Inspection·March 18, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete pandemic, the kitchen served more paper products to all the residents on this unit. She added there was no specific policy for dining in the secure dining room. On 03/18/21 at 12:45 PM, CNA C said the secure unit dining room did not have tablecloths on as laundry staff brought clean tablecloths too late. She added that residents did not receive hard plastic cups or regular silverware as the kitchen only sent Styrofoam cups and disposable spoons. Event ID: Facility ID: 105673 If continuation sheet Page 2 of 6 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 105673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian River Center 7201 Greenboro Dr West Melbourne, FL 32904 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 0687 Provide appropriate foot care. 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 arrange diabetic shoe services for a diabetic resident who had a history of toe wounds for 1 of 2 residents reviewed for non-pressure wounds in a total of 47 sampled residents, (#50). Residents Affected - Few Findings: Resident #50 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, diabetic neuropathy with diminished sensation to her right lower extremity, left above the knee amputation (AKA), and rheumatoid arthritis. The resident's most recent quarterly Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated no cognitive impairment. On 3/15/21 at 12:33 PM, the resident was observed with Registered Nurse (RN) E. Resident #50 said she had a wound on her right big toe. She pointed to the tennis shoe on her right foot and said the inside of the tennis shoe had rubbed against her big toe and caused the wound. RN E indicated the resident's toe wound started as a blister, became scabbed and then healed. The nurse said resident #50 presently had an order for Skin Prep treatment to the tip of her big right toe to protect and toughen the skin. The resident's shoes were made from a soft, stretchable cloth. The toe portion of the shoes were pointed in shape and the resident was not wearing socks. Review of a nurse's progress note dated 2/14/21 at 9:15 AM read, While being assisted to bed the customer [resident #50] complained of pain to right great toe. CNA [Certified Nursing Assistant] notified nurse and assessment finds hard darkened area at distal end of great toe. Customer [resident #50] states area hurts when it is touched and has been bothering her when it rubs against the inside of her shoe Review of the physician's treatment orders dated 2/14/21 for right toe wound included, Apply skin prep to right great toe, every shift for wound care . and Wound consult for right great toe. Both orders were dated 2/14/21. Review of a skin progress note dated 2/15/21 at 2:42 PM read, Tip of right toe has a hard flat area which looks like a callous or dried blister. Shoe may be too short causing toe to rub against it. On 2/15/21, a telephone order from the primary care physician read, No shoe on right foot until wound on right great toe resolves. On 2/15/21, resident #50's CNA Plan of Care [NAME] for Activities of Daily Living Care (ADLs) was amended to read, Dressing - no shoe to right foot. On 2/18/21, resident #50's right great distal toe wound was assessed by the wound care Advanced Practice Registered Nurse (APRN) consultant. His notes read . footwear trauma . discomfort with palpation .Wound #1 status is open, original cause of wound was blister. The wound is currently classified as an unclassifiable wound with etiology of trauma, and is located on the right distal toe, great. The wound measures 1.1 centimeter (cm) length x 1.1 cm width . no present amount of drainage noted .This is a dry, intact blister at the distal tip of the right great toe. This is a foot wear trauma, as the patient reportedly wears a shoe width is not a diabetic shoe .Ensure protection of the right foot. No shoe please. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105673 If continuation sheet Page 3 of 6 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 105673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian River Center 7201 Greenboro Dr West Melbourne, FL 32904 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 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/4/21, the APRN's wound care progress note revealed the right great toe distal wound was resolved. This is now a chronic, dry area of callus tissue. The APRN wrote, Continue to ensure protection of the right foot. No shoe please, until proper diabetic shoe can be obtained . On 3/4/21, the Unit Manager called resident #50's primary care physician and obtained a telephone order to allow the resident to wear her regular shoes because the wound to the right toe was resolved. This contraindicated the wound care physician's order for no shoe to the right foot until proper diabetic shoes could be obtained. On 3/17/21 at 2:45 PM, observation of resident #50's right