Health inspection·May 26, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm At 12:46 PM, observation in room [ROOM NUMBER] revealed the resident in Bed A eating her puree diet with a white plastic teaspoon and the resident in Bed B using a small white plastic fork for the meal and a white plastic teaspoon for the soup. An inquiry was made if she liked using plastic utensils to which she stated 'No'. The resident was observed to be having difficulty piercing the cut up chicken pieces on her plate with the plastic fork. Residents Affected - Few At 12:49 PM, Resident #10 in room [ROOM NUMBER] was observed in her room using a small white plastic fork for the meal and a white plastic teaspoon for her soup. She was observed to be having difficulty piercing the cut up chicken pieces on her plate with the small plastic fork and the rice kept falling off the plastic fork before she could get it to her mouth. At 12:51 PM, CNA Staff N was observed feeding Resident #84 in room [ROOM NUMBER]. She was feeding the resident his puree meal with a white plastic teaspoon. An inquiry was made to CNA Staff N why they are using plastic utensils to which she just shrugged her shoulders and had no response. At 12:53 PM, the resident's lunch tray in room [ROOM NUMBER] was observed to have a white plastic teaspoon for the soup and a metal silverware fork for the meal. An interview was conducted with CNA Staff K who was in the resident's room at the time, why they are using plastic utensils to which she stated that is what the kitchen sends on the trays. On 05/26/22 at approximately 9:20 AM, an interview was conducted with the Administrator and Director of Nursing inquiring about the reason for using plastic utensils to which the Administrator stated she was not aware of this practice and would find out why this was happening. On 05/26/22 at 10:46 AM, an interview was conducted with the Director of Food Services regarding the observations of residents having to use plastic teaspoons and forks for their lunch meals and the soup and dessert being served in Styrofoam bowls, to which she stated those residents must be in isolation. The Director of Food Services was advised these observations were conducted on the 3rd floor which does not have any isolation to which she then stated their silverware and 9 ounce bowls are is in short supply and she has placed an order for these additional items about 2 to 3 weeks ago. She stated she just pulled some spare silverware from storage today when she realized there were not enough. An inquiry was made why she just pulled the spares from storage today and when did she realize they were using plastic utensils and Styrofoam bowls, to which she stated the Administrator informed her about it this morning. The Director of Food Services could not state how long they have been using plastic utensils and Styrofoam bowls, further stating the tray line Supervisor should have informed her they were short. She stated they will be using the silverware from storage for meals moving forward until the order arrives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 2 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 05/23/22 at 9:22 AM, during a tour of the facility, the following issues were observed: Residents Affected - Few A nightstand observed in room [ROOM NUMBER] was noted to be in disrepair. In room [ROOM NUMBER] there was a scraped wall; the paint on the bathroom door was peeling off with splinters exposed. In room [ROOM NUMBER] there was scraped paint on the southwest wall. There was a heavily rusted and corroded electric wire on the running base board. In room [ROOM NUMBER] there was a scraped wall. In room [ROOM NUMBER] B, the electric outlet cover was not secured on the wall, exposing live wires. On the North Wing of the 400 unit hallway, the electric outlet cover was not securely screwed on, with live wires exposed. An environmental tour was conducted with the Maintenance Director and Environmental Service Director on 05/24/22 at 2:11 PM during which all identified issues were reviewed. The Maintenance Director reported that he will address the concerns as soon as possible. Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to ensure that it maintained a safe, clean, comfortable, homelike environment for 7 of 7 resident rooms identified during the initial environmental tour (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] for Resident #50 and room [ROOM NUMBER] for Resident #36.) The findings included: 1) During an observational room tour conducted on 05/23/22 at 9:32 AM, it was noted that Resident #50 was observed trying to clean the floor around her bed utilizing a paper towel on the end of her cane. Resident #50 in room [ROOM NUMBER] was originally admitted to the facility on [DATE] with diagnoses which included Dementia, Hypertension, Diabetes,, Glaucoma and Hypertensive Heart and Chronic Kidney Disease. She had a Brief Interview Mental Status (BIMS) score of 12 (moderately impaired). During a brief interview conducted on 05/23/22 at 9:36 AM with Resident #50 regarding her actions observed above, she stated the floor looked dirty to her and had not been cleaned in days, so that's why she was cleaning it. On 05/23/22 at 9:43 AM, it was noted that the baseboard at the entry of the resident #50's bedroom doorway was peeling, stained and in disrepair; the resident's bedside table was dirty, dingy, chipped and peeling on the edges. Also, there was a used, dirty wash rag towel noted to be in wash basin in the bathroom on top of the resident's toilet. (Photographic evidence obtained.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 3 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/24/22 at 9:05 AM, it was still noted that the baseboard at the entry of the resident #50's bedroom doorway was peeling, stained and in disrepair; the resident's bedside table was dirty, dingy, chipped and peeling on the edges. Also, there was a used, dirty wash rag towel still noted to be in wash basin in the bathroom on top of the resident's toilet. On 05/24/22 at 2:31 PM, it was still noted that the baseboard at the entry of the resident #50's bedroom doorway was peeling, stained and in disrepair; the resident's bedside table was dirty, dingy, chipped and peeling on the edges. Also, there was a used, dirty wash rag towel still noted to be in the wash basin in the bathroom on top of the resident's toilet, as observed during a tour conducted of the fourth Floor with the Director of Maintenance and Director of Housekeeping. 2) During an observational room tour conducted on 05/23/22 at 9:34 AM, it was noted that in Resident #36's room [ROOM NUMBER] the red sharps/needle box on the wall was observed to be only attached on one side with a screw; the other side was not attached/not screwed in and hanging half-off the wall inside of the resident's room. (Photographic evidence obtained.) Resident #36 was originally admitted to the facility on [DATE] with diagnoses which included Cerebrovascular Accident, Hemiplegia affecting right dominant side and Hemiparesis, Aphasia, Hypertension, Diabetes, and Peripheral Vascular Disease. She had a Brief Interview Mental Status (BIMS) score of 11 (moderately impaired). On 05/24/22 at 10:34 AM, Resident #36's room red sharps/needle box on the wall was still noted to be only attached on one side with a screw; the other side was not attached/not screwed in and hanging half-off the wall inside of the resident's room. On 05/24/22 at 2:31 PM, Resident #36's room red sharps/needle box on the wall was still noted to be only attached on one side with a screw; the other side was not attached/not screwed in and hanging half-off the wall inside of the resident's room, as was observed during a tour conducted of the 4th Floor with the Director of Maintenance and with the Director of Housekeeping. The Director of Maintenance and the Director of Housekeeping both acknowledged the above environmental observations during the tour, and they both recognized that repairs and cleaning were needed for the items in Resident #50 and Resident #36's rooms. Review of facility policy and procedure for Environmental Services Cleaning Procedures Manual dated reviewed 2015 stated in part, 'The seven step cleaning process is designed to maintain the highest standards of Shine cleanliness .Prerequisites: Safety, Hand Hygiene, damp wiping, waste handling, routine floor car, restroom cleaning and Infection prevention and control and the use of disinfectant.' FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 4 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop a Baseline Care Plan for fall risk for 1 of 3 residents sampled for accidents (Resident #101). The findings included: A review of the facility's policy titled Interdisciplinary Team Care Assessments reviewed on 01/12/21 revealed the following: An interim plan of care is initiated within 48 hours of admission to the facility. The nursing admission assessment/observation is begun on the day of admission. Development and implementation of the plan of care begin with the