Inspection·July 8, 2022

F 0554 On 07/05/2022 at 1:00 PM the two inhalers were observed on the Resident's bedside stand. Level of Harm - Minimal harm or potential for actual harm On 07/06/2022 at 8:40 AM two inhalers were observed on Resident #42's bedside stand. (Photographic evidence was obtained.) Residents Affected - Few On 07/07/2022 at 9:00 AM the Assistant Director of Nurses stated they do not have any residents approved for self-administration of medications. On 07/07/2022 at 11:00 AM the Unit Nurse Manager stated they do not have any residents approved for self-administration of medications. No documentation of a Physician's Order for Resident #42 to self-administer medications was noted in the medical record. No documentation of an interdisciplinary team approval or care plan for medication self-administration for Resident #42 was noted in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 2 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 provide Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) in a timely manner in order for residents and or resident's representatives to file an appeal, and failed to provide and inform the residents of their financial responsibilities after being discharged from Medicare for 3 of 3 residents reviewed for Beneficiary Protection Notification (Residents #224, 225 and 226). Residents Affected - Few The findings included: 1). Resident #224 was admitted to the facility on [DATE] and discharged on 04/10/22. A Modification of Admission/Medicare-5 Day Minimum Data Set (MDS) documented the resident as having a Brief Interview for Mental Status (BIMS) score of 14, indicating 'cognitively intact'. The SNF Beneficiary Protection Notification Review (form CMS-20052) filled out by the facility and provided to this surveyor documented Resident #224's Medicare Part A skilled services start date 01/24/22 and last covered day was 03/02/22. The NOMNC signed by Resident #224, dated 03/02/22, documented The Effective Date Coverage of Your Current skilled Services will end 03/02/22. The SNFABN signed by Resident #224, dated 03/02/22, documented Beginning on 3/2/22, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. In the section of the SNFABN to describe what care and services the resident would have to pay out of pocket and the estimated cost were left blank. In the section of the SNFABN to describe the 'Reason Medicare May Not Pay, the SNFABN documented Max rehab potential achieved. 2). Resident #225 was admitted to the facility on [DATE] and discharged on 04/15/22. An admission /Medicare 5-day MDS, dated [DATE] documented the resident with a BIMS score of 15, indicating 'cognitively intact'. The SNF Beneficiary Protection Notification Review (form CMS-20052) filled out by the facility and provided to this surveyor documented Resident #225's Medicare Part A Skilled Services start date 01/02/22 and Last covered day of Part A Services 02/12/22. The NOMNC signed by Resident #225 on 02/12/22 documented The Effective Date Coverage of Your Current Skilled Services Will End 2/12/22'. The SNFABN signed by Resident #225 on 02/12/22, documented, Beginning on 02/12/22, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. In the section of the SNFABN to describe what care and services the resident would have to pay out of pocket and the costs were left blank. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 3 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 0582 Level of Harm - Minimal harm or potential for actual harm In the section of the SNFABN to describe the 'Reason Medicare May Not Pay', the SNFABN documented, goals are met - Resident is tolerating regular diet/thin liquids w/out overt s/s of aspiration. Review of the resident's electronic health record, revealed that Resident #225 became 'private pay' on 03/17/22. Residents Affected - Few 3). Resident #226 was admitted to the facility on [DATE] and discharged on 04/21/22. An Admission/Medicare 5-day MDS, dated [DATE], documented the residnet with a BIMS score of 15, indicating 'cognitively intact'. The SNF Beneficiary Protection Notification Review (form CMS-20052) filled out by the facility and provided to this surveyor documented Resident #226's Medicare Part A Skilled Services Episode Start Date 01/06/22 and last covered day of Part A Service - 03/23/22. The NOMNC signed by Resident #226 on 03/23/22 documented, The Effective Date Coverage of Your Current Skilled Services will End 03/23/22. The SNFABN signed by resident on 03/23/22, documented, Beginning on 3/23/22, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. In the section of the SNFABN to describe what care and services the resident would have to pay out of pocket and the costs were left blank. In the section of the SNFABN to describe the 'Reason Medicare May Not Pay', the SNFABN documented, All goals are met. During an interview, on 07/08/22 04:14 PM, with the Social Services Director, the concerns were brought to her attention and she agreed that the NOMNCs were not given in a timely manner and that the SNFABNs were not complete. