Inspection·April 4, 2024

F 0584 Poinciana Unit (rooms #7201-7212): Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: Room walls and wall corners damaged and in disrepair with large areas of black scuff marks. Bathroom toilet paper holder broken and hanging from wall and one of 2 bathroom lights not working. Residents Affected - Some room [ROOM NUMBER]: Bathroom toilet paper holder broken and hanging from wall. room [ROOM NUMBER]: Room walls and wall corners damaged and in disrepair with large areas of black scuff marks, and toilet paper hold was broken. room [ROOM NUMBER]: Bathroom toilet paper holder broken and hanging from wall. room [ROOM NUMBER]: Room walls (4) in disrepair with large black scuff marks, bathroom toilet paper holder broken and not able to hold a roll of toilet paper, exterior of bathroom entry door in disrepair and numerous large black scuff marks, room [ROOM NUMBER]: The room dresser drawer was missing a pull knob, resulting in a long exposer screw. room [ROOM NUMBER]: The exterior of the overbed table was heavily worn and in disrepair, room walls (4) in disrepair with large areas areas of black scuff marks, and the exterior of the portable over-commode toilet seat had areas of peeling plastic and was rust laden. room [ROOM NUMBER]: Room walls (4) in disrepair with large black scuff marks, and bathroom toilet was broken. 2) During the environmental tour conducted on 04/03/24 at 10:13 AM with the Floor Manager of the Egret House the following were noted: Room # 5101: Room floor soiled and heavily stained. Room walls (4) noted to be in disrepair and numerous black scuff marks. Room # 5102: Room walls (4) noted to be in disrepair and numerous black scuff marks. Toilet paper holder broken and no toilet paper available. Room # 5103: Exterior of room entry door noted with numerous black scuff marks. Room walls (4) noted to be in disrepair and numerous black scuff marks, and and toilet paper holder broken and no toilet paper available. room [ROOM NUMBER]: Room base wall noted to be falling off the wall. Bathroom entry door noted with numerous black scuff marks. Toilet paper holder broken; no toilet paper available. The exterior of the portable commode seat noted to have large areas of rust. room [ROOM NUMBER]: Toilet paper holder broken and no toilet paper available. Room # 5108: Large section (4 ft X 4 Ft) of the bathroom sink vanity noted to be broken off and stored in the corner of the bedroom. Room walls (4) noted to be in disrepair and numerous black scuff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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. Toilet paper holder broken and no toilet paper available. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: Room floor soiled and heavily stained. Room walls (4) noted to be in disrepair and numerous black scuff marks. Residents Affected - Some Dining room area: Ceiling mounted air-conditioning vent noted to be heavily soiled; with dust and dirt. 3) During the environmental tour conducted on 04/03/24 at 10:36 AM with the Floor Managers and Nursing Educator of the Pine House, the following were noted: room [ROOM NUMBER]: Room walls (4) noted to be in disrepair and numerous black scuff marks. The exterior of the portable commode seat noted to have large areas of rust. room [ROOM NUMBER]: Exterior of room entry door noted with numerous black scuff marks. Room floor soiled and heavily stained. Room walls (4) noted to be in disrepair and numerous black scuff marks. room [ROOM NUMBER]: The exterior of the portable commode seat noted to have large areas of rust. 4) During the environmental tour conducted on 04/03/24 at 10:50 AM with Floor Managers and Nursing Educator of the Magnolia House, the following were noted: room [ROOM NUMBER]: Room floor soiled and heavily stained. Room walls (4) noted to be in disrepair and numerous black scuff marks. room [ROOM NUMBER]: Exterior of room entry door noted with numerous black scuff marks. Room floor soiled and heavily stained. Room walls (4) noted to be in disrepair and numerous black scuff marks. Dining Room area: The exterior of 4 out of 9 dining room chairs were noted to be in disrepair, heavily stained and soiled. Following the observation tours conducted on 04/01/24 and 04/03/24, the findings were again reviewed and confirmed with the facility's administration. The administration stated that they were unaware of the conditions observed in the houses and stated that the facility has a TELS (a maintenance management tool) system for staff to report housekeeping or maintenance issues. However, staff are not utilizing and reporting into the TELS system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to assess 1 of 1 sampled resident (Resident #63) for the use of bilateral full bed rails; failed to determine a medical symptom for the need of the bilateral use of full bed rails; and failed to obtain a consent from the resident's representative to use the full bed rails. Residents Affected - Few The findings included: Review of the facility's policy titled Proper Use of Bed Rails revised on 01/2023 documents .physical restraint is defined as any manual