Inspection·March 16, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During the tour and interview, conducted on 03/16/22 at 12:00 PM with Staff J, Laundry/Housekeeping Services, she stated she has been with the facility for 18 years. When asked if a staff member noticed an issue that requires maintenance or housekeeping how does the issue get relayed to the appropriate department, she stated there are maintenance/housekeeping request forms at each nursing station for the staff or resident to fill out and then they leave it in another slot to be picked up by maintenance or housekeeping. Forms are picked up Monday thru Friday. Most issues are taken care of the same day, but some may take a little longer. If a maintenance issue is found to require more than what the maintenance department can do, they call one of their contractors to come out to fix the issue. Staff J stated during the tour that the facility knows it has a problem with the air conditioning system. She also stated that when the maintenance request forms are picked up, they are brought to the maintenance office, once the work is completed the form signed and dated with the completion date and filed. Outstanding orders are held in a pile. During an interview conducted on 03/16/22 at 12:20 PM with Staff D Certified Nursing Assistant (CAN), when asked how she reports a maintenance issue, she stated she fills out a form from the nursing station and puts it back in the slot and then maintenance will pick it up the next day. During an interview conducted on 03/16/22 at 12:28 PM with the Activities Director, when asked how she reports a maintenance issue, she said you fill out a work order form by the nursing station and leave it in the file at the nursing station to be picked up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 2 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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** 3). Review of Resident #37's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included Urinary Tract Infection, Anxiety Disorder, Cerebrovascular Accident (CVA), Hemiplegia, Upper and Lower Extremities Contractures and Pulmonary Embolism. Resident 37's quarterly Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of Mental Status score of 6 (six), indicating a severe cognitive impairment. Residents Affected - Few Review of the resident care plan titled Resident BMI (body mass index) 19 initiated on 01/25/22 included in part interventions as to .weigh resident monthly/weekly/prn (as needed) or as ordered by MD (doctor), dietitian to evaluate and follow up at least quarterly . Review of the resident care plan titled Resident has self-care deficits related to a diagnosis of Weakness, COPD ( Chronic Obstructive Pulmonary Disease), CVA (Cerebrovascular Accident) and Upper and Lower Extremities Contractures initiated on 01/25/22 included in part interventions as to .extensive assist for meals . Review of Resident #37's weight history recorded on a Weight Work Sheet located on the third-floor nurses' station documented the following weight readings: Date: 01/22/22- 90 pounds Date: 02/02/22- 93 pounds Date: 02/14/22- 93 pounds Date: 02/19/22- 93 pounds Date: 02/23/22- 93 pounds Date: 03/01/22- 79 pounds Review of Resident #37's electronic clinical record and the Dietary notes, it wasd noted that the records lacked evidence of documentation to address the resident' significant weight loss of 14 pounds in 6 days. Further review of the resident progress notes from 01/27/22 through 03/14/22 revealed the lack of follow up documentation by nursing, the Dietitian, or the Dietary Technician to address the resident's significant weight loss. On 03/14/22 at 9:05 AM, observation revealed Resident #37 in bed, and her breakfast tray with most of the food left on the tray. An interview was conducted with the resident, and she stated she did not want to eat anymore. On 03/14/22 at 9:30 AM, an interview was conducted with Staff B, a Registered Nurse (RN) and stated Resident #37's finished a three-day Calorie Count (a count of everything the resident eat and drink daily) on 03/13/22. On 03/15/22 at 9:01 AM, observation revealed Resident #37 in bed and her breakfast tray revealed the resident ate approximately 75% of her meal. On 03/15/22 at 2:28 PM, an interview was conducted with the facility's Registered Dietitian (RD). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 3 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 RD stated the resident's initial nutrition history/assessment was initiated on 01/25/22 and completed on 01/27/22. She stated the resident's weight was 90 pounds on admission with a DBW (desirable body weight) between 81-99 pounds. The RD stated she recommended a 2-Cal (calorie and protein dense nutrition/supplement) twice a day, Liquid Protein and Multivitamin. Consequently, side-by-side review of Resident #37's nutrition assessment and weight record was conducted with the RD. The RD was asked if she was aware of the resident's weight loss from 93 pounds on 02/23/22 to 79 pounds on 03/01/22; 14 pounds weight loss in one week. She stated the staff usually tell her on the same day of weight changes. She added that she might had forgotten and that it was her fault. The RD stated that on 03/08/22 or later, on her return to the facility, she saw documentation of Resident #37's weight of 79 pounds done on 03/01/22. She stated she asked for a reweigh. A side-by-side review with the RD of the resident's electronic clinical record- weight readings was conducted. The review revealed the following weight readings: 93 pounds on 02/23/22; 79 pounds on 03/04/22 (three days discrepancy from the paper record) and 85 pounds on 03/10/22. She stated the resident's re-weight was 85 pounds on 03/10/22. The RD was asked why the resident was reweighed 6 days later, and not the same day. The RD stated she might had forgotten to ask for a re-weigh on the same day. On 03/15/22 at 