Inspection·November 2, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few days. I told them what you said, that I could get it when I asked, and they ended up giving it to me. The resident explained he felt it was important to shower this morning because he had an appointment with his doctor in the afternoon. 2. Review of the medical record revealed resident #617 was admitted to the facility on [DATE] with diagnoses including left hip fracture, unspecified fall, heart failure, and anxiety. Review of the MDS admission assessment with ARD of 10/30/23 revealed resident #617 had clear speech, was able to express his ideas and wants, and understood others. The document showed the resident had a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. The MDS assessment revealed resident #617 felt it was very important to choose between a tub bath, shower, bed bath, and sponge bath while in the facility. He required partial to moderate assistance from staff for showering or bathing. On 10/30/23 at 12:32 PM, resident #617 stated he had been in the facility for eight days and staff had not offered him a shower. He recalled a few days ago, a Certified Nursing Assistant (CNA) washed his back only. The resident stated over the past week he asked staff about a shower and they told him he would have a scheduled shower day. Resident #617 said, At home I shower every day or every other day. I would like to wash my hair. Review of the unit's Shower Assignment schedule revealed resident #617 was to receive showers on Mondays and Thursdays during the 3:00 PM to 11:00 PM shifts. Review of the CNA flowsheet from 10/23/23 to 10/29/23 revealed no documentation of showers or refusals. On 10/31/23 at 4:01 PM, the Short Stay Unit (SSU) Unit Manager (UM) explained on admission to the facility, either nurses or CNAs would inform residents of their scheduled shower days. She explained if residents chose additional days or a different time of day, facility staff would cater to their preferences. The SSU UM said, We educate CNAs to honor residents' choices. On 11/02/23 at 10:48 AM, the Director of Nursing (DON) confirmed the facility offered a minimum of two baths a week for every resident. She stated nursing staff were expected to write the shower days on the white boards in each room and relay the information verbally to residents within 24 hours of admission. The DON stated on a scheduled shower day, the assigned CNA should offer a shower and ask what time the resident would want it. The DON verified facility staff should provide as many showers as requested, according to residents' preferences. The facility's Shower Sheet for CNAs informed staff that showers were an important part of overall health. The document read, A shower should be offered at least 3 times during your shift. The facility's policy and procedure for General Resident Rights (undated) revealed the intent that all interactions with residents would enhance their self-esteem and self-worth, and incorporate their goals, preferences, and choices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 2 of 34 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 11/02/2023 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to respond to grievances identified by resident council. Residents Affected - Some Findings: During Resident Council meeting on 11/01/23 at 3:30 PM, members of Resident Council verified they met monthly. The members stated several grievances had been voiced regarding laundry, linen, nurse staffing, staff speaking other languages and dietary. The residents in attendance agreed the same concerns were voiced month after month without a resolution. The group expressed no one ever responded to the grievances and informed them of what was done. The resident council members were not aware of any grievances that had been filed on behalf of Resident Council. Review of Resident Council minutes from May 2023 through October 2023 revealed several repeat grievances concerning staff not speaking English, staff on cell phones, quality of linen and various dietary concerns. On 11/01/23 at 5:00 PM, the Activity Director stated she attended every Resident Council meeting along with her assistant. She explained the Resident Council agreed to have an open invitation to any management staff member who wanted to attend. She stated residents were encouraged to express grievances during Resident Council and she noted those under the appropriate department. The Activity Director stated she provided a copy of the Resident Council minutes to the Resident Council President and to the facility Administrator. She explained she brought up the issues in morning report and each department was supposed to address those issues. She acknowledged she did not fill out any grievance forms for resident council. The Activity Director acknowledged resident council members reported they did not feel like anyone was listening to them. On 11/01/23 at 5:22 PM, the Social Services Director (SSD) stated the Administrator was the primary grievance officer. She stated social services received the grievances and the grievances were shared with department heads in morning meetings. She explained the Administrator assigned the grievances to department heads to handle. The SSD stated grievances could include concerns about food, staff not speaking English, complaints about call lights, customer service and quality of care. She explained any grievance from Resident Council would be brought to social services and a grievance form was completed. The SSD reviewed the Grievance Log and verified there were no grievances submitted on behalf of Resident Council. She acknowledged there would be no way to show what was done to resolve the issue without a grievance and follow-up. On 11/01/23 at 5:47 PM, the Administrator verified she was the primary grievance officer. She explained her expectation was for the Activity Director to bring concerns from Resident Council to daily department head meeting which would then be assigned to the appropriate department to be addressed. She acknowledged they did not complete a grievance form. The Administrator explained the facility had completed grievance forms for Resident Council in past but was not sure why that stopped. She was unable to produce the facility's response to Resident Council grievances. Review of the facility's policy and procedure for Grievances Program revealed that a grievance would be documented on the facility Grievance Report, listed on the facility Grievance Tracking Log and investigated accordingly. The document indicated the grievance decision would be documented on the grievance form and include dates, summary statement of resident's grievance, and summary of findings, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 3 of 34 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 11/02/2023 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 0565 statement confirming or not confirming grievance, correction actions as indicated, and the date that the written decision was issued to the person filing the grievance. 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 4 of 34 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 11/02/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents wishes for a Do Not Resuscitate Order (DNRO) were honored for 1 of 2 residents, (#6), and failed to ensure residents had the capacity to make health decisions and sign for a DNRO for 1 of 2 residents reviewed for Advanced Directives, from a total sample of 63 residents, (#107). Findings: 1. Review of the medical record revealed resident #6 was admitted from an acute care hospital on [DATE] with diagnoses of stroke, atherosclerosis (arterial narrowing and clotting) of the heart and both legs, heart rhythm malfunction, presence of a cardiac pacemaker, and paranoid schizophrenia. The Minimum Data Set (MDS) Annual Assessment with Assessment Reference Date (ARD) of [DATE] noted the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact. The assessment showed she had disorganized thinking that fluctuated in severity, and had not rejected evaluation or care. The Comprehensive Care Plan noted the resident was dependent on staff to meet her emotional, intellectual, physical, and social needs that required staff to redirect her fixations and delusions, and she planned to remain in the facility for long term care placement. The Advanced Directives Discussion Document dated [DATE] showed resident #6 wished to withhold Cardiopulmonary Resuscitation (CPR), and she had signed a Do Not Resuscitate Order (DNRO). The DNRO form (DH Form 1896, Revised [DATE]) scanned to the Electronic Health Record (EHR) noted resident #6 and her physician signed the order on [DATE] that indicated the resident did not wish to receive life sustaining measures that included CPR in the event of cardiac or respiratory arrest. The Physician's Evaluation Of Resident's Capacity To Make Health Care Decisions Or Provide Informed Consent signed by resident #6's physician on [DATE] indicated she was incapacitated to make health care decisions. On [DATE] at 12:24 PM, the Social Services Director said residents with a DNRO who later underwent court proceedings for guardianship required court processing. Review of the Petition To Determine Incapacity signed by the facility's former Social Services Assistant on [DATE] was filed through the courts to designate a legal guardian for the resident. The Order Appointing Plenary Guardian Of Person And Property (Incapacitated person-no known advanced directive) was signed and ordered by a judge on [DATE]. The Letters of Plenary Guardianship Of The Person And Property signed by a judge on [DATE] read, . No known advance directives have been executed by the ward. The Order Summary Report indicated on [DATE], physician's orders were revised to discontinue the DNRO and implement resident #6's code status to Full Code (CPR). In a telephone interview on [DATE] at 3:17 PM, resident #6's court appointed guardian checked the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 5 of 34 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 11/02/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few records and said the intake documents to initiate guardianship received from the facility did not include the resident's DNRO. She stated the record showed subsequent annual reports and care plan updates to the court that specifically addressed Advanced Directives, and resident #6's records indicated there were no known Advanced Directives. She explained the normal process when facilities requested guardianship was to honor a resident's previous DNRO with an additional court order, and that it would have been requested if they had received the DNRO documents the resident signed from the facility. She said it was very important for guardians to honor a resident's wishes. During a joint interview on [DATE] at 2:20 PM, the Social Services Director and Nursing Home Administrator said they could not locate resident #6's guardianship request records submitted by the facility. The Social Services Director acknowledged there was a DNRO in the EHR the resident signed prior to her determination of incapacity or her guardianship order. She said she was not working at the facility when the request was submitted, and she conveyed the document should have been included with the initial request so it would have been properly processed to ensure the resident's wishes were honored. 