Inspection·January 13, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm scuff marks, toilet noted to need re-caulking to the floor, over commode seat was rust laden and ready to break, and 1 of 6 dresser drawers was missing pull knob. * room [ROOM NUMBER] - Room and bathroom floors heavily stained, exterior of over-bed table was pitted and rusted, and 2 pull knobs missing on dresser drawers. Residents Affected - Some * room [ROOM NUMBER] - The room floor area located near the room entrance way noted to have 1/2 inch separation and room floor heavily black stained. * room [ROOM NUMBER] - Bathroom floor heavily black stained, base of toilet molded, privacy curtain between beds to small to ensure resident privacy, privacy curtain stained with unknown matter, and exterior of bathroom door scratched and scuffed. * room [ROOM NUMBER] - Room floor heavily back stains. * room [ROOM NUMBER] - Privacy curtain between beds was too short to provide resident's privacy. * Ceiling tiles stained in hallway between(6) rooms between rooms #223 - #225. 2) [NAME] Wing: * Central Linen Storage Room - The ceiling mounted air-conditioning vent and adjacent ceiling area was noted to have a thick layer of black mold type substance. It was further noted that the vent was located directly over shelves that contained clean resident linens. The floor of the small storage room was also noted to be soiled and stained. After the observation, the Directors noted that the linens be removed and rewashed and also a terminal cleaning and sanitizing to the room and vent. * Community Shower #1 - The room floor was soiled and stained, the shower stall floor drain was rusted and clogged with debris, and the room walls required repainting. * Community Shower #2 - Room wall corners were noted to have broken plastic edges with sharp points, the front exterior had a large crack from top to bottom, the sink vanity exterior was broken resulting in exposure of raw wood, and 1 of 3 ceiling lights were not working. * room [ROOM NUMBER] - Room floor and bathroom floor had black stained areas., and the exterior of the sink vanity was broken result in exposure of raw wood. * room [ROOM NUMBER] - Room and bathroom walls damages with large scratches and scuff marks, bathroom floor noted top have large areas of black stains, and the bathroom nurse call light cord was wrapped 3 times around the wall handrail. * room [ROOM NUMBER] - Wall damage and room window, and dresser drawers missing pull handles. * room [ROOM NUMBER] - Bathroom floor noted to be have large black stains, bathroom base boards pulling away from the walls, room floor had large black stains, , and exterior of bathroom door was damaged. * room [ROOM NUMBER] - Room floor had areas of tape put down due to floor damage, and bathroom floor noted to have large black stains. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0584 * room [ROOM NUMBER] - Bathroom floor soiled and large areas of black stains. Level of Harm - Minimal harm or potential for actual harm Following the 01/12/22 tour, the Director were interviewed concerning the tour findings. It was revealed that the East and [NAME] Wings have a maintenance / housekeeping Log Book that staff are required to report and housekeeping / maintenance issues. The Director stated that the logbooks are checked 2-3 times per day. It was further discussed that staff are not reporting housekeeping/maintenance issues. Residents Affected - Some All the 01/12/22 tour findings were reviewed with the administrator. 3) On 01/10/22 beginning at 10:51 AM, observations of the corridors of the East and [NAME] unit and throughout the facility and common areas, revealed that the hand rails that residents were observed utilizing to propel themselves through the units and corridors were secured to the walls with raw and unfinished wood that was absorbent and uncleanable, with the potential for residents to obtain skin tears and splinters to their hands. It was also noted that there was accumulation of residue and debris, including used single use gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to address a residents' grievance in a timely manner for 2 of 2 sampled residents reviewed for grievances, Resident #66, and Resident #382. The findings included: 1) During an interview on 01/10/22 at 12:41 PM, the daughter of Resident #66 stated that her mother's quilt went missing about 6 months ago, when visitors could not come in to visit during COVID times. When she was allowed to visit, she went looking for the quilt and was unable to find it, she addressed her concerns with a case manager and then again in December 2021 with the Administrator. A review of the grievance log revealed there is no grievance documented for this concern. During an interview on 01/12/22 at 8:56 AM with the Administrator (NHA), she acknowledged that she spoke to the daughter of this resident in 12/21 and was aware of the daughter's concerns about the missing quilt, she mentioned it to me, and I looked in laundry, but forgot to call her to tell her that I did not see it. The surveyor asked if there was a grievance on this concern and the NHA stated yes. The surveyor requested to see the grievance. On 01/12/22 at 12:15 PM, the Administrator handed the surveyor a grievance document for this concern dated 01/12/22. The Administrator acknowledged that a grievance was not completed previously. 