method, physical or mechanical device, equipment .that meets all of the following criteria: is attached or adjacent to the resident's body; cannot be removed easily by the resident .resident assessment must also assess the resident's risk from using bed rails potential risks with the use of bed rails include: accident hazards (e.g. entrapment and other injuries sustained from attempts to climb over, around, between or through the rails .barrier to residents from safely getting out of bed .the facility will assess to determine if the bed rail meets the definition of a restraint. A bed rails is considered to be a restraint if the bed rail keeps a resident from voluntarily getting out of bed in a safe manner due to his/her physical and cognitive inability to lower the bed rail independently .informed consent from the resident or resident's representative must be obtained .prior to installation and use of bed rails . Review of Resident #63's clinical record documented an admission to the facility on [DATE], with no readmissions. The resident's diagnoses included Senile Degeneration of Brain, Vascular Dementia with Agitation, Anxiety, Muscle Weakness and Ataxia (loss of muscle control). Review of Resident #63's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of one (1) indicating the resident had severe cognition impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff to complete the activities of daily living. Further review revealed the assessment documented that bed rails were not used during the assessment period. Review of Resident #63's care plan titled ACTIVITIES OF DAILY LIVING (ADL): I have an ADL deficit and I require assistance with my ADL's because of Senile Degeneration of the brain, Dementia, Fatigue, Malaise, Weakness . The care plan interventions included: . Please ensure that I have 1-2 bedrails up as an enabler to promote increased independence with bed mobility . TRANSFERS/BED MOBILITY: I need extensive to total assistance of two person for my bed mobility and transfers. Please ensure that I use 1-2 bedrails for positioning and /or bed mobility . Further review of Resident #63's clinical record revealed the following physician order: -03/23/21 documented may use 1-2 bed rails for positioning and/or bed mobility. -07/02/21 documented Behaviors- monitor for the following: .restlessness (agitation) .psychosis, aggression . -11/12/21 documented admitted to (Local Hospice name), diagnosis- Senile Degeneration of Brain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -08/18/23- Seroquel tablet 25 milligrams at bedtime for behavioral disturbances related to Dementia and Anxiety. Review of Resident #63's Bed Rail Evaluation and Consent form dated 03/23/21 documented the resident did not have the ability to get out of bed independently and had impaired safety awareness related to cognitive decline; ¼ bed rails were indicated to reduce risk for injury related to seizure activity. Review of the resident's diagnoses did not include a Seizure diagnosis. Further review of the clinical record revealed the lack of an assessment for the resident's risk from using full bed rails and the potential risks with the use of full bed rails. The record lacked of a full bed rails consent from the resident's representative. Furthermore, review revealed the lack of a physician order for the use of full bed rails bilaterally. On 04/01/24 10:16 AM, observation revealed Resident #63 in bed with eyes open and alert. The surveyor attempted to conduct an interview with the resident, who kept eye contact with the surveyor, but did not answer to questions asked. Further observations revealed the resident's bed had full side rails up bilaterally and a scoop pressure relief mattress. On 04/01/24 at 12:31 PM, observations revealed Resident #63 continued to be in bed, with full side rails up bilaterally and a scoop pressure relief mattress. On 04/02/24 at 9:05 AM, observations revealed Resident #63 in bed, alert, with her eyes open and confused. Subsequently, a side by side observation of Resident #63 was conducted with Staff L, Shabazz. The observation revealed the resident's bed continued to have a full set of bed rails up bilaterally and a scoop pressure relief mattress. During the observation, Staff L acknowledged the resident had full bed rails up bilaterally. On 04/02/24 at 9:07 AM, an interview was conducted with Staff K, Licensed Practical Nurse (LPN), in Resident #63's room. Observation revealed the resident in bed, alert and with the full bed rails up bilaterally. Staff K did not attempt to lower one of the bed rails. On 04/03/24 at 7:49 AM, observation revealed Resident #63 out of bed in a recliner wheelchair. Subsequently, an interview and a side by side review of the resident's full bed rails was conducted with Staff D, LPN. Staff D stated that Resident #63 facility's bed was broken and hospice brought the current bed in. Staff D stated that when the resident was in bed, one rail was down and one was up because it becomes a restraint when the two are up. Staff D was asked if Resident #63 was able to get the bed rails down to get out of bed and stated No. Staff D was apprised