Inspection·September 9, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few by telephone on 9/08/25 and 9/09/25 by the survey team were unsuccessful. On 9/08/25 at 1:38 PM, in a telephone interview, resident #2's sister, listed in the medical record as the Health Care Surrogate, Power of Attorney (POA), and emergency contact for resident #1, confirmed her brother was discharged home on 7/06/25 but said she was not notified in advance. She shared she received a call from the facility afterward informing her the resident was no longer at the facility. On 9/08/25 at 8:15 PM, in a telephone interview, Certified Nursing Assistant (CNA) A shared she previously worked for the facility from March 2024 to August 2025. She recalled resident #2 was mostly independent. She acknowledged working some weekends and shared she did not see any visitors with resident #2 when she was assigned to his care. CNA A stated she did not assist, nor did she observe resident #2 packing his belongings or him leaving the facility during her 7 AM to 3 PM shift on Sunday, 7/06/25. On 9/09/25 at 1:48 PM, in a telephone interview, Licensed Practical Nurse (LPN) B stated she resigned mid-August 2025 and was assigned to resident #2's unit once or twice. She indicated she did not discharge anyone during her shift on Sunday 7/06/25. She explained she would have entered a progress note in the medical record if she discharged a resident. She did not recall any residents leaving for any reason that day. She stated no one from the facility had inquired about the care of resident #2 on Sunday 7/06/25 or afterwards. On 9/08/25 at 3:43 PM, 9/08/25 at 8:36 PM, and 9/09/25 at 10:39 AM, attempts were made to contact LPN C, who was assigned to resident #2 from 7 AM to 7 PM on Sunday 7/06/25, unsuccessfully. No reply from LPN C was received. On 9/09/25 at 12:26 PM, the Social Services Assistant indicated the Social Services Director (SSD) was out of the facility currently. He confirmed responsibility for discharge planning. He explained a perfect discharge process would include discussion during weekly Utilization Review (UR) meeting to learn about the resident's progress and set a discharge date . He shared once they established a discharge date , home care services and durable medical equipment was set up as needed. He mentioned it did not always happen this way and at times, when a resident wanted to leave the same day, it was not a smooth process, but they tried to follow the same process. He indicated a Discharge Summary form was opened in the system and each discipline responsible for their section of the form would complete it. The Discharge Summary should be placed in the folder and given to the resident at discharge. He recalled talking to resident #2 regarding his desire to go home but there were barriers with placement regarding his mobility and a big dog in the house. The Social Services Assistant indicated he spoke with resident #2 about his concerns, because his spouse worked so much. He stated there would be the staff to provide documentation about the discharge plan in the medical record. Later at 1:01 PM, the Social Services Assistant showed a copy of an email sent by the SSD to the Home Health Agency (HHA) on Monday 7/07/25 at 12:22 PM. He shared based on the email, he inferred this was not a planned discharge, otherwise, the HHA set up would have been done before resident #2 left. The assistant explained the HHA responded they received the message and there was no other messages from them. He shared the HHA would have communicated with the facility if the resident had declined services. He stated he did not assist the SSD with resident #2's discharge. The Social Services Assistant indicated he did not find any progress notes regarding the discharge planning or the SSD's conversations with resident #2 before his discharge. On 9/09/25 at 2:00 PM, the Director of Nursing (DON) explained code 3 in the MAR was used when a resident was out of the facility on a pass. She reviewed resident #2's Discharge Summary form and acknowledged it was incomplete and not signed. The DON was shown the email provided by the Social Services Director which indicated the resident was discharged on 7/06/25 but the physician order for discharge and referral sent to the HHA were not done until the next day, 7/07/25. The DON did not make any comments to explain. On 9/09/25 at 2:13 PM, in a telephone interview, the HHA's Administrator confirmed they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 2 of 5 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 09/09/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete received resident #2's referral on 7/07/25. She explained they attempted to set up a Start of Care visit multiple times but resident #2 declined the home health services on 7/16/25. On 9/09/25 at 3:05 PM, the DON stated she reached out to the nurses working on 7/06/25, both did not work here any longer, but was unsuccessful contacting LPN C. The DON indicated she spoke with LPN B who did not recall anything from that Sunday. The DON shared she also reached out to the DON at the time and was told resident #2 was discharged without a physician's order but did not recall anything else besides that. The DON stated the CNAs who worked with resident #2 that weekend were no longer employed by the facility. She explained they could not exactly determine when resident #2 left the facility, and that he probably left overnight or early that morning based on a census report updated at 4:00 AM on 7/07/25. At 3:10 PM, the Administrator (NHA) joined the interview. The NHA stated that weekend, two disgruntled employees who were no longer employed by the facility, were the Managers on Duty. She shared they were terminated because of findings from that weekend but did not provide details of their findings. The NHA stated she inferred while talking to staff about resident #2, there had been discussions about him going home but there were family disagreements on how to proceed. The NHA validated the medical record should have included notes regarding the discharge plan. She confirmed resident #2 was a long-term resident. On 9/09/25 at 4:30 PM, in a telephone interview, the former Social Services Assistant explained resident #2 was admitted to the facility with his sister being his POA. She recalled resident #2's discharge was mentioned by the resident when he got married in April 2025. She explained at that time he was not ready for discharge. Review of the facility's Transfers and Discharges policy and procedure, revised February 2024, read, The facility will