completion of assessments and observations. Resident #101 was admitted to the facility from an acute hospital on [DATE] with diagnoses of Hypertension, Alzheimer's, and heart disease. He was later discharged to the hospital on [DATE] after a fall sustaining a right hip fractured. A review of the admission Fall Risk Evaluation, completed on 04/06/22 by the admitting nurse, revealed that an answer of no was marked for any history of falls for Resident #101. It further revealed a total score of 25 (medium risk) that fell between 25 to 50. A review of the Physical Therapist's Progress Note dated 04/04/22 that was obtained from hospital records showed the following: Resident #101 had a history of multiple falls prior to admission and that he was admitted to the hospital on [DATE] because of a syncope (dizziness) episode that resulted in his right knee bucking on him. A review of the Care Plans did not show that a Base Line Care Plan was started on 04/05/22 when Resident #101 was admitted to the facility. Further review of the Care Plan that was only initiated on 04/14/22 (9 days after admission) documented the following: Resident #101 has the potential for falls related to a history of dizziness and syncope and a history of falls with impaired gait and balance. In an interview conducted on 05/26/22 at 10:51 AM, Staff O, Minimum Data Set Coordinator, stated that a Base Line Care Plan is done when a resident is first admitted to the facility. The admitting nurse starts the resident's Interim Care Plan that gets carried over to the Base Line Care Plan. The Base Line Care Plan is completed within 48 hours of admission. Staff O said that the Base Line Care Plan would have the residents' medication, diet, basic nursing plan, therapy, and risk for falls, if any. According to him, the admitting nurse would read the hospital records to see if the resident had any falls in the past or was at risk for falls. In an interview conducted on 05/26/22 at 9:20 AM, with the facility's Administrator, she acknowledged all findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 5 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to provide care and services in accordance with activities of daily living specifically nail grooming for 1 of 2 residents observed for Activities of Daily Living (ADL), Resident #26. Residents Affected - Few The findings included: During an initial observational tour conducted on 05/23/22 at 11:23 AM, Resident #26 was observed with long, sharp, jagged, dirty, unkempt fingernails on both hands. (Photographic evidence obtained.) Resident #26 was originally admitted to the facility on [DATE] with diagnoses which included Diabetes, Hypertension and bilateral above the knee amputations. She had a Brief Interview Mental Status (BIMS) score of 12 (moderately impaired). On 05/23/22 at 11:29 AM, a brief interview was conducted with Resident #26 in which she was asked if she liked her nails long or if she would like them to be trimmed and she said that she wanted them to be trimmed down and she added that she does not understand why they haven't been since she mentioned this to someone last week, but she could not recall who. During a second observational tour conducted on 05/23/22 1:28 PM, Resident #26 was still observed with long, sharp, jagged, dirty, unkempt fingernails on both hands. During a third observational tour conducted on 05/24/22 1:28 PM, Resident #26 was still observed with long, sharp, jagged, dirty, unkempt fingernails on both hands. During a fourth observational tour conducted on 05/25/22 at 9:40 AM, Resident #26 was still observed with long, sharp, jagged, unkempt fingernails on both hands. Record review of the most recent Resident #26's Monthly Certified Nursing Assistant (CNA) ADL (Activities of Daily Living) Flowsheet Record dated 05/21/22 revealed that it was documented that fingernail care was not needed for this resident. However, 2 days after this entry was made, Resident #26's fingernails were observed by this surveyor to be long, sharp, jagged, dirty, unkempt fingernails on both hands. Record review of the Resident #26's quarterly Care plan dated 03/09/22 indicated Problem: Resident #26 requires limited to mostly extensive assistance with Activities of Daily Living (ADL) tasks and mobility due to Diabetic Peripheral Angiopathy without Gangrene and Acquired Bilateral Above Knee Amputation (AKA) also the resident has the potential for pressure related skin issues due to history of pressure ulcers, impaired bed mobility and incontinence. Intervention: Ensure fingernails and toenails are clean and well-trimmed .Offer manicure, beauty parlor per personal preference, when possible. Goal: Resident #26 will maintain highest practicable level of participation without decline over the next ninety (90) days. Further record review of the Minimum Data Set (MDS) section G dated 03/03/22 for Resident #26, indicated that she requires extensive assistance with bed mobility, dressing and personal hygiene and total dependence with toilet use. An interview was conducted with the Staff A, an Activities Assistant on 05/25/22 at 10:20 AM, in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 6 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few which she stated that her department has been lightly clipping, filing and polishing the fingernails for the residents on the fourth floor. She said that daily she will check each resident's fingernails to see if care is needed. She also stated that the CNAs on the floor will provide fingernail care to the residents. She said that if the resident is Diabetic (as identified by a band on their wrist), she will only file and clean their fingernails. She said if a Diabetic resident's fingernails are long and dirty, she stated she will let the facility nursing staff know to follow-up. The Activities Assistant said that her department provided nail care service to Resident #26 sometime last month in April 2022. The Activities Assistant also acknowledged that Resident #26's fingernails were all long, sharp, jagged, dirty and unkempt on both hands. An interview was conducted with Staff B, a CNA on 05/25/22 at 10:31 AM, in which she revealed that they had not provided fingernail care to Resident #26, and she said that it is the responsibility of the CNAs to clean and trim the resident's fingernails. She further acknowledged that the resident's fingernails were long, sharp, jagged, dirty, and unkempt on both hands. An interview was conducted with Staff C, a Registered Nurse (RN) on 05/25/22 at 10:50 AM, regarding Resident #26's long, unkempt nails and she also agreed that Resident #26's fingernails were long, sharp, jagged, dirty, and unkempt on both hands. On 05/25/22 at 10:58 AM, an interview was conducted with Staff D, a RN Unit Manager, for the fourth floor, regarding Resident #26's fingernails being long, sharp and untrimmed and he agreed that it is the responsibility of the CNAs to clean and trim the residents nails and he further acknowledged that the resident's fingernails were long, sharp, jagged, dirty and unkempt on both hands, and that they should have been cleaned/trimmed/cut. Side-by-side computerized record review of the nursing progress notes for the entire month of May 2022, was conducted with Staff D, RN Unit Manager for the fourth floor, did not indicate or document any refusals for fingernail care by the resident. On 05/25/22 at 3:00 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #26's fingernails being long, sharp and untrimmed and she also acknowledged that it is the responsibility of the CNAs to clean and trim the resident's fingernails and she further acknowledged that the resident's fingernails were long, sharp, jagged, dirty and unkempt on both hands, and that they should have been cleaned/trimmed/cut. Review of facility job description for Certified Nursing Assistant (CNA) provided by the (DON) indicated the following: The Certified Nursing Assistant (CNA) under the direct supervision of the licensed nurse will provide direct patient care while maintaining patient comfort and safety .Essential Functions: .Performs/Assists with the personal hygiene and activities of daily living (ADLs) and documents as needed. Review of facility's policy and procedure for Increasing Resident Independence provided by the DON reviewed 04/02/22, documented under Policy: It is the policy of this facility to promote atmosphere of respect for human dignity in the provision of healthcare and services provided by the facility. Healthcare providers are to encourage resident independence to engender increased resident self-esteem and self-confidence. Procedure: Direct healthcare providers will assist, support and encourage the resident to maintain good standards of personal hygiene and grooming which include: .nail care. The healthcare providers assess the resident for level of functioning, desire and motivation to perform these tasks by self, and intervene with education, support and assistance as deemed necessary. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 7 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Activities of daily living will be performed by healthcare providers for those residents who are unable to perform the activities themselves. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 8 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of the clinical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses to include cerebral vascular accident with left sided weakness, dysphagia (inability to swallow), feeding tube, depression, anxiety, and multiple contractures. Review of the clinical record revealed a physician order dated 08/17/21 to 'Apply splint rolled wash cloth to bilateral hands continuous. May remove for hygiene and skin checks.' Review of a Quarterly Review Care Plan dated 03/08/22 documents 'Resident is on a restorative nursing program of contracture management; splinting, bracing, positioning to maintain functional abilities. Interventions to include: Apply splint rolled gauze/wash cloth to bilateral hand continuously. Remove for hygiene and skin check.' On 05/23/22 at 10:38 AM, 12:37 PM and 3:30 PM, Resident #21 was observed in bed in her room, in a hospital gown. Her left and right hands were observed to have contractures with no splints in place. Resident #21 was not interviewable. On 05/24/22 at 9:42 AM, Resident #21 was observed in her room in bed. Her left and right hands were observed to have contractures with no splints in place. On 05/24/22 at 4:10 PM, Resident #21 was observed in her room up in a wheelchair. Observed in her right hand was a white washcloth falling out with no washcloth to her left hand. On 05/25/22 at 9:35 AM, Resident #21 was observed in her room in bed in street clothes. There was a white wash cloth in her right hand falling out and nothing in her left hand. On 05/25/22 at 2:10 PM, an interview was conducted with the 3rd Floor Registered Nurse Unit Manager (UM) and a request made to see their restorative nursing binder. The UM stated they do not have a binder, it is the Occupational Therapist (OT) Manager who is responsible for the restorative nursing programs. A request was made for the list of residents who were receiving restorative nursing services to which she stated there is no list, they just look at it on a daily basis. She stated the OT Manager would be responsible for splints and braces. She further stated there is one Certified Nursing Assistant who does ambulation with the residents a couple of times a week, further stating it is not like it used to be due to the pandemic. She stated the residents receive passive range of motion during care but she is not sure of anything else, the OT Manager would be able to state for sure. On 05/25/22 at 2:15 PM and 4:20 PM, Resident #21 was observed in her room in bed in street clothes. There was nothing in her right or left hand. On 05/25/22 at 2:55 PM, the 3rd Floor UM stated she received a restorative list from therapy and provided a list titled Ambulation & Transfer. Review of the list revealed there were 10 residents from the 3rd floor of a census of 59 who were on the list for ambulation. An inquiry was made of these residents listed, were there any residents who wear splints for contractures. The UM confirmed there were no residents on her unit who wear splints. On 05/26/22 at 11:45 AM, Resident #21 was observed in her room in bed. There was a white wash cloth (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 9 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 falling out of her right hand and nothing in her left hand. Level of Harm - Minimal harm or potential for actual harm On 05/26/22 at 1:52 PM, an interview was conducted with the Director of Occupational Therapy (OT) Staff M and an inquiry made when the last evaluation or assessment was conducted for Resident #21. Review of the electronic record revealed the last Therapy Screen was conducted on 08/17/21 with the recommendation for Splints - Recommend rolled wash cloth bilateral hands to prevent contracture noted with contractures left and right contractures. Further a quarterly OT assessment was conducted on 12/23/21 which recommended the rolled washcloths to bilateral hands for contracture management. Staff M was apprised for the past 4 days of observation, this has not been provided. An inquiry was made who is responsible for ensuring the rolled wash cloths are placed in the resident's hands to which Staff M stated that would be nursing and it should be documented in the Treatment Record. Review of the Treatment Record with Staff M revealed licensed nursing staff have been documenting the rolled wash cloths have been provided when observations of the resident over the past 4 days showed otherwise. Staff M had no comment. Residents Affected - Few 3) Review of the clinical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease, glaucoma, sacral pressure ulcer and open wounds to the right foot and ankle. On 05/23/22 at 10:46 AM, Resident #84 was observed in his room in bed. His right hand was observed to be severely contracted with the fingers clenched, overlapping and tips of the fingers digging into his right palm. There was no splint or device in place or visibly observed in his room. Resident #84 was not interviewable. On 05/23/22 at 12:30 PM, Resident #84 was observed sitting up in a gerichair in his room. No splint was observed to his right hand. On 05/23/22 at 1:08 PM, Resident #84 was observed sitting up in a gerichair being fed by Certified Nursing Assistant (CNA) Staff L. No splint was observed to his right hand. On 05/24/22 at 9:48 AM and at 4:12 PM, Resident #84 was observed in his room in bed. No splint was observed to his right hand. On 05/24/22 a clinical record review was conducted which revealed under the Therapy Communication Notes, documentation dated 05/04/22 for an order for an OT evaluation and treatment for splinting. Further review of the Therapy Notes revealed an OT note dated 05/11/22, documenting, 'Equipment Recommended - right hand splint, treatment provided small washcloth was rolled up and placed in palm to prevent fingernails from pressing into the palm flesh. Registered Nurse notified. Patient to tolerate washcloth today x 4 hours. Patient would benefit from hand carrot/inflatable hand splint to prevent further skin breakdown and prevent infection.' On 05/25/22 at 10:30 AM and 2:15 PM, Resident #84 was observed in his room in bed. No splint was observed to his right hand. On 05/26/22 at 1:45 PM, an interview was conducted with the Director of Occupational Therapy (OT) Staff M and an inquiry made when the last time Resident #84 was evaluated by the OT. Review of the electronic record revealed Resident #84 was evaluated on 05/11/22 by the OT for a right hand contracture. Staff M stated the therapist recommend a rolled washcloth in the right hand or a carrot splint (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 10 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to keep the fingers from digging into his palm. She stated they were planning on ordering a carrot splint because they do not have those kind of splints here, but they are trying the washcloth first to see if that will be beneficial. She stated they very rarely do splinting here because so few people benefit from splints, stating the contractures are not going to be reduced by a splint. She further stated they would use palm guards more often than splinting. Staff M was apprised that over the past 4 days, Resident #84 has not been observed with any kind of washcloth or splint device in his severely contracted right hand, to which she could not comment. An inquiry was made where the OT wrote the recommendation for the washcloth to the right hand to which she confirmed the recommendation had not been officially documented, just that nursing was verbally notified. An inquiry was made who would be responsible for ensuring the rolled washcloth was put in place to which she stated that should be done by nursing. Staff M further confirmed the OT who did the assessment on Resident #84 on 05/11/22 did not write an order for nursing for his recommendation for the resident's right hand contracture. She stated Resident #84 will be seen as soon as possible for follow up. Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to provide treatment and care for application of a hand splint to address the resident's positioning needs for 3 of 9 residents observed for splints/range of motion (ROM), (Resident #36, Resident #21, and Resident #84). The findings included: Review of the facility policy and procedure on Restorative and Nursing Services documented in part, 'Restorative Nursing Policy: The facility will ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable A resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable. Procedure: Restorative Nursing Programs from the following categories may be implemented: 1. Range of Motion 4. Contracture-Splint/Brace/Seating/Positioning.' 