that both of Resident #63's full bed rails were up on 04/01/24 and on 04/02/24. Photographic evidence was shown to Staff D. On 04/03/24 at 8:15 AM, an interview was conducted with the Director of Maintenance who stated that Resident #63's bed was brought in by hospice and he was not aware that the bed had two full bed rails. The Director of Maintenance was apprised that the resident's two full bed rails were up at the same time, creating a restraint. The Director stated the resident was not able to put the bed rails down if she wanted to get out of the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 0604 Level of Harm - Minimal harm or potential for actual harm On 04/03/24 at 8:38 AM, a telephone interview with Resident #63's hospice nurse was conducted. The hospice nurse stated she heard that the facility called about the resident's previous bed not working and the bed was replaced by a hospice bed. The hospice nurse stated she did not know the type of bed that was delivered. The hospice nurse stated she did not call for the bed replacement, and added she will call back with information regarding the type of bed and delivery date. Residents Affected - Few On 04/03/24 at 8:58 AM, an interview was conducted with Staff J, Shabazz, who stated that Resident #63 was confused and had one (1) bed rail up when she saw the resident this morning. Staff J, stated that it is a restraint if the two bed rails are up (at the same time) and added they have to keep one rail down. On 04/03/24 at 9:04 AM, a follow-up telephone call was received from the hospice nurse to report that Resident #63's hospice bed was delivered to the facility on [DATE] with two full side rails. The hospice nurse stated she saw the resident last time on 04/01/24 in her room, and the resident was in bed and she did not notice that Resident #63 had two full bed rails up. The hospice nurse acknowledged that it becomes a restraint when the two rails are up. The hospice nurse stated she will request to replace the full bed rails for half bed rails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 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 obtain a physician's order for the monitoring and the continued care and services of a left arm skin tear wound and of a right lower leg blood-filled blister for 1 of 1 sampled residents observed, (Resident #150). Residents Affected - Few The findings included: Review of the facility policy and procedure titled, Skin Tear, provided by the Director of Nursing (DON) with a reviewe date of 07/14/23, documented in the Policy Statement: .7. Put an order into Point-Click-Care (PCC) to monitor skin tear to the affected area for signs of bleeding and infection Record review revealed Resident #150 was re-admitted to the facility on [DATE], with diagnoses which included Type II Diabetes Mellitus, Acute Kidney Failure, Parkinson's Disease, Vascular Dementia, Anemia, Multiple Sclerosis, Bradycardia, Hypertension, Atherosclerotic Heart Disease and Cardiac Pacemaker. He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). During an initial observational tour conducted on 04/01/24 at 10:15 AM, Resident #150 was observed with approximately four (4) one (1) and one (1) half long un-dated steri-strips on the outer aspect of his left elbow covering a dried, crusty scab-like skin tear wound area. As well as a clear un-dated Tegaderm dressing covering a reddened, thickened, bloody, dried drainage area underneath, which was located on his right upper inner shin area; both dressings with the edges curling up. On 04/01/24 at 2:15 PM, a brief interview was attempted with Resident #150 in which he was asked about the presence of the steri-strips located on his left outer elbow, and of the clear Tegaderm dressing located on his right lower inner shin area. He stated that he did not know exactly how long the dressing coverings had been there. But, he said that it was important to him that he gets appropriate care, at all times. He added that he does not recall anyone having treated either of the areas since the bandage coverings had been in place there. During a second observational tour conducted on 04/02/24 10:33 AM, Resident #150 was noted to still have four (4) one (1) and one (1/2) half-inch long un-dated steri-strips on the outer aspect of his left elbow covering a dried, crusty scab-like skin tear wound area. As well as a clear un-dated Tegaderm dressing covering a reddened, thickened, bloody, dried drainage area underneath located on his right upper inner shin area; both dressings with the edges curling up. During a third observational tour conducted on 04/02/24 03:11 PM Resident #150 was noted to still have four (4) one (1) and one (1/2) half-inch long un-dated steri-strips on the outer aspect of his left elbow, covering a dried, crusty scab-like skin tear wound area. As well as a clear un-dated Tegaderm dressing covering a reddened, thickened, bloody, dried drainage area underneath, which was located on his right upper inner shin area; both dressings with the edges curling up. During a fourth observational tour conducted on 04/03/24 at 10:30 AM Resident #150 was noted to still have