Health inspection·April 14, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the physician orders, dated [DATE], documented 'DNR', created by the facility's Infection Control Nurse. Further review revealed a prior physician order dated [DATE] that documented Full Code. Review of Resident #168's care plan, initiated on [DATE] and revised on [DATE], titled, Advanced Directives documented, Resident (name) has expressed the following wishes regarding code status and has the following advanced directives in place: is Full Code with interventions to include Full Code status .honor resident's wishes regarding advanced directives/ CPR (cardiopulmonary resuscitation) status . On [DATE] at 4:05 PM, a side-by-side review of Resident #168 facesheet and medication administration record (MAR) was conducted with Staff E, a Licensed Practical Nurse (LPN). Staff E did not address the resident code status discrepancy (both DNR and full code) as it was visible as soon as the record was opened. On [DATE] at 11:46 PM, an interview was conducted with Resident #168 who stated that he signed off 'to be a DNR'. On [DATE] at 4:05 PM, an interview was conducted with Staff F, an LPN who stated that if a resident codes (cardiac or respiratory arrest occurs), she would call a code and check the chart / record to see if the resident was a DNR or Full code. A side-by-side review of Resident #168's paper record was conducted with Staff F that revealed the Florida state required yellow form for a DNR was in the front of the chart signed by the resident on [DATE]. On [DATE] at 4:08 PM, an interview was conducted with Staff E, LPN who stated Resident #168 was a DNR. Staff E was asked how she could tell Resident #168 was a DNR. Staff E stated that she could see it in the computer. A side-by-side review was conducted with Staff E of the resident profile that revealed the record had been updated to show the DNR status only. Staff E and Staff F were apprised that on [DATE] and [DATE], the record had Resident #168 listed as both DNR and Full code status. Staff E stated she did not know who changed the status. On [DATE] at 9:01 AM, an interview was conducted with the facility's Director of Nursing (DON). The DON stated Resident #168's DNR status order was taken on [DATE] by the Infection Control Nurse. The DON was apprised that the advance directive care plan was not updated as the resident code status was changed on [DATE]. The DON stated the care plan had to be updated. On [DATE] at 9:07 AM, a joint interview was conducted with the Infection Control Nurse (ICN) and the DON. The ICN stated Resident #168 discussed the code status with the Advanced Practice Registered Nurse (APRN) and she obtained a DNR order on [DATE]. She confirmed that Resident #168 had both a DNR and Full Code status in the record. She was asked why the Full Code order was not discontinued and stated the information was passed on during a morning meeting and some else was supposed to discontinue the order. She stated she was not the responsible person to do it and did not know how to do it. She added that the nurses are supposed to check the resident chart. The ICN and the DON were apprised that Resident #168 had inaccurate code status in the record from [DATE] until [DATE] when the surveyor asked for the record to be printed. On [DATE] at 9:16 AM, an interview was conducted with Staff A, a Minimum Data Set (MDS) Coordinator. Staff A stated that residents' care plans are updated as soon as they know there is a change. He added that the change was to be done immediately after their knowledge of a change in the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 2 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 condition / status, when they find out from the Interdisciplinary Team (IDT) member. He stated that care plans are updated whenever something happens, like a new order, or a deviation on care. Staff A stated the team meets daily for morning meetings, clinical meetings, and added that they go over a variety of stuff for whatever happened in the last 24 hrs. Staff A was asked if a new physician order like a DNR order, was a deviation of care, and he stated it was and that he was notified today regarding Resident #168 and his DNR order. Staff A confirmed that the Resident #168's advance directive care plan related to the new DNR order was not updated as of [DATE]. Staff A was apprised that the resident's physician order for DNR was taken on [DATE]. On [DATE] at 10:04 AM, an interview as conducted with the facility's Director of Social Services (DSS). The DSS stated that she had 72 hours to update a resident care plan in case it happened over the weekend. The DSS stated she did not update Resident #168's advance directives care plan related to the new order for DNR and said she had missed it. On [DATE] at 2:14 PM, during an interview, the Administrator stated that on [DATE], she found an error on advance directives while reviewing / printing documents from Resident #168's electronic clinical record. She added that she called the ICN at the time and asked her to fix it. The administrator was shown photographic evidence taken on [DATE] that showed that Resident #168 clinical record had inaccurate information related to his code status, from [DATE] and until a copy of his record was requested by the surveyor on [DATE]. The administrator acknowledged the resident's advance directive care plan was not updated as of [DATE] with the change on the code status from a Full Code to a DNR status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 3 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0641 Ensure each resident receives an accurate assessment. 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 failed to ensure that the Minimum Data Set (MDS) assessment reflected the actual functional status of 1 of 5 sampled residents, Resident #102, reviewed for range of motion. Residents Affected - Few The findings included: Observation and interview conducted on 04/11/22 at 10:44 AM revealed that Resident #102 was in bed with a visible right-hand contracture. A splint was observed on the bed next to the resident. Resident #102 reported that she needed assistance to put on the splint, after she was asked why she was not wearing it. Subsequent observations on 04/13/22 at 10:02 AM, 04/13/22 at 11:12 AM, and 04/14/22 at 12:42 PM revealed Resident #102 wearing the splint. During an interview with Resident # 02 on 04/14/22 at 12:43 PM, she reported that they do not always put the splint on for her. Resident #102 said that if was only this week that they put it on daily, since Monday April 11, 2022. Review of Section C of the Minimum Data Set (MDS), dated [DATE], documented the resident's cognitive status showed that Resident #102 scored 9 of 15 on the Brief Interview for Mental Status (BIMS) score, indicating moderate cognitive impairment. In Section G of the MDS, respectively in sections G0110 and G0120, staff documented that Resident #102 required Extensive Assistance for personal hygiene, toilet use, dressing, transfer, and Total Dependence for bathing. In section G0400, assessing ROM, it was documented that Resident #102 had no impairment in ROM, which did not coincide with the assessments in sections G0110 and G0120. Review of the Care Plan, dated 12/28/21 and updated on 03/20/22, documented and confirmed that Resident #102 had a self-care deficit with dressing, bathing related to needing assistance with personal care task and mobility skills; cognitive deficit related to Dementia, and generalized weakness. Interventions on the care plan documented staff will provide hands on assistance with dressing, grooming, bathing as needed, and Resident #102 will wear hand splint 'on in the morning and off in the afternoon'. Review of the Occupational Therapy (OT) assessment, dated 03/10/22, showed that Resident #102 was referred to OT due to exacerbation of decrease in range of motion. Subsequently, OT made the following recommendations: 03/10/2022, Patient will wear a resting hand splint on right hand for up to 4 hours with minimal signs and symptoms of redness, swelling, discomfort or pain. From 03/23/22, Patient will wear a resting hand splint on right hand for up to 6 hours with minimal signs and symptoms of redness, swelling, discomfort or pain. On 04/08/22, Patient (Resident #102) will wear a resting hand splint on the right hand in the morning and off in the afternoon. This orthotic device is recommended because of the resident's functional limitations and related to contracture and inability to perform personal hygiene. In an interview with Staff H, a certified nursing assistant (CNA), on 04/14/22 at 12:52 PM, she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 4 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reported that the resident has been living at this facility for a while. She said that she was informed that the resident must wear the splint. She added that after they (CNAs) perform their required tasks, the nurses are the ones who document the residents' records. Staff H stated that whenever she cared for Resident #102 in her assignment, she makes sure that the resident has the splint on. In an interview conducted with Staff F, a Licensed Practical Nurse (LPN), on 04/14/22 at 12:57 PM, she concurred with the CNA that they do document the residents' records when the CNAs confirmed that that they have put on or taken off the residents' splints. In a follow-up interview, Staff F reported that on 04/11/22, she did not verify nor confirm whether Resident #102 had her splint on or off in the morning; therefore, she could not affirm or deny that the task was completed. In an interview conducted with the MDS Coordinator Staff A in the presence of the MDS consultant, on 04/14/22 at 1:16 PM, they reported that they use the resident assessment instrument (RAI) to complete the MDS assessment. The Consultant agreed after much provided evidence that section G0400 was not accurately completed since it did not coincide with the Occupational Therapist's assessment. The MDS coordinator could not provide much information regarding this assessment given his recency to this position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 5 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide fingernail grooming for 2 of 4 sampled residents reviewed for activities of daily living (ADLs), Resident #17 and Resident #87. Residents Affected - Few The findings included: Review of the facility's policy, titled, Care of Fingernails/Toenails, revised on October 2010, documented the following: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming. Review of the Certified Nursing Assistant (CNA) Job Description, revised on 01/01/15, documented that CNAs were to assist residents with nail care (clipping, trimming, and cleaning). 1. Review of the record documented that Resident #17 was re-admitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction, Dementia, Muscle Weakness and Major Depressive Disorder. Review of Section C of the Minimum Data Set (MDS), dated [DATE], documented that a Brief Interview for Mental Status (BIMS) was not conducted as Resident #17 was rarely / never understood. Review of Section G of the MDS, dated [DATE], documented that Resident #17 required extensive assistance with one-person physical assist for personal hygiene. Review of the Care Plan, dated 01/13/22, documented that Resident #17 had a self-care deficit with dressing, grooming, and bathing related to impaired mobility. Interventions were for staff to anticipate resident's needs with activities of daily living (ADLs). During an observation conducted on 04/11/22 at 9:47 AM, Resident #17 stated that she had been in the facility for 2 months. It was noted that Resident #17's fingernails were long, about ¼ inch past the tips of her fingers. When asked if she has had her fingernails cut while in the facility, she stated that she had not. When asked if staff had offered to cut her fingernails, she stated that they had not. During an observation conducted on 04/11/22 at 12:45 PM, Resident #17 was lying awake in her bed. Closer observation showed that Resident #17's fingernails were still long, about ¼ inch past the tips of her fingers. During an observation conducted on 04/12/22 at 10:55 AM, Resident #17 was seated in her wheelchair in her room. Closer observation showed that Resident #17's fingernails were still long, about ¼ inch past the tips of her fingers. During an observation conducted on 04/12/22 at 1:20 PM, Resident #17 was resident seated in her wheelchair in her room. Closer observation showed that Resident #17's fingernails were still long, about ¼ inch past the tips of her fingers. During an observation conducted on 04/12/22 at 3:02 PM, Resident #17 was resident seated in her wheelchair in her room. Closer observation showed that Resident #17's fingernails were still long, about ¼ inch past the tips of her fingers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 6 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 During an observation conducted on 04/13/22 at 8:49 AM, Resident #17 was lying awake in her bed. Closer observation showed that Resident #17's fingernails were still long, about ¼ inch past the tips of her fingers. The resident was observed awake in bed with long fingernails. During an observation conducted on 04/13/22 at 12:49 PM, Resident #17 was lying awake in her bed. Closer observation showed that Resident #17's fingernails were still long, about ¼ inch past the tips