2. Review of the medical record revealed resident #106 was admitted to the facility from an acute care hospital on [DATE], with diagnoses of stroke, heart failure, repeated falls, chronic pain syndrome, presence of a heart valve, heart dysrhythmias (abnormal heartbeat), expressive speech dysfunction, and dementia. The MDS Quarterly Assessment with ARD of [DATE] noted the resident scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated he was moderately cognitively impaired. The assessment showed he felt down, depressed, or hopeless for several days, sometimes felt lonely or isolated. had not rejected evaluation or care, and there was no discharge plan in place for him to return to the community. The Comprehensive Care Plan noted the resident had difficulty with his speech and abilities to complete sentences, was able to make his needs known to staff, and had advanced directives of a Do Not Resuscitate code status. Two Physician's Evaluation Of Resident's Capacity To Make Health Care Decisions Or Provide Informed Consent forms signed by different physicians on [DATE] and [DATE] indicated he was incapacitated to make health care decisions. The DNRO form (DH Form 1896, Revised [DATE]) was signed by resident #106 and his physician on [DATE] that indicated in the event of his cardiac or respiratory arrest, he did not wish for life sustaining measures or CPR. The Order Summary Report showed an active physician's order for Do Not Resuscitate (DNR) was implemented on [DATE]. On [DATE] at 4:15 PM, the Social Services Director explained DNRO forms were signed by residents who were determined to be competent to make their own health decisions, and when residents were deemed incapacitated by a physician, they could not sign a DNR, and the form required a guardian or Health Care Surrogate's signature. She checked the medical record and acknowledged resident #106 had an active letter of incapacity, and he was not able to make his own health decisions since [DATE]. She checked the record and acknowledged the resident signed his own DNRO on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 6 of 34 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 11/02/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm On [DATE] at 8:36 AM, the Social Services Director recalled she assisted resident #106 when he signed his DNRO form, and she was not aware of the physician's determination of incapacity. She stated she had not checked to verify his capacity status when he signed the form. She said Advanced Directives were reviewed every quarter and the error was missed. She explained the DNRO had not been valid for 18 months. Residents Affected - Few On [DATE] at 11:36 AM, the Director of Nursing said a resident with a designation of incapacity was not able to make their own health care decisions or sign a DNRO. She recalled resident #106's medical record profile always indicated he was his own decision maker. She said the Social Services Director was responsible for completing and processing Advanced Directives, determinations of capacity, DNRO reviews, and changes. She explained she was very concerned when she was recently informed the resident signed his own DNR while under incapacity because nurses relied upon the accuracy of residents' code status to initiate or withhold CPR and honor one's wishes. The facility's undated policy and procedure titled Resident Right - Advanced Directive Tracking Program read, Intent: It is the policy of the facility to honor the advanced directives of all residents and to make information available to the resident on how to prepare such directives, should the resident not have them in place or to change existing directives. 4. Social Services or the appropriate designee will carefully review any and all advanced directive related documents to ensure that the information is complete and that the requirements of the law are met. If there is a question it is the responsibility of the reviewer to seek clarification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 7 of 34 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 11/02/2023 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the appropriate notices of financial liability for 2 of 3 resident reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification, out of a total sample of 63 residents, (#53 and #96). Residents Affected - Some Findings: 1. Resident #53 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including anemia, gastrointestinal hemorrhage, unspecified mood affective disorder and personal history of transient ischemic attack. Review of resident #53's financial record revealed she began Medicare Part A skilled nursing stay on 4/01/23 with last covered day on 4/28/23. She had Medicaid as her primary payer effective 4/29/23. A SNF Beneficiary Protection Notification Review revealed resident #53 received a Notice of Medicare Non-Coverage (NOMNC) at the end of her Medicare Part A stay but did not receive a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). 2. Resident #96 was admitted to the facility on [DATE] with diagnoses including acute metabolic acidosis, adult failure to thrive, dysphagia and atherosclerotic heart disease. Review of resident #96's financial record revealed he began Medicare Part A skilled nursing stay on 6/01/23 with last covered day on 7/31/23. He had Medicaid as his primary payer effective 8/01/23. A SNF Beneficiary Protection Notification Review revealed resident #96 received a NOMNC at the end of his Medicare Part A stay but did not receive a SNF ABN. Review of residents discharged from a Medicare Part A stay in the last six months revealed there were 57 residents who discharged from a Medicare Part A stay without using all available days and remained in the facility. On 11/02/23 at 3:58 PM, the Social Services Director (SSD) explained she was not aware that a resident who discharged from a Medicare Part A stay with days remaining and stayed in the facility required a SNF ABN to be provided. She acknowledged she had not provided a SNF ABN to any of the 57 residents who remained in the facility following a Medicare Part A stay without exhausting their benefit days. The facility's policy and procedure for Resident Right - Medicaid/Medicare Coverage/Liability Notice read, If the Facility provides the beneficiary with the SNF ABN, the facility has met its obligation to inform the beneficiary of his or her potential financial liability and related stand claim appeal rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 8 of 34 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 11/02/2023 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record revealed resident #626 was admitted to the facility on [DATE] with diagnoses including quadriplegia, heart disease, osteomyelitis or bone infection, chronic kidney disease, and muscle wasting. Review of the Minimum Data Set (MDS) Discharge-Return Anticipated assessment with assessment reference date of 6/18/23 revealed resident #626 had an unplanned discharge. A Hospital Transfer Form dated 6/18/23 at 3:40 AM, indicated the resident was transferred to the hospital for evaluation and treatment of a change in condition. Review of the facility's policy and procedure for Notice Requirements Before Transfer/Discharge (undated) revealed the facility would send copies of transfer/discharge notices to the Office of the State Long-Term Care Ombudsman. On 11/02/23 at 12:25 PM, the Social Services Director (SSD) provided a copy of paperwork she faxed to the Ombudsman's office in July 2023 with the names of residents who were discharged from the facility in June 2023. Review of the Admission/Discharge To/From Report from 6/01/23 to 6/30/23 revealed resident #626's name was not included on the form. The SSD validated the resident's name was missing from the list. In addition, the SSD explained she was not able to find the fax confirmation sheet to prove the list was received by the Ombudsman's office. On 11/02/23 at 3:19 PM, the SSD stated she was still not able to figure out why resident #626's name was not on the list of discharged residents. She confirmed although she was responsible for sending the list to the Ombudsman's office once monthly, she did not review the document thoroughly before transmittal. She said, I trust the list is accurate. The SSD acknowledged there had to be a reason why resident #626's name did not show up. Closer review of the document revealed the list had a filter applied that specified, No Discharges selected. The document listed only admissions for June 2023 and was dated 11/02/23 rather than July 2023. The SSD stated she searched but did not find the fax confirmation sheet. She acknowledged the facility was unaware notification to the Ombudsman was not made as required. In response to a request for verification of notification, an email received on 11/06/23 from the Office of State Long-Term Care Ombudsman revealed the office had no documentation regarding the facility's transfers and discharges for June 2023. Based on interview, and record review, the facility failed to notify the State Long Term Care Ombudsman in writing, by phone, or in person for a facility-initiated emergency transfer/discharge for 2 of 2 residents reviewed for [NAME] Act and 1 of 3 residents reviewed for hospitalization out of a total sample of 63 residents, (#561, #562 and #626). Findings: 1. Review of the medical record revealed resident #561 was admitted to the facility on [DATE] and re-admitted on [DATE] from the hospital. His diagnosis included type II Diabetes, hypertensive heart disease with heart failure, mood disorders, history of traumatic brain injury, suicidal ideation, and anxiety disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 9 of 34 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 11/02/2023 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Minimum Data Set (MDS) Discharge-Return Anticipated assessment with assessment reference date of 3/16/22 revealed resident #561 had severely impaired cognitive skills for daily decision making. Review of the resident's medical record revealed the physician's progress note dated 3/16/22 indicated the resident was emergently transferred to the hospital due to the immediate risk of harm to self and others. The facility-initiated transfer met the criteria for [NAME] Act. Further review of the medical record indicated that the resident's Guardian was notified, however there was no evidence in the medical record that the State Long Term Care Ombudsman was notified of the emergency transfer. On 10/31/23 at 12:53 PM, the Social Service Director (SSD) stated the resident's Guardian was notified immediately of the resident's transfer, but the Ombudsman was not notified in writing, by phone, or in person. She did not know why the resident's discharge did not populate to the discharge report to be faxed monthly to the Ombudsman. The SSD acknowledged the facility did not contact the Ombudsman by phone or in person for [NAME] Act transfers. On 11/1/23 at 12:26 PM, the Director of Nursing (DON) stated the facility's process for facility-initiated emergency transfers was to contact the Ombudsman by fax monthly and they did not contact the Ombudsman by phone or in person. On 11/1/23 at 1:27 PM, the SSD confirmed the resident's name did not appear on the facility's March discharge report that was faxed to the Ombudsman and that she had not phoned or spoken in person to the Ombudsman regarding the emergency transfer. 