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 4 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 - Minimal harm or potential for actual 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** Based on record review and interview the facility failed to document review and revision of the care plan with the required Interdisciplinary Team (IDT) for 3 of 18 residents in the final sample (Resident#18, #32, #39), and failed to document required IDT involvement in the care planning process for 9 of 18 residents in the final sample (Residents #32, #8, #39, #44, #61, #48, #17, #15, #7). The findings included: 1) Review of Resident #32's electronic medical records revealed resident was admitted to the facility on [DATE] with diagnoses to include Hypertension, Dementia with Behavioral Disturbances, Mood Disorder, Lack of Coordination, Muscle Weakness, Difficulty Walking, and History of Falling. A review of her IDT Care Conference meeting was dated 11/23/21, this is the most recent in her records and documents that a registered nurse (RN) and Social Service attended meeting and resident's guardian attended meeting by telephone. There was no direct care aide or dietary at the meeting. 2) Review of Resident #39's electronic medical records revealed resident was admitted to the facility on [DATE] with diagnoses to include Lack of Coordination, Muscle Weakness, Difficulty Walking, Dysphagia, Dementia Without Behavioral Disturbances, Insomnia, Depressive Disorder, and Glaucoma. A review of her IDT Care Conference meeting was dated 11/30/21, this is the most recent in her records and documents a nurse, social worker, occupational therapy, and daughter attended the meeting. There was no direct care nurse, direct care aide or dietary at the meeting. 3) Review of Resident #8's electronic medical records revealed resident initial admission date to the facility was on 01/29/20 with a recent hospital admit and readmitted on [DATE]. Her diagnoses to include Iron Deficiency Anemia secondary to Blood Loss, Displaced Intertrochanteric Fracture, Hypo-Osmolality & Hyponatremia, Dementia with Behavioral Disturbances, Type II Diabetes, Abnormalities of Gait & Mobility, Muscle Weakness, Difficulty Walking, Spinal Stenosis, and Fusion of Spine. A review of Resident #8's IDT Care Conference meeting dated 04/19/22 with social service, activities, and resident's Power of Attorney in attendance. There was no direct care nurse, direct care aide or dietary at the meeting. 4) Review of Resident #15's electronic medical records revealed resident admitted to facility on 01/12/22 with diagnoses to include Fracture Hip, History of Falling, Diabetes, Muscle Weakness, Hypertension, Dementia Without Behavioral Disturbances, Idiopathic Peripheral Autonomic Neuropathy, Insomnia, Major Depressive Disorder, and Generalized Anxiety Disorder. Review of Resident #15's IDT Care Conference meeting dated 04/28/22 documents that dietary, social service and a family representative in attendance at meeting, though further notes document resident not family in attendance. There was no direct care nurse or direct care aide at the meeting. 5) Review of Resident #17's electronic medical records revealed resident admitted to facility on 04/13/21 with diagnoses to include Repeated Falls, Dysarthria and Anarthria, Diabetes, Cognitive Communication Deficit, Muscle Weakness, Cervical Disc Disorder with Myelopathy, Hypertension, Altered Mental Status, Major Depressive Disorder, Macular Degeneration, Benign Prostatic Hyperplasia, Generalized Anxiety Disorder, Occlusion and Stenosis of Right Carotid Artery, and Chronic Kidney Disease. Review of Resident #17's IDT Care Conference meeting dated 04/28/22 documents dietary, social service and family/resident representative in attendance. There was no direct care nurse or direct care aide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 5 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 at the meeting. Level of Harm - Minimal harm or potential for actual harm During an interview on 07/07/22 at 2:50 PM with the Director of Nursing (DON), she reviewed Resident #32 and Resident #39's IDT Care Conference meeting and acknowledged she is unable to locate a more recent meeting. For Residents #8, #15, #17, #32 & #39, she acknowledged that a direct care staff nurse and CNA (Certified Nursing Assistant) should be in attendance. She stated that the MDS Coordinator is the one who makes the meetings. Residents Affected - Some During an interview on 07/07/22 at 3:00 PM with the MDS Coordinator, she stated, I schedule the Care Plan meeting, but social service and the unit manager handles the meeting. They meet religiously but acknowledged there is no evidence that they ever met for any of the above residents. She stated the meetings are held Tuesday & Thursday. During an interview on 07/07/22 at 3:10 PM, with the Social Service Director (SSD), she stated the care conference meetings are done quarterly/ every three months. When asked where the documentation is kept, she stated it would be in the electronic records. The SSD acknowledged for Resident #32 she does not see a Care Plan meeting document after 11/21. She then reviewed the schedule for care plan meetings and stated she was scheduled for 02/22/22. A voice message was left on the legal aid machine but does not know if meeting was held, she was also scheduled for 05/19/22 but again acknowledges there is no documentation of ever having a meeting. The SSD stated for Resident#39 she was scheduled for a care conference meeting on 03/01/22 but acknowledged she is unable to find any documentation that she had the meeting and does not see that she was scheduled for June or July 2022. She also stated she was not aware of who is supposed to attend the care conference meeting. 