Health inspection·October 26, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few contained a blank form signed by Staff C (CNA) and the Nurse on duty, which was for 10/23/23 at 6:50 PM. There was nothing noted on the form regarding a shower or bed bath, and no skin check information was documented at this time. A second form, dated 10/13/23 at 7:00 PM, was completed by Staff D (CNA). She documented that Resident #38 had refused her shower because she had received a bed bath earlier that morning. No other Shower / Body Check Forms were found in this binder for Resident #38. On 10/26/23 at 11:30 AM, Resident #38 confirmed that she had received a shower that morning. It felt so wonderful to get a shower and get scrubbed down. I feel like a new person. On 10/26/23 at 12:05 PM, an interview was conducted with Staff B (one of 3 CNAs for the 200 unit). She stated that she was not assigned to Resident #38 today, but she has cared for this resident in the past. When asked what she would do if a resident requested a shower on one of her non-scheduled days and times, she stated, I would try my best to accommodate the resident and give her a shower. There may be times that I would not be able to do it because of my schedule and other tasks I would have to complete, but I would try to fit it in. On 10/26/23 at 1:55 PM, a call was placed to Staff C to inquire about Resident #38's showers, but the call went to voice mail. A message was left requesting a call back as soon as possible, but Staff C did not return the call before the time of exit from the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 2 of 11 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 10/26/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment related to medication use for 1 of 5 sampled residents, Resident #14. Residents Affected - Few The findings included: Review of the record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses to include anxiety. Review of the current MDS assessment dated [DATE] documented Resident #14 received an anti-anxiety medication on 7 of 7 days during the look-back period of 08/26/23 through 09/01/23. Review of the corresponding Medication Administration Records (MARs) revealed Resident #14 was receiving diazepam (an anti-anxiety medication) once daily. Further review of the August 2023 MAR revealed the medication was held on 08/30/23 and 08/31/23. Review of the corresponding progress notes revealed the medication was held on those two days for lethargy. During a side-by-side record review with the Director of Nursing (DON), and a phone interview on 10/26/23 at 2:07 PM, the MDS Coordinator agreed with the inaccurate MDS, and confirmed the anti-anxiety medication should have been coded as a 5, instead of a 7, on that MDS assessment, indicating Resident #14 received the medication five days during that look-back period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 3 of 11 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 10/26/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure care plans were initiated to reflect diuretic usage for 1 of 5 sampled residents, Resident #10. The findings included: During the unnecessary Medication, Psychotropic Medications, and Medication Regimen Review process for Resident #10, it was revealed Resident #10 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included Hypertension (high blood pressure). The quarterly minimum data set (MDS) assessment, reference date 07/02/23, recorded a Brief Interview for mental Status (BIMS) score of 15, indicating Resident #10 was cognitively intact. Further review of this MDS, under section N for medication, subsection G for Diuretic, it was revealed that Resident #10 had received diuretics 7 times on the 7 days look back period. Additional record review evidenced a physician order dated 10/12/23 of Bumetanide (a diuretic) 1 MG give 1 tablet by mouth one time a day every other day for fluid retention. Review of the October 2023 medication administration record (MAR) indicated Resident #10 had received the Bumetanide on the following days in October 2023: 10/12, 10/14, 10/16, 10/18, 10/24 and 10/26/23. Additional review of Resident 10's record revealed the comprehensive care plans, with review start date 09/09/2023 completed date 09/21/2023, and a care conference was held on 09/20/23. It was revealed that Resident #10's record lacked any evidence of a care plan to reflect the diuretic usage. On 10/26/23 at 1:04 PM, an interview was conducted with the nurse consultant, who reviewed Resident #10's records. She agreed there was no evidence of a care plan generated to reflect the diuretic order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 4 of 11 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 10/26/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, record review, and policy review, the facility failed to ensure proper care and services for 1 of 1 sampled resident, Resident #38, who received medications and nutrition via an enteral tube (feeding tube), as evidenced by failure to check for placement of the PEG (percutaneous endoscopic gastrostomy / surgical procedure for placement of a feeding tube), failure to administer medication via gravity, and failure to utilize purified water, as per facility policy. The findings included: Review of the policy, titled, Administering Medications through an Enteral Tube, revised November 2018, documented, in part, Steps in the Procedure: . 