Health inspection·July 1, 2022

F 0690 legs and there was no type of catheter tubing anchor noted. Level of Harm - Minimal harm or potential for actual harm An observation on 06/29/22 at 9:55 AM revealed the urinary catheter bag remained in the dignity bag, but the tubing with sediment was directly on the floor. Photographic evidence obtained. Residents Affected - Few An observation of personal and urinary catheter care was made on 06/29/22 at 10:06 AM with Staff B, a CNA. The CNA provided proper care but failed to hold the catheter tubing to secure it from moving or pulling during the cleansing of the catheter. The CNA did note there was no anchor and stated she would obtain one for Resident #7. An observation and interview with the Assistant Director of Nursing (ADON) was made on 06/29/22 at 10:49 AM. The ADON confirmed the lack of an anchoring devise for the urinary catheter for Resident #7. The ADON was informed of the urinary catheter bag being observed on the floor. The ADON noted the sediment in the urinary catheter tubing and stated they should have an order to change the catheter as needed, and further stated it needed to be done. During an interview and observation on 06/29/22 at 11:34 AM, Staff C, a Licensed Practical Nurse (LPN), who was also the direct care nurse for Resident #7 on 06/27/22, revealed the urinary catheter was now anchored and had been changed with clear yellow urine noted. When asked why the urinary catheter tubing for Resident #7 had not been anchored since 06/27/22 or why the cloudy urine with sediment had not been addressed on 06/27/22, the LPN stated, it was clear, referring to the urine. The LPN was informed of the previous observations and had no answer. Review of the record revealed Resident #7 was admitted on [DATE] with the indwelling urinary catheter. The rationale for the urinary catheter as per the Bladder and Bowel evaluation completed by the nurse on 03/22/22 documented the need for exact measurement of urine, yet there was no order for intake and output measurement. Further review of the record revealed a physician order, dated 03/22/22, that documented an indwelling catheter was in place and to obtain a bladder scan and assess for catheter discontinuation. The record lacked completion of this order. A subsequent order on 03/31/22 documented to remove the urinary catheter in the morning to complete a trial voiding. Further record review revealed the urinary catheter was replaced on 04/03/22 because of the lack of voiding. During an interview on 06/29/22 at 12:05 PM, when asked why the facility did not attempt to remove the indwelling urinary catheter sooner, the Interim Director of Nursing (DON) stated she believed the delay was because of the family just wanting Resident #7 to be comfortable. Resident #7 was receiving Hospice services. The DON was unable to provide any documentation related to the delay in discontinuation of the urinary catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 2 of 8 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 105404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford, The 601 Universe Blvd Juno Beach, FL 33408 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation interview and record review, the facility failed to ensure accurate documentation between the controlled medication utilization record and the medication administration record for 2 of 4 sampled residents reviewed during the medication storage process (Residents #4 and #8). The findings included: 1. During the review of medication storage process conducted on 06/29/22 at 2:50 PM at the 100-unit medication cart, two random residents' records were selected for review and for reconciliation of the substance control medications (narcotics). There was discrepancy found in one of the resident's records (Resident # 8). It was revealed that Resident #8 had an order of tramadol 50 mg 1 tablet by mouth twice daily as needed for pain. The controlled medication utilization record was compared against the June 2022 medication administration records (MARs). The controlled medication utilization record documented the tramadol was removed twice from the locked substance control box, in June 2022 (06/09/22 at 9:32 PM and 06/20/22 at 11:00 AM), however the June's MARs was signed out once. 2. The review of the medication storage process on 06/29/22 at 3:15 PM at the 200-medication cart. Two random residents' records were selected for review. There was discrepancy found in one of the resident's records (Resident #4). It was revealed that Resident #4 had an order of Diazepam 2mg 1 tablet by mouth every 12 hours as needed for muscle spasm. The controlled medication utilization record was compared against the June 2022 MARs. The controlled medication utilization record documented the medication was removed out of the substance control box on 06/14/22 at 11:00 PM, however the June MARs was not signed out to reflect this removal. On 06/30/22 at 11:18 AM, an interview and a side-by-side review of Resident #8 and Resident #4's records were conducted with the Assistant Director of Nursing (ADON), who confirmed the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 3 of 8 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 105404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford, The 601 Universe Blvd Juno Beach, FL 33408 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. Based on observation, interview, and policy review, the facility failed to ensure proper storage of medications by 1 of 4 nurses observed during the medication pass observations (Staff D, a Registered Nurse/RN),as evidenced by: Insulin for Resident #103 was left on the medication cart unattended; failed to ensure 1 of 3 medication carts (Wing A) was locked when unattended; and the Wing A medication cart was noted to be unlocked and unattended on three different observations, by two staff nurses during the survey (Staff E, an RN and Staff F, an RN) . There were 13 independently ambulatory residents residing in the facility at the time of the survey, two of whom resided on the A wing. The