Health inspection·January 24, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Nurse Assistants (CNAs) go to school to get the proper training they need regarding all those feeding techniques. The Administrator further stated that she wouldn't understand the reason behind the CNAs not knowing the correct way of feeding the residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 2 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to honor a resident or resident's representative's choice for advanced directives, for 1 of 1 sampled resident, Resident #3. The findings included: Record review revealed Resident #3 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #3 was not assessed for cognition due to resident was 'rarely / never understood.' Review of Resident #3's physician orders included: Full Code - 01/22/25. Review of Resident #3's care plans for advanced directives, dated 08/19/24, documented: Resident has the following Advanced Directives: Full code status, The goal of the care plan was documented as: Resident's wishes will be honored through the next review. Interventions to the care plan included: Identify, confirm, and review Advance Directives on admission, readmission, at least quarterly and PRN. Review of Resident #3's paper-based health record revealed that there was a 'Do Not Resuscitate' (DNR) order, signed by the resident's attending physician and the resident's Health Care Proxy on 11/26/24. Review of the resident's face sheet revealed the resident's choice for Advanced Directives was 'Full Code' During an interview, on 01/22/25 at 2:20 PM, with Staff E, Licensed Practical Nurse (LPN), when asked about documentation provided when a resident is sent out, Staff E replied, I give them the face sheet, the medication list. When asked what documentation of the Advanced Directive is provided, Staff E replied, we go by the code status that is on the face sheet and it's on the MAR also. During an interview, on 01/22/25 at 2:28 PM, with the Assistant Director of Nursing (ADON), when asked about information provided when a resident is sent out, the ADON replied, Transfer form if the doctor fills it out, the Situation Background Assessment and Recommendation (SBAR) form, Change in Condition (CIC) nurses notes, face sheet and Physician orders, Bed hold policy, AHCA form, recent labs and x-rays. When asked about the documentation of Advanced Directives, the ADON replied, We go by the code status that is on the face sheet. During an interview, on 01/22/25 at 2:57 PM, with the Social Services Director (SSD), here since May 2023, when asked about obtaining and updating a resident and/or resident's representative choice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 3 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for Advanced Directives, the Social Services Director stated she was responsible for obtaining the code status of a resident, when they come in, I work with Admissions Director and make sure there is a safe discharge plan from day one, whether they are short term or long term. If the status changes, I work with the team, and we figure out long term or short term. I make sure that the person is according to the code status. When the concern regarding Resident #1's choices for Advanced Directives was brought to her attention, the SSD acknowledged understanding of code status and stated she would update the resident's record. During an interview, on 01/22/25 at 3:06 PM, the Administrator stated that the DNR was done recently. The surveyor referred to the date of the DNR as 11/26/24. The Administrator acknowledged that the resident's choice for Advanced Directives had not been updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 4 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 observations, interviews and record reviews, the facility failed to follow physicians' order for accurately monitoring blood pressure for 1 of 1 sampled resident, Resident #237. Residents Affected - Few The findings included: Record review revealed Resident #237 was admitted on [DATE] with diagnoses that included Parkinson's Disease with Dyskinesia, Congestive Heart Failure, Hypertensive Heart Disease with Heart Failure, Atrial Fibrillation, Cardiac Pacemaker (a battery-powered device surgically inserted in a person's chest to provide electrical impulses to the heart), and Gastro-Esophageal Reflux Disease without Esophagitis. Review of the Minimum Data Set (MDS) assessment Section C submitted by the Social Worker on 01/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. Review of physician orders dated 01/18/25 revealed: no blood pressure (BP) on the left arm every shift for Pacemaker. Review of a hospital report dated 01/16/25 revealed Resident #237 was status post Pacemaker placement on 01/17/25. Review of Resident #237's recorded BP on the Electronic Health Record (EHR) revealed the following manually taken BPs: On 01/22/25 at 8:57 AM, 144/77 mmHg, position Sitting l [left]/arm. On 01/22/25 at 8:56 AM, 144/77 mmHg, position, Sitting l/arm. On 01/22/25 at 5:22 AM, 134/82 mmHg, position Sitting r/arm. On 01/21/25 at 9:30 