Health inspection·March 14, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) was accurately completed related to diagnosis of Dementia for 1 of 5 sampled residents reviewed for Unnecessary Medications (Resident #13). Residents Affected - Few The findings included: Resident #13 was admitted to the facility on [DATE] with a documented diagnosis by the resident's health care provider of Dementia in the resident's medical record. Resident #13's Psychiatry Care Plan, completed on 02/05/24, documents, Patient is at baseline . Dementia is persisting, but no behaviors. A review of Resident #13's Quarterly MDS, completed on 02/21/24, showed no documented diagnosis of Dementia. On 03/14/24 at 10:17 AM, the MDS Coordinator confirmed that Dementia was not documented in Section I (Diagnoses) of the February Quarterly MDS assessment for Resident #13. She stated, The resident does have a documented diagnosis of Dementia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686128 If continuation sheet Page 2 of 10 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 686128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ardie R Copas State Veterans Nursing Home 13000 SW Tradition Parkway Port Saint Lucie, FL 34987 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interview and policy review, it was determined, the nursing staff failed to ensure respiratory care and services were provided as specified by the facility policy and physician's orders for 2 of 2 sampled residents reviewed for respiratory care (Resident #3 and Resident #40). The deficient practice is evidenced by failure to complete a pre and post assessment for Resident #3 during the administration of a nebulizer treatment; failure to clean or dispose of the nebulizer mask after use; and failure to provide oxygen therapy with humidifier, as specified in the physician's order for Resident #40. Residents Affected - Few The findings included: 1) Medication administration observation conducted on 03/12/24 starting at 10:12 AM revealed Staff A, a Registered Nurse, administering medications to Resident #3. The nurse administered insulin and a nebulizer treatment. Staff A removed the mask from the resident's drawer, it was stored in a plastic bag, then poured the prescribed medication into the nebulizer cup, Ipratropium Albuterol combination, and placed the nebulizer mask on the resident. After the completion of the treatment, Staff A removed the nebulizer mask, placed it back inside the plastic bag and back inside the resident's drawer. Staff A assisted Resident #3 out of the room and confirmed the treatment was completed. Resident #3 was escorted to the patio for activities. Clinical record review conducted on 03/12/24 revealed a physician's order dated 06/03/23 Ipratropium Albuterol 0.5 milligrams/3 milliliter every six hours via nebulizer for shortness of breath and wheezing. Facility policy titled, Nebulizer Administration of Medications, dated 11/20/20 documents: The purpose of this procedure is to provide guidelines for the appropriate use and care of nebulizer equipment for aerosol therapy. The nurse or designee shall ensure that appropriate cleaning, per manufacturer's guidelines. Nebulizer equipment will be stored in the resident's room while in use. The tubing and mouthpiece will be disposed of when the treatment is completed. Post treatment Evaluation and Documentation: Date and time of treatment Vital signs and oxygen saturation, pre and post treatment Medication and dosage Tolerance to treatment Other relative information. Review of the administration records and progress notes dated 02/01/24 and 03/13/24 indicates the staff has not documented pre and post assessments for the nebulizer treatment administration. Interview with The Director of Nursing (DON) conducted on 03/13/24 at approximately 1:40 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686128 If continuation sheet Page 3 of 10 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 686128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ardie R Copas State Veterans Nursing Home 13000 SW Tradition Parkway Port Saint Lucie, FL 34987 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed the facility policy for nebulizer treatment administration does not address cleaning the mask after each use and furthermore documents to dispose the tubing and mouthpiece. The DON stated the nebulizer supplies are good for a week and they are to be clean after each use. Interview with Staff A conducted on 03/13/24 at 1:44 PM confirmed during the medication administration observation she did not perform pre and post assessment for the nebulizer treatment and did not clean or dispose of the nebulizer mask after use. Staff A elaborated they have a schedule to clean the nebulizer machines and change the supplies weekly. 