Inspection·February 3, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Maintenance Assistant should check and clean all smoking pole ashtrays daily, after the 4 PM smoke break. On 2/03/22 at 1:26 PM, the Maintenance Assistant stated he was just informed today that he was responsible for emptying the smoking pole ashtrays. He stated he was not aware this duty had been assigned to him and was one of his job responsibilities. Review of the policy and procedure for Smoking-Supervised revised on 2/07/20 read, The Center will provide a safe, designed smoking area for residents. Review of the policy and procedure Aspects of Care effective 11/30/14 revealed the maintenance department would provide and arrange for a safe and comfortable environment for all residents. 2. On 1/31/22 at 12:23 PM, resident #32 stated he was upset that he was given a cold shower a week ago Monday. He recalled one of the shower knobs in the shower room appeared to be broken and the water in one of the stalls was cold. On 2/01/22 at 2:26 PM, during the tour of the [NAME] Wing shower room, there were three shower stalls noted. The stall nearest to the door had hot water, but the water in the middle stall remained cold despite being left to run for over 5 minutes with the knob at maximum temperature. The shower stall furthest from the door had a knob that spun but no water flowed from the sprayer. On 2/03/22 at 12:49 PM, during a tour of the [NAME] Wing shower room with the Maintenance Director, resident #32 shouted from his room across the hallway to confirm that he was given a cold shower the previous week. The Maintenance Director used a thermometer to check the water temperatures in each shower stall. He stated the water temperature was 108 degrees in the stall nearest to the door but the temperature in the middle stall did not go above 80 degrees. He explained the mixer device used to control the water temperature was defective and needed to be replaced. He checked the water temperature in the furthest stall from the door and confirmed the maximum water temperature was tepid. The Maintenance Director stated no staff reported concerns to him regarding water temperature in the [NAME] Wing shower room. On 2/03/22 at 12:55 PM, Certified Nursing Assistant (CNA) E stated she was regularly assigned to resident #32 and other residents on the [NAME] Wing. She acknowledged the water temperature in the shower room was cold except for one stall. CNA E confirmed she had been aware of the lack of hot water for approximately one week but had not reported it to anyone. Review of the policy and procedure for Maintenance effective 11/30/14 revealed The facility's physical plant and equipment will be maintained through a program of preventative maintenance and prompt action to identify areas/items in need of repair. The document indicated the facility would conduct daily rounds to ensure the building was in proper physical condition. All staff were expected to report equipment in need of service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 2 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 0641 Ensure each resident receives an accurate assessment. 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 ensure Minimum Data Set (MDS) assessments accurately reflected Range of Motion (ROM) for 2 of 2 residents reviewed for ROM (#258, #27) failed to accurately assess bowel continence for 1 of 1 resident (#61), failed to identify discharge status for 1 of 1 resident reviewed for discharge, (#1), failed to accurately assess dental status for 2 of 3 residents reviewed for dental, (#32, #27) and failed to accurately assess active diagnoses for 1 of 5 residents, (#27) out of a total sample of 65 residents. Residents Affected - Some Findings: 1. Resident #258 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, heart failure, acute embolism and thrombosis, and hemiplegia and hemiparesis affecting left non dominant side. Review of the Hospital Discharge Summary revealed the resident had chronic contracture left upper and lower extremity consistent with previous CVA (Cerebrovascular Accident), left sided weakness. The resident's admission MDS assessment with Assessment Reference Date (ARD) of 1/27/22 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status (BIMS) score of 06/15. Section G0400: Functional Limitation in Range of motion was coded as 0 indicating the resident had no impairment of his upper and lower extremities. Review of the resident's Occupational Therapy (OT) notes, with start of care on 1/21/22, revealed the resident's left upper extremity was non- functional and patient needs to use compensatory methods for dressing/toileting/hygiene tasks. On 02/01/22 at 11:23 AM, and 12:40 PM, observations showed resident #258 lying in bed with contracted right hand/arm, and no splint applied. The resident verbalized his arm/hand was contracted, and he stated he did not have a splint for his arm. On 02/02/22 at 3:43 PM Licensed Practical Nurse (LPN) A stated resident #258's left arm was contracted, and he would not allow her to touch or moisturize his left arm. On 02/03/22 at 6:01 PM, the MDS Coordinator stated the resident's admission MDS assessment with ARD 1/27/22 was completed on 2/02/22. He stated a 7 day look back review of clinical records was used to complete the assessment, and OT notes were also reviewed. Section G0400 was reviewed with the MDS Coordinator. He stated the MDS assessment was inaccurate and did not reflect the resident's status. 2. Resident #61 was admitted to the facility on [DATE] with diagnoses of diabetes type II, intervertebral disc degeneration lumbar region, anxiety disorder, cardiac pacemaker, and obstructive and reflux uropathy. Review of the resident's admission MDS assessment with ARD 12/04/21, revealed the resident's cognition was intact with a BIMS score of 14/15. Section G: Functional Status revealed the resident required extensive assistance with one-person physical assist for toilet use, and personal hygiene. Section H0400 Bowel Continence was coded 9 not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 3 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 01/31/22 at 3:42 PM, resident #61 stated he had been having diarrhea on and off for approximately one month and verbalized that some medications helped. Resident #61 did not verbalize any episode of constipation. On 01/31/22 at 4:20 PM, Registered Nurse (RN) C stated the resident had Irritable Bowel Syndrome, and sometimes would have loose stool. On 2/03/22 at 4:00 PM, the MDS Coordinator and Lead MDS Coordinator stated MDS assessments were completed by doing a 7 day look back and review of the resident's clinical records, therapy notes, and interviews with the resident and staff. Section H0400 of the resident's admission MDS and physician's orders were reviewed with the MDS Coordinators. Documentation revealed the resident had a bowel regime for constipation in place, and the Medication Administration Record for December 2021 showed the