Inspection·May 1, 2025

F 0693 4-6 hours, prior to irrigation and PRN (Confirm with physician regarding withholding feedings). Level of Harm - Minimal harm or potential for actual harm An order dated 06/07/24 for Enteral Feed Order every shift Observe for signs of dehydration, nausea, vomiting, distention, diarrhea, reflux, constipation, and breath sounds every shift. Residents Affected - Few An order dated 06/07/24 for Enteral Feed Order every shift Elevate height of bed 30 to 45 degrees at all times during feeding and for at least 30 minutes after stopped. An order dated 07/03/24 for Enteral Feed Order every shift for enteral nutrition Jevity 1.5 via peg tube at 70cc/hour x 20 hours off at 10:00 AM and on at 2:00 PM. An order dated 03/07/25 for Enhanced Barrier Precautions. Review of the care plans for Resident #43 dated 06/07/24 with a focus on the resident required tube feeding to provide nutrition and hydration due to dysphagia, revealed: 'The resident is at risk for weight loss and dehydration due to enteral tube status and was recently hospitalized s/p [status post] seizures and pneumonia. Other conditions that could impact the resident's nutritional status include diagnoses of Parkinson's Disease, Gout, Dementia, and Constipation. The goals were for the resident to have no significant weight change in the next 30 and 180 days, will have no s/s dehydration, will have no s/s of aspiration or choking and will have no N/V/C/D [nausea / vomiting / constipation / diarrhea] related to peg tube feeding by the next review date. The interventions included in part the following: Provide resident with enteral feeding as ordered by my Medical Doctor (MD). Provide flushes as ordered by my MD. Family has preference for Jevity products.' On 04/29/25 at 2:18 PM, an observation was made of Staff A, Licensed Practical Nurse (LPN), who entered the room of Resident #43 to connect tube feeding to the resident. Staff A connected the tube feeding to the resident's PEG tube and turned on the tube feeding without checking placement of the PEG tube or checking the PEG tube for patency. An interview was conducted on 04/29/25 at 2:25 PM with Staff A who was asked about checking for placement, patency and residual of the PEG tube prior to connecting the tube feeding, Staff A stated she checked all of that between 12:00 PM and 1:00 PM when she administered medications to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 2 of 17 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 05/01/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observations, interviews, and record review, the facility failed to ensure all nursing staff professional standard of quality for 1 of 24 nurses employed by the facility observed during 1 of 4 medication administration observations, to ensure the correct process was followed. The findings included: Review of the facility's policy titled, Orientation for Professional Staff, dated 08/2021, included the following: To strive to assure that all nurses possess the competencies and skill sets necessary to provide nursing and related services to meet the residents'' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial wellbeing. Procedure: 1. The Orientation Checklist for Professional Staff is completed by the Director of Nursing (DON), who will provide orientation to the new employee. Review of the facility's policy, titled, Medication Administration & Management, dated 10/2019, included the following: To strive to ensure safe and efficient administration of medications to residents in [facility name]. Procedure: 3. Dose Preparation: All authorized community staff should adhere the following guidelines: f. Verify that the medication name and dose are correct. 4. Prior to Medication Administration: All authorized community staff should adhere to the following guidelines: a. Verify the correct drug, correct dose, correct rate, correct time and current resident prior to each medication administration. b. Confirm that the Medication Administration Record (MAR) reflects the most recent medication order. On 04/30/25 at 5:54 PM in the 200s unit hallway, the surveyor approached Staff D, Registered Nurse (RN), who was at a medication cart and actively crushing medications. She was asked if she had any other medication administration to do, she stated yes. Staff D poured the crushed medications into the medication cup and realized she did not have apple sauce on the medication cart. She stated she would get the apple sauce and then she stored the cup of crushed medications in the top drawer of the medication cart and locked the cart. She went down the hallway, around the corner where the nurses' station was located. An observation of the medication cart revealed only a pill crusher machine and a pitcher of water on top of the cart (no computer, notepad or cooler was observed). Staff D returned at 5:56 PM with a cooler (containing apple sauce and Boost supplement drinks) and a laptop computer. She sat them on top of the medication cart and attempted to log into the laptop but was not able to. She stated that she would be right back because she must log out of the other computer and at 5:57 PM left again, went down the hallway and around the corner where the nurses' station was located. She returned at 6:04 PM and was able to log into the laptop computer and began dispensing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 3 of 17 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 05/01/2025 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 0726 medications for a resident for the medication administration observation. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Staff D following the medication administration observation who stated she has worked at the facility for a month. The surveyor inquired about the medications that she previously had crushed and stored in the top drawer of the medication cart. She stated that she would discard them because the resident is not in his room. Staff D was asked how she knew which medications to dispense if she did not have the laptop computer on the medication cart. She then stated that she is always scheduled to this hallway, she knows her residents well and she had pulled up the resident's MAR in the other computer (which was located by the nurses' station). Staff D was asked if this is per facility's standards, she stated that this laptop computer gives her problems, and she does not like using it. She also stated management is aware, but the laptop still does not work well. During the medication administration, the surveyor observed the laptop was able to display the MAR for the resident. Residents Affected - Few On 04/30/25 at 6:50 PM, the surveyor discussed the medication administration observation conducted with Staff D with the Director of Nursing (DON). She was upset and stated that they have recently reviewed medication administration and Staff D is a new nurse. She stated there will be lots of education and training scheduled. On 05/01/25 at 1:25 PM, an interview was conducted with the Administrator. She stated Staff D recently became an RN. The NHA stated she was a Licensed Practical Nurse (LPN) prior. The Administrator stated the staff developer, who was also the Assisting Director of Nursing (ADON), was responsible for Staff D to complete the Orientation Checklist for Professional Staff. She acknowledged the ADON was terminated last Friday 04/25/25 due to inconsistency in her work. The Administrator was beside herself when she was told about the medication administration observation that was conducted with Staff D. She stated that it appeared that Staff D was not prepared to work, and it is not acceptable. A side-by-side review of Staff D's Orientation Checklist for Professional Staff was conducted with the Administrator. Review of the medication administration section of the checklist dated 04/12/25 revealed Staff D required education on preparing and organizing everything needed before starting Medication Administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 4 of 17 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 05/01/2025 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 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 record review, interview and observation, the facility failed to maintain a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 5 sampled residents reviewed for controlled medications, Resident #4. The findings included: Review of the facility's policy titled, Medication, Controlled Substances, with a revised date of 04/2024, included in part the following: To strive to ensure that strict management of controlled substances is maintained as evidence by special handling, storage , disposal and record keeping. When a resident receives a narcotic, the licensed nurse signs off each dose of the controlled medication given by documenting the following on the narcotic sheet and the electronic medication administration record [eMAR]. Record review for Resident #4 revealed a most recent readmission to the facility on [DATE] with diagnoses that included in part the following: Displaced Supracondylar Fracture Without Intracondylar Extension of Lower End of Right Femur Subsequent Encounter for Closed Fracture with Routine Healing, Fall on Same Level From Slipping Tripping and Stumbling Without Subsequent Striking Against Object Subsequent Encounter, Pain in Left Knee, and Periprosthetic Fracture Around Internal Prosthetic Left Knee Joint Subsequent Encounter. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 14 indicating a cognitive response. Review of the physician's orders for Resident #4 revealed an order dated 02/24/25 for Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain was discontinued 04/11/25. Review of the physician's orders for Resident #4 revealed an order dated 03/26/25 for Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 8 hours as needed for moderate (pain). Review of Controlled Medication Utilization Record for Resident #4 for Tramadol 50mg tablet give 1 tablet by mouth every 8 hours as needed for pain documented in part the following: On 04/10/25 at 1:30 AM, 1 tablet was removed. On 04/25/25 at 7:00 AM, 1 tablet was removed. Review of the Medication Administration Record for Resident #4 for the month of April 2025 revealed no documentation of Tramadol having been administered on 04/10/25 at 1:30 AM or on 04/25/25 at 7:00 AM. An interview was conducted on 05/01/25 at 11:00 AM with Staff C, Registered Nurse (RN), who stated she has worked at the facility for 5 years. When asked about the process of removing and administering controlled medications, she stated they remove the medication, mark it on the Control Sheet, and sign it off on the MAR once it is given to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 5 of 17 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 05/01/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 05/01/25 at 11:15 AM with Staff A, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 3 years. When asked about the process for removing and administering controlled medications, she stated they remove the medication, mark it on the Control Sheet, and sign it off on the MAR once it is given to the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 6 of 17 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 05/01/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to monitor behaviors as per physician's orders for 2 of 5 sampled residents reviewed for unnecessary medications, Resident #7 and Resident #23. Residents Affected - Few The findings included: Review of the facility's policy, titled, Psychotropic Medications, dated 03/2025, included the following: 3. The community supports the goal of determining the underlying cause of behavioral symptoms so that appropriate treatment of the environment, medical, and/or behavioral interventions, as well as psychotropic medications, (if clinically necessary), can be used to meet the needs of the individual resident. Procedure: 1. The physician or nurse practitioner, as allowed per state requirements, will document and substantiate reasons for use of the medication in the progress notes. The notes are to include: c. Identification of targeted symptoms/behaviors. 8. Documentation, in the care plan and nursing notes, should reflect the monitoring of the resident for the desired responses of medication use, in addition to the non-pharmacological interventions attempted. 9. Presence or absence of adverse behavior and side effects from medication use, if present, will be documented on the pharmacy provided behavior monitoring form, administration record, or in the progress notes. 1. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease, Vascular Dementia and Major Depressive Disorder. Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The physician order summary report showed an order for Sertraline HCl (a psychotropic medication) at 50 milligrams, to give 1 tablet by mouth in the morning for Depression dated 12/20/24. Continued review of the order summary report revealed an order for behaviors: monitor the following: feeling sad, tearful, emptiness or hopelessness, angry outbursts, irritability or frustration, loss of interest or pleasure in most or normal activities such as hobbies, sports or reading, sleep disturbances, including insomnia or sleeping too much. Indicate with (Y) if signs/symptoms noted, then write progress note. Indicate with (N) if no signs/symptoms note every shift with a start date 04/01/25. In addition, if a behavior was observed, there was a physician's order to enter the following intervention codes: (1)=Redirect (2)=One on one (3)=Ambulate (4)=Activity (5)=Return to room (6)= Toileted (7)=Give food (8)=Give fluids (9)=Change position (10)=Encourage to rest (11)=Backrub (12)=Refer to nurse's notes (13)=Assess for pain. outcome codes: (+)=Improved (-)=Worsened (0)=Unchanged (N)=See progress notes, every shift start date 04/01/25. Record review of the April 2025 Medication Administration Record (MAR) revealed Resident #7 was monitored for behavior and interventions. However, on 04/02/25 during the day and night shift and on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 7 of 17 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 05/01/2025 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 04/28/25 night shift, it had documented behaviors were observed (marked in the MAR with a Y), but there were no intervention codes documented on those days or in nursing progress notes. Review of the nursing progress notes dated 04/02/25 documented: was a behavior observed? Yes, however, no other documentation for which of the behaviors was observed, or the intervention that was implemented. On 04/03/25, the nursing progress note documented a behavior observed (not documented in the MAR), however no additional documentation was found regarding which behavior was observed and what interventions were implemented. Further review of the progress notes, on 04/17/25 documented behavior was observed (not documented in the MAR), and no follow up documentation for interventions. 2. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Depression and Dementia. Section C of the MDS dated [DATE] revealed Resident #23 had a BIMS of 00, indicating severe cognitive impairment. The physiciian order summary report showed an order for Mirtazapine (a psychotropic medication) at 7.5 milligrams, to give 1 tablet by mouth at bedtime for Depression dated 07/17/24. Continued review of the order summary report revealed an order for behaviors: monitor the following: feeling sad, tearful, emptiness or hopelessness, angry outbursts, irritability or frustration, loss of interest or pleasure in most or normal activities such as hobbies, sports or reading, sleep disturbances, including insomnia or sleeping too much. Indicate with (Y) if signs/symptoms noted, then write progress note. Indicate with (N) if no signs/symptoms note every shift with a start date 04/01/25. Further review revealed if a behavior was observed to enter the following intervention codes: (1)=Redirect (2)=One on one (3)=Ambulate (4)=Activity (5)=Return to room (6)= Toileted (7)=Give food (8)=Give fluids (9)=Change position (10)=Encourage to rest (11)=Backrub (12)=Refer to nurse's notes (13)=Assess for pain. outcome codes: (+)=Improved (-)=Worsened (0)=Unchanged (N)=See progress notes, every shift start date 04/01/25. The care plan that was initiated on 08/06/24 showed Resident #23 demonstrated behavior(s) such as restlessness, agitation, trying to get up the wheelchair without assistance and not easily to be redirected. Some of the interventions were shown to monitor the behavior episodes and attempt to determine underlying causes; consider location, time of day, people involved, and situations; and document my behavior and potential causes. Record review of the April 2025 MAR revealed Resident #23 was monitored for behavior however, the documentation was check marks instead of Yes or No to indicate if signs/symptoms were noted as per the physician's orders. Further review revealed intervention codes were documented on 04/12, 04/13, 04/21, 04/26 and 04/27/25 during the day shift. Review of the nursing progress notes for those dates revealed no documentation on the resident's behavior or the interventions that were put in place. An interview was conducted on 04/30/25 at 10:59 AM with Staff A, Licensed Practical Nurse (LPN), who stated she has worked at the facility since January 2025. She stated residents on psychotropic medication are monitored for behaviors daily. She also stated that any change in behavior is documented in the progress notes and will include what happened, the interventions that were implemented, then the provider is contacted, and monitoring of the resident will continue. An interview was conducted on 04/30/25 at 11:11 AM with Staff C, Registered Nurse (RN), who stated she has worked at the facility for 4 years. She stated they used to document the behaviors on paper, however, now they document in the computer which include the behavior, interventions and the side effects of the psychotropic medications. Staff C stated the physician's orders provides instructions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 8 of 17 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 05/01/2025 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 0757 on what to document and use codes for the interventions and then add it to the progress notes. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 04/30/25 at 3:00 PM with the Director Of Nursing (DON) who stated that the behaviors are monitored and documented in the progress notes. During the interview, a side-by-side review of Resident #7 and Resident #23's April MAR was conducted, the DON acknowledged that the documentation did not follow the physician's orders for monitoring of behaviors for both residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 9 of 17 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 05/01/2025 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, interview and record review, the facility failed to secure 1 of 3 medication carts, failed to secure 1 of 2 treatment carts, and failed to secure and properly dispose of medications (meds) during 1 of 4 medication administration observations. The findings included: Review of the facility's policy, titled, Storage and Expiration Dating of Medications and Biologicals, with a revised date of 08/01/24, included in part, the following: Facility should ensure medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators / freezers of sufficient size to prevent crowding. Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Facility should ensure the medications and biologicals for each resident are stored in the containers in which they were originally received. Facility should ensure no transfers between containers are performed by non-pharmacy personnel. 