Inspection·January 21, 2022

F 0563 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some process. The Administrator stated they were encouraging outdoor visits because of the outbreak, but if people want to come in we let them come in. The Administrator explained they were trying to schedule visits to keep track of how many people were in the facility for monitoring. The Administrator stated all Hospice residents could have family members anytime. When asked how the families were informed of the visitation status, the Administrator stated via call multipliers, which were messages recorded by the Administrator and sent out to residents and families via phone. The Administrator was informed that the receptionist was telling visitors they had to visit outside and per a scheduled appointment. The Administrator stated she was unaware the families were being told they had to schedule a visit. Review of the call multiplier message of 11/15/21, revealed the Administrator stated, . we will continue to suggest that appointments are made to visit your loved ones, however they are not required. Outdoor visits will continue to be preferred if your loved one which is our resident is not vaccinated. Review of the call multiplier message of 12/15/21, revealed the Administrator stated, We will be encouraging outdoor visitation, we will also appreciate if you could try to schedule your visitation so your loved one is ready when you arrive. 1. On 01/19/22 at 4:08 PM, Resident #16 was observed on the front outdoor patio with three visitors, one of whom was her adult son. When asked if the facility staff was allowing them to visit inside the facility, the son stated, No. They told us we weren't allowed. The family expressed that they don't mind some patio visits, understanding the potential for contracting the COVID-19 virus during the pandemic, but stated there were times when Resident #16 can't find something, and they just need to go in and help her rearrange her personal items or look for something she misplaced. During this interview, Staff E, the Concierge/Receptionist left the building headed for the parking lot, and the son followed her out to ask her a question. Upon return, the son explained he just asked Staff E if they were still on the schedule for next week's visit. When asked if they are only being allowed to visit their mom via appointment, the son stated yes, and explained they were told they need to make appointments. Resident #16 voiced she would like her family to be able to visit with her inside the facility. Review of the record revealed Resident #16 was admitted on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the admission MDS dated [DATE] documented it was very important to have her family involved in discussion about her care. 2. On 01/20/22 at 10:14 AM, Resident #148 was observed on the front outdoor patio, visiting with his spouse. The spouse explained Resident #148 had just returned to the facility this past Wednesday (01/12/22), after an extended leave at home. The spouse stated when she arrived at the facility on 01/12/22 with the resident's personal items, the receptionist informed her she could not go into the building because they were having an outbreak, referring to the COVID-19 pandemic with staff and / or residents who had tested positive for the virus. The spouse further explained the receptionist informed her she had to visit outside for 20 to 40 minutes as per a visitation schedule. During a subsequent interview on 01/20/22 at 10:54 AM, Resident #148 was in his room. When asked if he would prefer indoor or outdoor visitation with his wife, Resident #148 stated, Definitely inside, like it was before. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 2 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 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 0563 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the record revealed Resident #148 was originally admitted to the facility on [DATE], with the most recent readmission on [DATE]. Review of the Admission/readmission Nursing Evaluation date 01/12/22 documented Resident #148 was alert and oriented to person, place, time, and situation. 3. On 01/20/22 at 1:11 PM, Resident #149 was observed on the front outdoor patio visiting with his wife. The wife explained Resident #149 had been at the facility a week and that she had never been in his room. The wife explained she had followed the van from the hospital late on the afternoon of his admission and was not allowed into the facility. The wife stated on Friday 01/14/22, a woman at the front desk told her she could only have two outdoor visits a week, for one hour total. The wife explained it was difficult to keep up with his laundry if not allowed in to see what was dirty and needed to be taken home to wash. Resident #149 was covered with a blanket and the wife stated he had run out of clean slacks and wasn't wearing any, and that she had brought him more, but further stated she would like to go inside and find his clothes. Resident #149 stated he would like his wife to visit inside and help him with his clothes. 4. Review of the record revealed Resident #33 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], documented Resident #33 had a BIMS score of 15, indicating the resident was cognitively intact. On 01/20/22 at 1:31 PM, Resident #33 was observed on the outdoor front patio with her mother. The resident's mother stated the receptionist told her unless a resident is receiving Hospice services, visits have to be scheduled and outside. Resident #33 was on Hospice and said her mother was allowed inside to visit. During this interview Resident #33 asked if her fiancée could come inside for a visit. When asked why she (Resident #33) asked this, Resident #33 stated she was told visiting hours were only until 8 PM, and sometimes her fiancée did not get off work until 8:30 PM. Resident #33 stated it was the receptionist who told her visiting hours were only until 8 PM, and no one explained she could have visitors after that time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 3 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13. Review of the record revealed Resident #8 was admitted to the facility on [DATE]. The review revealed the most current MDS comprehensive or quarterly assessment was completed on 10/14/21. The record lacked any evidence of an interdisciplinary team care plan meeting at the time of this assessment. During an interview on 01/21/22 at 1:38 PM, Staff C-MDS and the staff responsible for ensuring interdisciplinary team involvement in the care planning process, provided a paper document titled, PIC/IPOC Summary, and explained this form is what is used to show who participated. Staff C-MDS explained the meetings are usually with herself, Social Services, the Life Enrichment Director (Activities), and the CDM (Certified Dietary Manager). Staff C-MDS stated she 'researches all about the residents prior to the meetings', but confirmed she does not always get input from the direct care staff. The PIC/IPOC Summary form for Resident #8, dated 10/18/21, documented participation by Staff C-MDS, the Life Enrichment Director, and Social Services. There was no documented participation by the direct care nurse or aide, nor any representative from food and nutrition services. This form documented Resident #8 had refused participation as she had just returned from dialysis and was tired. When asked what was discussed during this plan of care conference, Staff C-MDS agreed there was no documented note in the EMR, which she stated was usually completed by the Social Worker. 