, however, the wife chooses not to comply with the fluid restrictions. 2. Resident #120 was admitted to the facility on [DATE]. According to a Medicare 5-Day MDS, Resident #120 had a BIMS score of 11 of 15, indicating that the resident was moderately cognitively impaired. The assessment documented that Resident #120 was independent for eating. Resident #120's diagnoses at the time of the assessment included: Coronary Artery Disese (CAD), Orthostatic Hypotension, Diabetes Mellitus (DM), Atrial fibrillation, syncope and collapse, Chronic pancreatitis, and dependence on renal dialysis. The MDS documented that the resident had no swallowing disorders and no dental concerns. Resident #120's physician orders included: Fluid Restriction 1200 cc Dietary will provide 720 cc on tray with meals, Nursing will provide 480 cc as follows: 7AM-3PM may give 240 cc, 3PM-11PM may give 120 cc, 11PM-7AM may give 120 cc every day shift and encourage resident to comply with Physician prescribed order. During an observation of breakfast being served to the residents in their rooms, on 07/13/23 at 8:10 AM, Resident #120 was served 2 fried eggs, toast, cereal in milk, 4-ounces of orange juice and an 8-ounce carton of milk and coffee. The resident was noted to also have an 11-ounce container of a protein supplement on his night stand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 31 of 32 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 105474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vero Beach Care Center 1310 37th St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 The tray ticket that accompanied the meal documented: Level of Harm - Minimal harm or potential for actual harm 8oz Fluid restriction Standing orders: Residents Affected - Few 8 fl oz Milk Skim During an interview with Resident #120, on 07/13/23 at 8:32 AM, the resident stated, I'm not even supposed to have coffee, but every once in a while, I cheat. Resident stated that he was 'somewhat aware' of fluid restrictions. My daughter brings them in for me. I try to drink at least once a day. (Referring to the 11-ounce carton of protein supplement). During an interview, on 07/13/23 at 8:41 AM, with the ADON, when asked about Resident #120 being given fluids, the ADON replied, when he came in he was under a different Nephrologist, He did not want to adhere to the fluid restrictions, so the family preferred to go with a different nephrologist's order for fluid restrictions. They called his cardiologist, because he was always hypotensive and would not participate in therapy. They wanted to lift the fluid restrictions to allow him to have more fluids. The doctor said that because he is a dialysis patient, he has to adhere to the fluid restrictions and did not lift the restrictions. When the ADON was asked about education provided to the residents regarding the risk of being noncompliant with the fluid restrictions for Residents #22 and #120, staff were unable to provide documentation. During an interview, on 07/13/23 at 9:57 AM, with the Registered Dietitian and the Food Service Director when asked about the beverages provided to Residents #22 and #120, the Food Service Director replied, We only put the milk on the tray and the CNAs serve the coffee and juices from the cart when the residents request it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105474 If continuation sheet Page 32 of 32