Inspection·February 22, 2024

F 0693 initial that the label was checked against the order. Level of Harm - Minimal harm or potential for actual harm Documentation: Residents Affected - Few The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. Verification of tube placement. 3. Amount and type of enteral feeding. 4. The average fluid intake per day. 5. The name and title of the individual(s) who performed the procedure. 6. All assessment data obtained during the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. The signature and title of the person recording the data. 9. the signature and title of the person recording the data. Record review revealed Resident #42 was admitted to the facility on [DATE]. Review of the resident's most recent full assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 04, indicating the resident had severe cognitive impairment. Resident #42's diagnoses at the time of the assessment included: Anemia, Hypertension, Diabetes Mellitus, Hyperlipidemia, Non-Alzheimer's Dementia, Hemiplegia, Depression, Chronic lung disease, Dysphagia following cerebral infarction, Morbid obesity due to excess calories, Gastronomy status, and Constipation. Review of Resident #42's physician orders included: On 03/07/23, Nothing by Mouth diet, NPO texture, NPO consistency. On 10/11/23, Enteral Feed [TF] - every day shift for ON AT 2 PM AND OFF AT 10 AM Start Glucerna 1.5 cal@ 60ml/hr x 20hrs. With auto flushes at 50ml/hr x 20hrs. Turn on TF at 2pm and Turn off TF at 10am. Dispense 1200ml of formula and 1000ml of water. Review of Resident #42's care plan for enteral feeding, dated 09/17/28, documented, Resident is at risk for complications associated with enteral nutrition due to dx of: Dysphagia, Is NPO and receives enteral nutrition to meet nutritional and hydration requirements, clinically obese, has history of abnormal labs related to anemia, is advanced in age, has multiple nutrition related comorbidities including: (Cerebral Infarction, Constipation, Morbid obesity, Atherosclerosis, Dysphagia, Gastrostomy, HTN, HLD, Asthma, Vitamin B12 deficiency), has adjusted caloric needs to prevent weight gain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105125 If continuation sheet Page 2 of 9 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 105125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terraces of Lake Worth Care Center and Rehab 1711 6th Avenue South Lake Worth, FL 33460 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 0693 The goals of the care plan were documented as, Level of Harm - Minimal harm or potential for actual harm - Resident will remain free from significant weight gain (5% /30 days, 10%/180 days) and maintain adequate hydration thru the next review date. With a target date of 04/28/24. Residents Affected - Few - Resident will tolerate enteral feeding without complications thru the next review date. With a target date of 04/28/24. Interventions to the care plan included: - Administer treatment to peg site as per MD ordered. - Formula: Glucerna 1.5 as ordered - Verify tube feeding placement as ordered - Check enteral feeding residuals as ordered - Administer enteral feeding and flushes as ordered; observe for tolerance. - Weights as ordered and as needed. Notify physician of significant weight changes as needed. - Observe for complications r/t enteral feeding, aspiration, dehydration; update physician if noted. On 02/20/24 at 9:01 AM, Resident #42 was observed in bed with the TF initiated at 65 ml/hr (milliliters per hour). At the time of the observation, the date marked on the 1000 ml container documented it was initiated on 02/19/24 at 2:00 PM at a rate of 65 ml/hr. There was approximately 150 milliliters remaining in the 1000 ml-container of the supplement. At a rate of 65 ml/hr, the resident should have received approximately 1120 ml of supplement over the 19-hour period from the time the supplement was initiated. Review of Resident #42's electronic health record (EMR) revealed no documentation to justify why the enteral feeding was not being provided as ordered. An interview was conducted on 02/20/24 at 4:38 PM with Staff A, Licensed Practical Nurse (LPN). Staff A confirmed that the date marked on the container was accurate and that Staff A had administered the tube feeding. When asked why the feeding for the resident at not set at 60 ml/hr as the order documented, Staff A replied, Maybe I did it but that's how it was set from the last time. When asked about any reason for the order not met (1200 ml in 20 hours), Staff A replied, For some reason, the night nurse would change it when it runs out during the night shift. I was the one that changed it this morning. When they change the resident, they hold her feeding. I did not get any orders that she was having any problems. Staff A further stated that changing the resident and repositioning would take 'about 10 minutes or so.' At the conclusion of the interview, Staff A and the surveyor went to Resident #42's room. Resident #42 was observed in her bed with the tube feeding remaining at 65 ml/hr. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105125 If continuation sheet Page 3 of 9 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 105125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terraces of Lake Worth Care Center and Rehab 1711 6th Avenue South Lake Worth, FL 33460 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/21/24 at 7:18 AM, Resident #42 was observed in bed with tube feeding initiated at 60 ml/hr. The date mark on the container of supplement documented that it was initiated on 02/21/24 at 2:00 AM. At the time of the observation, there was approximately 850 ml of supplement remaining in the 1000 ml container. At a rate of 60 ml/hr, Resident #42 should have received 300 ml of the supplement. During an interview, on 02/21/24 at 7:26 AM, with Staff B, LPN, when asked about the resident's feeding being interrupted, Staff B replied, to change her they shut it off and sometimes she will pull it apart and it is hard to get it back on her, she fights and is combative and sometimes we can't get it back on her. When asked if there were any incidents as described, Staff B replied, Not on my time. I know that the nurses always complain about it. This is my second night working with her. The CNAs change her every two hours and I have to shut it off for them. If she is fighting it will take longer. Sometimes when I go back in there, she is fighting. Sometimes we have to wait until she calms down and have to go back in to restart it. When asked how long the feeding would be interrupted, Staff B replied, If not fighting, maybe about 10 minutes or so to change and reposition her. If she is fighting, sometimes we have to go back every 30 minutes. 2. Review of the facility's policy, titles, Weight Assessment and Intervention, revised March 2022, documented, in part: Weight assessment 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2. Weights are recorded in each unit's weight record chart and I the individual's medical record. 4. Unless notified of significant weight change, the dietitian will review the unit eight record monthly to follow individual weight trends over time. Care Planning 1. Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address to the extent possible: a. the identified causes of weight loss; b. goals and benchmarks for improvement; and c. time frames and parameters for monitoring and reassessment. Review of the care plans for Resident #42 for enteral feeding, dated 09/17/28, documented as follows, Weights as ordered and as needed. Notify physician of significant weight changes as needed. Review of Resident #42's electronic health record revealed there were no weights documented since 01/04/24. During an interview, on 02/21/24 at 2:47 PM Staff A, LPN, and Staff C, LPN, when asked about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105125 If continuation sheet Page 4 of 9 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 105125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terraces of Lake Worth Care Center and Rehab 1711 6th Avenue South Lake Worth, FL 33460 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few obtaining weights for Resident #42, Staff C stated that Staff H, Restorative CNA, was responsible for weights. An interview was condcuted on 02/21/24 at 2:50 PM, with Staff H, Restorative CNA, who confirmed she was responsible for obtaining residents' weights. When asked about the timing for residents' weights, Staff H replied, The DON or the NP [Director Of Nursing or Nurse Practitioner] verbally tell me. Every Wednesday I do weekly weights. The weights are documented in the computer in PCC (Point Click Care - the electronic health system used by the facility). The Restorative CNA further stated that she takes monthly weights on all residents in the last week of the month and documents the weights by the first week of the next month. When asked about weights for Resident #42, the Restorative CNA stated Resident #42 had not been weighed and was not on her list of residents to be weighed at this time. An interview was conducted on 02/21/24 at 3:40 PM with the Registered Dietitian who acknowledged the findings and stated that all residents were to be weighed monthly unless there was an order for different intervals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105125 If continuation sheet Page 5 of 9 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 105125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terraces of Lake Worth Care Center and Rehab 1711 6th Avenue South Lake Worth, FL 33460 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 on observations, interviews, and record review, the facility failed to secure medications at the bedside for 1 of 21 sampled residents, Resident #73. The findings included: Review of the facility's policy, titled, Storage of Medications, with a revised date of November 2020, included: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Record review for Resident #73 revealed the resident was originally admitted to the