Inspection·March 19, 2021

F 0610 Respond appropriately to all alleged violations. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to initiate an investigation for injury of unknown origin after a diagnosis of left tibial fracture was identified in the hospital for 1 of 3 residents reviewed for abuse/neglect of a total sample of 45 residents, (#71). Residents Affected - Few Findings: Resident #71 was admitted to the facility on [DATE] and readmitted from an acute care hospital on 2/3/21 with new diagnoses including unspecified fracture of upper end of left tibia, subsequent encounter for closed fracture with routine healing, urinary tract infection, muscle weakness, lack of coordination and left knee pain. Her prior diagnoses included dementia, polyarthritis and history of falls. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] (pre-hospitalization) indicated resident #71 had a Brief Interview for Mental Status (BIMS) of 11 that indicated moderate cognitive impairment. She was assessed to require supervision for bed mobility, transfers, walking in room and corridor, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing. Resident #71 was not steady but able to stabilize without staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet and surface to surface transfers (transfer between bed, chair or wheelchair). She required 1 person assist with toilet use and required set up or supervision for all other activities. Review of a nursing progress note dated 1/29/21 at 11:32 PM, read, Patient was leaning heavily to one side in wheelchair and verbally not making sense. Two CNAs (Certified Nursing Assistant) brought to my attention that she gets up and goes around the building. I assessed the patient while in bed and patient could not answer questions correctly. Another nurse confirmed that this was not her normal and that I should send her out for further evaluation. I obtained vital signs which were within normal range. I contacted the right persons and family. Daughter stated she would not be able to go visit her in the hospital but wanted to be updated on her status .Emergency unit arrived and they assessed patient who they stated the patient was answering back correctly and vital signs were stable for them .transported patient to .medical system (hospital). Review of the hospital Emergency Department (ED) record dated 1/29/21 read, presents to .ED with c/o (complaints of) left knee pain and swelling x 1 day. Patient is poor historian and d/t (due to) dementia her cognition kind of waxes and wanes .Patient denies falling/trauma to the left lower extremity .CT (computed tomography)of left knee with acute mildly comminuted fracture through intercondylar eminence and medial tibial plateau .received .IV (intravenous) Dilaudid (narcotic pain medication) .knee immobilizer. The hospital record revealed that resident #71 was admitted on [DATE] and the history and physical read, Assessment and Plan: Pleasant 86 yo (year old) F (female) who presents with the following, acute comminuted fracture, intercondylar eminence and medial tibial plateau, acute microcytic anemia, UTI (urinary tract infection) and elevated D-Dimer (indicates may be blot clot). Plan .keep immobilizer, .PT/OT (physical and occupational therapy) with instructions for no weight bearing on left leg . Review of the facility nursing progress note dated 1/30/21 at 9:31 AM read, Pt (patient) was sent to hospital at approx. 2230 (11:30 PM) last night. Daughter called the facility trying to find out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105530 If continuation sheet Page 2 of 12 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 105530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Healthcare and Rehabilitation Center 1550 Jess Parrish CT Titusville, FL 32796 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 0610 why she was sent and if she was being admitted . This writer spoke with . ED, pt is being admitted for UTI, anemia, elevated D-Dimer and left knee fracture. Daughter notified. Level of Harm - Actual harm Residents Affected - Few A review of the facility abuse and incident logs did not show that an investigation for injury of unknown origin had been initiated until brought to the Executive Directors/Abuse Coordinator attention by surveyor on 3/19/21, 7 weeks after the facility became aware of resident's left knee fracture. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Policies and Procedures with revision date of 11/28/17 read, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment .The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish disciplinary policy, which results in the fair and timely treatment of occurrence of resident abuse .Neglect .Failure to take precautionary measures to protect the health and safety of the resident .Training .Employee Obligation .Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect .including injuries of unknown source .Is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours .Preliminary Investigation .An incident report shall be filed by the individual in charge who received the report .Investigation: The abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of alleged abuse .Reporting/Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse .including injuries of unknown source .to a resident, is obligated to report such information immediately .Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely .a full investigation in order to obtain a clear picture of what actually happened . On 3/15/21 at 11:15 AM, resident #71 was observed lying in bed. She was oriented to person and place and was complaining of pain. She pressed the call light and the Activities Director (AD) came into the room and said she thought the resident's nurse had given her something earlier for pain and she would let the nurse know the resident was still in pain. On 3/15/21 at 11:40 AM, Licensed Practical Nurse (LPN) B said he had given resident #71 Tramadol approximately 30 minutes ago and that he had just checked on her and she was still in pain. He said he planned to call the physician if the medication was still not effective after 60 minutes. Resident #71 was ordered Tylenol pre-hospitalization and Tramadol was initiated after she returned to the facility post hospitalization. Tramadol is an oral medication that is used to help relieve ongoing moderate to moderately severe pain. Tramadol is similar to opioid (narcotic) analgesics. It works in the brain to change how your body feels and responds to pain. (www.rxlist.com) Review of the resident's Medication Administration Records (MAR) from January 2021 to present date 3/19/21 noted that prior to hospitalization, 1/29/21 the resident had not required any pain medication. Upon return from the hospital on 2/3/21 she had been given Tramadol 7 times. On 3/19/21 at 10 AM, the Regional Registered Nurse (RN) stated, It was the perfect storm and we missed doing an abuse investigation for resident #71 regarding hospitalization and new fracture of left knee. She said the MDS coordinator reviewed the medical record when the resident returned to the facility from the hospital, spoke to staff and no one reported a fall. She added their normal process (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105530 If continuation sheet Page 3 of 12 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 105530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Healthcare and Rehabilitation Center 1550 Jess Parrish CT Titusville, FL 32796 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 0610 regarding resident with an injury of unknown origin was to initiate an investigation right away and complete an immediate report to the Agency for Healthcare Administration. She acknowledged this was not done. Level of Harm - Actual harm Residents Affected - Few On 3/19/21 at 10:30 AM, the MDS coordinator said after the resident returned to the facility post hospitalization, she received therapy for pain/swelling of the left knee and decreased mobility. Prior to her going out to the ER (emergency room) on 1/29/21, the nursing staff thought she had a stroke as she did not have any pain. It surprised us when we found out she was having pain in the ER. The MDS coordinator said she spoke with the floor nurse who sent her out to hospital on 1/29/21 and found out that by the time the EMTs (Emergency Medical Technician) arrived at the facility, the resident was making more sense talking to them. The MDS coordinator said they discussed resident #71 at the morning meeting on 2/5/21 after she came back from the hospital (2/3/21) and could not remember the name of the staff person who reviewed her hospital record. They said she had a fracture to her left knee. We reviewed her chart and questioned if she fell and she had not. The MDS coordinator verified resident #71 had a new fracture. The MDS coordinator said there was no discussion at the meeting regarding initiating an allegation for an injury of unknown origin. She said she assumed an investigation was already done by the Director of Clinical Services (DCS). The MDS Coordinator verified no one asked her to interview the staff on the resident's unit. She said she asked the staff if resident #71 had any falls so that she could complete the significant change MDS assessment dated [DATE]. She verbalized the MDS assessment was initiated as the resident had a new fracture and she needed to complete the assessment which addressed falls. She noted she spoke to staff on 2/5/21 but did not document the names of the nurse or Certified Nursing Assistant (CNA) who were on duty as she was not conducting an investigation. She did not recall if the DCS was present at the morning meeting along with the Case Manager and other managers. The MDS Coordinator validated resident #71 had a significant change in her condition as a result of the new fracture. She said the resident had declined functionally in her Activities of Daily Living (ADL). She acknowledged prior to hospitalization, the resident was able to transfer herself from the bed to the wheelchair with stand by assistance of