2) On 01/13/22 at 11:00 AM review of grievance policy dated 08/30/18 indicated the purpose was to support each resident's right to voice grievances and to ensure that after a grievance has been received, the facility will actively work through to a conclusion while communicating progress to the resident and/or anyone working on their behalf in a timely manner. This policy shall be made available, upon request, for resident and/or anyone working on their behalf. Procedure included: when a resident, or anyone acting on their behalf, has a grievance, a staff member shall encourage and assist the resident, or person acting on the resident's behalf, to file a grievance with the facility using the grievance report. On 01/10/22 at 9:51 AM, Resident #382 stated she has been fighting with the facility since admission (on 01/07/22) regarding her medication-Omeprazole 40 mg. Resident #382 added she has GERD (gastro esophageal reflux disease, a digestive disease in which stomach acid or bile irritates the food pipe lining), and the GERD has been causing a lot of pain, to the point she has to squeeze her chest in order to get relief, and she cannot tolerate coffee and orange juice. Resident #382 said, the facility has provided Omeprazole in a pill form, she doesn't want it in a pill form, and she wanted it in capsule form which provide better relief for her. She further added, she has been taking Omeprazole in capsule form for 20 years. Resident #382 said; the facility provided Nexium instead of ensuring she received the Omeprazole 40 mg in capsule form. Resident #382 voiced she has been refusing the Nexium the facility provided, as it does not work for her. She informed the facility she had 90 days' supply of Omeprazole 40 mg at home, in capsule form, and her husband would bring it in for her to be self-administered. On 01/13/22 at 9:14 AM, an interview was held with the west wing unit Manager (UM), who revealed Resident #382 had voiced concern about the Omeprazole, and the facility has provided the Omeprazole to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #382, but in the pill form. She confirmed the resident preferred it in capsule form. The UM said the facility had informed Resident #382 that the capsule form was not available, and the pharmacy provided it under Nexium instead. On 01/13/22 at 9:27 AM, while interviewing the [NAME] wing unit Manager, the regional nurse consultant, asked the unit Manager whether Resident # 382 had voiced concerns regarding the Omeprazole before? The Unit Manager said yes. When the surveyor asked the regional nurse consultant should the facility have tried to obtain an order for the Capsule form to address Resident #382's concern? The regional Nurse consultant stated, the facility should be able to order the Omeprazole in capsule form for the resident. She then instructed the unit Manager to contact the attending doctor or the advance practical registered nurse (APRN) for an order. At this time, the UM was noted on the phone, and voiced she has obtained an order for the Omeprazole 40 mg in the capsule form. At 9:32 AM, the regional nurse consultant indicated the medication was on its way, and she instructed the unit manager to make sure there is an order in place. On 01/13/22 at 9:56 AM, a subsequent interview was held with the regional nurse consultant, and an inquiry was made regarding grievances. The surveyor asked for a filed grievance regarding the medication concern. She revealed if a resident voiced a concern, there should be a grievance file to address the concern based on the facility policy. The regional nurse consultant voiced, the Omeprazole 40 mg capsules form requires a prescription, the pill form does not come in 40 mg, it comes in 20 mg and does not require a prescription. The regional nurse consultant voiced that somebody went to the pharmacy to pick up the capsule form for Resident # 382 today (01/13/22). She revealed she has apologized to Resident # 382. During an additional interview with the regional nurse consultant on 01/13/22 at 10:42 AM, she confirmed there was no grievance file to address the medication concerns, and added she spoke to the [NAME] wing unit Manager who also confirmed there was no grievance filed for Resident #382. Record review revealed, Resident # 382 was admitted to the facility on [DATE]. Review of a Physician order, dated 01/08/22, revealed an order for Nexium (Esomeprazole Magnesium) Capsule Delayed Release 40M give 1 capsule by mouth one time a day for GERD, that was discontinued on 01/10/22. There was another Physician order dated 01/11/22 for Nexium Capsule Delayed Release 40 MG (Esomeprazole Magnesium) give 1 capsule by mouth in the morning for GERD. Review of the progress note dated 01/10/22 at 5:56 PM documented Resident #382 had concerns regarding Nexium. Review of a Physician progress note dated 01/10/22 at 10:29, documented, chief complaint: abdominal pain, nausea and vomiting with hematemesis, liquid output from ostomy. Interval history: status post hospitalization for abdominal pain, nausea vomiting with hematemesis (vomiting blood), liquid output from ostomy. CT scan 01/02/2022 demonstrated diverting colostomy in left mid abdomen, prominent dilated small bowel with a transition zone in nondilated loops of bowel, postulated to adhesions or early bowel obstruction. There is distention of the stomach and reflux of liquid into the esophagus. Surgery evaluated nasogastric tube was placed putting out copious amounts of coffee-ground. Obstruction resolved and patient tolerating diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide ongoing activity program to meet the residents' needs for 3 of 6 sampled residents reviewed for activities, Residents #1, #532, #69. Residents Affected - Few The findings included: 1). Resident #1 was initially admitted on [DATE] and discharged on 06/10/21. Resident was readmitted for current stay on 01/03/22. According to a 'Resident Data Set' evaluation, completed on 01/03/22, Resident #1 had a BIMS score of 8, indicating 'moderately impaired'. A 'Therapeutic Recreation/Activity Review', date 01/07/22, documented that the resident did not require a care plan for activities as, This resident can communicate her needs and preferences and her own independent leisure