Inspection·April 28, 2023

F 0755 On 04/27/23, at approximately 2:00 PM, a review of the above findings was reviewed with the Director of Nursing. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 2 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review, interview, and policy review, the facility failed to ensure timely review and follow-up of pharmacy recommendations for 3 of 5 sampled residents, Resident #12, #72 and #75. Residents Affected - Few The findings included: Review of the policy. titles, '9.1 Medication Regimen Review' revised 03/03/20, documented in part, 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR (Monthly Regimen Review) and the Director of Nursing to act upon the recommendations contained within the MRR. 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 7.2.1 If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. 8. Facility should alert the Medical Director where MRRs are not addressed by the attending physician in a timely manner. 11. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. 1. Review of the pharmacist's Consultant Report (report that documented the Medication Regimen Review/MRR) dated 03/01/23, revealed Resident #12 received the medication Methotrexate weekly for Arthritis but did not receive a Folic Acid supplement. This report recommended the addition of Folic Acid 1 mg (milligram) daily for Resident #12. This Consultation Report was signed by the physician on 03/18/23 with agreement to the pharmacy recommendation. Review of the record revealed a current order dated 03/17/23 for Folic Acid 400 mcg (micrograms), which was less than half the pharmacist's recommended dose and physician agreement, to be given daily as the supplement. This order was entered into the electronic record by the Unit Manager. During an interview on 04/28/23 at 10:35 AM, the Unit Manager was asked about the discrepancy between the pharmacy recommendation and the current order. The Unit Manager explained that the Folic Acid 400 mcg dose was part of their formulary, or stock medication. The Unit Manager stated she discussed the dose with the physician who agreed to use the stock medication. Review of the record and further review of the pharmacy recommendation lacked evidence for the use of the lower dose of medication. The Unit Manager agreed she failed to enter notation in the medical record related to the change from the pharmacy recommendation. 2. Review of the pharmacist's Consultant Report dated 12/14/22 revealed Resident #72 had a low TSH (thyroid stimulating hormone) level on 11/01/22, and was currently receiving Levothyronxine (medication for the thyroid) 112 mcg daily. This report recommended the reduction of the resident's Levothyroxine to 100 mcg daily, and to obtain a follow-up TSH in 6 to 8 weeks. The Consultation Report for December 2022 was signed by the physician on 03/07/23, with a handwritten note already completed. Review of the orders revealed the Levothyronxine 112 mcg dose was discontinued on 03/13/23, and changed to 110 mcg that same day, nearly three months after the pharmacist's recommendation. The orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 3 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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 0756 also lacked the 6 to 8 week follow-up TSH order. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/27/23 at 12:57 PM, the Unit Manager was shown the December 2022 pharmacist's Consultation Report. The Unit Manager agreed the dose of Levothyroxine was changed on 03/13/23, and was unable to locate a follow-up TSH in 6 to 8 weeks. Residents Affected - Few 3. A review of the pharmacy recommendations for Resident #75 revealed the pharmacy consultation report completed for December 1 through December 31, 2022, was not responded to in a timely manner by the resident's physician. The recommendation for a Lipid Panel and CMP (comprehensive metabolic panel) was not acknowledged by the resident's physician until 03/27/23 and the labs were completed on 03/28/23. On 04/28/23 at approximately 10:15 AM, the Director Of Nursing provided QAPI (Quality Aurance and Performance Improvement) review that identified a concern with timeliness of physician addressing pharmacy recommendations date 04/20/23 although they were aware of concern in March 2023. There was no evidence of a complete full house audit documented. The pharmacy recommendations used as examples for full house audit were faxed on 04/25/23, according to stamped date on the faxed forms but dated on PIP (Performance Improvement Plan) as being completed on 04/24/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 4 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and policy review, the medication error rate was 7.4 percent. Two (2) medication errors were identified while observing a total of 27 opportunities, affecting 2 of 11 sampled residents observed, Residents #158 and #81. Residents Affected - Few The findings included: 1. Review of the policy, titled, Eye Drops revised 04/25/17, documented, in part, Procedure: . 10. Pull lower lid gently downward to expose conjuctival sac [area of inner lower eye lid]. Instill eye drop per order in conjunctival sac. A medication pass observation was made on 04/26/23 beginning at 9:24 AM with Staff C, Licensed Practical Nurse (LPN), for Resident #158. The LPN obtained the medication Cyclosporin ophthalmic emulsion 0.05%, an antibiotic eye drop, to instill into the resident's left eye. Upon administration of the eye drop, the LPN stated, 'gonna go in the corner,' and administered the eye drop into the inner corner of the residents left eye, directly over the tear duct. During an interview on 04/26/23 at 9:33 AM, when asked why she administered the eye drop in the corner of the resident's eye, the LPN explained another nurse had taught her the drop would spread out over the eye better if placed in the corner of the resident's eye. 2. Review of the policy, titled, Subcutaneous Injection (page 17 of 18 of the Medication Administration policy), documented, in part, Insulin Injection: Assure type of insulin, unit dosage and syringe is correct. Guidance Steps in the Procedure: 1. Verify physician's orders. A medication pass observation was made on 04/26/23 beginning at 3:30 PM with Staff D, LPN, for Resident #81. The LPN obtained the resident's blood sugar level and verbalized the reading to be 288 [mg/dl]. The LPN returned to the medication cart and entered the blood sugar reading into the electronic medical record (EMR). The LPN obtained the resident's Lispro insulin via insulin pen, showed the surveyor she had dialed 4 units, and verbally confirmed the amount to administer was 4 units. Upon return to the resident's room, Staff D stated, I have your insulin for you . four units. The LPN again confirmed the blood sugar level was 288, retrieving the reading again from the glucometer (the device used to measure the blood sugar level). Review of the record revealed the current order for the Lispro insulin dated 01/23/23, was for the insulin to be administered as per a sliding scale. This order documented, should the blood sugar level be between 250 and 299, the nurse should administer 6 units of Lispro insulin. During an interview on 04/26/23 at 4:20 PM, when asked if she administered any additional medications or insulin to Resident #81, since the medication pass observation of 3:30 PM, Staff D stated she had not. Staff D was asked to look at the current sliding scale order for the Lispro insulin, and she confirmed the order documented to give 6 units of insulin for a blood sugar level of 288. The LPN stated when she put the blood sugar reading of 288 into the computer, the electronic medical record auto populated the dosage to administer as 4 units, not 6 units as per order. During a subsequent interview on 04/26/23 at 4:40 PM, Staff D explained she looked back at her entry in the electronic Medication Administration Record (MAR) and noted she entered an incorrect blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 5 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm sugar level of 248, instead of 288, and that was why the electronic MAR told her to give the 4 units. Further review of the electronic MAR revealed the LPN had entered a blood sugar level of 228, instead of the actual blood sugar level of 288. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 6 of 6