2. Review of the medical record revealed resident #562 was admitted to the facility on [DATE] from the hospital. Her diagnosis included spinal stenosis, cardiomyopathy, major depressive disorder, anxiety disorder, schizoaffective disorder-depressive type, and mood (affective) disorder. The MDS Quarterly assessment with assessment reference date of 8/14/22 revealed the resident's cognition was intact with a Brief Interview Mental Status (BIMS) score of 15 out of 15. Review of the resident's medical record revealed the progress note dated 10/27/22 indicated the resident was emergently discharged to the hospital due to violent behaviors that posed harm to self and other residents in the facility. There was no documentation in the medical record that indicated the State Long Term Care Ombudsman was notified of the facility-initiated discharge. On 10/31/23 at 12:53 PM, the Social Service Director (SSD) stated the Ombudsman was not notified in writing, by phone, or in person of the [NAME] Act. She did not know why the resident's discharge did not populate to the discharge report to be faxed monthly to the Ombudsman. The SSD acknowledged the facility does not contact the Ombudsman by phone or in person for [NAME] Act discharges. On 11/1/23 at 1:27 PM, the SSD confirmed the resident's name did not appear on the facility's October discharge report that was faxed to the Ombudsman and that she did not phone or speak in person to the Ombudsman regarding the emergency transfer. The SSD acknowledged that the Ombudsman should have been contacted regarding the emergency [NAME] Act transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 10 of 34 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 11/02/2023 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 transfer status, (#1), and vision status, (#15), at the time of the assessments, for 2 of 63 sampled residents. Residents Affected - Few Findings: 1. Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, heart disease, anxiety and depression. Review of the MDS Quarterly assessment with assessment reference date (ARD) of 8/24/23 indicated resident #1 required extensive assistance from two or more staff for transfers between surfaces including to or from the bed and wheelchair. On 10/31/23 at 10:10 AM, Certified Nursing Assistants (CNAs) Q and R transferred resident #1 from her bed to a reclining wheelchair with a mechanical lift. CNA R explained the resident required a mechanical lift for all transfers as she could not stand, follow directions, or assist staff. On 11/01/23 at 11:47 AM, CNA P stated she was regularly assigned to care for resident#1. She confirmed she always used a full-body mechanical lift, which required assistance from another staff member, to transfer the resident between her bed and wheelchair. On 11/01/23 at 12:03 PM, the Lead MDS Nurse explained MDS nurses would complete assessments after conducting a comprehensive head to toe evaluation of residents, interviewing the residents if possible, reviewing progress notes, and discussing the residents with the nurses and CNAs. The Lead MDS Nurse stated she would usually ask CNAs to describe how they transferred residents. She reviewed resident #1's MDS Quarterly assessment and validated the document showed the resident required extensive assistance of two or more staff for transfers. She acknowledged the MDS assessment was inaccurate as a full body mechanical lift transfer should have been documented as total dependence on two or more staff for transfers. 2. Review of the medical record revealed resident #15 was admitted to the facility 9/26/19 with diagnoses including anxiety, need for assistance with personal care, depression, and mild cognitive impairment. Review of the MDS Quarterly assessment with ARD of 9/14/23 revealed resident #15 had a Brief Interview for Mental Status score of 13 which indicated she was cognitively intact. The assessment showed the resident had adequate vision and did not use corrective lens. Review of the medical record revealed resident #15 had a care plan for glasses to correct visual impairment, initiated on 8/31/22 by the Lead MDS Nurse, and revised on 7/05/23. The interventions included to remind the resident to wear her glasses when up, and ensure her glasses were clean, free from scratches, and in good repair. On 10/31/23 at 9:50 AM, resident #15 explained she had a history of cataract surgery and vision problems. She stated she used to have glasses in the past, but no longer had them. Resident #15 stated she did not see properly without glasses and could not read or see the television. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 11 of 34 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 11/02/2023 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 On 11/01/23 at 12:21 PM, the MDS Licensed Practical Nurse acknowledged resident #15 was interviewable and would have been able to answer questions related to her vision during the data collection period prior to completion of the MDS Quarterly assessment. She reviewed resident #15's MDS Quarterly assessment and acknowledged the section related to the resident's vision was inaccurate based on her report of missing glasses and the existing care plan for glasses. Residents Affected - Few Review of the facility's policy and procedure for Resident Assessment - Resident Assessment Instrument (undated) revealed it was the policy of the facility to properly document and utilize the MDS to ensure comprehensive and accurate resident assessments and assist staff to identify health problems. The policy read, The assessment will accurately reflect the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 12 of 34 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 11/02/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer residents with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 2 of 6 residents reviewed for PASARR, out of a total sample of 63 residents, (#37 and #83). Findings: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, heart failure and unspecified dementia. Review of the Minimum Data Set (MDS) annual assessment with assessment reference date (ARD) of 10/09/23 revealed resident #37 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. The document indicated her active diagnoses included depression (other than bipolar), psychotic disorder (other than schizophrenia) and unspecified mood [affective] disorder. Review of resident #37's electronic medical record (EMR) revealed diagnoses of major depressive disorder with an onset date of 7/18/17, unspecified psychosis with an onset date of 9/23/22 and unspecified mood [affective] disorder with an onset date of 12/09/22. The record contained a Level I PASARR screening form dated 5/12/17 which did not indicate resident #37 had a mental illness (MI) or suspected MI. The record did not contain a Level II PASARR screening form. 2. Resident #83 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, type 2 diabetes mellitus, vascular dementia and chronic pain syndrome. Review of the MDS admission assessment with ARD of 8/16/23 revealed resident #83 had a BIMS score of 15 which indicated he was cognitively intact. The document indicated his active diagnoses included depression (other than bipolar) and psychotic disorder (other than schizophrenia). Review of resident #83's EMR revealed diagnoses of brief psychotic disorder with an onset date of 8/09/23, major depressive disorder with an onset date of 8/11/23 and unspecified psychosis with an onset date of 8/12/23. The record contained a Level I PASARR screening form dated 8/08/23 which did not indicate resident #83 had an MI or suspected MI. The record did not contain a Level II PASARR screening form. On 11/02/23 at 12:42 PM, the Social Services Director (SSD) stated new admissions from the hospital should have a Level I PASARR Screening completed by the hospital prior to admission. She explained she reviewed the PASARR upon admission. If the screening form was identified as inaccurate, the SSD and Director of Nursing (DON) would complete a new Level I PASARR. The SSD and DON reviewed the Level I PASARR and current diagnoses for residents #37 and #83. The SSD and DON acknowledged neither PASARR reflected each resident's MI diagnoses. The SSD explained the facility did not review the PASARR after admission. She stated she was not aware a resident with a newly evident or suspected MI diagnoses after admission needed to be referred for a Level II PASARR evaluation and determination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 13 of 34 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 11/02/2023 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 - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise care plans to reflect current transfer status for 1 of 4 residents reviewed for accidents, (#1); accurate oxygen administration orders for 2 of 4 residents reviewed for respiratory care, (#56 and #57); failed to provide the opportunity to participate in review and revision of the plan of care for 1 of 2 residents reviewed for Care Planning, (#154); and failed to updated code status for 1 of 5 residents reviewed for Advance Directives, (#148), out of a total sample of 63 residents. Findings: Review of the facility's policy and procedure for Comprehensive Resident Centered Care Plans revealed the intent .to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. The document indicated the purpose to ensure residents received individualized, goal-directed care based on their needs through appropriate interventions, and provide a means of interdisciplinary communication to promote continuity of care. The procedure revealed residents had the right to participate in the development and implementation of his/her person-centered plan of care. The care planning process would facilitate the inclusion of residents and/or their representatives. The policy indicated care plans would be discussed with the resident or representative in scheduled care conferences or when there was a significant change in status. Care plans could be modified at the time of the care conference or between conferences when appropriate to meet current needs. The document revealed care plans should be updated to reflect changes in interventions or new goals, diagnoses, and medications. 1. Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, heart disease, anxiety and depression. Review of the medical record revealed resident #1 had a baseline care plan dated 5/17/23, developed on admission, for activities of daily living self-care deficit. The document showed the resident required assistance of one staff member for transfers. A Transfer/Mobility Status Criteria form dated 5/17/23 revealed resident #1 was independent with transfers and did not require help or staff oversight. The document indicated resident #1 required oversight, encouragement, cuing, and use of a gait belt, and no lifting aid was to be used. Review of resident #1's medical record revealed her comprehensive care plan included a focus area of limited physical mobility related to weakness, initiated on 5/30/23. The care plan interventions instructed staff to provide supportive care and assistance with mobility as needed. The document did not include any interventions regarding the resident's transfer status including required equipment and level of assistance. Review of the Certified Nursing Assistant (CNA) care plan or Kardex revealed no care directives related to transfer method and/or equipment for resident #1. On 10/31/23 at 10:10 AM, CNA R explained the resident required a mechanical lift for all transfers as she could not stand, follow directions, or assist staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 14 of 34 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 11/02/2023 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 - Some On 10/31/23 at 0:14 AM, CNA Q reviewed resident #1's Kardex and validated there was no information regarding use of a mechanical lift for transfers. On 11/01/23 at 11:47 AM, CNA P stated she was regularly assigned to care for resident#1. She confirmed she always used a full-body mechanical lift, which required assistance from another staff member, to transfer the resident between her bed and wheelchair. On 10/31/23 at 5:30 PM and 11/01/23 at 12:03 PM, the Lead Minimum Data Set Nurse (MDS) confirmed she was the facility's care plan coordinator. She acknowledged information regarding transfer assistance should be on resident #1's nursing and CNA care plans. the Lead MDS Nurse reviewed resident #1's care plans and validated the document was not updated or revised to show the resident required a mechanical lift for transfers until 10/30/23. She confirmed resident #1 had care conferences on 6/06/23 and 9/05/23, but MDS staff did not identify that transfer information was missing. The Lead MDS Nurse said, I don't always review the current interventions. 