staff. Post hospitalization she required staff to provide weight bearing assistance. If resident #71 had a fall she would not be able to get up on her own. She said she assumed the DCS did an investigation as this was a fracture of unknown origin which should always be investigated. She then stated, next time I may have to prod people to do their job. Review of the significant change in status MDS assessment dated [DATE] (post-hospitalization), indicated the resident's BIMS was now 10 indicating moderate cognitive impairment. She previously required supervision only but now required 1 person extensive assistance for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. Resident #71 was now totally dependent with bathing, was not steady and only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet and surface to surface transfers (transfer between bed and chair or wheelchair). On 3/19/21 at 11:24 AM, the Case Manager (CM) said she was present at the morning meeting on 2/5/21. She could not recall if they signed in for the meetings at that time or who the DCS was. She remembered she attended the morning meeting on 2/4/21 and was led to believe the resident's fracture was of an indeterminate age and was not acute. She said an acute fracture or injury of unknown origin would be investigated by the Administrator and DCS. She said if she knew the resident had an acute fracture, she would have reported to the DCS and an investigation would have been initiated by her. The CM said she knew resident #71 well as she saw her daily during room rounds. She noted the resident was alert with confusion and may not have remembered if she had fallen. If she had fallen, she would not have been able to get back up. The resident was able to get around independently with her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105530 If continuation sheet Page 4 of 12 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 105530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Healthcare and Rehabilitation Center 1550 Jess Parrish CT Titusville, FL 32796 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 0610 wheelchair prehospitalization. The CM acknowledged that if the investigation was done timely, it would have been more accurate as some of the staff that worked in January 2021 no longer worked at the facility. Level of Harm - Actual harm Residents Affected - Few On 3/19/21 at 12 PM, resident #71 self-propelled in wheelchair in her room. She was talkative and pleasant. She said she was in the hospital due to her knee. She could not recall how her left knee was fractured and added she had to wear an elastic type brace when she came back to the facility. She could not remember if she had any falls. On 3/19/21 at 12:08 PM, a telephone interview was conducted with resident #71's daughter. She said that she and her sister had questions about their mother's fractured knee. The daughter went on to say their mother had dementia and could not tell them what happened. She noted the first week after the fracture, the facility said they did not know anything about it. The facility just said she was complaining of her knee hurting and had a UTI. The daughter said her mother did not try to get out of her chair on her own and had concerns she may have fallen. She added the facility had a lot of staff turnover and used agency staff. She said if the staff were rough, her mother would not report it because she felt, the less said the better. On 3/19/21 at 12:58 PM, LPN A acknowledged she was the nurse who spoke with resident #71's daughter by phone the morning of 1/30/21. She noted the resident had been transferred to the hospital the night before. She said the daughter called her on 1/30/21 because she could not get answers from the hospital. She stated she called the hospital and was informed the resident was admitted to the hospital with left knee fracture. The LPN noted the hospital made it sound as if it was not a new fracture. LPN A said she informed the resident's daughter and the Unit Manager (UM) of the fracture. LPN A then said, if she had known that it was an acute fracture she would have tried to figure out what happened. She would have spoken to the staff to see if the resident fell and would have documented the acute fracture in the medical record. LPN A verified the resident was able to get herself in/out of bed and was independently mobile in her wheelchair prior to hospitalization. When she came back from the hospital, she was put on the observation unit for 2 weeks and had new order of Tramadol for pain. She had to stay in her room for 2 weeks due to Corona Virus Disease 2019 quarantine procedures for new or re-admissions. On 3/19/21 at 1:26 PM, the UM said she started working at the facility on 1/25/21. She did not remember attending the morning meeting the week of 2/4/21 when the resident returned from the hospital. She did not remember any conversations regarding resident #71 having an acute fracture. She said the resident had increased pain due to the fracture and received Tramadol for