2:39 PM, a joint interview was conducted with the RD and Staff C, a Restorative Aide (RA)/Certified Nursing Assistant (CNA). Staff C-RA/CNA stated she does all residents' weight. Staff C was asked what she would do if she saw a significant weight change. Staff C stated she notifies the Dietitian or someone in the kitchen. Staff C was asked if she was able to see Resident #37's weight change on 03/01/22. She stated she saw the big change and told someone in the kitchen either the Dietary Tech or Food Manager regarding the resident's weight change. Staff C stated she keeps a stack of weights reading (paper charting) for 90 days. Staff C stated she enters the weight readings into the electronic record the same day she takes the weight. The RD stated that on 03/11/22 Resident #37 was started on Megace (appetite stimulant) twice a day and on 03/10/22 and the 2-Cal HN supplement was increased to three times a day. The RD stated they will wait about 7 days to see what happens with her weight and intake. An inquiry was made regarding Resident #37's weight increase of six (6) pounds in six (6) days. The RD stated Resident #37's weight was done via a mechanical lift. She added that the technique, and if the resident moves, the weight reading may be affected. During the joint interview, with the RD, and Staff C-RA/CNA, a request was made to weight the resident on 03/16/22 in the morning in the presence of the surveyor. They both acknowledge the request. On 03/16/22 at 9:15 AM, observation revealed Resident #37 sitting on a Geri chair with the mechanical lift (Hoyer lift) sling underneath of her. An interview was conducted with the resident and she stated they did her weight today and it was 93 pounds. Observation revealed Staff D, CNA at the resident bedside. An interview was conducted with Staff D-CNA and stated she was assigned to care for Resident #37. She stated the resident was provided with a shower today. Subsequently, Staff C-RA/CNA came into the resident room. An interview was conducted with Staff C-RA/CNA and stated the resident was weight already and her weight was 80.2 lbs. During an interview with Resident #37, she was explained regarding retaking her weight and agreed for to be taking again. Observation revealed the mechanical lift sticker documented the lift was calibrated on 01/31/22 and due to be checked on 04/2022. Subsequently, observation revealed Staff C and Staff D weighing Resident #37 via mechanical lift. The lift scale revealed a weight reading of 80.6 pounds. Based on observations, interviews, and record review, the facility failed to provide nutritional interventions in a timely manner for 3 of 7 sampled residents reviewed for nutrition (Resident #32, #35, and Resident #37). The findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 4 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 1. Review of the facility's policy titled Weight Assessment/Height and Weight Record maintenance and Reporting dated 11/15/21, showed that the Nursing assigned Restorative team shall be responsible to record heights and weights for our residents to prevent, monitor, and intervene in undesirable weight loss. It further showed that any weight loss of 5 pounds or more should be reported to the Dietary Department. In an observation conducted on 03/13/22 at 12:30 PM, Resident #32 received her lunch tray at 12:40 PM, and staff left the room to assist with other residents. At 1:00 PM, Resident #32 was observed with a tray 100% untouched and no assistance from staff. At 1:15 PM, the tray was still 100% untouched by Resident #32, the room. In an interview conducted on 03/14/22 at 8:43 AM, Staff H, Certified Nursing Assistants (CNA), stated that Resident #32 needs assistance with all her meals at the bedside. Chart review showed that Resident #32 was readmitted to the facility on [DATE] with diagnoses of Diabetes and Anemia. A review of the Minimum Data Set (MDS) dated [DATE] showed that Resident #32 had a Brief Interview of Mental Status (BIMS) score of 08 which is moderate cognitive impaired. Section G for eating showed that Resident #32 needed extensive assistance with one person assist. A review of the electronic charting showed that the following weights were recorded for Resident #32: On 01/07/22 at 205 pounds, on 01/13/22 at 210 pounds, on 01/26/22 at 208 pounds, on 02/14/22 at 193 pounds, and on 03//01/22 at 188 lbs. Further review of the weight binder located in the unit showed the following weights that were recorded for Resident #32: On 02/07/22 Refused, on 02/14/22 at 193 pounds, on 02/23/22 Refused, on 03/01/22 at 187 pounds, and on 03/14/22 at 182 pounds. A review of the Dietary follow-up note dated 01/25/22 showed that Resident #32 is with a current weight of 210 pounds. In this note, the Clinical Dietitian noted that Resident #32 is with varied PO intake and to continue with the current plan of care and follow up for any weight changes. Continued review of the Dietitian's progress notes did not show any follow-up note addressing the 8% weight loss from 01/13/22 to 02/14/22, and no follow-up was noted addressing further weight loss of 10% from 01/13/22 to 03/01/22. The Clinical Dietitian follow-up note dated 03/09/22 showed that Resident #32 had a significant weight loss, and that Resident #32 is on House supplements 3 times a day. A review of the care plan initiated on 10/22/21 showed that some of the interventions in place were to monitor weights and intake of meals and supplements. In an interview conducted on 03/15/22 at 9:20 AM, the facility's Dietitian Technician stated that they monitor all weight loss on a weekly basis and will do a significant weight loss change of 5% or more on all residents. She further reported that she runs the weights on all residents in the smart charting section of the electronic chart and will calculate the % weight loss when needed. If a resident is on nutritional supplements and not eating, she will visit the