Inspection·September 9, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A progress note dated 05/29/22 at 7:13 PM documented Therahoney was not administered due to awaiting from pharmacy. Further review of Resident #16's record did not reveal any documentation of the condition of the resident's right leg wound. A WCN dated 06/02/22 documented the wound as unhealthy, with excessive necrotic tissue, improvement of wound quality was noted. The plan was to continue current treatment autolytic debridement being utilized (Therahoney). A progress note dated 06/06/2022 10:23 PM documented: Spoke to pharmacy again. Therahoney still on back order. Further review of Resident #16's record did not reveal any documentation of the condition of the resident's right leg wound. A WCN dated 06/09/22 documented Resident #16's right leg wound noted with deterioration based on an increase in devitalized (dead) tissue noted. Will change treatment to Santyl (another debridement agent) daily and will debride (surgically cut out dead tissue) upon obtaining consent. A WCN dated 06/16/22 documented debridement was completed. A moderate amount of necrotic tissue was removed. Due to the extent of necrotic tissue and patient tolerance of debridement it is planned to return in 1 week for further debridement if needed. An interview was conducted with the Director of Nursing (DON) on 09/09/22 at 1:00 PM. The DON was questioned if the physician was notified the ordered treatment of Therahoney was not available for administration since ordered on 05/26/22. The DON acknowledged the note on 06/06/22 of the pharmacy with back order of the medication/treatment. The DON further acknowledged the lack of documentation of Resident #16's wound condition, and the ultimate deterioration of the resident's right leg wound, requiring surgery. The DON stated they must have had the medication (Therahoney) at one time, due to the documentation of it being administered on the resident's MAR on 05/27/22, 05/30/22, 05/31/22, 06/01/22, 06/03/22, 06/04/22, and 06/05/22. An telephone interview was conducted with a company's pharmacy technician on 09/09/22 at 1:30 PM. The tech stated an order was received from the facility for Therahoney on 05/26/22. The tech further stated the medication was not in stock, and there was a back order. The tech stated they ordered the medication from another supplier on 05/27/22, which generally takes 7-10 days to receive. The tech stated the ordered Therahoney was delivered to the facility on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 2 of 10 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 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court at St Andrews Estates 6152 N Verde Trail Boca Raton, FL 33433 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions to prevent falls with injury, for 1 of 2 sampled residents reviewed for falls (Resident #16); and failed to investigate 2 of 2 sampled residents reviewed for falls (Resident #16 and Resident #29). The findings included: A review of the facility's policy, titled, Falls Reduction and Management, revised 11/20, documented: To strive to identify residents at risk for falls and reduce the incidence of falls by identifying environmental, interpersonal and/or functional triggers and causes of fall and implementing person- centered interventions to reduce risks. To strive to ensure that the resident environment remains as free of accident hazards as possible, and that each resident receives adequate supervision, functional support, and assistance devices to prevent and/or minimize accidents. The policy further documented if the resident does fall, the licensed nurse will follow all policies and protocols relevant to incident reporting and complete the Incident report and the Fall Huddle Investigation Worksheet. 1. Resident #16 was admitted to the facility on [DATE]. Record review revealed a comprehensive assessment dated [DATE], documented the resident had moderate cognitive impairment, and required limited one-person assist with activities of daily living. Record review revealed Resident #16 was care planned for fall risk related to cognitive decline and decline in function, sometimes refused to sit in a regular chair in the dining room and sat on the walker seat. On 09/02/22, the resident had a fall with injury. Resident #16's interventions included: anticipate needs and provide safe environment with even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, side rails as ordered, handrails on walls, personal items within reach. A review of the facility's incident log revealed Resident #16 had 4 unwitnessed falls on 06/29/22, 07/13/22, 08/11/22, and 09/2/22. A progress note dated 06/29/22 at 4:32 PM documented: 'Resident was found in sitting position by her bedside reported by one of our staff members during lunchtime, no injury noted. No call light was activated. Resident was in bed prior her fall. Assisted to transfer via mechanical lift, full ROM (range of motion) with no limitation, denies any pain and discomfort. Resident is encouraged to use her call light for assistance, POA (Power of Attorney) and MD (Medical Doctor) are notified. Call light within easy reach with bed in the lowest position.' No further documentation was found regarding Resident #16's condition post fall. A progress note dated 07/13/22 at 7:38 PM documented: 'Resident sat in bed in lowest position. Slid off bed and sat on floor. Skin tear noted to right elbow. First aid applied. MD [medical doctor]and POA [power of attorney] notified.' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 3 of 10 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 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court at St Andrews Estates 6152 N Verde Trail Boca Raton, FL 33433 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 0689 No further documentation was found regarding Resident #16's condition post fall. Level of Harm - Minimal harm or potential for actual harm A progress note dated 08/11/22 at 11:40 PM documented: 'At about 11 PM, Patient was found on the floor alongside of her bed by the incoming nurse while rounding. No apparent injury noted at that time. At about 11:24 PM, called assigned doctor, message left on his answering machine. Responsible party is aware. Safety precautions maintained. Call light within easy reach.' Residents Affected - Few A progress note dated 08/12/22 at 6:06 AM documented: S/P (status post) fall resident continues with frequent observation by staff, denied any pain during the shift, no acute distress noted. V/S (vital signs) stable. No redness or swelling noted on the skin. Safety maintained, call light in reach. Nursing care continue.' A progress note dated 09/02/22 at 3:25 AM documented: 'While CNA [Certified Nurse Assistant] made round, observed resident laying on the floor prone position with left arm against the W/C (wheelchair) wheel. Resident stated, I was trying to walk to the bathroom, and I lost my balance and fell on the floor. Complete assessment initiated resident unable to moved left shoulder, complaint of pain and discomfort, V/S stable. Resident was alert and responsive. 911 called and transfer resident to Hospital for further evaluation. MD was notified. Resident family made aware. Resident left the facility via stretcher with 3 paramedics in stable condition.' An interview was conducted with Staff Z, a Registered Nurse (RN), on 09/08/22 at 2:50 PM. Staff Z stated when a resident has a fall, the resident is assessed for injuries, assisted back to bed/chair, an incident report is completed, the physician and family is notified, and the resident is assessed for 3 days each shift and documented in progress notes. An interview was conducted with Staff Y, RN, on 09/08/22 at 3:00 PM. Staff Y stated when a resident falls, do an assessment, do an incident report, notify physician and family. Staff Y further sated neurological checks are started, if needed, and interventions such as moving the resident closer to the nurses station, frequent checks, and involve family should be initiated. An interview was conducted with the Director of Nursing (DON) on 09/08/22 at 4:00 PM. The DON stated incident reports regarding falls were reviewed in morning meetings with department heads, and they discuss what happened, what to do / interventions to be put in place. The DON acknowledged there was no investigation of Resident #16's falls documented. The DON stated investigations were done internally but was not able to provide documentation of such. The DON further acknowledged the fall Resident #16 sustained on 09/02/22 that involved a wheelchair in the resident's room, when the resident ambulated using a walker. Resident #16 was not provided a safe environment free from clutter. 2. Resident #29 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident as mild to moderately cognitive impaired and required limited to extensive one-person assist with activities of daily living. Resident #29 was care planned for at risk for falls related to history of confusion and limited physical mobility. On 08/16/22, the resident had a fall with no injury. A progress note dated 08/16/2022 at 1:26 PM documented: 'Resident alert and oriented to person and place with forgetfulness. Assessment done. No apparent injuries noted. Denies any pain or discomfort (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 4 of 10 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 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court at St Andrews Estates 6152 N Verde Trail Boca Raton, FL 33433 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 0689 Level of Harm - Minimal harm or potential for actual harm at this time. Able to move all extremities without difficulty. MD notified. Health care surrogate notified. Vital signs stable.' There was no evidence of an investigation for Resident #29's fall found. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 5 of 10 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 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court at St Andrews Estates 6152 N Verde Trail Boca Raton, FL 33433 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document the needs to be met by the use of siderails, failed to attempt alternative interventions, assessment of resident for risk of entrapment, obtain informed consent, determine the resident's risks versa benefits, identify potential areas of entrapment and ensure compatibility of mattress with frame, for 1 of 1 sampled resident reviewed realted to siderails, (Resident #36). This deficiency has the potential to affect all residents because all facility beds have side rails attached. The findings included: Review of the facility Policy and Procedure, titled, Side/Bed Rail Usage (S-04WB), issued 11/2016 and last revised 8/2021, defined a bed rail as any adjustable metal or rigid plastic bar that attach to a bed. It read: They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. The procedure instructs the community to assess all residents for the use of side rails upon move-in to the community by completing the Side Rail Assessment. Then attempt to offer side rail alternatives prior to using or installing a side rail. It also instructs the licensed nurse to review the risks and benefits of side/bed rails with the resident or the resident's representative and obtain consent. Then provide written documentation describing the risks/benefits and safety of side rails use (See Appendix A - which was not attached for surveyor review). Additionally, the nursing and maintenance departments will: Look for risk of entrapment from the side (bed) rails at the time of installation and ongoing with the use of one or more rails; Ensure the bed's dimensions are appropriate for the resident's size and weight; and verify proper maintenance and function of the rails. Follow the manufacturer's recommendations and specifications for installing and maintaining side (bed) rails. When purchased separately, the maintenance will ensure that the side (bed) rail, mattress and bed frame are compatible. Review of the Side Rail Assessment Med, documented in part: F: 066 used in the facility and specified in the procedure, revealed 17 questions to be answered by the nurse, however the information requested does not comply with the current regulation by considering the resident's diagnoses, symptoms, height and weight, medications, ability to toilet, ability to communicate, mobility/ability to use or risk of falling. The assessment also does not tally or compute the information in a manner that assists staff to determine the risk of entrapment. It only asks the nurse if the mattress fits the bed properly to prevent entrapment. Review of the medical record for Resident #36 revealed an admission date for this stay on 12/27/21 with the most recent readmission on [DATE]. Relevant diagnoses included Cerebrovascular Disease, Depression, Anxiety, Muscle Weakness, Dementia, Long Term Use of Anticoagulants (blood thinners), Essential Tremor and Epilepsy (recurrent seizures). Current medications included Phenobarbital twice daily and Divalproex in the evening to control seizures, Escitalopram for depression and scheduled Lorazepam for anxiety. Review of the most recent comprehensive MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 12 out of 15 indicating a mild cognitive decline. The same assessment also revealed the resident required extensive assistance from one person to turn or reposition in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 6 of 10 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 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court at St Andrews Estates 6152 N Verde Trail Boca Raton, FL 33433 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bed, transfer from the bed, dress, toilet, and complete personal hygiene. The resident's care plan mentions side rail use as an intervention for her ADL deficit. It read: Quarter side rails up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition as necessary to avoid injury. Under the Seizure Disorder/Epilepsy focus, one of the two goals was to remain free from injury related to seizure activity. The side rails were not included in this section nor were they ever observed to be padded to protect the resident with involuntary movements. On 09/06/22, during the initial screening process, bilateral siderails were observed on all the residents' beds in the 200 Hall. Some were raised/in use and others were in the down position and covered by bedding when the beds were made. On the same day at 3:00 PM, large metal slatted 3/4 length siderails and an air mattress were observed on the bed for Resident #36. Photographic Evidence Obtained. On 09/07/22 at 3:45 PM, during an interview with the MDS (Minimum Data Set) Nurse, she was asked where to find the siderail consent forms for the residents. She responded, We don't have consent forms for side rails because they aren't restraints, so they aren't necessary. She called the DON (Director of Nursing) by phone to confirm this and then said her answer was correct by reaffirming, We don't have consent forms because they aren't restraints, so they don't need them, and all the beds here have them [siderails]. We don't need consents. On 09/07/22 at 3:55 PM, during an interview with the Director of Nursing (DON), she verbalized they don't have consent forms but there is a consent in the siderail assessment in the EHR (electronic health record). On 09/07/22 at 4:55 PM, during an interview with Resident #36, she said she doesn't use the rails to move around in bed and they have to put them down for her because she cannot operate them herself. She also doesn't know why they are on the bed and said, I guess they came with it. On 09/08/22 at 11:40 AM, the facility policy and procedure, titled, Side/Bed Rail Usage and the Guide to Bed Safety brochure, was reviewed. The