Inspection·January 20, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks, and exterior of room chair was heavily worn. Dining Room Area: The wall and base board located underneath the sitting area was noted to have numerous large black scuff marks. Residents Affected - Some Spa Room: Observations noted that the room was located at the end of hallway and unlocked. Further observation noted that an open cabinet located within the room contained a box of 25 razors. Following the observation, the Director of Nursing and Administrator were requested to remove or lock the razors to prevent potential resident injury. Orchid Home (Rooms 2201 - 2212): Dining Room Area - The exteriors of 5 of the 10 dining chairs were noted to be worn, stained and soiled. room [ROOM NUMBER]: Room walls noted to be in disrepair and numerous large black scrapes. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes, the exterior of the room chair was heavily worn. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrape and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrape and scuff marks, and the exterior of the bathroom entry door was noted to have numerous large black scrapes and scuff marks. room [ROOM NUMBER]: Room walls noted to be in disrepair and numerous large black scrape and scuff marks, and the tube feeding pole had areas of dried brown matter. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrape and scuff marks. Dove Home (Rooms 33101- 3112): room [ROOM NUMBER] - Room floor noted to be soiled and stained, and the exterior of the room chair was heavily worn. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrape and scuff marks, and entry door exterior noted to have numerous large black scrapes and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrape and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrape and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrape and scuff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 If continuation sheet Page 2 of 12 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John Knox Village of Pompano Beach 700 SW 4th Street Pompano Beach, FL 33060 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 0584 marks. Level of Harm - Minimal harm or potential for actual harm Ibis Home (Rooms #4101-4112): Residents Affected - Some room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks. Seagrape Home (Rooms #4201-41120): room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks. Egret Home (Rooms #5101 - 5112): Hand Wash Sink - Wall area located near kitchen entrance was noted to be in disrepair. room [ROOM NUMBER] - Bathroom shower floor grout located at base of wall was stained. room [ROOM NUMBER] - Room entrance door noted to have numerous large black scarp and scuff marks, and exterior of room chair was heavily worn. room [ROOM NUMBER] - Room walls noted to be disrepair and numerous large black scrape and scuff marks. room [ROOM NUMBER] - Room walls noted to be disrepair and numerous large black scrape and scuff marks, room entry door noted numerous large black scrapes and scuff marks, and exterior of room chair was heavily worn. Room walls noted to be in disrepair and numerous large black scrape and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrape and scuff marks, and room entry door noted numerous large black scrapes and scuff marks. Pine Home (Rooms #5201-5212): room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrape and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks, and room entry door noted numerous large black scrapes and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 If continuation sheet Page 3 of 12 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John Knox Village of Pompano Beach 700 SW 4th Street Pompano Beach, FL 33060 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER] - Room entry door was noted with numerous large black scrapes and scuff marks, and room walls noted to be in disrepair and numerous large black scrapes and scuff marks, and room floor noted to be soiled and stained. room [ROOM NUMBER] - Room entry door was noted with numerous large black scrapes and scuff marks, and exterior of room chair was heavily worn. Hallway -Wall area located outside of Rooms #5203 - 5204 noted to have large black scrapes and scuff marks. [NAME] Home - (Rooms #61016112): room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks; and room entry door was noted with numerous large black scrapes and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks. Living/TV Room Area - The exterior of 1 of 3 chairs was heavily worn. [NAME] Home (Rooms #7101-7112): room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks and bathroom toilet paper dispenser not secured to the wall and falling from wall. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks. Poinciana Home (Rooms #7201 - 7212) room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks; and exterior of entry room door noted to have numerous large black scrapes and scuff marks. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks; and bathroom toilet paper dispenser not secured and falling off from wall. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 If continuation sheet Page 4 of 12 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John Knox Village of Pompano Beach 700 SW 4th Street Pompano Beach, FL 33060 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 0584 marks. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks. Residents Affected - Some room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks; and room entry door was noted to have numerous large black scrapes and scuff marks. room [ROOM NUMBER] - Exterior of room chair was heavily worn and and bathroom toilet paper dispenser was missing from the wall. Following the 1/18/23 tour, the findings were again discussed and acknowledge with the Administrator. 2). During an observation of the main dining room that is shared by the Sailfish and Pompano Units, on 01/17/23 at 10:01 AM, Accompanied by the Nurse Educator, it was noted that the baseboard around the bottom of a column that was centrally located in the dining room was not secured to the walls of the column. On 01/19/23 at 9:38 AM, Maintenance was observed tending to the baseboard and 2 live and mature roaches were observed crawling out from behind the baseboard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 If continuation sheet Page 5 of 12 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John Knox Village of Pompano Beach 700 SW 4th Street Pompano Beach, FL 33060 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 - Some 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** 7) Review of Resident #148's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included History of Falling, Atrial Fibrillation, Dementia Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Depression. Review of Resident #148's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 3 out of 15, indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the facility's staff with her activities of daily living. Review of Resident #148's care plan lack evidence of a self-Medication Administration care plan. The clinical record lack evidence of the resident assessment to do Self-Medication Administration. On [DATE] at 10:05 AM, observation revealed an open box of Voltaren- Arthritis Pain (diclofenac sodium topical gel) 1% on top of Resident #148's bathroom sink. On [DATE] at 10:15 AM, observation revealed Resident #148 in her room with her Private Duty Aide (PDA). An attempt was made to interview the resident, but she was not available to answer questions asked. An interview was conducted with Resident #148's PDA who stated that the resident lived permanently at the facility. The PDA stated she takes care of the resident Monday to Saturday during the day. During the interview, observation revealed the PDA washed her hands, donned gloves, picked up the Voltaren box from the sink, pushed the box flap closed and stored the Voltaren box in the resident's night stand drawer. On [DATE] at 10:08 AM, a side by side review of Resident #148's bathroom was conducted with Staff C, RN and the resident's PDA. The review revealed a box of Voltaren- Arthritis Pain (diclofenac sodium topical gel) 1% on top of Resident #148's bathroom sink. During the review, Staff C stated that she was not aware of the medication in the room. Staff C stated she did not have an order for Voltaren medication. During the review, the resident's PDA stated that Voltaren was an over the counter medication (OTC) provided by the resident's daughter. An interview with the PDA was conducted and stated she applies the Voltaren gel to Resident #148's knee. The PDA confirmed that the Voltaren was on top of the sink on Tuesday and that she put it on the night stand. Staff C removed the medication from the resident's room and stated that she will call the doctor for an order. On [DATE] at 2:50 PM, a side by side review of Resident #148's Medication Administration Record (MAR) and the active physician orders was conducted with the DON. The DON confirmed that there was not a physician order for Resident #148's Voltaren medication. The DON stated that the resident should not have the medication in her room. Based on observation, interview, record review and review of policy and procedure, the facility failed to ensure that it secured and locked ten (10) over-the-counter (OTC) and two (2) un-ordered prescription medications for 6 of 6 sampled residents observed, (Resident #54, Resident #19, Resident #136, Resident #26, Resident #70 and Resident #148); and, the facility failed to promptly discard two (2) expired OTC medications for 1 of 1 sampled resident (Resident #26). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 If continuation sheet Page 6 of 12 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John Knox Village of Pompano Beach 700 SW 4th Street Pompano Beach, FL 33060 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 The findings included: Level of Harm - Minimal harm or potential for actual harm Review of the facility policy and procedure titled, Storage of Medications, provided by the Director of Nursing (DON), revised [DATE], documented, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner Policy Interpretation and Implementation 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents . Residents Affected - Some 1) During a Medication Administration observation on [DATE] at 10 AM, a three quarter (¾) full box of OTC Vitamin A & D ointment packets with an expiration date of 10/2024, was observed on top of the Alcove desk in the main hallway of [NAME] Unit. The packets were un-secured and accessible to residents, employees and visitors (Photographic evidence obtained). On [DATE] at 1:25 PM, a three fourth (¾) full box of OTC Vitamin A & D ointment packets was still observed atop the Alcove desk in the main hallway of [NAME] Unit. On [DATE] at 9:30 AM, a three fourth (¾) full box of OTC Vitamin A & D ointment packets was still observed atop the Alcove desk in the main hallway of [NAME] Unit. On [DATE] at 2:20 PM, a three fourth (¾) full box of OTC Vitamin A & D ointment packets was still observed atop the Alcove desk in the main hallway of [NAME] Unit. On [DATE] at 9:00 AM, a now one-half (1/2) full box of OTC Vitamin A & D ointment packets was still observed atop the Alcove desk in the main hallway of [NAME] Unit. 2) Resident #54 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Dementia, Major Depressive Disorder, Cerebral Ischemia and Heart Failure. He had a Brief Interview Mental Status (BIMs) score of 5, indicating the resident's cognition is severely impaired. During a Medication Administration observation on [DATE] at 10:22 AM, Resident #54 was observed to have a used tube of Selan 2% Zinc Oxide with Dimethicone 2.1% (OTC) located on the back of his bathroom sink, with an expiration date of 11/23. The medication tube was un-secured and accessible to residents, employees and visitors (Photographic evidence obtained). On [DATE] at 12:48 PM, Resident #54 was still observed as having a used tube of Selan 2% Zinc Oxide with Dimethicone 2.1% OTC, located on the back of his bathroom sink. On [DATE] at 9:35 AM, Resident #54 was still observed as having a used tube of Selan 2% Zinc Oxide with Dimethicone 2.1% OTC, located on the back of his bathroom sink. On [DATE] at 2:25 PM, Resident #54 was still observed as having a used tube of Selan 2% Zinc Oxide with Dimethicone 2.1% OTC, located on the back of his bathroom sink. 3) Resident #19 was admitted to the facility on [DATE] with diagnoses which included Displaced Comminuted Fracture of Shaft of Left Tibia and Fibula, Atrial Fibrillation, Anemia, Hypertension, Major Depressive Disorder, Glaucoma, Anxiety Disorder, Heart Failure and Atherosclerotic Heart Disease. She had a Brief Interview Mental Status (BIMS) score of 3 (severely impaired). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 If continuation sheet Page 7 of 12 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John Knox Village of Pompano Beach 700 SW 4th Street Pompano Beach, FL 33060 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 - Some During a Medication Administration observation on [DATE] at 10:05 AM, it was noted that Resident #19 was observed to have a used tube of un-ordered Selan 2% Zinc Oxide with Dimethicone 2.1% OTC, located on the back of her bathroom sink with an expiration date of 11/24. The medication tube was un-secured and accessible to residents, employees and visitors (Photographic evidence obtained). On [DATE] at 1:25 PM, Resident #19 was still observed as having a used tube of Selan 2% Zinc Oxide with Dimethicone 2.1% OTC, located on the back of her bathroom sink. On [DATE] at 10:30 AM, Resident #19 was still observed as having a used tube of Selan 2% Zinc Oxide with Dimethicone 2.1% OTC, located on the back of her bathroom sink On [DATE] at 2:30 PM, Resident #19 was still observed as having a used tube of Selan 2% Zinc Oxide with Dimethicone 2.1% OTC, located on the back of her bathroom sink. On [DATE] at 9:05 AM, Resident #19 was still observed as having a used tube of Selan 2% Zinc Oxide with Dimethicone 2.1% OTC, located on the back of her bathroom sink. 4) Resident #136 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Cerebral Infarction, Acute Cerebrovascular Insufficiency, Atrial Fibrillation, Hypertension, Metabolic Encephalopathy and Right-Side Sciatica. She had a Brief Interview Mental Status (BIMS) score of 5 (severely impaired). During a Medication Administration observation on [DATE] at 11:05 AM Resident #136 was observed as having a used container of prescription Hydrocortisone 2.5% lotion on her bathroom sink, with an expiration date of 04/24. Photographic evidence obtained. On [DATE] at 2:10 PM, Resident #136 was still observed as having a used container of prescription Hydrocortisone 2.5% lotion on her bathroom sink. On [DATE] at 9:40 AM, Resident #136 was still observed as having a used container of prescription Hydrocortisone 2.5% lotion on her bathroom sink. On [DATE] 2:35 PM, Resident #136 was still observed as having a used container of prescription Hydrocortisone 2.5% lotion on her bathroom sink. On [DATE] 09:10 AM, Resident #136 was still observed as having a used container of prescription Hydrocortisone 2.5% lotion on her bathroom