activity. Activity staff will visit for social interaction and provide activity supplies. The assessment documented resident's participation in the assessment. The assessment documented that Resident #1's interests for Activities included: Group activities, Independent activities, Day/Activity Room activities, Inside facility/off unit activities, Indoor and Outdoor activities. The assessment documented that an Activity care plan was not required as, (Resident) is able to make needs known & choose her own daily activities. She is interested in attending and participating in group activities, bingo, ice cream socials & music events as tolerated. During an interview with Resident #1, on 01/11/22 at 10:08 AM, when Resident #1 was asked about participation in activities, Resident #1 replied that she had not seen any Activities staff since being admitted . Resident #1 did not have a care plan for Activities. 2). Resident #532 was admitted for current stay on 01/05/22. admission assessment, dated 01/05/22, documented resident with a BIMS score of 6, indicating 'severe cognitive impairment.' A Therapeutic Recreation/Activity Review, dated 01/07/22, documented resident participation in assessment. The assessment documented that Resident #532 did not require an activities care plan as, (Resident) is able to make her needs known and choose her own daily activities. She is interested in attending and participating in group activities, bingo, ice cream socials & music events as tolerated Resident #532's care plan, initiated on 01/05/22, documented, (Resident) is self directed in choosing her preferred activities, both group and independent. The goal of the care plan was documented as, (Resident) will continue to make her own choices regarding daily activities by next review period with a target date of 01/20/22. Interventions to the care plan were documented as: * Invite and offer assistance to activities of potential interest * Respect residents right to choose to attend planned group activities or not as desired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident #532, on 01/11/22 at 10:14 AM, when asked about activities, Resident #532 replied that she had not seen any staff from the Activities department. During an interview with the Activities Director and the Activities Assistant, on 01/12/22 at 9:31 AM, when asked of Resident #1 and Resident #532's participation in activities and where it was documented, the Activities Director (AD) replied, in the I-PAD. We can document in the computer as well. She (the Activities Assistant) does all of the documenting. (Activities Assistant confirmed that she does the documentation). The AD confirmed it is written in the care plans to respect their decision to participate or not. If they decline, it isn't documented. The newer folks, we don't know them as well as the Long-term patients. They both (Resident #1 and Resident #532) like Rock and Roll music. I go around with this (pointing to an activity cart containing books, magazines, drawings and coloring, word search and crossword). She (Resident #1) does her own independent thing and I go see her twice a week with the cart. When asked for documentation of residents being invited to the group activities and activities that are of interest based on the assessment, the Activities Director stated that there was no such documentation of the residents being invited to, attending or declining invitation to attend activities. 3) Record review for Resident #69, revealed Resident #69 was admitted to the facility on [DATE], with diagnoses included: anxiety disorder. The admission minimum data set (MDS) assessment, reference date 12/23/21 recorded, Resident #69's brief interview for mental status score was 13, indicating he was cognitively intact. This MDS recorded under section F for Preferences- that it was somewhat important for Resident # 69 to have books, newspapers, and magazines to read. It was somewhat important for him to listen to music he likes. It was very important for him to do things with groups of people. It was very important for him to do his favorite activities. The MDS indicated, the primary respondent for daily and activity preferences was Resident # 69. The MDS further recorded Resident #69 required extensive assistance by the staff with activity of daily living such as: Bed mobility, transfer, locomotion on and off unit, dressing, and personal hygiene. A review of the recreation/activity assessment dated [DATE], indicated Resident #69's recreation interests/needs included: Group, Own Room, day/activities room, inside facility/off unit, indoor, and outdoor with passive participation. The recreation/activity assessment recorded, the activity care plan decision was by Resident #69, he can communicate his needs and choose his own daily activity. Review of Psychiatry evaluation note dated 12/18/21 revealed Resident #69 was on Trazadone 25 mg by mouth at bedtime for depression. An additional record review evidenced Resident #69 was fully vaccinated. On 01/12/22 at 3:49 PM an interview was held with the Activity Director, who stated Resident #69 was social, and he likes to converse. When asked for evidence from the Activity Director of group activity participation for Resident #69, as per his preference, voiced she did not have any documentation for group activity participation for him. At 4:02 PM the nursing home Administrator joined the interview process; and was made aware of Resident #69's lack of activity concern. On 01/10/22 at 9:33 AM, Resident #69 stated, he is not happy at all at the facility, he does nothing all day, there is no activity at the facility, he sits in his room, he is bored, he is thinking of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 all type of crazy expletives. Level of Harm - Minimal harm or potential for actual harm On 