Health inspection·January 25, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm herself understood and sometimes understands others. She repeatedly asks the same questions over and over. She is fixated on when her meal will arrive. She is followed by MD/psychiatrist for medication management. She continues to frequently refuse showers. Placement remains appropriate for long term due to need for 24 hrs. care/supervision. [Staff] Will visit for socialization, reality orientation, redirection, encouragement and emotional support as needed. Residents Affected - Few Review of an Activity progress note dated 11/18/23 documented: Resident #5 is alert with confusion and forgetfulness. She is very hard of hearing; staff are encouraged to speak in her right ear. She has adequate vision with her glasses. She prefers to stay in her room and will only come out to see when her meals are coming to her room. She is on one-to-one visits 2-3 times a week for sensory and mental stimulation. On 01/22/24 at 10:57 AM, it was observed that Resident #5 had her food tray placed across her bed right in front of the resident. Resident #5 was lying in a semi-erect position in her bed, and the room had an overwhelming and unsanitary ammonia-like odor. Resident # 5 could not be interviewed due to apparent cognitive deficits. On 01/22/24 at 12:46 PM, during lunch the same abhorrent odor described above was still present, and lunch was served. An interview with Employee A, Certified Nursing Assistant (CNA), on 01/22/24 at 12:48 PM, revealed the resident's room was not free of unpleasant odor, before she served lunch to Resident #5. On 01/23/24 at 10:33 AM, Resident #5 was observed in bed sleeping. The breakfast tray was on the bedside table which was placed transversal to the bed. The room odor was not as it was the day before but was noticeably 'masked'. The procedures in place were to ensure residents eat in a sanitary manner. The environment where Resident #5's meals were served dining meals had an unpleasant and nauseating ammonia-like odor. On 01/25/24 at 9:44 AM, Resident #5 was observed in her room in bed. There was no food tray on her bedside table. The urine-like odor in the room was nauseating. The surveyor could not stay to speak with the resident due to the overwhelming odor of urine. An interview was conducted with Employee B, CNA on 01/25/24 at 9:56 AM, who stated she started her shift at 7:00 AM. Employee B said she has been working at this facility for a long time. Employee B stated that Resident #5 always complains about being hungry, so they make sure to serve her first. She stated even when Resident #5 finishes eating, Resident #5 always complains to have her food tray. Staff B continued to state Resident #5 is hard of hearing, has mental illness, and even though Resident #5 refuses care, she knows, as a CNA, that it is not her acting, but it is the illness. Staff B stated they try to redirect the resident and postpone care for later. A follow-up interview was conducted with CNA, Employe A, on 01/25/24 at 10:05 AM, who revealed she had seven residents assigned to her to care for among whom was Resident #5. Employee A said that she provided early care to Resident #5 on that day before 7:00 AM, she had removed the dirty linens in the room, made the bed, washed the resident and had put new garments on her. At this time, they entered Resident #5's bedroom, and Employee A was asked to give her impression about the odor in the room. Employee A said that the room always smells bad. Employee A said that it was the carpet that smelled so bad, the carpet is dirty, and soiled with urine and feces. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 2 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm On 01/25/24 at 10:29 AM, an interview was conducted with the Minimum Data Set (MDS) Coordinator who clarified that Resident #5 exhibited abnormal behavior which consisted in Resident #5 urinating and defecating on the floor. She stated they had addressed that concern in Resident #5's care plan. The coordinator also confirmed that when they clean the room, it is okay for a few days then the odor comes back. Residents Affected - Few On 01/25/24 at 10:29 AM, the Director of Environmental Services stated they cleaned the room yesterday or on 01/24/24, because they noticed that it smelled bad. She said that the odor dissipated after the room was cleaned, and they usually clean up the rooms as necessary. She said, they have a monthly cleaning schedule for deep cleaning. She said that this week was the only time she became aware of a reoccurring odor in the room. The Director of Environmental Services said that she was not aware that Resident #5 had exhibited any abnormal toileting behaviors. The Environmental Service Director said that she has been working at this facility for nearly five years. On 01/25/24 at 10:44 AM, the Director of Nursing (DON) stated she has been working at this facility for 4 months. She said that she attends the care plan meetings, and Resident #5 stays in her room most of the time, ambulates with her walker; and is hard of hearing. The DON said that she did not know that Resident #5 had toileting-related behaviors. She said that before they do anything for the Resident, they must tell her what they are going to do for her before doing it, so she can comply. The DON said that Resident #5 has a regular CNA who is very familiar with her. The