Inspection·April 12, 2024

F 000 Complaint Investigations #2023007675, #2023015150, and #2024004858 were conducted from April 11 to April 12, 2024. Life Care Center of Palm Bay was in compliance with 42 CFR Part 483 and 488, requirements for Long Term Care Facilities. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Electronically Signed TITLE 04/15/2024 (X6) DATE 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: 28NK11 Facility ID: 35960988 If continuation sheet Page 1 of 1 Agency for Health Care Administration PRINTED: 04/29/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING ___________ C 04/12/2024 35960988 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 PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X6) COMPLETE DATE

N 000 INITIAL COMMENTS N 000 Complaint Investigations #2023007675, #2023015150, and #2024004858 were conducted from April 11 to April 12, 2024. 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 (X8) DATE Electronically Signed 04/15/24 STATE FORM 6809 28NK11 If continuation sheet 1 of 1