of her fingers. When asked if she wanted her fingernails cut, Resident #17 stated, I want them cut. When asked if staff had offered to cut her fingernails, she stated, No. In an interview conducted on 04/13/22 at 4:09 PM, Staff C, Certified Nursing Assistant (CNA), stated that CNAs were responsible for cutting residents' fingernails. When asked how often residents' fingernails were cut, she stated, When you see it. Staff C further stated that residents' fingernails were checked during care and that fingernails would need to be cut if they were long. Staff C then accompanied the surveyor to Resident #17's room. Staff C looked at Resident #17's fingernails and stated that they were long and needed to be cut. 2. Review of the record documented that Resident #87 was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's Disease, Altered Mental Status, Dementia, Aphasia and Muscle Weakness. Review of Section C of the MDS, dated [DATE], documented that that a BIMS was not conducted as Resident #87 was rarely / never understood. Review of Section G of the MDS dated [DATE] documented that Resident #87 required total dependence with one-person physical assist for personal hygiene. Review of the Care Plan, dated 03/25/22, documented that Resident #87 had a self-care deficit with dressing, grooming, and bathing. Interventions were to provide hands on assistance with dressing, grooming, and bathing as needed, and for staff to anticipate resident's needs with ADLs. During an observation conducted on 04/11/22 at 10:44 AM, Resident #87 was observed lying awake in bed with long fingernails that were about ¼ inch past the tips of his fingers. During an observation conducted on 04/11/22 at 1:05 PM, Resident #87 was observed lying awake in bed with long fingernails that were about ¼ inch past the tips of his fingers. During an observation conducted on 04/12/22 at 8:46 AM, Resident #87 was observed sleeping in bed. Closer observation showed that Resident #87's fingernails were still long, about ¼ inch past the tips of his fingers. During an observation conducted on 04/12/22 at 11:02 AM, Resident #87 was observed sleeping in bed. Closer observation showed that Resident #87's fingernails were still long, about ¼ inch past the tips of his fingers. During an observation conducted on 04/12/22 at 1:21 PM, Resident #87 was observed sleeping in bed. Closer observation showed that Resident #87's fingernails were still long, about ¼ inch past the tips of his fingers. During an observation conducted on 04/12/22 at 2:55 PM, Resident #87 was observed sleeping in bed. Closer observation showed that Resident #87's fingernails were still long, about ¼ inch past the tips of his fingers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 7 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 During an observation conducted on 04/13/22 at 7:05 AM, Resident #87 was observed lying awake in bed. Closer observation showed that Resident #87's fingernails were still long, about ¼ inch past the tips of his fingers. During an observation conducted on 04/13/22 at 8:51 AM, Resident #87 was observed lying awake in bed. Closer observation showed that Resident #87's fingernails were still long, about ¼ inch past the tips of his fingers. During an observation conducted on 04/13/22 at 12:52 PM, Resident #87 was observed sleeping in bed. Closer observation showed that Resident #87's fingernails were still long, about ¼ inch past the tips of his fingers. On 04/13/22 at approximately 4:15 PM, Staff C accompanied the surveyor to Resident #87's room. Staff C looked at Resident #87's fingernails and stated that they were long and needed to be cut. On 04/13/22 at 4:22 PM, the Director of Nursing was informed of the surveyor's findings and acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 8 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review, the facility failed to provide splints as per therapy recommendations to 2 of 5 sampled residents, Resident #102 and Resident #44. The findings included: 1. Review of the electronic clinical admission record revealed that Resident #44 was admitted to the facility on [DATE]. The most recent reentry date was on 03/31/20. Resident #44's diagnoses included, in part, Muscle Weakness (Generalized) as of 09/18/20, Aortic Aneurysm without Rupture Cardiovascular, and Coagulations 03/31/20, peripheral vascular disease. Review of the Minimum Data Set (MDS), section C (Cognitive Patterns), dated 02/08/22 revealed that Resident #44 scored 15/15 on the Brief Interview for Mental Status (BIMS), indicating Resident #44's cognition was intact. Section G (Functional Status) revealed that Resident #44 required supervision for all ADLS except dressing for which she required limited assistance. Yet, she was totally dependent on staff for bathing. Review of the care plan (CP) dated 02/22/22 documented that Resident #44 had a potential for complications related to contractures of (L) wrist, and (L) elbow. The contracture interferes with ADL (activities of daily living) ability or increases risk of injury. The CP revealed that staff will ensure that: a. Resident will maintain level of independence with self-care and mobility with use of splints through the next review date. b. Resident will remain free from progression of joint contracture thru the next review date. c. Resident will tolerate splint wearing schedule as established by therapy thru the next review date. d. Left hand splint as tolerated, on and off as ordered; Monitor skin integrity. e. Observe for color, movement, sensation, edema of affected extremity. f. Administer medication as ordered; observe for effectiveness and for signs and symptoms. Review of the physicians' orders for Resident #44 documented: 'Patient to wear (L) [left] hand splint on in am and off in pm, as tolerated. Check skin integrity daily. every shift other active 04/03/20 23:00 [11:00 PM]'. On 04/11/22 at 10:56 AM, Resident #44 was observed in bed laying down. Resident #44's left arm and hand were observed to have contractures. There was no splint on the resident's arm and hand. In an interview on 04/11/22 at about 10:58 AM, Resident #44 reported that she had a splint, but she did not know where it was at that time. She also reported that she needs assistance to put it on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 9 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0688 Observation conducted on 04/12/22 at 11:01 AM showed Resident #44 had no left hand splint on. Level of Harm - Minimal harm or potential for actual harm During a follow-up interview with Resident #44 on 04/14/22 at 12:29 PM, she reported that there are times when she asked staff to put the splint on for her, but they ignored her. This week because the State is here, she sees that they are putting it on for her every day since Monday. She thanked the surveyor for intervening. The resident also reported that she completed therapy and they informed her during the treatment that there was nothing else they could do to help improve the arm function. She just needs to continue to wear the splint to prevent worsening of the contractures. Residents Affected - Few In an interview with the Staff (F), a Licensed Practical Nurse, on 04/14/22 at 03:30 PM, she reported that she documented in the treatment administration record (TAR) according to information received from the CNAs. She attested to the fact that she did not verify whether Resident #44 assigned CNAs had actually performed the task of assisting the resident to put on the splint. 