sink. 5) Resident #26 was admitted to the facility on [DATE] with diagnoses which included Displaced Fracture of Lower Epiphysis of Right Femur, Diabetes Mellitus Type II, Cardiac Pacemaker, Hypertension and Ileus. She had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). During a Medication Administration Observation on [DATE] at 11:15 AM Resident #26 was observed as having the following un-ordered three (3) different medications located in her bathroom on the sink: two (2) used containers of OTC Miconazole Nitrate 2% Antifungal powder---one (1) with an expiration date of 09/21 and the other with an expiration date of 12/23, a used container of OTC Sterile Saline solution 0.9% with an expiration date of [DATE] and a roll-on container of Salonpas Lidocaine plus 4% maximum strength with an expiration date of 04/24. Photographic evidence obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 If continuation sheet Page 8 of 12 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John Knox Village of Pompano Beach 700 SW 4th Street Pompano Beach, FL 33060 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 - Some On [DATE] at 2:21 PM, Resident #26 was still observed as having the following three (3) different medications located in her bathroom on the sink: two (2) used containers of OTC Miconazole Nitrate 2% Antifungal powder, a used container of Sterile Saline solution 0.9% and a roll-on container of Salonpas Lidocaine plus 4% maximum strength. On [DATE] 2:40 PM, Resident #26 was still observed as having the following three (3) different medications located in her bathroom on the sink: two (2) used containers of OTC Miconazole Nitrate 2% Antifungal powder, a used container of Sterile Saline solution 0.9% and a roll-on container of Salonpas Lidocaine plus 4% maximum strength. On [DATE] at 9:15 AM, Resident #26 was still observed as having the following three (3) different medications located in her bathroom on the sink: two (2) used containers of OTC Miconazole Nitrate 2% Antifungal powder, a used container of Sterile OTC Saline solution 0.9% and a roll-on container of Salonpas Lidocaine plus 4% maximum strength. An interview was conducted on [DATE] at 12:14 PM with Resident #54, Resident #19, Resident #136, and Resident #26's nurse, Staff D, a Licensed Practical Nurse (LPN), regarding the OTC and prescription medication packets, bottles and tubes observed at the five (5) resident's bedsides and she acknowledged that the medication packets, bottles and tubes should not have been there. 6) Resident #70 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Parkinson's Disease, Major Depressive Disorder, Gastrostomy Tube, Unspecified Psychosis and Morbid Obesity. He had a Brief Interview Mental Status (BIMS) score of 15 (cognitively intact). During a Medication Administration observation on [DATE] at 11:20AM, Resident # 70 was observed as having the following three (3) medications located in his bathroom on the back shelf: a used bottle of un-ordered OTC Artificial Tears Lubricant eye drops with an expiration date of 02/23, a used tube of OTC Medihoney wound dressing with an expiration date of 10/25 and a used tube of prescription Venelex wound dressing ointment with an expiration date of 04/24 (Photographic evidence obtained). On [DATE] at 2:45 PM, Resident # 70 was still observed as having the following medications located in his bathroom on the back shelf: a used bottle of un-ordered OTC Artificial Tears Lubricant eye drops, a used tube of OTC Medihoney wound dressing and a used tube of prescription Venelex wound dressing ointment. An interview was conducted on [DATE] at 12:28 PM with Resident #70's nurse, Staff E, a Registered Nurse (RN), regarding the OTC and prescription medication bottles and tubes observed on Resident #70's bathroom shelf and she acknowledged that the medication bottles and tubes should not have been there. In fact, the OTC and prescription medication bottles and tubes were not removed from the sampled resident's bedsides, until after surveyor intervention. On [DATE] at 12:45 PM the Director of Nursing (DON) further acknowledged and recognized that the OTC and prescription bottle and tube medications should not have been left at any of the resident's bedsides. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 If continuation sheet Page 9 of 12 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John Knox Village of Pompano Beach 700 SW 4th Street Pompano Beach, FL 33060 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician ordered Fluid Restriction/Renal Diet for 1 of 9 sampled residents selected for nutritional review (Resident #35). The findings included: 1) Review of the facility's policy for Restricting Fluids noted the following: * When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room. Remove all fluid containers from the room 2) Review of the facility's Renal Diet noted the following: * Fruits- Not Recommended - High Potassium foods including Oranges * Vegetables Not Recommenced - High Potassium foods including Potatoes During the review of the clinical record of Resident #35, it was noted that