bowel regime was not given during the review period. The MDS Coordinators verbalized the assessment was inaccurate. On 02/03/22 at 4:12 PM, the accuracy of the MDS assessment was discussed with the Interim Director of Nursing. She stated she was responsible to review the assessments for accuracy and she signed them as completed. When asked if the MDS assessments were reviewed for accuracy, she stated she was told by the previous DON to just sign them. The facility's policy MDS with effective date 11/30/2014, and revision date 9/25/2017 read, Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy. 3. Resident #1 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of tongue and lymph nodes, and schizoaffective disorder. Review of a nursing progress note dated 11/10/21 revealed resident #1 went to a hospice facility on 11/9/21 for an overnight stay to evaluate pain management efficacy. Review of the discharge MDS assessment with assessment reference date 11/9/21 revealed Section A, Identification Information, A2100. Discharge Status was answered as resident #1 went to an Acute hospital. The Resident Assessment Instrument (RAI) instructions for A2100 read, Code 07, hospice: if discharge location is a program for terminally ill persons where an array of services is necessary for the palliation and management of terminal illness and related conditions. On 2/03/22 at 6:27 PM and 7:30 PM, the MDS Director and MDS Coordinator explained hospice is an option under discharge status. The MDS coordinator stated they were under the impression resident #1 went to get treatment for pain management and was returning to the facility. The MDS coordinator indicated the MDS coordinators received a Daily Census Report with the disposition for the discharged residents. He stated resident #1 was taken out of the facility but they were not informed where. The MDS Director explained he inaccurately chose acute hospital but should had been hospice as resident #1 went to a hospice facility according to the Daily Census Report dated 11/9/21. The MDS Director indicated it was unclear if resident #1 was to return to the facility and said, We are so rushed, and trying to get things done. The facility's policy and procedure titled MDS dated 9/25/17 read, Each person completing a section (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 4 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 0641 or portion of the MDS signs the Attestation Statement indicating its accuracy. Level of Harm - Minimal harm or potential for actual harm 4. Resident #27's MDS admission assessment with ARD of 11/05/21 revealed in section G0400 Functional Limitation and Range of Motion he had no impairment of his upper or lower extremities. Section I Active Diagnoses indicated the resident had no active diagnoses. Section L0200 Dental revealed resident #27 had no natural teeth or tooth fragments and was edentulous. Residents Affected - Some Review of resident #27 medical record revealed he had active diagnoses of stroke with left side weakness and paralysis, anxiety disorder, depressive disorder, convulsions, hypertension, heart failure and neuropathy. The Admission/readmission Data Collection dated 10/29/21 revealed resident #27 had loose teeth and full lower dentures that did not fit properly. On 1/31/22 at 11:41 AM, resident #27 showed his tightly contracted left hand, and demonstrated he was unable to open his fingers easily. The resident explained he had contractures of left arm and weakness of the left leg as a result of a stroke. The resident stated he had his own teeth, no dentures, and was interested in having a dental consult. On 2/03/22 at 1:20 PM, the Lead MDS Coordinator and the MDS Coordinator assessed resident #27 and validated the resident had upper and lower natural teeth and impaired range of motion of his left arm and left leg. The Lead MDS Coordinator confirmed that the resident's MDS assessment did not accurately describe his status. 5. Resident #32's MDS admission assessment with ARD of 10/31/21 revealed in Section L0200 Dental that resident #32 had no natural teeth or tooth fragments and was edentulous. On 1/31/22 at 12:27 PM, resident #32 reported he would like to see a dentist to address ongoing concerns with his teeth. He showed upper and lower natural teeth that appeared to be in good condition. On 2/03/22 at 1:22 PM, the MDS Coordinator interviewed resident #32 regarding his dental status and she confirmed he had upper and lower natural teeth. She acknowledged the MDS assessment was inaccurate. On 2/03/22 at 1:36 PM, the Lead MDS Coordinator explained sometimes assessment errors were caused by a wrong click. He stated the facility's corporate office provided guidance on identification of residents as edentulous. He acknowledged the corporate definition did not reflect either the residents' status or instructions in the Residents Assessment Instrument (RAI) manual. He confirmed MDS accuracy was essential to ensure care plans were appropriate and residents needs were met. On 2/03/22 at 07:29 PM, the Lead MDS Coordinator explained the MDS department did not conduct regular audits to ensure assessment accuracy. He stated MDS staff obtained information on residents from assessments and documentation in the chart, but only sometimes went out onto the units to actually assess and evaluate residents. The Lead MDS Coordinator said, We are so rushed. It's no excuse. We have to get things done so fast. Review of the policy and procedure MDS revised on 9/25/17 revealed the facility would conduct comprehensive assessments that included collection of data related to functional status using the RAI manual. The procedure indicated each person who completed a section of the MDS assessment would sign it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 5 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 0641 to attest to its accuracy. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 6 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Level II Preadmission Screening and Resident Review (PASARR) to ensure appropriate placement and evaluation for specialized services for 1 of 1 resident reviewed for Level II PASARR, of a total sample of 65 residents, (#62). Residents Affected - Few Findings: Resident #62 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. His diagnoses included End-Stage Renal Disease, chronic atrial fibrillation, major depressive disorder, heart failure, schizoaffective disorder, and hepatic failure. Review of the resident's Level I PASARR dated 9/17/21 revealed Section IV: PASARR Screen Completion read, Individual may not be admitted to a Nursing Facility. Use this form and required documentation to request a Level II PASARR evaluation because there is a diagnosis of or suspicion of indicated a Dx [diagnosis] of/or suspicion of . Serious Mental Illness. Guidance included in Appendix PP of the State Operations Manual read, The resident's Level II PASARR identifies the specialized services required by the resident (retrieved on 2/18/22 from www.cms.gov). The Preadmission Screening and Resident Review (PASARR) Notice of the Need for Further Evaluation dated 9/17/21 and addressed to resident #62 read, There are two screening levels. You have done Level I the results are below. Signs of a serious mental illness were found. Level II screening is needed. Results of screening will be sent to you when done. The Kepro PASARR program provides protections in line . with federal and state laws . to ensure that anyone with a serious mental illness . is served in the least restrictive setting (retrieved on 2/08/22 from www.floridapasrr.kepro.com). On 2/03/22 at 11:12 AM, the Social Services Director (SSD) stated if a Level II PASARR evaluation was required, she would provide the paperwork to the Director of Nursing (DON) and/or Assistant Director of Nursing (ADON). She explained they would complete the form and request the Level II screening from Kepro. On 2/03/22 at 11:21 AM, the Interim DON confirmed a Level II PASARR would be completed by the DON and/or ADON. During review of resident #62's clinical record with the Interim DON, she validated the Level I PASARR dated 9/17/21 indicated a Level II screening was required. The Interim DON could not say if a Level II evaluation was requested for the resident. She confirmed there was no documentation regarding a Level II evaluation request or report from Kepro. On 2/03/22 at 2:33 PM, the SSD stated she could not locate any documentation or a report from Kepro related to a Level II evaluation for resident #62. On 2/03/22 at 7:20 PM, the correspondence from Kepro dated 9/17/21 regarding resident #62's signs of serious mental illness and need for a Level II screening was reviewed with the Interim DON. She stated she never saw the letter and she would contact the SSD to check if the facility received a report from Kepro for this resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 7 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 0645 Level of Harm - Minimal harm or potential for actual harm On 2/03/22 at 7:55 PM, the Interim DON stated the facility did not have a report from Kepro based on a Level II PASRR report. The Interim DON could not confirm that a Level II evaluation was requested for the resident prior to admission to the facility, nor that the facility followed up to ensure the Level II evaluation was completed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 8 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 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** 2. Resident #303 was admitted to the facility on [DATE] with diagnoses of left femur fracture and generalized muscle weakness. Review of the clinical record revealed a baseline care plan was not completed for resident #303. The baseline care plan form included the resident's name, room number, and the admission date and time of 12/17/21 at 2:30 PM. There was no documentation on the form regarding orders and services, equipment needed, problem, goal and interventions that were necessary for the resident. 3. Resident #258 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, heart failure, acute embolism and thrombosis, and hemiplegia and hemiparesis affecting the left non-dominant side. Review of the clinical record revealed a baseline care plan with the resident's name and signatures of the resident and nurse on 1/20/22. However, no problem areas or interventions were identified or checked on the form. On 2/01/22 at 11:54 AM, the East Wing Unit Manager (UM) stated baseline care plans were usually done by the admission nurse and should be completed within 48 hours of admission for every resident. The East Wing UM stated chart reviews were conducted during the daily clinical meetings, and baseline care plans would be signed off by UMs. He explained if a baseline care plan was not completed, it would be returned to the admission nurse for completion. The UM verbalized the baseline care plan was completed to identify services residents required for care, and to identify any issues that needed to be addressed. He validated resident #258's baseline care plan was not completed as required. On 2/02/22 at 11:30 AM, RN C stated baseline care plans were initiated by the nurse admitting the resident, and should be completed, discussed with the resident, and then signed by the nurse and the resident or representative. The baseline care plans for residents #303 and #258 were reviewed with RN C. He validated the baseline care plans were not completed as no care areas were addressed. On 2/02/22 at 4:37 PM, the Interim DON stated a baseline care plan was initiated on admission and reviewed for completion the following day in the daily clinical meeting. She explained incomplete baseline care plans should be identified and completed at that time. The Interim DON reviewed the baseline care plans for residents #303 and #258 and acknowledged they were not completed as required. The facility's policy Plans of Care with effective date 11/30/2014 and revision date 9/25/2017 read, Develop and implement an Individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders . and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. Based on interview and record review, the facility failed to develop and implement a baseline care plan to address necessary care and services for tracheostomy, oxygen, suctioning, feeding tube, activities of daily living, and pain management for 1 of 9 newly admitted residents, (#111); and failed to ensure the baseline care plan summaries were reviewed with the resident or resident representative within 48 hours for 3 of 9 newly admitted residents, (#111, #303, #258), out of a total sample of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 9 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 65 residents. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Few 1. Resident #111 was admitted to the facility on [DATE]. His diagnoses included chronic respiratory failure with hypoxia, convulsions, tracheostomy status and gastrostomy status. Review of the medical record revealed an Admission/readmission Data Collection form dated 1/11/22 at 9:39 PM, which showed special treatments and procedures for oxygen, tracheostomy, seizures, and percutaneous endoscopic gastrostomy (PEG) tube. On 2/03/22 at 5:45 PM, review of resident #111's medical record with Registered Nurse (RN) D revealed the baseline care plan had no problems, goals or interventions for tracheostomy, oxygen, suctioning or feeding tube care. There were no signatures or dates to indicate the baseline care plan was reviewed by a nurse or a family representative. On 2/03/22 at 5:50 PM, the Lead Minimum Data Set (MDS) Coordinator validated resident #111's baseline care plan showed no focus areas for suctioning, tracheostomy, oxygen, seizures, or PEG tube. He stated MDS staff did not put baseline care plans in the medical chart until after initial care plan meetings, and the nursing department was responsible for completing