14. Review of the record revealed Resident #11 was admitted to the facility on [DATE]. Further review of the record revealed the current quarterly MDS was in progress as of 01/21/21, but Staff c-MDS volunteered they had just had a care plan meeting. Review of the PIC/IPOC Summary dated 01/20/22 documented a meeting but lacked any participation by the direct care nurse or aide. 15. Review of the record revealed Resident #13 was admitted to the facility on [DATE]. Further review revealed the annual MDS was completed on 10/14/21. Review of the corresponding PIC/IPOC Summary documented a meeting with a call to the resident's sister on 10/19/21. Documented participation included only Staff C-MDS and the social services. 16. Review of the record revealed Resident #16 was admitted to the facility on [DATE]. Further review revealed the most current quarterly MDS assessment was completed on 10/27/21. Review of the corresponding PIC/IPOC Summary provided by Staff C-MDS lacked documented participation by the direct care nurse. This form documented 's/w (spoke with) CNA - reports no concerns'. The form lacked the name or signature of the CNA. 17. Review of the record revealed Resident #43 was admitted to the facility on [DATE] with the completion of the admission MDS on 11/16/21. The record revealed a PIC/IPOC Summary with a meeting date of 11/17/21. Documentation revealed participation by only Staff C-MDS, the Director of Rehabilitation Services and Social Services. This meeting lacked participation by the direct care nurse and aide, along with a representative from food and nutrition services. 18. Review of the record revealed Resident #96 was admitted to the facility on [DATE] with a re-admission on [DATE]. The admission comprehensive MDS was completed on 12/03/21. The record contained a scanned PIC/IPOC Summary form dated 12/10/21 with documented participation by the Director of Rehabilitation services and Social Services. Staff C-MDS stated she forgot to sign the form. Staff C-MDS agreed there was no participation by the direct care nurse and aide, the Life Enrichment Director or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 4 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 a representative from food and nutrition. Level of Harm - Potential for minimal harm 7. On 01/21/22 at 12:12 PM, review of Resident #1's electronic health record (EMR) with Staff C-MDS, documented the last two care plan conferences with signature forms, that showed: Residents Affected - Some -10/08/21: Four signatures to include MDS, Activities, Dietary, and Social Services. A notation was made the stated, CNA reports no changes, but it did not indicate which CNA was asked about Resident #1's status. -01/04/22: Four signatures to include MDS, Activities, Dietary, and Social Services. A notation was made that stated, no changes per CNA, but it did not indicate which CNA was asked about Resident #1's status. There was no evidence that the direct care nurse or CNA participated in the care plan conference. 8. On 01/21/22 at 12:12 PM, review of Resident #36's EMR with the Staff C-MDS documented the last two care plan conferences signature forms that showed: -08/13/21: Four signatures to include MDS, Activities, Dietary, and Social Services. A notation was made that stated, spoke with CNA-no concerns, but it did not indicate which CNA was asked about Resident #36's status. -11/17/2021: Four signatures to include MDS, Activities, Dietary, and Social Services. A notation was made that stated, CNA reports no concerns, but it did not indicate which CNA was asked about Resident #36's status. There was no evidence that the direct care nurse or CNA participated in the care plan conference. 9. Review of Resident #29's quarterly care plan conference summary, dated 11/19/21, documented participation by Social Services, Dietary, Activities and the MDS Coordinator. Review of the care plan conference summary for Resident #29, dated 12/03/21, documented participation by Social Services, Dietary, Activities and the MDS Coordinator. There was no evidence of any point of care staff having participated in either of Resident #29's care plan meetings. 10. Review of Resident #26's quarterly care plan conference summary, dated 11/02/21, documented participation by Social Services, Dietary, Activities and the MDS Coordinator. There was no evidence of any point of care staff having participated in the care plan meeting. 11. Review of Resident #60's quarterly care plan conference summary, dated 01/03/22, documented participation by Social Services, Dietary, Activities and the MDS Coordinator. The care plan conference summary documented that a CNA 'reports no changes resident is total care', but there was no evidence that the CNA or any point of care staff participated in the care plan meeting. 12. Review of Resident #73's quarterly care plan conference summary, dated 12/29/21, documented participation by Social Services, Dietary, Activities and the MDS Coordinator. There was no evidence of any point of care staff having participated in the care plan meeting. Based on interview and record review, the facility failed to ensure and document interdisciplinary team participation of the nurses, certified nursing assistants or possibly other appropriate staff or professionals including the medical director, in the care planning process for 18 of 22 sampled residents reviewed, Residents #10, #28, #44, #21, #6, #35, #1, #36, #29, #26, #60, #73, #8, #11, #13, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 5 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 #16, #43 and #96. Level of Harm - Potential for minimal harm The findings included: Residents Affected - Some 1. Review of Resident #10's records revealed the quarterly comprehensive assessment was completed on 10/18/21. The care plan review was started on 10/25/21 and completed on 11/05/21. The care conference was held on 10/20/21 with the interdisciplinary team (IDT) participation that included: the social services, activity, dietary and the MDS coordinator. There was no evidence of the direct care nurse and certified nursing assistants (CNAs) participation in this care plan review. On 01/21/22 at 8:25 AM, an interview was held with the Minimum Data Set (MDS) Coordinator (Staff C-MDS), who, when asked how the facility ensures the direct care nurse and CNAs participate in the care planning process of the Resident #10, Staff C-MDS stated that 'direct care nurse does not participate, she's (MDS) a nurse, she covers that, the CNAs do not participate as well'. 