2. Review of the medical record revealed resident #56 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic rhinitis, and dependence on supplemental oxygen. Review of the medical record revealed resident #56 had a physician order dated 9/05/23 for oxygen at 2 liters per minute (L/min) continuously. The resident had a care plan for emphysema/COPD related to smoking, shortness of breath, coughing, and wheezing, initiated on 11/13/18. The document included an intervention to administer oxygen at 2 L/min via nasal cannula as needed, initiated on 11/13/18. The care plan was not revised to reflect the updated physician order for continuous oxygen therapy. 3. Review of the medical record revealed resident #57 was admitted to the facility on [DATE] with diagnoses including shortness of breath, dementia, and cognitive communication deficit. Review of the medical record revealed resident #57 had a physician order dated 8/03/23 for oxygen at 2 L/min as needed. The order was discontinued on 10/26/23. The resident had a care plan for oxygen therapy related to shortness of breath initiated on 6/16/23. The document included an intervention to administer oxygen at 2 L/min continuously via nasal cannula, initiated on 6/16/23. The care plan was not revised to show resident #57 no longer needed oxygen therapy. On 11/02/23 at 11:25 AM, the Director of Nursing (DON) explained MDS staff were responsible for reviewing care plans at least every three months and as needed. She stated care plans should be revised as indicated to show the current care needs for each resident. The DON verified it was important for care plans to be accurate and accessible to all nursing staff. On 11/02/23 at 3:56 PM, the Lead MDS Nurse stated she relied mainly on physician order summaries to revise care plans. She explained new orders for medications, treatments, and consults provided information on changing care needs. She noted resident #57's care plan was not revised to reflect his discontinued oxygen, as she reviewed active orders only and did not use filters to select discontinued or completed orders. The Lead MDS Nurse acknowledged care plans should be person-centered and revised to reflect all changes, not only physician orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 15 of 34 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 11/02/2023 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 - Some 5. Resident #148 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, type 2 diabetes, arteriosclerotic heart disease, traumatic brain injury with loss of consciousness and hypertension. Review of resident #148's electronic medical record revealed an active physician order dated 7/27/23 for Do Not Resuscitate and a State of Florida Do Not Resuscitate Order form dated 7/23/23 and signed by the physician on 7/27/23. Review of the Medication Administration Record (MAR) dated October 2023 identified resident #148's advance directive as Do Not Resuscitate. The Advance Directive care plan initiated 4/06/23, revised 7/07/23 identified resident #148's advance directive as Full Code. The interventions included to discuss advance directives with resident or his representative. On 11/01/23 at 1:17 PM, the Social Services Director (SSD) stated she was responsible for reviewing and discussing advance directives with the resident or their representative upon admission and throughout their stay. She explained if a resident or their representative made a change to their advance directives, it was social services responsibility to ensure the facility is provided with the updated information which included updating the care plan. The SSD reviewed resident #148's care plan and acknowledged it had not been updated to reflect the resident's current code status. She stated, I missed it. 4. Review of the medical record revealed resident #154 was admitted to the facility on [DATE] from an Assisted Living Facility, and had diagnoses of abdominal wall abscess (infection), stroke, mood disorder, anxiety, and dementia. The most recent Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date of 8/23/23 noted the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated the resident was not cognitively impaired. The assessment showed the resident had behaviors of inattention and disorganized thinking that were present and fluctuated; for one to three days he rejected evaluation or care necessary to achieve goals for health and well-being that had not been addressed with the resident or family by discussion or care planning, he required staff support and assistance to complete Activities of Daily Living (ADLs), and he was incontinent of bladder and bowel functioning during the 7 day look back period. On 10/30/23 at 12:09 PM, resident #154 was observed in his room lying in bed with an active intravenous (IV) infusion of antibiotic medication administered through an IV catheter in his left forearm. He said he was confused and concerned about multiple areas on his skin that had been infected for a long time that were not healing. The resident stated he was not invited to any meetings to review his plan of care, and he was visibly distressed when he explained he had been at the facility since May 2023 and said, I don't see nobody. Review of the Order Summary Report noted active physician's medication orders that included Augmentin (antibiotic) 500-125 Milligrams (MG) for abscess, Cipro (antibiotic) 500 MG for abscess, Doxycycline (antibiotic)100 MG for abscess, Depakene (anti-seizure) 500 MG for mood disorder, Lasix (fluid removal) 20 MG for edema, Lorazepam (anti-anxiety) 0.5 MG for anxiety, Mupirocin-Lidocaine ointment 2-2% for skin abscess. The Comprehensive Care Plan included focus that resident #154 was dependent on staff to meet his emotional, intellectual, physical, and social needs related to cognitive deficits, with goals that he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 16 of 34 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 11/02/2023 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 - Some would maintain involvement in cognitive stimulation and social activities. Interventions included to encourage ongoing family involvement in his care and activities and to monitor his anxiety, fear, and distress by encouraging him to discuss his feelings and concerns. The Care Conference Record showed resident #154's Comprehensive plan of care and treatment was reviewed and signed by the Lead MDS Coordinator and other facility staff on 5/30/23 and 9/5/23. Both reviews noted the resident's Power of Attorney (POA) was included in the reviews by telephone. The record did not show the resident participated in either review. Nursing Progress Notes dated 5/26/23 and 9/1/23 noted the Lead MDS Coordinator called the resident's POA to inform her of scheduled care plan review meetings, and the POA indicated she would attend by telephone. On 11/1/23 at 11:42 AM, the Lead MDS Coordinator said she scheduled care plan review meetings, and residents who had a BIMS score that showed they were able to participate, the family representative, and the Interdisciplinary Team (IDT). She said reviews were intended to ensure treatment and plans for care were person-centered and they were done on admission, quarterly, and as needed. She checked resident #154's medical record and said his BIMS score was 14 out of 15, and he had good cognition to participate. She provided a copy of the resident's Care Plan Conference sign in records that showed she herself had attended his last two reviews. She said the resident should have been invited to attend the meetings, and his input was important to evaluate his needs and concerns. She could not recall or explain why the resident was not invited to either review. On 11/02/23 at 11:54 AM, the Director of Nursing explained that MDS staff was responsible for coordinating the care plan reviews and meeting schedules. She conveyed it was important that residents were invited so they actively participated in their care planning reviews and revisions, and stated, especially if they know what's going on. Review of resident #154's Care Plan Conference schedule invitations addressed to, Resident Representative for reviews scheduled 5/30/23 and 9/5/23 both read, The team at (facility name) believes a meeting with the resident and/or resident representative is an important part of our planning process in order to provide the highest quality of Patient Centered Care. The facility's undated policy and procedure titled, Comprehensive Care Plan - Comprehensive Care Plans, read, . Resident's Goal refers to the resident's desired outcomes and preferences for admission, which guide decision-making during care planning. Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. 4. The resident will have the right to participate in the development and implementation of his or her person-centered plan of care . a. The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. b. The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care . d. The right to see the care plan, including the right to sign after significant changes to the plan of care. 5. The facility will inform the resident of the right to participate in his or her treatment and shall support the resident in this right. 6. The planning process will: a. Facilitate the inclusion of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 17 of 34 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 11/02/2023 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 follow policies and procedures and adhere to professional standards related to wound care and treatment for 1 of 5 residents reviewed for non-pressure skin conditions, out of a total sample of 63 residents, (#47). Residents Affected - Few Findings: Review of the medical record revealed resident #47 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, generalized muscle weakness, lack of coordination, muscle wasting and atrophy of the lower legs, and difficulty walking. Review of the Minimum Data Set (MDS) Medicare Part A Stay assessment with assessment reference date of 10/06/23 revealed resident #47 had a Brief Interview for Mental Status score of 12 which indicated moderate cognitive impairment. The document showed he had skin tears and nonsurgical dressings. Review of the medical record revealed resident #47 had a care plan for fall-related skin tears to his right and left arms, initiated on 10/12/23. The goals noted the resident would remain free of skin tears and the skin tears to both forearms would heal. The interventions read, If skin tear occurs, treat per facility protocol and notify [physician], family.monitor/document location, size and treatment of skin tear. On 10/30/23 at 11:28 AM, resident #47 stated last night he was seated on the side of the bed, slipped on the bedspread, and fell to the floor. He stated he injured himself and showed a white dressing on the back of his left hand. The dressing was not dated or initialed and there was an area of dark brown drainage in the middle of the dressing. Resident #47 could not recall who applied the dressing to his hand. On 10/30/23 at 11:30 AM, resident #47's assigned nurse, Licensed Practical Nurse (LPN) F, was informed the resident said he fell last night, and that he had an undated dressing on his left hand. She stated she was not aware of a recent fall or any new injuries. LPN F validated the dressing on the dorsal surface of resident #47's left hand was not dated. She explained the facility's policy was to notify the attending physician of new wounds or any injury of unknown origin, obtain a treatment order, and apply the dressing. During review of the medical record with LPN F, she confirmed there were no progress notes or change in condition forms regarding resident #47's left hand injury, and no associated treatment order. On 10/31/23 at 4:12 PM, the Short Stay Unit (SSU) Unit Manager (UM) verified it was essential to notify the physician of skin injuries and implement orders for wound care. She acknowledged there was no wound evaluation or treatment order for resident #47 until after LPN F was notified of the undated dressing on the resident's left hand. The SSU UM acknowledged it was important to obtain and document orders including treatment frequency and to date the dressing applied. She explained dressings needed to be applied and changed as ordered to prevent infection and allow for regular assessment to ensure the wound was not deteriorating. Review of the facility's policy and procedure for Wound Management (undated) revealed the purpose of the program was .to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 18 of 34 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 11/02/2023 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 0685 Assist a resident in gaining access to vision and hearing services. 