Health inspection·December 4, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm #1 at the hospital after the fall, the resident had knee surgery and she brought him flowers. The SSD added she recalls Resident #1 had surgery and soon after she learned he did not make it. Interview with the Administrator on 12/01/23 at approximately 2:30 PM confirmed the adverse event was not reported to the regulatory agency. Residents Affected - Few Record review revealed facility documents including list of reportable events and incident logs failed to provide evidence the facility identified he allegation as neglect, and failed to report the adverse incident to the appropiate agencies. Staff interviews conducted on 12/01/23 verified the facility had knowledge the resident sustained a fracture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106012 If continuation sheet Page 2 of 4 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 106012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Port Saint Lucie 3720 SE Jennings Rd Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview, the facility failed to report and implement corrective actions to minimize reoccurrence of an adverse event, a fall resulting in a fracture, involving 1 of 2 sampled residents (Resident #1). The findings included: Review of the facility policy titled, Conducting an Investigation, Reviewed 07/18/23 documents If it is determined that alleged abuse and neglect, injury of unknown source, exploitation, or misappropriation of resident property has occurred, the administrator, director of nursing, or his/her designee will promptly notify officials in accordance with state and federal regulations . If the alleged violations is verified appropriate corrective action must be taken. Record review revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation and was transferred to the hospital on [DATE] after a fall. Review of the Minimum Data Set, admission assessment with reference date 09/19/23, documented the resident was assessed as independent for skills of daily decision making, required extensive assistance with two people for transfers and had no falls prior to admission. Review of Care plans dated 09/18/23, documented the resident is at risk for falls and the goal noted the resident will not sustain serious injury requiring hospitalization through the review date. Review of Physical Therapy notes dated 09/28/23, documented Patient educated on high fall risk, recommending using Hoyer lift for transfer and using the beasy board. Spoke with patients' daughter with patient present about recommendations to decrease risk for fall and injury to staff and patients. Review of the progress notes dated 09/16/23 thru 10/06/23; interdisciplinary plan of care and therapy notes, failed to indicate Resident #1 refused the use of the mechanical lift for transfers. Review of progress notes dated 10/6/2023, documented Writer called to resident room, received report from staff, that while transferring resident to bed his knees buckled in and resident fell on the floor. Observed resident and noted he dislocated his left knee; it is swollen and tender to touch. Call placed to physician. On call supervisor notified and resident's daughter. 911 called and the resident was taken to the hospital. Hospital records dated 10/07/23, documented Resident #1 sustained proximal left tibial and fibular fractures. Interview with the Director of Rehabilitation Services conducted on 12/01/23 at 12:17 PM revealed the resident was at fall risk and refused to use the sliding board for transfers. Resident #1 wanted to transfer himself and the Director recalled his legs buckling. The therapy team then recommended the use of the mechanical lift. The Director stated that she was not aware of the resident's refusal to use of the mechanical lift for transfers. Interview with the Director of Nursing conducted on 12/01/23 at approximately 1:47 PM confirmed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106012 If continuation sheet Page 3 of 4 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 106012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Port Saint Lucie 3720 SE Jennings Rd Port Saint Lucie, FL 34952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clinical record does not provide documentation that Resident #1 refused to use the mechanical lift for transfers. Interview with Staff A, a Licensed Practical Nurse, on 12/01/23 at 2:50 PM revealed she cared for Resident #1 multiple times, for the most part he was alert and oriented. Staff A recalled the event, the aide came to her stating the resident was on the floor and she completed her assessment and notified the wife and physician. The nurse stated she was not aware of the resident's refusal to use the lift or the sliding board. The aide never reported to her that he did not want to use them. Interview with Staff B, a Certified Nursing Assistant, on 12/01/23 at 3:11 PM revealed her recollection of Resident #1. The resident had transferred from another unit, and she received report from the morning aide, the aide was told that the resident did not want to use the mechanical lift. Staff B explained she usually reads the [NAME], (document delineating the plan of care) but this time she did not and accepted the information given on shift report. In addition, Staff B explained she had transferred the resident multiple times with no issues. On 10/06/23, the resident's legs gave up, he fell on his knee, and she immediately called the nurse. Staff B was asked after the event, what corrective action was communicated to her and replied the Assistant Director of Nursing called her and asked her for a statement and is not aware of corrective measures. The investigation determined Resident #1 sustained a fall during transfer resulting in multiple fractures. The facility corrective action did not address the root cause of the adverse event. The staff did not follow the recommended plan of care; the staff did not report the resident's refusal of utilizing the recommended equipment for transfers and the staff did not provide additional interventions to mitigate the resident's fall risk, while accommodating the resident's preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106012 If continuation sheet Page 4 of 4