1. Upon entrance to the facility on [DATE] at 8:40 AM, an observation was made of an unlocked and unsecured treatment cart (later identified as the Pineapple treatment cart) located next to the East Reception Desk. On 04/28/25 from 10:15 AM to 10:30 AM, an observation was made of the Pineapple treatment cart located next to the East Reception Desk, and it was unlocked and unattended. A side-by-side observation on 04/28/25 at 10:30 AM with Staff A, Licensed Practical Nurse (LPN), was conducted who acknowledged the Pineapple treatment cart next to the East Reception Desk was left unlocked an unattended. Inside the treatment cart were several (no less than 15) prescription medications (including ointments, creams and powders) for various residents. The nurse immediately locked the cart. An interview was conducted on 04/28/25 at 10:30 AM with Staff A who stated she has worked at the facility since January 2025. When asked if med carts and treatment carts are left unlocked when unattended, she said, 'no, everything is supposed to be locked at all times'. 2. During an observation conducted on 04/30/25 at 12:07 PM while doing an environmental tour of the facility with the Administrator and the Maintenance Tech, there was an unsecured and unattended med cart on the Oasis hallway. The Administrator immediately called for the nurse. An interview was conducted on 04/30/25 at 12:10 PM with Staff A, LPN, who stated she had accidentally left the med cart unlocked when she answered a call light and entered a resident's room. 3. A medication administration (Med Pass) observation was conducted on 04/30/25 at 6:05 PM with Staff D, Registered Nurse (RN), for Resident #23. Observation revealed Staff D poured the following medications: Magnesium Oxide 400 mg one tablet for Supplement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 10 of 17 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 05/01/2025 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 Pravastatin Sodium 40 mg one tablet for Hyperlipidemia Level of Harm - Minimal harm or potential for actual harm Polyethylene Glycol 3350 Powder to give 17 Grams for Bowel management PreserVision AREDS 2 (Multiple Vitamins w/ Minerals) 1 capsule for Supplement. Residents Affected - Few During the observation, Staff D realized she had dispensed the medications and had not sanitized her hands throughout the Med Pass, however, she had no hand sanitizer bottle on top of her cart. She then walked away from the medication cart across the hallway (about 8 feet away with her back to the cart) to the wall sanitizer dispenser leaving the dispensed medications on top of the medication cart unattended. Staff D then returned to the cart and poured water into the cup with the Polyethylene powder, stirred it with a spoon, then threw the spoon in the garbage while touching the garbage lid. She again realized she needed to use the hand sanitizer and again walked across the hallway to the wall hand sanitizer dispenser, leaving the dispensed medications unattended on top of the cart. After the medication administration observation for Resident #23, Staff D was interviewed about leaving the medications unattended on top of the cart. She stated that she just went to use the hand sanitizer dispenser, and it did not take too long. She was asked about the medications that she had crushed (prior to starting the Med Pass for Resident #23) and are now stored in the top drawer of the medication cart. She stated that she would discard them because the resident was not in his room. Staff D opened the top drawer, removed the small cup with the crushed medications and discarded them in the garbage container attached to the medication cart. She was asked if that was per facility's policy to discard the medications in the garbage and she stated, I should have thrown them down the toilet. The surveyor asked Staff D to open the bottom drawer of the cart and pointed to a bottle, she picked up the bottle which was labeled Drug Disposal. Staff D acknowledged the medications are to be disposed of in the Drug Disposal bottle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 11 of 17 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 05/01/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and policy review, the facility failed to follow standards of professional practice for food safety, as evidenced by raw chicken and Mighty Shakes were stored in the refrigerator past the recommended time frames for food safety. This had the potential to affect 42 of 44 residents on oral diets. The findings included: Review of the facility's policy included a Food Storage Chart by HACCP, last revised in October 2014. It said that raw meat can be stored in the refrigerator for 4 days (including the day of delivery). Review of the United States Food and Drug Administration's (USFDA) Refrigerator and Freezer Storage chart dated March 2018, stated that uncooked chicken can be stored in the refrigerator for 1-2 days. According to the USFDA, these short but safe time limits will help keep refrigerated food, 40' F, from spoiling or becoming dangerous. The chart also stated that