Inspection·January 12, 2023

F 0692 her lunch meal with a divided plate and puree consistency. She ate about 50% of her lunch meal. Level of Harm - Minimal harm or potential for actual harm In an observation conducted on 01/11/23 at 8:00 AM, Resident #7 was noted in the room with the breakfast tray on the bed. She did not eat any of the items on the tray. In this observation, Resident #7 was asked if she wanted to lose weight, and she gave two thumbs up, and when asked if she wanted to gain weight, she gave two thumbs up as well. Residents Affected - Few In an observation conducted on 01/12/23 at 8:45 PM, Resident #7 was not in the room, and her breakfast tray was left on the bed. Closer observation showed that she ate about 50% of her breakfast meal. A review of the weight log showed the following weights for Resident #7 with no further weight obtained after the 12/15/22 weight until surveyor intervention: These were the following weights: 01/11/23 59.6 Lbs. (pounds) 12/15/22 57.99 Lbs. Standing 12/01/22 58.87 Lbs. Standing 11/15/22 58.32 Lbs. Standing 11/02/22 56.22 Lbs. Standing 10/19/22 58.42 Lbs. Standing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105175 If continuation sheet Page 2 of 11 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 105175 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plantation Nursing & Rehabilitation Center 4250 NW 5th St Plantation, FL 33317 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 10/05/22 Level of Harm - Minimal harm or potential for actual harm 61.2 Lbs. Standing Residents Affected - Few 09/05/22 62.61 Lbs. Standing 08/05/22 65.04 Lbs. Standing The weight loss from 08/05/22 to 10/19/22 showed 10.18 percent (%) weight loss in two months. The last weight documented in the electronic system was on 12/15/22, and no other weight was documented as taken after 12/15/22. A progress note written on 08/25/22 showed Resident #7 was on a Puree diet and tube feeding with Peptamen Junior (formulary type) at 250 milliliters (ml) 5 times a day. Another progress note on 09/27/22 showed that Resident #7 had a 3.7 percent weight loss in 1 month. It further showed that a potential for weight loss is anticipated with the recent COVID-19 infection. In this note, Staff A, Clinical Dietitian, recommended monitoring weight trends more frequently. On 10/19/22, Resident #7's weight dropped to 58.42 pounds from 65.04 pounds, and no progress note was completed by Staff A, addressing the severe weight loss of 11%. The next progress note was on 11/26/22, which was two months later. This note showed that Resident #7 was placed on an appetite stimulant and staff noted that she lost 7.4% of her body weight in 3 months. No other recommendations were noted at this time. Staff reported that they would continue to monitor the intake of meals and the weight trends. A Nutritional assessment, dated 12/22/22, showed that Resident #7 had a 7.4% weight loss in 3 months, and Staff made no further recommendations. Further review of the weight log showed that no new weight was taken since 12/15/22, 27 days apart. The care plan, dated 12/22/22, showed to provide Resident #7 with adequate nutritional / hydration support appropriate for weight / growth on an ongoing daily basis. Maintain weight/height +/- 3# per quarter with no signs or symptoms of dehydration and intact skin. In an interview conducted on 01/10/23 at 3:30 PM, Staff C, Licensed Practical Nurse (LPN), stated that Resident #7 is not verbal. She further said that she could communicate with staff by using her thumbs up if she wants something. In an observation conducted on 01/11/23 at 10:23 AM, Staff D, Certified Nursing Assistant (CNA), was asked to take the weight of Resident #7. Resident #7 was able to walk herself onto the standing scale, and the recorded weight was noted at 59.6 pounds, which is a 1.61 pound weight increase since the weight of 12/15/22. In this observation, Staff D was asked if she was aware of any orders to take (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105175 If continuation sheet Page 3 of 11 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 105175 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plantation Nursing & Rehabilitation Center 4250 NW 5th St Plantation, FL 33317 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 the weight on residents more than once a month, and she said no. She stated that she has no access to the orders in the electronic charting and any orders for weights are given to her from the Dietitian. She further said that all weights that are taken for the day are given back to the Dietitian to input into the electronic system. In an interview with Staff A, Registered Dietitian, on 01/11/23 at 1:26 PM, she said that