6. Verify placement of feeding tube. 9. Dilute medication: . with purified water. 11. Reattach syringe (without plunger) to the end of the tubing. 12. Administer medication by gravity flow. A medication administration observation for Resident #38 was made on 10/24/23 beginning at 1:32 PM with Staff E, Registered Nurse / RN. The RN obtained two medications, crushed each one, and put them into separate small medication cups. Upon entering the resident's room, Staff E obtained tap water from the bathroom sink, using it to dilute each medication. The RN then drew up about 20 ml of the tap water into the piston syringe and stated, I want to flush it. Staff E then quickly pushed the tap water through the PEG tube. Resident #38 jumped slightly and grimaced. The RN provided the two medications and flushes between and after each medication in the same manner, but with less force. Staff E failed to check for placement prior to administration of any fluids or medications, and failed to administer the fluids and medication via gravity. During an interview on 10/24/23 at 1:52 PM, when asked why she pushed the medications using the syringe into the resident's PEG tube instead of via gravity, Staff E stated she has done it via gravity before, and the resident usually coughed and the medications splashed up. When asked if she noted the resident jumped with the initial flush, the nurse stated she did notice and so she pushed the rest of the medications with less force. Review of the record revealed Resident #38 obtained the PEG tube on 09/21/23. Review of the care plan initiated on 09/22/23 documented the resident required the PEG tube and staff were to check for tube placement per facility protocol. Further review of the record lacked any documented evidence, care plans, or orders for the nursing staff to push the fluids or medications through the PEG, instead of via gravity. The record also lacked any documented difficulty with the PEG tube for Resident #38. During an interview on 10/25/23 at 9:57 AM with Resident #38, when asked if the nurses usually use the syringe to push the medications through her PEG, or if they administer them via gravity, Resident #38 stated sometimes they have to push them through when they get stuck. The resident explained they also have had to use the long stick to get it opened up. When asked about the fluid and medication administration from the previous day when she jumped, Resident #38 stated it wasn't painful, but that she was surprised that she felt something that time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 5 of 11 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 10/26/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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, failed to ensure proper care and services and properly assess 2 of 2 sampled residents, Residents #20 and #107, during respiratory treatments via a nebulizer (a device for administering a medication by spraying a fine mist), failed to document findings in the record; and failed to change the nebulizer tubing weekly for 1 of 2 sampled resident, Resident #107, as per facility policy. Residents Affected - Few The findings included: Review of the policy, titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, documented, in part, Steps in the Procedure . 17. Remain with the resident for the treatment. 18. Approximately five minutes after treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse. 19 Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment. 20. Stop the treatment and notify the physician if the pulse increases 20 percent above baseline or if the resident complains of nausea or vomits. 21. Tap the nebulizer cup occasionally to ensure release of droplets from the sides of the cup. 26. Obtain post-treatment pulse, respiratory rate and lung sounds. Documentation: The following information should be recorded in the resident's medical record. 5. Pulse, respiratory rate and lung sounds before and after the treatment. 6. Pulse during treatment. 8. The resident's tolerance of the treatment. Review of the policy, titled, Departmental (Respiratory Therapy) - Prevention of Infection, not dated, documented, in part, staff were to change the oxygen cannulae and tubing every seven (7) days, or as needed. 1. A medication administration observation for Resident #20 was made on 10/24/23 beginning at 2:04 PM with Staff E, Registered Nurse (RN). The RN obtained a vial of Acetylcysteine (an inhalant medication used to destroy or dissolve mucus) from the medication cart, and drew up the ordered dose. Before starting the nebulizer treatment, Staff E obtained the resident's heart rate, oxygen saturation level, and assessed his lungs. The RN started the treatment, verbalized it lasts about 15 minutes, and stepped outside of the room and into the hallway, leaving the door open. Staff E stated she usually waits right outside of the room until the medication is completed, as the resident will keep talking and try to take the mask off if she stays in the room. The RN stood outside of the door, occasionally looking into the room at the resident until the treatment was over. The RN failed to reassess the resident's pulse at about five minutes into the treatment. Review of the record revealed Resident #20 was admitted to the facility on [DATE] with orders for nebulizer treatments. Further review of the record lacked documented evidence of the nurses assessment of oxygen levels, heart rates, and lung sounds with each nebulizer treatment, as per facility policy. Review of the current care plan for oxygen therapy initiated 10/25/23 documented the resident removes his oxygen at times. 