6) Record review for Resident #48 revealed the quarterly care plan review was held on 06/07/22 with the following IDT participation: Dietary, Social Service Director and the unit Manager. There was no evidence of a direct care nurse and CNA participation in this care plan review. On 07/07/22 at 11:06 AM a side-by-side review of Resident #48's record was conducted with the Director of nursing (DON) and an interview with the DON and the Social Service Director (SSD), they acknowledged the lack of evidence of a direct care nurse and CNA participation in the care plan review. 7) Record review for Resident #7 revealed the quarterly minimum data set (MDS) assessment was completed on 04/05/22. There was no evidence of a care plan review following this MDS assessment. On 07/07/22 at 11:14 AM a side-by-side review of Resident #7's record was conducted with the Director of Nursing (DON) in searched for the care conference signing sheet or any evidence that the care plan was reviewed with the IDT team members. None were found. At that time, the DON alerted the MDS coordinator to come to the DON's office to show the evidence, the MDS coordinator did not locate any records, she indicated that the Social Service Director was responsible to schedule the care plan meetings for review of the care plan. The DON then alerted the Social Service Director. When she arrived at the DON's office, a request was made for the evidence of the quarterly care plan review. The Social service Director stated, she did not document the care plan review in the computer system. She then presented a document with only Resident #7's name written on it with date 04/14/22. The Social service Director stated, the care plan was reviewed on 04/14/22 with the interdisciplinary team (IDT) members which included Social Service Director, unit manager, Activity and Dietary. When asked if a direct care nurse and CNAs participated in this care plan review, she confirmed there was no direct care nurse and certified nursing assistant (CNA) participated in the care plan review. The Social Service Director explained, she was new to this role. 8) Record review for Resident # 61 revealed the care plan review was conducted on 06/21/22 with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 6 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 - Minimal harm or potential for actual harm following IDT participation: Dietary and the Social Service Director. There was no evidence of a direct care nurse and CNA participation in the care plan review. On 07/07/22 at 11:45 AM a side-by-side review of Resident #61's record was conducted with the DON and interview with the Social Service Director, they confirmed that the care conference summary record did not indicate a direct care nurse and CNA participation in the care plan review. Residents Affected - Some 9) A record review for Resident #54 was conducted, during the record review, it was revealed that the admission MDS assessment was completed on 06/04/22. The records lacked evidence of review of the care plan following the completion of the MDS assessment for Resident #54. On 07/08/22 at 12:05 PM, an interview and a side-by-side review of Resident #54's record was conducted with the Social Service Director, an inquiry was made regarding when the facility conducted a care plan review for Resident #54. The Social Service Director did not answer, she proceeded to continue reviewing the record in the computer system. It showed a care conference summary which was blank. There was no documentation to show if the care plan was reviewed and who participated in the review process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 7 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on Facility Policy, record review, interview, and observation the facility failed to document ongoing coordination of care with Hospice for 6 of 6 resident reviewed for Hospice (Resident #21, #67, #19, #68, #69 and #38). Residents Affected - Some The findings include: The Facility Policy titled Hospice provided by the facility dated July 2017 states, In general it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: a) determining the appropriate hospice plan of care; b) changing the level of services provided when it is deemed appropriate; c) proving medical direction, nursing and clinical management of the terminal illness; In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities include the following: d) communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day; The Facility provided policy titled VITAS Policy Manual dated 11/15/2016 states, All orders, events and communication must be accurately documented in the