residents to see why they are not taking the supplements and will change it to a different type of nutritional supplement. When asked as to why she did not address the significant weight loss on Resident #32 in a timely manner she did not know. An interview conducted on 03/15/22 at 10:26 AM with the facility's Registered Dietitian, stated that she prints out the monthly weights on a weekly basis to review any weight losses that are 5% in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 5 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 one month or 10% in 6 months. She stated that some of the interventions in place may be to increase the number of nutritional supplements, conduct a caloric count, or change the nutritional supplements to something more caloric dense. She was asked as to why Resident #32 did not have a follow-up assessment after her significant weight loss from 01/26/22 to 02/14/22 if she reviews all weight losses on a weekly basis. The Clinical Dietitian acknowledged that a follow-up note on Resident #32 should have been done sooner. She also stated that since Resident #32 had a history of weight loss from prior admission she did not address the weight loss. 2) Resident #35 was readmitted to the facility on [DATE] from the hospital following admission for altered mental status and urinary tract infection. She has a medical history that is significant for a Pressure Ulcer on her Sacrum, Leg Facture, Anemia, Dementia, Stroke, Depression, and Heart Disease. On 01/13/2022, the resident weighed 147 lbs. On 03/01/2022, the resident weighed 140 pounds which is a -4.76 % Loss. A review of her Significant Change Minimum Data Set (MDS) completed on 01/20/22 showed that the interpretation of her Brief Interview for Mental Status (BIMS) score is 5, indicating severly impaired cognition. It also shows that she requires extensive assistance from the staff for her activities of daily living including position changes while in bed, eating, toileting, and personal hygiene. The MDS indicates that Resident #35 is having unintentional weight loss. The section which covers skin conditions indicates that Resident #35 has a stage 4 pressure ulcer which was present on admission from the hospital. A review of Resident #35's physician orders indicates that she is supposed to have daily and as-needed wound care for her pressure ulcer by the nursing staff. The orders also indicate that Resident #35 is supposed to receive supplements for her weight loss including Glucerna 1.2 one carton 3 times per day, Eldertonic Elixir 2 times per day, and Liquid Protein Fortifier 2 times per day along with her regular diet. There are also orders for Vitamin C, Multivitamin, Folic Acid, and Zinc. A Nutrition Assessment was completed by the Dietary Technician on 01/05/22 shows that Resident #35's admission weight was 147 pounds. It shows the resident's nutrient needs as follows: Calorie needs 70x30/35=2100/2450 kcal; Protein needs 70x1.1-1.3=77/91 grams of protein; Fluid needs 70x30=2100cc. The assessment summary states the resident has a history of poor intake of oral supplements and the nutritional risk is inevitably weight loss. It says the resident's body weight of 147 pounds is above the calculated Desirable Body Weight (DBW) of 104 pounds to 127 pounds. The recommendation from the Dietary Technician is to consider restarting 1-ounce Liquid Protein 2 times per day along with Vitamin C, Multivitamin, and Zinc A Significant Change Care Plan was completed by the facility on 01/24/22 related to weight loss suffered by Resident #35. It states that the resident will tolerate her current diet consistency to maintain a weight of +/3 pounds monthly. The suggested interventions include providing medications/supplements, providing snacks, dietary consultations as needed, providing diet as ordered, and observing oral intake, weights, and labs. A review of the electronic Medication and Treatment Administration Records reveals that Resident #35 refuses or is not administered her ordered oral supplements almost half of the time during the months of January, February, and March. A dietary note was written on 01/20/22 by the Registered Dietitian which states, Resident's wt. (weight) 147# (pounds). Wt. loss noted. Diet order mech (mechanical) soft, NAS (no added salt), LCS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 6 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 (low concentrated sweets). She is on Glucerna 1.2 1 carton TID (three times per day). Also, on Elder Tonic to help with appetite/intake. Wound noted. Will add back liquid protein 1oz (ounce) BID (two times per day). Continue MVI (multivitamin), Vit (vitamin) C, Zinc. Meds noted. CNA (Certified Nursing Assistant) charting shows good intake at BF (breakfast) and lunch and varied intake at dinner. F/U (follow up) with care plan team and adjust POC (the plan of care) as needed. Residents Affected - Few A dietary note was written on 02/09/22 by the Registered Dietitian which states, Resident's wt. on 2/9 140#. Wt. loss of 28#. She is on Elder Tonic and Glucerna 1.2 TID. CNA charting showed varied intake poor to good. DBW (desired body weight) = 104-127 however rapid weight loss is not desired. Rec (recommend) 3-day calorie count to assess intake. Adjust POC as needed. Please note, the weight loss of 28 pounds talked about in this note is related to her original admission weight of 168 pounds taken on 11/12/21. A dietary note was written on 02/18/22 by the Registered Dietitian which states, Calorie count not available. CNA charting shows resident's intake on 2/10, 2/11, 2/12 was fair to good. 2/10/22 weight 142#. Will continue to observe intake/changes and adjust POC as needed. A dietary note was written on 03/16/22 by the Registered Dietitian which states, Resident's wt. 140#. Wt. stable x1 month after loss after a hospital stay. Diet order NAS, LCS diet. She is also on PO Supp (supplement) Glucerna 1.2 3x/day. MAR (medication