2. Review of Resident #102's Section C of the MDS, dated [DATE], documented the resident's cognitive status showed Resident #102 scored 9 of 15 on the Brief Interview for Mental Status (BIMS). In Section G of the MDS, respectively in sections G0110 and G0120, staff documented that Resident #102 required Extensive Assistance for personal hygiene, toilet use, dressing, transfer, and Total Dependence for bathing. In section G0400 assessing ROM (range of motion), they documented that Resident #102 had no impairment in ROM, which did not coincide with the assessments in sections G0110 and G0120. Review of the Care Plan, dated 12/28/21 and updated on 03/20/22, documented and confirmed that Resident #102 had a self-care deficit with dressing, bathing related to needing assistance with personal care task and mobility skills; cognitive deficit related to Dementia, and generalized weakness. As interventions, staff will provide hands on assistance with dressing, grooming, bathing as needed, Resident #102 will wear hand Splint on in the morning and off in the afternoon. Review of the Occupational Therapy (OT) assessment dated [DATE] showed that Resident #102 was referred to OT due to exacerbation of decrease in range of motion. Subsequently, OT made the following recommendations: 03/10/22, Patient will wear a resting hand splint on right hand for up to 4 hours with minimal signs and symptoms of redness, swelling, discomfort or pain. From 03/23/22, Patient will wear a resting hand splint on right hand for up to 6 hours with minimal signs and symptoms of redness, swelling, discomfort or pain. On 04/08/22, Patient #102 will wear a resting hand splint on the right hand in the morning and off in the afternoon. This orthotic device is recommended because of the resident's functional limitations and related to contracture and inability to perform personal hygiene. Observation and interview conducted on 4/11/22 at 10:44 AM revealed that Resident #102 was in bed with a visible right-hand contracture. A splint was observed on the bed next to the resident. Resident #102 reported that she needed assistance to put on the splint, after she was asked why she was not wearing it. Subsequent observations on 04/13/22 at 10:02 AM, 04/13/22 at 11:12 AM, and 04/14/22 at 12:42 PM revealed Resident #102 wearing the splint. During an interview with Resident #102 on 04/14/22 at 12:43 PM, she reported that they do not always put the splint on for her. Resident #102 said that if was only this week that they put it on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 10 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0688 daily, since Monday April 11, 2022. Level of Harm - Minimal harm or potential for actual harm In an interview with Staff (H), a certified nursing assistant (CNA), on 04/14/22 at 12:52 PM, she reported that the resident has been living at this facility for a while. She said that she was informed that the resident must wear the splint. She added that after they (CNAs) perform their required tasks and the nurses are the ones who document the residents' records. Staff H also stated that whenever she has Resident #102 in her assignment, she made sure that the resident has the splint on. Residents Affected - Few In an interview conducted with Staff (F), a Licensed Practical Nurse, on 04/14/22 at 12:57 PM, she concurred with the CNA that they do document the residents' records when the CNAs confirmed that that they have put on or taken off the residents' splints. In a follow-up interview, Staff (F) reported that on 04/11/22, she did not verify nor confirm whether Resident #102 had her splint on or off in the morning; and could not affirm or deny that the task was completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 11 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 04/11/22 at 11:36 AM, Resident #95 was overheard complaining of hunger. An observation revealed that Resident #95 was fed via a Peg-tube. There was no food (enteral feeding) on the pole placed next to the resident's bed. Review of the Physicians' orders dated 03/14/22 revealed the following order: Enteral Feed order two times a day auto flush 25ml/hr x 20hr via PEG. ON @ 1PM OFF @ 9AM. Later on that day, noted on 04/11/22, the order was changed to 'enteral feed twice a day, auto flush 25ml/hr x 20hr via PEG ON 4PM OFF 12PM. And twice a day Nepro @ 50ml/hr x 20hr via PEG. Total volume = 1000ml On @ 4PM Off @ 12PM.' On 04/12/22 at 9:30 AM, Resident #95 was observed in bed and the feeding machine was running. The Nepro 1.8 Cal bag was infusing at a rate of 50 ml/hr. Observation of the bag showed that the feeding started on 4/11/2022 at 3:22 PM. Photographic evidence obtained. There still were 400 cc or 4 hours of Nepro left to be infused. Based on the physician order and the calculations at 9: 22 AM, only 150 ml/cc should have remained. During an interview with Staff-F, LPN, on 04/13/22 at 11:28 AM, she reported that the 1000 CC should run for 20 hours. She could not explain why there were 400 cc left on the Nepro bag at 9:30 AM. She said that she will further investigate to find out what happened. An observation conducted on 04/13/22 at 12:30 PM showed that the resident was being prepared for dialysis and the feeding was discontinued with 200cc remaining in the bag, but the content should have totally been emptied at 12:00 PM. This was a deviation from the physician's order which read enteral feeding two times a day Nepro @ 50 ml/hr via PEG. Total volume =1000 ml; on at 4PM off 12 PM. Staff-F stated in a subsequent interview on 04/13/22 at 12:31 PM that she stopped the feeding to accommodate the dialysis treatment and said that she would place a new one bag of Nepro after the dialysis. Staff F failed to realize that the feeding should have already been completed. Review of the MDS, dated [DATE], section C showed the resident obtained a score of 9 of 15 on the BIMS, indicating moderate cognitive impairment. In Section I, Resident #95 diagnoses were listed as, Malnutrition, Adult Failure to thrive; and Dysphagia Oropharyngeal Phase. In Section G, it was documented that Resident #95 was totally dependent for feeding. Section K of the MDS showed that Resident #95 received 51% of caloric intake through feeding tube daily. Review of the plan of care dated 03/22/22 documented Resident #95 was at risk for an alteration in nutrition and/or hydration related to enteral feeding and or intravenous nourishment. Enteral feeding with flushes must be provided as ordered. 