Inspection·July 14, 2022

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a care plan meeting was scheduled in a timely manner to allow the resident and/or resident representative involvement in developing comprehensive, person-centered plans of care for 2 of 3 residents reviewed for participation in care planning, of a total sample of 40 residents, (#71 & #70). Findings: 1. Clinical record review revealed resident #71 was admitted to the facility on [DATE], with diagnoses including influenza and Alzheimer's disease. The resident's admission Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 6/18/22 revealed the resident's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of 7/15. The assessment indicated the resident required extensive assistance from one person for bed mobility and toilet use. The resident required limited assistance with transfers, dressing, and personal hygiene. On 7/11/22 at 11:46 AM, resident #71's responsible party stated during the four weeks since the resident's admission, no care plan meeting was held. She verbalized she had to request a meeting which was then scheduled for 7/12/22. On 7/13/22 at 9:58 AM, the MDS Coordinator explained the process for care plan meetings included preparing a list of residents whose care plan meetings were coming due. This list would be provided to the Receptionist, who would then send out invitation letters to the residents or the responsible parties. She explained when the Receptionist received responses, she would schedule meetings per the preference of residents or their family. The MDS Coordinator stated a care plan meeting for resident #71 should have been held on 6/28/22. She could not say why the meeting was not held, and could not ascertain if the resident/responsible party were provided with or received an invitation letter for their care plan meeting. On 7/13/22 at 1:43 PM, the Receptionist confirmed the process for scheduling a care plan meeting included sending out care plan invitation letters based on a list provided by the MDS Coordinator. She explained the letters were then uploaded to each resident's electronic medical record and a care plan meeting would be scheduled per the preference of the resident and/or family. The Receptionist stated the only reason an invitation letter would not be sent, would be if the resident was discharged from the facility, or if she called and scheduled the care plan meeting via phone. The resident's clinical records were reviewed with the Receptionist, and she validated there was no care plan invitation letter, which indicated an invitation was never sent to the resident or representative. 2. On 7/11/22 at 3:45 PM, resident #70 stated she had not been offered any opportunities to participate in her care planning process, but she wished to do so. A review of the resident's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Sepsis, Acute Respiratory Failure with Hypoxia, and Severe Protein-Calorie Malnutrition. The MDS admission Assessment with ARD of 6/17/22 noted a BIMS score of 15 which indicated the resident's cognition was intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 2 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 7/13/22 at 9:59 AM, the RN MDS Coordinator indicated the facility's process for resident/resident representative care plan participation included uploading a completed care plan conference sheet to the Electronic Medical Record (EMR). She explained the Receptionist was responsible for sending invitation letters to the resident or family. The RN MDS Coordinator was unable to locate a care plan conference sheet for resident #70 and said, We don't have any proof of any meeting that was held. There is not a signature sign in sheet for this resident. On 7/13/22 at 10:23 AM, the Social Services Director stated she usually attended care plan meetings and made a note in the EMR. She validated there was no record a care plan meeting was held for resident #70 and could not explain why. On 7/13/22 at 1:43 PM, the Receptionist was unable to locate an invitation letter for resident #70's care plan meeting. She validated no invitation letter was sent to the resident or her family. The facility's policy titled Care Planning - Interdisciplinary Team, Policy Interpretation and Implementation revised in September 2013 read, 3. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 4. