Inspection visit

Health inspectionNovember 18, 2021

Cascades Health and Rehabilitation CenterCMS #1053355 citations on this visit

5 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Potential for minimal harm Based on observation, interview, record review, it was determined that the facility failed to ensure that it responded to an active emergency call light in the shower room, on 1 of 4 units observed (Poinciana), affecting all 31 residents on this unit. Residents Affected - Some The findings included: During an observational tour conducted on 11/16/21 at 11:12 AM with the Director of Community Services, an unannounced test was conducted of the facility's emergency call light in the shower room located on the Poinciana Unit. The shower room located in close proximity to resident rooms 401-403 and approximately twenty-five feet (25) away from the Poinciana unit nursing station. The shower room emergency call light was pulled and activated by Staff D, an Environmental Services Lead, at 11:13 AM. Both the emergency call light in the shower area and in the commode area were blinking/flashing repeatedly. The floor in the shower area was noted as being wet. Even after this surveyor and the two (2) accompanying Community Services staff members had exited the shower room at 11:23 AM, it was further observed that both the emergency light located directly outside and above this bathing room door and the emergency light on the panel located at the Poinciana nurses' station, were also blinking/flashing repeatedly. It was noted that well after ten (10) minutes after the emergency call light in the shower room had been pulled and activated, there was still no response from any facility staff to this area. An interview was conducted with the Director of Community Services on 11/16/21 at 11:46 AM, in which he acknowledged that the resident shower room door is not kept locked. On 11/16/21 at 11:24 AM, an interview was conducted with Staff E, a Certified Nursing Assistant (CNA) working in the Poinciana unit and assigned to resident rooms 401-408. Staff E was observed walking near and just outside of the Poinciana shower room by this surveyor. However, she was not observed responding to the blinking/flashing emergency light in the shower room. Staff E, a (CNA) was asked if she heard, saw or was aware of the shower room emergency light blinking/flashing, for well over a period of ten (10) minutes; she replied no. Staff E was asked what she is supposed to do when an emergency light is flashing/blinking and she answered, we are supposed to respond to the emergency bathroom lights right away. This was not done. During an interview conducted on 11/16/21 at 12:10 PM with Staff F, a Registered Nurse (RN) working on the Poinciana unit and assigned to resident rooms 401-411. Staff F was also asked if she had heard, saw or was aware of the shower room emergency light blinking/flashing, for well over a period of ten (10) minutes; she also replied no. Staff F was also asked what she was supposed to do when an (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 105335 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 105335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades Health and Rehabilitation Center 2105 SW 11th Court Delray Beach, FL 33445 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 0558 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete emergency light is flashing/blinking and she also answered, we are supposed to respond to the emergency bathroom lights immediately. This was not done. An interview was conducted on 11/16/21 at 2:22 PM with the Director of Nursing (DON) in which she stated that the residents are always accompanied by a staff member and never alone. However, she did acknowledge that the staff members should all be responding to all call bells, in a timely manner. Event ID: Facility ID: 105335 If continuation sheet Page 2 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades Health and Rehabilitation Center 2105 SW 11th Court Delray Beach, FL 33445 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, records review, and interviews, it is determined that the facility failed to provide consistent activities of daily living (ADL) care and follow the orders for passive range of motion (PROM) to bilateral upper extremities (BUE) [shoulders, elbows, wrists digits], restorative nursing program (RNP) for PROM to bilateral lower extremities (BLE) [hips, knees, ankles] with a certified nursing assistant (C.N.A) 6 days a week, and splints to the hands of 1 of 1 sampled resident's hands (Resident #91) during the day. Residents Affected - Few The findings included: On 11/15/21 at 12:49 PM Resident #91's was observed in her room, lying in bed in a supine position. Her hair was observed to be uncombed, her fingernails untrimmed, her upper lips cracked and peeling. She had no splints on, and her hands, especially the left one, was severely contracted. An interview ensued at this time with Resident #91 thereafter confirmed that her hair had not been combed. She reported that they only pass water on her hair. Resident #91 reported that she had many strokes that affected her speech and left both arms paralyzed. Consequently, the Resident is totally dependent