01/10/22 at 12:31 PM, Resident #69 was observed sitting up in wheelchair, the TV was on, but Resident #69 kept both eyes closed. He was not observed participating in activity. Residents Affected - Few On 01/10/22 at 1:19 PM, Resident #69 was observed propelling himself in the wheelchair, roaming in his room aimlessly, he was not participating in activity. On 01/11/22 at 9:20 AM, Resident #69 was observed lying in bed, there was no activity. On 01/11/22 at 10:39 AM, Resident #69 was noted lying in bed, watching TV. He voiced, he hasn't been in activity. He stated, the facility doesn't have anything going on, there is no activities, he likes music, and bingo. He added he has been to places where there are activities such as bingo and music. He said he just lays here and watches TV and is getting bored. On 01/11/22 at 12:13 PM, Resident #69 was noted sitting up in wheelchair, the TV was on. He stated, I am bored, all day I do this, there's nothing to do. On 01/12/22 at 11:32 AM Resident #69 was observed sitting up in wheelchair, in his room, with his right hand on his face looking at the wall. The TV was on, he turned his back away from the TV, he was not participating in activity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physician orders for obtaining blood sugar levels and blood pressure parameters and notify the physician when the resident's blood sugar level was below 60 or above 250 for 2 of 2 sampled residents reviewed for following physician orders, Resident #20 and Resident #72; and failed to follow physician's orders to obtain daily weights for 1 of 2 sampled residents reviewed for following physician's orders, Resident #72. Residents Affected - Few The findings included: 1) A record review for Resident #20 revealed that this resident was admitted to the facility on 12/20/20 with a diagnosis to include Type II Diabetes, Chronic Kidney Disease, Hypertension, Atrial-Fibrillation, Congestive Heart Failure, Cardiac Pacemaker, Muscle Weakness, Neuropathy, Difficulty Walking, Morbid Obesity, and Chronic Obstructive Pulmonary Disease. A review of the Physician Orders, revealed documentation that Resident #20 was to haved accu checks four times a day. Blood sugars less than 60 or greater than 250 to notify the physician. This order was noted to be active with a start date of 09/24/21. A review of the December 2021 and January 2022 documented the following days the blood sugars (BS)were above 250, out of parameter range and the physician was not notified. a. At 7:30 AM on the following date: 12/06/21 - BS 252 b. At 11:30 AM on the following dates: 12/17/21-BS 253 12/20/21-BS 264 12/25/21-BS 254 12/29/21-BS 268 12/30/21-BS 254 01/08/22-BS 281 c. At 4:30 PM on the following date: 12/03/21-BS 261 d. At 9:00 PM on the following dates: 01/02/22-BS 266 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 01/08/22-BS 289 Level of Harm - Minimal harm or potential for actual harm 01/10/22-BS 258. Residents Affected - Few During an interview on 01/11/22 at 1:15 PM, with the Director of Nursing (DON), she stated that the nurses can document in the MAR (Medication Administration Record) that the physician was notified, there is a spot for them to do that and then it migrates over to the progress note. The DON reviewed the progress notes and acknowledged she does not see documentation of notifying physician when the BS were out of parameters. During an interview on 01/12/22 at 9:15 A.M., with Staff H- RN (registered nurse), if I have to notify physician, I would notify the physician and document in progress notes or you can go into the MAR. The surveyor asked the nurse to pull up BS to show surveyor the documents where she notified the physician of BS that were outside parameters. She acknowledged she had several outside the parameters, stated, I don't notify the physician they are ok, then stated the doctor is usually in building and will tell them but does not document anywhere. During an interview on 01/12/22 at 10:00 AM with Staff G-RN, Unit Manager, she looked at orders and read orders about notifying the physicians. She said, I would document under the progress notes. She then looked for a BS that she did on 12/30/2, with a BS of 254. She reviewed the progress notes and was unable to find a notification to the physician. 2) Subsequent record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses included: Atrial fibrillation and other dysrhythmias, coronary artery disease (CAD), and Heart failure (HF). The admission minimum data set (MDS) assessment reference date 12/15/21 indicated a brief interview for mental status score of 13, indicating Resident #72 was cognitively intact. The MDS recorded Resident #72 required extensive assistance by the staff for activity of daily living. A review of the comprehensive Care Plan, revealed, Resident #72 was at risk for altered cardiovascular status related to CHF and CAD. Interventions included: Monitor weights as ordered, and monitor / document / report to MD as needed for any signs and symptoms of Congestive Heart Failure included: weight gain unrelated to intake. Additional review of Resident #72's records lacked any evidence for omitting weights on the mentioned dates. A review of dietary Note dated 01/10/2022 written by the Dietitian for Weight/Wound review, indicated a body mass index (BMI) of 25.7 which reflects overweight status, Resident #72 was on daily weights monitoring for CHF with diuretic use, weight fluctuations anticipated. On 01/12/22 at 1:42 PM an interview was held with the Dietitian, she revealed, nursing staff were to enter daily weights in the computer system. The nursing staff have orders in place for daily weights. On 01/12/22 at 1:46 PM an interview was held with the [NAME] wing unit Manager, a side by side review of Resident #72's record was conducted with her and interview, in