Inspection·May 27, 2021

F 0679 Provide activities to meet all resident's needs. 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 individualized activities to meet the interest and needs for 1 of 2 residents reviewed for activities of a total sample of 46 residents, (#80). Residents Affected - Few Findings: Resident #80 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and generalized weakness. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 8 which indicated moderate cognitive impairment. Section F of the assessment Preferences for Customary Routine and Activities indicated it was very important for her to listen to music and to do her favorite activities. It was not very important to her to do things with groups of people or go outside to get fresh air when the weather was good. Resident #80 required extensive assistance from 2 staff for bed mobility and transfers and did not walk during the lookback period. She had unsteady balance, was only able to stabilize with assistance from staff and used a wheelchair for mobility. Review of resident #80's activity care plan initiated on 7/07/2020 revealed she had little to no involvement due to physical limitations. The goal was for the resident to express satisfaction with the type of activities and level of activity involvement. Interventions included explaining the importance of social interactions and encourage her to participate. The care plan directed staff to escort resident #80 to activity functions and provide room visits if she declined to attend small group activities. On 5/24/21 at 10:36 AM, resident #80 was lying in bed in a private room, staring through the window. The room was silent and there was no television or radio noted. She was alert, responded to her name only, but was not able to respond to simple questions or participate in conversation. There was a sign at the door indicating resident #80 was on contact isolation precautions. On 5/25/21 at 11:51 AM, resident #80 remained in bed seated in an upright position, again staring through the window. The room was still silent. On 5/26/21 at 10:58 AM, resident #80 was sitting up in bed with her eyes closed. On 5/26/21 at approximately 5:15 PM resident #80 remained alone in her room without any activities. On 5/26/21 at 5:37 PM, the Activities Director recalled resident #80 previously resided on the facility's Memory Care Unit. The Activities Director explained the resident was currently in a private room on the other unit as she had an infection. Review of the Record of One-To-One Activities form (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 106060 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 106060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Palm Bay 175 Villa Nueva Ave Palm Bay, FL 32907 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)