2. Review of Resident #28's records revealed the quarterly comprehensive assessment was completed on 11/09/21. The care plan review was started on 11/15/21 and completed on 11/15/21. The care conference was held on 11/15/21 with IDT participation that included: the social services, activity, dietary and the MDS coordinator. There was no evidence of the direct care nurse and CNAs participation in this care plan review. On 01/21/22 at 8:30 AM, an interview was held with staff C-MDS who confirmed the finding. 3. Review of Resident #44's records revealed the quarterly comprehensive assessment was completed on 11/20/21. The care plan review was started on 11/22/21 and completed on 11/22/21. The care conference was held on 11/23/21 with IDT participation that included: the social services, activity, dietary and the MDS coordinator. There was no evidence of the direct care nurse and CNAs participation in this care plan review. On 01/21/22 at 8:37 AM, an interview was held with Staff C-MDS; she confirmed the finding. 4. Review of Resident #21's records revealed the quarterly comprehensive assessment was completed on 10/30/21. The care plan review was started on 11/01/21 and completed on 11/01/21. The care conference was held on 11/08/21 with IDT participation that included: the social services, activity, dietary and the MDS coordinator. There was no evidence of the direct care nurse and CNAs participation in this care plan review. On 01/21/22 at 8:40 AM, an interview was held with Staff C-MDS who confirmed the finding. 5. Review of Resident #6's records revealed the annual comprehensive assessment was completed on 01/07/22. The care plan review was started and completed on 01/10/22. The care conference was held on 01/11/22 with the interdisciplinary team (IDT) participation that included: the social services, activity, dietary and the MDS coordinator. There was no evidence of the direct care nurse and CNAs participation in this care plan review. On 01/21/22 at 8:43 AM, an interview was conducted with Staff C-MDS, she confirmed the finding with no evidence of direct care nurse and CNAs participation in the care planning review. 6. Review of Resident #35's records revealed the quarterly comprehensive assessment was completed on 11/07/21. The care plan review was started on 11/05/21 and completed on 11/09/21. The care conference was held on 11/15/21 with IDT participation that included: the social services, activity, dietary and the MDS coordinator. There was no evidence of the direct care nurse and CNAs participation in this care plan review. On 01/21/22 at 8:53 AM, an interview was held with Staff C-MDS who confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 6 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 the finding. Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 7 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 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 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 observation, interview and record review, the facility failed to provide restorative nursing services as prescribed by therapy for 1 of 1 sampled resident reviewed, Resident #21. The findings included: Clinical record review evidenced Resident #21 was admitted to the facility on [DATE] with diagnoses that included: anxiety disorder. The quarterly minimum data set (MDS) assessment, reference date 10/30/21, evidenced a brief interview for mental status (BIMS) score of 11 of 15, indicating Resident #21 was moderately impaired in cognition. On 01/18/22 at 11:11 AM, during an interview with Resident #21, she stated, 'she wanted to go to therapy, because she lays down a lot, she wants to walk, she has a throbbing in her tail bone, she was not receiving therapy services currently'. On 01/21/22 at 9:28 AM, an interview was held with the Rehabilitation (Rehab) Director, who revealed Resident #21 was discharged from Physical and Occupation therapy with all goals met in June 2021, and that the Restorative Nursing Program (RNP) was to follow up. The Rehab Director said the RNP that was given was for upper body range of motion exercise; and therapy had given the referral to the restorative nursing program Director. During the interview process, the Rehab Director presented therapy documents that revealed Resident #21 was under their Physical Therapy (PT) case load from 05/14/21 through 06/04/21 and Occupational Therapy (OT) from 05/14/21 through 06/10/21. The 'PT discharge status and recommendations' record, dated 06/05/21, recorded that Resident #21 was placed on restorative nursing program (RNP) to facilitate patient maintaining current level of performance and in order to prevent decline. The 'PT development of and instructions' in the RNPs had been completed with the interdisciplinary team (IDT) for ambulation and transfers. Also, during the interview process, the Rehab Director presented documents that revealed the 'OT discharge status and recommendations' record, dated 06/16/21, recorded RNP was in place for bilateral upper extremities. Review of the restorative referral program care plan, signed and dated 06/01/21, recorded Resident #21 will participate during exercises using 1 lb (pound) dumbbell 3 sets x 15 reps of all planes as tolerated and active range of motion. review of another restorative referral program care plan, signed date 06/25/21, recorded Resident #21 was to receive gait training, and ambulation. On 01/21/22 at 9:44 AM, an interview was held with Staff B-RNP/ICP (Infection Control Preventionist) Director, who explained that Resident #21 was under the RNP from June 2021 until present ([DATE]) and that Resident #21 was supposed to be ambulated by the restorative staff, 5 days a week. When the surveyor asked Staff B-RNP/ICP for evidence of restorative nursing services provided, she voiced the restorative staff were to document the services under the evaluation tab in the computer system. A side by side review of the computer system record in search of documentations for providing RNP services was conducted with Staff B-RNP/ICP. She confirmed that there was no documenation except for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 8 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 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 0688 Level of Harm - Minimal harm or potential for actual harm one documented RNP service, dated for 01/21/22, which she had started during the interview with the surveyor and it was incomplete. She said she initiated it in error. There were no other documentations in the computer system and the physical chart to account for providing restorative nursing services as prescribed by therapy from June 2021 until present (January 21, 