Health inspection·December 22, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to maintain a safe, clean and homelike environment for 3 of 3 hallways observed. The findings included: During initial observations of the facility that included resident rooms on 12/19/22-12/20/22, the surveyors observed the following: room [ROOM NUMBER]-W: the back wall to the left of the bed had a stain running down the wall. room [ROOM NUMBER] walls/bathroom doors: has rust stains on them, bathroom floor missing tile, shower drain has green residue caked on drain. room [ROOM NUMBER]-D: the resident's over-the-bed table was missing laminate on the corner of the table, the drain in bathroom was not secure, and air conditioner was caked with dirt in the vent. room [ROOM NUMBER]-W: the bathroom had multiple rust spots on the walls and door, the metal wall frame in bathroom was rusted. The walls and ceilings had a darker paint color with dark spots coming through the paint (ark mold-like), the bathroom door had scuffed marks, and doorknob did not function properly. room [ROOM NUMBER]: the molding on floor of the doorway was lifting up. room [ROOM NUMBER]-D: the back wall by the air conditioner had paint peeling along the base of wall and the walls were scuffed up. room [ROOM NUMBER]-W: large block of concrete were missing from the back wall by the air conditioner. room [ROOM NUMBER]-W: the wall was damaged along the baseboard under the TV, as well as the bottom of entry door, the bathroom was discolored in a dark gray color (dark mold-like), and the metal frame in bathroom was all rusted. room [ROOM NUMBER]: the rubber lining at doorway was lifting up. room [ROOM NUMBER]-W: the wheelchair was torn on the left arm padding and cracked on right arm padding. room [ROOM NUMBER]-P: there is a bed pan with dried urine in it and the floor of the shower was wet along the caulking of the shower. A private aide for this resident stated that there wass urine on the floor in the shower that had been there since he was admitted , he does not use the shower or the bathroom, he has a catheter. She then stated there was a bed pan in bathroom as well with what looks like urine in it, that she stated is not his. She stated that the resident's bed moves everytime they work on him (give care). The resident's bed rolls, and has only one lock on the left bottom of bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 2 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER]-D: the resident's chair rail behind the bed was missing; there was a sugar packet with debris behind the bed; and the resident stated that it had been there a while. room [ROOM NUMBER]: initially no resident in room until 12/21/22; the sink was dripping, clothes were located in closet that belonged to another resident in another room, the drain in shower was not secure and had missing screws, the shower head was hanging down against wall, the rubber piece at doorway was lifting up, and the table tray was all rusty. The bathroom frame had caulking peeling away from the frame. room [ROOM NUMBER]: the room had no residents but had 'used' urinals observed in bathroom, there was no mattress on bed and the bed controls were lying on floor. The laminate was pulling away from door and the side table. The hallway ceiling lights were blinking on all three hallways. There were four lights blinking on the East Wing, one blinking on the [NAME] Wing and three blinking on the North Wing. East hallway: the metal plate was lifting up. On 12/19/22 at 9:30 AM, the Housekeeping / Environmental Service person was asked if rooms [ROOM NUMBERS] were clean and ready for a new admit, he stated they were clean. A tour was completed on 12/21/22 at 2:50 PM with Maintenance Director who acknowledged the findings. He said 'the lights blinking, I am aware of the lights but when I change one out then another light will start to blink.' He then stated that they called an electrician. A secondary tour was completed on 12/22/22 at 9:40 AM with the Housekeeping / Environmental Services person, Maintenance, the Administrator and Regional Director of Environmental Services, who acknowledged the findings. During an interview on 12/22/22 at 1:15 PM with Staff A, Certified Nursing Assistant (CNA), she was asked who she told that the bed moved and did not lock? She stated, I told a nurse and a CNA I think'. She stated that the wheel got stuck under the bed. She did not put it in the Tells System. An interview with the Administrator and the Director Of Nursing on 12/22/22 at 2:00 PM, when asked to provide a policy on the process of notifying maintenance for work to be completed, they both stated that there is not a policy on this, that all staff are responsible for putting requests in the Tells system, even the aides, and they are aware of this because we discuss it at staff meetings. During an interview on 12/22/22 at 2:46 PM with Staff B, CNA, Staff B said she 'did notice the resident's bed moved, even when it is locked. The first time was this past weekend. I think I told the nurse or CNA on the hall. I did not put it in Tells System, I should have but didn't.' FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 3 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0687 Provide appropriate foot care. 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 ensure continued podiatry services for 1 of 1 sampled resident (Resident #34). Residents Affected - Few The findings included: During an interview and observation on 12/19/22 at 10:40 AM, the toenails of Resident #34 were noted to be elongated, extending approximately half a centimeter past the end of his toes, and thickened. When asked if he was a diabetic, Resident #34 stated he was not. When asked if the staff cut his toenails, Resident #34 stated they did not and that a podiatrist cut them in the past. Review of the record revealed Resident #34 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS lacked any documented instances of the rejection of care, and revealed the resident needed the limited assistance of one person for personal hygiene. Further review of the record revealed a podiatry visit dated 04/19/22. This progress note documented the resident's toenails at that time were thickened, yellowed, and causing pain. This note also documented, Care of this patient by a non-skilled professional may be hazardous to the patient's health. Patient meets systemic diagnostic requirements, confirmed by the attending PCP (personal care physician), for routine foot care to prevent risks when performed by a nonprofessional. I have recommended foot care on a periodic 10-12 week basis ongoing. This would indicate Resident #34 would have needed additional podiatry services by 07/12/22. Review of the current and discontinued orders and social service notes from April 2022 lacked any mention of podiatry services. During an interview on 12/22/22 at 9:00 AM, the Social Services Director (SSD) explained she started at the facility on 10/31/22. The SSD was made aware of the 04/19/22 podiatry progress note and stated she would add Resident #34 to the podiatry list. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 4 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure continued range of motion (ROM) services for 1 of 1 sample resident (Resident #3). The findings included: During an interview on 12/19/22 at 1:49 PM, the adult family member of Resident #3 voiced concern that the facility was no longer providing range of motion services to the resident. When asked if she knows why the services were not being provided, the family member stated she was unsure. Review of the record revealed Resident #3 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #3 had functional limited range of motion to all four extremities. This MDS also documented the resident was not receiving therapy, restorative, or range of motion services. Review of the current orders lacked any orders for range of motion or restorative services. Review of the discontinued order dated 07/08/21 documented, Resident graduated from program will reevaluate in 1 month under the discontinued note in the order as of 11/02/21. Further review of the orders revealed Resident #3 had been receiving range of motion services via their restorative program since at least 12/16/20. Review of the current care plan initiated 09/03/20 and revised on 05/20/21 documented Resident #3 had limited physical mobility and ADL (activities of daily living) deficits related to multiple comorbidities including traumatic brain injury and contractures. One of the interventions was for staff to place rolled washcloths in both hands. During an interview on 12/21/22 at 2:24 PM, Staff H, Restorative Certified Nursing Assistant (CNA) confirmed she provides range of motion services to residents for maintenance. When asked about Resident #3, Staff H confirmed she had seen her in the past for ROM services, but was unsure why she was not currently seeing the resident. During an interview on 12/21/22 at 3:06 PM, the Director of Rehab (DOR) services confirmed they do quarterly therapy screens for the long-term residents. When asked about Resident #3 in regard to range of motion, the DOR stated he thought the resident was still on restorative services for ROM. During an interview on 12/21/22 at 3:07 PM, the Restorative Nurse stated she was not here in November 2021 when the restorative services were discontinued for Resident #3. The Restorative Nurse was unsure if Resident #3 was reevaluated in one month as per the discontinued order, or the reason why the resident was no longer on restorative services. During a subsequent interview and observation on 12/21/22 at 4:27 PM, the Restorative Nurse stated they were unable to locate the one-month reevaluations. The DOR joined the interview, again confirming he thought Resident #3 was on the restorative services, and confirmed the documented intervention for the towel palm rolls. Upon observation of Resident #3 at that time, the hand rolls were not in place. The DOR suggested reestablishing ROM services for Resident #3 to maintain her current level of mobility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 5 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 and interview, the facility failed to ensure a safe transfer for 1 of 1 sampled resident, Resident #215, reviewed for falls, as evidenced by the facility's process/policy requiring 2-person assistance for all Hoyer transfers not being followed by Certified Nursing Assistants (CNA). The findings included: Review of Policy, titled, Safe Resident Handling/Transfers, dated 11/20 with a revised review date of 01/22, documented all residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. Under compliance guidelines #10, it documented two staff members must be utilized when transferring residents with a mechanical lift. Review of Resident #215's medical records documented the resident was admitted to the facility on [DATE] with diagnoses to include Pathological Fracture Left Femur, Displaced Fracture of Base of Neck of Left Femur, History of Falling, Type II Diabetes with Diabetic Neuropathy, Heart Failure, Hypertension, Anxiety, Seizures, Dementia, and Major Depressive Disorder. Review of the resident's MDS (Minimum Data Set) Admission/Medicare 5 day, dated 05/12/22, documented the resident has a BIMS (Brief Interview for Mental Status) of 8, indicating his cognition is mildly impaired. For transfers, it was documented he is totally dependent on 2-person, extensive assistance of 2-person for Bed Mobility, Dressing, Toileting, and Personal Hygiene. Review of the resident's Care Plans documented he is at risk for falls. Further review of Progress Notes, dated 12/14/22 at 3:24 PM by Staff K, LPN (Licensed Practical Nurse), documented: the aide [CNA] notified me [LPN] that a patient was on the floor. Resident assessed for injuries. Resident denied hitting his head. Gash found on left lower extremity. Physician notified and orders given to send patient to ER [Emergency Room]. Resident's injury cleaned and covered before ER transfer. Review of the fall investigation documented on 12/14/22 11:00 AM, the resident fell out of Hoyer lift machine during transfer while being assisted in transfer; 1:1 education completed with CNA regarding Hoyer safety. Staff A, CNA, received a written warning on using a mechanical lift alone without assistance. The policy of the company is that mechanical lifts require 2-person assistance for safety. During an interview on 12/19/22 at 12:51 PM, Resident #215's spouse and private aide stated they dropped him [the resident] using the Hoyer lift and he had a gash on his leg, which required 14 external stitches and some on inside. During an interview on 12/21/22 at 10:15 AM with Staff K, LPN, she stated: 'I was called in the room by an aide who told me that she heard the resident fall; (Staff B), I went into room he was lying on floor, he had gash on left side of shin. There was an aide in there, the Hoyer lift was in the room. She said she was transferring him, it started to tip over and he was on the ground on top of Hoyer Pad. I called 911.' She was asked how he is supposed to be transferred and stated, he is a Hoyer lift for transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 6 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 During an interview on 12/21/22 at 1:05 PM with Staff L, CNA, revealed, 'I was assisting another resident and when I came out of the room I heard a loud boom and then heard a CNA call for help, she was in room [XX]. The Hoyer lift and the resident were by the door, she was trying to lift him and I told her to take the hooks out of the Hoyer so we can lift the Hoyer up. I went and got the nurse. There was blood on the floor. When we do a Hoyer we use 2 people she only used herself no one else.' Residents Affected - Few During an interview on 12/21/22 at 1:10 PM with Staff A, CNA, stated I was supposed to use two-person for the Hoyer but there was no one else to help me. I got him dressed and put the Hoyer pad under him, he was lifted up and the chair underneath him, one of the wheels was stuck under the bed and it tilted over. She said the bed moved because it does not lock. I now know not to do it by myself. I have been