Health inspection·November 3, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm table was difficult to wheel about. The baseboard behind the bed was in disrepair. For the room in general the clock appeared to be stopped. In the bathroom for 223 there was a hole in the wall next to the electrical outlet. The ceiling vent had a large amount of black debris. The closet furthest from the entrance had sawdust like matter and black debris on the floor around it. The door was in disrepair with black mold type debris next to it. Residents Affected - Few Note - Photographic evidence obtained all all environment concerns in resident rooms. Interviews were conducted with staff at the time of the observations, and they acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 2 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on records review and interviews, it was noted that the facility did not involve a Certified Nursing Assistant (CNA) in the developement of the care planning process of 2 of 22 sampled residents (Resident #33 & Resident #73). The findings included: 1.) Review of the Care Plan (CP) signing sheet for Resident #33 revealed that it was signed on June 28, 2022. The CP record showed that the participants who acknowledged their presence by their signature were: Resident #33, the Food Service Manager (FSM), the Clinical Reimbursement Director (CRD), RN, and the Social Service Director (SSD). Review of a second care plan meeting held on 10/6/2022 revealed that only Resident #33, the SSD, and the Registered Dietitian (RD), signed the CP. There was no CNA signature on the CP signing sheet. On 11/01/22 at 10:54 AM Resident #33 stated she had filed multiple complaints about her call bell not being answered on time. She reported that it can at times take more than 1 hour to receive assistance. Resident #33 is diagnoses included End Stage Renal Disease; Chronic Obstructive Pulmonary Disease, and Muscle Wasting and Atrophy. She scored 15 on the brief interview for mental status (BIMS). She is cognitively alert and able to make her needs known. 2.) Review of the care plan signing sheet of Resident #73 revealed that it was signed on June 16, 2022. The individuals who signed the document and who were present were Resident #73, the Resident's son via telephone, the SSD, and the CRD/ RN. During another care plan meeting held on 9/20/2022, the individuals who signed the CP were Resident #73, the CRD, and the RD. There was no CNA signature on the CP signingt sheet. Review of the electronic clinical record revealed that Resident #73'ss diagnoses included Muscle Wasting and Atrophy, Phlebitis and Thrombophlebitis Of Unspecified Deep Vessels Of Right Lower Extremity; Protein-Calorie Malnutrition; Muscle Weakness (Generalized); Acute Embolism And Thrombosis Of Other Specified Deep Vein Of Left Lower Extremity, and Osteoarthritis. On 11/01/22 at 11:06 AM Resident #73 reported that she had filed a few complaints regarding her call light not being answered timely to the Administration. She reported that her call light was at times not within reach or not being answered on time. In an interview with the staff responsible for the minimum data set (MDS) management or the MDS Coordinator on 11/03/22 at 2:23 PM, she reported that she has been trying to have CNAs attend the Care plan meeting with no success. She said she understands that it is important to have the CNAs attend the CP meetings so that they can provide their feedback and report any concerns in implementing the residents' plan of care. At the exit meeting on 11/03/2022, the findings were reported to the Administration and no additional information was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 3 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to provide nail grooming, in accordance with activities of daily living for 2 of 2 residents observed (Resident #7 and Resident #37). Residents Affected - Few The findings included: 1.) Review of the facility policy and procedure on Activities of Daily Living (ADL) Assistance, provided by the Director of Nursing (DON), effective July 2022 indicated 2. Staff will provide assistance with ADLs per plan of care/[NAME]. 3. Staff may assist residents with: .d. Nail care . Review of facility's Certified Nursing Assistant (CNA) job description, dated 07/01/19, Summary of Position: .Work will include components of direct patient care Ensures that each resident's personal care needs are being met in accordance with the resident's/patient's wishes .Provides nail and hair care . 