2022). Residents Affected - Few Staff B-RNP/ICP indicated that she was going to find out what happened with documentations. On 01/21/22 at 10:28 AM, Staff A, the regional nurse consultant/RNC, and Staff B-RNC/ICP was observed reviewing Resident #21's records. An interview was held with them both during that time. The surveyor had requested for evidence of RNP services for Resident #21. Staff A-RNC explained Resident #21 was supposed to be on RNP services for 5 days a week. The referral was to increase ambulation and gait training 5 x a week. When Staff B-RNP/ICP was asked how she was monitoring the restorative nursing program to ensure the resident was receiving services, Staff B-RNP/ICP stated there was no restorative nursing program in place for Resident #21. She stated that her main focus had been on covid; she hadn't had a structured specific RNP in place for Resident #21; and she is also the infection control nurse. Staff A-RNC and Staff B-RNP/ICP both confirmed there was no restorative nursing program in place for Resident #21. During this interview process, Staff B-RNP/ICP was noted to be putting the RNP order in the computer system, dated 01/21/22, that read, restorative nursing-ambulation-gait training 5x a week for 4 weeks. During this time, Staff B-RNP/ICP was also putting a care plan, dated 01/21/22, that read, 'Resident #21 is on a restorative program for ambulation 5x a week, one of the interventions included: assist to walk distance 5 days/week using: 2 persons assist/contact guard'. During this same interview, Staff B-RNP/ICP also put an order under the task section in the computer system that read, 'gait training 5 x a week for 4 weeks'. On 01/21/22 at 11:15 AM, the Director of Nursing (DON) joined the interview process and was made aware of the concerns The DON voiced, the facility had been focusing on covid. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 9 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure weekly weights were completed, as recommended by the Registered Dietician (RD), for 1 of 3 sampled residents, who subsequently had significant weight loss, Resident #11. Residents Affected - Few The findings included: Review of the record revealed Resident #11 was admitted to the facility on [DATE], with a four day hospitalization beginning on 11/18/21, and a readmission on [DATE]. During an interview on 01/19/22 at 8:58 AM, Resident #11 stated she was unsure of any weight loss. Review of the weight history and nutritional assessments for Resident #11 revealed the following: -On 10/15/21, the Registered Dietician (RD) completed an initial nutritional assessment. The resident's documented weighed was 115 pounds, which was appropriate for her height of 57 inches. No nutritional interventions were warranted at that time. -On 10/31/21, the resident weighed 111.2 pounds. -On 11/16/21, the resident weighed 111.7 pounds. -On 11/23/21, a nutritional note revealed the resident had a facility acquired pressure ulcer and the House Supplement was ordered. -On 12/06/21, the resident weighed 105.8 pounds. A subsequent note, dated 12/07/21, documented a significant weight loss and the addition of a daily House Shake, and facility staff were to obtain weekly weights. -No weight was recorded for 12/13/21. -On 12/16/21, the resident weighed 103.8 pounds. The record lacked any weights for the next two weeks (week of 12/19/21 and 12/26/21). A progress note, dated 12/30/21 by the RD, documented the 12/16/21 weight of 103.8 pounds with no current weight available. An observation by the RD revealed the resident needed assistance with set up of meals and consuming meals. The amount of House Supplement was increased. On 01/03/22, the resident weighed 93.4 pounds. On 01/04/21 the RD added a magic cup and a referral to Occupational Therapy (OT). On 01/10/22, the resident weighed 91.2 pounds, and Megace, a medication to stimulate a person's appetite, was started. On 01/17/22, the resident weighed 92.4 pounds. On 10/31/21, Resident #11 weighed 111.2 lbs. On 01/17/22, Resident #11 weighed 92.4 pounds, which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 10 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is a 16.91% weight loss in approximately 2 1/2 months. The facility failed to obtain any weights between 12/16/21 and 01/03/22, during which time the resident lost ten pounds. During an interview on 01/20/22 at 3:58 PM, the RD was asked the facility process for obtaining weights. The RD explained she ensures a list is provided to the restorative Certified Nursing Assistants (CNAs) each Friday. The RD stated the restorative aides obtain the weights over the weekend so that she can review them each Monday. The RD stated the week of 12/30/21, weights may have not been done as she was on vacation, although she had told the facility she would monitor the weights while she was gone. The RD further explained that Staff B, the Infection Control Preventionist (ICP) and Restorative Nurse Program Director (Staff B-ICP/RNP), is also over the Restorative Program and puts the weights into the electronic medical record. The RD located an email to Staff B-ICP/RNP, dated 12/14/21, regarding the lack of weights for the week. The RD confirmed the lack of weights for Resident #11 and stated obviously there is always something that can be done when she notes a weight loss. The RD stated the staff depend heavily on getting that list from herself in order to obtain the residents' weights. Regarding the documented observation on 12/30/21 that revealed Resident #11 needed assistance, the RD explained that it was just an observation, and because she did not have a current weight, she didn't do the referral to OT at that time. During an interview on 01/20/22 at 4:40 PM, Staff B, the ICP/RNP was asked the process for obtaining residents' weights. Staff B explained the RD provides a list of residents needing to be weighed on Tuesday or Friday each week, and the restorative aides obtain the weights over the weekends. Copies of the weights are routinely provided to herself, the RD, the Administrator, the Director of Nursing and the Certified Dietary Manager. Staff B-ICP/RNP stated she enters the weights into the electronic medical record Monday mornings. She explained if any resident refused to be weighed over the weekend, she would try to encourage and obtain the weight and a note would be put into the record. She explained the weights are then discussed in morning meetings on Tuesdays. Staff B-ICP/RNP stated she was also on vacation the week of 12/26/21, at the same time as the RD. During a subsequent interview on 01/20/22 at 5:45 PM, the RD and Staff B-ICP/RNP provided evidence that some weights were done on 12/20/21, but not for Resident #11. The RD further explained the weekly weights are not put in as an order, but she keeps a running log of residents, along with who needs weekly weights and emails that log to the managers. The RD stated she was still unsure as to why Resident #11 did not have weekly weights for the two weeks in question. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 11 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and job description review, the facility failed to ensure there was sufficient nursing staff to provide nursing services to residents on the 100 unit. This failure was evidenced by the failure to ensure there was a nurse for 1 of 4 facility units (100A-unit) on 01/19/22, and as evidenced by staff failure to ensure weekly weights were done for 1 of 3 sampled residents, Resident #11; failed to provide restorative services for 1 of 1 sampled resident, Resident #21; and a sampled resident who voiced concern of lack of staff, Resident #23. The findings included: 1. Review of the staff assignments posted at the nurse's station for the 100 unit on 01/19/22 at 11:04 AM, revealed only one nurse, Staff I, a Licensed Practical Nurse (LPN), was listed as the nurse for 100B. There was no nurse listed for the 100A section of residents. The census for the 100 unit at the time of entrance was 39. When asked if they ran with just one nurse on the 100 unit on the day shift, the Director of Nursing (DON) stated, No, of course not. When asked who the second nurse was for the 100 units, the DON looked at the posted schedule and stated she was unsure, but she would go speak with the Staffing Coordinator. Staff H, the Unit Manager (UM), arrived at the nurse's station. During the same interview on 01/19/22 at 11:04 AM, when asked who the second nurse was for the 100 unit, the Staff H-UM stated, Someone called in and they were supposed to get a replacement. When asked if the replacement had showed up yet, Staff H-UM stated they had not. When asked if the residents on the 100A had gotten their morning medications or been attended to by a licensed staff that morning, Staff H-UM looked down the hall and stated, (Name of Staff I, Licensed Practical Nurse/LPN) was working on them now. Staff I was noted at the medication cart at the end of the low 100 hall (100A assignment). When asked why she (UM) did not assist with the morning medication pass, the Staff H-UM stated, Because I've been pulled in so many directions this morning. During an interview on 01/19/22 at 11:12 AM, Staff I-LPN was observed at the end of the low 100s hall, She stated she was given report for the 100B assignment and half (the low 100s) of the 100A assignment that morning, and had just finished with all of her assignment. When asked about the resident in the 140s (the other half of the 100A assignment), Staff I stated she was unsure but sometimes the nurse for the 140s (unit) also has the 240s (unit) upstairs. On 01/19/22 at 11:13 AM, a nurse (Staff D-LPN) entered the nurse's station, putting down his personal items as if he just arrived. Staff D-LPN explained he was asked yesterday to come in early today to help out. Staff D-LPN stated he normally works 3 PM to 11 PM, and clarified he was asked to come in whenever he could. When asked what he was assigned to do now that he was at the facility, he stated, I don't know. I'll go talk to (name of Unit Manager of the 200 unit). On 01/19/22 at 11:17 AM, the DON explained that Staff H-UM for the 100 unit, was supposed to cover the 100A assignment for the day shift, as per the Staffing Coordinator. The DON stated Staff H-UM told her she forgot. Observations and interviews were completed for the eleven residents in the 140s (the assignment that has not been attended to) as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 12 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some -On 01/19/22 at 11:22 AM, Resident #63 was not in his room. At 11:33 AM, the resident was noted in the hallway. He was unsure if he had his morning medications. Resident #63 had a Brief Interview for Mental Score (BIMS) of 14, indicating he was cognitively intact. -On 01/19/22 at 11:23 AM, Resident #149 stated he was getting all his medications at night as they said, 'they can't get them in the day. Stated he would prefer his medications during the day. (Brand new admit; no BIMS and I didn't get his admit assessment). -On 01/19/22 at 11:25 AM Resident #11 could not recall if she had gotten her morning medications. BIMS = 15. -On 01/19/22 at 11:27 AM, Resident #70 stated she had not received her morning medications. Resident #70 had a BIMS score of 14, indicating the resident was cognitively intact. -On 01/19/22 at 11:28 AM Resident #16 stated he had not received his morning medications. Resident #16 had a BIMS score of 15, indicating the resident was cognitively intact. -On 01/19/22 at 11:28 AM, Resident #13 stated she got her medications early that morning and was not waiting on anything. BIMS = 8, indicating moderate cognitive impairment. -On 01/19/22 at 11:30 AM, Resident #43 stated he is was not aware of any need for medications. BIMS = 5, indicating moderate to severe cognitive impairment. -On 01/19/22 at 11:32 AM, both Residents #24 and #71 were unsure about their medications. BIMS 12 (moderate cognitively impairment) and 04 (severe cognitive impairment). -Two of these eleven residents (Residents #85 and #96) were not in their rooms at the time of these observations and interviews. During an interview on 01/19/22 at 11:35 AM, the Staffing Coordinator confirmed Staff H-UM, for the 100 unit, was supposed to cover 100A that morning. The Staff Coordinator explained she had a call off at about 3 PM on 01/18/22 for this morning's shift. The Staff Coordinator stated she let the DON and Assistant DON (Unit Manager of the 200 Unit) know, and then 'called all of her nurses'. The Staffing Coordinator stated she was unable to cover the shift, so she informed Staff H-UM last evening before leaving at about 4 PM, that she would need to cover the 100A assignment this morning. The Staffing coordinator stated the UM said it would not be a problem. Review of the signed job description for Staff H, the Unit Manager, titled Clinical Services Coordinator dated 11/2018 and signed on 01/12/22, documented Essential Functions: . Assist with clinical assessments and evaluations of residents. Assist with provision of medications and treatments. Prepare and adjust scheduling of unit personnel to provide appropriate staffing on a 24 hours/day, 7 days a week basis, in collaboration with Staffing coordinator. 