facility on [DATE] with a readmission date of 05/13/23 and with diagnoses that included: Paroxysmal Atrial Fibrillation, Need for Assistance with Personal Care, Unspecified Severe Protein-Calorie Malnutrition, Pressure Ulcer of Sacral Region Stage IV, and Spinal Stenosis Cervical Region. Review of the Minimum Data Set (MDS) assessment for Resident #73 dated 01/27/24 revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #73 revealed an order dated 01/05/24 for Cleanse sacrum with Dakin's solution 0.5% . Apply Collagen powder to wound bed first, hydrogel, calcium alginate, cover with bordered foam dressing daily every day shift for Wound care. An interview was conducted on 02/19/24 at 10:20 AM with the spouse of Resident #73 who stated she does the wound care 3 times a day. She brings in her own supplies. The spouse stated this is her choice because the nurses only do the wound care once a day, maybe around 2:00 (PM) and she has already cleaned her husband and changed his wound dressing twice by then. The spouse stated she is not working so she spends all day, every day with her husband. When asked if she had spoken to the nurses or the physician about her choices, she said no. When asked if she has attended any care plan meetings she said yes, but the wound care has never come up. An interview was conducted on 02/21/24 at 9:30 AM with Staff C, Licensed Practical Nurse (LPN), who was asked about Resident #73, and whether the spouse of the resident does any wound care. The LPN stated no, the nurses do wound care daily for the resident. An additional interview was conducted on 02/21/24 at 9:40 AM with spouse of Resident #73, who stated she is a massage therapist, is currently not working, and spends all day every day with the resident. The spouse was asked to clarify who is providing wound care for her husband, and stated the nurse does the wound care once a day and she does wound care 3 additional times a day. The spouse added the Wound Care Nurse comes once a week on Wednesdays to look at the wound, measures it, and sometimes scrapes the wound. When asked what she is using to provide wound care for the resident, she said let me show you. The spouse pulled items from the nightstand and laid them on the resident's bed. The items included: Bactine Max Wound Wash that contained Benzalkonium Cl 0.13%, Wound Wash (sterile saline), Bactine Max containing 4% Lidocaine HCL, 2 different kinds of disposable moist wipes, Witch Hazel Alcohol 14%, Aloe gel, Triple Antibiotic ointment, Vaseline Healing Jelly (Petroleum), surgical pads, and honeycomb gauze dry wipes. The spouse stated she cleans the wound by spraying the Bactine Max Wound Wash directly into the wound and wipes it out of the wound with the honeycomb gauze dry (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105125 If continuation sheet Page 6 of 9 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 105125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terraces of Lake Worth Care Center and Rehab 1711 6th Avenue South Lake Worth, FL 33460 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 wipe, sprays the Bactine Max with 4% Lidocaine for pain, wipes that off with the honeycomb gauze dry wipe, and wipes the wound out with the facility provided moist wipes that she has prepared by adding the Hypochlorite to the wipes (a solution also known as Dakin's Solution) which she gets from the nurses at the facility. The spouse stated she then takes a big scoop of the Vaseline Healing Jelly, fills the wound completely, and places a surgical pad over the wound, which is held in place by the diaper. The spouse said she wipes the resident's back with the other moist wipes she has prepared with Witch Hazel, mixes the Aloe Gel with the Triple Antibiotic ointment, and rubs on his back, so he does not get any rashes. When asked about the Hypochlorite solution, she said she gets that from the nurses. An interview was conducted on 02/21/24 at 12:05 PM with Staff D, Advanced Registered Nurse Practitioner (ARNP) with the Wound Care Company, who sated she follows Resident #73's wound care. When asked if she is aware that Resident #73's spouse is performing wound care, she stated no. When asked if the resident's spouse has shown her any over the counter mediations that she uses on the resident, she stated no. The ARNP stated that sometime when she goes into the room to examine the resident, the spouse has prepared the resident on his side and removes the old dressing for her so she can view the wound. An interview was conducted on 02/21/24 at 12:10 PM with the Director of Nursing (DON) who was asked if they are aware the spouse of Resident #73 provdes wound care for the resident. The DON stated she was not aware, and that the nurses do the wound care. The DON and the ARNP accompanied the surveyor to Resident #73's room, where the spouse showed the products she uses for the resident. The DON and ARNP acknowledged the medications at the bedside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105125 If continuation sheet Page 7 of 