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 3 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed resident #207 was admitted to the facility on [DATE]. She was on hospice services for congestive heart failure and had additional diagnoses including fibromyalgia, a history of cerebral infarctions with left sided weakness, asthma, and anxiety. Residents Affected - Some On 7/12/22 at 5:45 PM, resident #207 was observed resting in bed. She had multiple, long, light and dark colored facial hairs located on and under her chin, above her upper lip in the shape of a mustache, and beneath her bottom lip. The facial hairs measured approximately 1/4 inch to 3/4 inch long. On 7/13/22 at 12:30 PM, resident #207's long, facial hairs were unchanged. On 7/14/22 at 11:15 AM, resident #207 was in her room with a family member. The facial hairs noted on the previous two days were still present. The resident stated she did not like the facial hair and when at home she usually removed them with tweezers. The family member explained the resident could no longer do as much for herself after the strokes she suffered. The resident stated on the previous afternoon she attempted to remove her facial hair with tweezers but she became too fatigued and could not see well enough to do it. The resident said she needed help to remove the unwanted facial hair. On 7/14/22 at 11:45 AM, resident #207's assigned CNA I explained the resident required extensive ADL assistance for personal hygiene and grooming needs. During observation of the resident with CNA I, she acknowledged the resident had long facial hairs. CNA I stated that earlier in the day she provided the resident's morning care but did not offer or attempt to remove the facial hairs. Resident #207 then asked CNA I to help remove the facial hairs with the tweezers and asked for her eyeglasses, which were out of reach, to be brought to her. Review of resident #207's admission MDS assessment with an ARD of 7/05/22 indicated she required the extensive assistance from one staff member for daily personal hygiene needs. Resident #207's ADL care plan initiated on 6/28/22, revealed she required assistance with ADL functions which included grooming and personal hygiene needs. The document read, Someone must assist the resident to groom self. and assist with removing, placing on, storing and cleaning eyeglasses. The ADL care plan indicated the resident's ADL function could fluctuate due to her end stage diagnosis. On 7/14/22 at 1:45 PM, the Director of Nursing (DON) stated staff were expected to remove unwanted facial hair when a resident required that type of assistance. Based on observation, interview, and record review, the facility failed to provide services to maintain good grooming, and personal hygiene for 3 of 3 residents reviewed for Activities of Daily Living (ADLs) of a total sample of 40 residents, (#36, #207 & #90). Findings: 1. Clinical record review revealed resident #36 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fracture of the right femur, squamous cell carcinoma of the skin, scalp, and neck, generalized muscle weakness, and dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 4 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0677 Level of Harm - Minimal harm or potential for actual harm Review of the resident's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/20/22 revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 10/15. The assessment indicated the resident required extensive assistance from one person for bed mobility, transfers, dressing, and personal hygiene, and had functional limitation in range of motion to one side of her lower extremity. Residents Affected - Some On 7/11/22 at 4:15 PM, resident #36 had facial hair on her chin and upper lip. The resident stated if she had a shaver she could shave, and verbalized she was shaved once since her admission to the facility. On 7/12/22 at 4:33 PM, resident #36 was still noted to have facial hair on her chin and upper lip. The resident reiterated her facial hair needed to be shaved. On 7/13/22 at 11:18 AM, the Montecito Registered Nurse (RN) Unit Manager (UM) stated ADL care was provided by the Certified Nursing Assistants (CNAs) and shaving and grooming were to be completed during ADL care and/or on shower days. On 7/13/22 at 11:23 AM, resident #36 was seated in her wheelchair in the courtyard. Observation of the resident's facial hair was conducted with the UM and the 3:00 PM to 11:00 PM supervisor. They confirmed facial hair was present on the resident's upper lip and on her chin. Resident #36 informed them she wanted the facial hair shaved. On 7/13/22 at 2:15 PM, CNA E stated resident #36 was on her assignment this week but she had not shaved by her. CNA E described the resident's facial hair as whiskers and explained it was not a full-grown beard. CNA E said she would shave the resident when she noticed it needed to be done. She verbalized had not noticed the facial hair on the resident. The resident's care plan Requires assistance with ADL functions initiated on 5/13/22 and revised on 6/10/22, had a goal that she would show improvement in ADL function. The only intervention documented in the care plan was, Transfers: One assist with transfers. The care plan did not address the resident's grooming or personal hygiene needs. 