2) Observation of care conducted on 03/13/24 at 8:32 AM revealed Resident #40 sitting at the dining table, being assisted with the breakfast meal. The resident had oxygen via a nasal cannula, a portable oxygen tank was observed on the back of the wheelchair. There was no humidifier in use. Observation of care conducted on 03/13/24 at 10 AM revealed the resident being transported from the common area to the outside patio. The resident had oxygen via a nasal cannula, an oxygen tank was observed on the back of the wheelchair. There was no humidifier in use. Observation of care conducted on 03/13/24 at 11:53 AM revealed the resident in the dining area, awaiting the lunch meal. The resident had oxygen via a nasal cannula, an oxygen tank was observed on the back of the wheelchair. There was no humidifier in use. Observation of care conducted on 03/13/24 at 12:59 PM revealed the resident remains in the dining area after completion of the lunch meal. The resident had oxygen via a nasal cannula, an oxygen tank was observed on the back of the wheelchair. There was no humidifier in use. Interview with Staff B, a Licensed Practical Nurse, conducted on 03/13/24 at 1:10 PM verified Resident #40 is to have the humidifier at all times and is not receiving it at the time of the interview. Staff B explained the reason was the resident was outside for activities. Staff B confirmed the common areas have multiple floor plugs to ensure the oxygen concentrator can be in use and proceeded to instruct the aide to remove the portable oxygen tank and use the resident's concentrator. Clinical record review revealed physician's orders dated 11/15/23 for oxygen at 2 liters via nasal cannula with humidifier administered continuously. Check placement and functioning of oxygen and tubing at regular intervals throughout the shift. Physician's order dated 01/04/24 for Saline Gel spray, place a small amount of gel into each nostril three times a day as needed for nasal dryness. Care plan titled Resident has been admitted to Hospice related to diagnosis of Cerebral Atherosclerosis last revised 02/12/24 documents interventions as: Administer oxygen as ordered, check oxygen and nebulizer tubing weekly and check placement and functioning of oxygen at regular intervals throughout the shift. The observations conducted on 03/13/24 verified the staff is not implementing the physician's orders and plan of care for Resident #40. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686128 If continuation sheet Page 4 of 10 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 686128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ardie R Copas State Veterans Nursing Home 13000 SW Tradition Parkway Port Saint Lucie, FL 34987 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to ensure 1 of 2 medication carts in 1of 3 units (Freedom) were free of expired medications, and 1 of 1 treatment carts was secured. The findings included: On 03/11/24 beginning at 12:16 PM medication storage review process was started at the Freedom unit, with Staff C, a License Practical Nurse (LPN). While checking one of the medication carts, two expired pills bottles were found: 1) Calcium carbonate 500 mg chewable, expired since 01/2024, It was opened and used. There were no other Calcium carbonate 500 mg pill bottles in the cart; and 2) Aspirin 325 mg enteric coded expired 01/2024 there were 4 pills remaining in the bottle. There were no other Aspirin 325mg pill bottles in the med cart. Staff C confirmed the finding. On 03/13/24 at 10:03 AM, an interview was conducted with the Director of Nursing (DON); she was made aware of the expired medication bottles. A request of a list of residents at the Freedom Unit who were on Aspirin 325 mg and Calcium Carbonate 500 mg was made. She provided a list of 2 residents (Resident #44 and Resident #51). On 03/13/24 at 11:18 AM, a review of these residents' medication administration records was conducted for March 2024; it was revealed that Resident #44 had received Aspirin 325 mg from 03/01/24 through 03/11/24 in the morning. Record review indicated that Resident #44 was admitted to the facility on [DATE] with diagnoses that included Heart Failure. The Minimum Data Set assessment, reference date 03/11/24, indicated a brief interview mental status score of 09 which indicated Resident #44 was moderately cognitively impaired. On 03/13/24 at 1:00 PM, when walking to the Liberty Unit, a treatment cart was noted to be unlocked and unattended. When the surveyor opened the cart, several ointments/powders and lotions were observed Nystatin Powder, Vanicream HC, Triple Antibiotic, Triamcinolone, and Ketoconazole Shampoo. On 03/13/24 at 1:05 PM, an interview was held with the DON, and she was made aware of the finding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686128 If continuation sheet Page 5 of 10 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 686128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ardie R Copas State Veterans Nursing Home 13000 SW Tradition Parkway Port Saint Lucie, FL 34987 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 0775 Keep complete, dated laboratory records in the resident's record. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure laboratory results were included as part of the resident's record for 4 of 20 sampled residents (Residents #20, #42, #52, and #4). Residents Affected - Few The findings included: 1) During a phone interview on 03/13/24 at 11:28 AM, the daughter of Resident #20 stated she was concerned as she had not heard about recent laboratory results. The daughter explained the facility was going to check on the resident's kidney function, and she had not heard back. Review of the record revealed Resident #20 was admitted to the facility on [DATE]. Review of physician orders revealed the following recent laboratory values were to be obtained: On 01/03/24 an ammonia level. On 02/19/24 a comprehensive metabolic panel (CMP). Review of the electronic and paper records lacked the results of these ordered labs. Results of previously obtained ammonia and CMP test results revealed abnormal levels. During an interview on 03/13/24 at 12:59 PM, Staff B, Licensed Practical Nurse (LPN), was unable to locate the results for these two ordered labs. 2) Review of the record revealed Resident #42 was admitted to the facility on [DATE]. Review of the current physician orders revealed as of 10/13/23 a Comprehensive Blood Count (CBC), Basic Metabolic Panel (BMP) and Valproic Acid (VPA) level were to be drawn on that date, and every three months thereafter. Results from the 01/13/24 laboratory draw were not found in the electronic or paper records. 