9 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 105125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terraces of Lake Worth Care Center and Rehab 1711 6th Avenue South Lake Worth, FL 33460 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide timely dental services for 1 of 1 sampled resident, reviewed for dental services, Resident #78. Residents Affected - Few The findings included: The facility's policy, titled, Dental Consultant, revised April 2007, had a section, titled, Policy Interpretation and Implementation. Item #2 describes the services provided by the Consultant Dentist. Letter b documented the following: b. Providing a dental assessment of each resident within ninety (90) days of admission. Record review revealed Resident #78 was admitted to the facility on [DATE]. On 02/19/24 at 3:10 PM, an interview was conducted with Resident #78 during the Initial Pool process. At the time of the interview, the surveyor observed that Resident #78 had missing teeth in his right lower jaw, at the front of his mouth. Resident #78 was asked if he was okay with the missing teeth, and indicated he was not. When Resident #78 was asked if he wanted to see the dentist about the missing teeth, he replied yes. Record review conducted immediately after the interview revealed there were no orders for Dental Consultation prior to 02/19/24. This review included searching for active orders, completed orders, and crossed out orders. Using an Excel spreadsheet function to calculate 90 days from admission, which is the maximum number of days per the policy, the latest date for a dental consultation should be 11/12/23. The dental consultation order was placed on 02/19/24, which was 189 days after the admission date. On 02/21/24 at 9:39 AM, an interview was conducted with the Nursing Home Administrator (NHA) to determine how dental services are requested. The NHA stated that the nurses or CNAs would be responsible to make the request. The NHA elaborated that the CNAs should tell the nurse if a resident told them that dental services were needed or if the CNA noted the resident had pain or other dental issues. The nurse would be responsible for obtaining the order, if needed, and then informing the Social Services Director (SSD) who would contact the dental consultant's office to arrange for services. On 02/21/24 at 9:52 AM, an interview was conducted with Staff G, Certified Nursing Assistant (CNA), who stated if a resident complains of a tooth ache or asks to see the dentist, then Staff G would tell the nurse immediately. Staff G stated if the resident can't find their dentures, she tells the nurse and then searches the resident's room for the missing dentures. Staff G indicated there was no reason she could think of, where a resident would not get to see the dentist. On 02/21/24 at 10:50 AM, record review revealed that Staff F, Registered Nurse (RN), had documented in the admission note in the nurses' progress notes that Resident #78 clearly was identified as having missing teeth. On 02/21/24 at 1:40 PM, an interview was conducted with Staff F, regarding the observation of the resident's missing teeth upon admission. Staff F was asked why there was no dental consultation ordered for Resident #78, who stated she did not know why she did not further pursue the missing teeth as documented. The nurse agreed that she should have determined if the resident wanted a dental visit and then obtained an order for a dental visit if required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105125 If continuation sheet Page 8 of 9 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 105125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terraces of Lake Worth Care Center and Rehab 1711 6th Avenue South Lake Worth, FL 33460 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/21/24 at 1:48 PM, an interview was conducted with the Social Services Director (SSD) regarding dental consults. The SSD explained residents' needs are discussed either in the morning clinical meeting or the afternoon clinical meeting. The morning meeting is used to discuss issues from the previous night, or the weekend on Mondays, and the afternoon meeting is used to discuss new issues that had occurred during the day before the close of business for the day. The SSD explained when she is informed a resident needs dental services, she contacts the provider and then faxes the face sheet with insurance information to the provider. This allows the provider to obtain insurance authorization for services rendered. The SSD arranges for the dentist to come to the facility for the residents if needed. The SSD explained that the dentist and dental hygienist come to the facility monthly and as needed. On 02/21/24 at 2:38 PM, review of Social Services Notes in the Electronic Health Records for Resident #78 revealed no notes concerning dental care. Review of care plans revealed there were no care plans that addressed dental issues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105125 If continuation sheet Page 9 of 9