four (4) one (1) and one (1/2) half-inch long un-dated steri-strips on the outer aspect of his left elbow covering a dried, crusty scab-like skin tear wound area. As well as a clear un-dated Tegaderm dressing covering a reddened, thickened, bloody, dried drainage area underneath, which was located on his right upper inner shin area; both dressings with the edges curling up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review revealed on 01/09/24, the Skin Tear Care Plan documented Interventions: please apply treatment as ordered by my Physician and monitor for effectiveness Please monitor my skin tear for any signs of infection: redness, drainage, foul odor, swelling . Record review revealed on 01/09/24, the Diabetes Mellitus Care Plan documented Interventions: Please observe my skin for any redness or circulatory problems Record review revealed on 01/09/24, the Impaired Skin Integrity Care Plan documented Interventions: .Please provide the treatment as ordered by my physician Record review of the nursing progress note dated 03/06/24 at 10 PM by Staff G, Registered Nurse (RN), documented Left arm with several skin tears . Right lower leg blood filled blister An interview was conducted with Staff G, on 04/03/24 at 3:11 PM, in which she was asked the following two (2) questions: According to your 03/06/24 nursing progress note entry: 1) Was a physician's order obtained for Resident #150's skin tear wounds on his left outer elbow and the clear Tegaderm dressing right lower leg, at the time, for the care and continued treatment of both of these skin areas? She stated, no. 2) Is there documentation in your progress note to specifically indicate that the resident's physician was notified of the two (2) skin areas, at that time? She responded, no. The nurse stated that she did apply both the steri-strips as well as the Tegaderm dressings to the resident's skin areas. However, she acknowledged that there was no order obtained for the continued care and services of these two (2) areas, at the time. A side-by-side record review was conducted of the physician's orders, Daily Skilled Charting notes as well as of the weekly Skin Assessments with Staff G, and with the DON, but it was not noted or indicated in any of these that there was a documented physician's order for continued care and services, nor any specific detailed skin descriptions of either the outer aspect of Resident #150's left elbow, nor of the resident's right upper inner shin area. Neither were there any documented nurses' notes regarding the actual specific skin appearances, care and services provided to, or for either of these two (2) skin areas dating from 03/07/24 until 03/13/24. Nor, dating from 03/15/24 until 03/29/24 until current. However, further record review of the nursing progress note dated 03/14/24 at 1:29 PM by Staff H, Licensed Practical Nurse (LPN), documented Writer was made aware by PT personnel that guest suffered a skin tear to left hand. On assessment of the affected area a skin tear was noticed. Writer asked guest what caused the injury. Guest stated I bumped my hand on the edge of the table. Guest was made comfortable. Further assessment showed skin tear measuring 3.2 cm x 3 cm. area was cleanse with Normal Saline, pat dry, skin prep to peri wound and Steri-Strip applied. An interview was conducted with Staff H, on 04/04/24 at 11:28 AM in which she was also asked the following five (5) questions . According to your 03/14/24 nursing progress note entry: 1) Did you document that Resident #150 had a skin tear wound on his left outer elbow or to his left hand? She answered, no, it was to his left outer elbow. 2) Did you document anywhere in the nursing progress notes that this resident had a blood blister on right lower leg? She stated, no. 3) Did you document in this 03/14/24 nursing progress that the resident had a skin tear to his left outer elbow? She stated, no. 4) Was a physician's order obtained for treatment for this resident's left extremity skin condition, at the time? She stated, no. 5) Or, for any other skin condition, at the time? She stated, no. Further record review revealed, a physician's order to monitor the steri-strips to Resident #150's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 0684 left upper arm skin tear wound, was not obtained, until after surveyor inquisition/intervention. Level of Harm - Minimal harm or potential for actual harm The DON further recognized and acknowledged that on 04/04/24 at 10 AM that there was no physician's order obtained for the continued care and services of both Resident #150's skin tear wound left elbow steri-strips, nor of the resident's right upper inner shin Tegaderm dressing area, and also neither skin covering was dated nor recorded in the nursing progress notes as to when they were last changed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for potentially 47 residents residing within the [NAME] House (11 Residents), Dolphin House (13 Residents), Egret House (12 Residents, and Oak House (11 Residents). The findings included: 1) During the kitchen sanitation tour of the [NAME] House conducted on 04/01/24 at 9 :30 AM and accompanied with the facility's Registered Nurse Educator, the following were noted: (a) The interior of the kitchen ovens (2) were noted to be heavily worn, soiled, and covered with carbon build-up. (b) The exteriors of the kitchen cabinets were noted to be heavily worn, had areas of peeling paint, and numerous areas of dried food matter. (c) The ceiling mounted air-conditioning vent located over the serving preparation area of the kitchen was noted with a build up of dust and black mold type matter. (d) The ceiling area (4 feet) around the air-conditioning vent had a large build-up of dust and dirt. (Photographic Evidence Obtained). 