policy indicated the brochure is to be provided to residents/staff around the time of admission. Regular maintenance records were requested for review. The NHA (Administrator) was not able to explain why the large metal side rails were on Resident #36's bed. On 09/08/22 at 12:25 PM, the NHA reported the bed and large siderails had been brought in by hospice for this resident but neither she or the DON were aware they were in the building. Resident #36 was admitted to hospice on 01/09/22 and discharged from hospice on 08/31/22 therefore, the bed and siderails had been delivered sometime between those dates and not yet picked up after her discharge from hospice services. The NHA said the bed had been replaced the evening before with a facility bed (which has quarter rails and photographic evidence was obtained). The NHA also acknowledged that for any side rail, the proper documentation needed to be completed. On 09/09/22 at 1:15 PM the NHA and the DON were interviewed about the facility siderail use. The DON reported the consent is usually verbal and she notes who she speaks with on the side rail assessment. A pamphlet titled A Guide to Bed Safety written in 2000 and last revised 4/2010 is provided to residents or family during admission but the DON confirmed she does not read it or review it with anyone, and this is not always done prior to admission. In addition, the Social Services/Admissions Director also helps with admissions and obtains some signatures, but this could be days after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 7 of 10 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 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court at St Andrews Estates 6152 N Verde Trail Boca Raton, FL 33433 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admission. The DON confirmed that alternative interventions are not tried and/or documented prior to side rail installation because the siderails are already on the bed. She also confirmed she completes all the side rail assessments found in the EHR and she was not familiar with the weight restrictions for any of the beds. Both the DON and the NHA agreed the assessment does not help to determine any risk of entrapment. They confirmed that all the facility beds have side rails on them, as they came that way from the manufacturer. When asked how they determined the mattresses were compatible with the beds and siderails they advised that would have been determined at the corporate level with the vendors at the time of purchase. The DON confirmed any siderails used for residents with seizures or involuntary movements should be padded going forward. Regarding the use of any specialty mattresses like an air mattress, scoop, or bolster mattress, they advised the facility maintenance department should be measuring gaps when they replace the mattress to assess for entrapment risks. The NHA was also certain there wasn't any education provided to staff on the risks of injury or death, the zones of entrapment and safe use of side rails. On 09/09/22 at 1:50 PM, the Director of Facility Maintenance was interviewed. He reported checking five rooms/beds weekly which results in all beds being checked approximately every three and a half months. He checks electrical cords, connections, controls, and the security of the siderails. If a staff member reports an issue, he also has that documented on a work order. However, when asked about checking the Zones of Entrapment he said he did not know what that meant. He further stated he does not measure distances between the mattresses and siderails or headboard or anywhere else when replacing a standard mattress with a specialty mattress. The Director of Facility Maintenance reported three different models of beds in the building and all of them have side rails. A Work Order Report documenting Annual Bed and Side Rail Inspection was provided which lists the Seven Zones of Entrapment but does not include any measurements or parameters. He said he just looks at the gaps. This form is completed once yearly and only notes the comments as good and yes the assessment was completed. Review of the manufacturer's instructions for all three models revealed varying maintenance schedules from monthly to annually and weight totals between 450-500 pounds including the mattress, bedding, and head/foot boards. One model specified a mattress width and depth for use as well as suggesting the bed be left in the flat position when unattended to reduce the risk of entrapment. Another warned of risk of injury when raising or lowering of the bed which creates gaps, increasing the risk. All three contained warnings and referrals to the FDA (Food and Drug Administration) Recommendations regarding risk of entrapment with use. On 09/09/22 at 3:31 PM, during an interview with the Social Services Worker, she confirmed that she does not read or review the bed safety pamphlet with residents or family members on admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 8 of 10 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 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court at St Andrews Estates 6152 N Verde Trail Boca Raton, FL 33433 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to secure medications for 2 of 24 sampled residents reviewed, (Residents #214 and #42). The findings included: Review of the facility's policy titled, Self-Administration of Medication, with a revision date of 04/2018, revealed the following: Policy to strive to ensure that the resident is properly prepared and clinically appropriate to self-administer medications. Prior to participating in the self-administration of medication program, the resident will be observed by the nursing supervisor and/or charge nurse using the Self-Medication Administration Evaluation Form. The physician's order must state resident may self-administer medications if the evaluation by the interdisciplinary team (IDT) is satisfactory. The care plan must reflect the resident's ability to self-administer medications. All medications to be self-administered will be stored in a locked medication drawer in the resident's room or another designated area. 1. Record review for Resident #42 revealed the resident was admitted on [DATE] with a recent readmission on [DATE]. The diagnoses included Malignant Neoplasm of Head, Face and Neck, Type 2 Diabetes, and Chronic Kidney Disease. The Minimum Data Set (MDS) dated [DATE] revealed in Section C a brief interview for mental status (BIMS) score of 15 indicating intact cognitive response, bed mobility, transfers and dressing all had self-performance of limited assistance with support of one-person physical assist. Review of the Physician's Orders for Resident #42 revealed an order dated 08/05/22 for Saline drops: 2 drops to use as needed. Pt may use at bedside. Review of the care plans for Resident #42 revealed there was no care plan for medication at bedside or self-administration of medication. Review of the Self-Administration of Medication Evaluation form dated 08/05/22 for Resident #42 revealed under the physical evaluation portion, Can correctly self-administer eye drops/ointments, was N/A (not applicable). On 09/06/22 at 10:20 AM, an observation was made of over-the-counter eyedrops unsecured at the bedside for Resident #42. Photographic Evidence Obtained. On 09/07/22 at 09:30 AM, a second observation was made of over-the-counter eyedrops at the bedside unsecured for Resident #42. During an interview conducted on 09/06/22 at 10:25 AM with Resident #42, when asked about the unsecured eye drops at her bedside, she stated she uses those when she needs them and was never instructed to lock them up. During an interview conducted on 09/09/22 at 11:40 AM with Staff A Registered Nurse (RN), when asked about Resident #42 having medication at the bedside, she stated the resident has eyedrops at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 9 of 10 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 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court at St Andrews Estates 6152 N Verde Trail Boca Raton, FL 33433 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 bedside that she uses as needed. Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 09/09/22 at 12:00 PM with Director of Nursing (DON) when asked about residents self-administering medication at the bedside, she stated the facility only needed a physician's order for resident to have medication at the bedside for self-administration. When asked if the medications need to be secured (in a locked drawer/box) she stated no, the resident can just keep them in their bedside drawer. When asked if the resident needed to be evaluated for self-administration of medications, she replied 'yes of course'. Residents Affected - Few 2. Record review for Resident #214 revealed the resident was admitted on [DATE] with most recent readmission on [DATE]. The diagnoses included Chronic Obstructive Pulmonary Disease, Adult Failure to Thrive, Unspecified Visual Loss, and Cognitive Communications Deficit. The Minimum Data Set (MDS) dated [DATE] revealed in Section C a brief interview of mental status (BIMS) score of 15, indicating intact cognitive response. The MDS dated [DATE] revealed in section G bed mobility, transfers, dressing, and personal hygiene all had a self-performance of extensive assistance with support of one-person physical assist. Record review for Resident #214 revealed no order for medication at the bedside or to self-administer medication. Record review for Resident #214 revealed no care plan for medication at bedside or self-administration of medication. On 09/06/22 at 11:50 AM, an observation was made of over-the-counter eyedrops and prescription medication for Ciclopirox 8% Nail lacquer unsecured at the bedside for Resident #214. Photographic Evidence Obtained. On 09/07/22 at 11:00 AM, an observation was made of over-the-counter eyedrops and prescription medication for Ciclopirox 8% Nail lacquer unsecured at the bedside for Resident #214. Photographic Evidence Obtained. During an interview conducted on 09/06/22 at 11:55 AM with Resident #214, when asked about the unsecured medications at the bedside, she replied those are from home and she doesn't need to lock them up. During an interview conducted on 09/09/22 at 11:45 AM with Staff A Registered Nurse (RN), when asked about Resident #214 having medication at the bedside, she stated I do not think she has medications at the bedside. She verified this was correct according to the resident's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 10 of 10