the presence of the Dietitian. Both staff were not able to provide evidence for weight monitoring on the mentioned dates above. On 01/12/22 at 2:10 PM, an interview was held with the Director of nursing (DON), she was made aware of the concerns with the lack of daily weights, and voiced she would look for them. At 3:03 PM, the DON revealed she was not able to find the weights on the mentioned dates. Clinical record review for Resident #72, revealed a physician order, dated 12/10/2021, for 'daily weights in the morning for congestive heart failure (CHF)'. A review of the computer system under (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 the weight tab was conducted. Review of December 2021 and January 2022 medication and treatment administration records (MARs and TARs) lacked evidence of daily weights monitoring for the following dates: 12/12/21, 12/16/21, 12/21/21, 12/25/21, 12/26/21, 12/30/21, 01/02/22, 01/04/22, and 01/09/22. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview, and record review, the facility failed to provide a nourishing, palatable, well-balanced diet that met the nutritional needs of 88 of 88 facility residents, that included; Regular Diet: Sampled Residents' #1, #56, #36, #69, #53, #40, #27, #24, #9, ,#51, #19, #14, #71, #63, #52; Puree Diet: Sampled Residents' #22, #39, #48; and Mechanical Soft Diet: Sampled Resident's; #57, #66, #14, #26, #72, and #39. The findings included: 1. During the observation of the lunch meal on 01/10/22 at 11:30 AM, it was noted that the approved lunch menu was not followed for Regular Diets: Sampled Residents' #1, #56, #36, #69, #53, #40, #27, #24, #9, ,#51, #19, #14, #71, #63, #52; Puree Diet; Sampled Residents' #22, #39, #48, and Mechanical Soft Diet: Sampled Residents' #57, #66, #14, #26, #72, and #39. Interview with the breakfast/lunch cook (Staff A) stated that she does not follow the approved menu and prepares what ever she thinks the residents would like to eat for meals. Staff A also stated that often food is not delivered prior to the preparation of the meal. 2. During the observation of the lunch meal in the main kitchen on 01/10/22 and 01/11/22, it was noted that the breakfast/lunch cook (Staff A) failed to follow approved standardized recipes for the lunch and breakfast meal. Interview with Staff A revealed that the recipe ingredients for entrees (Chicken with Peach Sauce), starch (Rice Pilaf), vegetables (Normandy Vegetables), and desserts (Pound Care with Creme) were not followed. Observation during the breakfast meal on 01/11/22 noted that the menu documented fresh fruit for Regular and Therapeutic Diets. There was no fresh fruit prepared and served. It was also noted that no fruit substitute was replaced. Interview with Dietary Manager and [NAME] (Staff A) noted that they were unaware that the approved menu included fresh fruit and also noted there was no fresh fruit in supply. 2. During the observation of the lunch meal on the East Wing on 01/11/22, it was noted that the meal was served over 2 hours late resulting in numerous residents becoming anxious and angry concerning the late meal service. Because of the late service, numerous residents left the dining area and meal consumption intake was very poor. The late meal service affected 47 residents residing on the east wing the included sampled Residents #57, 51, #19, #14, #26, #71, #63, #52, #22, #49, #27, #24, and #9. 3. During individual interviews conducted on 01/10/22, it was noted that residents stated the following; Resident #4 - Breakfast does not come until 9:45 AM and dinner at 7:05 PM on a daily basis; I hate being served plastic silverware; Disposable dishes in no class; and The menu is not being followed and food quality is poor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #27 - The food trays come late all the time; Breakfast at 10 AM and dinner at 7 PM; I hate the plastic silverware as I cannot cut anything with it; and The facility food is terrible. Resident #24 - I complain that there is never any fresh fruit being served. No fresh salads are not being served; If you ask for fresh fruits you only get canned fruit cocktail and I hate that; and The menu is not being followed. Resident #9 - I think they ran out of food last night; I got a cold sandwich that I did not order; I think everyone got a cold sandwich; The menu is not being followed. 4. During the observation of the lunch meal service in the main kitchen on 01/10/22 at 11:30 AM and the breakfast meal of 01/11/22, it was noted that there was insufficient staff to carry out the functions of the dietary department. Interview with the Dietary Manager(DM) revealed that the department is short 4 dietary aides and 1 cook position. On 01/10/22, it was noted that nursing Certified Nursing Assistance (CNA) are scheduled daily to work in the dietary department due to insufficient dietary staff. The DM stated that on 01/11/22 the lunch dinner meals were short 4 dietary aides due to illness or 'no show no call' in sick. The DM stated that the CNA's working in the kitchen have not been properly trained in dietary policies and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, it was determined that the facility failed to employ sufficient staff with appropriate skills to carry out the functions of the food and nutrition services for 88 of 88 residents which included Sample Residents; #1, #56, #36, #69, #53, #49, #27, #24, #9, #57, #51, #19, #14, #26, #71, #63, #52, #22, #39, #48, #66, #26, and #72. The findings included: 1. During the observation of the lunch meal in the main kitchen on 01/10/22 and breakfast meal of 01/11/22, it was noted that the approved menu was not being followed for residents with Regular Diet , Mechanical Soft Diet, and Pureed Diet. Interview with the breakfast/lunch cook (Staff A) at the time of the observations noted to stated she does not follow the approved menu and makes her own decision of what she will prepare and serve on a daily basis, Staff A was also noted to state that the facility does not have food deliveries on a regular and timely basis to follow the approved menu. Staff A stated that she has not had in-service training on: following the approved menu, therapeutic diets, and following standardized menu recipes. 