3. Review of resident #90's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Cerebral Vascular Accident (CVA) with Hemiplegia and Hemiparesis, Respiratory Failure with Hypoxia, Osteomyelitis of sacral vertebra, Epilepsy, Aphasia, Severe Protein-Calorie Malnutrition and Gastrostomy. Review of the Annual MDS assessment dated [DATE] revealed the resident had short-term and long-term memory problems, with severely impaired cognitive skills for daily decision making. She was totally dependent on one to two staff for all ADLs, had impairments on both sides of upper and lower extremities, and had an indwelling urinary catheter. The resident's self-care deficit care plan initiated on 1/16/21 included the intervention Grooming: resident depends entirely upon someone else for all grooming needs. Observations conducted on 7/12/22 at 10:48 AM, 7/13/22 at 9:34 AM, 7/13/22 at 12:45 PM, and 7/13/22 at 5:25 PM revealed resident #90 had long hairs on her upper lip, lower lip and chin. Her fingernails were approximately 1/4 inch long and the edges of her nails were sharp. The fingers on both hands were noted to be contracted towards her palms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 5 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of #90's CNA care plan or Kardex revealed she was totally dependent on two staff for bathing, bed mobility, dressing, personal hygiene/oral care and to check nails every shift for length, cleanliness, and sharp edges. On 7/13/22 at 5:25 PM, CNA B stated she was assigned to resident #90 last night and tonight on the 2:45 PM to 11:00 PM shift. She explained she had to do everything for the resident as she did not speak, had contractures of her hands, arms and knees, and received tube feeding. CNA B added she had to provide urinary catheter care, oral care, turning and repositioning, and incontinence care for resident #90. CNA B stated the resident did not receive showers, instead staff provided bed baths on Tuesdays, Thursdays and Sundays on the 3:00 PM to 11:00 PM shift. CNA B said, She was supposed to have her bed bath yesterday but I did not give her her bath as scheduled. She explained the assigned CNA on the 7:00 AM to 3:00 PM shift communicated she had given the resident a bath earlier today on the day shift. CNA B explained CNAs were responsible for removal of facial hair for both males and females so the residents felt clean and good about themselves. She said, We are also responsible for checking a resident's fingernails and to cut and trim when needed. During review of resident #90's CNA Kardex with CNA B, she confirmed the instructions were to provide bed baths on Tuesdays, Thursdays and Sundays on the 3:00 PM to 11:00 PM shift and check the resident's nails every shift for length, cleanliness, and sharp edges. On 7/13/22 at 6:19 PM, observation of resident #90 was completed with Regional Nurse Consultant (RNC), RNC D and the DON. RNC C had to pry #90's fingers away from the palm of her right hand in order to observe her fingernails. RNC D also had to pry the reisdent's fingers away from the palm of her left hand in order to observe her fingernails. RNC C, RNC D and the DON validated the fingernails on both hands were long and the nail edges were sharp. RNC C, RNC D and the DON verified the resident had long facial hair on her upper lip, lower lip and chin. The DON verbalized CNAs were responsible for providing ADL care for dependent residents. On 7/14/22 at 9:41 AM, Licensed Practical Nurse (LPN) A stated resident #90 was dependent on staff for all ADL care needs. On 7/14/22 at 9:44 AM, resident #90's fingernails on both hands remained long with sharp edges, On 7/14/22 at 10:00 AM, the DON stated the resident's nail care should have been completed by the CNA yesterday on the 3:00 PM to 11:00 PM shift after it was brought to the facility's attention. On 7/14/22 at 3:58 PM, the DON explained residents were assessed on admission to determine the necesary level of assistance with ADL care, then an MDS comprehensive assessment was completed and a care plan was developed. The DON stated CNAs were responsible for the majority of residents' ADL care which included bathing, grooming, incontinence care, hair, oral, and nail care. He said, [Resident #90] should have had her fingernails cut and her facial hair removed. The DON stated CNAs on all shifts were responsible for providing dependent residents with their ADL care. The DON reviewed resident #90's July 2022 CNA documentation and confirmed there was no documentation for the period 7/09/22 to 7/11/22 which indicated the required ADL tasks had not been completed. Review of the Certified Nursing Assistant Job Description, dated 08/15/19, read, . Overview: Provide quality nursing care to residents in a long-term care environment which promotes their rights, dignity, freedom of choice and their individuality under the supervision of a Registered Nurse. Responsibilities: . Attend to the individual needs of the residents which may include assistance with grooming, bathing . or other needs in keeping with the individuals' care requirements, and scope of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 6 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some practice . Completes certified nursing records while using proper coding of Activities of Daily Living (ADLs) documenting care provided or other information in keeping with department policies. Review of the Facility's Activities of Daily Living (ADLs), Support Policy, revised March 2018, read, Policy Statement . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . 2. Appropriate care and services will be provided for resident who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . Review of the Facility Shaving the Resident Procedure, revised February 2018, read, The purpose of this procedure is to promote cleanliness and to promote skin care. Preparation 1. Review the resident's care plan to assess for any special needs of the resident . Review of the Facility's Fingernail/Toenail, Care of Procedure, revised February 2018, read, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. General Guidelines 1. Nail care includes cleaning and trimming. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Review of the Facility Assessment, revised August 5, 2021, revealed the facility would provide person-centered care by staff who were trained, educated and competent. The document indicated a focus of meeting each resident's individual needs in order to maintain or attain their highest level of physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 7 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 obtain a physician's order for oxygen (O2) therapy for 1 of 2 residents reviewed for O2 therapy, of a total sample of 40 residents, (#165). Residents Affected - Few Findings: Review of the medical record revealed resident #165 was admitted to the facility on [DATE] with diagnoses including sepsis, pneumonia, acute respiratory failure, emphysema, and chronic obstructive pulmonary disease. Observations on 7/12/22 at 9:57 AM and on 7/13/22 at 11:28 AM showed resident #165 received O2 at 3 liters per minute (LPM) via nasal cannula. Review of the resident's clinical record revealed no physician's order for O2 therapy. Review of the resident's O2 Sats or O2 saturation level summary for the period 7/05/22 to 7/14/22 revealed the resident's O2 saturation level was monitored while the resident received O2 on 7/05/22, 7/07/22, 7/08/22, 7/10/22,7/11/22, 7/12/22, 7/13/22, and 7/14/22. On 7/14/22 at 12:18 PM, Licensed Practical Nurse (LPN) F stated he was the resident's assigned nurse, and he confirmed the resident received O2 therapy. LPN F stated when resident #165 was first admitted he had a physician's order for O2, but it was discontinued. LPN F explained the resident's family kept applying the oxygen via nasal cannula. The resident's active and discontinued physician's orders were reviewed with LPN F, and he validated there was no current order for O2 therapy. On 7/14/22 at 12:22 PM, the Montecito Unit Manager (UM) confirmed resident #165 received O2 therapy which required a physician's order. The UM reviewed the physician's orders for the resident and acknowledged there was no order for O2 therapy. The facility's policy Oxygen Administration revised in October 2010 read, Review the physician's orders. for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 8 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pain management services in accordance with the comprehensive care plan, and the resident's goals for care and preferences for 1 of 2 residents reviewed for pain management, of a total sample of 40 residents, (#164). Residents Affected - Few The facility's failure to provide pain medications as requested by the resident, per physician's orders, and consistent with the plan of care and accepted standards of practice, resulted in actual harm from prolonged periods of unmanaged pain. Findings: Clinical record review revealed resident #164 was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included generalized muscle weakness, dysarthria and anarthria, post laminectomy syndrome, and myelopathy. The resident's History and Physical, dated 6/26/22, revealed diagnoses including chronic back pain syndrome. The document indicated the resident had multiple prior back surgeries and surgical revision with laminectomy on 6/20/22. A laminectomy is a type of back surgery used to relieve compression on the spinal cord . performed when less invasive treatments have failed. (Retrieved on 7/21/22 from www.healthline.com). Anarthria is a severe form of dysarthria. Dysarthria is a motor speech disorder that occurs when someone can't coordinate or control the muscles used for speaking. (Retrieved on 7/28/22 from www.healthline.com). Myelopathy is an injury to the spinal cord due to severe compression. (Retrieved on 7/28/22 from www.hopkinsmedicine.org). The resident's admission readmission Nursing Packet, dated 6/25/22, revealed on admission, resident #164 had pain to her sacrum, a vertical spinal surgical site, and complained of a burning sensation to her right lower leg. The assessment noted the resident described her pain as severe, sharp, radiating at level 10 on a pain scale of 1 to 10. The assessment identified the most likely cause of the resident's pain was her post-operative incision, and pain relief was achieved with pain medications. Review of the physician's orders for resident #164 revealed she was prescribed Fentanyl patch 75 microgram (mcg)/hour every 72 hours for chronic pain, and Percocet 10-325 milligram (mg) every 4 hours as needed for pain levels of 5 to 10. Fentanyl belongs to a class of drugs known as opioid analgesics. It works in the brain to change how your body feels and responds to pain. Percocet is a combination medication used to help relieve moderate to severe pain. (Retrieved on 7/21/22 from www.webmd.com). The resident's admission Minimum Data Set (MDS) assessment with assessment reference date of 7/02/22 revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 8/15. The assessment indicated the resident received scheduled and as needed pain medications for frequent pain of moderate intensity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 9 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0697 A physician's note, dated 7/09/22, read, Pain under control on great amount of narcotics around clock . acute on chronic back pain . [history of Thoracic-Sagittal spine] fusion. Level of Harm - Actual harm Residents Affected - Few On 7/11/22 at 4:38 PM, resident #164 stated she was sutured from T3 to L5-6, the Thoracic to Lumbar spine region, and had issues with her spine that caused both chronic and acute pain. She recalled on the day she was admitted to the facility, transportation from the hospital took over one hour. The resident stated by the time she arrived at the facility, her pain level was 10/10 and she had to wait for one hour to get pain medication. Resident #164 stated nursing staff explained there was a pharmacy problem as a nurse had not entered her prescribed medications into the computer system. She recounted another incident on 7/09/22 when she went without pain medications for eight hours. The resident said, It was not pretty. She described vomiting as she suffered high levels of pain. The resident's husband said, It was really bad! He explained that while his wife was vomiting, she was unable to get any medication. The resident and her husband stated the facility needed to be more consistent with administration of pain medications. Resident #164 stated she had informed a couple of Licensed Practical Nurses (LPNs) of her concerns, and she was told they would get caught up on her pain medication and/or pass her concerns to the next shift. The resident explained she usually tried to get pain medication prior to therapy but these requests were not always honored. Review of the resident's Medication Administration Record (MAR) for 7/09/22 revealed Percocet 10-325 mg was administered at 4:05 AM, 10:01 AM, 2:09 PM, and 6:36 PM. The document revealed a period of approximately 9 hours elapsed before the next dose was administered on 7/10/22 at 3:22 AM, as reported by the resident. On 7/12/22 at 3:42 PM, LPN J stated resident #164 was a post-surgical patient who received pain medication as scheduled and as needed. LPN J explained the resident's care needs included medication administration and pain management. On 7/13/22 at 11:41 AM, the resident stated last night, 7/12/22, was a bad night with pain as there was some problem with narcotic medications. She explained at 10:00 PM, a nurse told her the pharmacy would deliver her Percocet tablets no later than midnight. The resident stated she told her assigned nurse that the nurse on the 7:00 AM to 7:00 PM shift had promised her the Percocet tablets would arrive by 10:00 PM. Resident #164 stated the 7:00 PM to 7:00 AM nurse responded, I am not the pharmacy. The resident reported the nurse, whose name she could not recall, told her to lay off the call light as she had reached her limit for pain medication. The resident stated the nurse informed her she would not call the physician or the pharmacy to obtain the code to access the facility's emergency medication supply. Resident #164 stated at about 5:00 AM this morning, 7/13/22, the night nurse entered her room, placed a cup with a tablet on the tray table, and walked away. On 7/13/22 at 5:58 PM, in a telephone interview, LPN H stated she was regularly assigned to resident #164 on the 7:00 PM to 7:00 AM shift and was aware of the resident's condition. She verbalized the resident normally requested Percocet every 4 hours. She recalled during the change of shift report, the previous nurse, LPN J, informed her she had to retrieve Percocet for the resident from the facility's Emergency Drug Kit (EDK). She stated LPN J told her the pharmacy would deliver narcotics for the resident