product dates were not a guide for the safe use of a product. Photographic Evidence Obtained. Review of the product guide for Mighty shakes revealed that after Mighty shakes were thawed, the shelf life was 14 days when refrigerated. Photographic Evidence Obtained. During the initial observation of the kitchen on 04/28/25, at 9:00 AM, the surveyor was accompanied by the Director of Culinary Services (DCS) & Staff B. The following observations and interviews were occurred: a. A forty-pound box of boneless, skinless, chicken breast was observed in the walk-in refrigerator (Refrigerator #1). The lid of the box had a small white rectangular sticker with the date 04/22/25 on it. When the DCS was asked what the date on the sticker meant, she said the date April 22 was the date that the chicken was received at this facility. When the DCS was asked when the chicken was pulled out of the freezer, she said it was not put in the freezer after it arrived. She explained that after delivery, it was placed directly into the refrigerator. When the DCS was asked how long raw chicken was safe to use when stored in the refrigerator, the DCS said it was good to use for about one week. The DCS said the chicken had Cryovac packaging, (a low oxygen form of wrapping, that extends the shelf life of food). There was a large white rectangular sticker on the lower half of the box of raw chicken that came from the vendor / food distributor. It had the packed date, 04/16/25, printed in a large font. The packed date represented the date that the chicken was packed into the plastic bag before it was boxed for shipping from the distributor. There was no use by date on the box of raw chicken. On the date of the initial survey, the box of raw chicken breasts was stored in the refrigerator for 6 days. Photographic Evidence Obtained. b. In refrigerator #1, a box of Mighty shakes, dated 04/14/24, was observed on the shelf. The directions Keep Frozen were printed on the top edge of each 4-ounce carton. When asked what the date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 12 of 17 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 05/01/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 04/14/24 represented, the DCS said that's the date we received the item from the vendor. When asked when this item was pulled out from the freezer, Staff B said it was pulled out about 1 month ago. There was no use by date on the box of Mighty shakes. The surveyor informed the DCS and Staff B that Mighty shakes were safe to use for 14 days after they were removed from the freezer. The DCS said she was unaware of this and agreed to follow-up with the vendor of the Mighty Shakes for information related to the storage of the shakes in the refrigerator. During an interview with the DCS on 04/28/25 at 3:08 PM, the DCS said she received a printout from the distributor that said that the chicken had a shelf life of 16 days. The surveyor took a photo of the email printout that showed 16 in the box next to the word shelf, there was no mention of refrigeration or freezing on the printout. In addition, the DCS said she called the vendor of the Mighty Shakes. She said that the facility's sales representative confirmed that the Mighty shakes must be used within 14 days after they were removed from the freezer. During a follow-up tour of the main kitchen on 04/30/25 at 11:20 AM, the DCS and the surveyor entered Refrigerator #1 to revisit the boxes of uncooked chicken breasts. The DCS commented, we now have use by days written on these boxes. She showed the surveyor the use by label was dated 05/01/25 to indicate the raw chicken was to be used within 16 days of the packed date. On 04/30/25, the raw chicken was in the facility's refrigerator for 9 days. The surveyor observed that the plastic wrap was a loose plastic bag around the chicken. The surveyor reminded the DCS that on 04/28/25 the DCS said the chicken had Cryovac packaging. The surveyor pointed to items in the refrigerator that appeared to be wrapped with a Cryovac (low oxygen) method. The wrap for some meat in the refrigerator appeared to have a tight plastic covering that was sealed with a low oxygen packaging method. The surveyor clarified with the DCS that the box of boneless, skinless, chicken breasts was not packaged with a low oxygen process. The DCS acknowledged this. The packaging specifications were provided to the surveyor. There was no indication that low oxygen packaging was used. The surveyor informed the DCS that the USFDA's Refrigerator and Freezer storage chart for food safety recommended raw chicken in the refrigerator for 1-2 days. The DCS said she just followed recommendations from the distributor based on that individual product. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 13 of 17 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 05/01/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to perform hand hygiene during 1 of 4 medication (med) administration observations and failed to wear appropriate Personal Protective Equipment (PPE) during tube feeding connection for 1 of 1 sampled residents reviewed for tube feed (Resident #43). Residents Affected - Few The findings included: Review of the facility's policy titled, Guidelines for Isolation Precautions with a revised date of 03/2023 included in part the following: Under section Enhanced Barrier Precautions (EBP) 1. EBP are used as an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs). 2. This precaution expands on the use of PPE and refers to the use of gown and gloves during high-contact resident care activities (unless otherwise indicated as part of Standard Precautions) that provide opportunities for transfer of MDROs to staff hands and clothing. 3. EBP will be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: a. Wounds or indwelling medical devices, regardless of MDRO colonization status. 5. Implementation - High-contact resident care activities that require gown and glove use for EBP include: g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Review of the facility's policy, titled, Hand Washing and Hand Hygiene with a revised date of 03/2020, included in part, the following: To strive to prevent infections through adequate hand washing and hand hygiene techniques. If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminating hands. Always decontaminate hands: After removing gloves. Other aspects of hand hygiene a) The use of gloves does not eliminate the need for hand hygiene. 1. Record review for Resident #43 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Parkinsonism, Alzheimer's Disease, and Gastrostomy Status. The Minimum Data Set (MDS) assessmnet dated 03/28/25 documented in Section C a Brief Interview of Mental Status score of 0 indicating severe cognitive impairment. Review of the physician's orders for Resident #43 revealed in part the following: An order dated 06/07/24 for Enteral Feed Order every shift Check tube placement before initiation of formula, medication administration, and flushing tube or at least every 8 hours. An order dated 06/13/24 for Enteral Feed Order one time a day related to Gastrostomy Status flush before and after connecting/ disconnecting enteral feeding at 2:00 PM and 10:00 AM via peg tube 150n cc of water two times a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 14 of 17 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 05/01/2025 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 0880 An order dated 06/07/24 for Enteral Feed Order every night shift. Complete tube site care every day. Level of Harm - Minimal harm or potential for actual harm An order dated 06/07/24 for Enteral Feed Order every hour for nutrition and prevent clogged tubing flush hourly with 30 cc for 20 hours while feed running 2pm to 10 am Residents Affected - Few An order dated 06/07/24 for Enteral Feed Order every shift Continuous Feed: Check residual every 4-6 hours, prior to irrigation and PRN (Confirm with physician regarding withholding feedings). An order dated 06/07/24 for Enteral Feed Order every shift Observe for signs of dehydration, nausea, vomiting, distention, diarrhea, reflux, constipation, and breath sounds every shift. An order dated 06/07/24 for An order dated 06/07/24 for Enteral Feed Order every shift Elevate height of bed 30 to 45 degrees at all times during feeding and for at least 30 minutes after stopped. An order dated 07/03/24 for Enteral Feed Order every shift for enteral nutrition Jevity 1.5 via peg tube at 70cc/hour x 20 hours off at 10:00 AM and on at 2:00 PM An order dated 03/07/25 for Enhanced Barrier Precautions. Review of the care plan for Resident #43 dated 06/07/24 with a focus on the resident required tube feeding to provide nutrition and hydration due to dysphagia. The resident is at risk for weight loss and dehydration due to enteral tube status and was recently hospitalized s/p seizures and pneumonia. Other conditions that could impact the resident's nutritional status include diagnoses of Parkinson's Disease, Gout, Dementia, and Constipation. The goals were for the resident to have no significant weight change in the next 30 and 180 days, will have no s/s dehydration, will have no s/s of aspiration or choking and will have no N/V/C/D (nausea/vomiting/constipation/diarrhea) related to peg tube feeding by the next review date. The interventions included in part the following: Provide resident with enteral feeding as ordered by my Medical Doctor (MD). Provide flushes as ordered by my MD. Family has preference for Jevity products. On 04/29/25 at 2:18 PM, an observation was made of Staff A, Licensed Practical Nurse (LPN), who entered the room of Resident #43 to connect tube feeding to the resident. Staff A did not wear a gown, but only wore gloves. Staff A connected the tube feeding to the resident's PEG tube and turned on the tube feeding. During an interview conducted on 04/29/25 at 2:25 PM with Staff A who was asked if Resident #43 was on Enhanced Barrier Precautions, she said yes because he has a PEG tube. When asked what Personal Protective Equipment needed to be worn, she said gown and gloves. When asked why she did not wear a gown when connecting the tube feeding, she said because she was only connecting the tube feeding. 