patient's clinical record. Record review of Resident#21 revealed a readmission date of 01/06/2022 with diagnoses that include diabetes, heart disease and malignant cancer. The Minimum Data Set Assessment on 05/04/2022 documented the resident as being cognitively intact, requiring extensive assistance for all activities of daily living except independent for eating and is receiving Hospice Care. On 07/07/2022 at 8:00 AM the Hospice Binder at the nurse's station was reviewed by the surveyor. Two residents were found in the binder but were not residents listed as currently residing in the facility. No other Hospice entries were found. On 07/07/2022 at 8:31 AM Staff M RN stated she has one resident on Hospice (#21) and that all Hospice residents are listed in the Hospice binder at the nurse's station. The Hospice information is also kept in the resident's chart at the nurse's station. On 07/07/2022 at 9:00 AM the Assistant Director of Nurses (ADON) and Unit Manager stated there was no documentation of the Hospice visits for Resident #21 in the Hospice Binder or in his chart at the nurses' station. The ADON stated she thinks they keep their own notes and they talk to the staff verbally. When asked how the night staff keeps informed, no reply was given. When asked who the residents were in the Hospice book, they stated that one of them was Resident #42's wife (a previous resident of the facility) and she has been dead for maybe a year. When asked if that was how long the books have not been updated, no reply was given. On 07/07/2022 at 9:24 AM the Director of Nurses (DON) confirmed they do not have any documentation from Treasure Coast Hospice. She stated they had changed their charting to an electronic format, but it is encrypted, and they are unable to access the reports. She said they are coming in this week to fix the problem. On 07/07/2022 at 10:00 AM the Director of medical records stated that before COVID, Treasure Coast (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 8 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Hospice would bring in their reports each time they visited. Now their reports are electronic and encrypted in a file which she cannot open. She has been trying to get it fixed for a long time. On 07/07/2022 at 11:00 AM the list of all Hospice residents in the facility was received from the ADON. The surveyor with the Unit Manager went through each Hospice resident's chart and verified no documentation was found for Vitas Hospice, Treasure Coast Hospice and Chapters Hospice. The Hospice Binder located at the nurse's station was then reviewed. None of the current six Hospice residents had any documentation in the binder. The Hospice binder states all Hospice Representatives must document in the binder when a visit has occurred. The surveyor asked how the facility knows when and how often the Hospice Representative is seeing a resident, with no reply. On 07/07/2022 at 2:50 PM the DON verified no ongoing communication documentation for Hospice is noted in any of the Hospice resident charts or the Hospice Binder for all three Hospice Companies. She stated that they all email their progress notes, and the facility has not been able to access the notes. On 07/08/2022 at 8:10 AM Staff N LPN stated she had three residents on Hospice. She stated Hospice is designated on the computer chart and there is a book at the nurse's station for Hospice communication. On 07/08/2022 at 8:15 AM Staff O RN stated she does not have any Hospice residents today. She said Hospice notes are kept on the chart at the nurse's station but does not know which section. On 07/08/2022 at 8:20 AM Staff P LPN stated that she has a Hospice resident and that Hospice communicated both verbally and with notes in the chart at the desk. Record review on 07/08/2022 at 12 noon revealed the following: 1) Resident #21 receiving Hospice care from Treasure Coast Hospice beginning 01/26/2022 with no Hospice progress notes in the chart or Hospice Binder. 2) Resident #67 receiving Hospice care from Vitas Hospice beginning 06/11/2022 with no Hospice progress notes in the chart or Hospice Binder. 3) Resident #19 receiving Hospice care from Treasure Coast Hospice beginning 07/07/2022 with no Hospice progress notes in the chart or Hospice Binder. 4) Resident #68 receiving Hospice care from Vitas Hospice beginning 02/17/2022 with no Hospice progress notes in the chart or Hospice Binder. 5) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 9 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #69 receiving Hospice care from Treasure Coast Hospice beginning 09/14/2021 with no Hospice progress notes in the chart or Hospice Binder. 