administration record) shows intake of supp varies however will cont. (continue) as ordered and encourage intake. Meds noted. F/U for any new labs/wt./changes. Wt. maintenance acceptable as wt. is above DBW range. A review was conducted of wound assessment notes which were written on 01/26/22, 02/03/22, 02/16/22, 02/25/22, and 03/02/22. In each note, Resident #35's sacral wound was measured by the wound care doctor. There is no measurable improvement in the wound size documented during the time these notes were written. An interview was conducted on 03/15/22 at 09:28 AM with Dietary Technician. She stated she works in the facility 5 days per week. She said either herself or the Registered Dietitian completes the resident's dietary assessments- initial, follow up, high-risk residents, and significant change/weight loss. She said the follow-up assessments are done quarterly (every 3 months) or if there is a significant weight loss noted. She said the residents are all weighed on admission, then weekly for the first month, then monthly, but if there is a significant weight loss noted, the residents are changed to weekly weights. She said that a significant weight loss is considered a 10% drop in 6 months or a 5% drop in 1 month. When asked how she and the dietitian are notified of the residents who have significant weight loss, she said they print out the reports (found under the data collection history, underweights) monthly and watch the 6-month trend to calculate any weight loss. If there is any significant weight loss noted, they ask for the resident to be weighed again to make sure it was not a mistake. The Dietitian Technician reported that for any calorie count, nursing will tell the CNAs to record the calories in the resident's chart (found under the data collection history, under meal intake). When asked why it is important for calorie counts to be done accurately, she said it is important to know how much of each meal is being consumed by the residents. When asked how they know if ordered supplements are being consumed by the residents, she said if the residents are refusing the supplements, usually the nursing staff will tell them (dietary) and they will go to the resident to assess why they are refusing the supplement and if they would prefer a different kind of flavor. She said they also address supplements with the resident's quarterly assessments. When asked why a calorie count was not done despite being recommended by the dietitian on 02/09/22, she said she would prefer the dietitian to answer that question. When asked why there has been no follow-up on this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 7 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 resident refusing to consume her supplements, she said she did not know. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the Registered Dietitian on 03/15/22 at 10:25 AM. She said that any follow-up assessments are completed with significant changes or if the resident is not doing well. When asked how she is notified of a weight loss, she said she prints the monthly weight logs every week for every resident. She said if there is a change noted, she asks for the resident to be re-weighed and she reviews the plan of care and may do a calorie count. She said she may add or change a supplement and check with the resident or family about their preferences and encourage the family to bring outside foods in. The surveyor showed her the concerns about the resident's significant weight loss and non-healing wound and her calorie count that was recommended but not done. Despite these facts, she said that because the resident had gained 2 pounds and was not below her desired body weight, she was not concerned that the calorie count was not done. When asked if she looked at the medication and treatment administration record to see that the resident was not taking the ordered supplements, she confirmed she did not. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 8 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and observations, the facility failed to follow infection control practices during the initiation of in-house Hemodialysis using a Central Venous Catheter (CVC) site for 1 of 1 sampled residents reviewed for dialysis (Resident #36). Residents Affected - Few The findings included: A review of the Agreement for Dialysis Services between the facility and the dialysis company showed the following. When a resident is in the skilled nursing facility, their care will be provided according to acceptable standards of medical practice and by the facility policy and procedures. A review of the facility policy titled Handwashing/Hand hygiene revised in April 2020, showed the use of an alcohol-based hand rub for the following situation: before and after handling an invasive device (catheter), before donning sterile gloves, before handling clean or soiled dressing, before moving from contaminated body site to clean body site, after contact with resident's intact skin, after handling used dressing and contaminating equipment. A chart review showed that Resident #36 was admitted on [DATE] with End-Stage Renal Disease and depended on dialysis. In an observation conducted on 03/14/22 at 3:15 PM, Resident #36 was observed in the dialysis room to initiate CVC Hemodialysis by Staff I, Licensed Practical Nurse (LPN). Staff I was observed practicing hand hygiene, taking a clean gauze, and spraying it with ALCAVIS (disinfection solution) spray. She continued to touch her pen and statoscope around her neck and donned a new pair of gloves. She then walked to Resident #36's beside and touched all around the CVC access site. At 3:50 PM, Staff I used hand hygiene, opened the side cabinets, took a clean pad to create a clean surface at the side table. She then pulled a sterile gauze, sprayed it with ALCVIS spray, and continued to place a new pair of gloves. At 4:00 PM, she approached the bedside again