2. Refer to F692 for details. Review of the record revealed Resident #11 was admitted to the facility on [DATE], with a four day hospitalization beginning on 11/18/21, and a readmission on [DATE]. Review of the weight history for Resident #11 revealed staff failed to obtain weekly weights for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 13 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #11 the weeks of 12/19/21 and 12/26/21. During this time gap, the resident had a significant weight loss of 10 pounds. During an interview on 01/20/22 at 3:58 PM, the Registered Dietician (RD) was asked the facility process for obtaining weights. The RD explained she ensures a list is provided to the restorative Certified Nursing Assistants (CNAs) each Friday. The RD stated the restorative aides obtain the weights on the weekend so that she can review them each Monday. The RD stated for the week of 12/30/21, weights may have not been done as she was on vacation, but had told the facility she would monitor the weights while she was gone. The RD further explained that Staff B-RNC/ICP, the Infection Control Preventionist (ICP) / Restorative Nursing Program Director (RNP), is also over the Restorative Program and puts the weights into the electronic medical record. The RD found an email to Staff B-RNP/ICP, dated 12/14/21, regarding the lack of weights for the week. The RD confirmed the lack of weights for Resident #11. The RD stated the staff depend heavily on getting that list from herself in order to obtain the resident weights. During an interview on 01/20/22 at 4:40 PM, Staff B-RNP/ICP, was asked the process for obtaining resident weights. Staff B-RNP/ICP explained the RD provides a list of residents who need to be weighed on Tuesday or Friday, and the restorative aides obtain the weights on the weekends. Copies of the weights are routinely provided to herself, the RD, the Administrator, the Director of Nursing and the Certified Dietary Manager. Staff B-RNP/ICP stated she was also on vacation the week of 12/26/21, at the same time as the RD. During a subsequent interview on 01/20/22 at 5:45 PM, the RD stated she was still unsure as to why Resident #11 did not have weekly weights for the two weeks in question. An interview on 01/21/22 at approximately 5:00 PM with the Staffing Coordinator confirmed that managerial staff have been covering direct care duties. 3. On 01/18/22 at 2:52 PM, an interview was conducted with Resident #23, who stated, 'her concern was that the facility was shorthanded, they don't have enough staff, sometimes when she calls, it takes 1 to 1 hour and half for the staff to answer the call light' 4. Refer to F688 for details. Clinical record review evidenced Resident #21 was admitted to the facility on [DATE] with diagnoses included: anxiety disorder. The quarterly minimum data set (MDS) assessment, reference date 10/30/21 evidence a brief interview for mental status (BIMS) score of 11, indicating Resident #21 was moderately impaired in cognition. On 01/18/22 at 11:11 AM, during an interview with Resident #21, she stated she wanted to go to therapy, because she lays down a lot, she wants to walk, she has a throbbing in her tail bone, she was not receiving therapy services currently. On 01/21/22 at 9:28 AM, an interview was held with the Rehabilitation (Rehab) Director who revealed Resident #21 was discharged from Physical and occupation therapy with all goals met in June 2021, and restorative nursing program was to follow up. The Rehab Director revealed that the restoration nursing program was given for upper body range of motion exercises; therapy had given the referral to the Restorative Nursing Program (RNP) Director. The physical therapy discharge status and recommendations record, dated 06/05/21, recorded Resident #21 was placed on the RNP to facilitate the patient (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 14 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some maintaining current level of performance and in order to prevent decline. The development of and instructions in the following RNP's had been completed with the interdisciplinary team (IDT) for ambulation and transfers. Review of the occupational therapy (OT) discharge status and recommendations record, dated 06/16/21, recorded the RNP was in place for bilateral upper extremities. The restorative referral program care plan, signed date 06/01/21, recorded Resident #21 will participate during exercises using 1 lb (pound) dumbbell 3 sets x 15 reps (repetitions) of all planes as tolerated and active range of motion. Another restorative referral program care plan, signed date 06/25/21, recorded Resident #21 to receive gait training, and ambulation. On 01/21/22 at 9:44 AM, an interview was held with Staff B-RNP Director, who explained, Resident #21 was under RNP from June 2021 until present ([DATE]), and was supposed to be ambulated by the restorative staff, 5 days a week. When the surveyor for evidence of restorative nursing services provided, Staff B-RNP voiced the restorative staff were to document the services under the evaluation tab in the computer system, but there was no documentations for providing RNP services to the resdient. There was one documented RNP service, dated for 01/21/22, which was incomplete and started by Staff B-RNP during the interview with the surveyor. There were no other documentations in the computer system and the physical chart to account for providing restorative nursing services as prescribed by therapy from June 2021 until present (January 21, 2022). On 01/21/22 at 10:28 AM, Staff A (the Regional Nurse Consultant - RNC) and Staff B-RNP confirmed there was no restorative nursing program in place for Resident #21. Staff A-RNC voiced that she is planning to revamp the program and have a plan of correction in place. At 11:15 AM, the Director of nursing (DON) joined the interview process, was made aware of the concerns, and the DON voiced that the facility had been focusing on covid. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 15 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 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 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** 2. Review of the record revealed Resident #11 was admitted to the facility on [DATE], had a 4-day hospitalization beginning on 11/18/21, and was readmitted to the facility on [DATE]. The record revealed Resident #11 had a stage IV pressure ulcer and was being seen by an infectious disease physician to rule out osteomyelitis (an infection of the bone). Further review of the record revealed a physician order, dated 12/06/21, for weekly labs to be drawn every Tuesday, related to the wound. Review of the record lacked any laboratory results for 12/21/21 and 12/28/21. Residents Affected - Few During an interview on 01/20/22 at 4:27 PM, Staff H-UM, the Unit Manager of the 100 unit, was asked the process for obtaining ordered labs. The Unit Manager explained when an order is written a requisition and laboratory sheet is put in the Lab Book (a binder with tabbed dates). The laboratory technicians draw the labs, and the results are printed up each morning. If any results are critical, they get called to the physician or nurse practitioner. Staff H-UM was asked about the ordered labs for Resident #11 for the dates of 12/21/21 and 12/28/21. Staff H-UM thought Resident #11 may have gone out to the hospital during that time, but review of the record lacked any evidence to support the leave. As of the exit conference on 01/21/22, the facility had failed to provide any additional information. 