2) During the kitchen sanitation tour conducted of the Dolphin House (Seaside Cove) on 04/01/24 at 11 AM, and accompanied with the facility's Registered Nurse Educator, the following were noted: (a) The exteriors of 2 of the commercial cutting boards were noted to be heavily worn and had large areas of peeling plastic. The surveyor requested that the boards not be utilized and be discarded. (b) The entire surfaces of the kitchen cabinetry were noted to be worn, peeling paint, and covered with dried food matter. The surveyor requested that the cabinets be cleaned and sanitized prior to the next meal service. (c) The ceiling mounted exhaust fan located directly over the food preparation/serving area was noted to have a heavy build-up of dust and dirt. The surveyor discussed that the the dust and dirt may fall into foods resulting in potential contamination. (d) The interior shelving of the Horizon reach-in refrigerator (3) and reach-in freezer (3) were noted to have areas of peeling plastic and were rust laden. The surveyor discussed that the small plastic pieces and rust were potentially falling into refrigerated foods resulting in potential contamination. (e) During the observation it was noted that the [NAME] would stir a tomato meat sauce that was cooking on the stove top. After each stirring the cook would lay the commercial preparation spoon on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some paper towel that was located on the preparation surface. The surveyor discussed that the spoon must be kept with the sauce or a clean spoon be utilized for the next stirring. The Surveyor further stated staff must cease storing the soiled spoon out of the food product, as bacteria begins to grow on the spoon resulting in food contamination. (f) The off-kitchen storage room floor was noted to be heavily soiled and black stained. The surveyor discussed that the floor is not being cleaned properly on a regular basis. (Photographic Evidence Obtained). 3) During the kitchen sanitation tour conducted of the Egret House on 04/01/24 at 12:30 PM, and accompanied with the facility's Registered Nurse Educator, the following were noted: (a) The interiors of the ovens (2) were heavily worn, soiled, and covered with a black carbon matter. The surveyor discussed that the ovens are not being properly cleaned on a regular basis and that the carbon black carbon must be eliminated. (Photographic Evidence Obtained). 4) During the kitchen sanitation tour conducted of the Oak House on 04/01/24 at 12:45 PM, and accompanied with the facility's Registered Nurse Educator, the following were noted: (a) The light and lighting cords that were located directly above the food preparation and serving areas were noted to be dust laden. The surveyor discussed that the dust was potentially falling into foods resulting in potential contamination and the light fixtures were not being properly cleaned on a regular basis. (b) The interiors of the ovens (2) were heavily worn, soiled, and covered with a black carbon matter. The surveyor discussed that the ovens are not being properly cleaned on a regular basis and that the carbon black carbon must be eliminated. (Photographic Evidence Obtained). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to implement measures for infection control practices during laundry services for the Woodland Houses and Seaside Cove. In addition, the facility failed to maintain a sanitary laundry area for their central laundry. Residents Affected - Some The findings included: Review of the facility's policy titled, Laundry Services- Handling of Soiled and Contaminated Laundry, undated, included the following: To implement practices on proper handling of laundry/personal clothing that prevent gross microbial contamination of the air and persons handling the linen. Guiding Principles: Sorting of each resident's linen/laundry and identification during laundry process will be done to prevent cross contamination and inaccurate distribution. Availability of (PPE) Protective Personal Equipment (e.g. gowns if soiling of clothing is likely). Sanitation of machine basket between each use. Clean lint catcher in dryer after each use. Proper infection control practices. Guide or Designee will provide education to Shahbaz on the proper handling of soiled and contaminated linen. Shahbazim will sanitize the machine between use to decontaminate machine. During a tour of the Seaside Cove building conducted on 04/03/24 at 10:04 AM observed Staff I, Shahbaz, entered one of