develop and implement an effective discharge process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care. Event ID: Facility ID: 106123 If continuation sheet Page 3 of 5 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 09/09/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to accurately document the discharge plan and disposition in the medical record; and the Activities of Daily Living (ADLs) for 1 of 2 residents reviewed for discharge status and ADLs, of a total sample of 7 residents, (#2). Findings:Cross Reference F628 Review of resident #2's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including nontraumatic subacute subdural hemorrhage (brain bleed), chronic obstructive pulmonary disease, type 2 diabetes, repeated falls, speech and language deficits, abnormalities of gait and mobility, and difficulty walking. Review of resident #2's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/11/25 revealed the resident participated in the assessment, and there was an active discharge plan for return to the community. Review of the Discharge MDS assessment with ARD of 7/06/25 revealed a planned discharge home, return not anticipated. Review of resident #2's medical record revealed a Discharge Summary form with an effective date of 7/06/25 at 11:06 (time of day was not specified). The Summary of Stay section indicated the resident was discharged home with his spouse and mother-in-law. The resident status was listed as long term care. Several sections of the discharge form were left blank or unanswered, including Skin Evaluation, Treatments, Cognitive/Psychosocial, ADLs (Activities of Daily Living)/Functional Status, Sensory, Dietary, Rehabilitation Services, and Education/Acknowledgement. The Instructions After Discharge section was only partially completed. The Medications and Treatments questions were unanswered. The form instructed staff to **ATTACH COPY OF MEDICATION LIST**, enter pharmacy details, and document whether scripts were provided. These were not addressed and not documented. There was no evidence in the record that a copy of the Discharge Summary was given to resident #2, nor was it signed by the resident or staff. There was also no evidence of a medication reconciliation or confirmation that medications were provided upon discharge. Review of resident #2's physician orders revealed an order dated 7/07/25 and read, Discharge patient home with home health PT/OT (Physical Therapy/Occupational Therapy) and Nursing. Review of June and July 2025 Progress Notes did not reveal any entries regarding discharge planning. No documentation was found regarding education provided, disposition of medications, or scripts issued when the resident left. Review of resident #2's Documentation Survey Report for June 2025 and July 2025, which showed ADL tasks such as dressing, personal hygiene, bladder and bowel, eating and fluids documented by the Certified Nursing Assistant (CNAs) were left blank on the following shifts: 7 AM to 3 PM - 6/5, 6/7, 6/8, 6/9, 6/11, 6/12, 6/13, 6/17, 6/21, 6/22, 6/23, 6/25, 6/27, 6/28, 6/29, 7/3, 7/4, 7/5, 7/6 3 PM - 11 PM - 6/7, 6/12, 6/14, 6/15, 6/19, 6/20. 6/21, 6/23, 6/25, 6/28, 6/29, 6/30, 7/2, 7/5, 7/6 11 PM - 7 AM - 6/5, 6/7, 6/9, 6/13, 6/14, 6/20, 6/21, 6/22, 6/26, 6/29, 6/30, 7/3, 7/4, 7/5, 7/6 On 9/09/25 at 12:44 PM, the Director of Nursing (DON) shared her expectation was that CNAs documented the care they provided to the residents prior to leaving the facility and as close as possible to the time the care was performed. She explained nurses were to document their assessments and progress notes before a resident left the facility. Later at 2:00 PM, the DON stated she was not working in the facility at the time but responded, I understand what you mean, in regard to the blanks in staff's documentation for resident #2. She acknowledged the Discharge Summary was incomplete and unsigned. Review of the facility's Medical Records policy and procedure revised in January 2024 read, Medical Records will be maintained within the facility per federal requirements. Event ID: Facility ID: 106123 If continuation sheet Page 4 of 5 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 09/09/2025 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview, and record review, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained. Findings: Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program policy, undated revealed objectives which included to Establish systems through which to monitor and evaluate corrective actions. The Implementation section described the process in which the QAPI plan identified and corrected deficiencies. The key components included developing and implementing corrective action or performance improvement activities and monitoring or evaluating the effectiveness of the corrective action, revising when necessary. The facility had deficiencies at F842 in complaint surveys conducted on 12/14/23 and 10/16/24 for non-compliance with the medical record and accuracy of documentation. Review of the Statement of Deficiencies and Plan of Correction form for the survey conducted on 12/14/23 revealed a Plan of Correction was completed on 1/19/24. The facility documented education to the nursing staff on the components of F842, resident records, and accuracy of documentation was performed. Review of the Statement of Deficiencies and Plan of Correction form for the survey conducted on 10/16/24 revealed a Plan of Correction was completed on 11/22/24. The facility again documented education was provided to the current nursing staff and newly hired nurses on the components of F842. The Plan of Correction indicated audits were to be performed until compliance was reached. During this survey, deficiencies were again identified at F842, for resident records and accuracy of documentation. As a result of the repeated citation, it was identified there was insufficient auditing and oversight by the QAPI team to prevent repeated deficiencies. On 9/09/24 at 5:15 PM, the Administrator (NHA) stated she had attended two QAPI meetings since starting to work in the facility in mid-July 2025. She explained during the QAPI meeting, they reviewed processes relevant to each department to ensure no deficiencies or concerns with deviations from their policy were identified. She indicated when issues were identified, they worked with their corporate team to develop and implement a Performance Improvement Plan. The NHA stated she was not aware of the previous deficiencies regarding medical records documentation. Event ID: Facility ID: 106123 If continuation sheet Page 5 of 5