Health inspection·August 28, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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, and interview, the facility failed to ensure resident rights for 1of 3 sampled residents, as evidenced by the failure to assess Resident #20 for self-administration of medications.The findings included:Review of the policy titled, Resident Rights, implemented 11/2020 and revised on 01/2023, documented in part, 1. The right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. Record review revealed Resident #20 was admitted to the facility on [DATE] with a recent readmission date of 05/06/25. Review of the current Minimum Data Set (MDS) assessment documented Resident #20 had a Brief Interview for Mental Status (BIMS) score of 12 on a 0-15 scale, indicating the resident had moderate cognitive impairment. Further review of the record revealed Resident #20's diagnosis documented in part, Pleural Effusion, Chronic Obstructive Pulmonary Disease (COPD), and Acute and Chronic Respiratory Failure with Hypoxia.Review of the physician orders documented in part, Pulmicort Inhalation Suspension 0.5 MG\/2ML Give 1 vial by mouth two times a day for Shortness of Breath via nebulizer, and Albuterol Sulfate Nebulization Solution (2.5 MG\/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 4 hours as needed for Shortness of Breath.An interview was conducted on 08/27/25 at 8:23 AM. Resident #20 stated she gets her nebulizer treatments daily and as needed throughout the day and night and wanted to be able to give herself the nebulizer treatments like she did at home. Another interview was conducted on 08/28/25 at 8:22 AM. Resident #20 was asked if she told the nursing staff that she wanted to give herself the nebulizer breathing treatment. She stated that she tells the nurse that she wants to give herself the nebulizer treatments all the time and that she has asked the nurses to leave the medication in her room so she could do it herself and the nursing staff told her they are not allowed to leave the medication in her room.An interview was conducted on 08/28/25 at 8:38 AM with Staff E, Licensed Practical Nurse (LPN), who was asked if Resident #20 wanted to administer her nebulizer breathing treatments herself. Staff E stated she knew Resident #20 from another nursing home where Resident #20 used to self-administer her nebulizer treatments. Staff E was asked if Resident #20 had been assessed to self-administer her nebulizer medication at this facility to which she responded that she was not sure and when she checked she stated Resident #20 had not been assessed to self-administer the nebulizer medications. Record review after the staff interview on 08/28/25 revealed that a Self-Administration of Medication Evaluation was initiated for Resident #20. Residents Affected - Few Page 1 of 23 105579 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

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 observations, interviews, and record review, the facility failed to respond to a resident's request to remove food allergies from the meal ticket for 1 of 8 sampled residents reviewed regarding choices, Resident #34. The findings included: Record review revealed Resident #34 was admitted to the facility on [DATE] and 07/09/25 with a diagnosis of Anemia. An review of the care plans, revised on 07/29/25, showed that Resident #34 was at risk for altered nutrition and lab values.On 08/25/25 at 9:19 AM, Resident #34 was interviewed. She voiced her meal ticket recorded that she had allergies to shellfish and shrimp, but she did not have these allergies. She expressed frustration about her attempts to have the facility correct this information, saying, It's like talking to a brick wall.On 08/27/25 at 8:09 AM, the resident was observed lying in bed and her breakfast tray on the table. She reiterated that she does not have allergies to shellfish and shrimp. On 08/27/25 at 1:14 PM, the resident was again observed in bed, consuming her lunch. She stated she had been complaining to everyone who entered her room, requesting them to remove the allergy information from the meal ticket, stating, Sometimes complaining around here doesn't go very far. She recounted, overhearing a dietary staff talking to another resident across the hall regarding allergies to shellfish and shrimp; subsequently, the dietary staff came to speak to her. Resident #34 stated she believes the dietary staff may have mistakenly entered the other resident's food allergy information in her records. She expressed her disappointment and stated, she missed out on shrimp salads that was served at the facility, it pissed her off; and it upset her because she loves shrimp.On 08/28/25 at 9:31 AM, an interview was conducted with the Registered Dietitian (RD) regarding the documented food allergies. The RD reviewed the computer system and was surprised that it recorded these allergies. She confirmed the allergies were recorded on the meal ticket as well. She said Resident #34 had no allergies to shellfish and shrimp and noted that the resident had told her she loves shrimp and seafood. The RD acknowledged that allergies had been removed from the meal tracker but remained in the computer system. She commented, I understand if everyone else is getting it, and she [Resident #34] feels excluded. 105579 Page 2 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

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 observations, record review and interviews the facility failed to provide a safe, clean comfortable homelike environment for 3 of 4 units. The findings included: A tour of the facility was completed on 08/27/25 at 1:45 PM with the Maintenance Director and the Director of Housekeeping. The following was observed, and they acknowledged these findings: a. room [ROOM NUMBER] - there was white caulking patches on the wall, the tile in the bathroom below the sink was cracked, there was a metal bar above the toilet that was moved and the holes from the screws remained and the rust stains not repaired, the floor in the bathroom was dirty with black stains on beige tile and floor caulking was black, and the door trim outside the door had come off the wall. b. room [ROOM NUMBER] - Resident #30 stopped the surveyor and Maintenance Director during the tour on 08/27/25 at 2:45 PM and stated that his left brake on his wheelchair did not lock. c. room [ROOM NUMBER]-A - A water stain was noted on the ceiling tile above entrance door and Bed A. The left arm rest of the wheelchair in the room had rubber peeling off it. d. room [ROOM NUMBER]-A - There were numerous white patches of caulking behind the head of the bed. e. room [ROOM NUMBER]-A - The blind on the window was broken, wall patches noted without paint. In the bathroom, the white seat cushion that is part of the shower chair had multiple hard dried dark brown pieces of an unknown substance attached to the