3) Review of the record revealed Resident #52 was admitted to the facility on [DATE]. Review of physician orders revealed the following laboratory values were to be obtained: On 01/05/24 a CBC. On 02/05/24 a CMP. Review of the electronic and paper records lacked the results of these ordered labs. 4) Record review revealed Resident #4 was admitted to the facility on [DATE], with diagnosis that included End Stage Renal Disease. The quarterly Minimum Data Set assessment, reference date 02/12/24, recorded a BIMS score of 15, which indicated Resident #4 was cognitively intact. Review of a laboratory test order dated 02/04/24 for complete blood culture every 2 weeks on Tuesdays to be completed on 02/06/24, 02/20/24, and 03/05/24. On 03/13/24 at 12:23 PM an additional record review was conducted in search of the LAB test results (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686128 If continuation sheet Page 6 of 10 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 686128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ardie R Copas State Veterans Nursing Home 13000 SW Tradition Parkway Port Saint Lucie, FL 34987 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 0775 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in the computer system. It was revealed that the lab result dated 02/07/24 was uploaded, however the LAB result for 02/20/24 and 03/05/24 were not uploaded nor filed in the physical chart. On 03/13/24 at 1:25 PM, an interview and a side-by-side review of Resident #4's electronic records and the physical chart was conducted with the Director of Nursing (DON), and she confirmed that the LAB results were not in the resident's records. She revealed that she printed the result when the surveyor had requested it from the LAB website. When inquired of the facility's process for addressing LABs, the DON voiced that the LAB results automatically get faxed to the facility. Then they get placed in the doctor's folder for signature. Afterwards, they are to get uploaded in the computer, and a copy is to be placed in the physical chart. During an interview on 03/13/24 at 3:02 PM, the Director of Nursing provided all requested laboratory results, and stated she had to print them directly from the laboratory. The DON explained the expected process is that the laboratory would fax the results of all ordered labs to the facility. The Direct Care Nurse was responsible to obtain, review, and notify the Physician of the results. The laboratory results were then placed in a folder for Physician signature and then scanned into the electronic records. The results could also be placed in the paper chart. The DON agreed these results had not been part of the clinical records of Residents #20, #42, #52, and #4. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686128 If continuation sheet Page 7 of 10 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 686128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ardie R Copas State Veterans Nursing Home 13000 SW Tradition Parkway Port Saint Lucie, FL 34987 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to disinfect the glucometers (devices used to obtain a blood sugar level from a drop of resident blood), as per facility policy and manufacturer's instructions, before and after use for 3 of 3 sampled residents (Residents #58, #24, and #34). The facility also failed to follow enhanced barrier precautions (EBP), as per their policy and CDC (Centers for Disease Control and Prevention) recommendation for 2 of 2 sampled residents with wounds (Resident #52 and #42). Residents Affected - Few The findings included: 1) Review of the policy Blood Glucose Monitoring: Clinical Guidelines revised 09/26/19 documented, C. Cleaning/Disinfecting Blood Glucose Meters. Blood glucose equipment will be cleaned/disinfected before and after use per the manufacturer's instructions. Review of the manufacturer's instructions for the Assure Platinum Blood Glucose monitoring System (the glucometer) documented, Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. follow product label instructions to disinfect the meter. Review of the Sani-Wipe Germicidal Disposable Wipe instructions documented, To disinfect and deodorize hard, nonporous surfaces: . Unfold a clean wipe and thoroughly wet surface. Allow surface to remain wet for two (2) minutes. Let air dry. During an observation on 03/13/24 at 4:18 PM, Staff E, Registered Nurse (RN), prepared items to obtain a blood sugar level for Resident #58. The RN was unable to locate the resident's individual glucometer, stating the resident had recently been on a different unit, so she obtained the spare glucometer from the medication cart. The RN wiped the spare glucometer with a Sani-Wipe disinfectant wipe, and immediately wrapped the glucometer in a tissue. After three minutes, the RN unwrapped the glucometer, went into the room of Resident #58, and obtained the resident's blood sugar level via a drop of blood. Staff E returned to the medication cart, wiped the glucometer with a small individual alcohol wipe, and wrapped it in a tissue. After about five minutes the RN placed the clean, but not disinfected, glucometer back into the plastic bag and into the medication cart. During the continued observation on 03/13/24 at 4:32 PM, Staff E obtained the items to complete a blood sugar level for Resident #24. The RN