census upon entrance was 53. The findings included: Review of the policy, titled, Storage of Medications, revised April 2007, documented, 7. Compartments containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 1. A medication pass observation for Resident #103 was made on 06/27/22 beginning at 3:59 PM with Staff D, a Registered Nurse (RN). The RN gathered her equipment to obtain a blood glucose level. The RN also obtained an insulin syringe from the cart. The RN left the medication cart, located about halfway down the A Wing hallway, and proceeded to the resident's room near the end of the hall. The RN left the small plastic bag with the insulin vial on top of the medication cart. Staff D obtained the blood sugar level for Resident #103, then looked around and stated, Where is my insulin. The RN went back to the cart and found the insulin vial on top of the cart. The RN agreed the medication was not to be left unattended or on top of the cart. Staff D took the insulin into the resident's room to administer, returned to the medication cart and again placed it on top of the cart. During the continued observation on 06/27/22 at 4:27 PM, Staff D was asked to go to the room of Resident #153. The RN put the keys to her medication cart on the nurse's desk near where she parked the medication cart, just to the far side of the computer tower, as she did not have any pockets. The nurse left the insulin on top of the medication cart and went into the room at the front of the hall, leaving her keys on the desk and the medication unattended on top of the cart. On 06/27/22 at 4:30 PM, Staff D went back to the medication cart to obtain pain medication for Resident #153. She tried to pull open the lock to the medication cart. Realizing the medication cart was locked, she went to the nurse's desk to get her keys, as she did not have them in her possession. 2. On 06/27/22 at 4:44 PM, the surveyor went to the A Wing to do a medication pass observation. A nurse was not in sight and the lock to the medication cart was noted to be partially engaged. Upon pulling on the lock, it pulled all the way out and the drawers to the medication cart were opened (Photographic evidence obtained). A few minutes later, Staff E, an RN came to the medication cart. When asked why it was left unlocked, the RN stated she thought she had engaged the lock. The RN had been in a room at the end of the hall and the medication cart was parked in the middle of the hall, near the desk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 4 of 8 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 105404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford, The 601 Universe Blvd Juno Beach, FL 33408 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 3. On 06/29/22 at 2:39 PM, the 100-unit medication cart was observed unlock and unattended. The nurse was not around in the unit. During that time, the surveyor observed the Director of Nursing (DON) coming out of a room. The surveyor called her over to attend to the medication cart and she locked the medication cart. 4. On 06/29/22 at 3:10 PM, another observation was conducted at the 100-unit, and the 100-unit medication cart was found unlock and unattended again. The nurse was not around. There was one resident roaming at the hallway and two visitors walking in the hallway at the time. The surveyor stayed by the medication cart to guard it. At 3:13 PM, the DON was observed coming out of the nursing home administrator's office. The surveyor alerted her, and she came over and locked the medication cart. During that time, the attending nurse was observed coming out a resident room down the hallway. Event ID: Facility ID: 105404 If continuation sheet Page 5 of 8 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 105404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford, The 601 Universe Blvd Juno Beach, FL 33408 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure disinfection of a used blood glucose devise, as per manufacturer's instructions, by 1 of 2 nurses observed (Staff D, a Registered Nurse/RN), after obtaining the blood sugar reading of Resident #103. The facility failed to ensure proper hand washing and infection control standards during the medication pass observation with 2 of 5 staff observed (Staff D, an RN and Staff C, a Licensed Practical Nurse/LPN) while providing medications to Residents #103, #153 and #28. The facility failed to follow their admission policy related to isolation for 1 of 2 current residents not up to date with their COVID-19 vaccinations (Resident #102). The facility failed to ensure proper infection control practices during wound care observation for 1 of 2 sampled residents (Resident #26). Residents Affected - Some The findings included: 1. Review of the policy, titled, Cleaning and Disinfecting Blood Glucose Meters, dated 2019, documented to refer to manufacturer's instructions for the glucometer. Review of the manufacturer's instruction manual for the glucometer documented, To Clean and Disinfect the Meter: . 2. To Clean: . With ONLY Super Sani-Cloth Wipes, rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter. Discard used wipes. 3. To Disinfect: Using fresh wipes, make sure that all outside surfaces of the meter remain wet for 2 minutes. Make sure no liquid enters the Test Port or any other opening in the meter. A medication pass observation was made on 06/27/22 beginning at 3:59 PM with Staff D, an RN (Registered Nurse) for Resident #103. The RN obtained a glucometer (devise to obtain a blood sugar level) from her medication cart, and thoroughly cleaned it with a small alcohol prep pad/wipe. The RN went into the room of Resident #103, obtained the blood sugar level, placing the glucometer directly on the resident's used over-the-bed table. Staff D returned to the medication cart and again cleaned the glucometer with the alcohol wipe. During an interview after the medication pass observation, Staff D explained they use the same glucometer for multiple residents, unless they are on isolation. Staff D stated she only had one more resident who needed their blood sugar checked, but that resident had not yet returned from an appointment. During an interview on 06/27/22 at 5:14 PM, Staff D again stated the other resident had not yet returned to the facility. When asked the process to clean and disinfect the glucometers, Staff D stated she cleans them between each resident using the alcohol wipe. When asked if the alcohol disinfects the glucometer against blood-borne pathogens, the RN did not answer. When asked if she had a disinfectant like bleach, the RN stated she did have, explaining the canister was in the vital sign caddy. The RN stated she sometimes uses the disinfectant on the glucometer. 