cushion. f. room [ROOM NUMBER]-A - There were stains dripping down the wall across from the left side of the bed, the ceiling tile was stained above the entrance door and above bed A, the vinyl baseboard is torn along with the wall and was damaged at the corner of the bathroom and room wall meet. g. room [ROOM NUMBER]-A - The resident's wheelchair seat was torn at the front of the seat, and the tire was bald with the rubber on the tires disintegrating / rotting away from wheel. h. room [ROOM NUMBER]-B - The resident's wheelchair's rubber on both tires were bald and disintegrating. i. room [ROOM NUMBER]-B - The resident's wheelchair's tires were bald with the rubber on the tires disintegrating / rotting away from the wheel, and the right and left arm rests were cracked and torn, the wall under the window was scuffed, there was a crack in the wall in several places where the wall and the vinyl baseboard meet, and the vinyl baseboard was pulling away from the wall. j. room [ROOM NUMBER]-A - the resident's wheelchair tires had rubber that was disintegrating. The surveyor requested a policy on wheelchair maintenance and cleaning multiple times on 08/27/25 and 08/28/25. The Administrator stated on 08/28/25 at 8:05 AM that he was unable to find one and reached out to the regional office. The surveyor was not provided a policy. An interview was conducted on 08/28/25 at 2:08 PM with the Director of Rehabilitation who was asked if she had anything to do with the maintenance of the wheelchairs. She stated that she does an audit on the wheelchairs monthly. It shows who was looked at and who needs maintenance on chairs. She said she is not responsible for the cleaning of the wheelchairs but changing out the arm rest and the wheelchairs' back and seats. She said that a resident leaves that wheelchair that the resident used to be disinfected. She said that maintenance came to her yesterday after the tour and she said she can't order replacement backs and seats for the current chairs but obtained permission from the Administrator to order new chairs. The Director of Rehabilitation brought a copy of documentation to the surveyor on 08/28/25 at 2:40 PM showing that she goes around monthly and checks residents' wheelchair. It does not show any residents' wheels needing replacing. She also brought in a checklist for wheelchairs that included: checking bilateral brakes to see if they work safely and would fix as needed; checking bilateral arm rests for damage and to replace as needed; checking the wheelchair seats and back for damage and replace as needed; checking the wheelchair cushions and covers for damage and to request replacement as 105579 Page 3 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0584 needed; checking wheels for wear and tear and damage and replace as needed; and to check the alignment of wheelchair when pushed and fix wheel bearings as needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105579 Page 4 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a PRN (as needed) antipsychotic medication was addressed in a timely manner for 2 of 7 sampled residents, as evidenced by the Lorazepam (antipsychotic) prescribed to Resident #96 and Resident #85 did not have a discontinue date or documented rationale by the doctor to extend the order.1.Review of the record revealed Resident #96 was admitted to the facility on [DATE]. The annual comprehensive assessment dated [DATE], documented that the resident had a Brief Interview for Mental Status Score of 10 on a 0 to15 scale, indicating moderate cognitive impairment. The resident had a documented medical diagnosis history of anxiety disorder and mood disorder. Review of the record revealed an order dated 07/07/25 for Resident #96 to administer Lorazepam 0.5 milligrams (mg) 1 tablet every four hours as needed f[PRN] or anxiety with no date to discontinue or documented rationale by the doctor to extend the medication. A second order dated 05/31/24 instructed staff to administer 0.5 mg every 8 hours for anxiety. Review of the care plan revealed Resident #96 is at risk for complications related to the use of psychotropic drugs: antidepressant for management of depression symptoms and antianxiety for management of anxiety symptoms, appetite with a goal that the resident will have the smallest most effective dose without side effects. Review of the pharmacy medication review dated 07/31/25 recommended to the physician that the PRN psychotropic orders are limited to 14 days unless the prescriber deems it appropriate to continue and provides a clinical rationale and duration for the PRN Lorazepam prescribed since 07/07/05. The Advanced Registered Nurse Practitioner (ARNP) responded on 08/05/25 by disagreeing and writing that the resident is under hospice care. The medication was never discontinued or appropriate rationale provided. Photographic Evidence Obtained. An interview was conducted on 08/29/25 at 10:52 AM with the Director Of Nursing (DON) who was made aware that Resident #96 had an PRN order for Lorazepam dated 07/07/25 and the pharmacy had recommended on 07/31/25 that the medication be discontinued or a clinical rationale be given for use. The order in the record was provided for the DON to review, and she stated, The resident is on hospice. The DON was made aware that the order was written by the facility's attending physician not hospice. When asked if a resident being on hospice mean there can be an open-ended order for an antipsychotic, she gave no response. The DON stated, The hospice physician does not have privileges in the facility to write orders for psychotropic medication. I will reach out to the attending physician regarding the order. 2. Review of the record revealed Resident #85 was admitted to the facility on [DATE] under hospice care and services. Review of the physician order dated 07/16/25 documented staff were to provided Ativan, an antianxiety medication, 0.5 milligrams (mg), every four hours as needed for anxiety. This order lacked any duration or stop date as evidenced by the duration documented as indefinite in the order details. Further review of the record revealed a Consultant Pharmacist Medication Regimen Review dated 07/31/25 that documented Resident #85 had been on the as needed Ativan since 07/16/25, and that the as needed psychotropic orders were limited to 14 days unless the prescriber deemed it appropriate to extend the order and provide a duration of use. This recommendation was addressed by the Advanced 105579 Page 5 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0605 Practical Registered Nurse (APRN) of the resident's physician, who documented, disagree with the response documented as, Patient is under the care of hospice. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105579 Page 6 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure timely and appropriate care and services for 5 of 34 sampled residents as evidenced by the failure to clarify multiple physician orders and appropriately treat a rash for Resident #8; failure to ensure timely initiation of an antibiotic for Resident #96, who had an infected wound; failure to ensure medications were not provided by mouth for Resident #3, who had orders for nothing by mouth; failure to ensure treatment for a skin cancer wound for Resident #61; and failure to follow physician ordered blood pressure medication parameters for Resident #6.The findings included:1. Record review revealed Resident #8 was admitted to the facility 03/04/23, with the most recent readmission on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status Score (BIMS) of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented the resident was totally dependent upon staff for toileting. Residents Affected - Few Review of the current active physician orders for Resident #8 revealed the following: a) As of 05/30/25 staff were to apply Triad Cream to the resident's coccyx and buttocks every shift. This order was signed off as completed by Staff D, Licensed Practical Nurse (LPN) on 08/28/25 for day shift (7 AM to 3 PM), as per the August 2025 Medication Administration Record (MAR) . b) As of 08/01/25 staff were to apply Ketoconazole cream 2% to multiple areas of the resident's body to include her groin, once daily. This cream was scheduled for 9 AM and signed off by Staff C, LPN, on 08/28/25 at 9 AM. c) As of 08/26/25 staff were to apply Ketoconazole powder to the resident's perineal area and thighs, twice daily for a rash. This powder was scheduled for 9 AM and 5 PM and was signed off by Staff C on 08/28/25 at 9 AM. d) As of 08/26/25 staff were to apply [NAME] External Paste 40% to the resident's perineal area and thighs twice daily for a rash. This paste was scheduled for 9 AM and 5 PM and was signed off by Staff C on 08/28/25 at 9 AM. A current care plan initiated on 06/04/24 documented Resident #8 was at risk for complications due to being incontinent of urine and bowels related to immobility. The goal was to have the resident's incontinence care needs met by staff and to maintain dignity and comfort throughout. During an interview on 08/26/25 at 9:11 AM, Resident #8 stated, My butt hurts from lying in urine too long. The resident denied any wounds but stated it must be like a rash. The resident further stated she could not handle sitting up in her chair for more than a couple of hours anymore or her bottom would be killing her. An observation of personal care was made on 08/28/25 beginning at 11:00 AM for Resident #8. Staff B, Certified Nursing Assistant (CNA), provided perineal care to include the resident's front and back sides, and stated, You are very red (name of Resident #8) during the care. During the very gentle care, Resident #8 cried out in pain, but stated she knew it had to be done. An observation at that time revealed a bright red rash to the resident's groin and back side from her buttock down to her mid-thigh. When asked if this was something new, the CNA explained she hadn't worked with the resident in a while, but the last time she did, the resident was a little red. Staff B proceeded to apply 105579 Page 7 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0684 Triad cream to the resident's groin, buttock, and back of thighs on the reddened parts. Level of Harm - Minimal harm or potential for actual harm During a side-by-side record review and interview on 08/28/25 at 11:45 AM, when asked about Resident #8's rash, Staff A, LPN/Unit Manager, confirmed there were multiple orders for treatment to the perineum and groin. Staff A stated if she would have taken those orders she would have asked the doctor about the timing of each for clarification. When told Staff B applied the Triad cream to Resident #8, the Unit Manager stated that should be done by a nurse. Residents Affected - Few An interview was conducted with Staff C, LPN, and Staff D, LPN, on 08/28/25 at 11:54 AM. When asked if she had applied any type of treatment for Resident #8's rash that day, Staff D stated she was helping out with treatments that day but had not gotten to Resident #8 yet, but she was on her to do list. Staff D stated the CNAs usually tell her when they had cleaned the resident, but she had not been told as of yet. Staff C, the resident's direct care nurse, stated she had not put anything on the resident's rash that morning, but she thought Staff D had done so. When asked why she signed off a treatment that she did not apply, Staff C stated, Yes, that's a problem. We sometimes go together but confirmed neither had provided any treatment that day although both had signed the record as completed. 2. Record review revealed Resident #96 was admitted to the facility on [DATE]. Review of the record revealed a wound culture was collected on 07/17/25, reported to the facility on [DATE] at 2:25 PM, and reviewed by facility staff on 07/20/25 at 11:40 AM. Review of the current active physician orders documented as of 08/22/25, Cefepime 2 grams, an antibiotic, was to be provided intravenously, every eight hours for a left heel wound infection, until 09/13/25 at 6 AM. Review of the July 2025 discontinued orders and Medication Administration Record (MAR) revealed the following: a) An order dated 07/23/25 documented to start the Cefepime antibiotic at 10 PM. The corresponding MAR documented the medication was not given as, Vitals Outside of Parameters for Administration. There were no parameters related to the antibiotic. b) An order dated 07/24/25 documented to start the Cefepime antibiotic at 9 AM. The antibiotic was not provided as per order. c) An order dated 07/25/25 documented to start the Cefepime antibiotic at 9 AM. The antibiotic was initiated at this date and time, six days after receiving the results of the wound culture. d) Further review of the July 2025 MAR revealed the antibiotic was not provided on 07/28/25 at 6 AM, as evidenced by a blank on the MAR. During an interview on 08/27/25 at approximately 1:00 PM, the Director of Nursing (DON) was made aware of the findings and agreed the antibiotics were delayed for Resident #96. 3. Record review revealed Resident #3 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE], documented the resident was rarely or never understood and was totally dependent upon staff for eating, as she was not allowed anything by mouth and fed through a tube. 105579 Page 8 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0684 Level of Harm - Minimal harm or potential for actual harm A current care plan initiated on 12/28/23 documented Resident #3 required a feeding tube to meet her nutritional and hydration needs related to dysphagia, and difficulty swallowing. An intervention instructed staff to keep the resident NPO, meaning nothing by mouth. Review of the current active physician orders revealed the following: Residents Affected - Few a) As of 04/17/25, Glycopyrrolate 1 mg was to be given by mouth three times daily as a salivary inhibitor. b) As of 02/24/25, Methenamine Hippurate 1 gm, an antibiotic, was to be given by mouth every 12 hours for recurrent urinary tract infections. c) As of 04/21/25, Tylenol 325 mg, two tablets were to be given by mouth every 4 hours as needed for pain. d) As of 04/21/25, Tylenol 325 mg, two tablets were to be given by mouth every 4 hours as needed for a temperature greater than 100.4 degrees F. During an interview on 08/28/25 at approximately 4:00 PM, the DON agreed with the findings. 