Inspection visit

Health inspectionAugust 22, 2024

SEABRANCH HEALTH AND REHABILITATION CENTERCMS #1055095 citations on this visit

5 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, interview and record review, the facility failed to respond to a verbal grievance regarding delivery of food for 1 of 1 voiced grievance, affecting Resident #49. The findings included: Review of the Policy, titled, Resident and Family Grievances, dated 03/2023, indicated, in part, it is the facility policy to support each resident's and family members right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay. Grievances may be voiced in the following forums: verbal complaint to a staff member or grievance official. Written complaint to a staff member or grievance official. Written complaint to an outside party. Verbal complaint during resident or family council meetings. Via the company toll free customer service line. The staff member receiving the grievance will record the nature and specifies of the grievance on the designated grievance form or assist the resident or family member to complete the form. Take immediate actions needed to prevent further potential violations of any resident right. Forward the grievance form to the grievance official as soon as practicable. The grievance official will take steps to resolve the grievances, and record information about the grievance, and those actions, on the grievance form. Record review revealed Resident #49 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included Cancer and Depression. Resident #49 resides in the 100 halls at the [NAME] wing. Review of the annual Minimum Data Set (MDS) assessment, reference date 07/14/24, recorded a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #49 was cognitively intact. This MDS recorded no mood or behavior concern. The care plan had a revision date of 07/25/24 with revision still in progress. This care plan revealed Resident #49 was at risk for malnutrition related to cervix cancer. On 08/19/24 at 10:46 AM, an interview was conducted with Resident #49, who stated that she has been complaining about people spitting in her food to the staff, her food was always sent on the 300-food cart/hall, and when she received her food, she found spit in it. She stated she has asked the facility many times why they were letting her food go to the 300-food cart (at the East wing). She further stated, if she was a Caucasian person complaining, the facility would have fixed the problem immediately. She added one time she received her tray, and her eggs looked like somebody started eating it. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 105509 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 105509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabranch Health and Rehabilitation Center 4801 SE Cove Rd Stuart, FL 34997 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/22/24 at 8:35 AM, a subsequent interview was held with Resident #49, who reiterated again people keep spitting in her food, she had asked the facility to stop sending her tray to the 300 cart and stated if she was a Caucasian person this would have been straighten out. On 08/22/24 at 8:37 AM, an interview was held with the attending nurse, Staff C, and he stated you know what it is with her tray, not all the trays can fit in the 100 food cart, so several trays goes to the 300 carts including Resident #49's tray, some of the residents don't mind it, but she doesn't like it, she has told the facility about it three times. On 08/22/24 at 12:51 PM, an interview was held with Staff H, Social Service Director and Staff I, Social Service Assistance, regarding grievances relating to Resident #49's food/tray concerns. They revealed the only grievance they had for Resident #49 was regarding her previous roommate and TV being too noisy in February 2024. They denied having grievances relating to food/tray concern. When the surveyor inquired about the concern with people spitting in Resident #49's food, Staff H and Staff I voiced they had no knowledge about those concerns. On 08/22/24 at 1:09 PM, an interview was held with Staff J, Food Service Manager (FSM), and the Registered Dietician (RD). Staff J confirmed Resident #49's tray goes to the 300-hall food cart (at the East wing). Staff J stated, Resident #49 has been complaining to her that people spit in her food. During the interview, the surveyor informed Staff J, Resident #49 thought people were spiting in her food because the tray goes to the 300 halls, and she doesn't want that. Staff J then revealed that Resident #49's tray goes on the last food cart at the 300-hall. Staff J stated, that's not a problem; she can send the tray on the 2nd food cart at the 100 halls. Staff J revealed she did not start a grievance process for Resident #49. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105509 If continuation sheet Page 2 of 9 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 105509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabranch Health and Rehabilitation Center 4801 SE Cove Rd Stuart, FL 34997 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, interview, and record review, the facility failed to ensure restorative services were provided for 1 of 1 sampled resident, Resident #92. Residents Affected - Few The findings included: Review of the policy, titled, Restorative Nursing Programs, implemented on 11/03/20, documented, in part, Policy Explanation and Compliance Guidelines: . 10. A resident's Restorative Nursing Plan will include: . c. Frequency of activities d. Duration of activities . 12. Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting in the electronic medical record and/or on a Restorative Documentation Form. Review of record revealed Resident #92 was admitted to the facility 04/21/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #92 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS also documented the resident did not receive any restorative therapy services during the 7-day look back period. Review of the Therapy Referral to Restorative Nursing Program (RNP) or Functional Maintenance Program (FMP) Form dated 05/13/24, included the service of Active Range of Motion (AROM) with the frequency of services to be once a day. Review of the current order dated 05/13/24 specified the RNP was to provide AROM services. This order lacked any frequency and or duration. During an interview on 08/19/24 at 10:41 AM, when asked if he was able to walk, Resident #92 stated he was unable to and had only walked a few times while in the facility; he has not received physical therapy and feels weak. Review of Restorative Aide documentation in the electronic medical record revealed services for AROM were not provided to Resident #92 for 30 days during a 30 day look back period. During an interview on 08/22/24 at 12:13 PM, when asked how often restorative services were being provided and where it was documented, Staff E, Restorative Certified Nursing Assistant (R-CNA) stated, I have not been doing it because I am being pulled to other areas including working the floor, working the dining room, and going to doctor appointments. Staff D, Licensed Practical Nurse (LPN), covering for the Director of the RNP, stated she had only seen the resident once last week and he refused. Staff D was not able to locate documentation of the resident's refusal of services. An interview was conducted on 08/22/24 at 1:15 PM with the Staffing Coordinator. The Staffing Coordinator, when asked how often they pulled Staff E to other areas of the facility, stated it had not been often nor within the last month that Staff E was pulled to other areas. The Staffing Coordinator stated, this only happens if there were needs urgent for the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105509 If continuation sheet Page 3 of 9 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 105509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabranch Health and Rehabilitation Center 4801 SE Cove Rd Stuart, FL 34997 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, interview and record review, the facility failed to ensure proper care and services during bathing, peri and catheter care, for 1 of 2 sampled residents with Urinary Tract Infection (UTI), affecting Resident #55. The findings included: Review of the policy, titled, Hand Hygiene, dated 05/21/22, indicated staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applied to staff working in all locations within the facility. Hand hygiene technique when using soap and water: wet hand with water. Avoid using hot water to prevent drying of skin. Apply to hands the amount of soap recommended by the manufacturer. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Rinse hands with water. Dry thoroughly with single-use towel. Use clean towel to turn off faucet. Record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Neurogenic bladder. The Minimum Data Set (MDS) assessment, reference date 06/15/24, recorded a Brief Interview for Mental Status score of 07, which indicated Resident #55 was moderately cognitively impaired. This MDS revealed no mood or behavior concern. Review of physician orders, dated 08/12/24, revealed an order for urinalysis, culture, and sensitivity. It revealed the results were reported on 08/14/24, and was positive for UTI. Another physician order, dated 08/15/24, revealed an order for Ceftriaxone Inject 1 gram intramuscularly one time a day for 5 days for UTI. Review of physician progress note dated 08/14/2024 written at 5:26 PM documented Resident #55 was positive for UTI. On 08/19/24 at 10:08 AM, an observation was conducted on Resident #55. The resident was observed lying in bed, listening to a religious program in her native language. The catheter bag was observed to be directly on the floor with yellow urine in it. When asked her how the bag was on the floor, the resident (in her native language) said, when the staff had emptied the catheter bag this morning, they must have placed it to the floor. The resident denied placing the bag to the floor. On 08/22/24 at 9:24 AM, during the observation of the bed bath, peri and catheter care process, which was rendered by Staff B, Certified Nursing Assistance (CNA), revealed that after Staff B washed Resident #55's body, she did not remove her soiled gloves. Subsequently, she applied new gloves on top of the gloves she had on (she had doubled the gloves on each hand), and began to provide peri care and catheter care. At 9:27 AM, Staff B removed her gloves applied new gloves without hand hygiene in between gloves changes. At 9:33 AM, Staff B removed her gloves then washed her hands quickly (for about 6 seconds), she then opened the drawers, picked up a comb that was on the floor then applied new gloves without further hand hygiene. At 9:36 AM, Staff B went to the bathroom and put more water in the basin. She then applied another set of gloves on top of the gloves she already had on, (doubled the gloves on each hand) and continued the care. At 9:39 AM, Staff B removed one set of the gloves from the doubled gloves and continued the care, drying Resident #55 buttocks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105509 If continuation sheet Page 4 of 9 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 105509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabranch Health and Rehabilitation Center 4801 SE Cove Rd Stuart, FL 34997 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm On 08/22/24 at 10:31 AM, an interview was held with the Infection Control Preventionist (ICP). She was made aware of the findings observed during bathing, and peri care and catheter care. She was made aware of the manner in which the care was provided. The ICP agreed with findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105509 If continuation sheet Page 5 of 9 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 105509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabranch Health and Rehabilitation Center 4801 SE Cove Rd Stuart, FL 34997 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, observation, and interview, the facility failed to ensure respiratory services for oxygen use and maintenance was completed for 1 of 1 sampled resident, Resident #28. Residents Affected - Few The findings included: Review of the policy, titled, Oxygen Administration, reviewed and revised on 05/04/22, documented, in part, Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician . 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: . b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. c. Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Review of the record revealed Resident #28 was admitted to the facility on [DATE]. Review of the active orders revealed as of 08/19/24, staff were to change the oxygen tubing, with new label and date, weekly during the night shift on Thursdays. Another order, dated 08/19/24, documented staff were to change the humidification bottle as needed. A third order, dated 08/20/24, revealed Resident #28 was to receive: Oxygen at 2 liters/min (minute) via [specify delivery system] Nasal Cannula, Face Mask, Trach Collar. Humidification: Yes, every shift for Shortness of Breath. Review of the discontinued and completed orders revealed Resident #28 had been on oxygen previously as well, although the previous orders were discontinued as of 08/12/24. An observation on 08/19/24 at 3:24 PM, revealed Resident #28 in bed with the Oxygen running at 2.5 liters/minute via a nasal cannula. The oxygen tubing was dated 08/11/24. There was a partially used, with an opened connector, bottle of sterile water dated 07/26/24 inside of a plastic bag hanging on the concentrator, but not hooked up to the oxygen concentrator. The sterile water was used for humidity. Photographic Evidence Obtained. Additional observations on 08/20/24 at 10:52 AM and 08/21/24 at 10:08 AM revealed the resident with the Oxygen running at 2 liters/minute, utilizing the same tubing and lack of humidity. Photographic Evidence Obtained. During an interview on 08/22/24 at 11:18 AM, when asked how often the oxygen tubing was changed, Staff F, Registered Nurse (RN), stated most of the time it's changed about every three days or so because the residents drop the tubing on the floor and then it would be dirty. When asked how often the tubing is changed if not dropped on the floor or contaminated, the RN stated she thought the protocol was every five days. When asked who was responsible for the routine changing of the oxygen tubing, Staff F stated, Most of the time it's on the morning shift. During the continued interview, when asked about the Oxygen use for Resident #28, Staff F, RN, stated the Hospice provider was in that morning and said it was OK to use the Oxygen as needed, and that it was not humidified. The RN explained that she gave the resident a break from the oxygen use this morning as she was pulling it off and the resident's oxygen saturation was fine without the oxygen. Upon entering the room, Resident #28 was wearing the Oxygen with the tubing that was still dated 08/11/24 and the sterile water dated 07/26/24 was now being used as humidity. Photographic Evidence Obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105509 If continuation sheet Page 6 of 9 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 105509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabranch Health and Rehabilitation Center 4801 SE Cove Rd Stuart, FL 34997 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview and side-by-side review of the record and photographs, the Director of Nursing (DON) explained the Oxygen had been discontinued previously and agreed the tubing should have been changed. The DON stated the Oxygen order was incorrect and needed to be written clearly as to the provision being either continuous or PRN (as needed). When shown the Oxygen Administration policy, the DON agreed to the contradictory instructions regarding the humidity, and was unsure when it was to be changed as per the policy, but thought their process was to change it when empty. Event ID: Facility ID: 105509 If continuation sheet Page 7 of 9 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 105509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabranch Health and Rehabilitation Center 4801 SE Cove Rd Stuart, FL 34997 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, observation, and interview, the facility failed to maintain an infection control program to help prevent the spread of communicable diseases and infections for 1 of 2 sampled residents currently on droplet precautions for the Sars-CoV-2, the virus that causes COVID-19 (Resident #309), and for 1 of 3 sampled residents on Enhanced Barrier Precautions (EBP) (Resident #55). Residents Affected - Few The findings included: Review of the policy, titled, COVID-19 Standards and Guidelines, issued 01/15/24, documented, in part, PPE (Personal Protective Equipment)/Hand Hygiene: COVID UNIT - If the facility has an active COVID Unit, then facility staff and visitors on the unit should wear full PPE including N95 mask and eye wear. Residents are encouraged to wear N95 source control. Transmission Based Precautions will be implemented and signage instructing the appropriate use of PPEs will be posted outside the resident's door. Review of the current CDC (Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented, The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency. Personal Protective Equipment [PPE]: HCP (healthcare personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. Review of the policy, titled, Enhanced Barrier Precautions, issued 04/01/24, documented, in part, Implementation of Enhanced Barrier Precautions: . b. PPE (Personal Protective Equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room . 