2. During a medication administration (Med Pass) observation conducted on 04/30/25 at 6:05 PM with Staff D, Registered Nurse (RN), stated she has worked at the facility for a month. She dispensed the medications into a small medication cup and stated that the resident gets her medications crushed with apple sauce. Staff D then donned clean gloves, without performing hand hygiene, and poured the medication tablets into a pouch (except for a medication capsule) and crushed the medications and poured them into another cup. She threw away the pouch and removed the gloves, without performing hand hygiene, donned clean gloves and grabbed the medication capsule and stated that she squeezes the medication because the resident cannot swallow the capsule. After 15 seconds of squeezing the capsule, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 15 of 17 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 05/01/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff D was able to pop the capsule and liquid got on her gloves and some in the medication cup. She then removed her gloves and discarded them and the shell of the capsule in the garbage. Without performing hand hygiene, she continued to prepare the medications. An interview was conducted with Staff D following the medication administration observation. She stated she realized she should perform hand hygiene more often during the Med Pass observation. During an interview conducted on 04/30/25 at 6:50 PM with the Director of Nursing (DON), the surveyor discussed the medication administration observation. She was upset and stated that they have recently reviewed medication administration and hand washing. The DON acknowledged that there will be lots of education and training scheduled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 16 of 17 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 05/01/2025 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure bathrooms are adequately equipped to allow residents / staff / visitors to call for staff assistance through a communication system for 4 of 73 bathrooms in the facility. Residents Affected - Few The findings included: Review of the facility's policy titled, Call Light, Responding with a revised date of 10/2022, included in part the following: The call bell system will be checked routinely by maintenance for proper functioning. On 04/28/25 at 10:36 AM, an observation was made of the emergency pull cord wrapped around grab bar in bathroom next to Oasis Kitchen and was unable to be activated by pulling on the cord. On 04/28/25 at 10:55 AM, an observation was made of the emergency pull cord wrapped around grab bar in bathroom in room [ROOM NUMBER] and was unable to be activated by pulling on the cord. On 04/28/25 at 10:59 AM, an observation was made of the emergency pull cord wrapped around grab bar in bathroom in room [ROOM NUMBER] and was unable to be activated by pulling on the cord. On 04/28/25 at 11:02 AM, an observation was made of the emergency pull cord wrapped around grab bar in bathroom next to Social Worker office and was unable to be activated by pulling on the cord. On 04/29/25 at 8:45 AM, a second observation was made of the emergency pull cord wrapped around grab bar in bathroom next to Social Worker office and was unable to be activated by pulling on the cord. On 04/29/25 at 10:30 AM, a second observation was made of the emergency pull cord wrapped around grab bar in bathroom next to Oasis Kitchen and was unable to be activated by pulling on the cord. On 04/30/25 at 9:10 AM, a second observation was made of the emergency pull cord wrapped around grab bar in bathroom in room [ROOM NUMBER] and was unable to be activated by pulling on the cord. On 04/30/25 at 9:40 AM a second observation was made of the emergency pull cord wrapped around grab bar in bathroom in room [ROOM NUMBER] and was unable to be activated by pulling on the cord. On 04/30/25 at 9:42 AM, a third observation was made of the emergency pull cord wrapped around grab bar in bathroom next to Oasis Kitchen and was unable to be activated by pulling on the cord. During a tour of the facility conducted on 04/30/25 at 12:00 PM with the Maintenance Tech and the Administrator, they acknowledged the emergency pull cords were wrapped around the grab bare in the bathroom next to the Oasis Kitchen and in rooms [ROOM NUMBERS]. The bathroom next to the Social Worker office was locked and we were unable to enter at time of this tour. An interview was conducted on 04/30/25 at 12:20 PM with Maintenance Tech who stated they will make sure they do rounds to consistently look for the emergency pull cords to ensure they are no emergency pull cords wrapped around the grab bars. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105355 If continuation sheet Page 17 of 17