4. Record review revealed Resident #61 was readmitted to the facility on [DATE]. Review of the quarterly MDS assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 10 on a 0-15 scale, indicating moderate cognitive impairment. Review of documented medical history revealed a diagnosis of localized swelling, mass and lump. An observation was conducted on 08/25/25 at 9:55 AM. Resident #61 was observed sitting upright in bed. An area to his right jaw was draining a moderate amount of clear red drainage onto his gown. The area was not covered. An interview was conducted on 08/26/25 at 10:45 AM with the relative of Resident #61, who when asked if the staff is covering the area on his face, the relative stated, Well there is not much they can do about it because it's a type of skin cancer. When asked about the drainage that gets on his clothing, and the soiled towel noted on the bed, the relative stated, He uses that towel to wipe the area, if you think it's a concern please address it. During an observation conducted on 08/27/25 at 9:08 AM, Resident #61 was noted resting in bed with his head elevated. The cancer site to his right lower jaw was draining clear red drainage on a cloth napkin that was lying on his chest. Photographic Evidence Obtained. An interview was conducted on 08/27/25 at 9:20 AM., Observation of the area on Resident #61 right jaw was observed with Staff H, Licensed Practical Nurse (LPN), who when asked if there are any wound care orders for the area to the resident's jaw, Staff H, LPN stated, I think the wound care nurse was putting on a dressing, but the resident takes it off. When asked had the nurses ever performed wound care in the past to the area she stated, I don't think so, let me ask Staff I, Unit Manger (UM). An interview was conducted on 08/27/25 at 9:21 AM, who when asked if there was a treatment to the cancer area for Resident #61's right jaw, Staff I stated, I will have to check. An interview was conducted on 08/27/25 at 9:35 AM with Staff I who stated, Before Resident #61 went 105579 Page 9 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few out to the hospital we were doing wound care treatment to the area on his jaw. The resident went out to the hospital a couple of weeks ago to get some treatment done to the area and he didn't come back with any orders; it wasn't draining when he came back. Are you saying that the area is draining now? An observation of Resident #61 right jaw was conducted with Staff I. She was made aware that the area had been draining a moderate amount since Monday and the resident was using a towel to clean the area. Staff I stated, Thank you for letting me know I will address it right away. An interview was conducted on 08/27/25 at 10:25 AM, Staff I who stated, I spoke to hospice to let them know that they need to reevaluate the site to Resident #61 right jaw. The relative does not want him to have any procedures or anything. I did get an order to cover the area. 5. Record review revealed Resident #6 was admitted to the facility 10/26/23 with several readmissions with the last one being 07/16/25, with diagnoses that included End Stage Renal Disease, Primary Hypertension, and Type II Diabetes Mellitus with Diabetic Neuropathy. Review of the physician orders revealed the following: Start date 07/16/25 at 2200 (10 PM): Hydralazine HCL Oral tablet 100 Give 100 MG by mouth every 8 hours every Monday, Wednesday, Friday, Sunday for hypertension. Hold if SBP (Systolic blood pressure < (is less than) 115, Heart rate (HR) < (is less than) 60. On the following dates, documentation on the Medication Administration Record (MAR) showed the medications were 'held' when the medication should have been given: a. 08/04/25 at 0600 (AM), B/P 121/59 HR 61 - documents a #4 which in the chart codes means vitals outside the parameters for administration. This medication was not given but should have been given. b. 08/08/25 at 0600, B/P 120/59 HR 60 - documents a #4 which in the chart codes means vitals outside the parameters for administration. This medication was not given but should have been given. c. 08/13/25 at 0600, B/P 126/63 HR 63 - documents a #4 which in the chart codes means vitals outside the parameters for administration. This medication was not given but should have been given. d. 08/17/25 at 0600, B/P 118/66 HR 63 - documents a #4 which in the chart codes means vitals outside the parameters for administration. This medication was not given but should have been given. e. 08/22/25 at 0600, B/P 123/59 HR 61 - documents a #4 which in the chart codes means vitals outside the parameters for administration. This medication was not given but should have been given. f. 07/27/25 at 2:00 PM, B/P 123/58 HR 61 - documents a #4 which in the chart codes means vitals outside the parameters for administration. This medication was not given but should have been given. On the following dates, documentation on the MAR showed the medication should have been held but were given: a. 08/11/25 at 0600, B/P 156/72 HR 59 - documents the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. 105579 Page 10 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few b. 07/18/25at 0600, B/P 121/66 HR 59 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. c. 07/20/25 at 0600, B/P 145/54 HR 55 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. d. 07/23/25 at 0600, no B/P documented, HR 56 - tThe medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. e. 07/25/25 at 0600, 137/61 HR 59 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. f. 07/27/25 at 0600 B/P 146/54 HR 57 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. g. 07/30/25 at 0600, B/P 147/59 HR 54 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. Review of the Physician order with a start date of 04/25/25 and discontinued on 07/12/25 documented for Hydralazine HCL Oral tablet Give 100 MG by mouth every 8 hours every Monday, Wednesday, Friday, Sunday. For hypertension. Give if SBP (Systolic blood pressure >160 (is more then) Diastolic Blood Pressure > (DBP) (is more then). Start date 04/25/25 0600 AM and discontinued 07/12/25 01:58 AM. On the following dates documentation on the MAR showed the medication was given when it was outside the physician's parameters and should have been held: a. 07/01/25 at 10:00 PM, B/P 133/69 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. b. 