Health inspection·March 21, 2024

F 0688 Resident #108's left hand was noted to be contracted. Level of Harm - Minimal harm or potential for actual harm Review of the Physician's orders showed an order dated 02/16/24 for a left-hand splint after AM [morning] care and off HS [hour of sleep]. Review of the Occupational Therapy Evaluation dated 01/25/24 to 02/23/24 revealed that Resident #108 will tolerate a left-hand orthotic for up to hours to improve skin and joint integrity. Residents Affected - Few An interview was conducted on 03/20/24 at 2:07 PM with Staff E, Occupation Therapist Assistant who stated Resident #108 has a resting hand splint that needs to be placed on the Resident's left hand at AM after morning care and off at PM. She further stated Resident #108 has a left-hand contracture, and the splints will prevent skin breakdown and hygiene. Staff E accompanied the surveyor to Resident #108's room. The surveyor pointed at the resting hand splint at the side table and asked if it needed to be placed on Resident #108, and she said yes. Staff E reported that it is the responsibility of the Certified Nursing Assistants (CNAs) who are taking care of Resident #108 to place the splint on the left hand after morning care. An interview was conducted on 03/20/24 at 2:14 PM, Staff D, Certified Nursing Assistant (CNA), who stated that hand splints are placed on residents by the restorative team and sometimes by the Certified Nursing Assistants. She usually places it on residents after morning care. Staff D was asked if Resident #108 had a hand splint, and she said, I do not know. She was then asked to accompany the surveyor to Resident #108's room. When asked why the left-hand splint was not placed on Resident #108, she said that the restorative staff put it on this morning and must have removed it. An interview was conducted on 03/20/24 at 2:24 PM with Resident #108, who stated the staff has yet to place his left-hand splint on him all week. An interview was conducted on 03/20/24 at 2:50 PM with Staff F, Restorative Certified Nursing Assistant, who stated that she is assigned to some residents on the floor who have orders for hand splints and the designated Certified Nursing Assistant (CNA) assigned for the day. The splints are usually placed after morning care and taken off before she leaves, which is around 3:30 PM to 4:00 PM. She further said that since Resident #108 is on a maintenance program, it is the responsibility of his assigned CNA to place the hand splints on him. When asked if it was placed on Resident #108 this morning, she said that his CNA (Staff D) was assigned to him this morning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105119 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 105119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wilton Manors Healthcare & Rehabilitation Center 2675 N Andrews Ave Wilton Manors, FL 33311 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide nutritional interventions in a timely manner to prevent further weight loss for 1 of 5 sampled residents reviewed for nutrition, Resident #101. Residents Affected - Few The findings included: Review of the facility policy, titled, Nutrition Assessment, revised in October 2017, revealed the following: Any weight change of 5% or more since the last weight assessment will be verified, and nursing will contact the Dietitian for further evaluation. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends. Negative trends will be evaluated by the treatment team to determine whether or not the criteria for significant weight change has been met. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria where the percentage of body weight loss == (usual weight actual weight) (usual weight) - 100]: a. month 5% weight loss is significant; greater than 5% is severe. b. - 3 months -7.5% weight loss is significant; greater than 7.5% is severe. C. months - 10% weight loss is significant; greater than 10% is severe. Record review documented Resident #101 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia, Dysphagia, and Muscle Weakness. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/25/24, documented Resident #101 has a Brief Interview of Mental Status (BIMS) score of 14, indicating cognition was intact. Section B on the MDS revealed Resident #101's speech was unclear. Review of the Physician's orders, which started on 02/26/24 and discontinued on 03/05/24, revealed an order for a med pass (nutritional supplement) of 120 milliliters (ml) three times a day. It further revealed another order for a med pass written on 03/05/24. A phone interview was conducted on 03/18/24 at 4:00 PM, with Resident #101's Fiancé who stated she spoke to the facility's Dietitian a few weeks ago regarding her concerns with Resident #101's continued weight loss. The Dietitian told her she would review updating Resident #101's food preferences but had not heard back from her. In an observation conducted on 03/19/24 at 9:05 AM, Resident #101 was noted in his bed. Staff P, Certified Nursing Assistant (CNA), was noted setting up the breakfast tray for Resident #101 at the bedside. She then proceeded to feed Resident #101 his breakfast meal. The breakfast tray was observed with a regular puree diet and 4 ounces of a mighty shake (nutritional supplement). Continued observation revealed Resident #101 ate 50% of his breakfast tray but did not drink any of the mighty shakes on his tray. In an observation conducted on 03/20/24 at 8:47 AM, Resident #101 was eating his breakfast tray in his room. Staff D, CNA, was sitting near the resident, assisting him with his breakfast tray. The breakfast tray was noted to have a mighty shake (nutritional supplement). Staff D stated that when the resident is done eating, she will document the total amount