on staff for all her care needs. During an interview with the resident in the presence of the Speech Therapist Director on 11/17/21 at 12:46 PM, the resident reported that she would like her hair done by a hairdresser. She voiced deep concerns in tears that no one, prior to this Writer's intervention, cared to ask about her hair. She was pleased to realize that the Speech Therapist was able to communicate with her and cared for her wellbeing. Review of the MDS section G reveals the resident is totally dependent on staff for all activities of daily living. The record also noted that Resident #91 is impaired on both hands. Review of the Care Plan (CP) dated 11/3/2021 showed that Resident #91 required tube feeding related to Dysphagia. The Nursing CP revealed that Resident #91 had an ADL self-care performance deficit related to her Limited Mobility, Limited range of motion (ROM), Stroke with hemiplegia, bilateral hand contractures. She is totally dependent for all ADL care. The resident will maintain current level of function in ADL's through the next review date. The record further revealed that Resident #91 has an ADL self-care performance deficit related to Limited Mobility, Limited ROM, Stroke w/hemiplegia, bilateral hand contractures. She is totally dependent with ADL care. o The resident will maintain current level of function in ADL's through the review date. o BED MOBILITY: The resident is totally dependent on (2) staff for repositioning and turning in bed. o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105335 If continuation sheet Page 3 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades Health and Rehabilitation Center 2105 SW 11th Court Delray Beach, FL 33445 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 BEDFAST: The resident is bedfast all or most of the time. Level of Harm - Minimal harm or potential for actual harm o DRESSING: The resident is totally dependent on (2) staff for dressing. Residents Affected - Few o PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on (1) staff for personal hygiene and oral care. o PROM to BUE [shoulders, elbows, wrists digits] 2 x 10 reps each o Resident to wear bilateral resting hand splint during day, off at night except during ADL's and skin check o RNP for PROM to BLE [hips, knees, ankles] with a C.N.A 6 days a week (Restorative Nursing Program for passive range of motion to bilateral lower extremities. o TOILET USE: The resident is totally dependent on (2) staff for toilet use. o TRANSFER: The resident requires Mechanical Lift with (2) staff assistance for transfers. o SIDE RAILS: 1/4 rails up as per Dr.s order for safety during care provision, to assist with bed mobility. o Encourage the resident to participate to the fullest extent possible with each interaction. o Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105335 If continuation sheet Page 4 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105335 B. Wing (X3) DATE SURVEY COMPLETED A. Building 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades Health and Rehabilitation Center 2105 SW 11th Court Delray Beach, FL 33445 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Praise all efforts at self care. Level of Harm - Minimal harm or potential for actual harm Resident has impaired communication related to Expressive Aphasia, Stroke o Residents Affected - Few The resident will be able to make basic needs known on a daily basis through the review date. o Anticipate and meet needs. o Ask yes/no questions. o COMMUNICATION: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed. o Gain attention before talking. Resident #91 diagnoses include: Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side; Cognitive Communication Deficit; Major Depressive Disorder, Recurrent, Severe With Psychotic Symptoms. Review of the staff tracking activities performed, electronically documented in the facility's computerized system under TASK, for the month of November, 2021, documented that staff had placed the splints on the resident's hands 13 out of 17 days for thus far in the month. However, the Physicians' Orders indicated the following: Apply splinting device(s), per order -Resident to wear bilateral resting hand splint during day, off at night except during adl's and skin check. Although staff documented that the splint was placed on the resident's hands 13/17 days, the observation contradicted the documentation. For, on 11/15/21 at 12:49 PM, on 11/17/21 at 12:54 PM, Resident #91 was observed without the splints on her hands (photographic evidence obtained). No care was being provided during these observations. During an interview with Staff A, a Certified Nursing Assistant responsible for providing restorative care on 11/18/21 at 9:58 AM, she reported that when she provides restorative care, she places the splints on the resident's hands. She also reported that she did not have an order to provide passive range of motion (PROM) to bilateral upper extremities (shoulders, elbows, wrist digits) 2x10 repetitions each. As a result, she did not have any documentation. Review of the restorative record for the month of November revealed that the facility had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105335 If continuation sheet Page 5 