2. Review of the policy, titled, Administration of Oral Medications, revised October 2010, documented, 9. Prepare correct dose of medication: . e. For tablets or capsules from a bottle, pour the desired number into the bottle cap and transfer to the medication cup. Do not touch the medication with your hands. Current CDC (Centers for Disease Control and Prevention) recommendations included scrubbing your hands lathered in soap for at least 20 seconds, followed by thoroughly rinsing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 6 of 8 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 105404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford, The 601 Universe Blvd Juno Beach, FL 33408 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a. A medication pass observation was made for Resident #103 on 06/27/22 beginning at 3:59 PM with Staff D, an RN. The RN obtained supplies to obtain a blood sugar level. The nurse also had a small bag with an eye drop medication with her. Staff D went into the resident's room, set the tray with the items on the resident's dresser and went to wash her hands. The RN washed her hands for about 5 seconds and then turned off the faucet before obtaining paper towels. The RN cleaned the glucometer with an alcohol wipe and washed her hands a second time, again for about 5 seconds and turned the faucet off with her bare hands. Staff D placed the bag with the eye drops on the resident's used over-the-bed table. After obtaining the blood sugar level and providing insulin, the RN gathered the items and returned to the medication cart, placing the bag with the eye drops back into the clean medication cart. During the continued observation on 06/27/22 at 4:30 PM, Staff D obtained a bottle of Tylenol to administer two tablets to Resident #153. The RN poured three tablets out of the bottle into the cap, and then used her finger to push the extra tablet back into the bottle. During an interview after these two observations, the RN agreed she should not take medication containers into resident rooms or touch the medications. b. A medication pass observation was made for Resident #28 on 06/29/22 beginning at 1:00 PM with Staff C, a Licensed Practical Nurse (LPN). The LPN gathered one pill for administration, locked the cart, closed her computer, and then went into the resident's room. Staff C went into the resident's bathroom and washed her hands for a total of 5 to 10 seconds. After the LPN provided the medication to the resident, she washed her hands again for the same amount of time. 3. Review of the facility policy, titled, admission and readmission Guidelines for Health Centers (SNFs) During the COVID-19 Pandemic, revised 06/03/22, documented, 1. The admissions coordinator or admissions nurse will ascertain the patients COVID-19 vaccination status prior to or at the time of admission. Vaccination status will be documented in the resident's medical record. 3. Residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission, and should be tested following the testing guidelines. This policy further describes 'up-to-date' with COVID-19 vaccinations as having had both boosters. An observation on 06/27/22 at 9:14 AM revealed Resident #102 was a newly admitted resident (admitted on [DATE]), eating breakfast, and pleasantly confused. She was in a room with a roommate and there were no isolation precautions posted on the door. An observation on 06/27/22 at 11:00 AM revealed Resident #102 had been moved into a private room across the hall and was placed on droplet isolation precautions. The Assistant Director of Nursing (ADON) was nearby and was asked about the move. The ADON explained Resident #102 had been admitted on Friday (06/24/22) and we went by the information we had. The ADON further explained their Infection Control Preventionist (ICP) looked into it and realized she had not had her booster, so she was placed on 10-day isolation. The ADON confirmed the isolation had just been initiated for Resident #102. 4. A wound care observation was made for Resident #26 on 06/30/22 at 12:10 PM with Staff G, a Licensed Practical Nurse (LPN). The LPN gathered wound care supplies to include a table drape, a bottle of half-strength Dakins solution, gauze, and individual normal saline vials. The LPN went into the room and set the items on the used over-the-bed table, to include the bottle of Dakins that she placed directly on the table. The LPN spread the drape and then placed the items onto the clean drape. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 7 of 8 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 105404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford, The 601 Universe Blvd Juno Beach, FL 33408 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Staff G provided appropriate wound care as per order, disposed of the used supplies and took the bottle of Dakins back out of the room and placed it on top of the treatment cart. The LPN opened the treatment cart, obtained the plastic bag from the cart, and placed the Dakins back in the bag and started to place it back into the cart. The surveyor stopped the LPN and asked if that was a resident specific bottle of Dakins solution. The LPN stated it was a stock bottle and used in multiple resident rooms. The LPN was not aware that the stock supplies should not be taken from room to room. Event ID: Facility ID: 105404 If continuation sheet Page 8 of 8