3. Review of Resident #4's clinical record documented a re-admission to the facility on [DATE] with diagnoses that included: Myocardial Infarction, Type 2 Diabetes Mellitus, Hyperlipidemia, Hypertension, Adult Failure to Thrive and Dysphagia. Review of Section C of the MDS dated [DATE] documented that Resident #4 had a Brief Interview for Mental Status Score of 04, indicating she was severely cognitively impaired. Review of Section K of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 12 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0693 the MDS dated [DATE] documented the resident was on tube feeding. Level of Harm - Minimal harm or potential for actual harm Review of the resident's care Plan, titled, Resident receives enteral nourishment, initiated on 12/21/21 and revised on 04/14/22, documented interventions as to provide enteral feeding as ordered. Residents Affected - Few Review of the Physician's Orders documented Resident #4 had an order dated 02/17/22 for Glucerna 1.5 (tube feeding formula) at 50 milliliters (ml) per hour for 22 hours (on at 4:00 PM; off at 2:00 PM) via percutaneous endoscopic gastrostomy (PEG) for a total volume of 1,100 ml. On 04/11/22 at 12:54 PM, observation revealed Resident #4 lying in bed. Attempted to interview the resident and she was not responding to questions asked. The resident's had a Glucerna (feeding formula) 1.5 cal 1000 cc (centimeters cubic) bottle connected to a feeding pump running at 50 cc/hr. (centimeters cubic per hour). The bottle was dated 04/10/22 at 3:00 PM and had 200 cc was left to be infused. This showed that about 800 ml of formula had been infused and that Resident #4 had received 800 ml out of 1,100 ml of formula from her Physician ordered tube feeding regimen. On 04/12/22 at 9:20 AM, observation revealed Resident #4 sitting in a chair in her room. The feeding formula bottle was disconnected and the feeding pump was turned off. Further observation revealed a Glucerna 1.5 cal bottle hanging from the pole and had approximately 200 cc left in bottle. The feeding formula bottle was labeled as start date on 04/11/22 at 3:15 PM. On 04/12/22 at 3:42 PM, observation revealed Resident #4 lying in bed. The resident's had a Glucerna (feeding formula) 1.5 cal 1000 cc (centimeters cubic) bottle connected to a feeding pump running at 50 cc/hr (centimeters cubic per hour). The bottle had approximately 175 cc left to be infused. Observation revealed the resident's Glucerna formula bottle was the same bottle connected on 04/11/22 at 3:15 PM. This showed that about 900 ml of formula had been infused and Resident #4 had received 900 ml out of 1,100 ml of formula from her Physician ordered tube feeding regimen. On 04/13/22 at 1:01 PM, a side-by-side review of Resident #4's feeding formula bottle was conducted with Staff E, LPN. Staff E stated she stopped the resident's tube feeding for 2 hours from morning care around 9:00 to 9:30 AM. She was apprised that observation revealed the resident was connected at 9:47 AM. Staff E did not respond. (Photographic evidence obtained). Staff E stated she would hang a new bottle around 3:00 PM. Staff E was apprised that Resident #4 tube feeding was not infused as per physician order. Staff E stated she did not have any issues with the resident tube feeding, Staff E added the night nurse may had put the wrong time on the bottle. On 04/14/22 at 8:27 AM, an interview was conducted with the facility's Registered Dietitian (RD). The RD stated that residents at high nutritional risk were those with wounds, weight loss, abnormal labs, comorbidities, and tube feeding. The RD stated Resident #4 was to receive Glucerna 1.5 at 50 ml per hour for 22 hours. The RD stated Resident #4 was tolerating her tube feeding good and no issues had been reported to her. The RD was apprised of the findings and she acknowledged that the tube feeding for Resident #4 was not administered as per Physician's orders. Based on observations, interviews and record review, the facility failed to administer tube feeding as per Physician's Orders for 4 of 6 sampled residents reviewed for tube feeding, Resident #108, Resident #87, Resident #95, Resident #4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 13 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0693 The findings included: Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled, Enteral Nutrition, revised on December 2008, documented the following: Adequate nutritional support through enteral feeding will be provided to residents as ordered. Residents Affected - Few 1. Review of the record documented Resident #108 was re-admitted to the facility on [DATE] with diagnoses that included: Hemiplegia, Hemiparesis, Type 2 Diabetes Mellitus, Hyperlipidemia, Hypertension and Dysphagia. Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #108 had a Brief Interview for Mental Status Score of 00, indicating he was severely cognitively impaired. Review of Section K of the MDS dated [DATE] documented that Resident #108 was on tube feeding. Review of the Physician's Orders documented that Resident #108 had an order dated 03/14/22 for Glucerna 1.5 (tube feeding formula) at 70 milliliters (ml) per hour for 22 hours (on at 8:00 AM; off at 6:00 PM) via percutaneous endoscopic gastrostomy (PEG tube) for a total volume of 1,540 ml. Review of the Care Plan dated 04/06/22 documented Resident #108 was at risk for complications associated with enteral feedings. Interventions were to provide enteral feeding and flushes as ordered. During an observation conducted on 04/13/22 at 7:05 AM, Resident #108 was observed lying in his bed. Resident #108's tube feeding pump was turned off and a bottle of Glucerna 1.5, dated 04/12/22 at 4:00 PM, was hanging from the pole. Closer observation showed that there was about 450 ml out of 1,000 ml of formula remaining in the bottle. This showed that about 550 ml of formula had been infused and that Resident #108 had received 550 ml (825 calories) out of 1,050 ml (1,575 calories) of formula from his Physician ordered tube feeding regimen. During an observation conducted on 04/13/22 at 8:51 AM, Resident #108 was lying awake in bed. Resident #108's tube feeding was running at 70 ml per hour with a bottle of Glucerna 1.5 