and touched the access site. In an observation conducted on 03/14/22 at 4:20 PM, Staff I took a new pair of gloves without practicing handwashing before, touched the computer and drawers, and touched Resident's #32's CVC access site. She repeated that same process practicing handwashing before donning a new pair of gloves, but she touched the cabinets and her cell phone before touching Resident #36's access site. Continued observation of the clean surface on the side table showed that Staff I's cell phone was located near the clean gloves and gauzes during the duration of the dialysis initiation (photographic evidence obtained). In an interview conducted on 03/16/22 at 12:00 PM, with Staff I, she acknowledged all findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 9 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medications were administered as ordered for 1 of 5 sampled residents reviewed for Unnecessary Medications, Resident #25, as evidenced by the medication frequency was not being followed as ordered by the physician; and failed to ensure controlled substance medications were reconciled appropriately for 6 of 8 sampled residents reviewed during Medication Storage observation involving Resident #6, Resident #32, Resident #35, Resident #37, Resident #43 and Resident #374. The findings included: 1) Review of the facility Oral Medication Administration policy dated April 2018 documents in part, 'Purpose: To administer oral medications in a safe, accurate and effective manner. Procedures: Review and confirm medication orders for each individual resident on the Medication Administration Record prior to administering medications to each resident.' Review of the clinical record for Resident #25 revealed an admission date of 03/15/21 with diagnoses to include cerebral vascular accident with right sided weakness, atrial fibrillation and epilepsy (seizures). Resident #25 requires a feeding tube with feedings infusing for 23 hours daily to meet her nutritional and hydration needs in addition to providing a means to administer medications. Further review of the clinical record revealed Resident #25 was transferred to the hospital on [DATE]. Review of the September 2021 Medication Administration Record (MAR) revealed Resident #25 was receiving Topiramate (seizure medication) 50 milligrams (mg) daily at 8:00 PM. Resident #25 was readmitted to the facility on [DATE]. Review of the physician orders on readmission dated 09/25/21, revealed the Topiramate 50 mg daily was reordered. Review of the September 2021 MAR revealed the Topiramate was not administered on 09/25/21, was administered on 09/26/21 at 8:00 PM and was documented as discontinued on 09/27/21. Further review of the September 2021 MARs revealed a second entry dated 09/27/21 for Topiramate 50 mg tablet, give one tablet by gastrostomy tube daily at 8:00 PM with an indication for use documented as epilepsy. Review of the sign off section of the MAR to the right of the physician order, revealed a dose was administered on 09/27/21 and the dosage frequency was documented as every other day, not daily as ordered, with the next dose administered at 8:00 PM on 09/29/21. Review of the MARs from October 2021 through March 2022, revealed the Topiramate ordered on 09/27/21 to be administered daily, was being administered every other day as evidenced by an asterisk inserted on every other day as per the MAR coding, an asterisk indicates the medication is 'Not Scheduled' for that day. Review of Resident #25's electronic and paper clinical records revealed no physician order changing the Topiramate order frequency from daily to every other day. Further review of the MARs and Treatment Administration Records (TAR) from September 2021 through March 2022, revealed no documentation of any seizure monitoring or assessment. On 03/15/22 at 10:38 AM, an interview was conducted with the facility Pharmacy Consultant and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 10 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few review of the Pharmacy Consultant monthly reports were reviewed. The Pharmacy Consultant confirmed she had conducted medication reviews of Resident #25's medications on a monthly basis to include 09/29/21, 10/29/21, 11/27/21, 12/22/21, 01/19/22 and 02/10/22. The monthly medication reviews did not include any frequency discrepancy for the Topiramate. On 03/15/22 at 2:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) Staff A in the presence of Charge Nurse Registered Nurse (RN) Staff B, and a request was made to pull up Resident #25's electronic MARs. In reviewing the MARs, it was brought to LPN Staff A's attention the Topiramate which was ordered to be administered daily is being administered every other day. LPN Staff A stated the medication is to be administered every other day as there is an asterisk in the box on every other day indicating the medication is to be administered every other day. LPN Staff A was asked to read the Physician Order to the left of the sign off section of the MAR and stating out loud, LPN Staff A stated 'Topiramate 20 mg one tablet daily' then stated out loud 'Oh, the order is for daily, but it is documented on the MAR as being given every other day.' LPN Staff A then proceeded to review the paper clinical record and came across a hospital Medication Discharge summary dated [DATE] documenting the resident was to continue receiving the Topiramate 20 mg daily. An inquiry was made to LPN Staff A what the process is for reconciling the list of medications upon readmission from a hospital stay, to which she stated they look at the list of medications the resident was taking in the hospital, call the physician to see if he wants to continue with the medications, then they electronically enter the medications into the MAR system which then generates a MAR from the pharmacy. A further inquiry was made who double checks the list of medications inputted electronically