AM, 147/97 mmHg, position Sitting l/arm. On 01/21/25 at 9:28 AM, 147/97 mmHg, position Sitting l/arm. On 01/20/25 at 9:03 AM, 138/93 mmHg, position Standing l/arm. On 01/20/25 at 9:02 AM, 138/93 mmHg, position Standing r/arm. On 01/19/25 at 10:23 AM, 133/75 mmHg, position Sitting l/arm. On 01/18/25 at 11:06 AM, 130/76 mmHg, position Lying r/arm. On 01/18/25 at 11:04 AM, 130/76 mmHg, position Lying l/arm. The documented BPs were taken on the right arm on: 01/22/25 at 5:22 AM, 01/20/25 at 9:02 AM, and on 01/18/25 at 11:06 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 5 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 An interview was conducted with Staff K, Registered Nurse on 01/22/24 at 9:50 AM during a medication pass observation for Resident #237, who stated, while looking at the paper of recorded vital signs, I have taken the BP from the left arm earlier. When asked why she took the BP on Resident #237's left arm she stated, The left arm is closer to the heart and there is a difference between left and right arm. It would be better on the left arm. Residents Affected - Few An interview was conducted with Resident #237 on 01/22/25 at 11:30 AM, who when asked about staff taking his blood pressure, he stated, I remind nurses not to take BP on my left arm, but they do not listen. When asked what will happen if blood pressure is taken from the left arm, he stated, The reading is not accurate. Staff must use the right arm for correct blood pressure reading. An interview was conducted with the Director of Nursing (DON) on 01/24/24 at 11:41 AM, who when asked regarding care of the resident with newly inserted pacemaker, she responded Make sure to monitor the blood pressure, and monitor resident's chest and left side area. When asked if staff should follow a physician order to not use the left arm in obtaining blood pressure, she responded, Staff must follow physician order. When asked where the facility nurses record the blood pressure, she responded On the vital signs section of the EHR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 6 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to obtain physicians' orders for Oxygen (O2) for 1 of 1 sampled resident, Resident #15. Residents Affected - Few The findings included: Review of the facility's policy, titled, Oxygen, with a reference date of August, 2023, documented, in part: Policy: The facility will ensure oxygen is administered safely and per physician order. Procedure: 1. Verify the physicians order for oxygen administration. 9. Care plan to be implemented for those residents who require oxygen. Record review revealed Resident #15 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. The assessment documented the resident was dependent upon staff for all Activities of Daily Living (ADLs). Resident #15's diagnoses at the time of the assessment included: Anemia, Heart Failure, Hypertension, wound infection, Diabetes Mellitus, Chronic Lung Disease, Chronic Respiratory Failure with Hypoxia or Hypercapnia, Dysphagia, Presence of Automatic Cardiac Defibrillator, and Cardiomyopathy. Review of Resident #15's progress note in the electronic and paper-based health records revealed the following: On 01/22/25 at 6:25, Nursing Note Text: Resident remains in stable condition.He is on continuous oxygen (O2) via nasal cannula [n/c] 2L (liters) flow. On 01/20/25 at 4:05 PM, Nursing Note Text: Resident in stable condition. O2 sat [saturation] 98% on 2L via n/c. On 01/19/25 at 9:28 PM, 1/19/2025 21:28 Nursing Note Text: Resident in stable condition. O2 sat 98% on 2L via n/c. Safety and comfort maintained. On 01/08/25 at 5:56, Nursing Note Text: Resident remains in stable condition He is on continuous oxygen via nasal cannula 2L flow. Further review of Resident #15's electronic and paper-based health records revealed there were no orders for oxygen and no care plans developed and implemented for the use of oxygen. On 01/22/25 at 9:39 AM, Resident #15 was observed in bed with Oxygen via nasal canula initiated at 2L. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 7 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 01/23/25 at 8:31 AM, accompanied by the Administrator, Resident #15 was observed in bed with Oxygen via nasal canula at 2L. An interview was conducted on 01/23/25 at 8:35 AM with the Administrator and the Director of Nursing (DON), and when the concern was brought to their attention, the Administrator and the DON acknowledged there were no orders for Oxygen and no care plan related to the use of oxygen. The DON stated the oxygen was related to the resident having Chronic Obstructive Pulmonary disease (COPD) and Respiratory Failure. Event ID: Facility ID: 105296 If continuation sheet Page 8 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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** 4. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] with the diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Epilepsy and Dementia. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 05 indicating severe cognitive impairment. Review of Section GG of the same MDS revealed Resident #2 was independent for eating and able to roll from lying on his back to left and right side. Review of the Physician's orders documented Resident #2 had an order dated 03/12/24 for Plavix 75 mg tablet, give one tablet daily for blood clot prevention; Dorzolamide HCL Solution 2 %, instill one drop in both eyes twice daily for Glaucoma; Dilantin 100 mg capsule, give one capsule three times daily for Seizures; Timoptic Ophthalmic Solution 0.5%, instill one drop in both eyes twice daily for Glaucoma; Lactulose Solution 10 GM/15ml, give 60 ml three times daily for elevated ammonia; Levetiracetam 500 mg tablet, give one tablet three times daily for Seizures. The Physician's orders dated 03/27/24 documented an order for Daily Multiple Vitamin, one tablet daily for supplement. Review of the Physician's Orders dated 07/31/24 documented an order for Megestrol Acetate Suspension 400 mg/10 ml, give 10 ml daily for poor appetite. A medication administration observation was conducted on 01/22/25 at 7:55 AM with Staff E, Licensed Practical Nurse (LPN), who dispensed the following medications for Resident #2: 1. Plavix 75 mg tab daily for blood clot prevention 2. multi-vitamin tab daily 3. dorzolamide 2% 2x daily eye drops for Glaucoma 4. Lactulose 60 ml 3x daily for elevated ammonia 5. Levetiracetam 500 mg tab 3x daily for Seizures 6. Megestrol Acetate 400mg/ml, give 10 ml daily for poor appetite 7. Phenytoin cap 100mg three times daily for Seizures 8. Timolol twice daily both eyes for Glaucoma Staff E was observed entering Resident #2's room and placed the small cup containing the dispensed medications on the bedside table near the resident's left side. Staff E then walked away to the sink to wash her hands. Further observation revealed the medications were not within her line of sight. An interview was conducted on 01/22/25 at 8:10 AM with Staff E, who stated she has worked at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 9 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 facility for 18 years. She acknowledged leaving the dispensed medications unattended next to Resident #2 and that it is not per facility's protocol. 5. Record review for Resident #31 revealed the resident was admitted to the facility on [DATE] with the diagnoses that included Degenerative Disease of Nervous System, Type 2 Diabetes Mellitus with diabetic Neuropathy, Epilepsy, Human Immunodeficiency Virus (HIV) Disease, Bipolar II Disorder and Anxiety Disorder. Review of Section C of the MDS dated [DATE] revealed Resident #31 had a BIMS score of 10 indicating moderate cognitive impairment. Review of Section GG of the same MDS revealed that Resident #31 was independent for eating and able to roll from lying on his back to left and right side. Review of the Physician's orders documented Resident #31 had an order dated 03/12/24 for Docusate Sodium 100 mg capsule, give one capsule daily for Constipation; Dolutegravir Sodium 50 mg tablet daily for HIV Disease; Emtricitabine-Tenofovir AF 200-25 mg, give one tablet daily; Glimepiride 2 mg tablet, give one tablet daily related to Type 2 Diabetes Mellitus; Levetiracetam 500 mg tablet three times daily for Seizure. Review of the Physician's orders dated 12/14/24 documented an order for Pioglitazone HCl 15 mg tablet, give one tablet daily related to Type 2 Diabetes with Diabetic Neuropathy. A medication administration observation was conducted on 01/22/25 at 8:30 AM with Staff F, LPN, who dispensed the above medications in a small cup for Resident #31. Resident #31 took the dispensed medication cup and placed them in his mouth but one of the pills fell to the floor. Staff F donned gloves and picked up the pill from the floor, walked to the medication cart and disposed of the pill in a sharp container attached to the medication cart. An interview was conducted on 01/22/25 at 8:40 AM with Staff F who stated she has worked at the facility for over 10 years. She was asked if disposing of the pill in the sharp's container is per facility's protocol, which she responded she was not sure. Staff F opened the bottom drawer of the medication cart and pulled a bottle which was labeled: disposal for medications. She then acknowledged that she should have disposed of the pill into this bottle instead in the sharp's container. An interview was conducted 01/22/25 at 10:40 AM with the DON, who has worked at the facility for 15 years and 6 years as the DON, who stated the nurses know not to leave medications unattended and to dispose of wasted medications in the drug buster bottle and not in the sharp's container. The DON stated the nurses sometimes get nervous with surveyors but both nurses have been working at the facility for years and they have been through a few surveys in the past. This should not have happened. Based on observations, interviews and record reviews, the facility failed to dispose of expired medications timely; failed to secure supplements were not expired but ready for use; failed to safely and timely store medications for 2 of 5 residents, Residents #287 and #3; and failed to secure medications during medication