DON said that there was once a concern with odor in Resident #5's room. She notified housekeeping and they immediately took care of that, it has been three months. The DON further stated there was a plan to change the carpets in the rooms. She learned from the CNA that the resident tends to refuse care. She said they have an Advanced Psychiatric Nurse Practitioner (ARNP) who has been providing mental care to the resident. The DON said that she was informed this week that the room smelled bad. She saw housekeeping cleaning up the room. The DON stated Resident #5 tends to urinate on the bathroom floor due to incontinence. She said that there is a plan in place to remove the carpet in her room. An interview was conducted with the Administrator and the Executive Director of the facility on 01/25/24 at 11:12 AM. The Administrator acknowledged Resident #5 has toileting behaviors. She said that they have been discussing removing the carpets in the rooms in the area where Resident #5 resides. The Administrator stated she did not recall when the meeting was held, but a Company came and took measurements and has started replacing the carpets in some rooms. She said that they had a meeting to discuss Resident #5's behavior on 01/08/23, the Psychiatric nurse came in and saw the Resident on 01/11/24. The Administrator said the resident's behaviors entailed defecating and urinating on the floor, and that this behavior is not new. On 01/25/24 at 11:25 AM, the Executive Director provided their plan to replace the carpets that has been ongoing for nearly two years. She said that they have been meeting with the flooring company since April 2023, have recently started replacing the carpets in the hallways, will be changing the carpets in the rooms next and that Resident #5's room would be among the first ones. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 3 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to follow the physician orders for 1 of 5 sampled residents reviewed for Unnecessary Medications, as evidenced by not holding a medication when the resident's systolic blood pressure was below 120 as per physician order, Resident #15. Residents Affected - Few The findings included: Review of the facility's policy, titled, Medication Administration and Management, with no revision date, documented, .to ensure safe and efficient administration of medications to residents .verify the correct drug, correct dose . Review of Resident #15's clinical record documented an admission on [DATE] and no readmissions, with diagnoses that included: Essential Hypertension, Cerebrovascular Disease, Hypertensive Heart, Stage 4 Chronic Kidney Disease, Type 2 Diabetes Mellitus, and Vascular Dementia with Behavioral Disturbance. Review of Resident #15's Minimum Data Set (MDS) significant change assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 0, indicating the resident had severe cognition impairment. Resident #15's care plan, titled, I have an altered cardiovascular status related to hyperlipidemia, hypertension, initiated on 09/02/19, was reviewed. Review of Resident #15's physician order dated 09/02/22 documented, Carvedilol Tablet 12.5 mg (milligrams), give 1 tablet by mouth two times a day for Hypertension related to ESSENTIAL (PRIMARY) HYPERTENSION. Hold for systolic BP (blood pressure) less than 120. Review of Resident #15's November 2023 Medication Administration Record (MAR) documented Carvedilol Tablet 12.5 mg give 1 tablet by mouth two times a day for Hypertension, Hold for systolic BP less than 120. Further review revealed Resident #15's had a systolic blood pressure less than 120 and Carvedilol tablet was not held, as per physician order on the following dates: 11/16/23 morning (112/68). 11/21/23 morning (118/68). 11/24/23 evening (112/60). 11/25/23 evening (110/70). 11/28/23 evening (118/70). Review of Resident #15's December 2023 MAR documented, Carvedilol Tablet 12.5 mg, give 1 tablet by mouth two times a day for Hypertension, Hold for systolic BP less than 120. Further review revealed that Resident #15's had a systolic blood pressure less than 120 and Carvedilol tablet was not held, as per physician order on the following dates: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 4 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 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 0684 12/12/23 evening (118/60). Level of Harm - Minimal harm or potential for actual harm 12/14/23 morning (105/57). 12/14/23 evening (119/65). Residents Affected - Few 12/16/23 morning (115/65). 12/16/23 evening (118/77). 12/22/23 evening (114/66). 12/29/23 evening (119/64). 12/31/23 evening (118/68). Review of Resident #15's January 2024 MAR documented, Carvedilol Tablet 12.5 mg, give 1 tablet by mouth two times a day for Hypertension, Hold for systolic BP less than 120. Further review revealed that Resident #15's had a systolic blood pressure less than 120 and Carvedilol tablet was not held as per physician order on the following dates: 01/01/24 morning (114/69). 01/02/24 evening (118/72). 01/12/24 evening (114/62). 