Health inspection·September 11, 2025

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few provided the surveyor with a confirmation email dated February 23, 2025, at 1:46 PM which documented, Based on the information provided, a report for investigation has been accepted regarding Resident # 1. This was processed by Hotline Counselor. This information is confidential pursuant to section 39.202 and section 415.107, Florida Statutes, and can only be released as specified in the statute. The Administrator then reported that he submitted the report to the State Agency prior to interviewing the resident. After he interviewed the resident, he said that the resident felt that the aide was rushed during her transfer, but she didn't want the aide to get in trouble. However, the resident did request that the aide no longer work with her. So, they removed the aide from that assignment. He further stated that because the resident did not feel that the aide intentionally did anything, he did not report the incident to the Federal Agency. The surveyor then questioned the Administrator regarding not having the resident's name listed on the requested logs for reporting, i.e. incident reports, reports to the state and federal agencies. The surveyor then requested any reports or information of what was investigated regarding the incident with Resident # 1 and any subsequent education provided to the staff associated with the February 23rd reported incident for Resident # 1. He then reported that the Risk Manager is on vacation, and he is trying to get in the RM office to see what she has. The Administrator later reported that he did not have an incident report or any evidence of an investigation. Review of a State Agency's report revealed the following documentation, On 02/22/2025 during the 3pm to 11pm shift, Resident # 1 received two (2) bruises during a stand pivot transfer from the wheelchair to bed. The resident has fragile skin and during the transfer the resident stated to please stop but the aide continued to transfer. This was a single time occurrence and there is no prior history of occurrences. Resident # 1 did not want the aide to get in trouble, but she did not want to have the aide take care of her anymore. The aide was contacted for a statement but did not return the call. The aide was suspended pending an investigation. No recommendations were needed to be given as additional training was provided to the AP, and facility-wide training was conducted for staff on proper lifting techniques. The resident is an [AGE] year-old female who has capacity, who has been diagnosed with Intertrochanteric fracture of right hip, high blood pressure and diabetes. The resident requires assistance with her ADL's (activities of daily living) and IADL's. The facility's director confirmed that the allegations were found to be substantiated against the alleged CNA. The evidence presented during the investigation was sufficient to support the allegations. These findings are based on statements from the vulnerable adult, collateral statements from facility staff, and observations made by the API during the investigation. The evidence indicates that Resident # 1 did, in fact, sustain physical injuries. An act, threat, or omission (abuse) was committed, which could or is likely to cause significant harm to the victim. Resident # 1 sustained bruises from the CNA, which were noted during the investigator's visit. The bruises were visible on both of the resident's upper arms, corresponding with the hand placement that the CNA would typically use during a stand pivot transfer from a wheelchair to a bed. The allegations and medical records confirm that Resident # 1 has fragile skin, which would require extra care during handling. Resident # 1 has the capacity to understand, communicate, and make decisions, and she clearly explained to the investigator how she received the bruises. Review of the facility 's grievance log did identify a grievance on 02/23/25 at 10:30 AM, which documented that a nurse reported a concern for Resident # 1. The grievance documented the following information, the CNA was not careful during transfer from wheelchair to bed. The resident does not want the CNA anymore. The report documented that the concern was reported to the administrator on 02/23/25 at 11:00 AM. The report further noted that the Administrator spoke with the resident and staff member who took the report. The resident felt the aide rushed in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106012 If continuation sheet Page 2 of 3 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 09/11/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete transferring her. The aide was re-assigned from the resident. Additional transfer training to take place. An interview was conducted on 09/11/25 at 9:25 AM, with the Infection Preventionist, who was also the MOD (Manager on Duty) the weekend of the reported incident. The nurse stated that the Morning CNA reported to her regarding the incident, which is documented on the grievance, and so she contacted the Executive Director/Administrator. At this time, she does not remember about any injury to the resident. However, she did recall that the resident was insistent on the aide no longer working with her and was also willing to change rooms, if necessary to prevent the aide from working with her again. A telephone interview was conducted on 09/11/25 at 9:39 AM with the Certified Nursing Assistant (CNA), Staff A. She confirmed she was the CNA that reported the incident to the MOD on 02/23/25. As she recalls, Resident #1 wanted to get up and when she went to get her up, she remembered seeing bruises on her arms. She is not 100 % sure of the extent of the bruises at this time. She stated she asked the resident what happened, and the resident reported that something happened the night before with a shower or with the caregiver from the night before. She confirmed she noticed the bruises and knew they were new because she works with the resident five days a week. She stated she just reported the incident, but she doesn't recall giving a statement regarding the incident. She doesn't remember if it was the resident or daughter, who requested that the aide no longer worked with her, but remembers that one of them requested that the aide no longer care for the resident. An interview was conducted on 09/11/15 at 11:17 AM with the Licensed Practical Nurse, Staff B, who was the morning nurse on the date the incident was reported. She stated she did not think she was the nurse that the CNA reported the incident to but what she remembers is that the resident reported that the aide grabbed her rough during the transfer. She also recalled that the resident did not want that aide anymore. She thinks the resident may have had some skin issues, but she doesn't remember. The MOD then took over and reported the incident to the ED. The surveyor asked about bruises, she then stated she didn't remember and stated, let me check the record. The surveyor stated there was no assessment to identify what was observed on the resident regarding the bruises. She then stated usually, we will complete an incident report on the shift it occurred. She also thinks it may have been reported at night as well. There is no evidence that the facility followed their policy and procedure regarding Incident and Reportable Event Management concerning Resident # 1 and the incident which occurred with her. Event ID: Facility ID: 106012 If continuation sheet Page 3 of 3