pain. On 3/19/21 at 1:36 PM, the Physical Therapist (PT) said resident #71 received therapy from 2/4/21 to 2/24/21 due to fractured left knee. He said the resident returned from the hospital with left knee brace. She was guarded due to the pain and would not straighten her leg. He noted the resident was non weight bearing (NWB) when she returned from the hospital and was still presently NWB with the left leg. He noted she had poor cognition and it was challenging to do therapy as she needed frequent repeat instructions. He verbalized the resident could not get out of bed when she returned to the facility. We were doing the initial therapy with her in the bed for the first week. Prior to hospitalization, she could get out of bed by herself, bear weight both legs, get herself into the wheelchair, scoot, pivot with right leg into the chair. She could take herself to the bathroom and wheel self around the building. He said he completed the physical therapy evaluation when she returned from the hospital on 2/4/21. She was total care with everything at that time. He said he could not get her out of bed for therapy due to pain and treatments were done in bed for positioning and range of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105530 If continuation sheet Page 5 of 12 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 105530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Healthcare and Rehabilitation Center 1550 Jess Parrish CT Titusville, FL 32796 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 0610 Level of Harm - Actual harm Residents Affected - Few motion. He noted therapy got her out of bed 6 days after she returned, on 2/10/21 with maximum assistance and NWB to left leg. He said she was discharged from therapy services on 2/24/21 because of her insurance. He added that transfers were still difficult for her. On 3/19/21 at 2:20 PM, Certified Nursing Assistant (CNA) F said that prior to hospitalization, the resident could get herself into the wheelchair from bed, go the bathroom on her own, and bathe herself while sitting on the toilet. She stated she needed help with dressing and could wheel self around the building. When she got back from the hospital, she was on the observation unit for 2 weeks. CNA F said that when the resident returned to her usual unit she could not turn in bed and now needed 2 staff to help her with everything. She said that since the resident is NWB to left lower leg, it takes 2 staff to bathe/turn her in bed, get her into the wheelchair and assist her onto the toilet. She can wheel herself in the wheelchair but all other ADLs except for eating require 2 staff. On 3/19/21 at 3:11 PM, an interview was conducted with the Executive Director (ED) and DCS. The ED said they had clinical meetings at about 9:00 AM which consisted of nurse leadership. After this meeting, morning meetings were held consisting of the entire leadership team. The ED said they would have discussed resident #71 at both meetings as the resident had returned from the hospital. He said the DCS was not at the clinical meeting on 2/4/21. The DCS said she was not aware that resident #71 had diagnosis of acute fracture left lower extremity until it was brought to their attention by the surveyor this morning. The DCS stated no one looked at resident #71's hospital record until this morning and they were not aware she had an acute fracture. They thought something was wrong with her knee. The DCS said their usual practice was to review the hospital record at the clinical meeting, and they should have reviewed resident #71 when she came back to the facility. The DCS said they should not have assumed it was an old injury. They noted that since an investigation of the fracture had not occurred when it was discovered 7 weeks ago, it was unlikely the facility would be able to obtain a clear picture of what actually happened. They acknowledged the facility utilized agency staff and had turn over in their management staff. Some of the staff involved in the care of resident #71 no longer worked at the facility and were not available for interview during the survey. On 3/19/21 at 3:46 PM, the attending physician said he was not aware resident #71 had an acute fracture and that he would need to review the records. He acknowledged the facility staff should have investigated the acute fracture/injury of unknown origin and reviewed the hospital records upon her return to the facility. Although the facility indicated they were not aware of resident #71 having new diagnosis of acute fracture (left knee) they listed left tibial fracture on several of her care plans. The resident's plan of care initiated on 2/21/21 for pain medication included diagnosis of left tibial fracture. Plan of care revised on 2/4/21 for potential for pain included diagnosis of left upper tibia fracture. The following care plans reviewed by the facility on 3/3/21 for ADL self-care performance deficit, alteration in musculoskeletal status, potential for pressure injury and functional bladder incontinence also included