01/20/24 evening (118/70). On 01/22/24 at 10:20 AM, observation revealed Resident #15 sitting in a wheelchair and attempting to wheel himself out of his room. An attempt was made to interview the resident and he stated, get out of here. On 01/24/24 at 11:36 AM, an interview was conducted and a side-by-side review of Resident #15's January 2024 MAR with Staff G, Registered Nurse (RN). Staff G was asked what a checkmark written on the resident's MAR meant. Staff G stated they get a green check on the e-MAR when a medication was administered. On 01/24/24 at 11:47 AM, an interview was conducted with Staff D, Licensed Practical Nurse (LPN), who stated that if a resident's medication had blood pressure parameters, and the blood pressure was less than what the parameters stated, she would document code #5 meaning the medication was held due to blood pressure less than what the physician orders said. On 01/25/24 at 2:40 PM, a side-by-side review of Resident #15's November 2023 and January 2024 MAR for Carvedilol medication administration documentation, with the Nursing Supervisor, who confirmed Resident #15 received the medication when the nurses were supposed to hold it as per physician order. A joint interview was conducted with the Director of Nursing (DON) and the Nursing Supervisor, who both stated that a check mark written on the residents' MAR indicated the medication was administered. The findings were discussed with the DON and the nursing supervisor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 5 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure facility staff followed proper indwelling (Foley) catheter and pericare techniques consistent with accepted standards of practice and failed to follow the facility's Catheter Care and Perineal Care policy as observed during Foley/peri-care provided to 1 of 1 sampled resident reviewed for urinary catheter care review, Resident #10. The findings included: Review of the facility's policy, titled, Catheter Care, Indwelling, with no revision date documented, .attach the catheter to the resident's inner thigh using a leg strap .prevent the catheter .drainage bag from touching the floor .check the resident frequently .if the resident has a leg urine collection bag .when re-attaching the leg bag do the following: wrap the elastic leg straps around the resident's calf .when opening the drainage tubing junction, both ends must be kept sterile and both ends are to be cleaned with isopropyl alcohol before they are reconnected . Review of the facility's policy, titled, Perineal Care, with no revision date documented, .hold the shaft of the penis with one hand and wash with the other, beginning at the tip and working in circular motion from the center to the periphery .use a clean section of the washcloth for each stroke by folding each used section of the wash cloth inward. A separate washcloth may be used for each stroke . Review of Resident #10's clinical record documented an admission on [DATE] and no readmissions, and with diagnoses that included Hydronephrosis with Renal and Ureteral Calculous Obstruction, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Hydroureter, Malignant Neoplasm of Overlapping Sites Of Rectum, Anus and Anal Canal. Review of Resident #10's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 13, indicating that the resident had little to no cognition impairment. The MDS revealed the resident was dependent on the staff for his care. Resident #10's care plan, titled, I have an Indwelling Catheter due to bilateral Hydronephrosis, BPH (Benign Prostatic Hyperplasia) with urinary retention, slowing of urinary system, initiated on 07/16/22 and revised on 01/02/24, was reviewed. Review of Resident #10's Physician orders dated 07/16/22, documented, Catheter Care every shift. Review of Resident #10's Physician orders dated 11/04/23, documented, Foley Catheter reason / Diagnosis-Neurogenic Bladder. On 01/24/24 at 8:47 AM, observation revealed Resident #10 sitting up in a recliner. An interview was conducted with the resident who stated that he had the indwelling / Foley catheter for three (3) years. The resident stated the catheter was necessary and he did care for it himself. Further observation revealed the resident's Foley drainage bag to his right with cloudy yellow urine, the bag was touching the floor, and it did not have a privacy pouch. The resident lifted his gown, and the catheter was noted loose, and was not anchored to his right thigh, as per the facility's policy. The bag was placed facing the resident's room door. The resident gave a verbal consent for surveyor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 6 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 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 0690 observation of his Foley care. Level of Harm - Minimal harm or potential for actual harm On 01/24/24 at 8:57 AM, an interview was conducted with Staff D, Licensed Practical Nurse (LPN), who stated the Certified Nursing Assistants (CNA) do the catheter care for Resident #10. Residents Affected - Few On 01/25/24 at 8:38 AM, observation revealed Resident #10 sitting in a recliner chair. The resident Foley drainage bag was resting on the floor, and it did not have a privacy pouch. On 01/25/24 at 8:45 AM, an interview was conducted with Staff E, CNA, who stated that Resident #10 was assigned to her an she was the regular CNA assigned to him. Staff E stated that she always does his Foley care. On 01/25/24 at 9:58 AM, observation of pericare / Foley care for Resident #10 performed by Staff E, CNA and assisted by Staff F, CNA started. Staff E proceeded to remove the resident's pull-up. Observation revealed the catheter was not anchored to his thigh. Staff E placed the drainage bag