here since [DATE]. They did retraining with me, they were pretty strict with me about using two people but I now know why. I had him the other day and did a two person transfer but really need three. During an interview on 12/21/22 at 1:17 PM with the Rehabilitation (Rehab) Director, he was asked how Resident#215 was supposed to be transferred. He stated, by a Hoyer lift, we have determined he is a Hoyer lift but for therapy purposes he is transferred by two persons standing up. He is toe-touch for weight bearing on left lower extremity, that is the side he had the fracture. During an interview on 12/22/22 at 2:46 PM with Staff B, CNA, Staff B stated, [Resident #215] 'will try his hardest to help but he is a 2-person assist to get him up in chair, 2-people for pivot, and the family is uncomfortable with Hoyer so we try not to use it. I did notice his bed moving, even when it is locked it moved. The first time was this past weekend. I think I told the nurse or CNA on hallway. I did not put it in Tells [communication system for maintenance], I should have but didn't. He is a 2-person for everything.' FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 7 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on personnel file review, interview, and policy review, the facility failed to complete a performance review of nurse aides at least once every 12 months for 3 of 3 sampled nurse aides (Staff H, I, and J). Residents Affected - Many The findings included: Review of the policy, titled, Required Training, Certification and continuing Education for Nurse Aides, revised 07/25/22, documented, 6. In-service training will be provided by qualified personnel and will be based on the needs of the residents in the facility and any areas of weakness as determined in the nurse aide's performance reviews and facility assessment. During a side-by-side review of personnel files on 12/22/22 at 3:23 PM, the Business of Manager / Human Resources Director was asked the facility's practice regarding performance evaluations. The Human Resources Director explained that each department head should be doing annual evaluations around their anniversary date of hire. The Human Resources Director was asked to locate and provide the most current performance evaluation for Staff H, Restorative Certified Nursing Assistant (CNA) who was hired on 09/07/20; Staff I, CNA, who was hired on 04/25/12; and Staff J, CNA, who was hired on 05/21/12. The Human Resources Director looked through the three personnel files and could not locate any current performance evaluations. The most recent performance evaluation located was from 2020. During an interview on 12/22/22 at 3:42 PM, the Director of Nursing (DON), who had been at the facility as DON for at least two years, confirmed she was responsible for the annual performance evaluations for the nursing staff, including the nurse aides, on or about their anniversary date. The DON volunteered they had recently initiated a new form, but she had not used it yet. The DON agreed the evaluations had not been completed for the three sampled staff, and that she had not done any of the nurse aide annual evaluations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 8 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #36 was admitted to the facility with diagnoses which included a history of Venous Thrombosis, Embolism and Hypertension. Residents Affected - Few The following psychotropic medications were prescribed by the Primary Care Physician (PCP): a) Xarelto 10 MG Tablet Give 1 tablet by mouth in the evening for clot prevention. An annual Minimum Data Set (MDS), dated [DATE], documented Resident #36 has a Brief Interview For Mental Status (BIMS) score of 15, indicating cognitively was intact. A Care Plan was initiated on 12/05/20, and last revised on 12/01/22, for history of deep vein thrombosis. Interventions included providing medication as ordered and monitoring / documenting side effects and effectiveness. Review of Resident #36's November 2022 electronic Medication Administration Record (eMAR) showed orders related to observation on each shift for side effects monitoring related to anticoagulant use: discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, or nose bleeds. For the month of November 2022, there was no documentation of any observations being done for the evening shifts on 11/01/22 - 11/06/22, 11/08/22 - 11/09/22, 11/12/22-11/13/22, 11/15/22 - 11/16/22, 11/18/22, and 11/20/22. Staff were not utilizing Y [Yes] or N [No] for results of observations on Day shift, instead they are placing an X or na for 11/01/22 -11/02/22, 11/05/22 - 11/09/22, and 11/12/22 - 11/20/22. Staff were not utilizing Y or N for results of observations on the Night shifts, instead they are placing an X or na, for 11/01/22 -11/06/22, 11/08/22 - 11/10/22, 11/12/22 - 11/13/22, and 11/15/22 - 11/19/22. 3. Review of Resident #47's medical records revealed Resident#47 was admitted to the facility on [DATE] with diagnoses to include Unspecified Dementia with Behavioral Disturbances, Major Depressive Disorder, and Anxiety Disorder. Review of the Physician's Orders documented the resident is on Levothyroxine Sodium Tablet 50 MCG Give 1 tablet by mouth in the morning for hypothyroidism; and Pantoprazole Sodium Tablet Delayed Release 40 MG Give 1 tablet by mouth in the morning for GERD (Gastroesophagel Reflux Disease). Review of Resident #47's MAR for November 2022 and December 2022 revealed on the following days, the MAR was left blank with no documentation that the medication was given / administered: a. Levothyroxine Sodium tab 50 MCG 1 tab PO in am for Hypothyroidism 11/08/22, 11/11/22, 11/12/22, 11/16/22 and 11/27/22. b. Pantoprazole Sodium tab 11/08/22, 11/11/22, 11/12/22, 11/16/22 and 11/27/22 and 11/30/22 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 9 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0757 12/03/22. Level of Harm - Minimal harm or potential for actual harm 4. Review of Resident #215's medical records documented the resident was admitted to the facility on [DATE] with diagnoses to include Pathological Fracture Left Femur, Displaced Fracture of Base of Neck of Left Femur, History of Falling, Type II Diabetes with Diabetic Neuropathy, Heart Failure, Hypertension, Anxiety, Seizures, Unspecified Dementia with other Behavioral Disturbances, and Major Depressive Disorder. Residents Affected - Few Review of the resident's MDS (Minimum Data Set) admission / Medicare 5-day, dated 05/12/22, documented a BIMS score of 8, indicating cognition was mildly impaired. Review of Resident #215's physician orders documented the resident is on the following medications: a. Insulin Lispro (1 Unit Dial) 100 UNIT ML Solution pen-injector Inject as per sliding scale, subcutaneously before meals and at bedtime for Diabetes Mellitus. Blood sugar greater than 400 or less than 65, contact MD (medical doctor) for new orders start date 12/13/22: if 151 - 200 = 3; 201 - 250 = 5; 251 - 300 = 7; 301 - 350 = 9; 351 - 400 = 14. b. Insulin Lispro (1 Unit Dial) 100 UNIT ML Solution pen-injector Inject 18 unit subcutaneously in the morning for