2. On 10/25/23 at 12:17 PM, upon entering the room of Resident #107, the resident was noted lying in bed with a nebulizer treatment running. There was no staff present in or about the room. Staff F, Licensed Practical Nurse (LPN), had been seen in the alcove, halfway down the hall, on the way to the resident's room, which was located at the end of the hall. The surveyor stood outside the door until 12:35 PM, and no staff entered or came near the room. While waiting outside of the room, Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 6 of 11 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 10/26/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm #107 could be heard coughing numerous times. At 12:35 PM, the surveyor walked back through the hallway and did not see the LPN. Upon return to the resident's room at 12:39 PM, Staff F was in the process of disconnecting the tubing and mask from the nebulizer, and was telling the resident she was going to get new tubing. An observation of the tubing revealed a label dated 10/17, eight days prior. Resident #107 voiced to the LPN that she was still coughing, and the LPN stated she would call the physician. Residents Affected - Few During an interview on 10/25/23 at 12:45 PM, when asked the process for nebulizer administration, Staff F explained she would confirm the medication, listen to lung sounds, start the treatment, and stay with the resident for 15 minutes in case they aspirate or something. Staff F explained when the treatment was completed she would listen to the lungs again and wash out the equipment. When asked if there was anything else she would do, the LPN stated she would also check the resident's oxygen saturation level. When asked if there was anything else, the LPN stated not that she was aware of. When asked how often the nebulizer tubing and mask were changed, the LPN stated she was unsure, but would change it if it looked nasty or at least every three days. When asked if she noted the date on the oxygen tubing when she worked yesterday or before administration today, Staff F stated in report she was told the tubing had been changed and so she didn't verify it. When asked why she did not stay with Resident #107 today during her treatment, Staff F stated she was trying to verify an order with the physician for another resident, and volunteered, I could have stayed with her. When asked if the other resident had an emergency that took her away from Resident #107, the LPN stated it was not. When told their facility policy documented to reassess the resident's heart rate at about five minutes into the treatment, the LPN stated she was unaware of that and was unaware of the possible side effect of an increased heart rate. During an interview on 10/25/23 at 4:03 PM, when asked if the staff stay with her during the nebulizer treatments, Resident #107 stated they do not, and volunteered that she even took off the mask herself today. When asked if staff check her oxygen and or heart rate before, during, or after the treatment, Resident #107 stated they check her oxygen level and heart rate before the treatment, but never afterwards. When asked if the staff assess and or listen to her lungs, Resident #107 stated, nobody has ever listened to my lungs. Review of the record revealed Resident #107 was admitted to the facility on [DATE]. The record lacked any order or assessment for the self-administration of medications, and the baseline care plan completed on 10/16/23 documented No to the question regarding self-administration of medications. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #107 had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the record lacked documented evidence of the nurses assessment of oxygen levels, heart rates, and lung sounds with each nebulizer treatment, as per facility policy. Further review of the record lacked any order or documentation for changing the nebulizer tubing on a weekly basis. Review of the current care plan initiated 10/17/23 documented Resident #107 had COPD (Chronic Obstructive Pulmonary Disease) related to Asthma, and staff were to administer the aerosols or bronchodilators as ordered. This care plan also instructed to monitor and document any side effects and the effectiveness of the treatments. During an interview on 10/26/23 at 10:25 AM, Staff A, Registered Nurse (RN), confirmed the oxygen and nebulizer tubing and masks were to be changed once weekly on Sunday nights, or as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 7 of 11 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 10/26/2023 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 0697 Provide safe, appropriate pain management 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 interview, record review, and policy review, the facility failed to timely assess and treat a newly voiced complaint of pain for 1 of 1 sampled resident, Resident #14, who voiced pain on 08/17/23, after having not taking any pain medications since 08/11/23, and staff did not thoroughly assess the location or underlying cause of the new pain, and the resident was diagnosed with a fracture on 08/24/23. Residents Affected - Few The findings included: Review of the policy, titled, Pain Management, effective 10/25/22, documented, in part, Pain Management Guidelines: . 