6) Resident #38 receiving Hospice care from Chapters Hospice beginning 05/18/2022 with no Hospice progress notes in the chart or Hospice Binder. Event ID: Facility ID: 105804 If continuation sheet Page 10 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the facility was secure to prevent a resident with a risk of elopement from eloping the facility for 1 of 1 resident reviewed for accidents (Resident #54). The findings included: Resident #54 was initially admitted to the facility on [DATE]. According to an admission Minimum Data Set (MDS), dated [DATE], Resident #54 had a Brief Interview for Mental Status score of 12, indicating 'cognitively intact'. The MDS documented that Resident #54 'Usually Makes Self Understood' and had behaviors indicative of depression and behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 1 to 3 times during the 7-day look back period and wandering behaviors 1-3 days during the 7-day look back period. The MDS documented that Resident #54 required 'Supervision' and 'setup help only' for be mobility, transfer and toilet use, Resident #54 required 'Supervision' only for locomotion on and off of unit and was independent with walking in room and corridor. Resident #54's diagnoses at the time of the assessment included: Stroke, Anemia, Hypertension, Thyroid disorder, Cerebrovascular accident, Non-Alzheimer's Dementia, Malnutrition, Anxiety disorder, Depression and schizophrenia. Resident #54's care plan, initiated on 05/30/22, documented, Resident has a history of substance abuse: alcohol, or other drug use and has potential for complications such as; recurrence of substance abuse, postacute withdrawal symptoms, mood and/or other behavior disturbances. Resident #54's care plan for wandering, initiated on 06/01/22, documented, 5/28/2022 The resident is an elopement risk with wandering/exit seeking behaviors and requires the use of a wanderguard. Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness. The goals of the care plan were documented as: * The resident will not leave facility unattended through the review date. 06/01/22 and most recently revised on 06/14/22 with a target date of 09/20/22. * The resident's safety will be maintained through the review date. 06/01/22 and most recently revised on 06/14/22 with a target date of 09/20/22. Interventions to the care plan included: * 5/28/22 apply wander guard device to left wrist, monitor for placement & function every shift. * Assess for fall risk. * Check placement and function q shift. * Distract resident from wandering by offering pleasant diversions, structured activities, food, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 11 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 0689 conversation, television, book. Level of Harm - Minimal harm or potential for actual harm * Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need or more exercise? Intervene as appropriate. Residents Affected - Few * Monitor for fatigue and weight loss. * Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. During an interview, on 07/05/22 at 1:05 PM, during the initial pool process, when Resident #54 was asked about plans to be discharged from the facility, Resident #54 stated that he was not aware of his discharge plan. During an interview, on 07/05/22 at 1:33 PM, with the Social Services Director, when asked about Resident #54's discharge plan, she replied, His discharge plan is approved from the SS community outreach. It is not documented until he is post discharge. The goal was for him to discharge back to the community. The SS Community Outreach found placement in an ALF and he is approved to discharge. He did talk about it and we discussed it. He knows that he is here for therapy. On 07/07/22 at 10:28 AM an observation was made at the 100 unit. There was one nurse at the unit and an activity aid who was conducting activity with the residents. The residents were calm, no abnormal behaviors were observed. No abnormal activity at the unit. The 100 unit was not a lock unit (does not require a code to get in or out the unit). On 07/07/22 at 1:33 PM another observation was made the 100 unit. There was no abnormal activity noted. No residents were exit seeking. One resident was wandering the unit. No concerns were observed. On 07/08/22 at approximately 8:35 AM, the Administrator reported to this surveyor, At roughly 8PM last night, Resident #54 told his roommate and a couple of other residents that he would be leaving at 9PM today (07/07/22) to go to his new home. Right after he told the other resident, he decided to leave the building. He proceeded through the doors on the 100 hallway. He didn't tell any of the staff members that day or at that time that he was leaving or hinted to be leaving. Police were called and came in, they also did a full property search. The police stated that because of his alcohol abuse and drug use, he was not a danger to others. When family was notified, they said that this was a history and has previously done this on numerous occasions throughout the years and was fine. Family was not concerned about him leaving the facility. I got notified at 11:15 PM on shift change rounds that the resident was not in bed. I told staff to proceed to call the police and instructed all of the department heads to come to the facility. At 1AM, department heads were here, we went out and searched for 4 hours straight. Upon my searching out there, I stopped at the coin laundry down the street and the lady there said that she saw him at 8:30 at the store on State Road 70. Police were unable to locate him and the Officer texted me this morning and stated that they haven't found him either. On 07/08/22 at 9:39 