on top of the bed, donned gown, and gloves. Observation revealed a table with the following items: disposable wash cloths, a bottle of body wash and a bottle of perineal cleanser, a bottle of hand sanitizer and a leg bag. No alcohol pads were noted on the table. During the observation, Staff E stated that she put the leg bag on during the day. Observation revealed Staff E pulled the resident's penis foreskin and a moderate amount of a white matter was noted. Staff E stated that the white matter was the barrier cream they applied to the skin. Staff E wiped the resident's meatus area and above the foreskin multiple times with the same wipe creating a potential for cross contamination. Staff E then proceeded to wipe the Foley tubing with a wipe from the top to the bottom and then from bottom to top with the same wipe. Observation revealed Staff E was not turning the wipe for each stroke, as per the facility's policy. Staff E then cleaned Resident #10's left buttock from the hip down to the rectal area and then up using the same wipe multiple times without turning the wipe with each stroke. Observation revealed Staff E retrieved a new leg bag, removed the bag tubing cap and rested the bag tubing on top of the resident's sheet. Staff E then detached the Foley catheter from the drainage bag and cleaned the catheter opening with a paper towel soaked with soap and water multiple times without turning the sheet of paper. The catheter opening and the leg bag tubing were exposed to the air for approximately 28 seconds. Staff E did not provide Resident #10's peri /Foley care properly and did not anchor the resident's Foley catheter as per facility's policy. On 01/25/24 10:58 AM, a joint interview was conducted with Staff E, CNA and Staff F, CNA. Staff E was apprised that she used the same wipe to clean the meatus, the top of the foreskin and under the foreskin multiple times and back and forth. Staff F stated that she was supposed to use one wipe, clean and throw it away. Staff E was apprised that she cleaned the catheter tubing using one wipe from top to bottom twice without turning the wipe. Staff E stated that the resident's drainage bag should have had a privacy pouch and added she did not know why he did not have one. Staff E was asked regarding the resident's catheter to anchored to his thigh and stated the resident goes to the bathroom by himself. Staff E acknowledged Resident #10's Foley catheter was not anchored and it was supposed to be. On 01/25/24 at 3:01 PM, during a joint interview, the Director of Nursing (DON) and the nursing supervisor were apprised of the observation findings. The supervisor stated the CNAs were to clean the resident's buttock from the bottom upward. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 7 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 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 review of policy and procedure, observation and interview, the facility failed to ensure it secured and floor stock medications and prescription cream wound care treatment medications for four (4) of 4 sampled residents reviewed, Resident #6, Resident #204, Resident #19, and Resident #14, on 1 of 3 Wound Care Carts, [NAME] wing Bayshore unit. The findings included: Review of the facility policy and procedure on 01/25/24 at 3:19 PM, titled, Medication .Management, provided by the Administrator, revised 10/19, documented in the Policy Statement: To strive to ensure safe and efficient administration of medications to residents 6.medications for selected residents will be secured within the locked drawer . 1. On 01/22/24 at 10:22 AM, during an observational room tour, it was noted there was an un-attended, unlocked, unsecured and easily accessible Wound care Treatment cart for the [NAME] wing Bayshore Drive Hallway. The wound care cart contained prescription tubed, cream, topical medications for four (4) residents, along with floor stock medications for one (1) of three (3) Wound care carts, that included the following: a. Resident #6 - Voltaren cream, Betamethasone cream, Ketoconazole cream, [NAME] cream. b. Resident #204 - Acetate cream-Hydrocortisone. c. Resident #19 - Santyl cream. d. Resident #14 - Clobetasol solution. e. Wound care items not secured included: Triad cream stock medication tube, A & D ointment packets x 8, betadine iodine packets and skin prep wipes and wound care supplies. Photographic Evidence Obtained. An interview was conducted on 01/22/24 at 10:23 AM with the Director of Nursing, regarding the unlocked Wound Care Treatment located on the [NAME] wing Bayshore Hallway and she stated that, she had forgotten to check this one (1). She acknowledged the Wound Care Treatment Cart with residents' prescription cream medications must be kept locked and secured at all times. This was not done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 8 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure that it followed regular, routine Safety/Service Maintenance Checks for 3 of 6 sampled residents observed for 'active' routine and 'as needed' Nebulizer Treatment Therapy, Resident #23, Resident #18 and Resident #48. Residents Affected - Few The findings included: Review of the facility policy and procedure on 01/25/23 at 1:53 PM, titled, Use and Care of Equipment, provided by the Administrator, revised 11/20, documented in the Policy Statement: To strive to provide .resident equipment .per Guidelines 