Inspection·July 14, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility staff failed to ensure baseline care plans were individualized to include immediate health and safety needs. The failure affected 3 of 19 sampled residents (Residents #93, #159 and #103). The findings included: 1. Clinical record review conducted on 07/11/22 revealed Resident #93 was admitted to the facility on [DATE] with diagnosis including End Stage Renal Disease. admission Data Set assessment, dated 06/21/22, documented the resident receives hemodialysis treatments. Review of the baseline plan of care failed to include the resident's condition requiring dialysis treatments and goals and interventions to manage the resident's care. Further review of the comprehensive plan of care and revisions failed to include interventions for dialysis care. Interview with the Minimum Data Set (MDS) and Care Plan (CP) Coordinator on 07/13/22 starting at 3:16 PM revealed the nurse completes the resident's assessment upon admission and based on the information the baseline care plans are populated. The MDS and CP coordinator said, then by day 21, the care plan team ensures the comprehensive care plans are completed. The staff reviewed the electronic records and confirmed the care plans for Resident #93 did not address dialysis care and treatments. 2. Clinical record review conducted on 07/12/22 revealed Resident #159 was admitted to the facility on [DATE] status post hip surgery. admission Data Set assessment, dated 03/16/22, documented the resident's fall risk score as 12, a score greater that 10 indicates high risk for falls. Review of the baseline plan of care failed to include safety intervention to minimize risk of injury. Further review of the record indicated the resident sustained a fall on 03/19/22, with mildly displaced left greater trochanter fracture. Interview with the MDS and CP Coordinator on 07/13/22 starting at 3:16 PM revealed the nurse completes the resident's assessment upon admission and based on the information the baseline care plans are populated. The coordinator confirmed there was no fall care plan in place. 3. Clinical record review conducted on 07/11/22 revealed Resident #103 was admitted to the facility on [DATE] with diagnosis of weakness. Nurses Notes, dated 06/20/22, documented the resident is alert, verbal, and oriented with forgetfulness, admitting with generalized weakness. The past medical history included status post right hip fracture and dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105819 If continuation sheet Page 2 of 8 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 105819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tiffany Hall Nursing and Rehab Center 1800 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 0655 Level of Harm - Minimal harm or potential for actual harm Fall risk assessment, dated 06/20/22, documented the resident was assessed as high risk with a score of 15. Review of the baseline plan of care and the comprehensive plan of care on file failed to include safety intervention to minimize risk of injury. Residents Affected - Few Further review of the record indicated Resident #103 sustained a fall on 07/04/21 with injury and was hospitalized for three days. Interview with the MDS and CP Coordinator on 07/13/22 starting at 3:16 PM revealed the nurse completes the resident's assessment upon admission and based on the information the baseline care plans are populated. The coordinator confirmed there was no fall care plan in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105819 If continuation sheet Page 3 of 8 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 105819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tiffany Hall Nursing and Rehab Center 1800 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation of care conducted on 07/13/22 at 11:33 AM revealed Resident #85 in the day room, sitting up in the chair while the aide was setting up the lunch meal. On 07/13/22 at 12:47 PM, Resident #85 remained sitting in the chair, in the day room. On 07/13/22 at 4:00 PM, Resident #85 remained sitting up in the chair in the day room. Observation of care conducted on 07/14/22 at 10:56 AM revealed Resident #85 sitting up in the chair in the room. Subsequent observations conducted until 12:55 PM revealed the resident remained up in the chair, now finishing up her lunch meal. Record review conducted on 07/12/22 revealed Resident #85 was originally admitted to the facility on [DATE] with diagnoses including stage IV pressure ulcer. The Minimum Data Set (MDS), admission assessment with reference date 06/17/22 failed to document the presence of the stage IV pressure ulcer. Care Plan, dated 05/20/22 documented, I am at risk for impairment to skin integrity related to pressure wound to sacrum present, multiple skin tears and surgical wound on admission. I have co-morbidities that contribute to my skin impairment decreased functional mobility secondary to aftercare nondisplaced intertrochanteric fracture of right femur, and incontinence with brief use. Physician's order, dated 06/22/22, documented to limit sitting in wheelchair for no longer than 60 minutes at one time, to help promote proper wound healing. Review of the plan of care failed to provide evidence the plan of care was revised with the interventions limiting sitting up for longer than sixty minutes. Interview with the MDS Coordinator on 07/14/22 at 3:16 PM revealed the plan of care is revised quarterly and updated as needed with individualized interventions. After review of the care plans, the coordinator confirmed the care plan has not been revised with the intervention limiting sitting time for Resident #85. Interview with Staff A, a Certified Nursing Assistant, on 07/14/22 at 4:02 PM, confirmed the