consumed for the entire meal but will not document the percentage consumed from the nutritional supplement. Review of the Weight Log revealed Resident #101 had dropped from 11/03/24 to 02/07/24 from 148.2 pounds to 136.4 pounds, which was 8.3% severe weight loss in 3 months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105119 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 105119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wilton Manors Healthcare & Rehabilitation Center 2675 N Andrews Ave Wilton Manors, FL 33311 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a quarterly dietary profile note dated 02/26/24 noted it was written 19 days after Resident #101 had the significant weight loss. In this note, the facility's Dietitian recommended adding an additional nutritional supplement with med pass 120 ml three times a day. The Dietitian noted that Resident #101's Usual Body Weight was 150 pounds, and that Resident #101 had a weight loss of 8% in 2 months. The care plan dated 02/24/24 revealed Resident #101 was at risk for alteration in nutrition. It included Resident #101 will remain free from significant weight loss and to notify the Physician of significant weight changes if noted. Review of the Medication Administration Record (MAR) for March 2024 showed that the med pass nutritional supplement was not documented as given to Resident #101 after 03/05/24. An interview was conducted on 03/20/24 at 3:25 PM with the Dietitian who stated the mighty shakes are placed on the meal trays from the kitchen and that the nurses provide the med pass. The nursing aides will include the percent intake of the resident's meals in their documentation, but it is overall and not specific for the nutritional supplements. When asked how she knows if a resident is drinking any of the nutritional supplements that are placed on the meal tray, she stated that the nursing staff will let her know verbally. The Dietitian reported that she would run the Weight and Vital reports daily to review any severe weight loss triggered for all residents. When asked as to why she only addressed Resident #101 with a severe weight loss of 8.3% 19 days later, she did not know. She stated the electronic system would usually pop up with a significant weight loss when identified but was unsure why it did not for Resident #101. The Dietitian said she placed the order for a med pass on 02/26/24 but was wondering why it was not given after 03/05/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105119 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 105119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wilton Manors Healthcare & Rehabilitation Center 2675 N Andrews Ave Wilton Manors, FL 33311 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review documented Resident #230 was admitted to the facility on [DATE], with diagnoses to include Dependence on Renal Dialysis, Peripheral Vascular Disease, and Acquired absence of right leg below knee. On the 02/27/24, the Comprehensive Nursing Evaluation documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. On 03/19/24 at 9:20 AM, Resident #230 was observed eating his breakfast during medication administration. Resident #230 was observed with 2 fried eggs on his plate, a slice of toast and a half slice of an orange. Photographic evidence obtained. An observation of his meal ticket revealed the resident was on a renal diet, mechanically altered / ground diet. An interview was conducted with the resident at this time that revealed he was not happy with the breakfast and requested a ham sandwich. He had spoken to Staff O, Licensed Practical Nurse (LPN), and had requested a ham sandwich. Staff O asked Staff G, Certified Nursing Assistant, to bring him a ham sandwich. Shortly after that Staff G came back with a ham sandwich on white bread and the resident began eating it. On 03/19/24 at 3:33 PM, an interview was conducted with Staff C, Speech Therapist. Staff C was asked if fresh fruit, specifically an orange slice, was part of a mechanical soft diet and she stated it was not. On 03/19/24 at 4:09 PM, an interview was conducted with the Registered Dietician (RD) regarding Resident #230's diet order. It was explained to the RD that a ham sandwich was given to the resident and the RD stated that the nurse should have referred the resident to the dietician before giving the ham sandwich since a ham sandwich is not part of a mechanical soft diet. Based on observations, interviews, and record review, the facility failed to provide the correct food consistency for 3 of 3 sampled residents who were on a mechanical soft / chopped, who were observed during dining, Resident #34, Resident #87, and Resident #230. This has the potential to affect 30 residents on a mechanical soft/chopped diet. The census at the time of the survey was 138 residents. The findings included: Review of the facility's diet manual dated 2019, provided by the facility's Dietitian, showed the following foods that were allowed on the mechanical soft diet: canned fruits, cooked or steamed fruit desserts, ripe banana, diced watermelon, diced ripe melon, diced ripe strawberries, and smooth fruit sauces. It further showed that all other fresh fruits were not allowed. Review of the International Dysphagia Diet Standardization Initiative dated 2019, provided by Staff C, Speech Therapist, revealed the following: Level 5 minces and moist diet, to provide fruits served minced or chopped or mashed for level 6 soft bite-sized diet, to provide fruits that are soft enough to be cut into small pieces and not use the white part of an orange. 