2.) Resident #7 was admitted to the facility on [DATE] with diagnoses which included Atherosclerotic Heart Disease, Alzheimer's Disease, Vascular Dementia, Major Depressive Disorder, Anxiety Disorder, Hypertension and Schizoaffective Disorder. She was severely cognitively impaired. During an initial tour conducted on 10/31/22 at 10:22 AM, Resident #7 was observed with long, sharp, jagged, unkempt fingernails on both hands. Photographic evidence obtained. On 10/31/22 at 2:03 PM, Resident #7 was still observed with long, sharp, jagged unkempt fingernails on both hands. On 11/01/22 at 10:02 AM, Resident #7 was still observed with long, sharp, jagged unkempt fingernails on both hands. 11/01/22 3:47 PM, Resident #7 was still observed with long, sharp, jagged unkempt fingernails on both hands. Record review of Resident #7's Monthly CNA ADL Flowsheet Record dated 10/20/22 thru 11/01/22 revealed that on the resident's (ADL) flowsheet for Personal Hygiene Nail Care indicated that the CNAs were documenting on ten (10) of those days, that Resident #7's fingernail care was being done, when in actuality, it was not. Record review of the Resident #7's Care plan initiated 12/14/17 and revised 01/19/21 indicated Focus: Activities of Daily Living (ADL): Resident has an ADL Self-Care Performance Deficit as evidenced by inability to participate in ADL's, functional decline, weakness .Interventions: Bathing: Check nail length and trim and clean on bath day as necessary. Goal: Resident #7 Will maintain current level of self-performance with ADLs through next review .Nonetheless, Resident #7's fingernail care had not been done, on the dates from 10/31/22 thru 11/01/22; until after surveyor intervention. Further record review of the Minimum Data Set (MDS) sections A and G dated 09/11/22 for Resident #7 indicated that she required extensive assistance of one (1) person for personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 4 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with Staff B, a CNA on 11/02/22 at 10:31 AM, in which she revealed that they had not provided fingernail care to Resident #7 and she said that it is the responsibility of the CNAs to clean and trim the residents fingernails. She further acknowledged that the resident's fingernails were long, sharp, untrimmed, and unkempt. An interview was conducted with Staff C, a Registered Nurse (RN), on 11/02/22 at 10:54 AM, regarding Resident #7's long, unkempt nails and she also acknowledged that Resident #7's fingernails were long, sharp, untrimmed, and unkempt. 3.) Resident #37 was admitted to the facility on [DATE] with diagnoses which included Muscle Wasting and Atrophy, Alzheimer's Disease, Vascular Dementia, Anxiety Disorder, Altered Mental Status, Unspecified Psychosis, Hypertension and Dysphagia. She had a Brief Interview Mental Status (BIM) score of 03 (severely impaired). During an observational tour conducted on 10/31/22 at 12:47 PM, Resident #37 was observed with long, sharp, dirty, unkempt fingernails on both hands.Photographic evidence obtained. On 10/31/22 at 2:08 PM, Resident #37 was still observed with long, dirty, sharp, unkempt fingernails on both hands. On 11/01/22 at 11:40 AM, Resident #37 was still observed with long, dirty, sharp, unkempt fingernails on both hands. An interview was conducted with Staff D, a CNA on 11/02/22 at 10:41 AM, in which she revealed that they had not provided fingernail care to Resident #37, and she said that it is the responsibility of the CNAs to clean and trim the residents fingernails. She further acknowledged that the resident's fingernails were long, sharp, dirty, untrimmed, and unkempt. An interview was conducted with Staff C, an RN on 11/02/22 10:48 AM, regarding Resident #37's long, sharp, dirty, unkempt nails and she also acknowledged that Resident #37's fingernails were long, sharp, dirty, untrimmed and unkempt. Record review of the Resident #37's Monthly CNA ADL (Activities of Daily Living) Flowsheet Record dated 10/20/22 thru 11/02/22 revealed that on the resident's (ADL) flowsheet for Personal Hygiene Nail Care indicated that the CNAs were documenting on twelve (12) of those days, that Resident #37's fingernail care was being done, when in actuality, it was not. Record review of the Resident #37's Care plan initiated 09/30/15 and revised 04/07/20 indicated Focus: Activities of Daily Living (ADL): The resident has an ADL Self-Care Performance Deficit as Evidenced by: Weakness, Cognitive Impairments with decreased safety, high risk for falls medication Interventions: personal hygiene assist of 1 Goal: Resident will maintain current level of self performance with ADLs through next review. Nonetheless, Resident #37's fingernail care had not been done, on the dates from 10/31/22 thru 11/01/22; until after surveyor intervention. Further record review of the Minimum Data Set (MDS) sections A and G dated 09/12/22 for Resident #37 indicated that she required extensive assistance of one (1) person for Personal Hygiene. An interview was conducted with the Activities