when residents are first admitted , she has 72 hours to do the initial assessment but usually gets it done within the first few days. Every 60 days, she will make a follow-up note and the quarterly evaluation after that. For the most part, she feels that most of the kids in this facility are stable. When asked about the weight policy, she reviews the order listing report every morning for any changes or any new orders for weight changes. She then creates a list that is given to Staff D, Certified Nursing Assistant. The list is broken down to residents who need their weight taken once a month, twice a month, weekly or more often. When asked if she knew that Resident #7 had an order for weights twice a month, she said yes. When asked why it was not done, she said it was her fault as she did not move Resident #7 to the twice-a-month list she created. She further acknowledged that Resident #7 had a weight loss of 11% from 08/05/22 to 10/19/22, and no nutritional interventions were made to address the weight loss. 2. Resident #17 was admitted to the facility on [DATE]. Resident #17 had a medical history significant for Cerebral Palsy, Quadriplegia, Seizures, and was dependent on a gastrostomy tube for nutrition intake. An Annual Minimum Data Set (MDS) was done on 11/12/22. This MDS showed Resident #17 had a Brief Interview of Mental Status (BIMS) score of 99, which indicated he was severely cognitively impaired. This MDS showed Resident #17 was receiving tube feeding for all meals. This MDS documented Resident #17 had known weight loss but that he was not on a prescribed weight loss regimen. Review of Resident #17's Care Plans revealed a care plan was written on 08/06/18 regarding Resident #17 being at risk for altered nutrition. There was no care plan written regarding the noted weight loss. Review of Resident #17's physician orders revealed a previous order from 08/10/21 to 11/17/22 for Enteral Feed every 4 hours Nutren Jr Fiber 245 mL via G-Tube every 4 Hours run over 1 Hour per feeding tube. From 11/17/22 to 12/01/22, a new order was written for Enteral Feed every 4 hours Give 260 mL Nutren [NAME] w/ Fiber via g-tube every 4 hours run over 1 hour per feeding tube. On 12/01/22, a new and current order was written for Enteral Feed every 4 hours Run Nutren [NAME] w/ Fiber at 65 mL/hr x 24 hours continuously via g-tube per pump. During the initial tour of the facility conducted on 01/09/23 at 11:01 AM, it was noted that Resident #17 had a bag of Nutren [NAME] plus Fiber tube feeding infusing. During the initial review of Resident #17's record, it was noted that Resident #17 had suffered a significant weight loss. On 08/05/22, Resident #17 weighed 79.81 pounds; on 01/05/23, Resident #17 weighed 66.8 pounds, which indicated a 16.30% weight loss in 5 months. This is considered significant weight loss. Further review of Resident #17's weights revealed the following: on 07/05/22, Resident #17 weighed 75.62 pounds; on 08/05/22, Resident #17 weighed 79.81 pounds; on 09/05/22, Resident #17 weighed 75.4 pounds; on 10/05/22, Resident #17 weighed 71.65 pounds; on 11/15/22, Resident #17 weighed 67.68 pounds; on 12/01/22, Resident #17 weighed 66.81 pounds; and on 01/05/23, Resident #17 weighed 66.8 pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105175 If continuation sheet Page 4 of 11 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 105175 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plantation Nursing & Rehabilitation Center 4250 NW 5th St Plantation, FL 33317 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 On 01/11/23, the surveyors asked to have Resident #17 weighed. Staff D, CNA, weighed Resident #17 using a Hoyer lift. Staff D ensured Resident #17 was wearing only a diaper for this weight. The Hoyer lift scale was zeroed prior to obtaining Resident #17's weight. The weight taken was 67.2 lbs. This represented a 0.4-pound weight gain since the weight recorded on 01/05/23. Review of the Dietary Notes revealed Staff A, Registered Dietitian (RD), was aware of the weight gain noted in August 2022. The note stated that Staff A notified the physician but planned to continue to monitor Resident #17's weights and make no changes at that time. Another Dietary Note, written on 09/06/22, indicated Staff A was aware of the weight loss, but she recommended no changes to the tube feeding at that time. On 10/07/22, Staff A documented a note indicating she was aware of Resident #17's continued weight loss but again offered no interventions. On 12/01/22, Staff A documented her next note indicating she was going to increase Resident #17's tube feeding to provide additional calories and maximize absorption to promote weight restoration. An interview was conducted with