3. During an observation on 01/18/22 at 12:12 PM, a clean specimen container was noted on the top of the dresser in the room of Resident #96. This container was labeled with the resident's name, the date of 01/16/22, and documented occult blood. Photographic evidence obtained. Review of the record revealed Resident #96 was re-admitted to the facility on [DATE]. Further review of the record revealed a physician order, dated 01/13/22, to collect stool (bowel movement) for occult blood times three and discontinue the order after it was collected. The record lacked any laboratory results for the stool collection. Review of the January 2022 Treatment Administration Record (TAR) documented an entry, Collect stool for occult blood x 3 and d/c (discontinue) order after stool collected. This entry on the TAR allowed the nurses on the three shifts each day to document the completion of this task beginning on 01/13/22 on the night shift. Of the 21 opportunities, between 01/13/22 on the night shift and 01/20/22 on the evening shift, eight shifts were left blank, five shifts documented the stool was not obtained, and seven shifts documented a checkmark indicating the task was completed. The only documented bowel movement in the medical record was on 01/14/22. This was documented by Staff F-CNA, a Certified Nursing Assistant (CNA). During an interview on 01/21/22 at 10:02 AM, Staff H-UM was unable to find the occult blood results. Staff H-UM found a sheet in the lab book with a Pending Orders form, dated 01/15/22, that documented no specimen next to it. Staff H-UM explained that would have been documented by the laboratory technician if no specimen was found in the specimen refrigerator. Staff H-UM explained the night nurse should review the Pending Orders to ensure completion or continuation of the order. Staff H-UM stated the physician order will not drop off until the specimens were received. Observations of both the specimen refrigerators and the resident's room at that time lacked any specimen container for the occult stool. During a phone interview on 01/21/22 at 10:32 AM, Staff F-CNA was asked about the ordered stool collection on 01/13/22 for Resident #96 and that she had documented the resident had a bowel movement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 16 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 01/14/22. The Staff F-CNA stated she was not informed of the order for the stool collection. Staff F-CNA agreed she saw the specimen container earlier this week (indicating on 01/18/22 or 01/19/22) but she had not seen one before that time. Based on record review and interview, the facility failed to ensure laboratory tests were obtained as ordered by the physician for 3 of 9 sampled residents, Resident #4, Resident #96, and Resident #11, whose laboratory orders were reviewed. The findings included: A review of Resident #4's electronic health record showed a physician's order dated 01/14/22 for Urinary / Analysis Culture & Sensitivity. May straight cath. Discontinue order when collected. Put in order when collected. Every shift for cloudy urine. Further review of Resident #4's electronic health record showed no evidence a urine sample was collected or sent to the laboratory, including in the Results section and in the progress notes. Review of Resident #4's January 2022 Medication Administration Record (MAR) showed nurses initialed this order once on 01/14/22, twice on 01/15/22, once on 01/16/22, and twice on 01/18/22. An interview was conducted on 01/19/22 at 2:45 PM with Registered Nurse D-RN (Registered Nurse) regarding the laboratory order. He reviewed Resident #4's clinical record and was unable to find evidence the urine sample was collected. He was unable to state why the MAR was marked off multiple times. He stated when the sample is collected the order should be discontinued. An interview was conducted on 01/19/22 at 2:53 PM with the Regional Director of Clinical Services. The Regional Director of Clinical Services was unable to find results. She was unable to state why it had been checked off multiple times in the MAR. She reviewed a laboratory request sheet for Resident #4, but this was for a different laboratory test. A follow up interview was conducted with the Regional Director of Clinical Services on 01/20/22 at 9:27 AM. She stated the urine sample had not been collected at the time of the prior interview. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 17 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interview, the facility failed to ensure accuracy and completeness of residents' clinical records, as evidenced by lack of documentation of contact with physician per physician's orders for high blood sugar readings for 1 of 5 sampled residents, Resident #54, whose medication regimens were reviewed; and lack of documentation of daily medication administration items for 2 of 5 sampled residents, Resident #1 and Resident #36, whose medication regimens were reviewed. The findings included: 1. Review of Resident #54's clinical record was conducted beginning on 01/19/22. Review of Resident #54's physician's orders and the resident's December 2021 Medication Administration Record (MAR) showed an order for Humalog 100unit/ML per sliding scale parameters from 12/1/21 through 12/9/21. The order stated for blood sugar readings 351 [mg/dL] and above give 8 units and call the physician. On 12/09/21, an order for Humalog 100 unit/ML per sliding scale parameters changed the parameters to give 10 units and call the physician for blood sugar readings of 351 [mg/dL]and above. Review of Resident #54's December 2021 MAR showed Resident #54 had blood sugar readings of 351 and above on the following days: 12/05/21,12/06/21, 12/10/21, 12/11/21, 12/15/21, 12/19/21, 12/22/21, 12/23/21, 12/27/21, 12/28/21, and 12/30/21. Review of Resident #54's January 2022 MAR showed Resident #54 had blood sugar readings of 351 [mg/dL] and above on 01/02/22, 01/05/22, 01/07/22, 01/09/22, 01/12/22, and 01/16/22. Further review of Resident #54's clinical record showed no evidence the physician was contacted on the above days when the blood sugar levels were noted above 351 mg/dL. An interview was conducted with the Regional Director of Clinical Services on 01/20/22 at 3:05 PM. The Regional Director of Clinical Services reviewed Resident #54's record and was unable to find documentation that the physician had been notified. She explained the Nurse Practitioner is here everyday so they tell him directly and they should document this contact. An interview was conducted with the Nurse Practitioner on 01/20/22 at 3:14 PM. He stated he and his colleagues are informed and have been tracking Resident #54's blood sugars. An interview was conducted with the Director of Nursing (DON) on 01/20/22 at 3:19 PM. The DON stated the nurses should document their contact with the physician or nurse practitioner. 