Inspection·January 9, 2025

E 000 During the Fire & Life Safety recertification survey conducted on 1/09/25 at Life Care Center of Palm Bay, Emergency Preparedness was reviewed. Life Care Center of Palm Bay is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 483.73, Requirement for Long-Term Care Facilities.

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety recertification survey was conducted on 1/09/25 at Life Care Center of Palm Bay, a Long-Term Care facility in Palm Bay, Florida. Life Care Center of Palm Bay is not in compliance with 42 CFR 483.90 (a), and National Fire Protection Association (NFPA) 101 (2012 edition), NFPA 99 (2012), requirements for Long-Term Care facilities. Initial Plan Review: 2004 Existing NFPA 220 Construction Type: V(III) Number of beds: 140 Census: The following is a description of the noncompliance:

K 345 Fire Alarm System - Testing and Maintenance SS=E CFR(s): NFPA 101

K 345 2/9/25 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 01/17/2025 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: BRV721 Facility ID: 35960988 If continuation sheet Page 1 of 4 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 03/18/2025 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 01, 05 (X3) DATE SURVEY COMPLETED 106060 B. WING 01/09/2025 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 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (X5) PREFIX TAG (EACH SUMMARY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

K 345 Continued From page 1 available.

K 345 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This REQUIREMENT is not met as evidenced by: Based on record review, and an interview with the Maintenance Director, the facility failed to maintain the fire alarm system in accordance with NFPA 72. This failure resulted in possible endangerment to the residents, staff, and other building occupants. 1) Maintenance Director located report after life safety survey and is provided as an attachment to plan of correction to area office. Testing was completed on March 6, 2024. Findings Include: 2) Maintenance Director has received education related to improved organization of inspection binder to improve ease of use and retrieval of documents. During a record review with the Maintenance Director on 1/09/25 at 10:45 AM, he failed to provide evidence that the duct detectors' annual air flow testing had been conducted. An interview was conducted with the Maintenance Director at that time and he concurred and acknowledged the findings. 3) This task is in the TELS system and will be scheduled annually with provider during annual fire alarm testing. NFPA 101(2012 Edition) 19.3.4.4, 9.6.5.1 NFPA 72 (2010 Edition) 14.4.5.3.2 4) Maintenance Director will report to QAPl committee monthly the completion of all inspections as needed.

K 921 2/9/25

K 921 SS=D CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenan Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BRV721 Facility ID: 35960988 If continuation sheet Page 2 of 4 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 03/18/2025 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106060 (X2) MULTIPLE CONSTRUCTION A. BUILDING 01, 05 B. WING (X3) DATE SURVEY COMPLETED 01/09/2025 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 PREFIX TAG PREFIX TAG (PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY)

K 921 Continued From page 2

K 921 with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This REQUIREMENT is not met as evidenced by: 1) Electrical equipment testing was completed on 12/26/2024 which is the date inspection was due to be competed. Based on observation, interview, and record review, the facility failed to maintain the annual 2) Facility received completed inspection electrical testing of fixed and portable medical report on 1/16/2025. equipment. This failure resulted in possible endangerment to the residents, staff, and other building occupants. 3) Facility will request vendor provide Findings include: inspection report in a timely manner. During record review on 1/09/25 at 10:30 AM with Maintenance Director will inform the Maintenance Director a request for the annual administrator if facility does not receive biomedical testing was made. The Maintenance documentation from a vendor timely. Director was not able to provide the biomedical Administrator will follow up as appropriate. testing documentation. The date the biomedical 4) Maintenance Director will report the testing was last performed (on 12/26/24) was status of all required inspections to the identified from a sticker observed on equipment QAPl committee monthly in the rehabilitation room, which put the testing date out of compliance. An interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BRV721 Facility ID: 35960988 If continuation sheet Page 3 of 4 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 03/18/2025 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01, 05 (X3) DATE SURVEY COMPLETED 01/09/2025 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 PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE

K 921 Continued From page 3 conducted at that time with the Maintenance Director, and he concurred and acknowledged the findings. Per NFPA 99 (2012 Edition) 10.3, 10.5.2.1 K 921 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BRV721 Facility ID: 35960988 If continuation sheet Page 4 of 4 Agency for Health Care Administration PRINTED: 03/18/2025 FORM APPROVED DEPARTMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35960988 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 01, 05 B. WING ______ (X3) DATE SURVEY COMPLETED 01/09/2025 NAME OF PROVIDER OR SUPPLIER LIFE CARE CENTER OF PALM BAY STREET ADDRESS, CITY, STATE, ZIP CODE 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) (X5) COMPLETE DATE

K 000 INITIAL COMMENTS

K 000 A unannounced Fire & Life Safety relicensure survey was conducted on 1/09/25 at Life Care Center of Palm Bay, a nursing home in Palm Bay, Florida in accordance with National Fire Protection Association (NFPA) 1 and 101 (2021 edition) and applicable requirements of Florida State Fire Marshal's Rules and Regulations, Florida Administrative Code (F.A.C) 69A-3, F.A.C. 69A-53, F.A.C. 59A-4, and Florida Statutes (F.S.) 400 Part II, and F.S. 633.0215, adopting National Fire Protection Association (NFPA) 1 and 101 (2021 edition) known as the Florida Fire Prevention Code and all NFPA referenced standards and requirements adopted per NFPA 101, Chapter 2. The following is a description of the deficiencies, found at the time of the visit.

K 345 NFPA 101 Fire Alarm System - Testing and SS=E Maintenance

K 345 2/9/25 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.5, 9.6.7, 9.6.8, and NFPA 70, NFPA 72 This Statute or Rule is not met as evidenced by: Based on record review, and an interview with the Maintenance Director, the facility failed to maintain the fire alarm system in accordance with NFPA 72. This failure resulted in possible endangerment to the residents, staff, and other building occupants. 1) Maintenance Director located report after life safety survey is provided as an attachment to plan of correction to area office. Testing was completed on March 6, 2024. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Electronically Signed TITLE (X6) DATE 01/17/25 STATE FORM 8899 8RV721 If continuation sheet 1 of 3 Agency for Health Care Administration PRINTED: 03/18/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING: 01, 05 B. WING ____ 35960988 (X3) DATE SURVEY COMPLETED 01/09/2025 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 PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE

K 345 Continued From page 1 K 345 Findings Include: During a record review with the Maintenance Director on 1/09/25 at 10:45 AM, he failed to provide evidence that the duct detectors' annual air flow testing had been conducted. An interview was conducted with the Maintenance Director at that time and he concurred and acknowledged the findings. NFPA 101(2021 Edition) 19.3.4.4, 9.6.5.1 NFPA 72 (2017 Edition) 14.4.5.3.2 CLASS III

K 921 NFPA 99 Electrical Equipment - Testing and SS=D Maintenanc K 921 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed 2/9/25 AHCA Form 3020-0001 STATE FORM 699 8RV721 if continuation sheet 2 of 3 Agency for Health Care Administration PRINTED: 03/18/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: 01, 05 B. WING ______ (X3) DATE SURVEY COMPLETED 01/09/2025 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 PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE

K 921 Continued From page 2 K 921 operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.12, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 (NFPA 99) This Statute or Rule is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain the annual electrical testing of fixed and portable medical equipment. This failure resulted in possible endangerment to the residents, staff, and other building occupants. Findings include: During record review on 1/09/25 at 10:30 AM, with the Maintenance Director a request for the annual biomedical testing was made. The Maintenance Director was not able to provide the biomedical testing documentation. The date the biomedical testing was last performed (on 12/26/24) was identified from a sticker observed on equipment in the rehabilitation room, which put the testing date out of compliance. An interview was conducted at that time with the Maintenance Director, and he concurred and acknowledged the findings. Per NFPA 99 (2021 Edition) 10.3, 10.5.2.1 CLASS III 1) Electrical equipment testing was completed on 12/26/2024 which is the date inspection was due to be completed. 2) Facility received completed inspection report on 1/16/2025. 3) Facility will request vendor provide inspection report in a timely manner. Maintenance Director will inform administrator if facility does not receive documentation from a vendor timely. Administrator will follow up as appropriate. 4) Maintenance Director will report the status of all required inspections to the QAPI committee monthly. AHCA Form 3020-0001 STATE FORM esss 8RV721 if continuation sheet 3 of 3