Director (A.D.), Director of Activities, working in the facility for 3 years on 11/02/22 at 11 AM in which she stated that her department had been doing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 5 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fingernail polishing, trimming and filing for all of the residents in the facility routinely or upon request. The services are performed by the A.D. or either one (1) of two (2) facility CNAs. However, she added that she is able to cut resident's fingernails, only on a limited basis. She added that if her staff were to see a resident with long, dirty fingernails that she would alert the nursing department of the wing or unit involved to let them know to follow-up with the resident. The Activities Director said that her department had not provided nail care service to either Resident #7 nor for Resident #37, prior to this survey. The Director also acknowledged that Resident #7 and Resident #37's fingernails were all long, untrimmed, dirty and unkempt. On 11/02/22 at 11:13 AM, an interview was conducted with the Assistant Director of Nursing (ADON) and with Staff E, a RN/Unit Manager (UM), for the South wing, regarding Resident #7 and Resident #37's fingernails being long, sharp, dirty and untrimmed and they both acknowledged that it is the responsibility of the CNAs to clean and trim the resident's fingernails and they further acknowledged that the resident's fingernails were long, sharp and dirty and that they should have been cleaned/trimmed/cut. On 11/02/22 at 11:27 AM, an interview was conducted with the DON regarding Resident #7 and Resident #37's fingernails being long, sharp, dirty and untrimmed and she also acknowledged that it is the responsibility of the CNAs to clean and trim the resident's nails and she further acknowledged that the resident's fingernails were long, sharp, dirty and that they should have been cleaned/trimmed/cut. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 6 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, it was determined that the facility failed to manage a vulnerable resident's fragile, compromised skin wounds, in a safe and sanitary manner, in accordance with professional standards of practice, to prevent worsening of condition, or contamination, for 1 of 2 sampled residents observed for wounds (Resident #64). Residents Affected - Few The findings included: 1.) Review of the facility's policy and procedure on 11/03/22 at 1:50 PM titled Physical Environment provided by the Director of Nursing (DON) effective January 1, 2020 Policy: A safe, clean, comfortable and home-like environment is provided for each resident/patient . Review of facility's licensed nurse job description (undated) on 11/03/22 at 2:07 PM provided by the (DON), Summary of Position: The Licensed .Nurse is responsible for delivering care to residents/patients utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation; and effectively interacts with residents/patients, family members and other health team members while maintaining standards of professional nursing .Direct Care/Patient Responsibilities .Makes daily rounds on unit to ensure residents/patients care needs and environment standards .Assesses the needs of residents/patients to identify potential health or safety problems .Assist with residents/patients overall care and safety . Review of facility's Certified Nursing Assistant (CNA) job description, dated 07/01/19, Summary of Position: .Work will include components of direct patient care, nutrition, observation, documentation, transportation of patients and supplies, hygiene and general maintenance of the residents/patients environment Keeps residents/patients dry and clean Maintains cleanliness and sanitation of resident's/patient's units .Changes bed linens occupied and non-occupied . 2.) Resident #64 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder Bipolar Type, Squamous Cell Carcinoma of Skin of Left Ear and External Auricular Canal, Dysphagia, Muscle Wasting and Atrophy, Toxic Encephalopathy, Alzheimer's Disease, Metabolic Encephalopathy, Legal Blindness and Hypertension. He had a Brief Interview Mental Status (BIM) score of 6 (severely impaired). During an initial tour conducted on 10/31/22 at 11:43 AM, Resident #64 was observed with two flying insects constantly landing on his person, in bed. Additionally, there was also a live spider-like insect crawling on the wall just outside of Resident #64's room, which was also witnessed by the Assistant Director of Nursing (ADON). Further subsequent observation revealed that Resident #64 was noted with an open, moistened, crusty, exposed, foul smelling left ear cancer skin wound area, which was noted to be attracting the flying insects toward this vulnerable area on the resident's