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 arrange services in a timely manner to ensure access to appropriate prescription glasses, (#15); and failed to provide glasses to maintain vision abilities, (#154), for 2 of 6 residents reviewed for Vision/Hearing out of a total sample of 63 residents. Residents Affected - Few Findings: 1. Review of the medical record revealed resident #15 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, seizures, chronic pain, insomnia, and need for assistance with personal care. Resident #15 had a care plan for glasses to correct visual impairment initiated on 8/31/22 and revised on 7/05/23. The goal noted the resident would not experience a decline in visual function or have indicators of acute eye problems. The interventions included arrange consultation with an eye practitioner as required, monitor and report symptoms of acute eye problems, and remind the resident to wear her glasses when up. On 10/31/23 at 9:50 AM, resident #15 explained she had a history of cataract surgery and vision problems. She stated she used to wear glasses in the past, but no longer had them. Resident #15 stated she did not see properly without her glasses and was unable to read and watch television. The resident could not recall when she last had glasses but confirmed she had complained to staff about the issue. On 11/01/23 at 11:37 AM, Registered Nurse (RN) B received permission from resident #15 to check her personal belongings for her glasses. RN B searched the resident's bedside table, a plastic bin, all dresser drawers, the closet, and two purses, but found no glasses. RN B stated although he worked on the unit regularly and was familiar with the resident, he had never seen her with glasses. On 11/01/23 at 12:49 PM, the Social Services Assistant (SSA) recalled an Activities Department staff member came to her office and notified her that resident #15 was having vision issues as she complained of difficulty seeing the bingo cards. The SSA said, That is what triggered the referral. The SSA explained after referrals were sent to the contracted mobile vision provider, representatives would come to the facility to test residents and prescribe glasses if indicated. She reviewed an email dated 7/06/23 and noted the facility contacted the vision provider to follow up on an earlier referral. The SSA was informed resident #15 still did not have glasses. On 11/01/23 at 1:15 PM, the Social Services Director (SSD) stated she contacted the vision provider and discovered the company never received the referral for resident #15. The SSD acknowledged nobody from the facility followed up to ensure the resident had an eye exam and received glasses. She explained the vision provider visited the facility monthly but she did not realize resident #15 was not seen even after she sent the email in July 2023. The SSD validated not having glasses for months was a concern and might even contribute to the resident's behavioral symptoms. She said, It's a quality of life issue. Review of the medical record revealed a Social Services Progress Note dated 2/02/23 that read, SSD sent a referral to [name of vision provider] for a check up for [name of resident]. There were no additional Social Service progress notes regarding arrangements for vision services from February to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 19 of 34 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 11/02/2023 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 0685 November 2023. Level of Harm - Minimal harm or potential for actual harm On 11/01/23 at 5:09 PM, the SSD acknowledged she was not able to locate original documents or provide confirmation that the referral was sent to the vision provider with the necessary paperwork. She verified she wrote the Social Services Progress Note in February 2023 and thought she sent the referral. Residents Affected - Few On 11/01/23 at 4:13 PM, the Activities Assistant recalled one day as he assisted resident #15 out of the activity room, she kept asking for glasses. He stated he took the resident directly to the Social Services office as he knew that department arranged residents' vision services. The Activities Assistant recalled resident #15 had glasses in the past but he could not remember when he last saw her wear them. He explained she needed glasses to participate in some activities. Review of the facility's policy and procedure for Quality of Care - Treatments/Devices to Maintain Hearing/Vision (undated) revealed the intent to identify and provide needed resident-centered care and services, in accordance with the resident's preferences and goals for care to meet residents' vision needs. The procedure indicated the SSD or designee would coordinate vision services. Review of the job description for Director of Social Services (undated) revealed she would be a resident advocate who was responsible for the provision of services for the highest psychological and social well-being of residents. Job responsibilities included coordinate and monitor needed available services for residents. 2. Review of the medical record revealed resident #154 was admitted to the facility on [DATE] from an Assisted Living Facility, with diagnoses of abdominal wall abscess (infection), stroke, mood disorder, anxiety, and dementia. The most recent Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date of 8/23/23 noted the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated the resident was not cognitively impaired. The assessment showed he required staff support and assistance to complete Activities of Daily Living (ADLs), and he did not have corrective lenses. On 10/30/23 at 12:15 PM, resident #154 stated he couldn't see well and needed glasses. He said he had been waiting to see the eye doctor for a few months, and he didn't know why it was taking so long. Review of the Comprehensive Care Plan included a focus initiated on 7/14/23, that the resident had potentially impaired visual function, with an intervention that when required, the facility would arrange eye care services. The Order Summary Report noted on 5/16/23, the physician ordered, Optometry/Ophthalmology (Vision/Eye care) as needed. A (Provider Name) Permission Slip form that was signed on 7/12/23 by the resident's family representative noted the resident's eye problem and condition was decreased vision, with a request to receive on-site eye care services. On 11/02/23 at 10:07 AM, the Social Services Director said the vision care provider came to the facility every month to provide exams and glasses to residents, and they received services annually and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 20 of 34 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 11/02/2023 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few as needed. She explained, resident #154's glasses had not been ordered because there was an overdue balance that the resident's family representative still had not paid. She provided a Statement of Charges and Payments from the vision care provider addressed to the facility dated 11/02/2023 that noted the resident was examined for a glasses prescription on 8/02/23, three months prior. Review of a Social Services Progress Note dated 8/23/23 read, . (resident name) was referred to eye care services in late July for reports of eye discomfort. He will be seen on their next visit. He currently has orders for eye drops. Review of an email dated 11/2/23 to the Social Services Director from the eye care provider read, We are waiting on payment. Once we receive that we will get them (glasses) sent to the lab to be made. On 11/02/23 at 12:39 PM, the Business Office Manager said she had worked at the facility for approximately 18 months. She stated she had never received an invoice to pay the facility liability for any resident's vision care services. She explained, residents who were recipients of Medicaid received vision services and glasses that were included with their benefits. On 11/02/23 at 2:24 PM, the Nursing Home Administrator said resident #154's unpaid balance for vision services was the, left over after Medicaid benefits were paid directly to the provider. She stated the amount due was the facility's responsibility, and not the resident's nor the resident's representative. She did not explain why the resident's glasses had not been ordered since his exam, three months prior. The facility's undated policy and procedure titled, Quality of Care - Treatment/Devices to Maintain Hearing/Vision read, INTENT: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's hearing and vision needs. PROCEDURE: 1. The facility will ensure that resident's receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility will, if necessary, assist the resident: . 2. The Director of Social Services or Designee will coordinate the care and services related to vision and hearing needs of our residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 21 of 34 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 11/02/2023 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 therapy was administered according to physician orders for 2 of 4 residents reviewed for respiratory care, out of a total sample of 63 residents, (#56 and #57). Residents Affected - Few Findings: 1. Review of the medical record revealed resident #57 was admitted to the facility on [DATE] with diagnoses including shortness of breath, dementia, and cognitive communication deficit. The Minimum Data Set (MDS) Significant Change in Status assessment with assessment reference date (ARD) of 8/24/23 revealed resident #57 used oxygen. The resident had a care plan for oxygen therapy related to shortness of breath initiated on 6/16/23. The interventions included oxygen setting of 2 liters per minute (L/min) continuously via nasal cannula. Review of the medical record revealed resident #57 had a physician order dated 8/03/23 for oxygen at 2 L/min as needed that was discontinued on 10/26/23. On 10/30/23 at 12:08 PM, resident #57 wore his nasal cannula with one prong in his left nostril and other prong rested on his face to the left of his nose. The flow meter on the oxygen concentrator was set at 3 L/min. The resident explained he did not like to use oxygen and he removed the cannula and dropped it on the floor beside his bed. On 10/30/23 at 12:10 PM, Registered Nurse (RN) B was informed resident #57's nasal cannula was on the floor. The resident informed RN B that the oxygen irritated his nose and he did not want to wear it. RN B validated the concentrator