Staff A, RD, on 01/11/23 at 1:40 PM. When asked specifically about this resident, Staff A stated that the weight done in August [2022] was presumed to be incorrect, since it was above what Resident #17's usual weight fluctuations were. She clarified that she asked Staff D to re-weigh Resident #17 and the weight was still 79 pounds. Staff A said they assumed Resident #17 was constipated and that his would fluctuate back to his baseline, and this is why she offered no interventions at that time. Staff A stated Resident #17's weight did trend down to his baseline after August 2022 but that he continued to drop in weight in September and October 2022. Staff A said she spoke to the Nurse Practitioner (NP) in October but was told not to make any changes at that time. In December 2022, Staff A said she changed Resident #17 to continuous feedings to maximize absorption. Staff A stated she had plans to make additional adjustments this week and that she would possibly add a zinc supplement. She clarified that zinc increases metabolic efficacy. The facility staff did not act in a timely manner to intervene for Resident #17's significant weight loss over the course of the 5 months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105175 If continuation sheet Page 5 of 11 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 105175 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plantation Nursing & Rehabilitation Center 4250 NW 5th St Plantation, FL 33317 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 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #98 was admitted to the facility on [DATE]. Resident #98's diagnoses included: Cerebral Palsy, Seizure disorder, Chronic lung disease, Atrasia of Foramina, Epilepsy, Disturbances of Salivary secretion, Lack of expected normal physiological development n childhood, Diaphragmatic Hernia without obstruction or gangrene, Calculus of Kidney, and spastic quadriplegic. Resident #98's orders included: 09/22/22 - NPO [nothing by mouth] diet, NPO texture - feeds per g-tube only 12/19/22 - Enteral Feed - every shift Run Peptamen w/ Prebio at 50 mL/hr continuously via g-tube per pump. On 09/22/22, the resident weighed 75 lbs. On 12/05/22, the resident weighed 70 pounds which is a -6.67 % loss. On 01/09/23 at 10:17 AM, Resident #98 was observed in bed with enteral feeding pump display reading Flow error - clog in line downstream of pump. The date mark on the 1000 milliliter bag of supplement documented the supplement was initiated on 01/09/23 at 10:00 AM. On 01/10/23 at 7:54 AM, Resident #98 was observed in bed with tube feeding initiated at 50 milliliters per hour (ml/hr). The dated mark on the 1000 milliliter bag of the supplement documented the supplement was initiated on 01/09/23 at 10:00 AM. At the time of the observation, there was approximately 600 milliliters remaining in the 1000 milliliter bag of the supplement. At a rate of 50 ml/hr over 20 hours, the resident should have received the entire 1000 milliliters. 01/10/23 at 2:50 PM, Resident #98 was observed in bed with the same supplement that was initiated on 01/09/23 at 10:00 AM, according to the date mark on the bag of supplement. At the time of the observation, there was 200 milliliters remaining in the 1000 milliliter bag of the supplement. There was no documentation to justify why the order for enteral feeding was not met. During an interview, on 01/10/23 at 3:51 PM with Staff H, Registered Nurse (RN), confirmed that the bag of supplement was the bag from the observations for the entirety of the previous day and this day. Staff H stated, Maybe something happened on the night shift. If anything would have happened, they would have to document something in the MAR (Medication Administration Record) or in the progress notes. When I came this morning, the night nurse had put a new bag and had not connected it to the tube-feeding. The night nurse was the one that placed the new bag. She did not tell me if anything happened and did not report anything to me. During an interview, on 01/11/23 at 1:27 PM, with Staff A, Registered Dietician / Licensed Dietician (RD/LD), Staff A confirmed the order for the enteral feeding and acknowledged that the order had not been met, as well as the lack of documentation and communication as to why the feeding was not done as ordered. Based on observation, interview and record review, the facility failed to maintain aspiration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105175 If continuation sheet Page 6 of 11 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 105175 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plantation Nursing & Rehabilitation Center 4250 NW 5th St Plantation, FL 33317 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 