which was noted with a start date and time of 04/12/22 at 4:00 PM. Closer observation showed that there was still about 450 ml out of 1,000 ml of formula remaining in the bottle. This showed that about 550 ml of formula had been infused and that Resident #108 had received 550 ml (825 calories) out of 1,190 ml (1,785 calories) of formula from his Physician ordered tube feeding regimen. During an observation conducted on 04/13/22 at 12:52 PM (about 20 hours after Resident #108's tube feeding formula was hung), Resident #108 was lying awake in bed. Resident #108's tube feeding was running at 70 ml per hour with a bottle of Glucerna 1.5 which was noted with a start date of 04/12/22 at 4:00 PM. Closer observation showed that there was about 200 ml out of 1,000 ml of formula remaining in the bottle. This showed that about 800 ml of formula had been infused and that Resident #108 had received 800 ml (1,200 calories) out of 1,400 ml (2,100 calories) of formula from his Physician ordered tube feeding regimen. It was further noted that the full bottle of tube feeding formula (1,000 ml) dated 04/12/22 at 4:00 PM should have been infused after approximately 14 hours. In an interview conducted on 04/13/22 at 3:39 PM, Staff D, Licensed Practical Nurse (LPN), stated that Resident #108 was to receive Glucerna 1.5 at 70 ml per hour for 22 hours for a total volume of 1,540 ml. According to her, Resident #108 tolerated his tube feeding well and had not had any issues with his tube feeding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 14 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a subsequent interview conducted on 04/14/22 at 7:06 AM, Staff D stated that nurses were responsible for starting / stopping tube feedings. According to her, tube feedings would be disconnected or put on hold during care, which she stated would take about 30-45 minutes. During an interview conducted on 04/14/22 at 8:27 AM, the Registered Dietitian (RD), stated that residents at high nutritional risk were those with wounds, weight loss, abnormal labs, comorbidities, and tube feeding. The RD stated that Resident #108 was to receive Glucerna 1.5 at 70 ml per hour for 22 hours. According to her, Resident #108 was on tube feeding because he had dysphagia, aphasia, cerebrovascular accident, and did not eat by mouth. When asked how Resident #108 tolerated his tube feeding, she stated, He tolerates it good and no issues have been reported to me. The surveyor informed the RD of the findings and she acknowledged that the tube feeding for Resident #108 was not administered as per Physician's orders. 2. Review of the record documented that Resident #87 was admitted to the facility on [DATE] with diagnoses that included: Dysphagia, Aphasia, Cachexia, Dehydration, Stage 1 Pressure Ulcer of Sacral Region, Hyperlipidemia, and Dementia. Review of Section C of the MDS dated [DATE] documented that a BIMS was not conducted as Resident #87 was rarely / never understood. Review of Section K of the MDS dated [DATE] documented that Resident #87 was on tube feeding. Review of the Physician's Orders documented that Resident #87 had an order dated 03/07/22 for Jevity 1.5 (tube feeding formula) at 50 ml per hour for 22 hours (on at 4:00 PM off at 2:00 PM) via percutaneous endoscopic gastrostomy for a total volume of 1,100 ml. Review of the Care Plan dated 03/25/22 documented that Resident #87 was at risk for an alteration in nutrition and/or hydration related to enteral nutrition support for hydration/nutrition. During an observation conducted on 04/13/22 at 7:05 AM (about 25 hours after Resident #87's tube feeding formula was hung), Resident #87 was lying awake in bed. Resident #87's tube feeding was running at 50 ml per hour with a bottle of Jevity 1.5 which was noted with a start date and time of 04/12/22 at 6:00AM. Closer observation showed that there was about 200 ml out of 1,000 ml of formula remaining in the bottle. This showed that about 800 ml of formula had been infused and that Resident #87 had received 800 ml (1,200 calories) out of 100 ml (1,650 calories) of his Physician ordered tube feeding regimen. It was further noted that the full bottle of tube feeding formula (1,000 ml) dated 04/12/22 at 6:00 AM should have been infused after approximately 20 hours. In an interview conducted on 04/13/22 at 3:39 PM, Staff D, LPN, stated that Resident #87 was to receive Jevity 1.5 at 50 ml per hour for 22 hours for a total volume of 1,100 ml. According to her, Resident #87 tolerated his tube feeding well and had not had any issues with his tube feeding. During an interview conducted on 04/14/22 at 8:27 AM, the RD stated that Resident #87 was to receive Jevity 1.5 at 50 ml per hour for 22 hours. According to her, Resident #87 was on tube feeding because he had a history of dysphagia, cachexia, history of dehydration, and did not eat by mouth. When asked how Resident #87 tolerated his tube feeding, she stated, He tolerates it fine with no issues. The surveyor informed the RD of the findings and she acknowledged that the tube feeding for Resident #87 was not administered as per Physician's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 15 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliation was accurate for 5 of 9 sampled residents reviewed during the controlled substance record review at the facility's north and south wings, for Residents #45, #51, #92, #112 and #168. The findings included: Review of the facility's policy, titled, Controlled Substances, revised in December 2016, documented controlled substances must be stored .in a locked container . The policy did not address documentation of reconciliation of the locked controlled substances once it is removed of a locked container. 1. Review of Resident #45's clinical record documented an admission to the facility on [DATE]. The resident's diagnoses included, in part, Cerebrovascular Disease with Hemiplegia and Hemiparesis, Metabolic Encephalopathy, and Seizures. On 04/13/22 10:03 AM, a side-by-side review of the facility's south wing-controlled substance records with Staff F, a Licensed Practical nurse (LPN), was conducted. This review revealed the following: Resident #45's Controlled Drug Disposition form for 'Lorazepam 2 mg/ml (milligrams/millimeters) injectable once daily as needed for seizures' was removed from the locked container on 02/10/22, 02/14/22, 02/22/22 and on 02/25/22. During this review, an interview was conducted with Staff F who stated that once a controlled substance was removed from the container and administered, they had to document it on the resident's MAR. Review of the resident's physician orders for February 2022 lacked evidence of an order for Lorazepam 2 mg/ml (milligrams/millimeters) injectable once daily as needed