into their system, to which LPN Staff A stated the nurse Supervisor on call will review and double check the medication list. LPN Staff A, and now Charge Nurse RN Staff B who got involved in the conversation, proceeded to check the electronic MAR system where the nurse inputted the Topiramate order in September 2021. Charge Nurse RN Staff B and LPN Staff A confirmed the order frequency for the Topiramate was entered as every other day and not daily as ordered. Charge Nurse RN Staff B stated the nurse entered it in wrong, she inputted the wrong frequency, that is where the error is. Charge Nurse RN Staff B stated she will contact the physician about the error and see if he wants blood levels drawn to see if receiving the seizure medication every other day and not daily has affected the effectiveness of the medication. An inquiry was made to Charge Nurse RN Staff B about monitoring residents with a diagnosis of seizures or any assessments conducted to which Charge Nurse RN Staff B stated they monitor residents for seizure activity, however do not document that anywhere, it would not be included on the MAR or TAR. On 03/15/22 at 3:10 PM, an interview was conducted with the facility Pharmacy Consultant and RN Pharmacy Consultant who had just met with LPN Staff A and Charge Nurse RN Staff B and had been apprised of this finding. The Pharmacy Consultant admitted she did not catch this error and would not have caught this error, stating when she does her monthly reviews, she reviews the physician orders and in this case the physician order was correct however the frequency was entered incorrectly on the MAR. The Pharmacy Consultant stated she does not have access to review of the MARs when she does her monthly reviews. The Pharmacy Consultant and RN Pharmacy Consultant stated they checked where the data entry was inputted, and the nurse entered every other day, and it should have been entered as daily. The Pharmacy Consultant reiterated when she reconciles the medications monthly, she goes by the physician orders and does not have access to the MARs, stating again, she would not have caught this error. An inquiry was made to the Pharmacy Consultant, pointing out she is only one person who reviews the medications, however since September 2021 to the current date of March 15, 2022, not one nurse who administered the Topiramate every other day when the order clearly documents daily, did not notice the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 11 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few frequency was incorrect on the MAR. The Pharmacy Consultant and RN Pharmacy Consultant could not comment. A record review conducted on 03/16/22 revealed a new Physician Order dated 03/15/22 for Topiramate 50 mg tablet, give one tablet via gastrostomy tube daily. Review of the March 2022 MAR now documented the Topiramate to be administered daily, with no asterisks delineating the frequency of every other day. Review of the facility's policy titled Controlled Substances dated 08/2019 documented .Accurate accountability of the inventory of all controlled drug is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): date and time of administration (MAR , Accountability record) .initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability record) . 2). Review of Resident #43 clinical record documents an initial admission to the facility on [DATE] with a readmission on [DATE]. The residents' medical diagnoses included in part Closed Fracture of Left Femur, Unspecified Joint Pain, Restless Legs Syndrome. Resident's quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 3(three) indicating a severe cognitive impairment. Review of the resident physician orders dated 11/27/21 documented Norco (pain medication) 5-325 milligrams (mg) one tablet every six (6) hours as need for pain. On 03/14/22 at 2:38 PM, a side-by-side review of Resident #43's Medication Monitoring/Control Record form for Norco 5-325 mg tablets four times daily as needed for non-acute pain was conducted with Staff B, a Registered Nurse (RN). The Medication Monitoring/Control Record form documented that one tablet of Norco 5-325 mg was removed from the controlled substance locked box on 02/08/22 at 3:00 PM and on 02/25/22 at 9:00 PM. Continued side by side review with Staff B-RN of Resident #43's Medication Monitoring/Control Record form and the February 2022 MAR revealed the tablet of Norco 5-325 mg pulled from the controlled substance box on 02/08/22 at 3:21 PM and on 02/25/22 at 9:00 PM were not documented/reconciled as administered on the residents MAR. During an interview, Staff B stated that once a medication is pulled from the controlled substance box and documented on the control sheet it had to be documented on the MAR. Staff B confirmed that Resident #43's Norco 5-325 mg documented on the resident Medication Monitoring/Control Record form were not documented on the MAR. On 03/14/22 at 3:31 PM, during an interview, the Director for Nursing (DON) was apprised of the controlled substance medication for Resident #43 was not reconciled/documented as administered on the residents MAR. 3). Review of Resident #37's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included in part Urinary Tract Infection, Anxiety Disorder, Cerebrovascular Accident (CVA), Hemiplegia and Pulmonary Embolism. Resident's quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 6 (six) indicating severe cognitive impairment. Review of the resident physician orders dated 02/22/22 documented Ativan (antianxiety medication) 0.5 mg twice a day as needed for 30 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 12 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/14/22 at 3:30 PM, a side-by-side review of Resident #37's Medication Monitoring/Control Record form for Ativan 0.5 mg one tablet twice daily as needed was conducted with Staff E, a Licensed Practical Nurse (LPN) and Staff A, LPN. The review revealed a tablet