1a. Record review documented Resident #34 was admitted to the facility on [DATE] with diagnoses to include Dysphagia and Dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105119 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 105119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wilton Manors Healthcare & Rehabilitation Center 2675 N Andrews Ave Wilton Manors, FL 33311 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 0805 a Brief Interview of Mental Status (BIMS) score of 05, indicating severe cognitive impairment. Level of Harm - Minimal harm or potential for actual harm In an observation conducted on 03/18/24 at 1:04 PM, Resident #34 was noted eating her lunch in the Emerald dining room. Closer observation revealed a meal ticket with the following: Residents Affected - Few Regular mechanically altered ground pork. Mechanically altered ground orange twist. Mechanically altered ground black-eyed peas. Closer observation of the meal plate revealed a fresh 1/2 slice of an orange a quarter of an inch thick. Photographic Evidence Obtained. 1b. Record review documented Resident #87 was admitted to the facility on [DATE] with diagnoses to include Dysphagia and Dementia. The annual MDS assessment dated [DATE] showed a BIMS score of 06, indicating severe cognitive impairment. In an observation conducted on 03/18/24 at 1:04 PM, Resident #87 was noted eating his lunch in the Emerald dining room. Closer observation revealed a meal ticket with the following: regular mechanically altered ground pork, mechanically altered ground orange twist, and mechanically altered ground black-eyed peas. Closer observation of the meal plate revealed a fresh 1/2 slice of an orange that was a quarter of an inch thick. The mechanically altered ground pork was observed in chunks and not ground. An interview was conducted on 03/19/24 at 3:30 PM with Staff C, Speech Therapist, who stated the facility only has one type of mechanical soft diet. Fresh fruits are not part of a mechanical soft diet but are often used as a garnish. When asked if a mechanical soft / ground diet should have fresh fruit on the plate, she said no. Staff C stated she did not know why the mechanical soft diets on the meal tickets had altered ground noted. An interview was conducted on 03/19/24 at 4:17 AM with the Culinary Service Manager, who stated they have a mechanical soft diet in the facility and that the food provided on this diet is altered ground meat. She further stated they follow the 2019 diet manual and that soft, fresh foods are allowed on mechanical soft diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105119 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 105119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wilton Manors Healthcare & Rehabilitation Center 2675 N Andrews Ave Wilton Manors, FL 33311 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain a proper sanitizing solution in the central kitchen for 2 of 3 red buckets observed during the initial tour of the kitchen; and failed to offer or encourage hand hygiene prior to dining for 5 of 5 sampled residents observed during dining, Residents #10, #24, #381, #99, and #69. The findings included: 1. The first visit to the central kitchen was conducted on 03/18/24 at 8:50 AM, accompanied by the Culinary Food Manager. The following issues were observed: a. The Culinary Food Manager used a testing strip taken from the (Hydrion quaternary sanitizer test tape) to check the concentration of the solution from the first red bucket. Further observation showed the test strip read 500 ppm (parts per million). This revealed that the concentration solution in the 1st red bucket was too high. In this observation, the Culinary Food Manager stated that the reading of 500 ppm was too high. b. The Culinary Food Manager used a testing strip taken from the (Hydrion quaternary sanitizer test tape) to check the concentration of the solution from the 3rd red bucket. Further observation showed that the test strip read 500 ppm (parts per million). This revealed that the concentration solution in the 3rd red bucket was too high. In this observation, the Culinary Food Manager stated that the reading of 500 ppm was too high. c. The Artic Air commercial refrigerator reach-in had an unidentified container of food that needed to be dated and labeled. d. The walk-in freezer was noted to have debris all around the floor. Photographic Evidence Obtained. e. The dry storage area was noted to have a 6-pound, 10-ounce can of tropical fruit salad can that was dented. 2. Record review documented Resident #10 was admitted to the facility on [DATE] with diagnoses to include Dysphagia, Dementia, and Anxiety Disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #10 has severe cognitive impairment. In an observation conducted on 03/20/24 at 8:42 AM, Staff B, Certified Nursing Assistant, brought the breakfast tray into Resident #10's room and placed it on the side table. Staff B helped Resident #10 to a sitting position and set up the tray in front of the resident. Resident #10 started eating her breakfast food using her fingers. Staff B did not wash or use hand sanitizer to clean Resident #10's hands before she started eating. 3. During dining observation of Resident #24 on 03/19/24 at 8:45 AM, the surveyor asked Staff M, CNA, if she performs handwashing to residents who were unable to get up. She stated that she encourages residents to wash their hands and she just completed giving hand wipes to the resident. She further added that she tossed the wipes in the trash bin. When the surveyor requested Staff M to show her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105119 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 105119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wilton Manors Healthcare & Rehabilitation Center 2675 N Andrews Ave Wilton Manors, FL 33311 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few where the discarded wipes were, Staff M divulged that she did not wash the hands of the resident or offered him hand wipes today. 