1) During an initial observational screening tour conducted on 05/23/22 at 10:20 AM, Resident #36 was observed as having limited range of motion/weakness of her right-hand and no splint in place. The splint was noted in her wheelchair seat, during the daytime hours, and not on her right hand. Further observation revealed that the resident was not being provided any personal care by facility staff, at the time. Resident #36 was originally admitted to the facility on [DATE] with diagnoses which included Cerebrovascular Accident, Hemiplegia affecting right dominant side and Hemiparesis, Aphasia, Hypertension, Diabetes, and Peripheral Vascular Disease. She had a Brief Interview Mental Status (BIMS) score of 11 (moderately impaired). Photographic evidence obtained of Resident #36's right-hand splint sitting in her wheelchair, during the day and not on her right hand, as ordered. On 05/24/22 at 10:32 AM, Resident #36 was again noted without her right-hand splint on. It was noted in her wheelchair seat in her room, with no personal care being provided to the resident by facility staff, at the time of the observation. On 05/24/22 at 2:54 PM, Resident #36 was again noted without her right-hand splint on. It was noted in her wheelchair seat in her room. No personal care was being provided to this resident by facility staff, at the time of the observation. On 05/25/22 at 9:43 AM, Resident #36 was again noted with no splint on at this time. It was noted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 11 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in her wheelchair seat in her room. No personal care was being provided to this resident, at the time. The resident stated to this surveyor that her right splint brace was not on. She said that they usually will put it on early in the morning and she will keep it on all day and take it off at night. In addition, Resident #36 added that she does not understand why it is not on her right arm now. On 05/25/22 at 10:30 AM, an interview was conducted with Staff E a Certified Nursing Assistant (CNA) in which she stated that Resident #36 was supposed to have the right-hand splint applied every day, and she acknowledged that the splint was not continually in place during the day on the resident, as ordered. On 05/25/22 at 10:50 AM, an interview was conducted with Staff C, a Registered Nurse (RN) and Staff D, RN 4th floor Unit Manager in which they both acknowledged that Resident #36 was supposed to have the right-hand splint applied every day, and both acknowledged that the splint was not continually in place during the day on the resident, as ordered. On 05/25/22 at 1:22 PM, an interview was conducted with Staff F, the Manager of the Physical Therapy Department in which he stated that the resident had been receiving Occupational Therapy (OT) from 06/02/20 to 06/22/20 and Physical Therapy (PT) from 12/03/20 to 12/18/20 for a total of 6 visits 2 to 3 times per week. He said that Resident #36 had been initially evaluated for OT for late effect Cerebrovascular Accident for right-sided weakness for a right upper extremity splint. The Manager of the Physical Therapy Department also added that the right-hand splint application would continue to benefit the resident and was to be worn continually at 7 AM and removed at 7 PM on a daily basis by both restorative and nursing, up to this point. Review of physician's orders dated 06/02/20 documented for OT to issue right resting hand splint and an order dated 06/22/20 also documented to apply resting hand splint to right hand 7 AM daily and remove resting hand splint from right-hand at bedtime 7 PM. During a record review of the Resident #36's nurses' notes, there was no documentation nor notation entries of any issues/problems nor refusals of the right-hand splint application by the resident. Further record review of the Minimum Data Set (MDS) section G dated 03/10/22 for Resident #36 indicated that she requires extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #36's right-hand splint was observed as being off/not applied on 4 different occasions between the dates of 05/23/22 and 05/25/22. During a record review of the facility's annual review care plan dated 03/14/22 revealed Resident #36 was on a Restorative Nursing Program of contracture management to include splinting, bracing, positioning to maintain functional abilities by providing resting hand splint/brace as prescribed as well as for range of motion to maintain joint mobility; Resident #36 has mobility deficits in which nursing and therapy are to check for any developing contractures; and Resident #36 is at risk for pathological fracture related to Vitamin D deficiency; nursing staff are to provide contracture management with gentle range of motion with Activities of Daily Living (ADL) care. The goals are demonstration of increased range of motion with no development of contractures or pathological fractures, through next review date. On 05/25/22 at 3:00 PM, the Director of Nursing (DON) further acknowledged and recognized that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 12 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 right-splint should be continually applied on a daily basis, according to the physician's order and the facility's care plan; this was not done. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 13 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 observation, interview and record review the facility failed to ensure indwelling Foley catheter perineal care was conducted in a manner to prevent the potential for infection for 1 of 1 residents observed for Foley catheter perineal care, Resident #75. The findings included: Review of the clinical record for Resident #75 revealed an admission date of 04/04/22 with pertinent diagnosis to include urinary tract infection and urinary retention requiring the use of an indwelling urinary Foley catheter. On 05/23/22 at 10:48 AM, Resident #75 was observed in his room in bed with the Foley catheter drainage bag covered with a privacy cover and the connected catheter tubing laying on the bed. The urine in the tubing looked cloudy with whitish sediment. An inquiry was made to the resident how long he has had the Foley catheter to which he could not say. An inquiry was made if he has had any recent urinary tract infections to which he also could not say. Review of the April 2022 Medication Administration Records (MAR) revealed a physician order dated 04/04/22 for an oral antibiotic to be administered twice daily for 5 days for a diagnosis of Urinary Tract Infection (UTI). Further review of the MAR revealed the antibiotic was initiated on 04/05/22 and administered at 9:00 AM and 5: 00 PM with the last dose to be administered on 04/09/22 at 5:00 PM not signed off as administered. Further review of the April 2022 MARs revealed another physician order dated 04/05/22 for a second oral antibiotic to be administered 3 times daily for 5 days for a diagnosis of UTI. Further review of the MAR revealed the antibiotic was initiated on 04/05/22 and administered at 9:00 AM, 1:00 PM and 5:00 PM with the dose due at 5:00 PM on 04/09/22 not signed off as administered. Review of a Care Plan dated initiated on 04/05/22 documents under Problem: Resident has the potential for recurrent UTI due to current UTI. Under Interventions: Administer antibiotics as ordered and assess effectiveness. Review of the April 2022 and May 2022 Treatment Administration Records (TAR) revealed a physician order dated 04/17/22 to 'Provide Foley catheter care for urinary retention and obstructive uropathy every shift.' Further review of the April 2022 and May 2022 TARs revealed the licensed nurses signed off on the night, evening and day shifts Foley catheter care was being rendered. Review of a Care Plan date initiated on 04/13/22 documents under Problem: Resident is at increased risk for infection related to indwelling catheter due to urinary retention. Under Interventions: Provide indwelling catheter care daily and PRN (as needed); cleanse urinary opening with soap and water - make sure to cleanse bowel movement away from tubing if bowel incontinence occurs. Monitor urine for sediment, cloudiness, odor or blood. Notify MD promptly when changes occur. On 05/24/22 at 10:30 AM, Resident #75 was observed in his room in bed. The urine in the Foley catheter tubing looked cloudy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 14 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 On 05/24/22 at 4:16 PM, Resident #75 was observed in his room asleep in his bed. The urine in the Foley catheter tubing remained cloudy looking. On 05/25/22 at 10:20 AM, Resident #75 was observed in his room awake in his bed. The urine in the Foley catheter tubing remained cloudy looking. An inquiry was made how he was feeling to which he stated he is sleeping a lot. Review of the facility policy titled Foley Catheter Care stated in part, 'The purpose of catheter care is to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the bladder. Basic Procedures: Monitor for signs and symptoms of urinary tract infection, such as cloudy urine . Procedure for Males: Hold penis upward. Wipe around urethral opening with soapy wash cloth in one continuous stroke. Rinse cloth