2. During the initial sanitation tour of the kitchen /food service department on 01/10/22 it was noted that a nursing Certified Nursing Assistance (CNA-Staff B) was working within the department. During an interview with the Dietary Manager (DM) at the time of the observation it was noted that the facility does not employ sufficient dietary staff. The DM stated that the dietary Department has 4 dietary Aides open position and 1 cook position vacancies. The DM further stated that on 01/11/22 4 Dietary Aides did not show for work due to illness and no call no show for work. The DM further stated it is necessary for CNA staff to work in the kitchen in order for resident meals to be prepared and served. Interview conducted with Staff B stated he works daily in the Dietary Department for over the past 2 weeks and has not had any job training fro the dietary aide position. 3. During the observation of the breakfast meal on 01/13/22 it was noted that the Maintenance Director was delivering resident meal tray carts to the East and [NAME] Units. Further observation conducted on 01/13/22 noted the Director was working in the main kitchen and was coming into contact with prepared food, food preparation surfaces, and food serving surfaces. Following the observations, the surveyor requested to the Director that he is only allowed in the dietary department for maintenance repairs. The Director stated that the facility administration requested his assistance in the main kitchen. 4. During the observation of the lunch meal on 01/11/22 on the East Unit, it was noted that there meal tray delivery time of 12 PM was not followed. Further observation noted that 12 residents were seated in the dining area since 11:30 AM. Continued observations noted that meal trays were not served to the East Unit until 2 PM. During the 2 hours wait it was noted that the 12 residents in the dining area became anxious and angry to not receiving their meals. Some of the residents were removed by staff due to the anxiety. It was noted that the last resident finished the lunch meal after 2:30 PM. Interview with the Dietary Manager, following the lunch meal observation, noted to state that there was insufficient dietary staff to prepare and serve the meal. 5. During the observation of the breakfast and lunch meal on 01/13/22, it was noted that the residents were being served foods on disposable dishware. Interview with the Dietary Manager (DM) revealed that the department does not have sufficient staffing and further stated that he had to make the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some choice of cooking/preparing residents' meals or wash residents' dishware. The DM stated that he needed to cook/ prepare meals and made the decision to serve residents' meals on disposable dishware. 6. Individual resident interviews concerting food issues on 01/10/22, revealed the following: Resident #4 - Breakfast does not come until 9:45 AM and dinner at 7:05 PM on a daily basis. I hate being served plastic silverware. Disposable dishes in no class. Resident #27 - The food trays come late all the time. Breakfast at 10 AM and dinner at 7 PM. I hate the plastic silverware as I cannot cut anything with it. The facility food is terrible. Resident #24 - I complain that there is never any fresh fruit being served. No fresh salads are not being served. If you ask for fresh fruits you only get canned fruit cocktail and I hate that. The menu is not being followed. Resident #9 - I think they ran out of food last night I got a cold sandwich that I did not order. I think everyone got a cold sandwich. The menu is not being followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observatioin , interview, and record review, it was determined that the facility failed to follow the approved menu for 88 of 88 facility residents that included: Regular Diet: Sampled Residents #1, #56, #36, #69, #53, #40, #27, #24, #9, ,#51, #19, #14, #71, #63, #52, , Puree Diet; Sampled Residents #22, #39, #48, Mechanical Soft Diet: Sampled Residents; #57, #66, #14, #26, #72, and #39. The findings included; 1) During the review of the approved menu for the lunch meal of 01/10/22 , the following were noted: *Regular Diet - Chicken Breast (3 ounce) with Spiced Peach Sauce, [NAME] Pilaf (#8 scoop), Normandy Vegetables (#8 Scoop), Pound Cake with Creme (1 slice). Mechanical Soft - Ground Chicken (#8 scoop) with 1 ounce Spiced Peach Soft, [NAME] Pilaf with 1 ounce of Thick [NAME] Sauce, Pureed Bread/Roll or Slurry , and Pureed Pond Cake with Creme Sauce. Pureed Diet - Pureed [NAME] Pilaf (#8 Scoop), Pureed Normandy vegetable (#8 scoop), Pureed Bread/Roll or Slurry, and Pureed/Slurry Pound Cake with Creme (#10 Scoop) Interview with the Breakfast/Lunch [NAME] (Staff #A) on 01/10/22 noted she stated that she often does not follow the approved facility menu, and further stated the she determined what the residents don't like to eat and prepares other foods. Staff also stated that often menu foods are not delivered in time and is forced to change the menu. The interview was witnessed and discussed with the DM and facility Dietitian. 