07/02/25 at 0600, B/P 132/63 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. c. 07/02/25 at 10:00 PM, B/P 130/62 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. d. 07/03/25 at 10:00 PM, B/P 137/89 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. e. 07/04/25 at 10:00 PM B/P 126/60 - the medication should have been held but was given. There is a 105579 Page 11 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. f. 07/05/25 at 10:00 PM, B/P 147/70 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. g. 07/06/25 at 10:00 PM, B/P 130/60 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered h. 07/07/25 at 0600, B/P 143/66 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. i. 07/07/25 at 2:00 PM, B/P 132/78 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. j. 07/09/25 at 2:00 PM, B/P 149/60 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. k. 07/09/25 at 10:00 PM, B/P 136/60 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. l. 07/10/25 at 2:00 PM, B/P 152/66 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. m. 07/11/25 at 0600, B/P 157/66 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. n. 07/11/25 at 2:00 PM, B/P 140/82 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. o. 07/11/25 at 10:00 PM, B/P 135/79 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. An interview was conducted on 08/27/25 at 11:15 AM with Staff F, LPN (Licensed Practical Nurse) who was asked about the resident on Hydralazine and the BPs. She said she does not normally take care of this resident and did not have an answer. An interview was conducted on 08/27/25 at 11:25 AM with Staff A, Unit Manager, who was asked to review the MAR for this resident. She was asked about the order for Hydralazine. Staff A reviewed the 105579 Page 12 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0684 MAR and acknowledged the findings. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 08/27/25 at 12:55 PM with the DON (Director of Nursing) who reviewed this resident's MAR and acknowledged the findings related to Hydralazine. Residents Affected - Few 105579 Page 13 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, observations, record reviews, and interviews, the facility failed to provide care and services to prevent further decrease in range of motion for 1 of 3 sampled residents as evidenced by not applying the splints on Resident #25. The findings included: Review of the policy titled Restorative Nursing Program revised 05/2022 documented in part . It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Compliance Guidelines: 6. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services include: a. Passive or active range of motion. b. Splint or brace assistance. Record review revealed Resident #25 was admitted to the facility on [DATE]. Review of the annual comprehensive Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 10 on a 0-10 scale indicating moderate cognitive impairment. Further review revealed a documented medical diagnosis of unspecified lack of coordination. An observation was conducted on 08/25/25 at 10:15 AM. Resident #25 was observed lying in her bed sleeping on her back, she was dressed, and her hands appeared to be folded inward. Review of a physician order dated 07/30/25 revealed Resident #25 was on the restorative nursing program for application of bilateral hand splints. Review of the order dated 08/06/25 revealed Resident #25 is to wear bilateral hand splints up to five hours per day three times per week. Review of the care plan dated 05/25/05 revealed a focus that stated restorative nursing is to assist Resident #25 with bilateral lower extremity active range of motion (ROM) and bilateral upper extremity passive range of motion (PROM) then apply splints to bilateral upper extremities, with a goal to increase bilateral lower extremity strength and maintain hand range of motion. The restorative certified nursing assistant is to document participation. An observation conducted on 08/26/25 at 10:35 AM. Resident #25 was observed lying in bed fully dressed, with her hands folded inward. There were no splints on her hands.An observation was conducted on 08/27/25 at 1:42 PM Resident #25 observed lying in bed sleeping, with her hands folded inward. There were no splints on her hands.Another observation was conducted on 08/28/25 at 9:4 AM. Resident #25 was noted lying on her back in her bed fully dressed sleeping, with her hands folded, there was 2 grey colored splints noted on the nightstand next to her bed. Photographic Evidence Obtained. Review of the Task in the record for Resident #25 revealed the splints were only applied on 08/07/25, 08/09/25, 08/17/25, and 08/22/25. An interview was conducted on 8/28/25 at 9:48 AM with the Restorative Nurse (RN) who was asked how it is determined who cares for the residents on restorative. She stated, At the beginning of the shift, the assignment is split between the restorative aides. There are usually three restorative aides for the day shift (7:00 AM - 3:30 PM) and an evening aide comes in at 4:00 PM to10:00 PM. There is a book that has the assignments, and it is located on Reflections Unit on a desk in the area where the residents on restorative will have their meal. When asked if she is familiar with Resident #25, she stated, Yes, but I don't know what exact program she is on. The RN was made aware that Resident #25 is on the restorative program for ROM and splints to be applied. She stated, Oh yes, three times a week. When asked if the aides should be documenting in the task on the computer whatever they do for the resident, she stated, Yes. The RN was made aware that the splints were not being applied on Resident #25 as ordered according to documentation, and the resident was observed for two days without the splints. When asked if the staff apply the splints a 9:00 PM, she stated, No they should be taking them off at that time. The RN asked if the restorative aides were documenting that the 105579 Page 14 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident refused to have the splints. She was then asked if the refusal would be documented anywhere else besides on the task, and stated No, it would be on the task. The RN reviewed the task documentation for Resident #25 that revealed there had been no documentation of the resident refusing. Photographic Evidence Obtained. Review of the restorative weekly resident binder on 08/28/25 did not reveal documentation of which aides were assigned to the residents on restorative.An interview was conducted on 08/28/25 at 10:29 AM with Staff G, Certified Nursing Assistant (CNA), who was asked how it is determined which residents on restorative you see daily. She stated, Me and the other aides, kind of work together. We don't really split up an assignment. There is a list of residents on restorative, and it tells us what they are on the restorative program for. When asked how they document what is done for the residents, Staff G stated, We bubble the circle next to their name on the sheet, and we also document it on the computer. When asked what if a resident had splints ordered three times a week, what do you do, she stated, well sometimes it might be for certain days like Monday, Wednesday, Friday. When asked what if no one saw the resident on Monday is the resident seen on another day, Staff G stated, Yes. Staff G and surveyor reviewed the rehab service recommendation sheet that was signed by Staff G and other staff on 07/08/25. It indicated Resident #25 was to have splints three times a week. When asked if it was an old sheet that was completed for the resident, Staff G stated, No, because it said the service was started on 07/29/25. 