thoroughly and repeat to remove soap. Cleanse six inches of catheter, starting from the meatus, with other cloth. Dry area, cover resident and leave him in a comfortable position.' On 05/25/22 at 2:30 PM, a Foley catheter care observation was conducted, with the consent of Resident #75. Certified Nursing Assistant (CNA) Staff J and CNA Staff K had arranged on the overbed table 1 basin of soapy water, 1 basin with clear water and a stack of wipes. Pads, diapers, towels and gloves were on another table. CNA Staff J turned the resident to his left side and Staff K bundled the pad underneath him and removed his adult brief. She proceeded to cleanse his buttocks area, removed the pad from both sides and replaced it with a new pad. CNA Staff K removed her gloves, washed her hands then donned new gloves. CNA Staff J was observed standing beside the bed looking unsure of what she should do next. CNA Staff K came from around the privacy curtain and Staff J said to her you have to change the water. CNA Staff K proceeded to take the basin with soap and water to the bathroom, replaced the water and brought it back to the bedside table where she poured liquid soap into basin. CNA Staff K then proceeded to clean around the catheter insertion site with a soapy wipe going around and around in a circular motion. She retrieved another cloth cleansed down the penis and while doing this she was holding the tip of the penis with her fingers around the catheter insertion site. CNA Staff K continued to hold the tip of penis at the catheter insertion site while cleansing the scrotal area. While still holding onto the penis at the catheter insertion site, she retrieved another soapy cloth and cleansed partially down the catheter. Then, while still holding onto the tip of the penis at the catheter insertion site, CNA Staff K and CNA Staff J had an inaudible discussion across the resident and the bed about what to do next, then CNA Staff J said we have to clean his bottom. CNA Staff J repositioned the resident to his left side and CNA Staff K cleansed his buttocks again. The underpad was replaced and a new adult diaper placed back on the resident. The resident was then repositioned to his left side and covered with blankets. A comment was made to CNA Staff J and CNA Staff K that the resident's urine in the catheter tubing looks cloudy with whitish sediment, to which they both stated they had not noticed. On 05/25/22 at 3:15 PM an interview was conducted with the 3rd floor Unit Manager who was apprised of how the Foley catheter care was performed with the potential for contamination around the catheter insertion site while the care was being performed and how the resident's urine has looked cloudy for the past 3 days. The Unit Manager shook her head and had no comment. Review of the electronic clinical record on 05/26/22 at 10:00 AM, revealed a physician order dated 05/25/22 for a urinalysis with culture and sensitivity (C & S). Review of the electronic clinical record lab section revealed no urinalysis report available for review. Review of the paper clinical record revealed no urinalysis report available for review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 15 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 On 05/26/22 at approximately 2:00 PM, a request was made to the Director of Nursing and Administrator for the results of the urinalysis for Resident #75. On 05/26/22 at approximately 3:30 PM, the Administrator produced a confirmation sheet from the lab documenting the urinalysis and urine culture was collected on 05/26/22 at 4:14 AM. She stated the lab technician had left the facility before the urine sample was collected so they have called the lab to pick up the sample today. A request was made to the Administrator to provide this surveyor with the results when they are available. On 05/27/22 at 2:50 PM, email correspondence was received from the Administrator with the results of the urinalysis collected on 05/26/22 for Resident #75. Review of the results revealed the following: Results reported to the facility on [DATE] at 1:38 PM. Abnormal findings included: Urine clarity - Turbid (reference clear); Blood - Moderate (reference - negative); Leukocyte - Large (reference negative); [NAME] Blood Cells - 51-100 (reference - 0-5); Urine Bacteria - Many (reference none). The Administrator stated in the email the urine culture results are still pending. In consideration of the urinalysis results documenting there were many bacteria present, the results of the urine culture and sensitivity will determine if and what kind of bacterial infection is present in the urine and what antibiotic treatment would be effective to treat the infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 16 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status. It failed to provide nutritional interventions in a timely manner to prevent significant weight loss for 3 of 7 sampled residents for nutrition (Resident #101, Resident #73 and Resident #23). Residents Affected - Few The findings included: A review of the facility's policy titled Nutrition Assessment and Monitoring reviewed on 04/02/22 showed the following: The Dietitian evaluates the resident when changes are noted that could affect the nutritional status. The Dietitian will document the evaluation and make the appropriate recommendation when necessary. It also showed that The Dietitian would ensure that the resident maintains acceptable parameters of nutritional status, such as body weight or desirable body range, unless the resident clinical condition demonstrates that this is not possible. A review of the facility's policy titled Resident Weights reviewed on 04/02/22 showed that all resident's weights shall be properly documented in the electronic system, and proper interventions shell be put in place and monitored. 1) Resident #101 was admitted to the facility from an acute hospital on [DATE] with diagnoses of Hypertension, Alzheimer's, and heart disease. He was later discharged to the hospital on [DATE] after a fall with a right hip fractured. On 05/02/22, Resident #101 went to the hospital for respiratory distress and was readmitted on [DATE]. A review of the weight log for Resident #101 showed the following weights recorded: On 04/06/22, a weight of 168 pounds; on 04/22/22 he refused; on 04/29/22 he refused; 04/22/22 patient refused came back from the hospital on [DATE]; on 05/10/22 the weight was 157.8 pounds and on 05/17/22 the weight was at 154 pounds. The Initial Dietary Assessment, which was done on 04/06/22, showed that Resident #101 is with a weight of 162. 5 pounds and is on a Regular diet and thin liquids. It further showed that he will be provided with a Diabetic snack, but no other nutritional supplements were recommended. In an interview conducted on 05/25/22 at 8:15 AM, Staff R, Certified Nursing Assistants (CNA), stated that Resident #101 received his breakfast tray at 8:00 AM and that she tried waking him up to eat, but he was sleeping. She further noted that he only wakes up around 9:00 AM to eat his breakfast. She also said that he eats very little and needs help with his meals. The Nutrition Risk Assessment conducted on 05/10/22 showed that Resident #101 weighed 157.8 pounds with multiple areas of unstageable pressure ulcers. Resident #101 intake of meals was between 76 percent and 100 percent, and his current weight is within the desirable weight range for older adults. It further showed that Resident #101 is at risk for malnutrition and recommended (name of protein supplement for wound healing) but no other nutritional supplement for weight gain. A review of the Nutrition Assessment that was completed in the hospital on [DATE] showed that Resident #101 had a weight of 145 pounds with a poor intake of meals of around 25 percent. The hospital's Dietitian recommended (name of Nutritional supplement) 3 times a day to aid with extra calories for weight gain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 17 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Care Plan, which was initiated on 04/22/22, showed that Resident #101 was at risk for weight loss and dehydration and that he could feed himself after tray set up. It further showed goals for not showing a decrease of 5 percent or more in less than or equal to 30 days. In an observation conducted on 05/25/22 at 9:20 AM, Resident #101's weight was taken after Surveyor requested that a new weight be taken. A Hoyer lift was used to take Resident #101's weight which was noted at 149.7 pounds. This showed a significant weight loss of 5.1 percent or 8.1 pounds weight loss in 15 days. In an interview conducted on 05/25/22 at 9:30 AM, Resident #101 stated that today he ate most of his Breakfast meal. An interview conducted on 05/25/22 at 9:30 AM with Staff S, CNA, stated that the weights are taken by her when she is assigned to do them. If she is not in the facility, another staff member will take the weights. On the weekend, she does patient care, and any needed weights are taken by the staff who is assigned to that specific resident. Staff S reported that the weights required for the day are written on a paper provided by the Dietitian, and when she is done taking the weights, the list is given back to the Dietitian. 