2. Pain management is a multidisciplinary care process that includes the following: . b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; . 4. Conduct a comprehensive pain assessment upon admission to the community, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 5. Assess the resident's pain. Assessment: . Characteristics of pain, such as: (intensity, pattern, location, frequency, and duration) . Monitoring and Modifying Approaches: 1. Re-assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain. 3. Monitor the following factors to determine if the resident's pain is being adequately controlled: a. The resident's response to interventions and level of comfort over time. b. The status of the underlying cause(s) of pain, if identified previously; . 6. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and adjust as indicated. Documentation: 1. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. Reporting: Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain; . Review of the record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses to include chronic pain syndrome. Review of the facility's incident log included a fracture for Resident #14 on 08/24/23. Review of the physician orders and progress notes revealed Resident #14 started refusing her scheduled oxycodone pain medications on 08/02/23 secondary to hallucinations, requesting it to be decreased from three times daily to twice daily. On 08/08/23, the resident declined her scheduled dose related to lethargy. On 08/10/23, Resident #14 declined both doses of oxycodone, and on 08/11/23, the resident refused her morning dose of oxycodone. As per a progress note dated 08/11/23 at 1:37 PM, Resident #14 explained that she did not like the way the oxycodone made her feel throughout the day, and agreed to a PRN (as needed) dose only. Further review of the record revealed Resident #14 did not request any PRN oxycodone from 08/11/23 until 08/17/23. Review of the pain level assessments conducted on each shift documented a pain level of 0, 1, or 2, on a pain scale of 0 to 10, from 08/01/23 through 08/16/23. Further review of the progress notes and corresponding August 2023 Medication Administration Record (MAR) related to pain revealed the following: On 08/17/23 at 8:44 PM, Resident #14 requested a PRN dose of oxycodone. The MAR documented a pain level of 4, on a 0 to 10 scale, and the corresponding administration progress note lacked any type of assessment or location of the pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 8 of 11 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 10/26/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm On 08/18/23 at 10:34 AM, Resident #14 requested a PRN dose of oxycodone for a pain level of 5. The corresponding progress note documented bilateral lower extremity pain. On 08/20/23 at 3:48 PM, Resident #14 requested a PRN dose of oxycodone for a pain level of 6. The corresponding progress note documented generalized pain. Residents Affected - Few On 08/21/23 at 11:47 AM, Resident #14 requested a PRN dose of oxycodone for a pain level of 4. The corresponding progress note documented the resident complained of pain, repositioned resident with no effects, and the medication was given. This note lacked any assessed location of pain. On 08/22/23 at 10:10 AM, Resident #14 requested a PRN dose of oxycodone for a pain level of 6. The corresponding progress note documented the resident complained of pain. This note lacked any assessed location of pain. On 08/22/23 at 8:04 PM, Resident #14 was provided two 325 mg tablets of Tylenol for the complaint of left hip pain rated at a 5. On 08/23/23 at 10:11 AM, Resident #14 requested a PRN dose of oxycodone for a pain level of 3. The corresponding progress note lacked any type of assessment or location of the pain. On 08/23/23 at 10:30 PM, Resident #14 was provided PRN oxycodone for generalized pain rated at a 5. On 08/24/23 at 9:23 AM, a portable X-ray of the left hip was ordered STAT (immediately). On 08/24/23 at 9:45 AM, Resident #14 was provided two Tylenol for a complaint of left hip pain rated at a 4. At 11:00 AM, the left hip pain had increased to an 8 and Resident #14 was provided a PRN dose of oxycodone. A progress note on 08/24/23 at 2:00 PM by the Director of Nursing (DON) indicated Resident #14 stated her pain started about a week ago. The nursing staff failed to identify the new complaint of pain on 08/17/23, and failed to conduct a comprehensive pain assessment. Review of the facility investigation and staff statements revealed the following: The management description of the event documented on 08/24/23 the daughter of Resident #14 alerted the nurse that the resident complained of pain to her left hip. At that point, the physician was notified, an X-ray was ordered, and Resident #14 was interviewed about her pain. A written statement by the private aide dated 08/28/23 documented