105579 Page 15 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to follow physician orders for nutritional support via a feeding tube for 2 of 2 sampled residents, Residents #3 and #5.The findings included:Review of the policy Care and Treatment of Feeding Tubes reviewed 11/27/23, documented in part, 1. Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. 9. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided: . e. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders.1. Record review revealed Resident #3 was admitted to the facility on [DATE]. The current Minimum Data Set (MDS) assessment lacked a cognitive rating as the resident was rarely or never understood. This MDS also documented the resident was dependent on staff for eating related to her nothing by mouth status and nutritional needs being met by a feeding tube.A current care plan initiated on 12/28/23 documented the resident required feeding via a tube to meet nutritional needs and also documented the resident could not have anything by mouth. A current physician order dated 06/17/25 documented Resident #3 was to receive Osmolite 1.5 at 50 milliliters (ml) per hour 9h), for a total of 20h or until 1000mL administered. A full canister of Osmolite was 1000 ml in volume. The order specified to start the feeding at 2 PM and to stop the feeding at 10 AM.An order dated 02/19/25 documented the resident was not allowed anything by mouth.An observation on 08/26/25 at 9:58 AM revealed the Osmolite 1.5 canister was started on 08/25/25 at 2 PM. At the time of the observation, the tube feeding had been discontinued and there was about 300 ml of feeding left in the canister. Resident #3 only received about 700 of the prescribed 1000 ml of nutrition.An observation on 08/27/25 at 10:42 AM revealed the Osmolite 1.5 had been initiated on 08/26/25 at 1:37 PM and had been discontinued with about 150 ml left in the container. Resident #3 received about 850 of the prescribed 1000 ml of nutrition. A supplemental observation on 08/27/25 at 2:14 PM revealed the same bottle of Osmolite 1.5 now running with the 150 ml of feeding remaining, indicating the nurse had just recently started the feeding.During an interview on 08/28/25 at 2:46 PM, when asked the intent of the Osmolite 1.5 ml order for Resident #3, the Registered Dietician (RD) confirmed Resident #3 was to receive the 1000 ml of feeding during that 20-hour time period. When told of the feeding not administered to Resident #3, the RD stated it was the responsibility of nursing to ensure the provision of nutrition. 2. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses to include Dysphagia (difficulty swallowing) and G-tube (Gastrostomy tube - tube within the stomach to provide nutrition). Review of the current MDS dated [DATE] documented the resident was not to eat by mouth and had a feeding tube for nutrition.Review of the current order dated 08/06/25 documented staff were to administer Nepro at 50 mL per hour for a total of 20 hours or until 1000 ml was administered. Staff were to initiate the feeding at 2 PM and discontinue it at 10 AM. A current care plan initiated on 07/01/24 documented the need for Resident #5 to receive feeding via a tube and instructed staff to provide the diet as ordered. An observation by two surveyors on 08/26/25 at 10:01 AM revealed the feeding of Nepro 1.8 running at 30 ml per hour.An observation on 08/27/25 at 2:16 PM revealed the Nepro 1.8 was started on 08/26/25 at 1:41 PM. The feeding had been stopped at this time but there was about 100 ml left in the canister.During an interview on 08/28/25 at 3:09 PM, when told of the observation of the tube feeding for Resident #5 running at 30 ml per hour, Staff A, Licensed Practical Nurse (LPN)/Unit Manager, stated she had not been aware of the decreased feeding. The Unit Manager reviewed the 105579 Page 16 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0693 Level of Harm - Minimal harm or potential for actual harm record, to include the orders and progress notes, and did not find a reason for the decreased rate of administration. The Unit Manager was also made aware of the failure to provide the feeding as per order for both Residents #3 and #5 and agreed with the findings. Residents Affected - Few 105579 Page 17 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

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 observation, interview, and record review, the facility failed to ensure oxygen orders and cleanliness of oxygen equipment for 1 of 3 sampled residents, Resident #5, who lacked any order for oxygen, failure of staff to change an oxygen nasal cannula that had been on the floor, and failure to ensure a clean oxygen canister filter.The findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses to include Respiratory Failure and dependence upon supplemental oxygen. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the resident was receiving supplemental oxygen.Review of the current physician orders lacked any order for the administration of the oxygen with an ordered rate of administration. The orders did document to clean the oxygen filter every night shift on Sundays.A current care plan initiated on 02/13/24 documented Resident #5 was dependent upon oxygen and to administer the oxygen as per physician order.An observation on 08/25/25 at 1:15 PM revealed Resident #5 receiving oxygen via nasal cannula at 4 liters. Photographic Evidence Obtained.An observation and interview on 08/26/25 at 10:01 AM revealed the oxygen remained at 4 liters via nasal cannula. Resident #5 stated she used the oxygen at 3 liters via nasal cannula.An observation on 08/27/25 at 8:28 AM revealed the oxygen remained at 4 liters via nasal cannula. The filter was dust laden. Photographic Evidence Obtained.An observation on 08/27/25 at 2:18 PM revealed Resident #5 was out of her room, but the oxygen concentrator was running at 4 liters via nasal cannula. The oxygen tubing, including the nasal cannula (the part the goes directly into the resident's nose to administer the oxygen) was lying directly on the floor, near the head of the bed and slightly behind the concentrator. The