diagnosis of left tibia fracture with impaired weight bearing. Review of the Facility Assessment Tool, dated, 8/18/17, revealed the facility was competent to provide care and services for residents with diagnoses of dementia and fractures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105530 If continuation sheet Page 6 of 12 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 105530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Healthcare and Rehabilitation Center 1550 Jess Parrish CT Titusville, FL 32796 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide personal hygiene for 2 of 5 residents dependent on staff for activities of daily living (ADL) out a total sample of 45 residents, (#489, #26). Residents Affected - Few Findings: 1) Resident #489 was initially admitted on [DATE] then readmitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, muscle weakness, osteoarthritis and fatigue. The quarterly Minimum Data Set (MDS) assessment with assessment reference date of 12/31/2020 revealed that resident #489 had a brief interview for mental status (BIMS) score of 15 that indicated his cognition was intact. He did not reject care. He required extensive assistance of 1 person for toilet use and personal hygiene and was totally dependent on 1 person for bathing. On 03/15/21 at 11:30 AM, resident #489 was observed in bed. His fingernails on both hands were long, approximately 8 millimeter (mm) long, jagged, with black debris underneath. He stated he wanted his nails cut and cleaned and could not remember the last time his nails were cut but was sure it was more than 3 weeks ago. On 03/16/21 at 9:50 AM, resident #489 was in bed, watching television. His fingernails were observed to be in the same condition as the previous day. He stated he wanted his fingernails cleaned and cut. On 03/17/21 at 9:55 AM, the resident was seated in his wheelchair by his bedside. His nails remained long and jagged with black debris under the nails. A review of the resident's flow sheets revealed the resident was scheduled to receive showers on Wednesdays and Saturdays during 7 AM to 3 PM shift. A review of the bath sheet from 02/17/21 to 03/17/21 revealed he received bed baths on 03/07, 03/11 and 03/13. He received partial baths on several days but there was no check mark to note if he received showers. A review of the resident's care plan for ADL self care performance deficit revised 01/01/21 included interventions for bathing/showering: check all nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On 03/17/21 at 3:00 PM, Licensed Practical Nurse (LPN) D acknowledged the resident's nails were long and dirty. She stated they needed to be cleaned and cut. The resident informed the LPN the last time his nails were cleaned and cut was with another Certified Nursing Assistant (CNA) that LPN D determined was more than a month ago. 2) Resident #26 was initially admitted on [DATE] with latest readmission on [DATE]. His diagnoses included dementia, paranoid schizophrenia, cognitive communication deficit and muscle weakness. His latest Minimum Data Set (MDS) assessment with assessment reference date 12/29/20 revealed he had a Brief Interview for Mental Status (BIMS) score of 12 that indicated his cognition was moderately impaired. He required extensive assistance of 1 person for dressing, toilet use and personal hygiene. He was totally dependent on 1 person for bathing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105530 If continuation sheet Page 7 of 12 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 105530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Healthcare and Rehabilitation Center 1550 Jess Parrish CT Titusville, FL 32796 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 - Minimal harm or potential for actual harm Residents Affected - Few On 03/15/21 at 10:41 AM, resident #26 was observed in bed, watching television. His fingernails were about 1 cm long, jagged, with black debris under the nails. The resident was unshaven with long facial hair. He stated he wanted his nails trimmed and wanted to be shaved. On 03/16/21 at 9:55 AM, the resident was in bed, asleep. His finger nails remained long and dirty and he was unshaven with long facial hair. On 03/17/21 at 9:51 AM, the resident was noted with his fingernails unchanged and his face unshaven. A review of the resident's flow sheets revealed he was scheduled for showers on Wednesdays and Saturdays during 7 AM to 3 PM shift. His bath sheet dated 02/17/21 to 03/17/21 revealed he received partial baths every 2 to 3 days during night shift. There was no indication he received showers during the above specified time period. A review of the resident's care plan for ADL self care deficit initiated on 04/06/19 indicated interventions for bathing/showering: check all nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On 03/17/21 at 3:05 PM, LPN D stated she did not understand why his nails were long and dirty. She also stated that whoever was the assigned CNA for him, should not have let his nails grow long. She