skin. There was no clean pillowcase barrier covering located underneath the resident's head. Photographic evidence obtained. During a second observational tour conducted on 11/01/22 at 11:27 AM, Resident #64 was noted to have a foul smell emanating from his right ear area as observed by two (2) Registered Nurse (RN) surveyors. Resident #64 was again observed as having a small flying insect hovering near his left ear cancer skin wound area, there was also a small amount of blood stained soaked drainage area located on the dirty pillowcase and bed sheet linens which were laying directly atop the Resident #64's exposed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 7 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few left ear cancer skin wound area. There was no clean pillowcase barrier located underneath his head. Photographic evidence obtained. On 11/01/22 at 11:31 AM, this surveyor attempted to interview Resident #64 to see if he was having any pain or discomfort in his ear areas because he was initially observed, grimacing with furrowed brows. However, he only indicated that he was unable to hear clearly. During a third observational tour conducted on 11/02/22 at 11:28 AM, Resident #64, was resting in bed, head of bed elevated with a blood stained soaked drainage area located on the dirty pillowcase and bed sheet linens which were noted as laying directly atop the resident's exposed left ear cancer skin wound area. Resident #64 was also observed with a towel wrapped around his head and face and laying directly atop of his exposed left ear cancer skin wound; it was also noted that a small amount of blood stained drainage was located on the dirty towel. Additionally, also noted was a foul smell emanating from his right ear area, as verified by the ADON, with a small flying insect observed near Resident #64's head, during the dressing change. Photographic evidence obtained. A side-by-side record review conducted with Staff E, an RN/Unit Manager (UM), on the South wing, documented that there was a physician's order dated 11/02/22 for Left Ear: Cleanse with normal saline solution, pat dry, apply triple Antibiotic (TAO), leave open to air (OTA). Additional record review revealed that there was a physician's order dated 11/02/22 for Right Ear: Cleanse with normal saline solution, pat dry, apply TAO, leave OTA. During an interview conducted on 11/02/22 at 11:55 AM with Staff C, an RN regarding Resident #64's cancer skin wound, she acknowledged that this resident did have an order to leave the left and right ear wounds OTA. She acknowledged that she had seen Resident #64's dirty bed sheets, pillows, towels and linen laying directly on his open left and right ear wounds, along with flying insects around Resident #64's bed near his left ear wound, as observed in photographic evidence presented. Staff C also acknowledged that in both of the above scenarios, it could present a potential for infection for this vulnerable resident. An interview was conducted consecutively on 11/02/22 at 12:00 PM with Staff E, an RN/UM, South Wing side and with the ADON, regarding Resident #64's cancer wounds, they both acknowledged that this resident did have an order to leave the left and right ear wounds OTA. They both subsequently acknowledged that they had seen Resident #64's dirty bed sheets, pillows, towels and linen laying directly on his open left and right ear wounds, along with flying insects around Resident #64's bed near his left ear wound, as observed in photographic evidence presented. Staff E and the ADON also acknowledged that with both of the above scenarios, it could present a potential for infection for this vulnerable resident. There were seven (7) skin cancer wound care progress notes for September and October 2022 by the DON, dated 9/20/2022 and 10/25/22, by the (ADON) dated 09/28/22, 10/04/22, 10/11/22 and 10/18/22, and by Staff E, RN/UM, South wing dated 10/12/22, all of which clearly documented that Resident #64's left ear wound had notable odor after cleaning. Review of skin measurement progress notes for dates listed above, it was revealed that the resident's left ear cancer wound showed worsening, for three (3) out of (7) dates of service (DOS), 9/28/2022, 10/12/2022 and 10/25/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 8 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few .His skin cancer of his ears continues to progressively worsen . as documented by Resident #64's primary care physician (PCP) dated 11/01/22. On 08/24/21 the revised care plan documented Skin Integrity Risk: The resident has potential/actual impairment to skin integrity related to Cancer Lesion to Left Ear, Right Ear Interventions: Review potential causative factors and eliminate/resolve where possible . There was no evidence