1. Resident #23 was re-admitted to the facility on [DATE] with diagnoses that included Atrial Fibrillation, Obstructive Sleep Apnea, Pleural Effusion, Lobar Pneumonia, Chronic Obstructive Pulmonary Disease (COPD) and Unspecified Dementia. The documented Brief Interview Mental Status (BIMS) score was 8, idicating the residentwas moderately impaired. During an initial observational tour conducted on 01/22/24 at 10:41 AM, Resident #23's room was observed to have a Therapy Equipment Tech Services/Lincare Services Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date. The last service date was February 27th 2021, and a due date of February 2022. Photographic Evidence Obtained. On 01/23/24 at 10:04 AM, Resident #23's room was still observed to have a Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date of February 27th 2021, and a due date of February 2022. On 01/23/24 at 1:44 PM, Resident #23's room was observed again to have the same Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date of February 27th 2021, and a due February of 2022. On 01/24/24 at 11:52 AM, Resident #23's room was again observed to have the Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date of February 27th 2021, and a due date of February 2022. On 12/17/23, the initial physician's order for Resident #23 indicated an order for Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer two (2) times a day for COPD/SOB (Shortness of Breath). Record review of the Medication Administration Record (MAR) for Resident #23 for December 2023 and January 2024 revealed that Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer two times a day for Chronic Obstructive Pulmonary Disease / SOB related to COPD, with a start date of 10/26/23; and initialed and signed off as being administered to the resident by licensed nursing staff. Further record review of the Respiratory Care Plan for Resident #23, initiated 09/25/17, showed the Problem List: Resident has potential for altered respiratory status/difficulty breathing related to Congestive Heart Failure, SOB, Anxiety, Allergic Rhinitis, COPD; Interventions: Administer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 9 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications / inhalers as ordered. Monitor for effectiveness and side effects; and Goals: Resident will have no complications related to SOB through review date. 2. Resident #18 was readmitted to the facility on [DATE] with diagnoses that included Pneumonia, Diastolic Congestive Heart Failure (CHF), Pleural Effusion, Cough, Shortness of Breath and Atrial Flutter. The record documented a BIMS score of 8, indicating moderate cognitive impairment. During a observational tour conducted on 01/22/24 at 11:06 AM, Resident #18's room was observed to have a Therapy Equipment Technician Services Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date of February 27th 2021 and a due date of February 2022. Photographic Evidence Obtained. On 01/23/24 at 10:17 AM, Resident #18's room was still observed to have the Nebulizer machine with an outdated (almost two (2) years past due) service date of February 27th 2021 and a due date of February 2022. On 01/23/24 at 1:44 PM, Resident #18's room was still observed to have a Nebulizer machine with an outdated/almost two (2) years past due service date of February 27th 2021 and a due date of February 2022. On 01/24/24 at 11:56 AM Resident #18's room was observed again to have a Nebulizer machine with an outdated (almost two (2) years past due) service date of February 27th 2021 and a due date of February 2022. On 12/05/23, the initial physician's order for Resident #18's dcocumented an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 milliliter inhale orally via nebulizer two times a day for Shortness of Breath (SOB)) Wheezing related to COPD. Record review of the Medication Administration Record (MAR) for Resident #18's for December 2023 and January 2024 revealed that Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer two times a day for Cough, had a start date of 12/08/23; and it was initialed and signed off as being administered to the resident by licensed nursing staff. Further record review of the Respiratory Care Plan dated initiated 10/27/23 for Resident #18's showed the Problem List: Resident is at risk for altered respiratory status/difficulty breathing related to history of Pneumonia, Cough, Pleural Effusion, Wheezing and SOB; Interventions: Administer medications / inhalers as ordered .give breathing treatment as ordered; and Goals: Resident will have no complications related to SOB through review date. On 01/24/24 at 12:38 PM, an interview was conducted with Staff C, Registered Nurse (RN), who acknowledged Resident #23 was currently receiving Nebulizer treatments of Albuterol Sulfate Nebulization Solution inhaled orally via nebulizer two (2) times a day for COPD and SOB, and verified the order. During the interview, the nurse acknowledged and read aloud the following label attached to the outside of the Nebulizer machine as: Service date of February 27th 2021 and due date February 2022, 2 years outdated. Staff C stated the Nebulizer treatments are given on either the 11PM-7AM shift or on the 3PM-11PM shifts by other nurses. Staff C was asked 'Who do you report the outdated inspection date for the nebulizer equipment to, in order to ensure that the resident's Nebulizer equipment is currently operating