obtained the resident's individual glucometer, placed it and the other needed items on a disposable tray, and went into the resident's room. The RN obtained the blood sugar level, placed the glucometer directly on the resident's over the bed table, and then on the resident's sink while washing her hands. The RN threw away the used items, but left the disposable tray at the bedside. Upon return to the medication cart, Staff E cleaned the glucometer with a small individual alcohol wipe and wrapped it in a tissue, later returning it to the plastic bag in the medication cart. During the continued observation on 03/13/24 at 4:43 PM, Staff E used the individual glucometer for Resident #34 to obtain his blood sugar level, and again wiped it with a small alcohol wipe, wrapped it in a tissue, and then later placed it back into the medication cart. During an interview after these observations, Staff E, RN, stated if she used a glucometer for more (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686128 If continuation sheet Page 8 of 10 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 686128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ardie R Copas State Veterans Nursing Home 13000 SW Tradition Parkway Port Saint Lucie, FL 34987 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few than one resident she would disinfect it using the Sani-Wipe, but otherwise she used the alcohol wipe. Upon review of the disinfectant wipe instructions regarding the 2 minute wet time, the RN agreed that wrapping the glucomenter in a tissue would not follow the instructions. The RN had no other reason she failed to disinfect each glucometer. During an interview on 03/14/24 at 9:26 AM, when told of the observations with Staff E, the Infection Control Preventionist (ICP) agreed with the concerns. 2) Review of the facility policy Multi Drug Resistant Organisms (MDRO) revised 11/08/22 documented, Procedures: . Guidance from the CDC suggests that MDRO transmission is common in skilled nursing facilities. The CDC suggests that focusing only on those residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization which contributes to the silent spread of MDROs. As such, their recommendation to implement EBP as an infection control intervention will be followed by the FDVA (Florida Department of Veterans' Affairs). This recommended use of PPE employs targeted gown and glove use during high contact care activities for the following residents due to their higher vulnerability: Residents with a wound and/or indwelling medical device such as a urinary catheter, central line, or a feeding tube. High Contact resident care activities included dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. Resident #42 was admitted to the facility on [DATE]. Review of the wound care physician's progress note dated 03/05/24 documented Resident #42 had a stage 3 (full thickness ulcer that might involve the subcutaneous fat) pressure injury to the right heel, with wound care being provided three times weekly. Review of the record lacked any indication for the use of Enhanced Barrier Precautions (EBP). An observation on 03/11/24 at 3:14 PM lacked any sign for EBP or available Personal Protective Equipment (PPE) at or about the room of Resident #42. During an observation on 03/13/24 at 3:35 PM, Staff F, Registered Nurse (RN) provided wound care to the right heel of Resident #42. The RN wore gloves, but failed to wear a gown during the provision of wound care. During an interview on 03/14/24 at 12:55 PM, when asked about the use of EBP in the facility, Staff D, Licensed Practical Nurse (LPN) stated, You mean Standard Precautions? After explaining EBP to Staff D, the nurse stated, Oh yeah, like we use for (name of resident with a dialysis catheter). When asked if EBP was used for residents with open wounds, the nurse stated she was unaware of that recommendation. Resident #52 was admitted to the facility on [DATE]. Review of the record revealed a stage 3 pressure ulcer of the coccyx was identified on 10/22/23. As of 12/06/23 the wound had light drainage, and had been noted by the Wound Care Physician on 12/05/23 as a declining stage 3 wound. As of 02/15/24 the Physician documented the wound as improving. Review of the orders revealed the wound was present at the time of the survey and wound care was being provided three times weekly. Further review of the record and observation of the resident's room lacked any evidence of the use of EBP. During an interview on 03/14/24 at 1:09 PM, the ICP agreed the facility had implemented the use of EBP, as per their policy and CDC guidelines. When asked about the use of EBP for residents with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686128 If continuation sheet Page 9 of 10 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 686128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ardie R Copas State Veterans Nursing Home 13000 SW Tradition Parkway Port Saint Lucie, FL 34987 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 0880 Level of Harm - Minimal harm or potential for actual harm wounds, the ICP stated the precautions were used when a resident had a significant open wound, or with tunneling and/or drainage. During a side-by-side review of the policy, the ICP agreed the EBP were to be used for a resident with a wound. Further review of the CDC guidance revealed if the wound was insignificant, such as a skin tear, EBP was not necessary, but otherwise, the use of EBP was recommended for a resident with a wound. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686128 If continuation sheet Page 10 of 10