precautions for a resident who was being fed by enteral means (tube feeding), as evidenced by staff not consistently keeping the head of the bed elevated while the tube feeding was running for Resident #77; and failed to follow Practitioner orders for tube feeding (Resident #98), for 2 of 6 sampled residents reviewed for tube feeding. Residents Affected - Few The findings included: 1. Resident #77 is two years old and has a tracheostomy related to Impaired breathing mechanics, is on a ventilator and has a history of Chronic Respiratory Failure and Dysphagia. He was initially admitted on [DATE] and readmitted on [DATE]. In an observation conducted on 01/10/23 at 3:00 PM, Resident #77 was noted in his crib sleeping sideways across the mattress with his head flat down. Continued observation showed a tube feeding running at 40 milliliters an hour with Peptamen Junior (tube feeding formulary). Staff B, Licensed Practical Nurse (LPN), was noted outside the room on her computer. In an observation conducted on 01/10/23 at 3:30 PM, Resident #77 was noted in his crib sleeping sideways across the mattress with his head flat down. Continued observation showed a tube feeding running at 40 milliliters an hour with Peptamen Junior (tube feeding formulary). Staff B, LPN, was noted outside the room on her computer. In an observation conducted on 01/10/23 at 3:45 PM, Resident #77 was noted in his crib sleeping sideways across the mattress with his head flat down. Continued observation showed a tube feeding running at 40 milliliters (ml) an hour with Peptamen Junior (tube feeding formulary). In this observation, Staff B was asked by the surveyor if it was okay that the tube feeding was still running while Resident #77 was flat across the bed. Staff B said that Resident #77 tends to move a lot and that she is not his nurse for the day. When asked how often the staff monitors the residents, she said there is no particular time frame, and they can check at any given time. When the surveyor expressed concerns regarding the tube feeding running while Resident #77's head was not elevated, Staff B turned Resident #77 sideway and elevated the mattress. In an observation conducted on 01/10/23 at 4:30 PM, Resident #77 was noted in his crib sleeping sideways across the mattress with his head flat down. Continued observation showed a tube feeding running at 40 milliliters an hour with Peptamen Junior (tube feeding formulary). Staff B, LPN, was noted outside the room on her computer. A review of the orders showed an order for Aspiration precautions to keep the head of the bed elevated during feedings as tolerated every shift dated 12/24/22 and another order for tube feeding Peptamen Junior (tube feeding formulary) continuously run over 40 ml for 24 hours via G-tube per pump dated 12/20/22. The care plan dated 11/23/22 showed that Resident #77 is at risk for aspiration related to Enteral Tube Dependency and Tracheostomy Status, with interventions to: Keep the head of the bed elevated during feeding as tolerated. It further showed that Resident #77 is at risk for nutritional status and aspiration alteration with : Total nutritional / hydration support via G-Tube and is vent-dependent and has a diagnosis of dysphagia. In an interview conducted on 01/12/23 at 10:00 AM with the facility's Administrator, he was told of the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105175 If continuation sheet Page 7 of 11 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 105175 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plantation Nursing & Rehabilitation Center 4250 NW 5th St Plantation, FL 33317 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, record review and interview, the facility failed to ensure that it obtained a current, written physician's order for Oxygen therapy treatment for 2 of 2 sampled residents observed, Resident #358 and Resident #6. Residents Affected - Few The findings included: Review of the facility policy and procedure on 01/11/23 at 1:55 PM, titled, Oxygen Administration, provided by the Director of Nursing (DON) revised 05/04/22, documented in the Policy Statement: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician 3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. They type of oxygen delivery system. b. When to administer, such as continuous or intermittent and/or when to discontinue. c. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. e. Monitoring for complications associated with the use of oxygen. Review of the facility policy and procedure on 01/11/23 at 2:05 PM, titled, Medication Administration, provided by the DON revised 05/04/22, documented in the Policy Statement: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of facility's undated licensed Registered nurse job description on 01/11/23 at 2:11 PM provided by the DON documented, Purpose of Your Job Position: .provides direct care, administers treatments and medications, organizes and distributes daily assignments to direct care staff consistent with staff competency and each individual resident's comprehensive resident assessment and care plan .Performance Requirements: Knowledge of nursing principles and professional standard of nursing practice and ability to apply to resident specific circumstances. Able to identify, implement and evaluate appropriate objectives and interventions for residents. Review of facility's undated licensed Practical nurse job description on 01/11/23 at 2:22 PM provided by the DON documented Purpose of Your Job Position: .provides nursing care according to physician's instructions and in conformance with state approved Florida Board of Nursing Practice, established standards and administrative policies .Duties: 1. Check and administer medications and treatments per standards of Florida Nurse Practice Act and facility policy; order medications from pharmacy .5. Maintain accurate records of nursing and medical care received by the resident . 1. Resident #358 was admitted to the facility on [DATE] with diagnoses which included Embolism and Thrombosis of Unspecified Artery, Unspecified Fracture of Sacrum, Idiopathic Peripheral Autonomic Neuropathy, Post-Menopausal Bleeding and Obstructive and Reflux Uropathy. She had a Brief Interview Mental Status (BIMS) score of 14, indicating cognition was intact. During an observation conducted on 01/09/23 at 11:20 AM, Resident #358 was observed with Oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105175 If continuation sheet Page 8 of 11 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 105175 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plantation Nursing & Rehabilitation Center 4250 NW 5th St Plantation, FL 33317 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 infusing in place at 2-3 liters/minute. Photographic Evidence Obtained. Level of Harm - Minimal harm or potential for actual harm A brief interview with Resident #358 on 01/09/23 at 11:26 AM was conducted who stated she was not wearing any oxygen prior to admission to the facility, at home. The resident also stated that she has been wearing her oxygen here in the facility continuously. She also stated that she has not had any shortness of breath or difficulty breathing while residing in the facility. Residents Affected - Few On 01/10/23, Resident #358's Oxygen Saturation Summary, dated 12/31/22 through 01/10/23, documented that the Resident #358's Oxygen Saturation Levels were in a range of: 97-98% were either on Room air or Oxygen via nasal cannula. Neither the Medication Administration Record (MAR), Treatment Administration Record (TAR), facility nursing progress notes, nor the resident's care plan reflected or made reference to any Oxygen orders / treatments for Resident #358, during her facility stay from 12/31/22 to current. 01/10/23 9:41 AM, the resident was observed with Oxygen infusing at 3 liters/minute. 01/10/23 01:55 PM, the resident was observed with Oxygen infusing at 3 liters/minute. 01/11/23 at 9:55 AM, the resident was observed with Oxygen infusing at 3 liters/minute. A side-by-side record review was conducted with the Assistant Director of Nursing (ADON) in which it was noted / indicated that there was no physician order for Oxygen Therapy to be administered to Resident #358, during her facility stay. An interview was conducted with Staff F, Licensed Practical Nurse (LPN), on 01/11/23 at 9:55 AM regarding Resident #358's Oxygen therapy infusion, who acknowledged the resident did have the Oxygen infusion and she should have had an order on file for it. An interview was conducted with the Assistant Director of Nursing (ADON), on 01/11/23 at 10:05 AM regarding Resident #358's Oxygen therapy infusion, who also acknowledged that there should have been an order on file for it. The Oxygen order was not obtained and recorded in the resident's medical file, until after surveyor inquisition / intervention. The DON further recognized and acknowledged on 01/11/23 at 12:10 PM that a physician's order should have been obtained and this was not done. 2. Resident #6 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #6 had a medical history significant for Cerebral Palsy, dependence of Tracheostomy and Gastrostomy tube, persistent vegetative state, Dysphagia, Epilepsy, and Hypoxic Ischemic Encephalopathy. A Quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 99, which indicated Resident #6 had severe mental impairment. This MDS documented Resident #6 had a tracheostomy