Diabetes Mellitus 09:00 AM, Start Date 12/12/22. c. Insulin Lispro (1 Unit Dial) 100 UNIT\/ML Solution pen-injector Inject 25 unit subcutaneously in the afternoon for Diabetes Mellitus 1:00 PM start date 12/12/22. d. Insulin Lispro (1 Unit Dial) 100 UNIT ML Solution pen-injector Inject 20 unit subcutaneously in the evening for Diabetes Mellitus 5:00 PM Start date 12/11/22. e. Insulin Glargine 100 UNIT/ML Solution pen-injector Inject 35 unit subcutaneously at bedtime for Diabetes Mellitus 10:00 PM Start Date 12/16/2022. f. Midodrine HCl Tablet 10 MG Give 1 tablet by mouth two times a day for hypotension do not administer if SBP > 140: DBP > 90. Start Date 12/12/22. Review of Resident #215's MAR revealed, on the following days, the physician orders were not followed by contacting the physician when the blood sugar was greater than 400 or less than 60. There was no evidence in the progress notes the physician was notified as well as the insulin not given as ordered: aa. On 12/15/22 at 11:30 AM, the blood sugar (BS) was 464 (progress note documented BS 504 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 10 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10:08); Documented in progress note that 18 unit was injected subcutaneously in the morning for Diabetes Mellitus, that the blood sugar was 504, does not document that the physician was notified for blood sugar being out of parameters. bb. On 12/16/22 at 4:30 PM, documented 'N/A 5', which meant hold/see progress notes. There was not a blood sugar documented for this time and why it was not given. cc. On 12/17/22 at 6:30 AM, Blood Sugar 444; was documented '10' indicating vitals / blood sugar out of parameter. Does not document that the physician was notified. dd. On 12/17/22 at 5:00 PM, documented in progress note that the blood sugar was 134 and was out of parameters and therefore the order for Insulin Lispro (1 Unit Dial) 100 UNIT ML Solution pen-injector Inject 20 unit subcutaneously in the evening for Diabetes Mellitus was not given. No sliding scale should be given but the evening dose did not have a hold for blood sugar amount. The dose was not given and therefore did not follow physician's order. ee. On 12/18/22 at the 5:00 PM dose, documented code #10, which indicated the blood sugar was out of the parameters at 121. No sliding scale should be given but the evening dose did not have a hold for blood sugar amount. The dose was not given and therefore did not follow physician's order. ff. On 12/20/22 at the 5:00 PM dose, documented code #10, which indicated the blood sugar was out of the parameters. No sliding scale should be given but the evening dose did not have a hold for blood sugar amount. The dose was not given and therefore did not follow physician's order. gg. On 12/20/22 at 10:00 PM, Insulin Glargine 100 UNIT/ML Solution pen-injector Inject 35 unit subcutaneously at bedtime for Diabetes Mellitus; Documented code#10, which indicated the blood sugar was out of the parameters. No sliding scale should be given but the evening dose did not have a hold for blood sugar amount. The dose was not given and therefore did not follow physician's order. g. On 12/12/22, an order for Entresto tab 24-26 mg give 1 tab by mouth in AM for Hypertension, hold if systolic blood pressure is under 100 or diastolic blood pressure is under 60, start date 12/12/22. Review of the MAR documented a code of #9 indicating 'other/see progress note'. There is no note, or a B/P (blood pressure) documented. h. On 12/12/22, an order for Midodrine HCL tab 10mg give 1 tab twice a day for hypotension, do not administer if Systolic blood pressure is over 140 or diastolic blood pressure is over 90: aaa. Documented on 12/12/22 at the 9:00 AM dose the code #10, vitals outside parameters, but does not document what the blood pressure was. At 5:00 PM, the B/P was 148/82 and documented that it was given even though the physician order documented to hold if systolic blood pressure is over 140. bbb. On 12/14/22 at 5:00 PM, the B/P was 148/86 and documented that it was given even though the physician order documented to hold if systolic blood pressure is over 140. ccc. On 12/18/22 at 5:00 PM, the B/P was 144/54 and documented that it was given even though the physician order documented to hold if systolic blood pressure is over 140. ddd. On 12/19/22 at 5:00 PM, the B/P was 142/72 and documented that it was given even though the physician order documented to hold if systolic blood pressure is over 140. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 11 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0757 On 12/21/22, the B/P was 145/76 and documented it was given. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/21/22 at 10:24 AM with the DON (Director of Nursing), the MARS were reviewed. The DON acknowledged the MARS are not filled out completely with holes, medication given when not supposed to be when out of parameters, and could not find documentation under progress notes that the physician was ever notified when Insulin was out of the parameters. Residents Affected - Few During a telephone interview with Resident #215's physician, with the DON sitting in on conversation, on 12/21/22 at 10:58 AM, he stated that the resident is a super brittle diabetic with regiment of his BS's spiking above 200-400. He is supposed to get coverage if he spikes. He is on basal insulin as well. He stated that he is supposed to get the ordered dose 4 times a day and then on top of the order dose, he is supposed to get the sliding scale insulin if he falls within the parameters. He stated he cannot recall if he ever was contacted for when his insulin was outside the parameters. Based on record review, policy review and interview, the facility failed to ensure monitoring of medications related to following physician ordered parameters and medication administration for 3 of 5 sampled residents (Residents #47, #215 and #25). The findings included: The facility policy, titled, Medication Administration and revised 02/09/22, documented in part: Administer medication as ordered in accordance with manufacturers specifications Observe residents' consumption of medication Sign medication administration record after administration For medications requiring vital signs, record vital signs onto the MAR (Medication Administration Record). 