of Ativan 0.5 mg was removed from the controlled substance locked box on 03/10/22 at 4:30 PM; 03/11/22 at 12 noon; 03/13/22 at 3:00 PM and on 03/14/22 at 12:39 PM. Continued side by side review with Staff E-LPN of Resident #37's March 2022 MAR revealed that Ativan 0.5 mg tablet removed from the controlled substance locked box were not documented/reconciled as administered on the residents MAR. During an interview, Staff E-LPN stated that once a medication is pulled from the controlled substance box and documented on the control sheet it had to be documented on the MAR. Staff E-LPN confirmed that Resident #37's Ativan 0.5 mg tablets documented on the resident Medication Monitoring/Control Record form were not documented on the MAR. 4). Review of Resident #35's clinical record documents an initial admission to the facility on [DATE] and readmission on [DATE]. The residents' medical diagnoses included in part Fracture of Left femur, Dementia, Coronary Heart Disease and Diabetes Mellitus. Resident's significant change minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 5 (five) indicating a severe cognitive impairment. Review of the resident physician orders dated 01/04/22 documented Tramadol (pain medication) 50 mg one tablet every six hours as needed for pain. On 03/14/22 at 4:29 PM, a side-by-side review of Resident #35's Medication Monitoring/Control Record form for Tramadol 50 mg tablets was conducted with Staff F, LPN. The review revealed that a tablet of Tramadol 50 mg was documented as removed from the controlled substance locked box on 02/15/22 at 9:00 AM and on 03/03/22 at 9:00 AM. Continue side by side review with Staff F-LPN of Resident #35's February 2022 and March 2022 MAR's revealed that Tramadol 50 mg tablet removed from the controlled substance locked box were not documented/reconciled as administered on the residents MAR. During an interview, Staff F-LPN stated once the medication was removed from the controlled locked box, it had to be documented on the residents MAR. 5). Review of Resident #374's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included in part Pneumothorax and Malnutrition. Review of the resident physician orders dated 02/16/22 documented Percocet (pain medication) 5-325 mg one tablet every six hours as needed for pain. On 03/14/22 at 4:39 PM, a side-by-side review of Resident #374's Medication Monitoring/Control Record form for Percocet 5-325 mg tablets was conducted with Staff F, LPN. The review revealed that a tablet of Percocet 5-325 mg was documented as removed from the controlled substance locked box on 03/09/22 at 12:00 AM. Continue side by side review with Staff F-LPN of Resident #374's March 2022 MAR's revealed that Percocet 5-325 mg tablet removed from the controlled substance locked box was not documented/reconciled as administered on the residents MAR. 6). Review of Resident #32's clinical record documents an initial admission to the facility on [DATE] and a readmission on [DATE]. The residents' medical diagnoses included in part Bacteriuria, Peripheral Vascular Disease, Dermatitis and Tachycardia. Resident's quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 8 (eight) indicating a moderate cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 13 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the resident physician orders dated 12/12/21 documented Percocet (pain medication) 5-325 mg one tablet every four hours as needed for pain. On 03/14/22 4:51 PM, a side-by-side review of Resident #32's Medication Monitoring/Control Record form for Percocet 5-325 mg tablets was conducted with Staff G- LPN. The review revealed that a tablet of Percocet 5-325 mg was documented as removed from the controlled substance locked box on 02/09/22 at 2:00 PM, on 02/26/22 at 9:00 AM and on 03/12/22 at 12 noon. Continued side by side review with Staff G-LPN of Resident #32's February 2022 and March 2022 MAR's revealed the Percocet 5-325 mg tablet removed from the controlled substance locked box were not documented/reconciled as administered on the residents MAR. During an interview, Staff G stated once a medication was removed from the controlled locked box, it had to be documented on the residents MAR. 7). Review of Resident #6's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included in part Generalized Anxiety Disorder, Hypothyroidism, and Insomnia. Resident's quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 8 (eight) indicating a moderate cognitive impairment. Review of the resident physician orders dated 02/07/22 documented Ativan 0.5 mg by mouth twice a day as needed for 30 days. On 03/14/22 4:58 PM, a side-by-side review of Resident #6's Medication Monitoring/Control Record form for Ativan (Lorazepam) 0.5 mg tablets twice daily as needed for Anxiety was conducted with Staff G-LPN. The review revealed a tablet of Ativan 0.5 mg was removed from the controlled substance locked box on 02/18/22 at 12:00 PM and on 02/26/22 at 9:00 AM. Continued side by side review with Staff G-LPN of Resident #6's February 2022 MAR's revealed that Ativan 0.5 mg tablet documented/removed from the controlled substance locked box were not documented/reconciled as administered on the residents MAR. On 03/15/22 at 3:36 PM, a joint interview was conducted with the facility's Administrator, the Consultant Pharmacist, and the DON. They were apprised of the lack of controlled substance medication reconciliation for 6 of 8 residents record reviewed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 14 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a psychotropic (drugs that affect a person's mental state) medication ordered by the practitioner with a frequency of as needed, did not exceed the 14 days requirement for 2 of 2 sampled residents (Residents #6 and #37) reviewed during the controlled substance record review at the facility's second and third floor wings. The findings included: Review of the facility's policy titled Medication Orders: Stop Orders dated [DATE] documented the following classes of medications, whether the order is for routine or as needed (PRN) use, are stopped automatically after the indicated numbers of days .PRN psychotropic medication orders 14 days . 