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades Health and Rehabilitation Center 2105 SW 11th Court Delray Beach, FL 33445 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few applied the splints as ordered and has not provided PROM to BUE [shoulders, elbows, wrists digits] 2 x 10 reps each as indicated in the plan of care. Resident #91 to wear bilateral resting hand splint during day, off at night except during ADL's and skin check. During an interview with the Physical Therapy Director on 11/18/21 at 10:52 AM, she reported that the resident received occupational therapy (OT) from 7/20/2021-8/13/2021.Physical therapy (PT) was last provided from 3/23/2021 to 4/5/2021. When the service terminated the order was given for PROM to BUE [shoulders, elbows, wrists digits] 2 x 10 reps each, six days a week as per PT Director. Review of the PT order dated 1/27/2021 ordered from the PT Director revealed a standing order for Restorative PROM to bilateral Lower extremities. The record revealed that: Resident will tolerate ROM to: BL hip (body part) for 2x10 repetitions. Resident will tolerate ROM to: BL ankle (body part) for 2x10 repetitions. Resident will tolerate ROM to: BL Knee (body part) for 2x10 repetitions. There was no evidence provided before, during, and after the exit meeting on 11/18/2021 to indicate that staff carried out those tasks as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105335 If continuation sheet Page 6 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades Health and Rehabilitation Center 2105 SW 11th Court Delray Beach, FL 33445 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records review, and interviews, the facility had failed to provide ongoing activities to maintain the quality of life of the following 3 of 18 sampled residents (Resident #17, #25, and #91). Residents Affected - Few The findings included: 1) On 11/15/21 at 12:42 PM, Resident #91 was observed in her room lying in bed, the television was on. Resident #91 was admitted on [DATE]. Diagnoses include: Cerebral Infarction, Unspecified; Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side; Cognitive Communication Deficit; Major Depressive Disorder, Recurrent, Severe With Psychotic Symptoms. Review of the MDS section G revealed Resident #91 is totally dependent on staff for all activities. Section C revealed that the resident's cognitive ability for daily decision is severely impaired. Section F of the MDS which outlines the resident's Preferences shows that the resident enjoys listening to Music. The Care Plan for activities showed that Resident #91 prefers independent leisure activities as opposed to groups. She enjoys watching movies, game shows, anything happy on TV. The facility: o will continue to offer Resident #91 1:1 visit. o will provide resident #91 with a calendar of monthly activities. The resident's preferred activities includes, Music, so the facility will continue to invite Resident #91 to our musical activities. During an interview with the resident in the presence of the Speech Therapist Director on 11/17/21 at 1:14 PM, the resident stated that she has not had any activities. She reported that she likes music. She also reported that no one has been to her room to do one on one activities with her. During an interview with the Activity Director (AD) on 11/17/21 at 2:12 PM, she reported that she has been working at this facility for only 4 weeks. She says that her assistant Staff B has met with the resident, but she was not sure where the records are kept. During an interview with the Social Service Director (SSD) on 11/17/21 at 2:41 PM, she reported that during the initial assessment the resident was able to make herself partially understood. She said that the resident has three sons, but none are actively involved in the resident's life and care for personal and medical reasons. The SW reported that the resident has a legal guardian, and an Attorney who is responsible for her financial decisions. The legal guardian makes all healthcare decision. The SW reported that to fully assess Resident #91's cognitive ability, after interviewing the resident, she had contacted the resident's legal guardian to validate the information she received. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105335 If continuation sheet Page 7 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades Health and Rehabilitation Center 2105 SW 11th Court Delray Beach, FL 33445 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Based on what she was told, she determined that the resident was not cognitively competent. Additionally, the SW stated that the resident receives the care that she requires. The Activity Director indicated that she has seen the resident in her room when activity staff performed 1:1 activity with her. However, she was not certain what the 1:1 activity entailed, when questioned. During a follow-up interview with the Activities Director, on 11/18/21 at 9:05 AM, she reported that she has not been doing 1:1 activity, her assistants are the ones responsible for that task. Her assistants are responsible for documenting the activities performed and to report to her. She also stated that her assistants already had rooms assigned to them when she started working at