resident was sitting up in the chair when she arrived for her shift. Staff A explained she typically works on the other side of the hallway and is not very familiar with Resident #85. Staff A could not answer if the resident had a pressure wound and was not aware of any restrictions limiting how long she should sit up in the chair. Interview with Staff B, a Certified Nursing Assistant, on 07/14/22 at 12:55 PM, revealed the resident got out of bed around ten or eleven this morning, and she did it by herself. The resident has been up since then and just finished her lunch. Staff B stated the resident has a wound to the buttocks and uses barrier cream to protect the area, the resident is alert with confusion, and sometimes is able to follow directions and sometimes does not. Staff B denied knowledge of restrictions regarding how long she can sit up in the chair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105819 If continuation sheet Page 4 of 8 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 105819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tiffany Hall Nursing and Rehab Center 1800 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 0656 Level of Harm - Minimal harm or potential for actual harm Further review of the clinical record failed to provide evidence of resident's refusal to limit prolonged sitting time. The nursing staff failed to update the plan of care with prescribed interventions to limit prolonged sitting time for Resident #85 and the direct care staff had no knowledge or had not implemented the intervention. Residents Affected - Few Based on observations, interview and record review, the facility failed to implement interventions as delineated in the care plan, for 1 of 2 sampled residents, Resident #17, reviewed for Wanderguard ( an alarm system to monitor residents who are a wander risk) and Resident # 85 for failure to limit position to promote wound healing. The findings included: The policy, titled, Comprehensive Person-Centered Care Plan, and revised 02/18/19 documented in part: The comprehensive plan of care must describe the following: Include interventions to attempt to manage risk factor Include treatment goals with measurable objections Include interventions to prevent avoidable decline in function or functional level. 1. During the record review for Resident #17, the care plans and orders were reviewed. On 04/07/22, an order was written to check the Wanderguard function and placement every shift. The shifts are documented as Day, Evening and Night. Resident #17's care plan for elopement was reviewed. Review of the Treatment Administration Record for April 2022 revealed the Wanderguard was not documented as being checked for function or placement for a total of 5 shifts. Review of the Treatment Administration Record for May 2022 revealed the Wanderguard was not documented as being checked for function or placement for a total of 16 shifts. Review of the Treatment Administration Record for June 2022 revealed the Wanderguard was not documented as checked for function or placement for a total of 11 shifts. Review of the Treatment Administration Record for July 1- July 11, 2022 revealed the Wanderguard was not documented as being checked for function or placement for a total of 5 shifts On 07/13/22 at approximately 2:00 PM, the findings were reviewed with the Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105819 If continuation sheet Page 5 of 8 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 105819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tiffany Hall Nursing and Rehab Center 1800 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide activities to meet the needs of 1 of 3 sampled residents reviewed for activities, Resident #79. Residents Affected - Few The findings included: The policy, titled, Scheduling Activities and revised 03/13/19, documented in part: 1. Activities, social events and schedules will be developed in conjunction with residents' interests, assessment, and plan of care. 2. Activities will be scheduled 7 days a week 1. Resident #79 is alert, speaks a foreign language and understands some English. The resident is currently receiving hospice care. An interview was conducted on 07/11/22 at 9:29 AM with Resident #79's family member. The resident's family member is the resident's emergency contact. She stated she would like the resident to be up and sitting in the wheelchair. She stated she has not observed her out of bed for a while or going to any activities. Resident #79 was observed in bed on 07/11/22, 07/12/22, and 07/13/22. The resident did not attend any activities or no activities were brought to her room from the time period of 07/11/22 through 07/14/22. On 07/14/22 at 11:00 AM, the resident's hospice nurse arrived. At this time, the resident could not open her eyes because staff had not yet washed the junk out of her eyes. The resident told the hospice nurse in Spanish, 'I could talk to you if I could see'. The hospice nurse used 'goggle translate' on her phone. Resident #79 stated she would like to go outside. On 07/14/22 at 11:55 AM, Resident #79 was interviewed (in the resident's foreign language). She stated she would like to get out of bed sometimes and she would like to have music as an activity. The documentation for the resident's activities were reviewed. The resident had 1 documented activity in the last 30 days. The last activity was documented as music on 06/21/22. On 07/14/22 at 1:16 PM, an interview was conducted with the Activities Assistant. She stated if the last activity of music was documented as 06/21/22 and no other activities are documented then that is the last activity the resident had received. She stated when she goes to Resident #79's room for activities, the resident wants to sing songs, but