was set at 3 L/min. RN B reviewed resident #57's medical record and discovered the resident did not have an active order for oxygen therapy. On 10/30/23 at 12:22 PM, Certified Nursing Assistant (CNA) D stated resident #57 was regularly on her assignment and to her knowledge, he should have continuous oxygen. CNA D confirmed the resident had the nasal cannula in place when she started the 7:00 AM shift this morning. CNA D said, He does not like it. But whenever I come in, I make sure it's on, and if I go out and he takes it off, I put it back on again. On 10/31/23 at 3:36 PM, CNA E stated nurses applied resident #57's oxygen and he monitored that the resident kept it on. On 10/31/23 at 3:53 PM, RN S stated resident #57 had been on his assignment for several months with a physician order for continuous oxygen. RN S explained typically, oxygen orders were noted in the Treatment Administration Record (TAR) and nurses would monitor and document oxygen administration and oxygen levels every shift. RN S stated he could not explain how assigned nurses had missed that there was no physician order for resident #57's for oxygen. On 10/31/23 at 4:05 PM, the Short Stay Unit (SSU) Unit Manager (UM) recalled during rounds on the unit during the previous week, RN A informed her resident #57 had good oxygen levels and no longer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 22 of 34 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 11/02/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed oxygen therapy. The SSU UM stated she called the resident's physician and obtained an order to discontinue oxygen therapy. She acknowledged she did not remove the concentrator from the resident's room after she wrote the new order. The SSU UM explained it was the responsibility of each nurse assigned to the resident to check that his his oxygen was applied at the correct flow rate at the start of the shift, and document as required by the end of shift. She confirmed none of the assigned nurses noted the absence of an oxygen order for the resident. 2. Review of the medical record revealed resident #56 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic rhinitis, and dependence on supplemental oxygen. The MDS Quarterly assessment with ARD of 8/18/23 revealed resident #56 used oxygen. The resident had a care plan for emphysema/COPD related to smoking, shortness of breath, coughing, and wheezing, initiated on 11/13/18. The interventions included administer oxygen at 2 L/min via nasal cannula as needed. Review of the medical record revealed resident #56 had a physician order dated 9/05/23 for oxygen at 2 L/min continuously. On 10/30/23 at 12:15 PM, resident #56 had a nasal cannula with oxygen infusing at 3.5 L/min. The resident stated he required oxygen at all times but he was unsure of ordered flow rate. RN B validated the concentrator was set at 3.5 L/min. He reviewed the resident's medical record and stated the physician order was for oxygen at 2 L/min. On 11/02/23 at 11:19 AM, the Director of Nursing stated nurses were expected to treat oxygen as a medication and it was important to follow physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 23 of 34 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 11/02/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain safe and secure storage of medication to prevent access by unauthorized persons for 1 of 2 medication carts on the East Wing (400 hall). Findings: On 10/30/23 at 5:47 PM, Registered Nurse (RN) G stood at his cart and prepared medications for administration. He removed one pill from a blister pack and placed it in a small plastic cup. RN G recalled he had not yet checked the resident's blood pressure and pulse, so he placed the cup in top drawer of the medication cart and entered room [ROOM NUMBER]. The medication cart was located against the wall, across and down the hallway from room [ROOM NUMBER]. RN G did not lock the medication cart and on inspection, all drawers opened freely and medications were easily accessible. While RN G was in room [ROOM NUMBER], a resident exited the room next to the medication cart and propelled his wheelchair in close proximity to the open drawers. When RN G exited room [ROOM NUMBER], he acknowledged he left the medication cart unlocked. He confirmed there were residents on the 400 hallway and other areas on the East Wing who were ambulatory or able to self-propel in wheelchairs, and some residents were cognitively impaired. RN G verified his medication cart should have been locked as it was out of his line of sight. On 10/30/23 at 5:50 PM, the East Wing Unit Manager stated her expectation was nurses would ensure medication carts were locked appropriately to ensure medications were secured and residents were safe. The Director of Nursing validated a medication cart should never be unlocked if the nurse was not present at the cart. Review of the facility's policy and procedure for Storage of Medication, dated September 2018, revealed medications were to be stored properly and .shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy indicated medication storage areas should remain locked when not in use or when authorized persons were not in attendance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 24 of 34 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 11/02/2023 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 0791 Provide or obtain dental services for each resident. 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 follow up dental services for 1 of 2 residents reviewed for Dental out of a total sample of 63 residents, (#154). Residents Affected - Few Finding: Review of the medical record revealed resident #154 was admitted to the facility on [DATE] from an Assisted Living Facility, with diagnoses of abdominal wall abscess (infection), stroke, mood disorder, anxiety, and dementia. The most recent Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date of 8/23/23 noted the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated the resident was not cognitively impaired. The assessment showed the resident required staff support and assistance to complete Activities of Daily Living (ADLs). On 10/31/23 at 11:38 AM, resident #154 was visibly distressed when he explained he had been waiting for follow up dental services for months since he was seen by the facility's Dentist. He said the provider recommended partial dentures, and he really needed them. Review of the Comprehensive Care Plan included a focus initiated on 5/17/23 for oral/dental health potential problems with an intervention to coordinate arrangements for dental care as needed. The Order Summary Report showed active physician's orders for, Dental as needed ordered 5/16/23. On 11/01/23 at 3:07 PM, the Social Services Director said the facility's dental provider came to see residents every month and provided services. She provided a document that listed the names of residents who were scheduled to be seen. Resident #154 was not included on the list. Review of a Social Service Progress Note completed by the Social Services Director on 5/26/23 noted resident #154 required a dental evaluation for, loose and missing teeth. A (Provider Name) Services Screening Report dated 6/12/23 noted the resident was to receive partial dentures, and Social Services was to follow up for approval. The medical record included two (Provider Name) Confirmation of Authorization forms that showed consent for dental services was signed by resident #154's family representative on 7/13/23 and 8/29/23. A Social Service Progress Note completed by the Social Services Coordinator on 8/23/23 read, . also referred for dental services. He will be evaluated by the dentist and hygienist on their next visit. A Social Service Progress Note completed by the Social Services Coordinator on 10/31/23 read, On this date, (resident name) approached SSC (Social Services Coordinator) and reported he was experiencing tooth discomfort. SSC subsequently send a referral to (Provider name) . On 11/02/23 at 2:25 PM, during a joint interview with the Nursing Home Administrator and Social (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 25 of 34 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 11/02/2023 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 0791 Level of Harm - Minimal harm or potential for actual harm Services Director, the Social Services Director said resident #154 was evaluated by the dental provider on 6/12/23. She said she had not followed up on the recommendations and ensured the resident was properly processed to receive continued services for partial dentures. She said the resident should have been seen again within 30 days of the recommendation. She explained her department's follow up and tracking were flawed, and they needed to revisit their process. Residents Affected - Few The facility's undated policy and procedure titled Dental Services, read, INTENT: It is the policy of the facility to ensure that residents obtain needed dental services, including routine dental services, to ensure the facility provides the assistance needed or requested to obtain these services . PROCEDURE: 1. The facility will provide from an outside source routine and 24-hour emergency dental services to meet the needs of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 26 of 34 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 11/02/2023 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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 required built up utensils and weighted cup were provided for 1 of 5 residents reviewed for nutrition of a total sample of 63 residents, (#41). Residents Affected - Few Findings: Resident #41 was admitted to the facility on [DATE] with diagnoses that included stroke, difficulty swallowing after stroke, chronic lung disease, protein-calorie malnutrition, muscle wasting and weakness. Review of the Minimum Data Set assessment dated [DATE] revealed resident #41 was cognitively intact but required one-person physical assist for eating supervision. Review of the Order Summary Report dated 11/02/23 revealed resident #41 had a physician's order for a regular diet with regular texture and nectar thickened fluids. The order report also showed an Occupational Therapy (OT) clarification order for resident #41 to have a blue 8 ounce (oz.) weighted cup with blue lid and built-up utensils with all meals dated 7/27/23. Resident #41 had a care plan for increased nutritional risk related to his medical diagnoses and history of pneumonia from food aspiration. The goal was for resident #41 to maintain adequate nutrition. Interventions included the same OT clarification for the resident to have a blue 8 oz. weighted cup with blue lid and built-up utensils with all meals dated 8/07/23. Another intervention included staff to assist resident #41 with all meals. On 10/30/23 at 1:00 PM, resident #41 was observed sitting partially up in bed with his lunch in a Styrofoam container. There was a sign taped to the wall that noted the resident should be seated upright as much as possible and gave other suggestions to aid with his eating. The meal ticket on his tray indicated he was supposed to have a weighted cup and built-up utensils. His lunch tray contained disposable plastic utensils and a carton of thickened beverage with a straw in it. There were no built-up utensils nor the blue lidded 8 oz. cup with his meal. Resident #41 used his hands in an attempt to eat the ham provided for lunch. He stated he was not able to use the plastic disposable utensils that came with the meal. On 10/30/23 at 5:47 PM, resident #41 was observed sitting in his room with his dinner tray. Built up utensils had been provided but the blue lidded and weighted 8 oz. cup was not. Resident #41 had a patty melt sandwich but struggled to eat it. He stated he could