administration for 2 of 5 sampled residents, Residents #2 and 31. The findings included: Review of a provided document, titled, Medication Storage, with an effective date of 12/08/23, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Statement #4 revealed the facility shall not use discontinued, outdated and deteriorated drugs or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 10 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Level of Harm - Minimal harm or potential for actual harm The Centers for Disease Control and Prevention (CDC) website provides additional information regarding opened and/or accessed medications: http://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html as follows: Residents Affected - Few The CDC statement revealed, if a multi-dose vial has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. The CDC statement also revealed that if a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date. Review of a provided policy, titled Administering Medications, revealed a policy statement that medications shall be administered in a safe and timely manner, and as prescribed. 1. A [NAME] wing medication storage room observation was conducted on 01/21/25 at 10:25 AM with Staff D, the Assistant Director of Nursing (ADON), that revealed a Latanoprost ophthalmic solution (eye drops) 0.005 %, for Resident #287, and the next available refill was 01/07/25. When the ADON was asked about the refill date, she responded We have to send it back. When asked why the medication was still inside the refrigerator, she did not respond to it. 2. The continued observation in the [NAME] storage medication room on 01/21/25 at approximately 10:25 AM revealed an Omeprazole 2 mg /1 ml, oral (by mouth) medication with instructions to give 5 ml (milliliters) through peg (percutaneous endoscopic gastrostomy) tube for Resident #3 and to discard on 01/11/25. On 01/21/25 at 10:49 AM, when the ADON was asked why this expired medication was kept for the resident, she stated she must dispose of it. Record review revealed Resident #3 was admitted on [DATE] with diagnoses including Gastroesophageal Reflux Disease (GERD). The physician orders dated 08/07/24 revealed an order for Omeprazole oral suspension 2 Milligram (MG)/milliliters (m)l, give 5 ml via Percutaneous Endoscopic Gastrostomy (PEG)-tube in the morning. 3. Observations also revealed an unlocked drawer labeled 'Foley' (Inventor's name of urinary tubing) in [NAME] medication storage room that stored several plastic bags with residents' names and medications inside including the following: a. Dorzol/Timol eye drop for a resident with an expiration date of 11/14/24. b. Novolin R 100 unit/ml, not refrigerated, for a resident that was opened on 10/18/24. The ADON stated it had no expiration date. c. Brimonidine solution 0.2 % for a resident which was opened on 10/16/24, with expiration date of 11/14/24. d. Latanoprost solution 0.005 % eye drop for Resident #287 which was opened on 10/16/24 with expiration date of 11/30/24. Resident #287 was admitted [DATE] with diagnoses that included Unspecified Glaucoma. Review of the physician orders dated 01/14/25 revealed Latanoprost Solution 0.005 %, instill 1 drop in both eyes at bedtime related to Unspecified Glaucoma. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 11 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 e. Dorzolamide,1 drop, 2% solution for a resident which was opened on 11/13/24 with no expiration date. Level of Harm - Minimal harm or potential for actual harm Record review revealed all these expired medications belong to residents who are still residing in the facility. Residents Affected - Few On 01/21/25 at 11:00 AM, an interview was conducted with the ADON, who when asked why these residents' medications were in the catheter drawer with the sterile Foleys and when they would be discarded, she responded, I will discard them as soon as possible. I will not wait, discard them today and inform the DON. During an additional observation on 01/23/25 at 8:50 AM with the ADON, the East medication storage room revealed a cabinet with the bottom shelf storing 20 packs of Jevity 1.5 with an expiration date of 01/01/25. When the ADON was asked why the expired feeding tube supplements were kept in the East medication storage room, she responded Someone must have stocked them during the night, but I will check with the Director of Nursing (DON) for the name of the Staff who put them on the bottom shelf. She stated she is responsible for stocking and removing them from the medication storage rooms. When asked why these medications were still inside the medication storage rooms, and when are you planning to discard them, she stated, I will discard them as soon as possible, I will not wait, and I will discard them today and inform the Director of Nursing (DON) who was informed on 01/21/25 at 11:00 AM. An interview was conducted with the Director Of Nursing (DON) on 01/24/25 at 11:42 AM, who was asked regarding the storage of residents' medications on the East and [NAME] medication storage rooms, she responded, No residents' medications