Health inspection·February 20, 2025

F 0684 124 F - 3 minutes Level of Harm - Minimal harm or potential for actual harm 120 F - 5 minutes 100 F - see below Residents Affected - Few Note: Burns can occur even at water temperature below those identified in the table above, depending on the individual's condition and length of exposure. 1. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnosis that included displaced commuted fracture of the left tibia. The resident's cognitive status according to the 02/04/25 Minimum Data Set (MDS) assessment, recorded a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Further review of the clinical record revealed the resident sustained a burn on 02/16/25, apparently from being exposed to hot tea being spilled on him during the dinner meal. The resident was sent to the hospital for further evaluation on 02/16/25 and returned to the facility later that same evening. Review of the hospital emergency room record for 02/16/25 documented the resident was presented to the ER and upon exam the physician noted the resident had blistering with pain covered with superficial partial thickness burn. An observation and interview were conducted on 02/19/25 at 11:24 AM with Resident #1, who was served his lunch tray. There were no hot beverages given to the resident for this meal. The resident was provided with a bowl of soup, and the aide removed the lid on the soup and placed the soup at the top of the tray. The interview with the resident revealed his accounting of the incident on 02/16/25, during the dinner meal and stated he had asked the aide for a cup of hot tea. He stated the aide set up the tray and the hot tea. He stated the aide put the tea on the end of the table, and the aide's foot hit the table and knocked over the hot tea off into his bed. He said that there were two aides in the room. One was trying to line up his bed table. One of the aides kicked the table and knocked the cup over. An interview was conducted on 02/19/25 at 4:09 PM with the Certified Nursing Assistant, Staff B, who reported that on the day of the incident, Resident #1's tray table was in front of him. She had set up the resident's tray and he then asked for hot tea. She stated she went to get the resident some hot tea and she put the tea on the tray. The resident then asked for salt and pepper, so she went out of the room to the cart in the hallway, to get the salt and pepper, when she heard the resident scream, mommy, I'm burning. She further stated that he said, he poured soup on him. But when she looked, the soup had not been touched. She stated she had the resident turn to the side and when she turned the sheet, she saw the empty cup. She stated when the resident turned at that time, his skin was attached. She removed the sheets and sat them on the floor. She stated she then ran to get the nurse. An interview was conducted with the Wound Care Physician on 02/20/25 beginning at 8:43 AM. The physician reported that he saw the resident on Tuesday, 02/18/25, and the resident's burns were second degree burns, involving the epidermis and blistering. He noted the resident did not have any infection or necrosis in the burns, so he changed the dressing to Xerofoam dressing, because the Xerofoam won't stick to the area. He stated the resident did not complain of any pain while we were performing the wound care. He was conversing with us that he wanted to go home. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106012 If continuation sheet Page 2 of 5 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 02/20/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 02/20/25 at 9:15 AM with the Registered Nurse, Staff C. She reported that she was on another unit when the incident occurred with Resident #1. She stated Staff B came running toward her, stating that Resident #1 had been burned. His skin was burned on the side. The aide had already removed everything when she had arrived to see Resident #1. She further stated that at the time she was unaware of what had caused it. She said the resident did not want to be touched and wanted 911 called. She stated that from her skin assessment, she could see that the skin was mostly intact but wrinkled. There was a small part of the skin that was open on the hip about 3 inches. She was unaware of the amount of time which had elapsed. Review of the facility's investigation revealed the facility interviewed the staff who were involved in the incident to determine how the hot tea was spilled but there is no evidence of the staff monitoring to determine the probable temperature of the liquid served from the canister used to serve the resident. There was no evidence of the facility conducting further monitoring of hot beverages being served on the various nursing units to prevent future reoccurrence of the incident. An interview was conducted on 02/20/25 at 11:16 AM with the Assistant Director of Nursing / Risk Manager. The facility's investigation reviewed the disparity in accounting of the incident from Resident #1 and the staff involved. Interviews were conducted with the staff involved. The facility determined there was one staff member on the unit at the time of the incident. The second aide was in the dining room and the nurse was on another unit. She also noted the temperature documented on the Temperature log from the kitchen for 02/16/25 at dinner was 145F (Fahreneit). She further stated she would have preferred that staff would have tested the curio (container used to store hot liquid for transport to the nursing units) for the water temperature, but she confirmed this did not happen. The surveyor also reviewed the Temperature log documentation for February 2025 and noted there were several entries where the documented temperature exceeded the acceptable range of 140-170 F. degrees and there was no apparent follow-up to the high temperature. An observation in the facility's kitchen during the lunch meal preparation was conducted on 02/19/25 beginning at 11:15 AM. Upon entering the kitchen, the surveyor observed 5 carts with hot beverage canisters already stored on top of the cart. An interview was conducted with the Dietary Aide, Staff A, who confirmed the canisters contained hot coffee or hot water. Staff A further stated, she had already tested the coffee. The surveyor then inquired about the documentation regarding the temperature checks. She then