baseline care plans. On 2/03/22 at 6:00 PM, the Interim Director of Nursing (DON) stated the facility's practice was to fill out the baseline care plan on admission. She explained the admission nurse completed the baseline care plans on paper and it was to be reviewed with the residents and/or family as soon as possible. She stated MDS staff were responsible for completion of baseline care plans and review with the family. The Interim DON stated baseline care plans were reviewed by the interdisciplinary team and MDS staff in daily clinical meetings. She acknowledged resident #111's baseline care plan was incomplete and said, I do not know what happened. Review of the facility's in-service education system revealed all staff completed education on completion of baseline care plans between 6/03/21 and 12/17/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 10 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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** Based on interview and record review, the facility failed to develop comprehensive care plans related to oxygen use for 1 of 4 residents reviewed for respiratory care, (#138). Findings: 1. Resident #138 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure and atrial fibrillation. Review of resident #138's Minimum Data Set (MDS) admission assessment dated [DATE], Section O, revealed she was received oxygen while a resident and prior to admission to the facility. Section J of the MDS assessment indicated resident #138 suffered from shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat. Review of the medical record revealed a physician's order dated 12/17/21 that read, oxygen as needed PRN 2 liters via [nasal] cannula. The order was discontinued and a new order dated 2/01/22 read, Oxygen as Needed PRN (as needed) 4 liters/via [nasal] cannula. Review of resident #138's medical record revealed there were no care plans for oxygen use or respiratory care. On 2/01/22 at 11:53 AM, resident #138 requested a breathing treatment. The resident was seated in a wheelchair with oxygen set at 4 liters per minute (LPM) via nasal cannula. On 2/03/22 at 6:11 PM, the Lead MDS Coordinator stated he reviewed the Medication Administration Record form in residents' charts to obtain information to answer section O of the MDS assessment. He stated the MDS Coordinator was responsible for creating the residents' care plans and confirmed resident #138 did not have a care plan for oxygen use. The Lead MDS Coordinator acknowledged resident #138's shortness of breath and oxygen use made care plans for oxygen and/or respiratory care pertinent. He said, It was just missed. The facility's policy and procedure for Plans of Care revised on 9/25/17 read, Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The document revealed the interdisciplinary team would ensure care plans addressed residents' needs. The policy indicated care plans were . oriented toward attaining or maintaining the highest practicable physical, mental and psychological well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 11 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop comprehensive care plans within 7 days of completion of the comprehensive Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for catheter (#61) and for 1 of 5 residents reviewed for participation in care planning (#149), of a total sample of 65 residents. Findings: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses of diabetes type II, intervertebral disc degeneration lumbar region, anxiety disorder, cardiac pacemaker, benign prostatic hyperplasia, and obstructive and reflux uropathy. Review of the resident's medical record revealed physician's orders dated 11/29/21 for a urinary catheter size 16, change catheter as needed, and catheter care every shift as needed. Review of the resident's admission MDS assessment with Assessment Reference date (ARD) of 12/04/21, revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 14/15. Section H of the MDS assessment revealed the resident had an indwelling catheter. Resident #61 had a care plan for admitted with indwelling catheter due to obstructive uropathy initiated on 1/31/22, 57 days after the completion of the resident's comprehensive MDS assessment. On 1/31/22 at 3:45 PM, resident #61 was in bed with the tubing attached to his indwelling catheter and a drainage bag clearly visible. The resident stated the urinary catheter was placed in the hospital prior to his admission to the facility. On 2/03/22 at 10:05 AM, and at 4:00 PM, the Lead MDS Coordinator and the MDS Coordinator stated MDS assessments were completed by doing a 7-day look back and review of the resident's clinical records, therapy notes, and interviews with the resident and staff. The Lead MDS Coordinator stated care plans were developed as soon as the MDS assessment was completed, and the facility had until day 21 after admission to develop comprehensive care plans. The resident's admission MDS with ARD 12/04/21, and care plan for indwelling catheter initiated on 1/31/22 were reviewed with the MDS Coordinators. They stated a baseline care plan would not cover that extensive period and a comprehensive care plan should have been developed. When asked why a comprehensive care plan was not initiated until 1/31/22, the Lead MDS Coordinator said, I have no excuse 2. Resident #149 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease stage 3, dementia, diabetes type II, and atrial fibrillation. The resident's admission MDS with ARD of 1/18/22 revealed the resident's cognition was severely impaired with a BIMS score of 3/15. Review of the resident's medial record revealed comprehensive care plans were initiated on 2/02/22, 15 days after the completion of the comprehensive MDS assessment. On 1/31/22 at 11:34 AM, resident #149 stated no one could tell him why he was at the facility. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 12 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated his care plan was never discussed with him and although he kept asking, he had not received a straight answer. On 2/03/22 at 10:05 AM, the Lead MDS Coordinator #1 stated day 8 of the resident's admission was used to complete the admission assessment. He explained the process included observation of the resident, an interview if the resident was interviewable, clinical record review, and interview of staff involved in the resident's care. The Lead MDS Coordinator stated he then made a list of issues that required a care plan, and as the care plans were developed and entered into the electronic system, they would be taken off his list. The Lead MDS Coordinator explained comprehensive care plans were developed as soon as the comprehensive assessment was completed. During review of resident #149's care plans with the Lead MDS Coordinator, he confirmed the care plans were initiated on 2/02/22 and were not developed within the required timeframe. On 2/03/22 at 10:20 AM, the MDS Coordinator stated a care plan meeting was