acknowledged he needed his facial hair shaved. On 03/17/21 at 3:26 PM, the DON stated that CNAs were supposed to perform nail care as needed unless the resident was diabetic. They were expected to shave facial hair as well if the residents requested it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105530 If continuation sheet Page 8 of 12 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 105530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Healthcare and Rehabilitation Center 1550 Jess Parrish CT Titusville, FL 32796 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 0694 Provide for the safe, appropriate administration of IV fluids 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 observation, interview and record review, the facility failed to provide dressing changes for midline intravenous (IV) catheter according to current professional standards of practice for 2 of 2 residents with IVs of a total sample of 45 residents, (#690 and #695). Residents Affected - Few Findings: 1. Resident #695 was admitted to the facility on [DATE] with diagnoses of Staphylococcus, arthritis of left knee, cellulitis of left lower limb and long-term use of antibiotics. The nursing Admission/readmission data collection dated 3/5/21 listed resident #695 as alert and oriented to person, place and time and midline IV to right upper arm. A midline catheter is put into a vein by the bend in your elbow or your upper arm . The midline tube ends in a vein below your armpit .midline catheter may allow you to receive long-term intravenous (IV) medicine or treatments .(www.drugs.com). On 3/15/21 at 8:06 AM, resident #695 was observed with Licensed Practical Nurse (LPN) B during medication administration. The resident had a midline intravenous to right upper arm. The IV dressing was undated, and a square 5 x 4 transparent dressing covered the midline IV. The dressing had become loose and lifted about 3 inches. LPN B applied tape to reinforce the loosened dressing. LPN B stated the midline dressing should be changed as it was not dated and was not intact. She acknowledged the loosened dressing to the area should be changed as the site could become infected if not intact. LPN B added the midline dressing should be changed weekly and anytime it became loose. The resident stated the dressing was placed when he was in the hospital. Review of the hospital transfer form reflected IV midline was inserted on 3/3/2021. Review of nursing progress notes, and Medication/Treatment Administration Records did not indicate any evidence of midline dressing changes since admission to the facility. 2. Resident #690 was admitted to the facility on [DATE], with diagnoses that included sepsis, infection, and inflammatory reaction due to indwelling urethral catheter. Review of the current Physician Orders dated 3/10/21 included Meropenem Solution Reconstituted 1 Gram intravenously every 8 hours for infection. Change Dressing on admission or 24 hours after insertion and weekly thereafter and as necessary (PRN). On 03/17/21 at 12:03 PM, LPN A disconnected the IV medication post administration and flushed midline with 10 cubic centimeters (cc) of normal saline. The midline dressing was dated 3/8/21. LPN A stated the midline IV dressing dated 3/8/21, should have been changed on 3/15/21 on the evening shift. LPN A added the dressing should be changed as ordered to prevent infection. On 3/18/21 at 9:30 AM, the DON stated the midline dressings should be changed as per the company's Infusion Manual upon admission and at least weekly and documented on the Treatment Administration Record (TAR). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105530 If continuation sheet Page 9 of 12 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 105530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Healthcare and Rehabilitation Center 1550 Jess Parrish CT Titusville, FL 32796 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 0694 Level of Harm - Minimal harm or potential for actual harm The company's Infusion Manual, Midline Catheter Dressing Change dated July 2012 read, Sterile dressing change using transparent dressings is performed 24 hours post-insertion or upon admission, at least weekly or if the integrity of the dressing has been compromised (wet, loose, or soiled). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105530 If continuation sheet Page 10 of 12 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 105530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Healthcare and Rehabilitation Center 1550 Jess Parrish CT Titusville, FL 32796 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to follow physician orders for blood tests as per pharmacy recommendations for for 1 of 5 residents reviewed for unnecessary medications out of a total of 45 sampled residents, (#47). Residents Affected - Few Findings: Resident #47 was initially admitted to the facility on [DATE] with diagnoses of Cerebrovascular Accident, Dementia, Hypothyroidism, Epilepsy, Seizures, and Schizoaffective disorder. Resident #47's latest