2) During the review of the approved facility menu for the breakfast meal of 01/12/22, the following were noted; * Regular Diet - Serving (#8 scoop /half cup of Seasonal Fruit * Mechanical Soft Diet - Serving (#8 scoop) of Soft Canned Fruit (NO Pineapple or Fruit Cocktail) * Pureed Diet - Serving (#8 scoop) of Pureed Canned fruit (No Pineapple or fruit Cocktail) Observation of the tray assembly line in the Main Kitchen on 01/12/22 at 7:30 AM noted that the seasonal fruit, canned fruit, and pureed fruit was not prepared or served for the meal. Interview with the Dietary manager and facility Dietitian at the time of the observation revealed that the menu and dietary spread sheet was not reviewed by the morning cook (Staff A) to ensure that the approved menu was going to be followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on obserevation, interview, and record review, it was determined that the facility failed to prepare oatmeal in a form designed to meet the needs of 10 residents (includes Residents #22, #39, and #48) with physician ordered dysphagia pureed diet. The findings included: During the observation of the breakfast meal in the main kitchen on 01/11/22 at 7:30 AM accompanied with the facility's Licensed Dietitian, the following was noted: 1) The cooked pureed oatmeal identified by the cook (Staff A) appeared to be very lump and had notable large pieces of Oatmeal. At the request of the surveyor , at taste test of the pureed cooked cereal was conducted along with the facility's Dietitian. The result of the testing noted the cereal was not smooth and had large chunks of Oatmeal. The surveyor requested that the Oatmeal not be served to Pureed residents until the mixture was blended to the correct smooth pureed consistency. 2) Interview conducted with the breakfast/lunch cook (Staff A) on 01/11/22 revealed that she does not follow standardized recipes for the preparation of pureed foods. She stated that she was unaware of consistency of pureed foods for the prevention of potential aspiration for dysphagia residents. Staff A also stated she did not have specific training for the preparation of pureed diets and was unaware of residents specific nutritional needs with a diagnosis of dysphagia. A review of the facility diet census for 01/10/22 noted that there were currently 10 residents with physician ordered dysphagia pureed diets. Of these 10 residents it was noted that 3 of the residents were sampled including Residents #22, #39, #48. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on Observation, interview, and record review, it was determined that the facility failed to provide meals at regular times comparable to normal times in the facility for 47 residents residing on the East Wing. Of the 47 residents it was noted that the following were sampled residents #40, #27, #24, #9, #57, #51, 19, #14, #26, #71, #63, #52, #22. The findings included: During the observation of the lunch meal on 01/11/22 at 11:30 AM, it was noted the 12 facility residents were seated in the East Dining Room awaiting the delivery of the lunch meal . Further observation noted at 12:30 PM the residents began get visually and verbally upset that the lunch meal had not been delivered. At 1:15 PM it was noted that 2 residents ( Resident # 14) became very upset , began to yell and had to be taken away from the dining room area to reduce their anxiety with the late meal. At 1:15 PM the surveyor contacted the administrator and requested to be informed of why the late meal service was occurring. The administrator stated she was unaware why the issue was occurring. At 1:35 PM the first food cart arrived to the East Wing however only some of the 12 residents seated in the dining groom room received a tray. Specifically it was noted that 5 residents did not receive their lunch tray and had to sit and watch other residents eat their lunch meal while seated at the same table. At 2:10 PM the lunch trays finally arrived to the East wing and were served to the 5 residents. Continued observation noted that that the last residents seated in the dining room (including Resident #19) and residents eating in room ( including Resident #71) finished eating the lunch meal at 2:35 PM. Following the lunch meal observation an interview was conducted with the Dietary Manager (DM) on 01/12/22 at 2:45 PM concerning the late meal service on the East Wing. The DM stated that the dietary department has been short staffed since his hire 1 week ago. Further stated that nursing CNA's had to be scheduled to work in the dietary department on a daily basis. The DM also included that on 01/12/22 short staffed by 4 dietary aides and 1 cook. The DM stated that the 4 dietary aides absent on 01/12/22 included 2 illness and 2 no show no call. Following the DM the Administrator was interviewed concerning the meal time and dietary staff shortages. It was noted that the administrator was aware of the shortages and steps had been put into place to hire new dietary staff. It was also noted that an action plan had not been developed concerning the meal and staffing issues and the surveyor requested that an action plan be developed and submitted to the surveyor for review on 01/13/22. On 01/11/22 interviews were conducted with 4 residents residing on the East Wing concerning food and meal times . The findings of the interviews included the following: Resident #4 - Breakfast does not come until 9:45 am and dinner at 7:05 PM on a daily basis. I hate being served on plastic dishes and silverware, I feel that's no class. Resident #27 - The food trays come late all the time. Breakfast served at 10 AM and dinner at 7 PM. I am served disposable dishes and I hate the plastic silverware as I cannot cut anything. Resident #24 - I complain that there is never any fresh fruit being served. No fresh salads are not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0809 being served. If you ask for fresh fruits you only get canned fruit cocktail and I hate that. Level of Harm - Minimal harm or potential for actual harm Resident #9 -I think they ran out of food last night I got a cold sandwich that I did not order . I think everyone got a cold sandwich . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food serve safety; including ensure fresh ice is not being contaminated, silverware is handled in a safe and sanitary manor, cooking equipment is free of carbon build-up, and food storage shelving are being cleaned properly. The findings included; 1) During the kitchen/food service sanitation tour conducted on 01/10/22 at 9 AM accompanied with the Dietary Manager (DM), the following were noted: (a) Observation of the interior of the commercial ice machine noted the sides and top had a large growth of black mold type matter. The top of the ice level was in contact with the black mold type matter. The surveyor stated to the DM that there was potential that the ice was contaminated and there was a potential risk of resident illness. The surveyor requested that the machine be unplugged and drained and thoroughly sanitized prior to use. On 01/10/22 it was noted that an outside refrigeration/ice machine vendor was sanitizing and servicing the commercial ice machine. *Photographic evidence obtained. (b) Observation of the walk-in refrigerator noted large rust laden area on the entry door and on the interior walls of the unit. Further noted that 12 of 12 food storage shelves were soiled with dried food matter. *Photographic evidence obtained. (c) Observation of the walk in refrigerator noted that foods were not being stored on shelving to prevent possible contamination. Specifically cases of raw eggs (2) and fresh fruits (grapes) were being stored on the bottom shelf together. The surveyor discussed that there was possible food contamination if broken raw eggs came in contact with the fresh fruits. The surveyor requested that fresh fruit be washed and stored above the cases of raw eggs. (d) Observation of the commercial convection ovens noted that 2 of 2 ovens were soiled with large areas of black carbon. it was discussed with the DM the ovens had not been properly cleaned in some time and needs to be put on regular cleaning basis. The DM further stated that 1 of the ovens was not even operational. *Photographic evidence obtained. (e) Cooked eggs (5) were noted to be located on a pan on the preparation table . An interview with the cook noted that the eggs were leftover from the breakfast meal, but were intended for use for egg salad. At the request of the surveyor the temperature of the cooked eggs was taken by use of the facility's calibrated thermometer. The temperature was recorded at 126 degrees F. The surveyor informed that the eggs were not being held at the required temperature of 41 degrees F or below, or 135 degrees F or above. (f) The walls of the food preparation area near the 3-compartment sink were noted soiled and to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 have numerous areas of dried food matter. Level of Harm - Minimal harm or potential for actual harm *Photographic evidence obtained. Residents Affected - Many (g) Observation noted 3 of 3 food preparation skillet pans exteriors covered with a layer of thick black carbon. *Photographic evidence obtained. (h) The trash bin located at the hand wash sink failed to have a cover. *Photographic evidence obtained. (i) Observation of the dish machine room noted that the ceiling mounted air-conditioning vent located in the middle of the room was heavily soiled and covered with a black mold type substance. It was also noted the walls of the room and the exterior of the dish machine were heavily soiled. The surveyor discussed with the DM that clean dishes, cart, staff can become contaminated and requested that the vent, dish machine, and room walls be properly cleaned on 01/10/22. *Photographic evidence obtained. 2) Observation of the trash/dumpster area on 01/10/22 at 9:45 AM accompanied with the Dietary Manager noted that the ground area surrounding the dumpster was littered heavily with tray, rotting food, and discarded PPE . The area with infectious waste bins were noted to have the ground surface molded and build up of vegetation and leaves. The surveyor requested that the issues be reported to the Administrator and Infection Control staff for immediate attention. *Photographic evidence obtained. 3) During the subsequent second tour of the main kitchen on 01/10/22 at 11:30 AM, it was noted a staff member who is a CNA in the facility that has been scheduled for dietary staff was not handling clean silverware in sanitary manor. Specifically the silverware was not washed and sanitized properly and was put into silverware tubes with the eating portion in up position. The surveyor requested to have Staff cease rolling the contaminated silverware and have the silverware re-sanitized and stored properly prior to handling. 4) During the subsequent third tour of the main kitchen on 01/11/22 at 11:30 AM, it was noted a staff member who is a CNA in the facility that has been scheduled for dietary staff, was not handling clean silverware in sanitary manner. Specifically the silverware was not washed and sanitized properly and was put into silverware tubes with the eating portion in up position. The surveyor requested to have Staff cease rolling the contaminated silverware and have the silverware re-sanitized and stored properly prior to handling. 5) During routine observations of the Main Kitchen on 01/13/22 at 8:45 AM it was noted 3 separate observations of the Director of Maintenance in kitchen preparation and serving areas. The Director was observed helping out with the breakfast meal service. The surveyor requested that the Director not be in the kitchen to assist with meals unless it is for kitchen repairs. It was also discussed the issues of contamination potential of the Director assisting with food preparing and serving. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 21 of 21