not cut the sandwich himself because he could only use one hand due to his previous stroke and staff had not assisted him. On 10/31/23 at 12:18 PM, resident #41 was observed in bed with his lunch of a cheeseburger and cake. On the tray were standard metal silverware and a standard red plastic mug for his drink. The cake was covered and the condiments for his burger sat in the package unopened. He stated he could pick up the burger to eat with his hands, but he could not open the packages himself for the condiments and no staff had assisted to set his meal up. Resident #41 said he could not eat the cake with the silverware that was provided. On 11/01/23 at 12:52 PM, Certified Nursing Assistant (CNA) O delivered resident #41's lunch tray (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 27 of 34 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 11/02/2023 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and assisted him to uncover the food items. The built-up utensils were present on the tray but there was no 8 oz blue weighted and blue lidded cup. Resident #41 stated he didn't have the strength to open things himself and needed staff to assist. CNA O stated the kitchen was supposed to send the blue weighted cup and the built-up silverware, but they had not been sending them. CNA O indicated resident #41 could just use the regular red cup that was sent on his tray, but he explained he could not use that one very well, and the blue cup was easier for him to manage. He said he had not seen the blue weighted cup since last week. CNA O stated she was going to ask the kitchen for the blue cup and returned a few minutes later with it. This blue cup had a white disposable type lid that did not fit on the cup and fell off when resident #41 lifted it up to take a drink which allowed the beverage inside to easily spill. Resident #41 stated this was not the weighted blue cup with lid he usually had. On 11/01/23 at 2:52 PM, Occupational Therapist M stated she had worked with resident #41 on his ability to feed himself when he returned from the hospital from [DATE] to 8/04/23. She stated resident #41 had tremors so it helped him to have the weighted cup with lid and the built-up utensils to aid his grip and to prevent food spillage. OT M explained she submitted the clarification order detailing the needed adaptive equipment for nursing staff after his OT evaluation and also submitted an order for the kitchen to supply the weighted, blue 8 oz. lidded cup and built-up utensils to resident #41 with every meal. On 11/01/23 at 3:20 PM, the Certified Dietary Manager (CDM) explained once they received an order from therapy for adaptive devices, it was entered into their computer-based meal tracking system. The computer system listed the required adaptive devices for each meal ticket along with a picture of the device and a description of the items. The CDM stated there was a bin for adaptive equipment for the kitchen staff to utilize when they set up the meal trays on the tray line, and CNAs should fill the weighted cup with the appropriate beverage once they received the tray. The CDM stated residents should receive the appropriate adaptive device even if the facility used disposable tableware due to the broken dishwasher as occurred on the previous Monday 10/30/23. She could not say why resident #41 had not received his built-up silverware or weighted blue cup and said it should be muscle memory for the kitchen staff to put the appropriate adaptive equipment on the trays. The CDM also could not explain why resident #41 did not receive his weighted cup all week until requested at lunch that day nor why it did not have the appropriate lid. She explained she later learned when the CNA came to the kitchen to ask for the cup at lunch, the kitchen staff told her they did not have the lid and gave her a disposable lid instead which did not fit the cup. The CDM stated if she did not know about the problems she could not fix them. Review of the undated Food and Nutrition Services policy and procedure revealed the intent of the facility to ensure facility staff support the nutritional well-being of the residents. #12 of the procedure section detailed the facility would provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 28 of 34 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 11/02/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure dishes were rinsed at the appropriate temperature and with the proper level of sanitizer with regard to the dish machine's data plate and manufacturer's instructions and failed to maintain equipment in a safe condition. Finding: On 10/30/23 at 10:25 AM, during kitchen observation, staff were observed running dishes through the dish machine. The temperature dial on the dish machine did not register the rinse temperature. The Data Plate on the machine noted the rinse temperature should be 120 degrees Fahrenheit (F). The Certified Dietary Manager (CDM) acknowledged the gauge was not registering the water temperature on the rinse cycle. She explained the dish machine was a low-temp chemical machine. Dietary Aide K was observed as she removed wet plates from the dishwasher, stacked them and placed them in the plate warmer with other plates. The CDM asked Dietary Aide K to test the chemical parts per million (ppm). Dietary aide K removed a container of test strips from the top of the dish machine, opened the container and tipped it to allow test strips to come out. Water poured out of the container into her hand along with the test strips. She took the test strip and attempted to test the chemical ppm, but it did not register. The CDM instructed Dietary Aide K to get the other container of test strips which were also on top of the dishwasher. When she opened it, water also came out of the container. The CDM acknowledged the test strips were not any good and could not be used to test the chemical ppm. Dietary aide K reported she had not tested the chemical ppm that morning and was unaware the strips were unable to be used. The CDM stated she may have some test strips in her office and went to check. Dietary aide K continued to remove items from the dishwasher. She removed wet serving trays, stacked them and turned them upside down on a cart on top of other serving trays. CDM returned and stated she only had test strips for the 3-compartment sink. She verified those would not work to test the chemical ppm for the dish machine. The CDM was made aware of the items being stacked wet on top of other items. The CDM acknowledged items should be allowed to air dry and should not be stacked wet due to the risk of bacterial growth. The CDM stated they were going to re-wash all the dishes from the previous wash that day once the machine was repaired and she obtained chemical testing strips. On 11/01/23 at 12:41 PM, the CDM confirmed the repairman had come to the facility around 3:30-3:45 PM on 10/30/23 and repaired the temperature dial for the rinse cycle and gave the CDM new test strips at that time. The CDM reviewed the temperature and ppm test log which showed wash and rinse temperatures and chemical ppm levels recorded for both breakfast and lunch on 10/30/23. The CDM acknowledged the form was completed and should not have been. She could not explain why the staff had done so. The Food and Drug Administration 2017 Food Code notes in section 4-501.15 A, that a warewashing machine and its auxiliary components shall be operated in accordance with the machines data plate and other manufacturer's instructions. On 11/01/23 at 11:44 AM, during tray line observation, two dietary aides and one cook were performing meal service. The CDM and the Dietary Aide Supervisor were in the kitchen but were not consistently watching the tray line. A cart with stacked serving trays used for meal service was observed next to the tray line. The first dietary aide removed the trays and placed them on the line. They were prepared as the tray traveled down the line where the second Dietary Aide placed the completed tray (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 29 of 34 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 11/02/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete in the meal cart for delivery. Several of the stacked trays were noted to be chipped and in disrepair. The dietary staff did not remove these trays from the line. The first meal cart for the 500 unit was completed and staff began to close the door for delivery. The dietary staff were asked who was responsible for monitoring the tray line. The CDM indicated it was the cook and the two Dietary Aides on the line who monitored the tray line. The CDM and the Dietary Aide Supervisor were made aware there were four trays on the cart ready for delivery that were chipped in multiple places and had a rust-colored substance on the trays. The Dietary Aide Supervisor stated most of the trays were like that. The CDM acknowledged meals should not be served on those trays and instructed the Dietary Aide Supervisor to remove them and place the meals on different trays for delivery. Event ID: Facility ID: 105861 If continuation sheet Page 30 of 34 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 11/02/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to respiratory care. Findings: Cross reference F641, F657, and F695 Review of the facility's survey history revealed repeat deficiencies related to accuracy of Minimum Data Set (MDS) assessments, timing and revision of care plans and failure to ensure oxygen delivery per physician order during the current survey ending on 11/02/23. Past deficiencies revealed systemic concerns with similar findings on the previous recertification survey dated 2/03/22 for accuracy of MDS assessments and revision of care plans and on the past two previous recertification surveys (2/03/22 and 10/20) for oxygen delivery per physician orders. In an interview on 11/02/23 at 4:48 PM, the Administrator was unable to say what changes were made after the last survey to ensure the same concerns with MDS assessments, care plans and oxygen delivery did not reoccur. She stated they tried to keep a focus on it, and she felt they had a good resolution since the last survey. She said the facility was aware, oxygen was an issue, but they did not currently have an audit or performance improvement project in place. She explained the QAPI committee was not aware the other concerns brought to their attention during the survey were a current problem. The Administrator noted the QAPI committee usually tried to bring up the concern for 3 months in their meetings and then did spot checks. She said then they asked for opinions on how the audits went, and asked how other departments felt about the issue? She explained they tried to use an audit form when they conducted random spot checks and reported back to the committee. She indicated the team had successfully completed all of their performance improvement projects this year. The Administrator detailed the committee monitored an issue to determine if it had been corrected usually for 3 months and said if there were no concerns, it was considered completed. The Administrator said after the last survey, they were able to get a second Social service Director and they did three months of regular audits and then 3 months of random audits and felt confident the changes had been implemented. Review of the undated Quality Assurance and Performance Improvement policy/procedure revealed the following, These policies are intended to ensure the facility develops a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. The QAPI plan policy addressed that the facility must take action to track performance to ensure improvements are realized and sustained. The plan also detailed the facility would develop and implement policies that addressed how the facility would monitor the effectiveness of its performance improvement activities to ensure improvements were sustained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 31 of 34 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 11/02/2023 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 0880 Provide and implement an infection prevention and control program. 