held with resident #149's representative on 2/01/22. She validated the resident's care plans were initiated on 2/02/22, which exceeded the regulated timeframe. The facility's policy Plans of Care with effective date 11/30/2014 and revision date 9/25/2017 read, Develop and implement an Individualized Person-Centered comprehensive plan of care by the Interdisciplinary Team that includes but is not limited to- the attending physician, a registered nurse with responsibility for the resident . and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident . within seven (7) days after completion of the comprehensive assessment (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 13 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 observation, interview, and record review, the facility failed to schedule follow-up care with an orthopedic physician in a timely manner for 1 of 1 resident with a right wrist /hand fracture and right-hand cast, of a total sample of 65 residents, (#58). Residents Affected - Few Findings: Resident #58 was admitted on [DATE] with diagnoses of Corona Virus 2019 disease, wedge compression fracture 5th lumbar vertebra, fracture of the right wrist and hand, generalized muscle weakness, and fall. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 11/20/21 revealed the resident's diagnoses included right radius fracture, and she had a closed reduction the right radius surgical procedure performed. Discharge instructions from the hospital dated 11/25/2021 read, To make appt [appointment] for MD [Medical Doctor], GI [Gastroenterologist], Oncology, Pulmonology. An undated, handwritten note read, Patient needs a follow-up ortho appointment for cast and screws in the right arm following a right radius fracture and closed reduction of the right radius . The resident's Admission/readmission Data Collection form dated 11/26/21 read, . The primary dx [diagnosis] is right radius fracture . A closed reduction surgery was performed on the right distal radius as well as an L5 (lumbar) Kyphoplasty with bone biopsy . The Physical Therapy initial evaluation with start of care 11/27/21 read, Pt [patient] presents with pain and deficits in strength, balance, and functional mobility following recent compression fracture of L5 (Lumbar) and fracture of R [right] wrist. Pt is NWB [non-weight bearing] to her RUE [Right upper extremity] . splint + cast to RUE and L5 kyphoplasty . Review of the resident's progress notes revealed documentation on 11/26/21, 11/28/21, and 11/29/21 which indicated Cast on Rt . There was no documentation regarding follow up with the orthopedic surgeon as noted in the hospital discharge instructions. On 1/31/22 at 1:34 PM, resident # 58 was observed with a cast to her right arm. The resident stated the cast had been on for more than 10 weeks and she did not know when it was to be taken off. She stated she had not seen a physician about her arm since admission to the facility. On 2/02/22 at 2:46 PM, Registered Nurse (RN) C stated resident #58 was admitted to the facility with a cast to her right arm and had not yet had a follow up appointment with an Orthopedic surgeon. RN C stated the resident asked him today, 2/02/22, when the cast would be removed. RN C stated the resident's hospital records were reviewed on admission, and if there were any follow-up appointments, they would be noted by Medical Records` personnel who would schedule the follow up appointment(s). RN C stated resident #58 was not admitted with orders for a follow-up orthopedic physician appointment. When asked what would be done if a resident was admitted without an order for a follow up appointment, RN C verbalized that the resident's hospital records would be reviewed to identify the surgeon and an appointment would be scheduled for the resident. He stated no one could identify the name of resident #58's surgeon, and he was not sure what was done regarding a follow up appointment for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 14 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 resident. Level of Harm - Minimal harm or potential for actual harm On 2/02/22 at 3:04 PM, RN L stated the resident informed him on 2/01/22 that she did not have a follow up appointment with an Orthopedic surgeon. RN L stated he reviewed the resident's hospital medical records but did not identify any information regarding a follow up orthopedic appointment. He verbalized that during the record review he identified the surgeon's name, and he wrote a note for the Unit Manager (UM) and the Interim DON to inform them the resident needed a follow-up appointment with the Orthopedic surgeon. He explained he also provided the name of the hospital where the surgery was done. RN L stated he provided a copy to the scheduler this afternoon, 2/02/21, to schedule an appointment for resident #58. RN L stated follow up appointments would usually be noted on admission, and copies of the information would be given to the scheduler and the UM, and a physician's order would be placed in the resident's electronic medical record. RN L verbalized that a follow-up appointment for Orthopedic was not sent from the hospital and was missed on the resident's admission to the facility. Residents Affected - Few On 2/02/22 at 3:32 PM, the Medical Records Director/Scheduler stated resident #58 had follow up appointments with GI, Oncology, and Pulmonology which were cancelled by the resident on 12/21/21, 12/15/21, and 1/05/22 respectively. The Medical Records Director/Scheduler stated the original hospital form did not have a follow-up visit with an Orthopedic physician listed. He explained he received a handwritten note documented on the hospital form today regarding scheduling an appointment for the resident with an Orthopedic physician. On 2/02/22 at 3:54 PM, and at 04:37 PM, the Interim DON stated resident # 58 was admitted with a cast to her right arm. The Interim DON stated residents were usually admitted with follow up appointment(s) already set up from the hospital. She stated if the resident was not admitted with any instruction regarding follow-up, the UM would investigate. The hospital discharge form with follow appointments, with the handwritten note regarding an Orthopedic follow up was reviewed with the Interim DON. She stated the handwritten note was not on the form when it was received from the hospital. She could not say when it was documented and stated she believed RN L documented the note on 2/01/22. The Interim DON stated the facility should have looked up the surgeon in the hospital discharge paperwork. She verbalized the surgeon was contracted by the hospital to follow up with patients for 90 days. She stated the surgeon should have been contacted by the facility for an appointment to obtain instructions regarding the resident's cast. The Interim DON stated all charts for new admissions were reviewed by the Interdisciplinary team for clarification of orders, physician visits, and signed consents. Any follow up orders would be