referred the surveyor to the cook. An interview was then conducted with the cook, Staff E, who stated she was the one to note the temperatures of the food and beverages. She also stated she had gotten the temperature of the hot beverages, but she was unable to state what the temperatures were when tested. Upon further investigation, it was noted that the sheet for the documentation for food and beverages was blank for 02/19/25 for the lunch meal. It should be noted that the hot beverages were already in the containers on each of the carts and there was no evidence the temperatures were checked prior to the hot beverages being placed into the containers or were going to be checked prior to beverages leaving the kitchen. The staff on the floor do not check the temperatures on the unit, prior to serving. The surveyor was informed that the staff tests the temperature from the brewing machine, and they document the temperature on the log. On 02/19/25 at approximately 11:40 AM, a test of the coffee coming from the brewing machine tested at 169 degrees Fahrenheit. The staff then stated we will have to put ice in it to lower the temperature before serving. The surveyor requested the staff test the hot beverage content already in the canisters. Temperature checks of the hot beverage content in the canisters on the carts ranged from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106012 If continuation sheet Page 3 of 5 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 02/20/2025 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 0684 122.8 F to 158.9 F. Level of Harm - Minimal harm or potential for actual harm The Food Temperature Log documented the following: Temperature Standards: Cold foods should be at 40 degrees Fahrenheit or below, and hot foods should be at 140-170 degrees Fahrenheit. Temperatures are recorded before food is served. If food temperatures are not within ranges, corrective action must be taken before food is served to residents. Record below the temperature of all hot and cold foods, including modified textures and alternatives. Residents Affected - Few Further review of the Food temperature log for February 2025 revealed multiple entries where the temperature documented for the hot beverage exceeded the above stated range: 02/19/25 - breakfast - 194F. 02/18/25 - breakfast - 178F. 02/09/25 - breakfast - 178F. 02/10/25 - lunch - 181F. 02/08/25 - dinner - 173F. An interview was conducted on 02/19/25 at approximately 11:40 AM with Cook, Staff F, who stated the temperature is checked by obtaining a cup of hot liquid from the brewing machine and is documented on the log. They had no explanation as to why there was no information documented for 02/19/25 and the hot beverages were already in canisters and ready to be sent to the floor. She further stated the aides on the floor distribute the trays and pour the hot liquid into the cups, they do not test the hot liquids. This is done in the kitchen. An interview with the Dietary Manager was conducted on 02/19/25 beginning at 12:00 PM. The surveyor inquired about the staff checking the temperature of the hot liquids. She stated that the staff usually test in the kitchen prior to serving. An interview was conducted on 02/19/25 at 1:29 PM with Cooks, Staff E and Staff F. The [NAME] does the temperature, right before serving. She tests the food and liquid. She tests from the brewing machines. Closer observation of the brewing machine did not indicate a temperature setting for liquid being dispensed. If the temperature is above the stated limit, they are supposed to put ice in the drink. They document the temperature from the Brewing Machine. They do not test the liquids in all the canisters. Another observation was conducted on 02/20/25 at 7:30 AM in the kitchen. Again, the food carts had hot beverage canisters already stored on the carts and the surveyor had been informed that one cart had already gone to the unit. The surveyor again requested to see the Temperature log for the hot beverages. Again, the log was incomplete for the temperature of the hot beverages. 2. Review of the facility's policy regarding Area of Focus: Basic Skin Management, revised 11/21/2024, documented All residents have a head-to-toe skin inspection upon admission/readmission, then completed weekly, and as needed by nursing. It is documented into PCC (Point Click Care). Further review of the clinical record for Resident #1 revealed the resident had an external fixator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106012 If continuation sheet Page 4 of 5 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 02/20/2025 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 0684 secondary to fracture tibia. The physician prescribed wound care for the area as follows: Level of Harm - Minimal harm or potential for actual harm a. On 02/01/25, the physician prescribed clean pin sites (8) R/T [related to] external fixator on left leg with Betadine solution, pat dry and leave open to air every day-shift. Residents Affected - Few b. On 02/01/25, the physician prescribed clean staples on the left upper thigh (near abdominal fold) with wound cleanser, cover with bordered Telfa dressing every day-shift. c. On 02/01/25, the physician prescribed clean stitches on left outer lower leg with wound cleanser, pat dry, cover with bordered Telfa dressing every day-shift. Review of the February 2025 Treatment Administration Record revealed the staff failed to place their initials in the appropriate box to indicate the treatment was performed as follows for the above 3 treatment orders: Monday, 02/03/25; Friday, 02/07/25, Monday through Wednesday, 02/10 - 02/12. An interview was conducted on 02/20/25 at approximately 3:30 PM with the Wound Care Nurse, Staff D, who performs treatments Monday through Friday. The surveyor inquired about the wound care being done. She stated, the girls usually tell me that I missed. Review of the Weekly Skin Checks revealed the staff conducted a skin check on admission, 01/31/25. There were no further weekly skin checks until 02/14/25. There was no documented weekly skin check for 02/07/25. An interview was conducted with the Director of Nursing on 02/20/25 at approximately 4:00 PM, who reported the weekly skin check apparently did not populate in PCC (Point Click Care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106012 If continuation sheet Page 5 of 5