1. Resident #25's orders were reviewed. The resident's medication, Eszopiclone 2mg, was ordered on 11/16/22 and was to be given as 1 tablet at bedtime for insomnia. Review of the resident's MAR revealed no documentation for administration of the medication on 12/01/22, 12/03/22, 12/06/22, 12/07/22 and 12/08/22. No documentation was found to indicate why medication was not administered. The orders were reviewed for Resident #25's medication, Zosyn Solution Reconstituted 3.375 (3-0.375) GM. The medication was to be given intravenously (IV) every 6 hours for wound infection. The order was started on 11/17/22 and was to continue until 12/27/22. The times for the medication to be administered were at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. On 12/12/22, the 6:00 AM dose was not documented on the MAR to indicate it was given. Review of the record revealed no explanation for the missing administrated dose of the antibiotic. The medication, Omeprazole 20mg, was ordered on 11/18/22., and two capsules were to be given in the morning for Resident #25's reflux. Review of the MAR revealed no documentation the medication was given at 6:30 AM on 12/12/22. The medication, Ipratropium Albuterol Solution 0.5-2.5 MG/3ML (3 ml inhale orally via nebulizer every 4 hours), for COPD) (Chronic Obstructive Pulmonary Disease). The medication was ordered to start (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 12 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0757 Level of Harm - Minimal harm or potential for actual harm on 11/16/22. The medication was scheduled to be given at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. Review of the MAR revealed the medication was not documented as given on 12/12/22 at 4:00 AM. No documentation was found for why the medication not being administered for Resident #25. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 13 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure documentation of behavior monitoring and monitoring of side effects for psychotropic medications 3 of 5 sampled residents (Residents #47, #215, and #36). The findings included: 1. Resident #36 was admitted to the facility with diagnoses which include Anxiety, Depressive Disorder, and Bipolar Disorder. The following psychotropic medications were prescribed by Primary Care Physician: a) Venlafaxine HCl ER Tablet Extended Release 24 Hour 150 MG Give 2 tablet by mouth one time a day related to Major Depressive Disorder. b) Trazodone HCl Tablet 100 MG Give 2.5 tablet by mouth at bedtime related to Major Depressive Disorder c) Lamictal Tablet 200 MG Give 1 tablet by mouth in the morning for mood disorder The Annual MDS, dated [DATE], documented Resident #36 had a BIMS of 15, indicating intact cognition. A Care Plan was initiated on 12/18/20, and last revised on 12/02/22, for psychotropic drug use related to diagnosis of Depression and Bipolar Disorder. Interventions included monitoring for side effects and consulting with physician and pharmacist as needed. A Care Plan was initiated on 09/20/21, and last revised on 12/01/22, for behaviors related to toileting issues, refusing to wear TED hose, having monthly weight, refusing care, getting out of bed without assistance, refusing medications and incontinence care. Review of Resident #36's electronic Medication Administration Record (eMAR) showed orders related to Antidepressant medication to observe for behaviors of sadness and crying. Instructions stated to document Y if resident has behaviors and N if the resident does not have behaviors. If Y, document in the PNs [Progress Notes] every shift. For the month of November 2022, there was no documentation of any observations being done for the evening shift on 11/01/22 - 11/06/22, 11/08/22 - 11/09/22, 11/12/22-11/13/22, 11/15/22 - 11/16/22, 11/18/22, and 11/20/22. Staff are not utilizing Y [Yes] or N [No] for results of observations on Day shift, instead they are placing an X or na [non-applicable] for 11/01/22 -11/02/22, and 11/05/22 - 11/20/22. Staff are not utilizing Y or N for results of observations on Night shift, instead they are placing an X or na, for 11/01/22 -11/06/22, 11/08/22 - 11/10/22, 11/12/22 - 11/13/22, and 11/15/22 - 11/19/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 14 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #36's electronic Medication Administration Record (eMAR) showed orders related to Mood Stabilization medication to observe for behaviors of frequent mood swings, refusals of care, anger outbursts, tearfulness. Instructions stated to document Y if resident has behaviors and N if the resident does not have behaviors. If Y, document in the PNs [Progress Notes] every shift. For the month of November 2022, there is no documentation of any observation being done for the evening shift on 11/01/22 - 11/06/22, 11/08/22 - 11/09/22, 11/12/22-11/13/22, 11/15/22 - 11/16/22, 11/18/22, and 11/20/22. Staff were not utilizing Y or N for results of observations on Day shift, instead they are placing an X or na for 11/01/22 -11/02/22, and 11/05/22 - 11/09/22, 11/12/22 - 11/20/22. Staff are not utilizing Y or N for results of observations on Night shift, instead they are placing an X or na, for 11/01/22 -11/06/22, 11/08/22 - 11/10/22, 11/12/22 - 11/13/22, and 11/15/22 - 11/19/22. Review of Resident #36's electronic Medication Administration Record (eMAR) showed orders related to observation each shift for side effects monitoring related to Akathisia-restlessness/pacing/inability to sit still/anxiousness/sleep disturbances; Tardive Dyskinesia-lip smacking/chewing/abnormal tongue movement/spasmodic movement of arms/legsrocking/swaying; Sore throat; Seizures; Photosensitivity; Suicidal ideations; Hepatic or renal abnormalities; Ataxia; Nausea /Vomiting; Diarrhea; Abdominal Discomfort; discolored urine; black tarry stools; bruising; and nose bleeds. For the month of November 2022, there is no documentation of any observation being done for the evening shift on 11/01/22 - 11/06/22, 11/08/22 - 11/09/22, 11/12/22-11/13/22, 11/15/22 - 11/16/22, 11/18/22, and 11/20/22. Staff are not utilizing Y or N for results of observations on Day shift, instead they are placing an X or na for 11/01/22 -11/02/22, and 11/05/22 - 11/09/22, 11/12/22 - 11/20/22. Staff are not utilizing Y or N for results of observations on Night shift, instead they are placing an X or na, for 11/01/22 -11/06/22, 11/08/22 - 11/10/22, 11/12/22 - 11/13/22, and 11/15/22 - 11/19/22. Review of Resident #36's electronic Medication Administration Record (eMAR) showed orders related to observation each shift for side effects monitoring related to Dystonia, torticollis (stiffness of neck); Anticholinergic symptoms: dry mouth/blurred vision, constipation/urinary retention; Hypotension; Sedation/drowsiness; Increased falls/dizziness; Cardiac abnormalities (tachycardia, bradycardia, irregular, H.R., NMS); Anxiety/agitation; Blurred Vision; Sweating/rashes; Headache; Urinary retention/hesitancy; Weakness; Hangover effect; Pseudo parkinsonism; Insomnia; and New Onset Confusion. For the month of November 2022, there is no documentation of any observation being done for the evening shift on 11/01/22 - 11/06/22, 11/08/22 - 11/09/22, 11/12/22-11/13/22, 11/15/22 - 11/16/22, 11/18/22, and 11/20/22. Staff are not utilizing Y or N for results of observations on Day shift, instead they are placing an X or na for 11/01/22 -11/02/22, and 11/05/22 - 11/09/22, 11/12/22 - 11/20/22. Staff are not utilizing Y or N for results of observations on Night shift, instead they are placing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 15 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0758 an X or na, for 11/01/22 -11/06/22, 11/08/22 - 11/10/22, 11/12/22 - 11/13/22, and 11/15/22 - 11/19/22. Level of Harm - Minimal harm or potential for actual harm Review of Resident #36's electronic Medication Administration Record (eMAR) showed orders