AM an interview was held with the DON, she revealed that the resident was supposed to be discharged this morning. He has never tried to elope before; he has not exhibited behavior of exit seeking. He has a history of alcohol abuse. The resident eloped yesterday at around 8 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 12 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility called the police. The family was notified, they said he has done that before. The DON stated the facility hadn't known of this behavior. When asked if the cameras were reviewed, the DON voiced she thinks the NHA has reviewed the cameras but was not able to get a full picture of the event as some of the cameras are not working. The facility is still in the process of searching for the resident. During an interview, on 07/08/22 at 10:09 AM with the Administrator, Regional Nurse, Corporate Risk Manager, and the Maintenance Director, the Administrator stated, I went through the 100 hall with the camera that is looking down the 100 hallway. He lived with his ex-wife and then became homeless. He was supposed to go home today. We found him a community house to stay in after discharge. Observation of video on 07/08/22 at 10:13 AM showed that Resident #54 was seen on camera exiting the unit through a door that is not secured from the 100 unit, to the area around the nurse's station on 07/07/22 at 7:51 PM, there was no staff at the nurse's station and resident was wearing a wanderguard on right ankle and left wrist. Staff were seen returning to the nurse's station at 7:52 PM. At 7:54 PM resident was seen returning to the area of the nurse's station and returning to the 100 unit. At 7:56 PM was seen on camera talking to Staff Q, CNA who left resident at the nurse's station at 7:57 PM and entered the 100 unit while the resident left the area of the nurse's station. There was no video of the resident after that time, due to the camera system malfunctioning. The Administrator stated that the last time that the resident was seen was at approximately 8:30 PM, It was the nurse that called me last night. During the survey, the doors that lead to the outside area, where the smoking and activities took place, were not equipped with alarms of any kind, including the wanderguard system. During a tour of the outside grounds, on 07/08/22 at 11:30 AM, it was noted that the perimeter of the facility grounds was fenced in with gates in areas of the fencing. The gate on the north end of property and fence were noted to not be secured as was a second gate on the south end of the property and fence. During an interview with Resident #54's ex-wife, on 07/08/22 at 11:49 AM, when asked about being notified about Resident #54 exiting the facility, she stated, I was notified that he left the facility at around 11:30 last night. When he was in the hospital, he did leave when he was first there. He just kept saying that he wanted to go home. He was settling down and he was anxious to do therapy. During an interview, on 07/08/22 at 12:02 PM, with Resident #54's daughter, when asked about being notified of Resident #54 eloping from the facility, she replied, after 12:00 last night. My mom called me and told me first. I asked them how long he had been gone before they noticed he was gone and she said for a few hours. He wanted to go home. He's got dementia and has been in the hospital for 2-3 months now. He wants to get out of the hospital. He has never done that before. When asked if this was normal behavior for Resident #54, she replied, No, he's probably trying to get back to where he lived at, but he doesn't know the address. I shared the address with them and the police and they sent an officer out to see if he was there and he was not. We thought he was secure, because the doctors at the hospital said that he wouldn't be able to function in the community. When asked about the 'accident' prior to being admitted , Resident #54's daughter replied, We don't actually know. He was driving around on three flat tires and the police pulled him over. The hospital called us on him. During an interview, on 07/08/22 at 12:05 PM with the Social Services Director, an inquiry was made regarding when did the facility conduct a care plan review for the resident, the SSD did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 13 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few answer, she proceeded to review the record in the computer system, which showed the care conference summary was blank. There was no documentation to show if the care plan was reviewed and who participated in the review process. During an interview, on 07/08/22 at 12:17 PM interview with Staff Q, CNA, when asked about her talking to Resident #54, as see on the video, Staff Q replied, when I saw him, I told him 'do you know you are not allowed to be out in the hallway' he told me 'today is my last day and I am visiting my friend and going to get some fresh air'. I told him, 'let's go back inside (to the unit from the area around the nurse's station), he told me he was visiting his friend and going outside because 'today is my last day here'. He thought that he was going home today. He