2) A chart review showed that Resident #73 was admitted to the facility on [DATE] with diagnoses of Hemiplegia, Dysphagia, and Anxiety. In an interview conducted on 05/23/22 at 11:00 AM, with Resident #73's 2 family members, they stated that Resident #73 had not been out of bed in over 9 days. They further reported that Resident #73 lost weight but was unsure how much. According to one family member, Resident #73 has complained of chest pain and wants to go to the hospital. In an observation conducted on 05/23/22 at 12:20 PM, Resident #73 was observed eating the lunch meal in his room. He was observed eating on his own with no help from staff. A bottle of (name of nutritional supplement) was noted at the bedside in this observation. In this observation, Resident #73's family member stated that Resident #73 drinks the (name of supplement) and that he likes them. A review of the weights log showed the following: on 04/05/22, Resident #73 weight was 153.7 pounds. On 04/25/22, his weight was noted at 148.4 pounds, and on 05/11/22, his weight was noted at 142.6 pounds. This showed a 7.2 percent significant weight loss in about 1 month. The Nutrition Initial assessment dated [DATE] showed that Resident #73 did not want any nutritional supplements at this time and that he was at risk for malnutrition. It further showed that Resident #73's meal intake is between 26 percent to 75 percent. The Certified Nursing Assistants' intake of meals showed that from 04/05/22 to 04/29/22, Resident #73 ate the following: 15 meals at 75 percent intake, 3 meals at 0 intake, 14 meals at 50 percent intake, 9 meals at 25 percent intake and 4 meals at 100 percent intake. This showed an average daily intake of 55 percent of meals. The next Nutrition Assessment by the facility's Dietitian was not until 05/11/22 when Resident #73's weight dropped further from 148.4 pounds to 142.6 pounds. In this note, the Dietitian noted a significant weight loss and that Resident #73 meal intake was between 50 percent to 100 percent. She further recommended (name of nutritional supplement) twice a day and a night snack for Resident #73. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 18 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Care Plan, which was initiated on 04/05/22, showed that Resident #73 is at risk for weight loss and dehydration related to recent hospitalization and advanced age. Goals noted in place to prevent weight loss of 5 percent or more in less than or equal to 30 days. It further showed to assess weights as per facility protocol. 3) Resident #23 was admitted to the facility on [DATE]. She has a medical history significant for syncope (passing out), falls, seizures, dementia, anemia, and sacral pressure ulcer. During an initial tour conducted on 05/23/22 at 10:50 AM, it was noted that Resident #23 was asleep and appeared noticeably thin. An observation was made on 05/24/22 at 8:08 AM of Resident #23. A seated staff member was assisting her in consuming her breakfast meal. She had consumed more than half of the meal at the observation time. An observation was made on 05/26/22 at 7:56 AM. A seated staff member was present at Resident #23's bedside, assisting her in eating her breakfast meal. Resident #23 had consumed approximately 75% of the meal, but she was still eating at the observation time. A Significant Change Minimum Data Set that was completed on 03/03/22 revealed that Resident #23's Brief Interview for Mental Status score was 9, which shows the resident has moderate cognitive impairment. Regarding Resident #23's functional status, she required 1 person assistance with eating. A review of Resident #23's Care Plan, updated with a Quarterly Assessment on 05/24/22, showed the following care plans: Confusion, alteration in a thought process related to dementia. Has poor dentition as evidenced by no natural teeth. Interventions include dental consult and follow-up care, social services to evaluate and educate residents about dental options, ST to evaluate diet texture as indicated, and dietary evaluation. It further showed that Resident #23 was at risk for weight loss and dehydration. Interventions include: Providing diet and supplements as ordered by MD; Honoring food preferences; Assessing weight per facility protocol; Assisting/feeding meals and snacks as needed.; Offering fluid with meals; Monitoring intake/tolerance to meals; Providing assistance/ encouragement to complete >75%. Resident #23's Physician Orders showed she was ordered a Regular diet with thin liquids on 12/23/21. A diet order was also written on 12/23/21 that specified her to be on a No Added Salt, Low Fat, Low Cholesterol diet. On 12/24/21, an order was written for Nursing to provide fluids: 240 ml (milliliters) three times daily and for (name of supplement), give 240 ml by mouth three times daily for Nutritional Supplement. Further review of Resident #23's orders showed she had an order for Eldertonic Elixir 15 ml before meals for anorexia from 12/24/21 to 03/29/22 and for Omeprazole 20 milligrams (mg) daily for stomach pain from 03/30/22 to 04/24/22. Also noted was an order placed on 12/29/21 for Marinol 2.5 mg, take 1 capsule twice a day for anorexia. This medication is an appetite stimulant and is used to aid people in gaining weight. When reviewing Resident #23's weights, it was noted she had suffered a severe weight loss during her stay at the facility. Resident #23's admission weight was recorded on 12/24/21 as 175.2 pounds. The last documented weight in the chart was on 05/04/22; this weight was 130.6 pounds. This indicates a 25.46% weight loss since her admission to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 19 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/26/22 at 9:24 AM, a request was made to Staff G Registered Dietitian, Staff H Certified Nursing Assistant, and Staff I Nurse Manager to weigh Resident #23. The resident was weighed with a Hoyer lift (a piece of machinery that is used to safely lift a resident out of bed without injuring them) with a gown, an adult brief, and the Hoyer sling. The Hoyer was zeroed before weighing the resident (which Staff G told was facility policy). The weight was 128.4 pounds. After Resident #23 was safely lowered back into the bed, Staff H and Staff I asked if she should be weighed a second time. Staff G said yes, they should do a double weight (she said it was facility policy that each resident is weighed twice and that they document the second weight). Staff H and Staff I re-zeroed the Hoyer lift and reweighed Resident #23. The second weight was 127.5 pounds. Staff G verbalized she would document the first weight in Resident #23's chart. The second weight of 127.5 pounds shows an additional weight loss of 3.1 pounds in 22 days; this brings Resident #23's weight loss to 27.23% since her admission to the facility on [DATE]. A review of the Initial Nutritional Risk Assessment written on 12/24/21 showed Resident #23 had an initial weight documented of 175 pounds. Staff G indicated in the note that Resident #23 was asked what her usual weight is, and she replied 164 pounds. The resident was not reweighed to confirm if the documented weight of 175 pounds was accurate. Staff G recorded that Resident #23 would be ordered a Regular diet, thin liquids; Staff G added that the No Added Salt, Low Fat, Low Cholesterol diet would be in place because of Resident #23's history of hypertension and hyperlipidemia. Staff G wrote that the nursing staff had indicated that Resident #23's appetite was poor, so she wrote for Eldertonic Elixir as an appetite stimulant and (name of supplement) three times per day to promote oral intake. Staff G also said the resident had no reports of chewing or swallowing difficulties at this evaluation. On 02/23/22, a Significant Change Nutritional Risk Assessment was documented by Staff G. She stated in this assessment that Resident #23's weight was 143.3 pounds, indicating a significant weight loss of 20.7 pounds (or 12.6%) since admission. Staff G documented this weight loss may have been partly due to improving edema status as Resident #23 was admitted with edema in January. Staff G reported in this note that Resident #23 receives assistance from the staff to consume her meals and nutritional supplements. Staff G also wrote that a CNA reported that Resident #23 occasionally chews and spits out food that may be too tough to chew. Staff G wrote Resident #23 received Eldertonic Elixir and Marinol for appetite stimulants. Staff G did not write for any changes in diet, supplements, or appetite stimulants despite noting the significant weight loss in this note. There were no other follow-up notes or assessments that were documented from the Dietary department during March and April. However, the resident's weight continued to drop. On 05/23/22, a Quarterly Nutritional Risk Assessment was documented by Staff G. She stated in