2. A review of Resident #1's clinical record was conducted beginning on 01/18/22. Review of Resident #1's December 2021 MAR showed multiple blank entries for the following days: -Atorvastatin 12/27/21 -Ciclopirox 12/25/21 and 12/17/21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 18 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 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 0842 -Artificial tears 12/27/21, 1700 (5 PM) dose Level of Harm - Minimal harm or potential for actual harm -Behavior monitoring 12/25/21 and 12/27/21 Evening (3 PM - 11 PM) -Monitoring with the use of Eliquis 12/15/21 and 12/17/21 Evenings Residents Affected - Few -Monitoring for pain 12/25/21 and 12/27/21 Evenings Review of Resident #1's January 2022 MAR showed multiple blank entries for the following days: -Monitoring with the use of Eliquis 01/03/22 Evening -Monitoring for pain 01/03/22 Evening -Monitoring for behaviors 01/03/22 Evening -Ativan 01/03/22, 2100 (9 PM) dose -Ativan 01/12/22, 2100 (9 PM) dose. 3. A review of Resident #36's clinical record was conducted beginning on 01/18/22. Review of Resident #36's December 2021 MAR showed multiple blank entries for the following days: -Respiratory monitoring 12/20/21 Day, 12/25/21 Evening and Night, 12/27/21 Evening -Dietary House Supplement 12/20/21 1400 (2 PM) dose, 12/27/21 2000 (8 PM) dose -Monitoring for behaviors 12/20/21 Day, 12/25/21 Evening and Night, 12/27/21 Evening -Monitor vital signs 12/20/21 Day, 12/25/21 Night, 12/27/21 Evening -Baclofen 12/05/21, 0600 (6 AM) dose, 12/20/21, 1200 (12 PM) dose -Cleanse left knee 12/20/21, 12/26/21 -Weekly skin check 12/22/21 -Low bed 12/04/21 Evening, 12/20/21 Day, 12/22/21 Day, 12/24/21 Night, 12/25/21 Day and Evening, 12/26/21 Day, and 12/27/21 Evening Review of Resident #36's January 2022 MAR showed multiple blank entries for the following days: -Ferrosol tablet 01/14/22, 1000 (10 AM) dose -Folic Acid 01/14/22, 1000 (10 AM) dose -Respiratory monitoring 01/14/22 Day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 19 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 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 0842 -Dietary House Supplement 01/14/22, 1000 (10 AM) dose and 1400 (2 PM) dose Level of Harm - Minimal harm or potential for actual harm -Monitoring for behavior 01/14/22 Day -Monitor vitals 01/14/22 Day Residents Affected - Few -Baclofen 01/14/22 1200 dose -Low bed 01/03/22 Day and Evening, and 01/04/22 Evening. An interview was conducted with the Regional Director of Clinical Services on 01/21/22 at 10:14 AM. The Regional Director of Clinical Services reviewed the resident's MARs and stated, 'nurses have to chart. If there is something, they may need to call the doctor'. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 20 of 21 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 105600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952 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 0886 Perform COVID19 testing on residents and staff. 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 review of the manufacturer's instructions, the Infection Control Preventionist (ICP) nurse failed to obtain the COVID-19 test sample as per manufacturer's instructions for 2 of 2 sampled resident observations (Resident #66 and #52). Interview revealed the ICP nurse had been conducting these tests in the observed manner for a few weeks, indicating the possibility of improper collection for any resident's test. Improper testing technique can lead to false negative results. Residents Affected - Few The findings included: Review of [NAME] BinaxNOW COVID-19 AG Card instructions documented, Test Procedure 1. Hold Extraction Reagent bottle vertically. Hovering 1/2 inch above the TOP HOLE, slowly add 6 DROPS to the TOP HOLE of the swab well. DO NOT touch the card with the dropper tip while dispensing. 3. Rotate (twirl) swab shaft 3 times CLOCKWISE (to the right). Do not remove swab. NOTE: False negative results can occur if the sample swab is not rotated (twirled) prior to closing the card. PRECAUTIONS . 8. Proper sample collection, storage and transport are essential for correct results. 13. Inadequate or inappropriate sample collection, storage, and transport may yield false test results. 18. INVALID RESULTS can occur when an insufficient volume of extract reagent is added to the test card. To ensure delivery of adequate volume, hold vial vertically, 1/2 inch above the swab well, and add drops slowly. 19. False Negative results can occur if the sample swab is not rotated (twirled) prior to closing the card. 22. Do not store the swab after specimen collection in the original paper packaging. If storage is needed use a plastic tube with cap. SPECIMEN TRANSPORT and STORAGE: Do not return the nasal swab to the original paper packaging. LIMITATIONS: . A negative test result may occur if the level of antigen in a sample is below the detection limit of the test. False negative results may occur if a specimen is improperly collected, transported, or handled. if inadequate extraction buffer is used (e.g. less than 6 drops) . if specimen swabs are not twirled within the test card . if swabs are stored in their paper sheath after specimen collection. During an observation on 01/20/22 at 9:18 AM, the ICP (infection Control Preventionist) nurse obtained a sterile swab and went into the room of Resident #66. The ICP nurse donned gloves, obtained the sample from both nares, placed the swab back into the paper sheath, placed it into a plastic bag, and sanitized her hands. The ICP walked from the second floor resident room down to the first floor conference room where the BinaxNOW COVID-19 Ag Cards were located. The ICP nurse opened up a clean field, quickly placed a drop or two of the Extraction Reagent onto the card, obtained the swab from the paper sheath and placed it on the card. When asked the process of sample collection for each resident, the ICP nurse explained that she starts testing the residents at 5:30 AM if they are awake, stating she goes from the resident's room to the conference room between each resident, even for those residents that reside upstairs. When asked why she does the collection in that manner, the ICP nurse explained she did not like having the cart in front of each room with people walking by. The surveyor asked for and received the manufacturer's instructions. The surveyor asked to observe an additional test collection to ensure the rotation of the swab in the test card. On 01/20/22 at 9:59 AM, a resident test observation was made for Resident #52. The ICP nurse, after previous surveyor questioning, now had a cart at the door of the resident's room with a clean field. The ICP nurse donned gloves, obtained the specimen, carefully added six drops of the Extraction Reagent to the card, placed the specimen in the card turning the swab in a back-and-forth motion. The ICP nurse failed to rotate the swab three times clockwise. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105600 If continuation sheet Page 21 of 21