came back and got some cups, that was the last time that I saw him. He takes care of himself and pulls the curtain and goes to bed and to sleep on his own. He is alert and he said that he was going to see his friend. He knows that today is his last day for sure. It was like 10:45 PM or something when I saw that the curtain was still pulled and the bed looked like he was still sleeping on it. That was when I noticed he was gone. I came and told the nurse and we searched everywhere, in the hallways and outside. The police were already here when I left. During a follow up interview, on 07/08/22 at 12:46 PM with the Administrator, the Administrator started, They just did a GDR on him for his schizophrenia and bipolar medications - Abilify on 07/01 (confirmed) He never left that hallway in 40 days. During an interview, on 07/08/22 at 12:56 PM, with Staff P, LPN an inquiry was made regarding residents with wander guard at the 100 unit and how she checks for function of the wander guard. Staff P voiced that at this time she only has 1 resident with wander guard, the wander guard device was kept lock in the med cart. She obtained the device and proceeded to check the function of the wander guard for the only resident they have with wander guard (Resident #55), and it was functioning. The maintenance director and the nurse then checked the wander guard at the 100 unit exit door; it beeps (meaning it was functioning). The maintenance staff revealed he has checked the wander guard function for Resident #55 this morning and it was in function. During the observation at the 100-unit, 4 residents were sitting at the 100-unit consuming lunch, an activity staff was present assisting with feeding. The nurse was at the unit (standing in front of the med cart). No abnormal activity was noted at the unit, no residents exhibiting abnormal behaviors, exit seeking or wandering. On 07/08/22 at 3:40 PM, Resident #54's daughter reported to this surveyor, he has been found at the last place that he lived. He used to rent a room there. The owner won't let him in, because that is where he used to do drugs. I just got the phone call 40 minutes or so ago. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 14 of 15 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 105804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Fort Pierce 700 S 29th Street Fort Pierce, FL 34947 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record and interview the facility failed to ensure accurate documentation of medication administration between the controlled substance record and the medication administration records (MARs) for 3 of 4 residents reviewed during the medication storage process (Residents #15, #59 and #68). The findings included: 1.On 07/06/22 at 9:33 AM the review of the medication storage process began, record review for Resident #15 revealed an order of oxycodone 5/325 mg one tablet by mouth every 8 hours as needed for pain for 7 days. The controlled substance record was compared against the July 2022 MARs. There were discrepancies found. The controlled substance record documented the medication was removed from the lock box 4 times on July 2nd: 7/2 at 12 AM, 8:30 AM, 5 PM, and 11 PM. The MARs did not have the 11 PM removal documented. The controlled substance record documented the medication was removed on July 3rd at 9:55 AM and 7:30 PM, the MARs did not show documentation for July 3rd 7:30 PM removal. The controlled substance record documented the medication was removed on July 4th at 9:11 AM, 4 pm and 11:45 PM, the MARs lacked evidence of July 4th 11:45 PM removal. The controlled substance record showed the medication was removed on July 5th at 9:38 AM, 4 pm and 10:31 PM, the MARs lacked evidence of documentation for July 5th 10:31 PM removal. 2.Record review for Resident #59 revealed an order of oxycodone 10 mg 1 tablet by mouth every four hours as needed for pain. The controlled substance record was compared against the July 2022 MARs. There were discrepancies found. The MARs revealed that the medication was removed out of the lock box on the following days: July 1st at 1:00 AM and 5:10 AM, the controlled substance record did not have documentation for the July 1st 1:00 AM removal. The controlled substance record documented the medication was removed on July 4th at 9 PM, the MARs had no documentation for that day. 3. Record review for Resident #68 revealed an order of Hydrocodone 5/325 mg 1 tablet by mouth every 6 hours as needed for non-acute pain. The controlled substance record was compared against the July 2022 MARs. There were discrepancies found. The controlled substance record showed a removal of the medication on July 1st at 08:08 AM and at 4 PM. But the MARs lacked documentation to reflect the removal for 08:08 AM. The controlled substance record showed a removal of the medication on July 2nd at 6 PM, the MARs lacked evidence of documentation for this removal. On 07/07/22 at 10:45 AM, and interview and a side-by-side review of the resident's records was conducted with the Director of Nursing (DON), and she acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105804 If continuation sheet Page 15 of 15