given to the Medical Records Director/Scheduler for scheduling of appointment(s). Clinical record review revealed no documentation regarding the resident's cast, or follow-up appointment with the Orthopedic surgeon, this was confirmed by the Interim DON. She stated if the resident was admitted without an Orthopedic follow-up appointment, the expectation was the UM would follow up with the surgeon, and have an appointment set up for the resident. The Interim DON explained the UM was currently out of the country and said, There is no way to verify that this was done. On 2/03/22 at 12:54 PM, resident #58 stated she reminded the nurse about her cast yesterday, 2/02/22. She stated she was overdue to see the orthopedic surgeon, and still did not know if a follow up appointment had been made. On 2/03/22 at 3:47 PM, the Interim DON stated an appointment with the Orthopedic surgeon was scheduled for 2/21/22. She acknowledged the facility should have identified the need for a follow up appointment, and ensured it was scheduled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 15 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services for splinting to prevent worsening of contractures for 4 of 5 residents reviewed for mobility of a total sample of 65 residents, (#27, #46, #74, and #137). Findings: 1. Resident #27 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, stroke with left side weakness and paralysis affecting left dominant side, and nerve damage to hands and feet. The Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of [DATE] revealed resident #27 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. The assessment showed the resident did not reject evaluation or care that was necessary or his health and well-being. The MDS assessment did not include the resident's active diagnoses and it did not reflect his functional limitation in Range of Motion (ROM). The documents indicated resident #27 did not received therapy or Restorative Nursing Program (RNP) services in the look back period. Review of the Order Summary Report revealed resident #27 had active physician orders dated [DATE] for Speech Therapy, Physical Therapy (PT), Occupational Therapy (OT) and restorative/maintenance program as needed. Resident has an order for weekly skin sweeps every Sunday on the 7 AM to 3 PM shift. Resident #27 had a care plan for limited physical mobility related to weakness initiated on [DATE]. Intervention included, monitoring, documenting, and reporting any signs and symptoms of immobility, contractures forming or worsening and skin breakdown. The document directed staff to initiate PT and OT referrals as ordered and provide gentle ROM as tolerated with daily care. A contracture develops when normally stretchy tissues are replaced by non-stretchy fiber-like tissue which prevents normal movement. Contractures affect range of motion and function and often cause pain (retrieved on [DATE] from www.medlineplus.gov). Review of Progress Notes from [DATE] to February 2022 revealed resident #27 was assessed by the physician and/or Advanced Practice Registered Nurse on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. All progress notes included a recommendation for PT evaluation for left side weakness. On [DATE] at 11:41 AM, resident #27 demonstrated he was unable to open the fingers of his tightly contracted left hand. He stated he did not have a splinting device to maintain his hand in an open position. The resident said, They asked a bunch of questions the first day I was here, but no splint yet. He explained he had significant pain in his contracted left hand and required pain medications regularly. On [DATE] at 1:12 PM, resident #27 still did not have splint for his tightly clenched left hand. On [DATE] at 4:18 PM, the Director of Rehab stated resident #27 had never been on therapy case load. He explained the therapy department generally screened all newly admitted residents and made (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 16 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some referrals for the appropriate type of therapy as indicated. The Director of Rehab confirmed resident #27 never received a therapy screening and could not explained why it was not be done. He said, If it's not documented it's not done. If we didn't do the screen, we didn't do the screen. He explained if services were deemed necessary after admission, nursing staff should complete referral forms located at the nurses' stations on each unit. The Director of Rehab provided a splint order list dated [DATE] which indicated resident #27 required a left large progressive hand splints and left large elbow splint. He explained the order was submitted to Central Supply staff but could not provide any documentation that resident #27 ever received the splints. The Director of Rehab confirmed using splints would prevent worsening of resident #27's contractures. He acknowledged since the resident was not screened on admission, the degree of his contractures was not measured and therefore it would be impossible to know if it had worsened. The Director of Rehab confirmed resident #27 had been without a splint for three months and said, Three months is too long. On [DATE] at 4:43 PM, the Director of Rehab assessed resident #27 contracted left hand. He gently pried the resident's tightly clenched fingers open. Resident #27 said, Sometimes it can get painful. Sometimes it can get mighty dirty in there and I try to clean it out with a paper towel. He informed the Director of Rehab that he was measured for hand and elbow splint so after admission, but never received any devices. The Director of Rehab acknowledged although the process was initiated, there was no follow through regarding the resident's splints. On [DATE] at 5:23 PM, the Director of Nursing (DON) stated if nurses noticed a decline in ROM or increase in pain, they were to make a therapy referral. She explained nurses conducted weekly skin assessments for all residents and Certified Nursing Assistants (CNAs) also the opportunity to observed skin during daily care. The DON stated all nursing staff were educated on the therapy referral process and by completing referral forms. She confirmed splints were necessary to prevent skin breakdown and worsening contractures. The Therapy referral form read, Nursing and rehab collaboration is critical in ensuring quality of life for the residence. The document indicated staff would advocate for necessary services, communicate with screening tool and nursing documentation and collaborate with the interdisciplinary team to ensure residents' needs were met. OT and PT triggers for therapy referrals included use of extremities, weakness, pain, limited ROM, contractures and the splinting. On [DATE] at 10:30 AM, the OT explained residents with contractures required splints to prevent skin breakdown, decease pain, and avoid decreased ROM. She stated new residents were screened on admission and the degree of contracture was measured and documented. The OT confirmed the Rehab department had some splints on site, and if none was available staff could use rolled wash cloths or towels while awaiting for order. 