related to observation each shift for side effects monitoring related to Antidepressant use. If observed, the following letters were to be used: Residents Affected - Few A=Sedation; B= Drowsiness; C= Dry Mouth; D= Blurred Vision; E= Urinary Retention; F= Tachycardia; G= Muscle Tremor; H= Agitation; I= Headache; J= Skin Rash; K=Photosensitivity; L= Weight Gain; NA= None. If side effects present, document in PNs and notify MD. For the month of November 2022, there is no documentation of any observation being done for the evening shift on 11/01/22 - 11/06/22, 11/08/22 - 11/09/22, 11/12/22-11/13/22, 11/15/22 - 11/16/22, 11/18/22, and 11/20/22. Staff are not utilizing NA for none on Day shift, instead they are placing an X for 11/01/22 -11/02/22, and 11/05/22 - 11/09/22, 11/12/22 - 11/20/22. Staff were not utilizing NA for none on Night shift, instead they are placing an X for 11/01/22 -11/06/22, 11/08/22 - 11/10/22, 11/12/22 - 11/13/22, and 11/15/22 - 11/19/22. Review of Resident #36's electronic Medication Administration Record (eMAR) showed orders related to observation each shift for side effects monitoring related to Mood Stabilizer use. If observed, the following letters were to be used: A=Tremors; B= Drowsiness; C=Diarrhea; D= Constipation; E=Nausea; F= Vomiting; G=Decreased Appetite; H= Dizziness; NA= None. If side effects present, document in PNs and notify MD. For the month of November 2022, there is no documentation of any observation being done for the evening shift on 11/01/22 - 11/06/22, 11/08/22 - 11/09/22, 11/12/22-11/13/22, 11/15/22 - 11/16/22, 11/18/22, and 11/20/22. Staff are not utilizing NA for none on Day shift, instead they are placing an X for 11/01/22 -11/02/22, and 11/05/22 - 11/09/22, 11/12/22 - 11/20/22. Staff were not utilizing NA for none on Night shift, instead they are placing an X for 11/01/22 -11/06/22, 11/08/22 - 11/10/22, 11/12/22 - 11/13/22, and 11/15/22 - 11/19/22. 2. Review of Resident #47 medical records revealed Resident #47 was admitted to the facility on [DATE] with a diagnoses to include Unspecified Dementia with Behavioral Disturbances, Major Depressive Disorder, and Anxiety Disorder. Review of the resident's Medicare 5-day MDS (Minimum Data Set), dated 09/26/22, documented the resident had behaviors 4-6 days having physical behavioral symptoms directed towards others; verbal behavioral symptoms directed towards others. Review of the resident's care plan documented the resident had the following behavior problem(s) of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 16 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0758 being physically aggressive, and verbally aggressive. Level of Harm - Minimal harm or potential for actual harm Review of the Physician's Orders documented the resident is on Quetiapine Fumarate Tablet 50 MG to give 100 mg by mouth at bedtime for bipolar, Quetiapine Fumarate Tablet 25 MG to give 25 mg by mouth two times a day for bipolar, Ativan Gel 0.5 mg to apply to skin topically three times a day for anxiety, to observe for behaviors of antipsychotic Medication; Observe for behavior: screaming, fighting, and hallucinations. Document: Y if resident is having behaviors and N if the resident does not have behaviors. If Y document in the Progress Notes. every shift. Observe for behaviors of antianxiety medication; withdrawn, crying, and agitation. Document Y if resident has behaviors and N if the resident does not have behaviors. If Y document in the Progress Notes. every shift. Document side effects of Antipsychotic Medication: Indicate letter if observed: A= Sedation; B= Drowsiness; C= Dry Mouth; D= Constipation; E= Blurred Vision; F= EPS; G= Wt. Gain; H= Edema; I= Postural Hypotension; J= Sweating; K= Loss of Appetite; L= Urinary Retention; NA= None. If side effects present, document in Progress Notes and notify MD. every shift. Document side effects of Antianxiety medication: Indicate letter if observed: A= Sedation; B= Drowsiness; C= Ataxia (Drunk Walk); D= Dizziness; E= Nausea; F=Vomiting; G= Confusion; H= Headache; I= Blurred Vision; J= Skin Rash; NA= None. If side effects present, document in PNs and notify MD. every shift. Residents Affected - Few Review of the Resident #47's MAR (Medication Administration Record) for Behaviors and side effects revealed on the following days, the MAR was left blank with no documentation: Side effects of Antipsychotics: day shift 12/10/22. Evening shift: 11/15/22, 12/01/22, 12/03/22, 12/05/22, 12/06/22, 12/07/22, 12/08/22 12/12/2212/16/22, 12/19/22. Night shift 12/04/22. Side Effects for Antianxiety: evening shift:12/16/22, 12/19/22. Observation of behaviors for Antipsychotic Medication: Evening 11/15, 12/16/22 and 12/19/22. Observation of behaviors for Antianxiety Medications: Evening 12/16/22 and 12/19/22. 3. Review of Resident #215's medical records documented the resident was admitted to the facility on [DATE] with diagnoses to include Pathological Fracture Left Femur, Displaced Fracture of Base of Neck of Left Femur, History of Falling, Type II Diabetes with Diabetic Neuropathy, Heart Failure, Hypertension, Anxiety, Seizures, Unspecified Dementia with other Behavioral Disturbances, and Major Depressive Disorder. Review of the resident's MDS (Minimum Data Set) admission / Medicare 5-day, dated 05/12/22, documented a BIMS score of 8, indicating cognition was mildly impaired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 17 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the resident's care plan documented the resident had impaired cognitive function/impaired thought processes related to Dementia with behaviors. Review of Resident #215's physician orders documented the resident is prescribed Wellbutrin XL Tablet Extended Release 24 Hour 300 MG to give 1 tablet by mouth in the morning for depression; Quetiapine Fumarate Tablet 50 MG to give 1 tablet by mouth at bedtime for mood disorder; Observe side effects of Antidepressant Medication; sadness, tearfulness, and or self-isolation. Document Y if resident has behaviors and N if the resident does not have behaviors. If Y document every shift. Observe for side effects of the Akathisia: restlessness, pacing, inability to sit still, anxiousness, sleep disturbances. Observe for side effects of Tardive dyskinesia: lip smacking, chewing, abnormal tongue movement, spasmodic movement of arms, legs-rocking, swaying; sore throat, Seizures, Photosensitivity, Suicidal ideations, Hepatic or renal abnormalities, Ataxia, Nausea and Vomiting, Diarrhea, Abdominal Discomfort, discolored urine, black tarry stools, bruising, nose bleeds every shift for medication side effect monitoring. Observe for medication side Effect: Dystonia, torticollis (stiffness of neck), Anticholinergic symptoms: dry mouth, blurred vision, constipation, urinary retention, Hypotension, Sedation, drowsiness, Increased falls, dizziness, Cardiac abnormalities (tachycardia, bradycardia, irregular, H.R, Anxiety, agitation, Blurred Vision, Sweating, rashes, Headache, Urinary retention, hesitancy, Weakness, Hangover effect, Pseudo parkinsonism, Insomnia, New Onset Confusion every shift for medication side