of any interventions put in place to prevent Resident #64's dirty pillowcases, towels and other bed linen from coming into direct contact with his fragile, vulnerable wounds. And, neither was there any evidence of any devices or other interventions in place to keep any disease carrying flying pests from accessing Resident #64's exposed, compromised wounds. The DON further recognized and acknowledged on 11/02/22 at 2:45 PM that the flying insects should not have any access to Resident #64's left or right ear cancer wounds and neither should the resident's bed sheets and linens come into direct contact with the resident's cancer wounds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 9 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 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 Based on interviews and records review, 1 of 5 sampled dialysis residents (Resident #33) did not receive a lunch bag before going to a dialysis treatment center which is remotely located. Residents Affected - Few The findings included: On 11/02/22 at 4:11 PM, during an interview with Resident #33, she reported that she was a dialysis patient and went to dialysis three times a week, on Monday, Wednesday, and Friday at 8:00 AM. Resident #33 said that she usually returns to the facility by 3:00 PM and added that she did not receive her lunch bag when she went to dialysis the morning of 11/2/2022. She informed that this occurred not only once, but multiple times. During an interview with the Dietitian, Employee H, on 11/02/22 at 3:57 PM, she reported that there are five residents on dialysis. She informed that when residents are going to dialysis, they always give them a lunch bag, as required. She said that the lunch bags are usually prepared in the early morning for the residents who have to leave by 8:00 AM. But, there is one resident who eats his breakfast at the facility before going to dialysis. She said that to her knowledge Resident #33's lunch was prepared and sent to the nursing unit. She believed that Resident #33 should have received the lunch bag before leaving the facility. She said that the nurses should have made sure that she does. During an interview with the assistant Director of Nurses (ADON) on 11/02/22 at 4:08 PM, she stated that the dialysis resident's nurse is responsible for giving the residents their lunch bags before they go to dialysis. However, occasionally, the residents refuse to take the bag. During an interview with the Food Service Manager on 11/02/22 at 4:14 PM, he said that the cook reported to him that he had prepared egg salad for Resident #33 today, or on 11/02/2022. He said that once the meal is turned over to the nurse's station, they are responsible for it. On 11/02/22 at 4:22 PM, interview with Resident #33's nurse, Employee I, she said that she received two lunch bags for the residents the morning of 11/02/2022. However, she said that she did not give the lunch bag to the residents. She was not sure whether the night nurse might have given one of the lunch bags to Resident #33. During a follow up interview with Resident #33 on 11/02/22 at 4:24 PM Resident #33 reported that she had a blue lunch bag, but no one gave it to her as she was going to dialysis on 11/02/2022. She said as a matter of fact, on Friday 10/28/2022, they did not give it to her either. Review of the Physician orders revealed the following: Resident #33 dialysis days were on Mondays, Wednesdays, and Fridays. Her dialysis chair time was at 9 AM, her pick up time was at 7 AM. The Orders also revealed that Resident #33 was supposed to receive a lunch bag with meal/snack to go to Dialysis. The order was effective since 09/19/2022 at 07:00 AM. Review of the nutritional care plan showed that Resident #33 had nutritional problems related to therapeutic diet. Resident #33's anticipated weight fluctuations related to dialysis treatment; she had multiple nutrition related comorbidities including: Muscle wasting, diabetes mellitus type 2, end stage renal disease. Resident #33's weight trended down post her last hospitalization. The CP outlined that Resident #33 was to receive a Bag meal/sack to go to dialysis, for Lunch. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 10 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 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 During the Exit meeting on 11/03/2022, the information was discussed with the Administration and no additional information was provided. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 11 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to ensure that it secured and locked the over-the-counter (OTC) medications for 3 of 3 residents reviewed during a Medication Administration Observation (Resident #64, Resident #37 and Resident #12). The findings included: 1) During a observation room tour conducted on 10/31/22 at 11:48 AM, Resident #64 was observed sitting up in his room in his wheelchair watching television (TV). Resident #64's room was observed with a full bottle of OTC Tums Antacid Tablets expiration date January 2026, on his bed side table, unsecured, visible, and accessible to other residents, employees and visitors. Resident #64 was admitted to the facility on [DATE] with diagnoses which included Aphasia following Cerebral Infarction, Diabetes Mellitus Type 2, Muscle Wasting and Atrophy, Atrial Fibrillation, Hypertension, Benign Prostatic Hypertrophy. He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). A brief interview was conducted on 10/31/22 at 11:48 AM with Resident #64 in which he was asked about the bottle of OTC Tums, he stated that he does not take the Tums and does not know how they got there. On 10/31/22 at 2:08 PM Resident #64's room was still observed with a full bottle of Tums on his bed side table. On 11/01/22 at 11:09 AM Resident #64's room was still observed with a full bottle of Tums on his bed side table. On 11/01/22 at 3:24 PM Resident #64's room was still observed with a full bottle of Tums expiration date January 2026 on his bed side table. On 11/02/22 at 10:02 AM Resident #64's room was still observed with a full bottle of Tums on his bed side table. An interview was conducted on 11/02/22 at 10:07 AM with Resident #64's nurse, Staff F, a Registered Nurse, regarding the full bottle of Tums medication observed on Resident #64's bedside table and she acknowledged that the Tums medication bottle should not have been there. During an interview conducted consecutively on 11/02/22 at 12:49 PM with the Assistant Director of Nursing (DON) and Staff E, RN, Unit Manager (UM) South wing, they both indicated this resident does not self-administer any of his own medications and neither was he assessed to be able to do so. A side-by-side record review was conducted with Staff E, in which it was noted that neither Resident #64's hard copy chart nor his computerized Point-Click-Care (PCC) medical record indicated that the resident had any self-assessment completed in order for him to administer his own medications. There was no order on the Resident #64's Medication Administration Record (MAR) for this OTC medication to be administered to this resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 12 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2) During a observation room tour conducted on 10/31/22 at 11:01 AM, Resident #37 was observed resting in his bed watching television. In his room, there was an opened bottle of OTC 91% Isopropyl Rubbing Alcohol on his bedside table, unsecured, visible, and accessible to other residents, employees and visitors. Resident #37 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following other Non-Traumatic Intracranial Hemorrhage affecting Non-Dominant Side, Diabetes Mellitus Type 2, Dysphagia, Major Depressive Disorder, Unspecified Psychosis, Hypertension and Atherosclerotic Heart Disease. He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). Photographic evidence obtained. An interview was conducted on 10/31/22 at 11:08 AM with Resident #37's nurse, Staff F, regarding the opened bottle of OTC 91% Isopropyl Rubbing Alcohol observed on Resident #37's bedside table and she acknowledged that the bottle should not have been there. On 11/01/22 at 11:14 AM, Resident #37's room was still observed with the bottle of OTC 91% Isopropyl Rubbing Alcohol on his bedside table. On 11/01/22 at 3:27 PM, Resident #37's room was still observed with the bottle of OTC 91% Isopropyl Rubbing Alcohol on his bedside table. On 11/02/22 at 10:04 AM, Resident #37's room was still observed with the bottle of OTC 91% Isopropyl Rubbing Alcohol on his bedside table. During an interview conducted on 11/02/22 at 12:52 PM with the Assistant Director of Nursing (ADON) and Staff E, they both indicated that this resident does not self-administer any of his own medications and neither was he assessed to be able to do so. A side-by-side record review conducted with Staff E, indicated that neither Resident #37's hard copy chart nor his computerized Point-Click-Care (PCC) medical record reflected that the resident had any self-assessment completed in order for him to administer his own medications. There was no order on Resident #37's MAR for this OTC medication to be administered to this resident. 