quarterly Minimum Data Set (MDS) assessment with assessment reference date of 1/21/21 revealed the resident's Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. Review of the Pharmacy Consultation Report dated 11/4/20 revealed that resident #47 received Clopidogrel (antiplatelet medication), Oxcarbazepine (anti-seizure medication), Levothyroxine (thyroid medication) and Risperidone (antipsychotic medication) and had not had a CBC (complete blood count), CMP (comprehensive metabolic panel ), TSH (thyroid stimulating hormone) or lipid panel evaluation documented in the medical record in the last 6 month. Recommendation was made to consider monitoring a CBC, CMP, TSH or lipid panel on the next convenient lab day and then every 6 months (every 12 months for TSH and lipid panel.) The physician accepted the recommendation and wrote labs next week on 11/27/20. Review of the Pharmacy Consultation Report dated 2 months later on 1/5/21 read, repeated recommendation from 11/4/20: Please respond promptly to assure facility compliance with Federal regulations. The recommendation indicated that resident #47 had not had a CBC, CMP, TSH or lipid panel evaluation documented in the medical record in the last 6 months. Recommendation was made to consider monitoring a CBC, CMP, TSH or lipid panel on the next convenient lab day and then every 6 months (every 12 months for TSH and lipid panel). Review of resident's #47 medical record revealed a physician order was entered on 1/13/21 and read, LABS Fasting every night shift every 6 month(s) starting on the 13th for 1 day(s) for Medication monitoring related One time and then every 6 months per pharmacy. There were no lab results found in the medical record nor nursing notes explaining why labs were not obtained as per pharmacy recommendations and physician orders. On 3/18/21 at 12:13 PM, the Unit Manager (UM) explained that pharmacy recommendations were received by the Director of Nursing (DON) and then distributed to the UMs. The UM reviewed the recommendations, obtained physician's orders or faxed to the physician's offices for signature. She said she worked on the Pharmacy Recommendations as soon as she received them. Once order is reviewed and signed by the physician, she entered the order into their computer system. On 3/18/21 at 1:52 PM, the DON reviewed the Pharmacy Recommendation dated 11/4/20 which was signed by the physician on 11/27/20 who accepted the recommendation from the pharmacist. The DON acknowledged the physician's order to complete labs was not followed. She added the resident had refused to have labs drawn but noted there were no nursing notes entered explaining the number of attempts or notification to the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105530 If continuation sheet Page 11 of 12 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 105530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Healthcare and Rehabilitation Center 1550 Jess Parrish CT Titusville, FL 32796 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/19/21 at 12:46 PM, the DON said she could not find any recent laboratory results for resident's #47. She noted the last labs done for the resident were from November 2019. On 3/19/21 at 12:59 PM, the resident's physician explained via telephone call that he was not in his office and did not have access to this resident's medical record. He stated he could answer general questions. He explained the resident's medication, Clopidogrel could cause low level of platelets and needed to be monitored by doing routine blood work. He explained the resident's other medications, such as Oxcarbazepine and Risperidone could affect his liver. He said labs needed to be done as recommended to ensure the resident was monitored before any negative outcome could develop. On 3/19/21 at 4:27 PM, the DON explained that when she received the pharmacy recommendations, she handed them to the UM, and the UM followed up with the physician. She said she did not know why the physician orders from the pharmacy recommendations were not followed. On 03/19/21 at 4:43 PM, the Consultant Pharmacist explained via telephone the labs she recommended for resident #47 were considered routine lab work. She added that medication dosages could be adjusted based on the lab results. Monthly Drug Regimen Review Policies and Procedures with a revised date of 10/10/18 revealed, routine recommendations to be communicated to the DON/designee, attending physician, and Medical Director for response and resolution, after the completion of the Monthly Drug Regimen Review. The policy noted, If follow up for consultant pharmacist recommendations are not completed within the specified time frame this should be reported to the Medical Director for follow up with attending physician as indicated. Physician Orders Policies and Procedures with a revised date of 3/3/21 revealed, the center will ensure that physician orders are appropriately and timely documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105530 If continuation sheet Page 12 of 12