4. Resident #83 was observed in the dining hall on 03/19/24 at 12:03 PM. Staff were observed washing their hands before touching the contents of the food cart, but the surveyor did not observe staff encouraging Resident #83 to wash her hands or offer hand sanitizer to her. 5. Resident #381 was observed in his room receiving a snack post dialysis on 03/18/24 at 10:45 AM. There was no bottle of sanitizer or hand wipes observed when snacks were placed on the resident's overbed table. 6. Resident #99 was observed in his room receiving lunch on 03/19/24 at 1:10 PM. The facility failed to provide the resident with hand wipes or hand sanitizer prior to eating his lunch meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105119 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 105119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wilton Manors Healthcare & Rehabilitation Center 2675 N Andrews Ave Wilton Manors, FL 33311 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide restorative rehabilitation services in a manner that promotes the highest practicable level of functioning for 1 of 5 sampled residents receiving restorative services during dining (Resident #10). Residents Affected - Few The findings included: Review of the facility policy, titled, Restorative Nursing Services,, revised in July 2017, revealed that Residents would receive restorative nursing care as needed to help promote optimal safety and independence. Residents may start on restorative nursing programs upon admission, during stay or when discharged from rehabilitative care. Restorative goals may include: Supporting and assisting the Resident in adjusting or adapting to changing abilities. Maintaining dignity, independence, and self-esteem. Developing and strengthening physiological and psychological resources. Resident #10 was admitted to the facility on [DATE] with diagnoses of Dysphagia, dementia, and anxiety disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident has severe cognitive impairment. Review of the Physician's orders, dated 10/30/23, revealed an order for all food to be served in bowls and beverages in coffee cups with each meal to assist with safe self-feeding. The care plan dated 01/02/24 revealed Resident #10 would participate in the Restorative Nursing Programs: Dining will improve / maintain current self-care abilities related to participation in specified restorative programs as ordered by the next review. Allow adequate time to eat and provide interventions as needed. In an observation conducted on 03/19/24 at 9:00 AM, Resident #10 was noted in her room with Staff B, Certified Nursing Assistant (CNA), standing near Resident #10, feeding her the breakfast meal. Resident #10 attempted to take the spoon from Staff B, who gently pushed Resident #10's hand away. In this observation, Staff B stated that Resident #10 likes to eat independently, but she makes a mess, and it is easier to feed the resident. Staff B continued feeding Resident #10, and at 9:10 AM (10 minutes later) took the breakfast tray out of the room. In an observation conducted on 03/19/24 at 12:15 PM, Resident #10 was noted in the Emerald dining room (Restorative Dining Room) eating her lunch meal with Staff A, Occupational Therapist (OT), sitting near the resident. Resident #10 was observed eating a peanut butter sandwich with no issues. She then picked up a mug/bowl with food inside and used a spoon to scoop the food towards her mouth. In this observation, Staff A stated that Resident #10 can handle a cup and use a spoon for eating, which is why the food is placed in cups and not on plates. She further said that Resident #10 needs supervision, so she sometimes does not pick up the food with her hands and needs reminding. Resident #10 eats in the Restorative dining room on weekdays from Mondays to Fridays. Staff A stated Resident #10 eats breakfasts and dinners in her room. The staff has been educated on the setup and feeding techniques for Resident #10 and said that, hopefully, they are following the same things she is doing with Resident #10 in the restorative dining room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105119 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 105119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wilton Manors Healthcare & Rehabilitation Center 2675 N Andrews Ave Wilton Manors, FL 33311 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the OT evaluation from 02/8/24 to 03/13/24 showed that Resident #10's Puree food will come in cups. Present cup handle to left hand and give teaspoon to Right hand with voice commend to use her spoon. [Resident #10] is with appropriate self-feeds utilizing her spoon with occasional reminders for use of the spoon. She completes 100% of intake with supervision. In an observation conducted on 03/20/24 at 8:42 AM, Staff B brought the breakfast tray into Resident #10's room and placed it on the side table. Staff B helped Resident #10 to a sitting position and set up the tray in front of the resident. Resident #10 started eating her breakfast food using her fingers. Staff B did not wash or use hand sanitizer to clean Resident #10 hands before she started eating. Continued observation showed Staff B encouraging Resident #10 to use the spoon to eat her meal. After a few minutes, Resident #10 used her fingers to scoop up the food and then started using the spoon to pick up the food. In this observation, Staff B was asked why she fed Resident #10 her entire breakfast meal yesterday and why she let Resident #10 eat independently with cueing today. Staff B said, I like her to be independent, and so I am letting her eat on her own. Event ID: Facility ID: 105119 If continuation sheet Page 10 of 10