Inspection·June 2, 2023

Agency for Health Care Administration PRINTED: 06/27/2023 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING: ________________ (X3) DATE SURVEY COMPLETED R-C 06/02/2023 35960988 B. WING ________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LIFE CARE CENTER OF PALM BAY 175 VILLA NUEVA AVE PALM BAY, FL 32907 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (N 000) INITIAL COMMENTS (N 000) A Revisit to the Relicensure survey was conducted from 6/01/2023 to 6/02/2023. All previously cited deficiencies were cleared as of 5/20/2023. Life Care Center of Palm Bay did not have any deficiencies found at the time of the visit. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 06/16/23 STATE FORM 6899 RDBH12 If continuation sheet 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 06/27/2023 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY ID PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING R-C 106060 B. WING 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LIFE CARE CENTER OF PALM BAY 175 VILLA NUEVA AVE PALM BAY, FL 32907 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5) PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX PROVIDER'S PLAN OF CORRECTION COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (EACH CORRECTIVE ACTION SHOULD BE DATE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (F 000) INITIAL COMMENTS (F 000) A Revisit to the Recertification survey was conducted from 6/01/2023 to 6/02/2023. All previously cited deficiencies were cleared as of 5/20/2023. Life Care Center of Palm Bay was in compliance with 42 CFR 483 and 488, requirements for Long-Term Care facilities. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 06/16/2023 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See Instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RDBH12 Facility ID: 35960988 If continuation sheet Page 1 of 1