effect monitoring. Observe for Antipsychotic Medication; Observe for delusions, hallucinations and\/or paranoia. Document 'Y if resident is having behaviors and N if the resident does not have behaviors. If Y document every shift. Review of Resident #215's MAR for Behaviors and side effects revealed on the following days, the MAR was left blank with no documentation, as follows: Observe for side Effects for Akathisia: Day shift 12/13/22, 12/16/22. Observations of side effects for Dystonia: Days shift 12/13/22, 12/16/22, Observe for antidepressant medication side effects: Day shift 12/16/22 day. During an interview on 12/22/22 at 2:50 PM with Staff B, CNA she was asked if Resident#47 had behaviors. The CNA stated, 'when I would change her and put her in the chair, she cries but once in chair she is fine. When she cries, she says momma, momma. She is confused, and I think she thinks I am her momma. Her cognition is very low. She can follow commands but will protest.' FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 18 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and policy review, the facility failed to properly secure medications for 1 of 3 medication carts (West Unit), and for 1 of 3 treatment carts (East Unit). The census at the time of the survey was 59, and the number of independently ambulatory residents was 4. The findings included: Review of the policy, titled, Medication Storage revised 05/04/22, documented, 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medications carts, .) . c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 1. A medication pass observation was made on 12/19/22 beginning at 4:04 PM, with Staff G, Licensed Practical Nurse (LPN), on the [NAME] Unit. While the LPN was gathering the medications for Resident #25, she realized one was missing. The LPN left the medication cart at the far end of the [NAME] Unit, leaving it unlocked, and went into the medication room near the nurses' station with the evening supervisor, to get the medication out of the automated medication distribution system. Staff G returned to the medication cart and obtained the rest of the medications for Resident #25. At 4:15 PM, Staff G went into the room of Resident #25, again out of sight of the medication cart, leaving the cart against the wall between two rooms, with the unlocked drawers facing out into the hallway. A visitor, Certified Nursing Assistant (CNA), and another nurse were noted in the hallway at the time. Upon return to the medication cart, Staff G did not notice the cart was unlocked. The LPN obtained a requested pain medication for Resident #25, and returned to the resident's room, again leaving the cart unlocked. Upon return to the medication cart, the LPN did not notice the cart had been left unlocked. During the continued medication pass observation on 12/19/22 at 4:19 PM, Staff G obtained medications for Resident #12. At 4:23 PM, the LPN left the medication in the same location, went into the room of Resident #12, leaving the medication cart unlocked a third time. Upon return to the medication cart on 12/19/22 at 4:26 PM, Staff G asked the surveyor how she did with the medication pass. When asked about locking the medication cart, the LPN looked at the medication cart lock, looked surprised and stated, I didn't lock my cart? And when you were coming my way, I was telling myself, I need to lock the cart. 2. On 12/21/22 at 3:08 PM, the East Unit treatment cart was noted near the front of the East Unit hallway, against the wall and unlocked. Upon opening the drawers, multiple wound care medications / ointments and dressing supplies were noted. While standing at the treatment cart, the Director of Nursing (DON) arrived and agreed with the unlocked and unattended treatment cart. The DON summoned Staff K, direct care LPN for the East Unit, who confirmed she had left it opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 19 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 policy review, the facility failed to maintain an infection control program to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 5 of 8 sampled residents. Staff nurses C, D, and F, failed to properly clean and or disinfect the glucometer (device used to obtain a resident's blood sugar level) for Residents #15, #7, and #215. Staff G and E failed to clean nebulizer equipment as per facility policy, after use by Resident #25. Staff E touched pills with her bare hands while preparing the medications for Resident #25. Staff D utilized a syringe and water container that had fallen to the floor during tube feeding administration for Resident #43. Residents Affected - Some Additionally, Staff C greeted all residents on the North Unit at the beginning of two different shifts, touching or assisting several of them, without any hand hygiene between the resident contact. The findings included: Review of the policy, titled, Blood glucose Monitoring revised 01/2022, documented, Policy Explanation: 3. The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. Procedure: 3. Perform hand hygiene and don gloves. 14. Discard the lancet in a puncture resistant sharps container. 18. Clean and disinfect the glucometer as per manufacturer's instructions. Review of the policy, titled, Nebulizer Therapy revised 11/2021, documented, Care of the Equipment 1. Clean after each use. 2. Wash hands before handling equipment. 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. Review of the policy, titled, Medication Administration revised 02/09/22, documented, 13. Remove medication from source, taking care not to touch medication with bare hand. 1a. On 12/19/22 at 3:17 PM, Staff C, Registered Nurse (RN), was standing in front of her medication cart, preparing to start evening blood sugar checks. The RN was holding her clipboard that had two zip lock bags, each containing a glucometer for a different resident (Resident #15 and #7). Taking both glucometers with her, the RN went into the room of Resident #15, placing a paper towel on the resident's over the bed table. The RN placed her clipboard directly on the resident's over-the-bed table, pulled the glucometer for Resident #15 out of the plastic bag and placed it on the paper towel, obtained the blood sugar level for the resident, scooped up the used lancet, strip and alcohol pad into her gloved hand, and removed the glove to dispose of in the trash. The RN then placed the used glucometer back into the plastic bag without any type of cleaning or disinfecting. During the process, the plastic bag with the glucometer for Resident #7 slid off the RN's clipboard and onto the paper towel, and the plastic bag for the glucometer for Resident #15 slipped directly on the resident's over-the-bed table. During the continued observation on 12/19/22 at 3:22 PM, Staff C went into the main dining room to locate Resident #7. The RN placed the container of glucometer strips directly on the table and went to find a paper towel. Upon return, the RN placed the plastic bag containing the glucometer for Resident #7 directly on the dining room table. The RN pulled out the equipment from the plastic bag