and that she was receiving oxygen therapy. Review of Resident #6's care plans revealed there was a care plan in place regarding Resident #6 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105175 If continuation sheet Page 9 of 11 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 105175 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plantation Nursing & Rehabilitation Center 4250 NW 5th St Plantation, FL 33317 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 having an artificial airway in place and for the staff to monitor her oxygen saturation numbers and to provide oxygen as ordered. Initial review of Resident #6's physician orders conducted on 01/09/23 revealed there was no active order for oxygen present. Residents Affected - Few During observation conducted on 01/09/23 at 10:53 AM, it was noted that Resident #6 was receiving oxygen via a tracheostomy mask at 3 liters per minute. The oxygen tubing was dated 01/07/23. During the initial review of Resident #6's record, it was noted that Resident #6 did not have an active physician order for oxygen. Additional observations made of Resident #6 on 01/10/23, 01/11/23, and 01/12/23 revealed Resident #6 was on oxygen continuously through a tracheostomy mask. An interview was conducted with Staff E, Respiratory Therapist, on 01/11/22 at 1:30 PM. The surveyor asked Staff E to find the order for the oxygen in Resident #6's chart. Staff E looked and said he could not find the active oxygen order. He told the surveyor he would talk to the doctor to make sure an order for oxygen was added to the chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105175 If continuation sheet Page 10 of 11 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 105175 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plantation Nursing & Rehabilitation Center 4250 NW 5th St Plantation, FL 33317 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 0921 Level of Harm - Potential for minimal harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and review of policy and procedure, the facility failed to ensure that it maintained clean and sanitary dryer drums in the laundry area for 2 of 3 dryers observed. Residents Affected - Some The findings included: Review of the facility policy and procedure on 01/10/23 at 2 PM, titled, Healthcare Services Group, Inc., Laundry In-Service provided by the Director of Housekeeping reviewed 01/01/20 documented in the Policy Statement: Care of Equipment. Purpose: To review the use and care of all equipment used by the Laundry Department to perform their daily duties. Care of Equipment: Laundry Departments work with two (2) types of equipment: -Large pieces (washers/dryers, etc.) Larger equipment must be maintained on a regular basis. Preventative Maintenance (PM) work may be the responsibility of the Maintenance Department in some buildings, but the Laundry Supervisor must still be familiar with daily cleaning and simple maintenance .Laundry Equipment: A) Large pieces Dryers: .The drums of each dryer should be cleaned after each load to prevent any type of trash or lint from heating up and melting to the inside Always document the dryer cleaning . During a Laundry area observation conducted on 01/10/23 at 10:25 AM of dryer #2 and dryer #3, in the clean utility area, it was noted there were multiple areas located inside both dryers, which contained heavy, crusted and peeling amounts of potentially contaminants and melted dark matter, along the inner drums of both dryers. Photographic Evidence Obtained. On 01/10/23 at 10:30 AM, an interview was conducted with Staff G, laundry aide, in which she was asked if she knew what this melted, dried substance could be in the 2nd and 3rd dryer drums, and whether or not she noticed it. She stated that she did note it and added that it could be some type of plastic or melted crayons or something else that is burnt in the dryer. She acknowledged that the inside of the dryer drums should be clean and free of any debris. During an interview conducted with the Director of Housekeeping on 01/10/23 at 10:45 AM, he acknowledged that the inner dryer drums should be inspected and cleaned daily, as necessary, and prior to placing resident clothing inside. This was not done. From January 1, 2023 through January 9, 2023, the Laundry Cleaning Schedule documented that the dryers were being cleaned and maintained by facility staff. This was not done. Dryer #2 and #3 drums were not cleaned, until after surveyor intervention. The Administrator further recognized and acknowledged that on 01/10/23 at 2:30 PM the facility's dryer drums should have been cleaned and free from debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105175 If continuation sheet Page 11 of 11