are stored in the medication storage rooms except for refrigerated insulin. When asked about the process of disposing expired medications, she responded, Nurses put the residents' expired medication inside the medication storage room temporarily. They will write a note for the DON to check and get the expired medications to be returned to Pharmacy. The DON stated, upon receipt of the notes from staff regarding the expired medication, she would go to the medication storage rooms and pack them to be sent to the Pharmacy. When asked about the 20 packs of expired Jevity inside the East wing medication storage room cabinet, she stated It was an oversight. When asked if staff submitted any notes for the expired medications from the East and [NAME] medication storage rooms, she responded, No. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 12 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews, the facility failed to provide a dental consultation in a timely manner for 1 of 2 sampled residents, Resident #80, reviewed for dental care. Residents Affected - Few The findings included: Review of the facility's policy, titled Ancillary Services, effective 12/08/23, documented in part, routine ancillary services (vision, podiatry and dental) are available to meet the residents health needs in accordance with the resident's assessment and plan of care .social services .will assist with coordinating services. Documentation of the resident's care and services are maintained in the medical record . Review of Resident #80's clinical record documented an admission on [DATE] with no readmissions with diagnoses that included Acute Respiratory Failure with Hypoxia, Bipolar Disorder, Depression, Attention-Deficit Hyperactivity Disorder, Predominantly Inattentive Type, Psychosis, and Chronic Pain. Review of Resident #80's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 indicating no cognition impairment. Review of Resident #80's care plan records revealed no care plan initiated related to the resident's broken/rotten teeth. Review of Resident #80's progress notes lacked written evidence of Resident #80 refusing to be seen by the dental provider. On 01/21/25 at 10:43 AM, an interview was conducted with Resident #80 who stated he would like to see a dentist. On 01/23/25 at 10:45 AM, an interview was conducted with the Social Services Director / Activities Director (SSD/AD) who stated she has worked in the facility for two years. The SSD/AD explained that upon admission she places every resident on a list sent out to the dental provider for potential consultation, and the list of residents is e-mail to the dental provider. The SSD/AD stated the dental provider was last in the facility on 01/13/25 and would let her know who needs treatment. The SSD/AC was asked regarding Resident #80's dental consultation status and stated they were looking into his insurance and added she had not heard that the resident had dental issues. On 01/23/25 at 10:55 AM, a joint interview was conducted with the SSD/AD and the Medical Record Clerk, the clerk stated Resident #80 had not been seen by the Dental Provider. On 01/23/25 at 11:06 AM, a joint interview with Resident #80 and the SSD/AD was conducted. The SSD/AD asked the resident when he mentioned that he was having a dental issue, and the resident had responded at the every three (3) month's meeting. Resident #80 was asked to show his teeth and voluntarily opened his mouth, observation revealed rotten and broken bottom teeth. Resident #80 was asked what dental problems he was having and stated a little problem with chewing. The SSD/AD stated she was not aware of Resident #80 dental issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 13 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/23/25 at 11:10 AM, a side-by side record review and interview was conducted with Minimum Data Set (MDS) Coordinator who stated she does care plan meeting every three months (3) months. Resident # 80's Interdisciplinary Care Plan Conference Record dated 12/12/24 documented the resident was present in the meeting and requested to see a dentist. The record documented the SSD/AD was informed. The MDS coordinator stated she informed the SSD/AD that Resident #80 requested to be seen by the dentist. The MDS coordinator was asked if she had seen the resident's broken and rotten teeth. Stated the resident always said he was fine and that no dental care plan was initiated. On 01/23/25 at 12:56 PM, a second interview was conducted with the SSD/AD who stated she was responsible to follow-up on Resident #80's request during care plan meeting on 12/12/24 and added that she missed it. On 01/24/25 at 12:04 PM during an interview, the Administrator was apprised of Resident # 80's dental concern and was asked for the facility's policy regarding dental care. The Administrator replied that everything was fine, that the resident refused the dentist on 01/13/25 and asked the surveyor to check with the SSD. The Administrator was informed Resident #80 was never put on the list to be seen by the dental provider on 01/13/25. On 01/24/25 at 12:24 