and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 20 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some placed it on the paper towel. The RN took the resident's finger and started the procedure, looking up at the surveyor and asked if it was okay to do it without gloves. The surveyor simply stated it was up to her. The RN left the dining room, went out to obtain gloves, and returned to the dining room with gloves donned. The RN completed the blood sugar level, placing the used glucometer back into the plastic bag. While walking back to the cart, the RN dropped the container of glucometer strips on the floor. Upon return to the medication cart, the RN placed the two plastic bags with the resident's glucometers, and the dropped container of strips back into the top drawer of the medication cart. The RN then placed the trash to include the lancet, used strip, and alcohol pad into the garbage. During a subsequent interview on 12/21/22 at 4:00 PM, Staff C, who had just finished using a glucometer, summoned the surveyor and stated, I know I have to clean it and grabbed an alcohol pad and wiped off the glucometer, took a second alcohol pad and while trying to place it on the end of the glucometer at the strip insertion site, stated, I don't know why I am doing this but they told me to. When asked why she did not clean or disinfect the glucometer during the observation on 12/19/22, the RN stated, Because they did not tell me to do so. I was in home care for 20 plus years. I was just told to clean them. The surveyor asked the evening supervisor to show Staff C the facility's process for cleaning and disinfecting glucometers. The supervisor explained the process using the disinfectant wipes. 1b. On 12/19/22 at 3:47 PM, Staff F, LPN, stated she was ready to do a blood sugar level for Resident #215. The LPN obtained a zip lock bag from the medication cart that contained the glucometer, along with other needed supplies to include the canister of glucometer strips. The LPN entered the resident's room, placed the clear plastic bag with all the supplies directly on the resident's over-the-bed table. The LPN took a paper towel and placed the items from the bag onto the towel. The LPN obtained the blood sugar level, and placed the used glucometer and container of strips into the plastic bag. After hand washing, the LPN returned to the medication cart, placed the container of strips back into the top drawer of the medication cart, along with the plastic bag with the used glucometer. The LPN did not disinfect the glucometer. During a subsequent interview on 12/21/22 at 4:15 PM, Staff F was reminded of the observations with the glucometer, plastic bag, and container of strips from 12/19/22 and agreed with the infection control issues. 1c. On 12/21/22 at 11:40 AM, Staff D, LPN, obtained a blood sugar level from Resident #15. After the procedure, the LPN appropriately threw away all disposable items and then placed the glucometer directly on the resident's over-the-bed table to wash her hands. The LPN then took the glucometer and placed it directly on top of the medication cart. After proper disinfection of the glucometer, the LPN stated she was done and asked how she did. When informed of the observation of the used glucometer directly from resident's table to the top of the medication cart, the LPN understood the infection control concern and proceeded to wipe off the top of the medications cart with a disinfectant wipe. 2. On 12/19/22 at 4:01 PM, the surveyor arrived at the medication cart located near the room of Resident #25, who was holding her nebulizer treatment while it was running. Staff G, LPN, returned to her medication cart from a different room and informed the surveyor she had set up the resident's nebulizer and did an assessment. The LPN was prepping to do another resident's medications. At 4:03 PM, Resident #25 stopped the nebulizer and put the equipment back into the drawer. Staff G was followed until 4:26 PM, and she failed to return to Resident #25's room to clean the nebulizer equipment. On 12/19/22 at 5:04 PM, the Director of Nursing (DON) informed the surveyor she had educated Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 21 of 22 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 106075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960 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 G on the nebulizer policy. The DON was informed the LPN failed to clean the nebulizer equipment. Level of Harm - Minimal harm or potential for actual harm 3. A medication observation was made on 12/21/22 at 8:24 AM with Staff E, RN, for Resident #25. During this medication pass, the RN removed 10 pills from the pill packets. The RN touched the pills with her bare hands on several occasions, while popping the pill out of the pill pack. After administering all of the pills, the RN set up the resident's nebulizer, did a respiratory assessment, then provided the medication. The RN stated she would stay with the resident, reassess her at the end of the treatment, and wash out the equipment with tap water and place back into the plastic bag. The RN was made aware the policy documented to clean with sterile or distilled water and allow to air dry, and the RN stated she had never done that. The RN was also made aware of the touching of the pills with her bare fingers and agreed to the infection control concerns. Residents Affected - Some 4. During an observation on 12/19/22 at 12:18 PM, Staff D, LPN, went into the room of Resident #43 to start the resident's tube feeding. While opening the new tubing set and setting up supplies, the LPN knocked over the large syringe and container used during tube feeding or medication administration, and both fell onto the floor. The LPN picked up the syringe and container from the floor and rinsed them off in the resident's sink. The LPN proceeded to fill up the canister and put the tap water into the new set. The LPN used the syringe to flush the resident's feeding tube with tap water. During a subsequent interview on 12/21/22 at 11:40 AM, Staff D, LPN was asked about using the syringe and container for Resident #43, after having dropped them on the floor. The LPN stated, Yes, but I washed them off. 5. On 12/19/22 at 2:59 PM, Staff C, LPN, arrived to the North Unit and introduced herself to the day nurse and the surveyor. Staff C proceeded to go to every room on the North Unit, to introduce herself to the residents and do a quick observation. Although not all rooms were observed, the LPN was seen patting two of the residents, moving an over-the-bed table in one room, and assisting one resident by handing them the call bell. The LPN failed to perform any hand hygiene between each resident. On 12/21/22 at 3:05 PM, Staff C was observed doing the same routine, going in and out of every resident room without any type of hand hygiene. During an interview at this time, the LPN was made aware of the observation of failing to perform hand hygiene between resident contact, and stated she hadn't thought of that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106075 If continuation sheet Page 22 of 22