properly', and replied she would remove the machine and try to get a replacement. She then stated she would report this to either the Maintenance Director or to the Director Of Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 10 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 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 0908 (DON). She acknowledged that this had not previously been done by her. Level of Harm - Minimal harm or potential for actual harm 3. Resident #48 was re-admitted to the facility on [DATE] with diagnoses that included Cerebral Atherosclerosis, Wheezing, Encephalopathy, Atrial Fibrillation, Hypoxemia, Pleural Effusion and Dementia. The record documented a BIMS score of 00, indicating severe cognitive impairment. Residents Affected - Few During an observation conducted on 01/23/24 at 1:44 PM, Resident #48's room was observed to have a 'Therapy Equipment Tech. Services / Pioneer' Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date of February 27th 2021, and a due date of February 2022. Photographic Evidence Obtained. On 01/24/24 at 11:29 AM, Resident #48's room was still observed to have a Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date of February 27th 2021, and a due date of February 2022. On 12/11/23, the initial physician's order for Resident #48 documented an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) three (3) ml inhale orally in the morning for SOB related to Hypoxemia. Record review of the MAR for Resident #48 for December 2023 and January 2024 revealed that Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% three (3) milliliter inhale orally via nebulizer two (2) times a day for COPD/SOB, with a start date of 12/12/23; and was initialed and signed off as being given to Resident #48 by licensed nursing staff. Further record review of the Respiratory Care Plan dated initiated 07/28/23 for Resident #48 showed the Problem List: Resident is at risk for altered respiratory status/difficulty breathing related to history of SOB/Hypoxemia, Pleural Effusion, Wheezing; Interventions: Administer medications/breathing treatment as ordered. Monitor for effectiveness and side effects; and Goals: Resident will have no complications related to SOB through review date. On 01/24/24 at 1:07 PM, an interview was conducted with Staff D, Licensed Practical Nurse (LPN), who acknowledged Resident #48 was currently receiving Nebulizer treatments of Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML one (1) vial inhale orally every twelve (12) hours as needed for SOB/Wheezing. During the interview, the nurse acknowledged and read aloud the following label attached to the outside of the Nebulizer machine as: Service date of February 27th 2021, and a due date February 2022, two (2) years outdated. Staff D stated the Nebulizer treatments are given on the 7AM-3:30PM shifts. Staff D was asked Who would she report the outdated nebulizer equipment to in order to ensure that the resident's Nebulizer equipment was currently operating properly, and replied she would remove the machine and try to get a replacement, and then she would also report this to either the Maintenance Director, or the DON. She acknowledged that this had not previously been done by her. During a telephone interview conducted on 01/25/24 at 1:15 PM with both the Field Lead Biomedical Technician of fifteen (15) years, along with the facility's Regional Clinical Director, the Field Lead Biomedical Technician was asked about what types of services need to be checked with regard to residents' Nebulizer machines. He stated that Nebulizers check are performed for electrical safety purposes in order to verify that these are functioning correctly to avoid the risk of electric shock for both resident and the individual administering the nebulizer treatments. He staed this should be done on a yearly or biannual basis. The Field Lead Biomedical Technician ended the conversation by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 11 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 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 0908 clearly stating that after one (1) year, the Nebulizer machine would no longer be in compliance. Level of Harm - Minimal harm or potential for actual harm Upon request, the facility was unable to provide the surveyor with any specific documentation of the Manufacturer's Recommendations pertaining to the Nebulizers currently being utilized by residents residing in the facility. Residents Affected - Few The three (3) outdated Nebulizer machines with stickers were not removed from the three (3) residents' bedsides and replaced with an updated Nebulizer machine, until after surveyor intervention. The DON recognized and acknowledged on 01/24/24 at 2:24 PM that all 3 residents ordered Nebulizer treatment medications were being administered to them on a regular, routine basis, via the outdated Nebulizer machines in their rooms. She also acknowledged that the service and due dates for Safety / Calibration recorded on the outside of the Nebulizer machines, with regard to service / maintenance were outdated/past due. The DON indicated that she should have reported this to both the Administrator and the Maintenance Director to notify them since these Nebulizer machines needed to be checked, serviced and monitored on an annual basis. This was not done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 12 of 12