the resident's rooms and rolled the resident's hamper to the laundry room. He donned gloves and without donning a gown proceeded to retrieve the soiled clothes and placed them into the washer. Staff I confirmed a urine smell-like coming from the resident's hamper. Further observation revealed that Staff I removed his gloves, walked to the kitchen, and performed hand hygiene and proceeded to prepare residents' meals. An interview was conducted with Staff I, who stated he does not wear a gown when he does the residents' laundry. An interview was conducted on 04/03/24 at 10:18 AM with Staff J, Shahbaz, at the Seaside Cove. She stated that each Shahbaz has two residents' laundry to do. She also acknowledged that the hampers were full, and the residents' laundry needed to be done. In addition, she stated that they don't use Protective Personal Equipment (PPE) when doing laundry. On 04/03/24 at 10:40 AM Staff E, Shahbaz, at the Seaside Cove laundry room was observed not wearing PPE while folding residents' clothing. An interview was conducted with Staff E, and she stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she does not wear a gown while doing residents' laundry. In addition, she stated that she works in the kitchen and assists the floor Shahbaz if needed. A tour of the Magnolia and Dove House laundry rooms was conducted on 04/03/24 at 11:10 AM with two Floor Managers and the Nurse Training Educator revealed that cleaning supplies were stored in the laundry room, including mop, broom, vacuum, etc. There was no Personal Protection Equipment (PPE) available for staff to utilize when handling soiled clothing and linens. An inspection of the two dryers revealed that the lint catcher in both dryers was not cleaned, photographic evidence obtained. An interview was conducted on 04/03/24 at 11:19 AM with Staff A and B, Shahbaz at the Dove House. They stated that at this house they only do residents' personal laundry. They both confirmed that no PPE was utilized prior to starting laundry services nor do they sanitize the machine basket between each use. A tour of the Pine House laundry room was conducted on 04/03/24 at 11:23 AM with two Floor Managers and the Nurse Training Educator. Similar set-up as the Magnolia and Dove House. One out of the two of the washers' drums was in disrepair and in need of replacement, (photographic evidence obtained). In addition, an interview conducted with Staff C at the Pine House confirmed that no PPE is worn during laundry practice nor that the machine baskets are sanitized between use. She also stated that at the Pine house they launder the bed linens as well as residents' personal clothing. An interview was conducted on 04/03/24 at 11:29 AM with the Floor Managers and the Nurse Training Educator. They confirmed that the Shahbaz have not been using PPE to handle the soiled clothing and linens during laundry services. In addition, they stated that there are no PPE supplies in any of the other houses' laundry rooms as all the houses in Woodlands are set up the same way. An interview was conducted on 04/03/24 at 1:00 PM with the Infection Preventionist, Assistant Director of Nursing (ADON). She stated that she was not aware of the PPE requirement for the laundry room. During the tour of the Central Laundry located at the Seaside Cove building conducted on 04/03/24 at 2:35 PM accompanied with the 2 floor managers, nurse training educator, and the Housekeeping Manager of Seaside Cove. An observation of the hallway used to transport soiled and cleaned linens in and out of the laundry revealed a ceiling mounted Air Conditioning (AC) vent with condensation and black scuff marks and surrounded ceiling tiles (9) rust laden and soiled, (photographic evidence obtained). Upon entrance to the washer room revealed cleaning supplies were stored in the room. There were four commercial washers and four transport linen carts (used to transport the clean wet linens to the dryer room). The exterior of 4 out of 4 transport linen carts were noted to be rust laden and dirty, (photographic evidence obtained). The exterior of the ceiling light fixture located at the center of the washer room was noted to be rust laden and the light was not working. (photographic evidence obtained). During the tour of the dryer room observation revealed four dryers and one of the dryer's exterior and interior was noted to be rust laden and dirty. Above the clean linen folding table, a ceiling mounted AC vent and the surrounding ceiling tiles (6) was noted to be soiled with dust and a layer of black mold substance, (photographic evidence obtained). In addition, there were 20 employee lockers located in the dryer clean room. Further observation revealed that the exterior of the lockers were heavily soiled and rust laden. Specific lockers that were able to be open were noted to have food being stored within, soiled clothing, chemicals, and trash and debris, (photographic evidence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 0880 obtained). Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 04/03/24 at 2:48 PM with the Floor Managers and the Nurse Training Educator revealed that the previous housekeeping supervisor would order the aprons for the Woodlands laundry rooms. However, the Woodland building is in transition for a housekeeping supervisor and the administration staff was not aware of the PPE requirements for the laundry. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined that the facility staff were responsible for causing the resident call system to be ineffective on resident rooms located on resident's the Egret Unit, [NAME] Unit, Poinciana Unit, and Ibis Unit that effected Resident's #82, #38, #125, #28, #54, #157, #69, #24, #126, and #378. Residents Affected - Some The findings included: 1) During the observation tour conducted of the of [NAME] Unit (Room's #7101-7112) and the Poinciana Unit (Room's # 7201-7212) on 04/01/24 at 12:30 PM, accompanied with the facility's Registered Nurse Educator, [NAME]/Poinciana Guide, and Assistant Director of Maintenance, it was noted that the bathroom emergency call pull cords were wrapped around the wall handrails or were placed on top of the sink vanity. Both resulted in the call bells being not able to be pulled or reached by staff and/or residents during in need of assistance or emergency. The specifics included the following: (a) Resident #82 (room [ROOM NUMBER]) - review of the resident with the Assistant Director of Nursing on 04/03/24 noted that the bathroom is utilized by the resident with staff assist for toileting, showers, and ADL (Activities of Daily Living) care. (b) Resident #38 (room [ROOM NUMBER]) - review of the resident with the Assistant Director of Nursing on 04/03/24 noted that the bathroom is utilized by the resident with staff assistance for toileting, showering, and ADL care. (c) Resident #125 (room [ROOM NUMBER]) - review of the resident with the Assistant Director of Nursing on 04/03/24 noted that the bathroom is utilized by the resident with staff assistance for toileting, showering, and ADL care. (d) Resident #28 (room [ROOM NUMBER]) - review of the resident with the Assistant Director of Nursing on 04/03/24 noted that the bathroom is utilized by the resident with staff assistance for toileting, showering, and ADL care. (e) Resident #54 (room [ROOM NUMBER]) - review of the resident with the Assistant Director of Nursing on 04/03/24 noted that all resident is bed-bound and all ADL care is completed in bed. (f) Resident #157 (room [ROOM NUMBER]) - review of the resident with the Assistant Director of Nursing on 04/03/24 noted that the bathroom is utilized by the resident with staff assistance for toileting, showering, and ADL care. (g) Resident #69 (room [ROOM NUMBER]) - review with the Assistant Director of Nursing on 04/03/24 of the resident noted that the resident utilizes the bathroom sink for tooth brushing. 2) During the observation tour conducted of the of the Egret Unit (Room's #5101-5112) and the Poinciana Unit (Room's # 7201-7212) on 04/01/24 at 12:30 PM, accompanied with the facility's Registered Nurse Educator and CNA/Guide Supervisor, it was noted that the emergency call pull cords were wrapped around the wall handrails or were paced on top of the sink vanity. Both resulted in the call bells being not able to be pulled or reached by staff and/or residents during in need of assistance or emergency. The specifics included the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 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 105255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (h) Resident #24 (room [ROOM NUMBER]) - review of the resident with the Assistant Director of Nursing on 04/04/24 noted that the resident utilizes the bathroom with staff assistance for toileting, showering, and ADL care. (i) Resident #126 (room [ROOM NUMBER]) - review of the resident with the Assistant Director of Nursing on 04/04/24 noted that the resident utilizes the bathroom with staff assistance for toileting, showering, and ADL care. 3) During the screening of Resident #378 who resides on the Ibis Unit on 04/01/24 at 10:30 AM, it was noted that the room emergency call cord was wrapped around the back side of the bed rail and could not be reached by the resident to utilize for assistance. The resident was noted to have difficulty communicating verbally with the surveyor. However, stated she cannot reach the call bell on numerous occasions when in need for staff assistance. Further observation conducted on 04/01/24 noted that the call bell remained wrapped around the bed rails and was not in reach of the resident from the original observation time of 10:30 AM through 3:10 PM. A review of the the clinical record of Resident #378 on 04/04/24 noted an MDS dated [DATE] that documented the resident sometimes understands and understood. Following the 04/01/24 tour the findings were again confirmed by the surveyor with the Director of Nursing Registered Nurse Educator, and [NAME]/Poinciana Guide. It was confirmed that facility staff were responsible for the emergency call light cords to be wrapped around hand rails and to be placed at a distance too high for residents/staff to reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105255 If continuation sheet Page 16 of 16