the resident's admission date to the facility was on 06/06/22. The resident's diagnoses included, End Stage Renal Disease, Dependence on Renal Dialysis, Acute Kidney Failure, Chronic Kidney Disease Stage IV, and Hyponatremeia. Resident #35's Current Physician Orders included: * 11/9/22 - Fluid Restriction 1200 ml day -Includes 240 ml at Breakfast , Lunch and Dinner, and 160 ml per shift * 11/9/22 Fluid Restriction 160 ml per shift from nursing. * 10/27/22 - Renal Diet Further review revealed Resident #35's weight history included: 1/16/23 = 148 1/2/23= 146 11/28/22 = 149 11/21/22 = 152 10/19/22 = 164 7/11/22 = 170 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 If continuation sheet Page 10 of 12 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John Knox Village of Pompano Beach 700 SW 4th Street Pompano Beach, FL 33060 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 0808 * Weight loss of 22 pounds from 7/11/22 through 1/16/23. Level of Harm - Minimal harm or potential for actual harm Review of Resident #35's Minimum Data Set MDS assessment dated [DATE] for Significant Change - Weight Loss, documented the following: Residents Affected - Few Section B: Understood & Understands Section C: BIMS= 11 (Some Cog Impairment) Section D: Mood - Feeling Tired , Poor Appetite , 2-6 days Section G: Supervision With Eating Section K: 62/146 #, weight loss - not on prescribed weight loss regimen. Review of Nurses Progress Notes, noted the following dates and times of return from dialysis sessions: 1/18/23 = 1:30 PM 1/16/23 = 2:42 PM 1/13/23 = 4:04 PM 1/11/23 = 3:03 PM 1/09/23 = 1:59 PM 1/06/23 = 3:48 PM 1/04/23 = 3:07 PM 1/02/23 = 3:58 PM 12/30/22 = 2:59 PM 12/28/22 = 3:37 PM 12/23/22 = 1:24 PM 12/21/22 = 2:45 PM During the observation of the breakfast meal on 01/18/23 at 7:30 AM, it was noted Resident #35 was sitting in bed with an overbed table that contained 4 ounce disposable cups of water and 8 ounce container of what appeared to be Nepro supplement. Further observation revealed the resident was confused and could not state if she had her breakfast meal yet. Upon interview, with the CNA (Staff A) she stated, today the resident leaves for Dialysis around 8:30 AM, and had a bowl of hot cereal and milk early this morning. The CNA (Staff A) stated she did not know the amount of milk provided because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 If continuation sheet Page 11 of 12 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John Knox Village of Pompano Beach 700 SW 4th Street Pompano Beach, FL 33060 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 0808 it was served by the nursing night shift staff. Level of Harm - Minimal harm or potential for actual harm Continued observation noted that the resident was being wheeled out of the facility for transportation to the dialysis center. The surveyor asked the medication nurse (Staff B) to observe the items that were in the resident's bag located on the back of the wheelchair. Observation of the bag revealed 5 - 8 ounce containers of water and the insulated lunch bag did not contain any lunch or snack foods. Continued interview with the nurse (Staff B) revealed at the time of the observation, she was aware that the resident was on a physician ordered fluid restriction but was unaware that the resident's dialysis bag contained 5 10 ounce (1500 total ml) containers of water. Staff B further stated that the dialysis center must be putting the bottled water in the bag each dialysis visit. However, facility staff failed to remove them from the bag after each dialysis session. The nurse also stated that the resident is required to have lunch or snack foods to go to dialysis but did not know why no foods were included today. The surveyor asked if she was going to provide food to go to with the resident to dialysis and was noted to only put 2 individual packages of [NAME] Crackers and 4 ounce container of Sugar Free Jello in the resident's insulated lunch bag. The surveyor expressed to the nurse that the resident had recent significant weight loss and will be out of the facility for 4-5 hours and a significant meal, snack, fluid was not being provided. The resident left to the dialysis center without any additional foods. Residents Affected - Few Observation of the room of Resident #35 on 01/18/23 at 9 AM, revealed a bag, located at the bedside was noted to include a fresh orange and 1 bag of Lays potato chips . Interview with the facility's Registered Dietitian following observation, the following was discussed: * The 1200 Fluid Restriction was not followed as water was located in the resident's overbed table and 5- 8 ounce (1,500 ml) bottles of water were located in the resident's dialysis bag. * No bagged Renal lunch or snack was included on Resident #35's dialysis day of 1/18/23. It was discussed that the resident is without food from the last 12 dialysis sessions from 8:30 AM until returns of 1:30 PM through 4:04 PM. * A fresh orange and bag of potato chips were noted on the resident's bedside table. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 If continuation sheet Page 12 of 12