date on the tubing was documented as 08/24 with an unidentifiable name on a piece of tape wrapped around the tubing. Photographic Evidence Obtained.An observation on 08/28/25 at 10:31 AM revealed Resident #5 lying in bed, wearing the same oxygen tubing dated 08/24 with the same unidentifiable name on the tape. The oxygen was being administered at 4 liters per minute. Photographic Evidence Obtained.During a side-by-side record review and interview on 08/28/25 at 3:09 PM, Staff A, Licensed Practical Nurse (LPN)/Unit Manager revealed an order for oxygen to be administered at 2 liters per nasal cannula that was entered on 08/26/25 at 3 PM. When told the oxygen had been set at 4 liters per minute that week, and shown the photographs, the Unit Manager had no response. When told the nasal cannula had been found on the floor on 08/27/25 at 2:18 PM and the same oxygen tubing was observed being used by Resident #5 on 08/28/25 at 10:31 AM, the Unit Manager immediately asked another staff member to change out the tubing for a new set and had no other response. Residents Affected - Few 105579 Page 18 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review and interviews, the facility failed to ensure that it was free of medication errors for 2 of 4 sampled residents, as evidenced by a medication error rate of 14.81% with 27 opportunities due to failure to ensure that Resident #22 received medications prescribed to him and was available for him, failure to ensure Resident #86 received medications prescribed to him and was available and failure to follow physician orders for a narcotic prescribed to Resident #86.The findings included:1. An observation of medication administration pass was conducted on 08/27/25 at 5:05 PM with Staff J, Licensed Practical Nurse (LPN), who prepared medications for Resident #22. She prepared Acetaminophen 325mg 2 tablets, Vitamin C 500mg 1 tablet, Atorvastatin 40mg 1 tablet, Methocarbamol 500mg 1 tablet. After preparing the medications, Staff J was asked how many pills she had in the medicine cup and she stated, 5 pills. Staff J crushed the medications all together and added applesauce to the cup. Staff J was observed administering the 5 medications to Resident #22.Review of the physician orders for Resident #22 revealed that staff were instructed to administer Vitamin D 50mcg 1 tablet in the evening and Eliquis 5mg 1 tablet twice and day at 9:00 AM and 5:00 PM.An interview was conducted on 08/27/25 at 5:45PM, who when asked if she would verify which medications were administered during the observation of med pass, Staff, J opened the computer to Resident #22 medication record and reviewed them. The Vitamin D 50mcg or Eliquis 5mg was not signed off on the medication record. When asked how many pills she had administered during observation of med pass, Staff J stated, Acetaminophen, Vitamin C, Atorvastatin, Methocarbamol. When asked why she didn't administer the Vitamin D 50mcg and Eliquis 5mg, she stated, I did administer the Vitamin D. Staff J was reminded that she only had 5 pills in the cup, which was the Acetaminophen 2 tablets, Vitamin C 1 tablet, Atorvastatin 1 tablet and Methocarbamol 1 tablet, which made 5 pills. Staff J stated, You're right. When asked why she didn't administer the Eliquis, Staff J stated, I don't have it. I have to look for it, it may be in the pyxis.An interview was conducted on 08/28/25 at 9:37 AM with Staff E, LPN, who was asked about the Eliquis medication prescribed to Resident #22. She looked in the medication cart and could not find the medication. Staff E, stated, Let go check and see if it's in the med room. Staff E came back to the medication cart without medication. She stated, Let me check when the last time the medication was reordered. Staff E looked in the computer and stated, The medication was last ordered on 08/12/25. I will reorder it. 2. An observation of medication administration pass was conducted on 08/27/25 at 5:20 PM with Staff K, Registered Nurse (RN), who prepared Oxycodone 15mg 1 tablet for Resident #86. She stated The resident is supposed to get Folic Acid, but I can't find it. I'm going to go ahead and give him the Oxycodone. Staff K was observed administering 1 pill to Resident #86. After administering the medication, Staff K stated, I'm going to check the medication room to see if the Folic Acid is in the overflow. She came out of the medication room with a bottle of folic acid and stated, This is not the right dose, but I'm going to give him this one. Staff K was asked if the nurse could order medications from the computer directly and she stated, Yes. When asked could you tell when the last time the Folic Acid was reordered, Staff K looked in the record and stated, It said the last time is was reordered was 03/15/25, but I will call the pharmacy to confirm. Staff K placed a call to the pharmacy, and confirmed, per the pharmacy, that the last time the folic acid was reordered was on 03/15/25. Staff K stated, I will call the doctor to make him aware that the medication was not available to give to the resident. Review of a physician order dated 05/16/25 instructed staff to administer Oxycodone 15mg Immediate Release 1 tablet three times a day at 6:00 AM, 1:00 PM and 10:00 PM. Review of the MAR documented the administrfative times were scheduled at 12:00 AM, 12:00 PM, 6:00 PM. An interview was conducted on 08/28/25 at 11:05 AM with the Director Of Nursing (DON) who was made aware of Residents Affected - Few 105579 Page 19 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the order for Oxycodone HCL 15 mg and that the times scheduled on the Medication Administration Record (MAR) did not coinciding with what the physician orders for administration. The DON stated, I will look at the order, but there should be an actual script uploaded in the resident's record, because he is seen by pain management outside of the facility.Review of the prescription dated 05/16/25 with the DON, written for Resident #86, instructed staff to administer Oxycodone HCL 15 mg three times a day at 6:00 AM, 1:00 PM, and 10:00 PM. Photographic Evidence Obtained.Review of the August 2025 MAR for Resident #86 revealed Oxycodone Hcl 15 mg was being administered by staff at 12:00 AM, 12:00 PM, and 6:00 PM. 105579 Page 20 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the laboratory test was completed as ordered for 1 of 5 sampled resident records reviewed, Resident #5. The findings included: Record review revealed Resident #5 was re-admitted to the facility on [DATE], with diagnoses that included Diabetes and cancer. Review of the care plan, revised on 08/04/25, noted that Resident #5 was at risk for nutritional problems due to type 2 Diabetes, altered nutrition-related lab values, Dysphagia (difficulty swallowing), and dependence on enteral nutrition. The intervention outlined in the care plan included reviewing labs as indicated.Review of physician orders dated 08/22/25 revealed that a blood laboratory test for A1C (a test that measures the average blood glucose levels over the past two to three months) was ordered. There was no evidence that the A1C test was completed, as the test result could not be found in the records. There was no documentation revealing that the test was refused. On 08/28/25 at 9:19 AM, the Director of Nursing (DON) was interviewed regarding the A1C level. After reviewing the records, she stated, she didn't see it under results in the computer system. She said she would check the lab book to see if it was recorded there. The DON confirmed that she could not locate the test result. Residents Affected - Few 105579 Page 21 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