2. Resident #74 was admitted to facility on [DATE]. His diagnoses included stroke with weakness of paralysis and muscle spasms. The MDS Quarterly assessment with ARD of [DATE] revealed the resident had a BIMS score of 12 which indicated moderate cognitive impairment. The document indicated resident #74 did not reject evaluation or care. Had Impaired ROM in one upper and one lower extremities. The MDS assessment revealed resident did not receive therapy or RNP services in the look back period. Review of the Order Summary Report revealed resident #74 had an order dated [DATE] for RNP program for sit to stand exercises and ROM for his legs. A physician order dated [DATE] directed staff to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 17 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 0688 Level of Harm - Minimal harm or potential for actual harm conduct weekly skin evaluation every Thursday. There were orders dated [DATE] for PT and OT to evaluate and treat as indicated. Review of splint order list dated [DATE] revealed resident #74, required a left medium progressive hand splint and left medium elbow splint. Residents Affected - Some Resident #74 had a care plan for Activities of Daily Living (ADL) self-care deficit initiated on [DATE]. The care plan did not address splinting or other preventative nursing interventions. On [DATE] at 11:02 AM, the Director of Rehab and the OT assessed resident #74. The OT confirmed the resident had a tightly contracted left hand and left elbow. Resident #74 used his right hand to hold left hand and arm close to his chest. The resident stated he never had a splint. The OT attempted to extend the residents elbow contracture but stopped when he complained of pain. The resident grimaced as the OT gently tried to open his left hand, and she discovered the resident had very long fingernails. When asked how his hand was cleaned the resident stated he did it himself with a washcloth. Resident #74 stated he had regular pain in his left arm and hand. The OT described the condition of the resident's contracture and fingernails as not acceptable. On [DATE] at 11:06 AM, Licensed Practical Nurse (LPN) H, confirmed resident fingernails were all longer than half inch. She stated she was aware the resident had a contracture and but she had never seen him with a splint or reported the contractures to therapy. On [DATE] at 11:17 AM, Restorative CNA stated he provided ROM services for resident #74 and worked with him on transfers and exercised his elbow. He stated never performed ROM on resident hand therefor never saw his fingernails. Review of Therapy Communication to Restorative Nursing Program form dated [DATE] revealed no instructions to perform ROM on resident #74 upper extremities. 3. Resident #46, was admitted to facility on [DATE]. Her diagnoses included traumatic brain injury, joint contractures, and generalized muscle weakness. The MDS Quarterly assessment with ARD of [DATE] revealed the resident had a BIMS score of 11 which indicated moderate cognitive impairment. She did not reject evaluation or care and had impairment of all extremities. The MDS assessment revealed the resident did not received therapy or RNP services. Review of the Order Summary Report revealed resident #46 had no active orders for RNP, splints or therapy. Review of the medical records revealed resident #46 had a care plan for ADL self-care performance deficit initiated on [DATE]. Interventions included observe and report decline in abilities. A care plan for Impaired skin integrity initiated on [DATE]. Directed staff to observe the skin under the resident splint and report any abnormalities. Review of splint order list dated [DATE] revealed resident #46, required a right small resting hand splint. On [DATE] at 10:50 AM, resident #46 informed the Director of Rehab and OT she did not have a splint. They confirmed she had a right-hand contracture and no splint. The Director of Rehab and OT searched the residence room with her permission and confirmed there was no splint in the bed side table (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 18 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 0688 drawers, closet, dresser. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 10:55 AM, CNA G stated she was regularly assigned to care for resident #46 and was not aware the resident ever had a splint. Residents Affected - Some 4. Resident #137 was admitted to facility on [DATE]. Her diagnoses included multiple sclerosis and generalized muscle weakness. MDS Quarterly assessment with ARD of [DATE] revealed resident #137 had a BIMS score of 14 which indicated she was cognitively intact. She did not reject evaluation or care. The assessment showed the resident had functional limitation in ROM and one upper extremities and both lower extremities. Resident #137 did not received therapy services in the look back period but received active and passive ROM on 5 days. Review of the Order Summary Report revealed resident #137 had an order dated [DATE] orders for RNP to provided ROM to her left hand. There was no order noted for splints. Review of splint order list dated [DATE] revealed resident #137, required a left small comfy resting hand splint and left small elbow splints. On [DATE] at 11:09 AM, resident #137 informed Director of Rehab and OT that she did not have a splint. Review of policy and procedures for Contractures, Prevention revised on [DATE], revealed a goal to To prevent contracture of extremities for those residence who no longer have full use of their extremities. The document indicated the facility would evaluate every resident on admission, readmission, and as needed for contracture prevention procedures as indicated. The policy provided instructions to place either commercial hand rolls or roll wash cloths in any hand that a resident could not move. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 19 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 dressing changes for seven days for a midline intravenous (IV) catheter according to current professional standards of practice for 1 of 2 residents with IV catheters of a total sample of 65 residents, (#260). Residents Affected - Few Findings: Resident # 260 was admitted to the facility on [DATE] with diagnoses including sickle cell disease, convulsions, and respiratory failure. An admission / readmission Data Collection form dated 1/28/22 indicated the resident was alert and oriented to person, place, and time, and had no vascular access IV present. On 2/02/22 at 11:30 AM, resident #260 had a midline IV catheter noted in his right upper arm with a dressing dated 1/25/22. The transparent dressing that measured approximately 4 centimeters (cm) x 5 cm and covered the midline IV insertion site. The edges of the dressing were noted to be loose and not secured to the skin. Resident #260 said, I came from the hospital with this midline dressing. I told the nurse who flushed it yesterday that the dressing needs to be changed. A midline IV catheter is put into a vein by the bend in your elbow or upper arm. The midline tube ends in a vein below your armpit. This type of IV catheter may allow you to receive long-term IV medicine or treatments (retrieved on 2/08/22 from www.drugs.com). On 2/02/22 at 5:28 PM, Licensed Practical Nurse (LPN) A validated resident #260 had a midline to his right arm with a dressing dated 1/25/22. LPN A said, The IV midline dressings are changed weekly at any place I have worked. LPN A confirmed there was a physician order in the electronic medical record that directed nurses to change the IV dressing on admission, then weekly and as needed. LPN A explained resident #260's IV dressing should have been changed on admission as ordered, and when noted to be loose and/or dirty to prevent infection. The following day, on 02/03/22 at 8:15 AM, resident #260 still had the same loose dressing dated 1/25/22 to his right upper arm midline site. On 2/03/22 at 8:24 AM, the East Wing Unit Manager (UM) stated that resident #260's midline IV dressing should have been changed within 72 hours of admission and at least weekly. The UM explained dressing changes were a standard of care and were necessary to prevent infection. On 2/03/22 at 1:16 PM, Registered Nurse C confirmed the admission / readmission Data Collection form did not accurately reflect resident #260's IV access site. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 20 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure oxygen (O2) therapy was administered as per physician's orders for 1 of 3 residents reviewed for O2, of a total sample of 65 residents, (#62). Residents Affected - Few Findings: Resident #62 was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included End Stage Renal disease, chronic atrial fibrillation, major depressive disorder, heart failure, schizoaffective disorder, and hepatic failure. Review of the medical record revealed a physician's order dated 1/31/22 for Oxygen 3 liters per minute (L/min) continuously every shift for shortness of breath (SOB). A progress note dated 2/01/22 at 5:52 PM indicated resident #62 had labored breathing SOB on exertion SOB lying flat . Oxygen is used via nasal cannula 3 L/min . On 2/01/22 at 9:46 AM, resident #62 was observed with O2 infusing via nasal cannula at 4.5 L/min. The resident stated he was not sure of the correct setting for his oxygen. On 2/01/22 at 9:52 AM, Registered Nurse (RN) C reviewed resident #62's medical record and validated the resident had a physician order for O2 at 3 L/min continuously. During observation of the O2 setting with the RN C, he confirmed the gauge was set at 4.5 L/min rather than 3 L/min as ordered. RN C stated he did not know who adjusted the setting and verbalized only a nurse could adjust O2 settings. He explained O2 was a medication and should be administered as ordered. RN C stated he did not check the O2 setting for resident #62 earlier that morning and was not sure how long the resident was receiving O2 at 4.5 L/min instead of 3 L/min as ordered by the physician. On 2/01/22 at 12:10 PM, the East Wing Unit Manager (UM) stated the assigned nurse was responsible for ensuring O2 was administered at the prescribed rate. The UM confirmed the resident's O2 order was for 3 L/min continuously. On 2/02/22 at 4:37 PM, the Interim Director of Nursing (DON) stated nurses were supposed to check residents' O2 settings at the beginning of their shifts, when providing care, and when giving medications, to ensure the setting corresponded with the physician's orders. The interim DON stated O2 was considered a medication and should be administered only according to the physician's order. The resident's baseline care plan, Altered Cardiac/ Respiratory Functioning dated 1/4/22 included the intervention O2 therapy as ordered. The facility's policy Oxygen Therapy with effective date of 11/30/2014, and revision date 8/28/2017 read, Review physician's order . Start O2 flowrate at the prescribed liter flow . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 21 of 22 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 105861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of Melbourne 3033 Sarno Rd Melbourne, FL 32934 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 Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 10 of 12 required monthly drug regimen reviews were completed for 1 of 5 residents reviewed for Unnecessary Medications, Psychotropic Medications and Medication Regimen Review, out of a total sample of 65 residents, (#2). Findings: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including depressive disorder, hypertension, long term use of insulin, type 2 diabetes and left hip pain. Review of the medical record revealed resident #2 had physician orders for Duloxetine 60 milligrams (mg) daily for depression, Hydroxyzine 25 mg three times daily for anxiety, Aspartame insulin 100 units/ml (milliliter) inject four units three times a day for diabetes, Detemir Solution insulin 100 units/ml inject 20 units at bedtime for Diabetes, Spironolactone 25 mg give once daily for diuresis, Trulicity Solution Pen-Injector 0.75 mg/0.5ml inject 1 dose every Saturday morning for diabetes, Hydrocodone-Acetaminophen 5-325 mg every six hours as needed for pain, and Xarelto 20 mg give 1 tablet once daily in the evening. Further review of resident #2's medical record and the facility's monthly medication regimen review binders revealed no documentation of pharmacy review for irregularities, recommendations, or gradual dose reduction consultation reports for the months of March, May, June, July, August, September, October, November, and December 2021. The facility was unable to provide a pharmacy review consultation form for January 2022. On 2/03/22 at 7:15 PM, the Interim Director of Nursing (DON) explained she was responsible for making sure pharmacy recommendations were addressed by the physician and forms were completed. She stated the facility's consultant pharmacist reviewed residents' medications monthly and emailed the list of all residents who were reviewed and any recommendations to the facility. The Interim DON stated although she received recommendations for residents she did not receive a list of residents who were reviewed and had no recommendations or irregularities found. She acknowledged she could therefore not reconcile monthly medication review forms and reports to ensure there no recommendations were overlooked. Review of policy and procedure Monthly Drug Regimen Review effective 4/21/17 revealed a procedure To ensure the requirement is met for monthly drug regimen review the [Executive Director]/DON should implement the following process: . Discuss the recommendations not responded to and develop a plan for completing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 22 of 22