for seizures. Review of Resident #45's Medication Administration Record (MAR) for February 2022 revealed the lack of documentation / reconciliation for Lorazepam injectable administration on 02/10/22, 02/14/22, 02/22/22 and on 02/25/22. Review of the resident's progress notes lacked documentation of any seizures active during the dates that Lorazepam ordered for seizures was administered. On 04/14/22 at 9:27 AM, a side-by-side review of Resident #45's MARs for February 2022 was conducted with the facility's Director of Nursing (DON). The DON confirmed the lack of documentation / reconciliation in the resident February 2022's MAR. He stated he did not see a physician order noted in the resident medical record for Lorazepam for February 2022. He added because he did not see a physician order for Lorazepam, he asked for the medication to be removed from the refrigerator. The DON stated he did not see any progress notes related to the resident having seizures in February 2022. On 04/14/22 at 10:09 AM, an interview was conducted with the facility's Infection Control Nurse who stated she did not see any progress notes related to Resident #45 having seizures during the month of February 2022. A side-by-side review of the physician order for Lorazepam 2 mg/ml once a daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 16 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for seizures was conducted with the Infection Control Nurse. She stated the medication was ordered on 12/02/21 and discontinued on 12/03/21. 2. Review of Resident #51's clinical record documented an admission to the facility on [DATE]. The resident's diagnoses included, in part, Urinary Tract Infection, Alcohol Abuse, Disorders of Bilirubin Metabolism, Altered Mental Status and Other Symptoms and Signs involving Appearance and Behavior. Review of the resident's physician orders, dated 03/14/22, documented, Lorazepam tablet 0.5 mg every 4 hours as needed for Anxiety/Agitation. On 04/12/22 3:17 PM, a side-by-side review of the facility's north wing-controlled substance records with Staff G, a Registered Nurse (RN) was conducted. This review revealed the following: Resident #45's Controlled Drug Disposition form for 'Lorazepam 0.5 mg tablets every 4 hours as needed for Anxiety', was removed from the locked container on 04/08/22 at 7:30 PM and on 04/11/22 at 9:00 PM. During the review, an interview was conducted with Staff G who stated that once a controlled substance was removed from the container and administered, they had to document it on the resident's MAR. On 04/14/22 at 10:41 AM, a side-by-side review of Resident #51's April 2022 MAR was conducted with the DON. The DON confirmed that Lorazepam tablets removed from the locked container on 04/08/22 and on 04/11/22 at 9:00 PM were not documented / reconciled in the resident's MAR. The DON stated that once a medication was removed and administered, the nurses were to document it on the residents MAR. 3. Review of Resident #92's clinical record documented an admission to the facility on [DATE] with a readmission on [DATE], with diagnoses that Bell's Palsy, Diabetes Mellitus with neuropathy, Pain in Left Shoulder, and End Stage Renal Disease. Review of the resident's physician orders, dated 07/14/21, documented, Tramadol tablet 50 MG every 6 hours as needed for Moderate Pain. On 04/12/22 at 3:54 PM, , a side-by-side review of the facility's south wing-controlled substance records with Staff E, LPN, was conducted. This review revealed the following: Resident #92's Controlled Drug Disposition form for Tramadol 50 mg tablets every 6 hours as needed for pain was removed from the locked container on 12/30/21 at 1530 hours (3:50 PM) and on 02/08/22 at 1000 (AM or PM was not documented). During the review, an interview was conducted with Staff E who stated that controlled substance medication administration had to be documented on the controlled disposition form and on the residents MAR. On 04/14/22 at 10:55 AM, a side-by-side review of Resident #92's February 2022 MAR was conducted with the DON. The DON confirmed that Tramadol tablets, removed from the locked container on 12/30/21 at 1530 hours and on 02/08/22 at 1000 (AM or PM was not documented), were not documented / reconciled in the resident's MAR. 4. Review of Resident #112's clinical record documented an admission to the facility on [DATE], with diagnoses that included Fusion of Spine and Dorsalgia (Back Pain). Review of the resident's physician orders, dated 03/23/22, documented, Oxycodone-APAP (Percocet) 10-325 mg every 4 hours as needed for pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 17 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/12/22 at 3:55 PM, , a side-by-side review of the facility's south wing-controlled substance records with Staff E, LPN, was conducted. This review revealed the following: Resident #112's Controlled Drug Disposition form for Oxycodone-APAP (Percocet with acetaminophen) 10-325 mg every 4 hours as needed for pain was removed from the locked container on 04/09/22 at 2046 hours (8:46 PM), 04/10/22 at 2100 hours (9:00 PM), 04/11/22 at 10:00 AM, and on 04/12/22 at 10:00 AM. During the review, an interview was conducted with Staff E who stated that controlled substance medication administration had to be documented on the controlled disposition form and on the residents MAR. On 04/14/22 at 10:35 AM, a side-by-side review of Resident #112's April 2022 MAR was conducted with the DON. The DON confirmed that Oxycodone-APAP tablets removed from the locked container on 04/09/22 at 2046 hours, 04/10/22 at 2100 hours, 04/11/22 at 10:00 AM, and on 04/12/22 at 10:00 AM were not documented / reconciled in the residents MAR. 5. Review of Resident #168's clinical record documented an admission to the facility on [DATE] and a readmission on [DATE], with diagnoses that included: Chronic Osteomyelitis, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, and Non-Pressure Chronic Ulcer of Right Foot. Review of the resident's physician orders, dated 04/07/22, documented, Percocet (Oxycodone-acetaminophen) 5-325 mg every 4 hours as needed for pain. On 04/12/22 at 4:05 PM, , a side-by-side review of the facility's south wing-controlled substance records with Staff E, LPN, was conducted. This review revealed the following: Resident #168's Controlled Drug Disposition form for Oxycodone-APAP (Percocet with acetaminophen) 5-325 mg every 4 hours as needed for pain was removed from the locked container on 04/09/22 at 2145 hours (9:45 PM), 04/11/22 at 1300 hours (1:00 PM) and on 04/12/22 at 12:30 (AM or PM was not documented). On 04/14/22 at 10:39 AM, a side-by-side review of Resident #168's April 2022 MAR was conducted with the DON. The DON confirmed that Oxycodone-APAP