1). Review of Resident #37's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included in part Urinary Tract Infection, Anxiety Disorder, Cerebrovascular Accident (CVA), Hemiplegia and Pulmonary Embolism. Resident's quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 6 (six) indicating a severe cognitive impairment. Review of Resident #37's clinical record documented a care plan Resident takes an antianxiety medication for anxiety onset date [DATE] and revised on [DATE]. Review of Resident #37's physician orders dated [DATE] documented Ativan (antianxiety/psychotropic medication) 0.5 mg twice a day as needed for 30 days. The review revealed the practitioner/physician order exceeded 14 days as per regulation. On [DATE] at 3:30 PM, a side-by-side review with Staff E, a Licensed Practical Nurse (LPN) and Staff A, LPN of Resident #37's Medication Monitoring/Control Record form for Ativan 0.5 mg one tablet twice daily as needed was conducted. The control record documented 26 tablets of Ativan received on [DATE] from the pharmacy. Continue review revealed a tablet of Ativan 0.5 mg was removed from the controlled substance locked box on [DATE] at 4:30 PM; [DATE] at 12 noon; [DATE] at 3:00 PM and on [DATE] at 12:39 PM. The review revealed the practitioner/physician order for Ativan expired on [DATE] as per regulation. On [DATE] at 5:05 PM, during an interview with the Director of Nursing (DON) it was brought to her attention that Resident #37's physician order for Ativan as needed exceeded 14 days. The DON stated the physician ordered for 30 days and it was okay to give the medication within the time frame from [DATE] to [DATE]. The DON was apprised that psychotropic medication (Ativan) ordered on as needed basis is to be renewed every 14 days. She stated that as long as they had a physician order, they were okay to administer Ativan to Resident #37 on [DATE], [DATE], [DATE] and on [DATE]. On [DATE] at 1:16 PM, an interview was conducted with the facility's Consultant Pharmacist (CP). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 15 of 16 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 105205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Savoy at Fort Lauderdale Rehabilitation and Nursin 2121 E Commercial Blvd Fort Lauderdale, FL 33308 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 0758 She stated she had not reviewed Resident #37's medication record. Level of Harm - Minimal harm or potential for actual harm A side-by-side review of Resident #37's physician order dated [DATE] for Ativan. The CP stated the order exceeded the 14 days. Residents Affected - Few 2). Review of Resident #6's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included in part Generalized Anxiety Disorder, Hypothyroidism, and Insomnia. Resident's quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 8 (eight) indicating a moderate cognitive impairment. Review of Resident #6's clinical record documented a care plan Resident takes an antianxiety medication for anxiety onset date [DATE]. Review of the resident physician orders dated [DATE] documented Ativan 0.5 mg by mouth twice a day as needed for 30 days. The review revealed the practitioner/physician order exceeded the 14 days as per regulation. On [DATE] 4:58 PM, a side-by-side review of Resident #6's Medication Monitoring/Control Record form for Ativan (Lorazepam) 0.5 mg tablets twice daily as needed for Anxiety was conducted with Staff G-LPN. The control record documented 28 tablets of Ativan received on [DATE] from the pharmacy. Continue review revealed a tablet of Ativan 0.5 mg was removed from the controlled substance locked box on [DATE] at 9:00 AM and on [DATE] at 4:50 PM. The review revealed that Resident #6 received Ativan 0.5 mg tablets on [DATE] and on [DATE]. The review revealed the practitioner/physician order for Ativan expired on [DATE] as per regulation. On [DATE] at 1:26 PM, a side-by-side review of Resident #6's practitioner/physician dated order dated [DATE] for Ativan 0.5 mg by mouth twice a day as needed for 30 days was conducted with the facility's Consultant Pharmacist (CP). The CP stated she did a pharmacy review for Resident #6's on [DATE] and did not catch that the resident had and order for Ativan (a psychotropic) that exceeded the 14 days requirement. She added she missed it. The CP stated that she comes to the facility once a month to do residents pharmacy (medications) reviews. She added that she started to sign into the system once a week because the facilities were having problem adhering to the psychotropics 14 days rule. The CP stated that as needed basis psychotropic medication such as Ativan, have to have a 14 days stop date. She stated that on review she made sure those medications had a physician order with a stop date, if not she will make recommendation to stop or provide a stop date. She added if it is passed 14 days her recommendations is to discontinue it right t away. The CP stated she gives all her recommendations to the Director of Nursing (DON). The DON will review them and contact the physician. She added that it is a struggle to have the physician on board writing a 14 days stop date for psychotropic medications. The CP stated it was brought to the Quality Assessment and Performance Improvement committee to review as needed physician orders. On [DATE] at 1:44 PM, an interview was conducted with the DON. She stated that psychiatrist comes in evaluate the resident an order the medication as necessary. The DON stated that it requires a physician note and assessment to continue the psychotropic for more than 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105205 If continuation sheet Page 16 of 16