she wants to sing them in her foreign language. The Activities Assistant stated that she (Activities Assistant) doesn't speak the resident's foreign language and is unable to accommodate the resident. The Activities Assistant agreed Resident #79 needed to be receiving activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105819 If continuation sheet Page 6 of 8 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 105819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tiffany Hall Nursing and Rehab Center 1800 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to ensure medication regimen was free of unnecessary medications, for 1 of 6 sampled residents reviewed for medication management and COVID 19 infections (Resident #62). Residents Affected - Few The findings included: Clinical record review conducted on 07/11/22 revealed Resident #62 was admitted to the facility on [DATE] with diagnosis of Chronic Respiratory failure. The record indicated the resident tested positive for the COVID 19 virus on 07/01/22. Progress Notes dated 07/04/22 documented the following: Resident was seen by the ARNP (Advance Registered Nurse Practitioner) today and to start Paxlovic. Received a phone called from the Pharmacy stating that resident Flomax needs to be placed on hold due to the interaction with the medication. ARNP was made aware and it is ok for Flomax to be held for the duration of the Paxlovid until complete. Resident at times has SOB (Shortness of Breath), ARNP saw resident and chest was order and also Paxvolic. Resident Flomax will be placed on hold for 5 days until covid pills are complete. Review of the Medication Administration Record dated 07/2022 indicates the resident received Paxlovic 150 milligram from 07/05/22 through 07/11/22. The record validates the staff did not follow the provider's orders and Flomax 0.4 mg was administered from 07/05/22 through 07/11/22 while on concurrent therapy with Paxlovic. Interview with the Director of Nursing (DON) on 07/13/22 at 3:53 PM confirmed she was the one who wrote the note to ensure the medication was held and will check and clarify the record. Interview with the DON on 07/04/22 at approximately 11 AM revealed she was able to reach the nurse involved and confirmed the medication was not held as per the pharmacy recommendation and a medication error has been written. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105819 If continuation sheet Page 7 of 8 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 105819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tiffany Hall Nursing and Rehab Center 1800 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews and record review, the facility failed to maintain a safe and properly functional environment, as evidenced by not securing 2 of 2 'Dirty Utility Rooms, located on the [NAME] and East units, in an attempt to prevent residents from entering the rooms. This has the potential to affect all residents that are confused and that can ambulate independently. The census at the time of the survey was 99 residents. The findings included: On 07/11/22 at 11:15 AM, it was noted that the Dirty Utility room on the [NAME] unit was not secured. It was also noted that there was a key hanging on a hook underneath a sign to the left of the door. Staff were observed entering and exiting the room without initiating the lock and by simply turning the handle and applying minimal force to open the door. Once inside of the room, there were numerous carts with trash/refuse, dirty linens and Biohazardous waste items. There was also a counter that had a jagged surface on the underside as well as unused plumbing protruding from the wall. During an interview, on 07/13/22 at 9:15 AM Staff H, Laundry, and Staff I, Laundry, were observed entering and exiting the Dirty Utility Room without securing the door. When asked about the policy for securing the soiled/dirty utility rooms, Staff H replied, that's okay, the key is hanging right there in case you accidentally lock the door. During an interview, on 07/13/22 at 9:32 AM with Staff J, Certified Nursing Assistant (CNA), when asked about the soiled/dirty utility rooms not being secured, Staff J replied, The lock is broken, they ordered a new combination lock like the one on the other doors. During an interview, on 07/13/22 at 9:45 AM with Staff K, Registered Nurse (RN), when asked about the soiled/dirty utility rooms not being secured, Staff K replied, it's supposed to be locked. It is usually locked. On 07/13/22 at 9:57 AM, in the company of the Infection Preventionist (IP), it was noted that the Dirty Utility Room on the East unit was not securely closed. During an interview with the Infection Preventionist, he stated that Maintenance had to cut the lock on Monday (07/11/22) as it did not work. It was noted that the door was ajar and was opened by this surveyor by simply applying minimal force to push the door open. Once inside of the room, it was noted that there were carts that contained soiled/dirty linens and items, containers of trash/refuse and a 'biohazardous' container, as well as a counter mounted reach-in cooler (that was empty) and some unused plumbing protruding from the wall. During an interview, on 07/13/22 at 10:18 AM with the Maintenance Director, while on the [NAME] unit, when asked about the locks not working on the soiled/dirty utility room doors, the Maintenance Director replied, I just found out about it a few days ago. I called 'Doors R Us' yesterday and they will be out to fix the door next week. The code lock broke and I got them in yesterday (visually confirmed that the new lock that required a code to initiate and open was on site and in the Maintenance Office). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105819 If continuation sheet Page 8 of 8