Inspection·August 6, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Communities of Florida, Health Center Admissions Comprehensive Form Acknowledgments (Revised 3/2024), Page 5 read: A log will be maintained of all complaints and grievances showing progression of resolution. On 08/06/2025 at 12:25 PM, an interview was conducted with the Administrator, who explained the grievance process and stated their facility had a unique situation as the community was extremely small, allowing staff the opportunity to quickly resolve issues brought up to the resident or the resident's family's satisfaction. She said the issues were received and resolved verbally and then asked what the definition of a grievance was. A review of the facility's policy and procedure titled Resident and Family Grievances (revised 5/2025) revealed: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Definitions: Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and activity working toward resolution of that complaint/grievance. 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; issuing written grievance decisions to the resident. 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than three years from the issuance of the grievance decision. (Copy Obtained) 2. On 08/04/2025 at 1:03 PM, an interview was conducted with Resident #7, who reported her wheelchair didn't fit her well. She stated she told her Certified Nursing Assistant (CNA) and her nurse that she wasn't comfortable in her wheelchair. A record review for Resident #7 revealed she was admitted to the facility on [DATE]. Her medical diagnoses included unspecified abnormalities of gait and mobility, muscle weakness (generalized), nonexudative age-related macular degeneration, bilateral, stage unspecified, age-related osteoporosis without current pathological fracture, and unspecified osteoarthritis. A review of the most recent Comprehensive Minimum Data Set (MDS) assessment, dated 06/23/2025, revealed that the resident had a BIMS score of 15 out of 15 possible points, indicating intact cognition. No hallucinations, delusions, or behaviors were noted. On 08/06/2025 at 10:56 AM, an interview was conducted with Certified Nursing Assistant (CNA) E who stated she had worked at the facility for approximately 20 years. She confirmed being familiar with Resident #7 but could not recall whether or not the resident ever complained about her wheelchair. On 08/06/2025 at 11:06 AM, an interview was conducted with Licensed Practical Nurse (LPN) B who reported she had worked at the facility for a little over two years. She confirmed being familiar with Resident #7 and was aware that she had complained about her wheelchair to the therapy department approximately three to four weeks ago. On 08/06/2025 at 11:14 AM, an interview was conducted with the Therapy Program Director, who reported she had worked for the facility in her role for 4 1/2 years. She confirmed that Resident #7 was on her case load and the first time she received a complaint about her wheelchair was earlier this year in January. She explained the process when a complaint was received; they notified Social Services, who oversaw grievances and the grievance process. When asked if she reported the complaint about the wheelchair to Social Services, she confirmed she did not report it to Social Services. A review of the facility's Grievance Log for the period of July 2024 - July 2025 revealed no recorded grievances for Resident #7 alleging that she was uncomfortable with her wheelchair. Further, the facility had no reported grievances to review during this period of time. A review of the facility's admission Packet titled Westminster Communities of Florida, Health Center Admissions Comprehensive Form Acknowledgments (Revised 3/2024), Page 5 read: A log will be maintained of all complaints and grievances showing progression of resolution. A review of the facility's policy and procedure titled Resident and Family Grievances (revised 5/2025) revealed: It is the policy of this facility to support each resident's and family member's right to voice grievances without (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106040 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 106040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster St Augustine 230 Towerview Drive Saint Augustine, FL 32092 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete discrimination, reprisal or fear of discrimination or reprisal. Definitions: Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and activity working toward resolution of that complaint/grievance. 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; issuing written grievance decisions to the resident . 8. Grievances may be voiced in the following forum: a. Verbal complaint to a staff member or Grievance Official . 10. Procedure: b. The staff receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. (Copy Obtained) Event ID: Facility ID: 106040 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 106040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster St Augustine 230 Towerview Drive Saint Augustine, FL 32092 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 Based on observation, interview and record review, facility staff failed to 1) Properly perform hand hygiene between disposable glove changes for one (Resident #1) of six residents observed during medication administration, and 2) Ensure to don the proper personal protective equipment for accessing a Peripherally Inserted Central Catheter (PICC) line for one (Resident #1) of one resident with a PICC line.The findings include: During an observation on 08/05/2025 at 11:10 AM, Licensed Practical Nurse (LPN) A completed Resident #1's blood glucose monitoring and removed the gloves from both hands. LPN A disposed of the used gloves and donned a new pair of gloves without performing hand hygiene in between. During continued observation on 08/05/2025 at 11:10 AM, LPN A flushed Resident #1's PICC line wearing gloves only. Resident #1 had a sign posted outside of his room door advising of Enhanced Barrier Precautions and that a gown and gloves were to be utilized when accessing an internal dwelling device. During an interview on 08/05/2025 at 11:20 AM, LPN A stated, I forgot to wash my hands. After prompting, LPN A stated, I'm supposed to wear a gown when I deal with his (Resident #1's) PICC line. During an interview on 08/06/2025 at 9:00 AM, the Director of Nursing (DON) stated, I expect them to perform hand hygiene in between glove changes. I also expect them to wear a gown and gloves and observe Enhanced Barrier Precautions for any resident with a PICC line. A review of Resident #1's active physician's orders dated 07/11/2025 revealed, Enhanced Barrier Precautions-staff to wear gloves and gown while performing high-contact care activities. Further review of Resident #1's active physician's orders dated 7/11/2025 revealed, Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) Use 10 ml [milliliters] intravenously every shift for maintenance. A review of the facility's policy titled Enhanced Barrier Precautions (reviewed January 16, 2025), revealed, Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multi-drug resistant organism] as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices). Policy Explanation 4. Showed to read High-Contact resident care activities include g. device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. A review of the facility's policy titled Hand Hygiene (reviewed January 16, 2025), revealed, Policy Explanation and Compliance Guidelines: 6.a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106040 If continuation sheet Page 4 of 4