3) During a observation room tour conducted on 10/31/22 at 12:10 PM, Resident #12 was observed resting in bed watching TV, it was noted that Resident #12's room was observed with a package of OTC Halls Cough Drops expiration date September 2024 on his bedside dresser, unsecured, visible and accessible to other residents, employees and visitors. Resident #12 was originally admitted to the facility on [DATE] with diagnoses which included Muscle Wasting and Atrophy, Diabetes Mellitus Type 2, Chronic Atrial Fibrillation, Major Depressive Disorder, Heart Failure, Spinal Stenosis Cervical Region and Hypertension. He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). Photographic evidence obtained. During a brief interview with Resident #12 on 10/31/22 at 12:15 PM, this surveyor inquired of Resident #12, regarding the package of OTC Halls Cough Drops on his bedside table, the resident replied that he takes it whenever he needs it. On 11/01/22 at 11:15 AM and 3:41 PM, Resident #12's room was still observed with OTC Halls Cough Drops on his bedside dresser. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 13 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/02/22 at 10:00 AM, Resident #12's room was still observed with OTC Halls Cough Drops on his bedside dresser. An interview was conducted on 11/02/22 at 10:07 AM with Resident #12's nurse, Staff C, regarding the package of OTC Halls Cough Drops observed on Resident #12's bedside table and she acknowledged that the OTC medication package should not have been there. During an interview conducted on 11/02/22 at 1 PM with the Assistant Director of Nursing (ADON) and Staff E, they both indicated that this resident does not self-administer any of his own medications nor was he assessed to be able to do so. A side-by-side record review conducted with Staff E, indicated that neither Resident #12's hard copy chart nor his computerized Point-Click-Care (PCC) medical record indicated that the resident had any self-assessment completed in order for him to administer his own medications. There was no order on the Resident #12's MAR for this OTC medication to be administered to this resident. 4.) On 11/02/22 at 2:41 PM the Director of Nursing (DON) further acknowledged and recognized that the OTC bottles of Tums, 91% Isopropyl Rubbing Alcohol, and the package of Halls Cough Drops should not have been left at either of the resident's bedsides. Review of facility policy and procedure on 11/03/22 for Bedside Medications provided by the (DON) effective date 09/18 Policy: Bedside Medication Storage is permitted for residents who are able to self-administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgement of the nursing care center's Interdisciplinary resident assessment team .Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. 5. All nurses and nurse aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 14 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to keep the loading dock area clean and in a sanitary manner to prevent an environmental condition that harbors rodents, pests, and insects. Residents Affected - Few The findings included: During a follow-up visit to the kitchen on 11/02/2022 at 12:07 PM, the Surveyor toured the loading dock area and observed the refuse area with the Maintenance Director and noted there was a substantial amount of standing water that gave out a foul odor. The Maintenance Director stated that it was an issue that he could immediately resolve. He said that this never happened before. Also, there were some debris stored near the electric system by the loading zone. During an interview with a housekeeping staff on 11/02/22 at 12:10 PM, she stated that whenever it rains the area is flooded. This is evidence that the issue was a lingering problem. However, after draining the standing water, it was observed that the drainpipe was completely occluded with debris, [NAME], rocks, and dirt. The Maintenance Director realized that the problem was bigger than what he thought. During a follow-up interview with the Maintenance Director on 11/03/22 1:22 PM, he reported that the issue was resolved. A plumbing company was hired to unclog the draining pipe. However, the debris stored by the loading area was still in the area (photographic evidence obtained). On 11/03/2022 during the Exit meeting, the findings were discussed with the Administration, and they acknowledged with the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 15 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to document the resident's blood sugar monitoring results daily for 1 of 2 residents sampled for unnecessary medications review as evidenced by blood glucose (sugar) monitoring test results not documented in the resident's clinical record for the month of September, October and November 2022. (Resident #30). The findings included: Review of the facility's Clinical Guidelines Standard-Diabetes Management effective December 2007, provided by the facility's Corporate Nurse, documented .document blood glucose on the MAR (Medication Administration Record) . Review of the facility's Clinical Guidelines