great toe was conducted with RN E while the nurse applied Skin Prep treatment to the toe. RN E removed resident's right tennis shoe and applied Skin Prep to the distal end of the resident's great right toe. A scant amount of dried reddish residue was observed under a patch of dry cracked skin located to the right distal tip of the toe. The resident had a wide foot span at the toe area. Her tennis shoes were narrow in width than the width of her toe area. The resident reported she did not have diabetic shoes. RN E acknowledged the resident did not have diabetic shoes. RN E said she thought the Social Services Director (SSD) was responsible to obtain diabetic shoes for residents. On 3/18/21 at 12:35 PM, the SSD said the nursing department was responsible to obtain diabetic shoes for residents. On 03/18/21 at 2:13 PM, the Unit Manager (UM) revealed she was aware of the resident's toe wound caused by the shoes she wore. She said the nursing department was responsible to contact the therapy department when a referral for diabetic shoes was required. She stated the diabetic shoe vendor came to the facility once a year but had not been in the facility in 2020 due to Corona Virus Disease 2019 pandemic. She said the resident probably would not want wear the diabetic shoes as they were too plain, and the resident liked more stylish shoes. On 03/18/21 2:28 PM, a sample of a diabetic shoe that was wider and rounder in the toe area was shown to the resident by the UM. The resident said she would be willing to try the diabetic shoe to help prevent wounds on her toe. On 3/18/21 at 2:33 PM, the Therapy Director said she had a contact person to fit residents for diabetic shoes when needed. At 2:45 PM, the Therapy Director said she called the diabetic shoe vendor and someone would come to the facility today to fit resident #50 for diabetic shoes. On 03/18/21 at 4:06 PM, phone interview with the wound care APRN acknowledged that he treated resident #50's toe wound. He said it was initially a dried serous blister cap located at the distal end of the great right toe. He reiterated the etiology was shoe trauma and not a pressure ulcer. He stated that on 3/4/21, he had given an order for the resident to not wear a shoe on her right foot until a diabetic shoe was provided to prevent the reoccurrence of the toe wound. On 03/18/21 4:14 PM, the Director of Nursing (DON) indicated that she and the Unit Managers were responsible to round with the wound care physician and follow up with his orders. On 3/18/21 at 4:51 PM, the UM acknowledged that she had made wound rounds with the wound care APRN and did not realize the wound care APRN had given the order on 3/4/21 for no shoe to be worn on the resident's right foot until proper diabetic shoes were obtained. She stated she had missed the order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105673 If continuation sheet Page 4 of 6 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 105673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian River Center 7201 Greenboro Dr West Melbourne, FL 32904 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 0687 On 3/18/21 at 5:14 PM, the DON stated the facility did not have a policy and procedure for foot care and services for diabetic residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105673 If continuation sheet Page 5 of 6 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 105673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian River Center 7201 Greenboro Dr West Melbourne, FL 32904 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to label or date food items in 1 of 3 Nourishment rooms, (Key West). Residents Affected - Few Findings: On 3/17/21 at 11:12 AM, the Key [NAME] Nourishment Room freezer was noted with 1 gallon container of lactose free vanilla ice cream and a beef patty. The beef patty and the ice cream did not have names or dates on them. A sign posted on the freezer door read Attention Families and Staff for the safety and wellbeing of our customers everything put into this refrigerator must be 1. Labeled with the customer's name 2. Dated on the day it was put in the refrigerator 3. Items that are without a name or date will be discarded immediately 4. All items will be discarded after 3 days from the date on the item. On 3/17/21 at 11:22 AM, Certified Nursing Assistant, (CNA) B said she did not know who the food in the freezer belonged to. She added she was not aware food in the nourishment fridge/freezer needed to be labeled or dated. On 3/18/21 at 2:02 PM, the Director of Food Services said frozen items were harder to label. She said when food was received at the front desk from resident's family member, CNAs were responsible for labeling the food with date and name of resident. She added that food services staff checked food items for dates. She said there was no policy on food items in Nourishment Rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105673 If continuation sheet Page 6 of 6