the facility. She said that based on the conversation she had with Staff B, Resident #91 usually refuses to attend musical activities. The AD reported that the music activities are held every Monday at the facility. The AD said that Staff B told her that she did 1:1 activity with the resident. She added that Staff B was on vacation, she left on Tuesday November 16, 2021, and that there was no supporting evidence or records to confirm that the resident had refused to attend the music activities. Review of the activity tracking log for 1:1 activity provided by the AD reflected that the resident participated in socialization and watched lifetime TV every other day from 11/01/2021 to 11/12/2021 with Staff B. There was no clarification given to the type of socialization. According to the AD, the activity associate (Staff B) was on vacation and could not be reached via phone. 3.) Resident #17 was observed sleeping in bed on 11/16/21 at 10:00 AM. Resident #17 was observed sleeping in bed on 11/16/21 at 12:00 PM, and again at 3:00 PM. Resident #17 was observed sleeping in bed on 11/17/21 at 10:00 AM. Record review revealed Resident #17 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented Resident #17 had severe cognitive impairment, and required extensive one-person assist with activities of daily living. The assessment further documented the resident had not had any untoward behaviors. Resident #17 was care planned to be encouraged to accept 1:1 visits. An intervention included to honor the resident's desire to decline invitations to group activities and provide 1:1 as needed. An interview was conducted with the Activity Director on 11/17/21 at 2:45 PM. The Director stated Resident #17 had extreme mood swings. The Director further stated Resident #17 would receive in room [ROOM NUMBER]:1 visits if the resident did not want to leave her room, which was frequently. The Director stated they kept documentation of 1:1 room visits. The Activity Director was not able to provide any documentation of any activities provided to Resident #17. Furthermore, no documentation of Resident #17 refusing any group activities was found. 4.) Resident #25 was observed sleeping in bed on 11/16/21 at 10:00 AM. Resident #25 was observed sleeping in bed on 11/16/21 at 12:00 PM, and again at 3:00 PM. Resident #25 was observed sleeping in bed on 11/17/21 at 10:00 AM, and again at 12:00 PM. Record review revealed Resident #25 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, and required extensive to total 1 to 2 person assistance for activities of daily living. The assessment further documented the resident had not had any untoward behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105335 If continuation sheet Page 8 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades Health and Rehabilitation Center 2105 SW 11th Court Delray Beach, FL 33445 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #25 was care planned for assistance and reminders to groups of interests due to cognitive impairment. An intervention included to provide an escort to all sensory and all musical activities on and off the unit. The resident's preferred activities are: live music, dancing, exercise group, sensory stimulation groups, and ball toss. An interview was conducted with the Activity Director on 11/17/21 at 2:45 PM. The Director stated Resident #25 participated in activities sometimes, depending on her mood. If the resident was having a good day, the resident would be out to activities, if not, they would do a room visit. The Activity Director was not able to provide any documentation of any activities provided to Resident #25. Furthermore, no documentation of Resident #25 refusing any group activities was found. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105335 If continuation sheet Page 9 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades Health and Rehabilitation Center 2105 SW 11th Court Delray Beach, FL 33445 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 residents reviewed for unnecessary medications (Resident #17). Residents Affected - Few The findings included: Record review revealed Resident #17 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented Resident #17 had severe cognitive impairment, and required extensive one-person assist with activities of daily living. The assessment further documented the resident had not had any untoward behaviors. A review of Resident #17's Pharmacy recommendation dated 07/01/21 revealed the resident received Ibandronate (medication for osteoporosis) once monthly at 6:00 AM along with Omeprazole and Tylenol. The pharmacist's recommendation was to administer intact Ibandronate tablet at 6:00 AM (at least 60 minutes before first food, beverage or medication (Omeprazole and Tylenol) of the day with 6-8 ounces of plain water. Individuals should not lie down for at least 60 minutes and until after the first food of the day. Record review did not reveal a response from the Physician to the Pharmacist's recommendation. A review of Resident #17's Medication Administration Record revealed the resident was administered all 3 medications at 6:00 AM on 07/23/21, 08/22/21, 09/22/21, and 10/21/21. An interview was conducted with the Assistant Director of Nursing (ADON) on 11/18/21 at 1:00 PM. The ADON acknowledged the above. The ADON stated she would contact the Physician to get a response. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105335 If continuation sheet Page 10 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades Health and Rehabilitation Center 2105 SW 11th Court Delray Beach, FL 33445 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. Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute, and served food in accordance with professional standards for food service safety, that included holding perishable foods at the regulatory temperature of 41 degrees F below or 135 degrees F or above. The findings included: 1) During the initial kitchen/food service sanitation tour conducted on 11/15/21 at 9 AM , accompanied with the Food Service Director, it was noted that numerous containers (40 - 1/8 steam table pans) of prepared foods were sitting out on a preparation table at room temperature. Interview with Staff A who was preparing the foods noted that the foods included pureed and mechanical soft meats, pureed and mechanical soft vegetables, and other food menu items. Further interview with Staff A revealed that the foods were prepared prior to 9 AM and that the foods were intended for both lunch and dinner meals in the Health Center. Staff A continues to state that the foods would be left out for hours at room temperature until the lunch and dinner meal service. Further interview revealed that Staff A was not aware of the regulatory holding of perishable foods and that prolonged holding of these foods will negatively effect their nutritive value. At the request of the surveyor the temperatures of the foods were taken with the facility's calibrated thermometer. The temperature test revealed that the foods were not being held at the regulatory temperatures of 41 degrees F or below or 135 F degrees F or above, as per the following: * Pureed Beef (5 pans) = 110 F * Ground Chicken (5 pans ) = 103 F * Pureed Chicken (5 pans) = 108 F * Pureed Turkey (5 pans) = 110 F * Ground Turkey (5 pans) = 108 F * Pureed Mushrooms (5 pans) = 102 F * Boiled Eggs (2 dozen) = 52 F * Ground Beef = (5 pans) = 106 F * Chopped Beef (5 pans) = 104 F * Pureed Beets (5 pans) = 108 F A separate interview conducted with the Head Chef during the tour, who stated Staff A has worked in the dietary department for approximately 18 years, and has conducted in-service numerous times concerning the preparation techniques and regulatory temperature requirements. 2) During the observation of the lunch meal on 11/15/21 at 12 PM through 1 PM temperatures of hot (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105335 If continuation sheet Page 11 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades Health and Rehabilitation Center 2105 SW 11th Court Delray Beach, FL 33445 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 and cold foods were obtained with the facility calibrated thermometer in all 4 satellite kitchens (Garden, Cobblestone, Gulfstream, and Ponciana). The temperature testing revealed that cold foods were not being held at the regulatory temperature of 41 degrees F or below and hot food of 135 degrees F or greater, as per the following: Residents Affected - Some 1) Garden Unit (100 Rooms): * Potato Salad (1/3 steam table pan/approx. 12 portions) = 75 degrees F * Mashed Potatoes (1/3 steam table pan/approx. 12 portions) = 115 degrees F 2) Cobblestone Unit (200 Rooms): * Potato Salad (1/3 steam table pan/approx. 12 portions) = 76 degrees F * Pureed Turkey (1/8 steam table pan) = 99 degrees F * Pureed Tuna (1/8 steam table pan) = 51 degrees F * Sliced Turkey (approx. 10 portions) = 56 degrees f * Boiled Eggs (12 each) = 45 degrees F * Sour Cream (16 ounces) = 45 degrees F * Yogurt (Individual Servings) = 45 degrees F 3) Gulfstream Unit (300 Rooms): * Potato Salad (1/3 steam table pan/approx. 12 portions) = 69 degrees F * Tuna Salad ((1/3 steam table pan/approx. 12 portions) = 67 degrees F * Sliced Turkey (5 portions) = 57 degrees F 4) Poinciana Unit (400 Rooms): * Potato Salad ((1/3 steam table pan/approx. 12 portions) = 75 degrees F * Tuna Salad (1/3 steam table pan/approx. 12 portions) = 65 degrees F * Sliced Turkey (10 portions) = 54 degrees F * Note: The surveyor requested the facility Administrator to accompany the food temperature testing and verified all temperatures. Photographic evidence obtained of food temperatures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105335 If continuation sheet Page 12 of 12

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Citations

5 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0558GeneralS&S Bno actual harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0679GeneralS&S Dpotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.

FAQ · About this visit

Common questions about this visit

What happened during the November 18, 2021 survey of Cascades Health and Rehabilitation Center?

This was a inspection survey of Cascades Health and Rehabilitation Center on November 18, 2021. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Cascades Health and Rehabilitation Center on November 18, 2021?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·November 18, 2021