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 observation, interview, and record review the facility failed to ensure infection control standards for 4 of X34 sampled residents as evidenced by the failure to ensure timely contact precautions for Resident #33 who had symptoms of C-diff (Clostridium difficile, a highly contagious infection characterized by diarrhea); failure to collect a stool sample timely to ensure timely treatment for C-diff for Resident #51; failure to follow contact precautions during the medication pass observation for Residents #51 and #22; and failure to follow Enhanced Barrier Precautions (EBP) for Resident #129. The findings included:1. Record review revealed Resident #33 was admitted to the facility on [DATE]. A stool sample was collected on 07/13/25 with reports of C-diff positive results reported to the facility on [DATE] at 11:16 AM. This result was reviewed by facility staff on 07/16/25 at 8:08 PM. Residents Affected - Few Review of progress notes revealed Resident #33 had frequent loose stools as of 07/13/25 and an order to collect the stool sample was received and collected the same day. Further review of the orders revealed contact precautions were not initiated until 07/15/25, two days after the identification of loose stools. 2. Record review revealed Resident #51 was admitted to the facility on [DATE]. A physician order dated 07/20/25 documented staff were to collect a stool sample to rule out C-diff. A stool sample was collected on 08/07/25, 18 days after the order, which indicated the resident had C-diff. Review of the Certified Nursing Assistant (CNA) documentation revealed Resident #55 had loose/diarrhea stools on 07/20/25 during the day shift; on 07/21/25 during the day and evening shifts, on 07/22/25 during the day shift; on 07/23/25 during the day shift; on 07/24/25 during the evening shift; and on 07/25/25 during the day shift. The stool specimen was not collected during any of those shifts. During an interview on 08/27/25 at 3:54 PM, when asked the reason the stool sample was not collected as per the physician order of 07/20/25, Staff A, Licensed Practical Nurse (LPN) / Unit Manager stated she thought the resident did not have an appropriate specimen, meaning no loose/diarrhea stools. The Unit Manager was made aware of the CNA documentation of numerous loose/diarrhea stools and agreed with the findings. 3. Record review revealed Resident #51 was readmitted to the facility on [DATE] with a medical diagnosis of Extended Spectrum Beta Lactamase bacteria (ESBL/contagious infection) in the urine. Review of the physician orders dated 08/25/25 instructed staff to administer Fosfomycin Tromethamine Oral Packet 3 GM 1 packet by mouth one time a day for ESBL in the Urine. An observation was conducted on 08/27/25 at 10:00 AM of Resident #51, who was noted to have a blue sign on her door that stated Contact Precautions (need to wear gown and gloves to prevent an infection). Staff L, LPN, entered Resident #51's room and placed a medication cup and 1 nasal spray and 1 inhaler directly on the resident's bedside table without a barrier. Staff L proceeded to check the resident's blood pressure with a blood pressure cuff that she placed on the resident's wrist. Staff L did not wash her hands when she entered the resident's room or prior to touching the resident. Staff L did not apply a gown or gloves prior to providing care to the resident. Staff L administered the medications in the cup. She donned gloves then assisted the resident with administering the nasal spray. Staff L offered the resident something to clean her nose with and handed the resident a paper towel that was laying on the bedside table. She prepared the inhaler to give to the resident, but she 105579 Page 22 of 23 105579 08/28/2025 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few could not get the inhaler to work. Staff L left the resident's room and put the blood pressure cuff that she used on Resident #51 directly on the medication cart without cleaning it. She proceeded down the hallway to get another nurse to assist her with the inhaler. Staff I, UM, came to the medication cart and took the same wrist blood pressure cuff, without cleaning it, and was observed checking Resident #45 blood pressure with the wrist blood pressure cuff. Staff L came back to the medication cart and the other nurse demonstrated to her how to use the inhaler. Staff L took the inhaler and as she was getting ready to walk back into Resident #51's room, Staff I, UM stopped her and stated Look up and read the instructions on the door. At that time Staff L applied her PPE before proceeding into the resident's room. 4. Record review revealed Resident #129 was admitted to the facility on [DATE] with a primary diagnosis of necrotizing fasciitis, a bacterial infection affecting the tissue under the skin called fascia. The care plan dated 08/05/25 documented Resident #129 was at risk for skin breakdown due to a surgical wound on the right posterior leg. An intervention documented in the care planb included enhanced barrier precautions (EBP). Review of the progress notes for 08/05/25 documented Resident #129 had a primary diagnosis of necrotizing fasciitis and had undergone debridement of the right calf. Review of the physician orders dated 08/06/25 included enhanced barrier precautions related to the right calf wound. On 08/25/25 at 10:40 AM while the surveyor was standing in the hallway near Resident #129's room, it was observed that the resident's door was wide open and two staff members, the wound care nurse and a nurse practitioner, were providing wound care for the right calf. Notably, neither staff member was wearing a gown. At 10:43 AM, when the wound care nurse approached the door to obtain items from the treatment cart, an interview was conducted with her. She confirmed that they were caring for the resident's surgical leg wound. On 08/28/25 at 11:21 AM, the Director of Nursing (DON) was interviewed. She was informed about concerns regarding the observed lack of EBP in which the nurse practitioner and the wound care nurse performed wound care without wearing gowns. 105579 Page 23 of 23