Standard-Physician Orders effective October 2021, provided by the facility's Corporate Nurse, documented .confirm the accuracy of orders. Review orders daily in Clinical meeting to confirm accuracy in transcription and identify errors of omission .assigned nursing staff will complete a monthly review to ensure physicians orders are captured accurately on the monthly physician's orders . Review of Resident #30's clinical record documented an initial admission to the facility on [DATE] and a readmission on [DATE]. The resident diagnoses included Type 2 Diabetes Mellitus, Protein-Calorie Malnutrition, Anemia, Atherosclerotic Heart Disease, Metabolic Encephalopathy, Congestive Heart Failure ,and Acute Kidney Failure. Review of Resident #30's care plan titled Diabetes Mellitus: The resident has Diabetes Mellitus initiated on 01/31/2022 with a revision date on 01/31/2022. The care plan included intervention that read .Blood Glucose Monitoring as ordered (Refer to Order for current orders: Before Breakfast: 70-105 mg/dl, Before Lunch or Dinner: 70-110 mg/dl, One hour after meals: Less than 160 mg/dl, Two hours after meals: Less than 120 mg/dl, Between 2-4 AM:Greater than 70 mg/dl, For Blood Glucose less than 70 administer food or glucose gel per manufactures recommendations and notify MD initiated, on 01/31/2022 . Review of the physicians orders for Resident #30 documented the following: -09/01/22- Consistent Carbohydrate diet, Regular texture, Regular(Thin) consistency double Portions at meals for diet. - 09/02/22- Accu-check per order related to diabetic monitoring of Hypo/Hyperglycemic activity. -09/04/22- Fasting blood sugar in the morning. -09/02/22 For Blood Sugar Less Than 70 and able to Swallow, Administer Food or 1 tube of Glucose Gel, recheck blood sugar in 15 minutes and Notify MD, as needed for hypoglycemia administer 15 g of rapid-acting carbohydrates , wait 15 minutes, then retest Glucose gel tubes are measured in 15 g carbohydrate dosages. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 16 of 17 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 105219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Raton Rehabilitation Center 755 Meadows Road Boca Raton, FL 33486 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -09/02/22- For Blood Sugar Less than 70 and Unable to Swallow/unconscious. Administer IM Glucagon administer 1 mg (1 unit) of glucagon Obtained from EDK, Recheck Blood Glucose in 15 minutes and Notify MD as needed for hypoglycemia (1 vial containing 1 mg (1 unit) of glucagon powder and a disposable syringe containing 1 ml sterile water for reconstitution (mixing). Notify MD of low blood sugar. -09/02/22- May obtain blood glucose as needed if symptoms of hypo/hyperglycemia present and notify MD as needed. -09/02/22-Levemir Subcutaneous (Insulin Detemir) Inject 14 unit subcutaneously in the morning for Diabetes. -09/02/22- Metformin HCl Oral Tablet 850 mg 1 tablet by mouth two times a day for Diabetes. -09/07/2022- Boost Glucose Control every day shift for Nutritional Supplementation. Review of Resident #30's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the months of September, October and November 2022 revealed daily nurses initials that the residents blood glucose (sugar) monitoring was done during the months of September, October and November 2022. Further review revealed the resident blood glucose test result were not documented daily. Review of Resident #30's blood sugar summary documented last entry for the resident's blood sugar test results dated 07/27/22. Review of Resident #30's current progress notes from 09/02/22 to the last progress note on file dated 10/05/22 revealed no documentation of the resident's blood sugar monitoring test results. On 11/01/22 at 11:27 AM, during an interview, Staff G, Licensed Practical Nurse stated that the residents blood glucose test results are documented in the resident's TAR. On 11/03/22 at 2:55 PM, a joint interview was conducted with the facility's Assistant of Director of Nursing (ADON) and the Director of Nursing (DON). The ADON and the DON were apprised that Resident #30's blood glucose test result were not documented daily. Subsequently, a side by side review of Resident #30's September, October and November 2022 MARs and TARs was conducted with the DON. The DON confirmed that the resident's blood glucose test results were not documented in the MAR, the TAR or any other place during those months. The DON stated the nurses are checking the resident's blood sugar. The DON and the ADON were asked if the resident's blood sugar/glucose test result should be documented in the resident record. The DON and ADON did not answer the question. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105219 If continuation sheet Page 17 of 17