3. High-contact resident care activities include: . g. Device care or use: central lines, urinary catheters . 1. Review of the record revealed Resident #309 was admitted to the facility on [DATE]. Review of the active order dated 08/14/24 documented Resident #309 was to be isolated with Droplet Precautions due to COVID-19. On 08/21/24 at 5:31 PM, Staff G, Physical Therapy Assistant (PTA), was observed standing outside of Resident #309's room, donning PPE to enter the room. Staff G was wearing a general use surgical mask, donned a gown, gloves, and a face shield, and enter the room. A Droplet Precaution sign was noted on the door (Photographic Evidence Obtained). The PTA remained in the room until 5:45 PM. Upon leaving the room, the PTA kept the same general use surgical mask on, that he had used while in the resident's room. Staff G went back to the therapy area at the end of that hall. On 08/21/24 at approximately 6:10 PM, the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were noted in the [NAME] Unit hallway, where Resident #309 resided. The managerial staff confirmed Resident #309 was on Droplet Precautions for COVID-19 and that an N95 mask was to be worn while in the room and disposed of upon exiting the room. The managers noted the empty box of N95 masks on top of the PPE storage bin outside of the room. The mangers were made aware of the surveyor's observation of Staff G, as noted above. The managers were also made aware their sign for the isolation did not indicate which type of mask was to be used (as per their policy). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105509 If continuation sheet Page 8 of 9 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 105509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabranch Health and Rehabilitation Center 4801 SE Cove Rd Stuart, FL 34997 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/22/24 at 11:10 AM, the Infection Control Preventionist (ICP) was informed of the observation of Staff G, from the previous evening. The ICP stated she had heard, and that Staff G had been reeducated. The ICP agreed the N95 mask should have been used while in the room of Resident #309. On 08/22/24 at 11:50 AM, Staff G, PTA,, came to the surveyor and stated he was sorry he did not wear the N95. When asked what he did after taking care of Resident #309 last evening, the PTA stated he went back to the office for a minute and then went to provide therapy to other residents. When asked if he changed his mask after leaving the COVID positive room, he stated probably not. 2. On 08/19/24 at 11:29 AM, Staff A, Certified Nursing Assistant / CNA, was in the process of passing trays to the residents on the 100 unit (West wing). At 11:34 AM, Staff A went into a droplet precaution room (COVID+) without gown, or gloves, with regular surgical mask. Subsequently, Staff A came out of the droplet precaution room and continued to go to other residents' rooms to pass trays without changing her mask. On 09/22/24 at 12:16 PM, an interview was held with the ICP, who was made aware of the observed infection control concern. 3. Record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: Neurogenic Bladder. The Minimum Data Set (MDS) assessment, reference date 06/15/24, recorded a Brief Interview for Mental Status score of 07, which indicated Resident #55 was moderately cognitively impaired. This MDS revealed no mood or behavior concern. The record revealed there was a physician order dated 08/08/24 for catheter size 16 FR and 10CC. Another physician order dated 08/08/24 ordered for Enhanced Barrier Precautions. Review of care plan dated 06/25/24 recorded Resident #55 has a Foley catheter due to Neurogenic Bladder. Interventions included: Enhanced barrier precautions in place. On 08/22/24 at 9:08 AM, during observation of bed bath, peri/and catheter care, rendered by Staff B, Certified Nursing Assistant (CNA), she provided direct care to Resident #55 without wearing a gown. At 9:42 AM, an inquiry was made regarding the Enhance Barrier Precaution (EBP) sign, that was above Resident #55's bed, Staff B said Resident #55 was on precaution. She stated one have to wash their hands when working with her, and wear gloves. Subsequently, Staff B began to read the sign and realized she needed to wear a gown. She further stated, she should have known better, because they've always had to wear a gown during care for her. On 08/22/24 at 10:31 AM, an interview was conducted with the Infection Control Preventionist (ICP) who was made aware of the observed infection control findings relating to lack of proper PPE use during direct care of Resident #55. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105509 If continuation sheet Page 9 of 9

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

5 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0676GeneralS&S Dpotential for harm
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0585GeneralS&S Dpotential for harm
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.

FAQ · About this visit

Common questions about this visit

What happened during the August 22, 2024 survey of SEABRANCH HEALTH AND REHABILITATION CENTER?

This was a inspection survey of SEABRANCH HEALTH AND REHABILITATION CENTER on August 22, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SEABRANCH HEALTH AND REHABILITATION CENTER on August 22, 2024?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·August 22, 2024