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 adhere to proper infection control practices for cleaning of a glucometer to prevent the potential transmission of bloodborne pathogens for 1 of 2 residents tested for blood glucose levels, (#75), out of a total sample of 63 residents; and failed to ensure staff used proper hand hygiene during meal service with the potential to spread infection to residents on the [NAME] Wing. Residents Affected - Some Findings: 1. Review of the medical record revealed resident #75 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and end stage renal disease with dependence on hemodialysis. Review of the Medication Administration Record revealed resident #75 had a physician order dated 10/14/23 for Novolog Flexpen ReliOn Subcutaneous Solution Pen-injector 100 units per milliliter to be injected according to a sliding scale, two times daily. Resident #75 had a care plan for Diabetes, initiated on 5/20/22, which directed nurses to obtain blood glucose levels via finger sticks and administer insulin as ordered. On 10/30/23 at 4:40 PM, Licensed Practical Nurse (LPN) H prepared to check resident #75's blood glucose level prior to insulin administration. She removed the blood glucose meter or glucometer from the top right drawer of the medication cart and confirmed it was the only device in that cart. LPN H opened a package that contained one alcohol wipe and used the wipe to clean the glucometer. She entered resident #75's room, placed the device on top of a tissue on the resident's tray table, and obtained a blood sample from his finger which she tested with the glucometer. LPN H returned to the medication cart and again cleaned the glucometer with an alcohol wipe before she returned it to the drawer. On 10/30/23 at 4:46 PM, LPN H validated she used alcohol wipes to clean the glucometer before and after use for resident #75. When asked if alcohol wipes were adequate to disinfect the device, she paused briefly, then opened the bottom drawer of medication cart and retrieved a container of disinfectant wipes. LPN H acknowledged she should have used the disinfectant wipes instead of alcohol wipes to properly disinfect the glucometer as it was shared between residents. On 10/30/23 at 4:51 PM, the East Wing Unit Manager (UM) stated her expectation was nurses would disinfect glucometers with wipes provided by the facility to avoid contamination and exposure to bloodborne diseases from improperly disinfected devices. Review of the facility's policy and procedure for Infection Control - Point of Care Devices and Injection Safety (undated) revealed the facility would .ensure that appropriate infection prevention and control measures are taken to prevent the spread of infection. The document revealed shared point of care devices were to be cleaned and disinfected before and after each use with a disinfectant wipe. Review of educational material used by the facility titled Cleaning and Disinfecting the Meter revealed the goal to minimize the risk of transmitting bloodborne pathogens. The document indicated glucometers should be cleaned and disinfected after use on each patient. The cleaning procedure was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 32 of 34 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 11/02/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some needed to clean dirt, blood, and other bodily fluids from the exterior of the glucometer and was to be performed before disinfecting. The disinfecting procedure was needed to prevent the transmission of bloodborne pathogens. The educational material instructed nurses to use one wipe for cleaning and another for disinfecting. 2. On 10/31/23 at 12:21 PM, Certified Nursing Assistant (CNA) I was observed on the [NAME] wing assisting the resident in room [ROOM NUMBER]-B to open dishes and cut up the food. CNA I left the room without washing her hands at the sink or sanitizing her hands with hand sanitizing gel and went to the tray cart parked in the 100-unit hallway. She pulled out a new tray and took it to room [ROOM NUMBER]-B. CNA I did not sanitize her hands, set the lunch tray on the bedside table, and then uncovered the food on the tray and placed the napkin on the resident's chest. Then she moved the tray table closer to the resident. CNA I was observed again not washing or sanitizing her hands when she exited that room and went to the meal cart in the hallway to get another tray. She then took room [ROOM NUMBER]-B their lunch tray, came out of the room again without performing hand hygiene and got another tray from the meal cart in the hallway and delivered it to room [ROOM NUMBER]-A. CNA I then came out without performing hand hygiene and picked up a new tray and delivered it to room [ROOM NUMBER]-B without performing hand hygiene. She dropped off the tray on the bedside table and adjusted the curtain between the beds. CNA I exited the room, again not performing any hand hygiene, then adjusted the front of the surgical face mask she was wearing while she spoke to a resident in the hallway. She did not perform hand hygiene after touching her face mask and then retrieved another meal tray and delivered it to room [ROOM NUMBER]-A. CNA I exited the room without performing hand hygiene, went to the meal cart where she adjusted some of the trays inside and wheeled the cart down to the 200 hall and cleaned her hands with hand sanitizer. On 10/31/23 at approximately 12:27 PM, CNA J was observed delivering beverages to the residents on the 100 hall while CNA I delivered the meal trays. CNA J came out of a resident room and returned to the beverage cart parked in hallway. She prepared a drink and entered room [ROOM NUMBER] without performing hand hygiene. CNA J dropped off the drink to the resident in 108-A then touched the divider curtain between the residents and left the room without performing hand hygiene. She then went to her cart, poured a drink, and returned to 108-A also without performing hand hygiene. CNA J then left the room, again without hand hygiene and walked down the hall to the unit pantry. She came out a few minutes later after she touched the door handle to the pantry and entered room [ROOM NUMBER] where she delivered a coffee in a disposable cup and again did not perform hand hygiene coming in or out of the room. CNA J then handled the trash bag hanging from her cart and pushed the cart to the 200 hall, with no hand hygiene performed. On the 200 hall at approximately 12:34 PM, CNA L was observed exiting room [ROOM NUMBER]-A with no hand hygiene performed. She moved the cart down the hall, took a tray, and without performing hand hygiene delivered it to room [ROOM NUMBER]-A. She set the tray down on the resident's bedside table, uncovered the food and unwrapped the silverware and placed it down on the tray. CNA L then took a dirty tray from the previous meal, left the room without hand hygiene, and placed the tray on top of the meal cart. CNA L grabbed the next clean tray and went to room [ROOM NUMBER]-B again without hand hygiene, delivered the tray and came out of the room with no hand hygiene. She then touched another staff member's back who was bent over preparing drinks and when she reached the clean meal cart, got another tray out of the cart and delivered it to room [ROOM NUMBER]-B without hand hygiene going in or out. CNA L then got the dirty trays and took them back to a cart near the kitchen. On 10/31/23 at approximately 12:39 PM, CNA L stated she was supposed to either wash her hands or use alcohol-based hand gel between delivering each resident's meal tray. She was unaware she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 33 of 34 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 11/02/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some perform hand hygiene while being observed delivering lunch trays on the 200 unit and after touching another staff and touching dirty trays. CNA L acknowledged this observation and said she might have forgotten to perform hand hygiene but said she usually cleaned her hands. On 10/31/23 at approximately 12:41 PM, CNA I acknowledged she was supposed to perform hand hygiene between each resident and room when delivering meal trays. She said she might have forgotten to clean her hands when she was delivering the trays. On 10/31/23 at 12:43 PM, the [NAME] wing Unit Manager (UM) said staff should wear gloves when handling resident's food. She said she was unsure of the policy, and said she felt it would be better if CNAs wore gloves when handling food. The [NAME] wing UM explained staff should perform hand hygiene both before and after putting on the gloves and then agreed staff should also perform hand hygiene both before and after going in and out of residents' rooms. In interviews on 10/31/23 at 3:29 and 3:57 PM, the Director of Nursing (DON) said she was not aware if staff were supposed to wear gloves when handling resident food like cutting it up or removing the covers and was also not sure if staff were supposed to perform hand hygiene between each resident or only between the rooms. She asked if she could verify their new policy. The DON then said staff should not wear gloves when handling resident's food, but they should be doing hand hygiene when delivering the meal trays. She explained the facility's policy said hand hygiene should be performed between handling each resident's environment to prevent the spread of infection or bacteria between residents. She acknowledged it was important to sanitize hands after touching someone's dirty tray or other things. On 11/01/23 at 12:52 PM, CNA N and CNA O were observed preparing to deliver the lunch trays to the 100 hall. The alcohol-based hand sanitizer gel receptacles were mounted on the walls of the 100 hall by the shower at one end of the hall and the next container was about 42 steps away between rooms [ROOM NUMBERS]. CNA N was observed delivering a tray and then had to walk down to the end of the hall to the nearest alcohol-based sanitizer gel receptacle to perform hand hygiene then walk back up the hall to get the next tray. CNA O then took the disposable alcohol-based hand sanitizer gel bottle from the nearby nurse's medication cart and placed it on top of the meal tray so they would not have to walk down the hall to perform hand hygiene. On 11/01/23 at 3:20 PM, the Certified Dietary Manager (CDM) stated she was not aware CNAs were not performing hand hygiene when delivering meal trays at lunch. She was not aware the alcohol-based hand sanitizer gel receptacles were so far apart on the halls and that some halls did not have them in the resident rooms. The CDM stated she had not considered putting disposable containers of alcohol-based hand gel on top of the carts but agreed it would be easier for staff to utilize if it was more available for staff to easily access. Review of the undated Infection Control- Hand Hygiene Policy/Procedure revealed the intent of the facility was to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and World Health Organization. The procedure described that soap and water was required for hand hygiene before and after eating or handling food. The procedure also detailed that alcohol-based hand rub may be used when soap and water was not indicated, and hand hygiene was to be performed after contact with the resident environment and before and after assisting a resident with meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105861 If continuation sheet Page 34 of 34