PM, a third interview was conducted with the SSD/AD who stated she had spoken with Resident #80 prior to sending the list to the dentist and the resident told her that he was fine and declined the dental consult. The SSD was asked to submit written documentation related to Resident #80 declination of the dental consult, and she did not document her conversation and the resident refusal of dental care. The SSD submitted a list of residents needing dental care consult sent out to the dental provider on 01/10/25, and Resident #80 was not listed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 14 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #49 was admitted on [DATE]. Review of the quarterly MDS Section C, dated 01/16/25, revealed a BIMS score of 04 indicating severe impaired mental cognition. Residents Affected - Few Review of the physician orders dated 11/16/24 revealed Enhanced Barrier Precaution, Percutaneous Endoscopic Gastrostomy (PEG), every shift for Prophylaxis related to enteral feed two times a day related to Dysphagia. During an observation on 01/24/25 at 8:44 AM, two staff members went inside room [ROOM NUMBER], which had an Enhanced Barrier Precaution (EBP) sign posted on the left side of door, without performing any hand hygiene. In an interview on 01/24/25 at 8:50 AM with Staff B, Restorative Certified Nursing Assistant (CNA), and Staff C, Physical Therapy Staff, when asked a question regarding EBP, they both responded when you go inside the room with an EBP sign, staff should wash their hands. When asked why they did not perform hand hygiene before and after leaving the room with an EBP sign, they did not respond. They continued walking and passed a hand sanitizer dispenser in the hall, but neither one used it. 4. Record review revealed Resident # 23 was admitted on [DATE]. Review of the MDS assessment, Section C dated 11/19/24, revealed a Bried Interview for Mental Status (BIMS) score of 00 indicating severely impaired mental cognition. Review of the orders dated 11/01/24 revealed Enhanced Barrier Precautions: PEG (Percutaneous Endoscopic Gastrostomy) tube, Foley (urinary tubing) catheter, every shift for prophylaxis. During observation on 01/23/25 at 9:39 AM, for urinary care and wound care, both staff were wearing Personal Protective Equipment (PPE) when assembling supplies and positioning Resident #23. Staff G, CNA, wanted to support Resident #23's left leg and left the room to obtain a pillow. She removed her PPE, but did not perform hand hygiene. She came back with a pillow, and without performing hand hygiene, adjusted the resident's legs, and put the pillow under them. She then put on the PPE including a blue gown and gloves without first performing hand hygiene per CDC guidelines. Based on observations, interviews, and record review, the facility failed to ensure their infection control program was implemented as evidenced by failing to follow Enhanced Barrier Precautions (EBP) guidelines for 4 of 4 sampled residents, Resident #287, Resident #82, Resident #23, and Resident #49, who had indwelling medical assistive devices such as Percutaneous Endoscopic Gastrostomy (PEG) tubes, Foley catheters or had wounds; and failed to ensure hand hygiene was completed between resident to resident contact and entereing and leaving residents' rooms. The findings included: Review of the facility's policy titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, included the following: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE [Personal Protective Equipment]. For Enhanced Barrier Precautions [EBP], signage should also clearly indicate the high-contact resident care activities that require the use of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 15 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 gown and gloves. Make PPE, including gowns and gloves, available immediately outside of the resident room. Center for Disease Control and Prevention (CDC) guidance is located at:: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. Residents Affected - Few 1. Record review revealed Resident #287 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Pressure Ulcer of sacral Stage 4. Review of the Minimum Data Set (MDS) assessment entry dated 01/13/25 revealed a Brief Interview of Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Review of the physician's orders documented Resident #287 had an order dated 01/14/25 for Enhanced Barrier Precautions: Peg Tube, wound, every shift. Review of the care plan dated 01/06/25 documented Resident #287 had alteration in functional performance as evidenced by: Needs assist from at least 1 helper to complete self-care tasks i.e. Oral care, eating and/or toileting hygiene, needs assist of at least 1 helper to complete mobility tasks related to bed mobility, transfers, impaired cognition. Interventions were to enhanced barrier precautions: peg tube, wound and foley catheter every shift. During an observation conducted on 01/21/25 at 9:05 AM, the surveyor observed that no sign was posted that Enhanced Barrier Precautions were in place at or on the room door. Observations