tablets removed from the locked container on 04/09/22 at 2145 hours, 04/11/22 at 1300 hours and on 04/12/22 at 12:30 (AM or PM was not documented) were not documented / reconciled in the residents MAR. On 04/14/22 at 11:01 AM, during an interview, the DON was apprised that 5 of 9 residents' controlled substance records were not reconciled appropriately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 18 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, interviews, and record review, the facility failed to follow the portion sizes for the approved regular menu for the lunch meal on 04/13/22 for 77 of 77 residents on regular diets, which affected 22 sampled residents (Residents #107, #20, #110, #32, #51, #73, #30, #76, #34, #86, #80, #91, #92, #57, #44, #168, #21, #16, #96, #40, #112 and #81). The findings included: Review of the approved lunch menu for regular diets for 04/13/22 showed that the items to be served included: 4 ounces Salisbury steak. During an observation of the lunch tray line conducted on 04/13/22 at 11:51 AM, Salisbury steak was being plated for the lunch meal. At the request of the surveyor, the Certified Dietary Manager (CDM) calibrated the facility's food scale and measured the weight of the Salisbury steak. The weight of the Salisbury steak was recorded at 3.5 ounces, which was 0.5 ounces below the portion size listed on the approved menu. As the CDM removed the steak from the scale, the calibration dial had shifted from 0 ounces to 0.5 ounces. The CDM acknowledged that the calibration dial had shifted and further stated that this scale was used to measure the raw meat for the Salisbury steaks, which were prepared by hand. She further acknowledged that the Salisbury steaks were below the approved portion size of 4 ounces. In an interview conducted on 04/13/22 at 3:03 PM, the Registered Dietitian (RD) confirmed that the Salisbury steak was supposed to be served as a 4-ounce portion. The RD then acknowledged the surveyor's findings. Review of the diet census, dated 04/13/22, documented that 77 residents were to receive a regular texture diet, which included 22 sampled residents, Residents #107, #20, #110, #32, #51, #73, #30, #76, #34, #86, #80, #91, #92, #57, #44, #168, #21, #16, #96, #40, #112 and #81. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 19 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to obtain a physician's order for oxygen therapy for 1 of 1 sampled resident, Resident #168, as evidenced by the resident receiving oxygen therapy via a nasal cannula without a physician order. The findings included: Review of the facility's policy, titled, Physician Medication Orders, revised in April 2010, documented Medications shall be administered only upon the written order .drug and biological's orders must be recorded on the physician's order sheet in the resident's chart . Review of Resident #168's clinical record documented an admission on [DATE] and a readmission on [DATE], with diagnoses to include: Muscle Weakness, History of Falling, Lack Of Coordination, Unsteadiness on Feet, Chronic Osteomyelitis to Right Ankle and Foot, Difficulty in Walking, Chronic Obstructive Pulmonary Disease (COPD), Seizures Essential Hypertension, Emphysema, Anxiety Disorder, and Peripheral Vascular Disease. Review of Resident #168's Minimum Data Set (MDS) a 5-day scheduled assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed limited assistance for personal hygiene, toilet use and dressing. The assessment did not document the resident oxygen therapy use. Review of Resident #168's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed supervision with his activities of daily living. The assessment did not document the resident oxygen therapy use. Review of Resident #168's care plan, titled, (Resident name) has a potential for complications of respiratory distress related to a diagnosis of COPD. Resident is a smoker, initiated and revised on 03/29/22. The care plan interventions included administer medications as ordered, observe for effectiveness and side effects .administer oxygen as ordered . Review of Resident #168's physician orders documented the resident's oxygen therapy was discontinued on 11/17/21. Further review of the resident's physician orders from readmission on [DATE] to 04/13/22 lacked evidence of a physician order for oxygen therapy. Review of the resident's Treatment Administration Record (TAR) from 11/19/21 to 04/13/22 lacked evidence of oxygen therapy monitoring/administration. On 04/11/22 at 11:27 AM, an interview was conducted with Resident #168 who stated that he used the oxygen when he was in his room because he had Emphysema. Observation revealed the resident wearing a nasal cannula connected to the oxygen concentrator machine set at 3 liters of oxygen per minute and the oxygen tubing was connected to a humidifier bottle. During the interview, the resident stated that the nurse changed the oxygen tubing two to three days ago. Observation revealed the oxygen tubing was not labeled with a date of change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 20 of 21 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 105336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center and Rehab 3370 NW 47th Terrace Lauderdale Lakes, FL 33319 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/13/22 at 12:04 PM, observation revealed Resident #168 lying in bed wearing oxygen via nasal cannula at 3 liters per minute. During an interview, the resident stated he had been using the oxygen since he came back from the hospital back in November 2021. He stated again he used the oxygen when he was in his room. On 04/13/22 at 12:10 PM, an interview was conducted with Staff E, a Licensed Practical Nurse (LPN) who stated Resident #168 used the oxygen as needed when he was in the room. Subsequently, a side-by-side review of the resident using the oxygen was conducted with Staff E, who confirmed Resident #168 was wearing a nasal cannula connected to oxygen at 3 liters per minute. Staff E was asked to show a physician order for the resident's oxygen therapy and was not able to find it. Staff E stated they must have an order because they could not administer the oxygen without a physician's order. Staff E was apprised that there was not an order for Resident #168's oxygen therapy. On 04/13/22 at 12:19 PM, an interview was conducted with the facility's Director of Nursing (DON) and he was apprised of the lack of a physician order for Resident #168's oxygen therapy. Subsequently, a side-by-side review of the resident currently active physician orders was conducted with the DON. The DON stated he did not see a physician orders for oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105336 If continuation sheet Page 21 of 21