that when she arrived to work on Monday 08/21/23, Resident #14 told her she was in pain. The private aide confirmed the resident had been up in her wheel chair over the weekend. This written statement documented the resident stated to the private aide that her legs were spread wide during incontinence care and after the care she felt a pain. The record and investigation lacked any evidence the private aide informed the facility staff of the pain over the weekend or the resident's statement as to when she felt pain. The record and investigation lacked any evidence of a thorough assessment or attempt at identifying the underlying cause (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 9 of 11 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 10/26/2023 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 0697 of the new pain of 08/17/23, until 08/24/23. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/25/23 at 3:30 PM, Staff A, Registered Nurse (RN), was asked the process should a resident ask for a PRN pain medication. The RN stated she would attempt non-pharmacological interventions, and if ineffective she would assess the level and location of the pain, and provide the ordered pain medication. When asked if Resident #14 can make her needs known and or describe the location and intensity of her pain, Staff A confirmed the resident was alert and oriented, and if eye to eye contact is made and time given, she will make her needs known and provide requested information. Staff A volunteered the resident had a time prior to her fracture that she did not want pain medications as it made her foggy. When asked about the fracture of Resident #14, Staff A stated she just recalled she was told of the fracture and they all were in-serviced on logrolling. When asked if she noted the initiation of the PRN pain medications after the routine had been discontinued, Staff A stated she just thought that her chronic pain had returned after not having her routine pain medications. Residents Affected - Few During an interview on 10/26/23 at 11:00 AM, the daughter of Resident #14 stated she did tell the nurses several days that her mom was in pain. The daughter stated the staff kept telling her that they were giving the pain medications, but that after several days the daughter told them she understood they were treating the pain, but that they were not finding out the cause of the pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 10 of 11 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 10/26/2023 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow through with an ordered laboratory test for 1 of 1 sampled resident, Resident #3. Residents Affected - Few The findings included: Record review revealed Resident #3 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: high blood pressure (Hypertension), Hyperlipidemia (high cholesterol), Non-Alzheimer's Dementia, and malnutrition. The quarterly minimum data set (MDS) assessment, reference date 09/13/23, recorded a Brief Interview for Mental Status (BIMS) score of 08, indicating Resident #3 was moderately cognitively impaired. This MDS recorded mood of Feeling down, depressed, or hopeless. Trouble falling or staying asleep or sleeping too much. Feeling tired or having little energy. No behavior exhibited. This MDS indicated Resident #3 required extensive assistance with activity of daily living (ADLs). Subsequent review of the records evidenced a physician assessment dated [DATE] at 12:05 PM, it indicated that Resident #3 had Dementia, COPD (Chronic obstructive Pulmonary Disease), CKD stage 3 (Chronic Kidney Disease), A fib (Atrial Fibrilation), Depression, Hypertension, Hyperlipidemia and decreased endurance. The Plan was: medications reviewed and ordered to get labs next week. Additional record review revealed a Physician order for a laboratory (LAB) test, dated 10/03/23 for complete blood count (CBC), and comprehensive metabolic panel (CMP) for high blood pressure. During additional review of Resident #3's record, it was revealed that a comprehensive care plan with review start date 09/13/23, review completed date 09/25/23, and a care conference meeting held date 10/12/23. This comprehensive care plan revealed Resident #3 had weight loss of 11 pounds with 6.8% weight loss in 1 week and 10 pounds 6% weight loss in 2 weeks which was likely related to fluid, diuretic use. Intervention included: obtain and monitor lab / diagnostic work as ordered; Report results to MD and follow up as indicated. Further review of Resident #3's records and progress notes lacked evidence of the laboratory test result and reason for omitting the lab. On 10/26/23 at 12:25 PM an interview was conducted with the Director Of Nursing (DON). She was made aware there was no evidence of the ordered lab. She voiced she was going to look for the result. At 12:56 PM, a subsequent interview was held with the DON, with the nurse consultant present. The DON and nurse consultant voiced the lab was missed, it was not done. The nurse consultant added the requisition was there for the blood to be drawn, however they were not aware why it wasn't done. The nurse consultant stated they were going to call the physician today and reorder the lab. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105404 If continuation sheet Page 11 of 11