conducted on 01/22/25 at 9:10 AM revealed that no sign of Enhanced Barrier Precautions were placed on or at the room door of Residents #287. An interview was conducted on 01/22/25 at 3:10 PM with the Assistant Director of Nursing (ADON) who stated the CNAs know which residents are on EBP based on the sign that is usually placed at the door of the resident's room. The ADON further stated they put a star next to the resident's name on the wall at the door to help identify the residents that are on EBPs. 2. Record review revealed Resident #82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pressure ulcer stage 3 and surgical aftercare following surgery on the circulatory system. The MDS assessment entry dated 11/05/24 revealed the resident's BIMS score was 99 indicating they were unable to conduct the interview due to severe cognitive impairment. Review of the Physician's orders showed Resident #82 had an order dated 11/18/24 for Enhanced Barrier Precautions: Peg Tube, wound, every shift for prophylaxis. Review of the care plan dated 11/13/24 documented Resident #82 had alteration in functional performance as evidenced by: totally dependent with self-care and mobility. Interventions were Enhanced Barrier Precautions: peg tube, wound every shift for prophylaxis. During an observation conducted on 01/22/25 at 10:08 AM, the surveyor observed Staff J, CNA, in Resident #82's room without a gown on. In an interview conducted on 01/22/25 at 10:09 AM, Staff J stated she had just finished providing care to Resident # 82. Staff J explained that when the rooms have the Enhanced Barrier Precaution signs, they must wear gloves and masks only to care for the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 16 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete An interview was conducted on 01/22/25 at 3:10 PM with the ADON who stated that PPE consists of gloves, gown and mask which are stored in the medication cart due to the challenging population they are caring for at the facility. The ADON stated the Director Of Nursing (DON) educates the CNAs every week. The DON was made aware of the missing EBP sign at the residents' room doors, and the PPE was not fully worn, according to the facility's policy. Event ID: Facility ID: 105296 If continuation sheet Page 17 of 18 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 105296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Nursing and Rehab Center 440 Phippen Waiters Road Dania Beach, FL 33004 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to have an effective pest control system, as evidenced by sightings of live roaches in the Main Dining Room. This has the potential to affect residents that choose to eat in the Main Dining Room. The census at the time of the survey was 84 residents. Residents Affected - Some The findings included: During an observation of lunch in the Main Dining Room, on 01/21/25 at 11:32 AM, 2 live roaches were observed by two surveyor. At the conclusion of the lunch meal, on 01/21/25 at 1:04, at the request of the surveyor, the Maintenance Director had a staff member pick up the scale. Upon raising the scale, there was an accumulation of residue and debris and multiple roaches observed. During further observation in the Main Dining Room, there were two (2) vending machines, one for soda and another for snack foods (e.g. cookies, crackers, chips). It was noted that there was an accumulation of debris and residue around and under the vending machines. At the request of the surveyor, the Maintenance Director had the vending machines moved from the wall. Upon moving the vending machines, there were live roaches, in all stages of life and too numerous to count behind the vending machines. Review of pest control invoices provided by the facility revealed the following documentation by the pest control technicians: 01/15/25: the cafeteria had a decent amount of food in the corners which can lead to an increase in insect activity. 12/18/24: .hit various hot spots where there has been roach activity. Talked with Maintenance about the use of gel baits to further curtail the roach population. Further review of pest control invoices dating back to 08/22/24 revealed no documentation of roach activity in the facility. During an interview, on 01/21/25 at 3:03 PM with the Pest Control Technician, the Pest Control Technician stated this was only his second visit to the facility and the previous Pest Control Technician was no longer with the company. The Pest Control Technician reported the reason for the visit was for the newly identified concern that was identified by the survey team. On 01/24/25 at 11:22 AM, the Administrator stated the facility had a Performance Improvement Plan PIP) beginning December 2024 related to pest control and the facility had changed pest control companies in November 2024. The Administrator could not provide documentation of the Dining Room being part of the PIP, including cleaning and inspecting the areas of the Dining Room where the concerns were identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105296 If continuation sheet Page 18 of 18