Inspection·February 13, 2025

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 03/18/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING ______ (X3) DATE SURVEY COMPLETED R 02/13/2025 106060 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) COMPLETION DATE (F 000) INITIAL COMMENTS (F 000) A revisit to the recertification survey of 1/09/25 was conducted by desk review on 2/13/25. All previously cited deficiencies were cleared as of 2/09/25. 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 Electronically Signed TITLE 02/13/2025 (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: BRV712 Facility ID: 35960988 If continuation sheet Page 1 of 1 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 (X3) DATE SURVEY IDENTIFICATION NUMBER: A. BUILDING: __________ COMPLETED B. WING ________ R 02/13/2025 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 PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) (N 000) INITIAL COMMENTS (N 000) A revisit to the relicensure survey was conducted on 2/13/25 by desk review. All previously cited deficiencies were cleared as of 2/09/25. 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 02/13/25 STATE FORM 8899 8RV712 If continuation sheet 1 of 1