this assessment that Resident #23's weight was 130.6 pounds, indicating an additional significant weight loss of 12.7 pounds (or 8.9%) in 90 days. Staff G referred to her last note regarding the CNA's report of Resident #23 having difficulty chewing and swallowing some foods. She stated in this note that her recommendation is to downgrade Resident #23's diet at this time. Staff G wrote, Recommend to encourage PO (oral) intake to help improve. Nursing to continue to encourage additional 240 ml fluids per shift to promote hydration. She also indicated that Resident #23 continued to receive the Marinol but not the Eldertonic Elixir for appetite stimulation. Staff G offered no further recommendations regarding Resident #23's additional significant weight loss in this note. Resident #23 received a Speech Therapy (ST) Consultation on 12/24/21. The note stated Resident #23 had no changes in swallow noted or reported by the staff. The therapist wrote that Resident #23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 20 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few maintained her baseline level of cognition and could convey her wants and needs adequately to the team. The note ended with No further ST at this time. There were no further Speech Therapy evaluations done despite the CNA reporting Resident #23 having difficulties swallowing certain foods and the noted significant weight loss in the two Nutrition Notes. An interview was conducted with Staff G on 05/26/22 at 1:43 PM. She said the facility used to have three full-time dietitians and a part-time dietary manager, but she was the only full-time Dietitian at this time. When asked about the facility's policy on weights, she stated that each resident is supposed to be weighed on admission, then weekly for at least four weeks, and then once the resident is stable, they are changed to monthly weights. When asked how often she does assessments on the residents, she stated she does an initial evaluation when a resident is admitted and then quarterly assessments unless a resident has a significant change that requires an additional evaluation, such as significant weight loss. She clarified that significant weight loss is calculated as a 3% weight loss in 1 week, 5% weight loss in 1 month, or 7.5% weight loss in 90 days. She stated that if a significant weight loss happens, she looks at the resident's meal intake record and physician's orders to see if supplements or appetite stimulants are ordered. She further stated that she would ask the resident if they had complaints about the food or different meal preferences, and then she would make her recommendations based on that assessment. She said she could recommend appetite stimulants, supplements, fortified foods, or the downgrade of a diet if it is noted that a resident is having trouble swallowing. Staff G further reported that she encourages residents to have their families bring in food to ensure they receive meals they prefer whenever possible. When asked how she knows what the resident's weights are, she stated she provides the CNAs with an Excel spreadsheet of each resident where they document the weights, and then she inputs the weights into the system. When asked if the CNAs specify what scale they use for each resident's weight, she said they sometimes make a notation on the spreadsheet but not always. According to Staff G, some CNAs are better than others at getting the resident's weights and that if she questions a weight based on it being drastically different than the last weight, she asks the CNA to reweigh the resident, and then she documents the new weight. When asked specifically about Resident #23's weight loss, she said she remembers the resident was admitted with edema, so it was not a surprise when there was a weight loss at first. When asked about what was done regarding the continued weight loss, she stated Resident #23 already had physicians' orders for appetite stimulants and Ensure supplements. She also said the documentation showed Resident #23 was consuming 100% of the Ensure and varied meal intake. When asked what other recommendations she made, she stated she hoped that Resident #23 would have a better meal intake with the diet being changed to mechanical soft. A review of Resident #23's Medication Administration Record (MAR) and Treatment Administration Records (TAR) for the months of January 2022 through May 2022 was conducted. These records show how much supplements Resident #23 consumed during these months. When tallying the total percentage of supplements consumed from January to May, it showed that Resident #23 had 100% of 160 supplements, 75% of 99 supplements, 50% of 132 supplements, 25% of 49 supplements, and 0% of 18 supplements. This indicates Resident #23 consumed 68% of her supplements throughout her stay at the facility. It is also documented on the MARs and TARs that Resident #23 did consistently receive her Eldertonic Elixir three times per day until the order was discontinued on 03/29/22 and the Marinol two times per day. However, despite these 2 appetite stimulants, Resident #23 consistently lost weight. An abbreviated review of Resident #23's CNA Charting of Meal Intake was conducted from 03/09/22 to 03/31/22. For these dates, there were 69 meals documented. The calculated meal consumption percentage was 35.8%. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 21 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to identify a resident on Dialysis; failed to obtain a physician order for Dialysis; and failed to monitor the Bruit (rumbling sound) and Thrill (rumbling sensation) for 1 of 1 residents reviewed for Dialysis (Resident #590). Residents Affected - Few The findings included: A chart review showed that Resident #590 was admitted to the facility on [DATE] with diagnoses of End-stage renal disease, Anemia, and Hemiplegia. A review of the Physicians' Orders on admission did not show that an order for Dialysis was given for Resident #590. On 05/23/22 at 10:00 AM, observation showed that Resident #590 was not in his room. A review of the Entry Minimum Data Set (MDS) dated [DATE], under section O, did not show that Resident #590 was coded for Dialysis. Further review of the 5 day MDS dated [DATE], under section O, did not show that Resident #590 was on Dialysis. The Baseline Care Plan, which was started on 05/13/22, did not show that Resident #590 was on Dialysis, and no problems or care plan goals were initiated for Dialysis. In an interview conducted on 05/24/22 at 12:10 PM, Resident #590 stated that he goes to a Dialysis Center 3 times a week. In an interview conducted on 05/24/22 at 3:36 PM, Staff P Registered Nurse (RN), stated that she is not familiar with Resident #590 and that it was her first day working with the residents. When asked by Surveyor if Resident #590 was receiving Dialysis, she did not know. In an interview conducted on 05/24/22 at 3:45 PM, Staff Q RN, stated that the Bruit and Thrill is checked for residents on Dialysis and that it is documented in the Medication Administration Record (MAR). She then said, no, it is documented in the electronic charting system under Dialysis Charting. Staff Q proceeded to show this Surveyor the specific location in the electronic system. When asked where the Dialysis access site on Resident #590 is, she was not sure. In this interview, she also acknowledged that Resident #590 did not have an order for Dialysis. A review of the Dialysis Charting for Resident #590 did not show that the Bruit or Thrill were checked and documented on dialysis days. A review of the Care Plan that was initiated on 05/18/22 showed that Resident #590 required Dialysis 3 times a week related to End-stage renal disease. It further showed to monitor vascular site daily for signs and symptoms of infection, redness, drainage, or pain. It further showed to monitor for bleeding at access site post dialysis appointments and notify the doctor. Review of the Physicians' Orders showed an order for: Dialysis 3 times a week on Mondays, Wednesdays, and Fridays which was dated 05/24/22 and an order to monitor Dialysis site of left chest dialysis access dated 05/24/22. These orders were placed after Surveyor interventions. In an interview conducted on 05/26/22 at 9:20 AM, with the Director of Nursing, she acknowledged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 22 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 0698 all findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 23 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 observation, interview, record review and review of policy and procedure, it was determined that the facility failed to ensure that it secured seven (7) over-the-counter (OTC) medications for 4 of 31 residents observed, Resident #3, Resident #85, Resident #110, and Resident #96. And, failed to assess the residents for Self-Administration of Medications. The findings included: Review of facility policy and procedure for Bedside Medication Storage dated reviewed April 2022, documented in part, 'Policy: Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. Procedures: A. A written order for the bedside storage of medication is present in the resident's medical record. B. Bedside storage of medications is indicated on the resident medication administration record (MAR) and in the care plan for the appropriate medications. C. For residents who self-administer medications, the following conditions are met for bedside storage to occur: 1) The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only of unlocked storage is deemed inappropriate. Facility management should have a copy of the key in addition to the resident E. At least once during the shift, the nursing staff checks for usage of the medications by the resident .F. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary H. Bedside medication storage is routinely monitored .during medication storage review.' 1) During an initial observational room tour conducted on 05/23/22 at 10:49 AM, it was noted that there were 3 OTC medications at Resident #3's bedside: 1) Gold Bond 4% Lidocaine cream with hand-written expiration date of 03/23; 2) Triple Antibiotic---Bacitracin Zinc, Neomycin Sulfate and Polymyxin B Sulfate tube ointment expiration date of 06/23; and 3) Curad Bacitracin Zinc Ointment First Aid Antibiotic expiration date of 06/23. All 3 were visible, unsecured and accessible to other residents, staff members and visitors. Resident #3 was originally admitted to the facility on [DATE] with diagnoses which included Degenerative Disease of the Nervous System, Atrial Fibrillation, Hypertension, Anxiety Disorder and Gastroesophageal Reflux Disease. She had a Brief Interview Mental Status (BIMS) score of 15 (cognitively intact). Photographic evidence obtained of the 3 OTC medications located in Resident #3's bedroom. On 05/23/22 at 1:26 PM, Resident#3's bedroom was still observed with the same 3 OTC medications at the bedside. On 05/24/22 at 10:53 AM, Resident #3's bedroom was still observed with the same 3 OTC medications at the bedside. On 05/24/22 at 2:49 PM, Resident #3's bedroom was still observed with the same 3 OTC medications at the bedside. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 24 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 On 05/25/22 at 10:04 AM, Resident #3's bedroom was still observed with the same 3 OTC medications at the bedside. 2) During a subsequent observational room tour conducted on 05/23/22 at 11:24 AM, it was noted that there was an OTC Benzedrex inhaler on Resident #85's overbed table no expiration date on the container which was visible, unsecured and accessible to other residents, staff members and visitors. Resident #85 was admitted to the facility on [DATE] with diagnoses which included Cellulitis of lower limbs, Parkinson's Disease, Osteoarthritis, Hypertension and Generalized Muscle Weakness. Resident #85 had a Brief Interview Mental Status (BIMS) score of 15 (cognitively intact). Photographic evidence obtained of the OTC medication located on Resident #85's over bed table. On 05/23/22 at 1:34 PM, Resident #85's over bed table was still observed with the OTC Benzedrex inhaler noted on top of it with no expiration date on the container. On 05/24/22 at 11:17 AM, Resident #85's over bed table was still observed with the OTC Benzedrex inhaler noted on top of it with no expiration date on the container. On 05/24/22 at 2:52 PM, Resident #85's over bed table was still observed with the OTC Benzedrex inhaler noted on top of it with no expiration date on the container. On 05/25/22 at 10:18 AM Resident #85's over bed table was still observed with the OTC Benzedrex inhaler noted on top of it with no expiration date on the container. 3) During a continuing observational room tour conducted on 05/23/22 at 11:26 AM, it was noted that there was an OTC bottle of green rubbing Isopropyl alcohol 70% expiration date of 02/23 sitting on Resident #110's bedside dresser drawer, visible, unsecured and accessible to other residents, staff members and visitors. Resident #110 was originally admitted to the facility on [DATE] with diagnoses which included Convulsions, Hypertension and Diabetes Mellitus Type II. Resident #110's Brief Interview Mental Status (BIMS) indicated severe cognitive impairment. Photographic evidence obtained of OTC medication located on Resident #110's bedside dresser drawer. On 05/23/22 at 1:47 PM , Resident #110's bedroom was still observed with the OTC bottle of green rubbing Isopropyl alcohol 70% expiration date of 02/23 sitting on Resident #110's bedside dresser drawer. On 05/24/22 at 11:02 AM, Resident #110's bedroom was still observed with the OTC bottle of green rubbing Isopropyl alcohol 70% expiration date of 02/23 sitting on Resident #110's bedside dresser drawer. On 05/24/22 at 2:52 PM, Resident #110's bedroom was still observed with the OTC bottle of green rubbing Isopropyl alcohol 70% expiration date of 02/23 sitting on Resident #110's bedside dresser drawer. On 05/25/22 at 10:16 AM, Resident #110's bedroom was still observed with the OTC bottle of green rubbing Isopropyl alcohol 70% expiration date of 02/23 sitting on Resident #110's bedside dresser drawer. 4) During a final observational room tour conducted on 05/23/22 11:38 AM, it was noted that there was a full unopened bottle of Magnesium Citrate expiry date 01/24 and an undated used bottle of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 25 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 Hydrogen Peroxide located on the shelf next to Resident #96's bedside bureau shelf visible, unsecured and accessible to other residents, staff members and visitors. Resident #96 was originally admitted to the facility on [DATE] with diagnoses which included Quadriplegia, Arthritis and Major Depressive Disorder. Resident #96 had a Brief Interview Mental Status (BIMS) of 15 (cognitively intact). Photographic evidence obtained of the OTC medications located on Resident #96's bedside bureau shelf. Residents Affected - Few On 05/23/22 at 1:52 PM, Resident #96's room was observed to still have a full unopened bottle of OTC Magnesium Citrate expiry date 01/24 and an undated used bottle of OTC Hydrogen Peroxide located on the bedside bureau shelf next to his bed. On 05/24/22 at 10:27 AM, Resident #96's room was observed to still have a full unopened bottle of OTC Magnesium Citrate expiry date 01/24 and an undated used bottle of OTC Hydrogen Peroxide located on the bedside bureau shelf next to his bed. On 05/24/22 at 2:46 PM, Resident #96's room was observed to still have a full unopened bottle of OTC Magnesium Citrate expiry date 01/24 and an undated used bottle of OTC Hydrogen Peroxide located on the bedside bureau shelf next to his bed. On 05/25/22 at 10:39 AM, Resident #96's room observed to still have a full unopened bottle of OTC Magnesium Citrate expiry date 01/24 and an undated used bottle of OTC Hydrogen Peroxide located on the bedside bureau shelf next to his bed. On 05/25/22 at 10:55 AM, an interview was conducted with Staff C, a Registered Nurse (RN) and Staff D, Registered Nurse/ 4th floor Unit Manager, regarding the total of 7 OTC medications left unattended and unsecured at each of the 4 resident's bedsides and they both acknowledged that the medications should not have been there and should have been properly secured. On 05/25/22 at 3:00 PM, an interview was conducted with the Director of Nursing (DON), regarding the total of 7 OTC medications left unattended and unsecured at each of the 4 resident's bedsides and she further acknowledged that the medications should not have been there and should have been properly secured. Review of the clinical records revealed there were no current physician orders noted for any of the above resident's OTC medications found in the bedrooms, and at the bedsides for Resident #3, Resident #85, Resident #110, nor for Resident #96. Further, none of these 4 residents had been assessed by the facility, as being able to safely and responsibly, self-administer their own medications. None of the unattended/unsecured OTC medications were removed from the resident's bedsides, until after surveyor inquisition/intervention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 26 of 27 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 105371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Johns Nursing Center 3075 NW 35th Ave Lauderdale Lakes, FL 33311 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to dispose of the garage and refuse correctly. The findings included: Residents Affected - Few In an observation conducted on 05/23/22 at 10:00 AM of the waste dumpster area, the following were noted: A pile of debris and garbage consisting of used gloves, plastic, and other unidentified matter. The waste was concentrated behind the caged dumpster bin with a foul odor (photographic evidence obtained). An interview conducted on 05/26/22 at 9:20 AM with the facility's Administrator stated that the primary garbage dumpster is picked up twice a week. She further acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105371 If continuation sheet Page 27 of 27