on the next scheduled pharmacy run. LPN H stated the resident received her last dose of Percocet on 7/12/22 at approximately 5:00 PM. She verbalized the resident asked for pain medication between 9:30 PM to 10:00 PM on 7/12/22 and reported her pain level at that time as 7 on a pain scale of 1 to 10. LPN H stated she told the resident she would get her medication when the pharmacy delivered it. LPN H explained that when a medication was not available, the facility's process included either checking if it could be obtained from the EDK or calling the pharmacy for a stat or rush (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 10 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0697 Level of Harm - Actual harm Residents Affected - Few delivery. LPN H stated she could not obtain a code from the pharmacy to access the EDK because the previous nurse had already used a code, retrieved and administered one tablet to the resident. LPN H further explained if the pharmacy delivery was in transit, she could not obtain a code for emergency medication. She acknowledged she did not notify the physician or request any additional medication to address the resident's report of level 7 pain and lack of access to as needed medications for breakthrough pain. LPN H stated she rounded on the resident at 3:00 AM and she was asleep. However, LPN H verbalized she did not actually enter the resident's room to assess her pain level, but observed the resident from the hallway. She confirmed resident #164 requested pain medication at 9:30 PM but did not receive Percocet for pain until 8 hours later at 5:30 AM on 7/13/22. Review of the facility's job description for Licensed Practical Nurse revealed the LPN was responsible for the optimal quality of care for residents, and his/her responsibilities included administration of medication and treatments according to the physician's orders and assumes responsibility for ordering medications. On 7/14/22 at 9:43 AM, the Montecito Unit Manager (UM) stated the goal of pain management was for pain to be treated and managed appropriately. She stated the facility had an Automated Dispensing System (ADS) and all LPN H had to do was submit another request to the pharmacy to obtain Percocet from the ADS. The UM stated the physician should have been notified that the medication was not available, and an order obtained for breakthrough pain medication. She said, Ultimately, the nurse should have obtained medication from the ADS. The UM stated it was not acceptable for the resident to be in pain and not receive medication as ordered. She validated the resident's pain was not managed adequately. On 7/14/22 at 10:12 AM, the Director of Nursing (DON) stated the facility had an ADS, and the process was for the physician to contact the pharmacy to authorize dispensing of medication. The nurse would then contact the pharmacy to obtain a code to access the ADS, and two nurses would retrieve the medication from the ADS using the code. The DON stated he was not aware the nurses could not obtain a code if a pharmacy delivery was in transit as described by LPN H. He verbalized the physician should have been informed the medication was not available, and LPN H should have then repeated the process used by the previous nurse to obtain the medication from the ADS. The DON stated the expectation was for the nurse to follow the physician's order and utilize the ADS to obtain medications that were not available in the medication carts. The DON stated if a resident requested pain medication, it should be administered within a reasonable timeframe. He confirmed LPN H should have contacted the physician and obtained orders to address resident #164's pain in a timely manner. Review of the resident's Medication Administration Record (MAR) for the period 7/01/22 to 7/12/22 revealed the resident requested and received Percocet 10-325 mg routinely around the clock, approximately every 4 hours. The MAR showed on 7/12/22, Percocet 10-325 mg was administered at 5:24 PM and the next dose was not given until 7/13/22 at 5:32 AM, approximately 12 hours between doses and 8 hours after the medication was requested. During review of the MAR with the DON and the Montecito UM on 7/14/22 at 10:12 AM and 7/14/22 at 9:43 AM respectively, they acknowledged the findings. Review of the Policies and Procedures for Management of the [name of Automated Dispensing Systems] read, Nursing and Pharmacy will use the ADS Station as an inventory, charging and information system for the control and distribution of medications for Emergency, First-Dose use and other situations where medications are not available from the pharmacy . The facility must contact the pharmacy and obtain an authorization code for removal of any controlled substance . If there is no script on file, the pharmacist will page the prescriber for an electronic prescription or an emergency supply . If (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 11 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0697 the medication is not available, call the pharmacy using the after- hours emergency number(s) if necessary. Level of Harm - Actual harm On 7/14/22 at 11:05 AM, resident #164 stated she would be comfortable with a pain level of 3/10. She explained that after her post-operative acute pain was resolved, she would be able to cope better with her chronic pain. Residents Affected - Few Interventions on the resident's care plan At increased risk for alteration in comfort [related to] generalized discomfort and recent laminectomy initiated on 7/11/22 included administer pain medication as ordered, and notify physician of unrelieved or worsening pain. The facility's policy Pain Assessment and Management, revised in March 2020, read, The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The policy Administering Pain Medications revised in October 2010 revealed steps in the procedure included, Administer pain medications as ordered. The Facility Assessment, updated/reviewed on 6/29/22, indicated services and care offered by the facility would be based on the residents' needs and included assessment of pain and pharmacologic and non-pharmacological pain management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 12 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to honor meal preferences for 2 of 10 residents reviewed for food out of a total sample of 40 residents, (#50 & #105). Findings: 1. Review of resident #50's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Hyperlipidemia and Gastroesophageal Reflux Disease (GERD) and Iron Deficiency Anemia. She was cognitively intact and independent with eating. Review of her physician's orders documented a Consistent Carbohydrate (CCHO), regular texture, thin consistency with No Added Salt (NAS) diet. On 7/11/22 at 1:55 PM, resident #50 stated all her meals were cold and she did not receive the meals she ordered. The resident said, This is very frustrating. On 7/12/22 at 5:47 PM, resident #50's meal consisted of chicken, cubed potatoes and a mix of broccoli and cauliflower which she had not eaten. Resident #50 explained she continuously wrote No vegetables on the meal slip, but she kept getting vegetables on her plate. She said, I don't eat vegetables. On 7/13/22 at 12:30 PM, resident #50 was in the main dining room for the lunch meal which consisted of beef stew with vegetables. Review of resident #50's Diet Review /Food & Beverage Preference List form dated 6/04/22 showed the resident's preference as no vegetables. Review of resident #50's Resident Detail form dated 3/31/22 indicated the facility failed to include her preference for no vegetables under the section for disliked foods. On 7/13/22 at 4:45 PM, the Dietary Manager stated resident #50's Diet Review /Food & Beverage Preference List form dated 6/04/22 indicated she did not want vegetables. The Dietary Manager explained she was responsible for completing the Resident Detail forms. The Dietary Manager acknowledged resident #50 had been receiving vegetables with all her meals since her preference for no vegetables was not recorded on the electronic Resident Detail form. 2. Review of resident #105's medical record revealed she was admitted to the facility on [DATE] with diagnoses of GERD, Esophagitis, Anemia and diseases of the digestive system. She was cognitively intact and required supervision with meals. Review of the physician's orders revealed the resident had a CCHO, regular texture, thin consistency, NAS diet. On 7/11/22 at 3:25 PM, resident #105 stated all her meals were cold and rubbery and she could not get a salad when she selected the special meal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 13 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 7/13/22 at 12:42 PM, resident #105 was seated in front of her meal tray. She stated she ordered a Chef salad and removed the lid that covered her plate to show she received only lettuce, cucumbers and tomatoes. The resident explained she had been at the facility for one year and despite discussions in care plan meetings regarding her food concerns, nothing ever got fixed. On 7/13/22 at 1:00 PM, the Dietary Manager explained resident #105 did not receive the Chef salad she requested as the facility had not received the delivery of the meat and cheese required for the Chef salad. She stated she prepared chicken as a substitute meat for the Chef salad. The Dietary Manager could not explain why the person who was responsible for checking trays had not checked the Chef salad before it was sent out to the resident. The Dietary Manager said, A regular salad does not have the same nutritional value as a Chef salad. On 7/13/22 at 1:30 PM, a meeting was held with the Kitchen Manager, Regional Dietary Manager, Registered Dietitian and Assistant Kitchen Manager. The Dietary Manager acknowledged resident #105 should have received the Chef salad she ordered. The Dietary manager said, I have no excuse for the kitchen staff not making sure that the meal was correct. The Regional Dietary Manager confirmed resident #105 had not received a substitute salad which was of equal or greater nutritional value. On 7/14/22 at 5:01 PM, the Administrator explained the facility identified issues with resident preferences during the Resident Council meetings. The Administrator stated a Performance Improvement Plan (PIP) was developed on 6/02/22 because residents stated they were not getting the food that they had requested and the dietary staff were substituting food items that the residents did not like. The Administrator explained that a Food Satisfactory Survey with a 1 to 5 coding system was distributed to only the residents who had voiced numerous food concerns. She stated the PIP was on-going for three months and the survey scores had improved. The Administrator confirmed the Food Satisfactory Survey had not been distributed to all residents who received meals to obtain their input, and staff assigned to visit residents were not inquiring about the quality of the food. The Administrator was informed that despite the facility's PIP, there were current identified concerns related to residents not receiving requested meals, substitutions being made by the kitchen staff and resident preferences not being added to their electronic Resident Detail form which generated the meal tickets. The Administrator responded, We need to get this corrected and we will get it right for the residents. Review of the Facility's Menus Policy, revised October 2017, read, . Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy . Review of the Facility Alternate Food Choices, Substitutions and Honoring Food Preferences Policy, dated 1/15/21, read, Policy: The Facility embraces resident choice and honors food preferences . Procedure: . 2. The designated staff member will obtain the patient's/resident's food preferences upon admission. Preferences will be implemented into the menu program with appropriate substitutions or alternates offered that meet the nutritional standards of care and the patient's/resident's needs. 3. The Dietitian will monitor for menu compliance and will include the resident's food preferences in the nutrition plan of care . 5. The Food Service Director (FSD) will update preferences into the menu traycard system. Review of the Facility Assessment, revised 8/05/21 revealed the facility offered nutritional services focused on a resident's individual dietary requirements. Food and nutrition services included Food Service Manager, Registered Dietitian, Cooks and Dietary Aids. The facility's dietary staff would complete annual in-services to ensure competency with food preparation, serving and distribution (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 14 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0803 procedures in order to meet the residents' individual needs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 15 of 16 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food stored in the kitchen's walk-in refrigerator was appropriately labeled and dated. Residents Affected - Some Findings: On 7/11/22 at 10:30 AM, during observation of the kitchen's walk-in refrigerator with the Dietary Manager and Registered Dietitian (RD), an unlabeled, heavy, clear plastic container with a green lid contained chopped onions was identified. A square, metal pan covered with plastic wrap that contained multiple sausages was also unlabeled. A large, heavy clear plastic container that contained 8 quarts of lemonade, a clear plastic container with 10 quarts of ice tea and a clear plastic container with 10 quarts of fruit punch were all noted to have no labels. The Dietary Manager explained all containers in the refrigerator should be labeled with the name of the food product and dated. Two disposable foil pans covered with aluminum foil contained macaroni and cheese and neither container was labeled or dated. The Dietary Manager said, All food products not in original packaging is required to be labeled and dated. I don't know why this was not done. On 7/12/22 at 12:30 PM, the Regional Dietary Services Manager explained any food product out of its original package needed to be labeled and dated. Review of the Facility's Food Receiving and Storage Policy, dated 1/15/2021, read, . Foods shall be received and stored in a manner that complies with safe food handling practices . 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of the Facility Assessment, revised 8/05/21, read, . Annually, the dietary and food-handling employees will complete in-service training on food safety . food handling and preparation techniques, food-borne illness . leftover food handling policies, time and temperature controls for food preparation and service . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 16 of 16