Inspection·June 9, 2022

F 0557 A inventory form, dated 6/7/22, was provided by the social worker on 6/8/22 and it listed the 4 shirts. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the social worker on 6/9/22 at approximately 10:30 AM, regarding Resident #514's grievances and missing clothes, she stated they are continuing to look for his clothes and that is why they are not on the Grievance Log. Residents Affected - Few 2.) Resident #515 was admitted to the facility on [DATE]. On 6/8/22 during an interview he stated that he had 3 outfits when he was admitted but they are all in the laundry since last week and he was waiting for them to be returned. He stated he had a friend buy him two additional outfits so he had clothes to attend his therapy. He was observed in a shirt and shorts at this time. On 6/9/22, at approximately 10:00 AM, he stated he still hasn't received his clothes back from laundry. On 6/9/22 at around 11:00 AM an interview was conducted with the Director of Laundry Services and the Social Worker regarding Resident #515's clothes that were sent to laundry last week. They stated the clothes should have been returned the next day. They will get a description of the clothes from the resident and go look for his 3 shirts and 2 shorts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 2 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Delray South 1717 Homewood Blvd Delray Beach, FL 33445 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents will remain free from falls for 3 of 3 sampled residents reviewed for falls (Residents #19, 52, 18). The findings included: Review of the facility's policy titled Falls Prevention and Management Program, revised 09/23/19 revealed the following: Fall Risk Evaluation frequency: just prior to or on admission to the community; following a fall; following any changes of status; quarterly or as required by regulations. Initial Post-Fall Evaluation: assess the resident for any obvious injuries and to then conduct an initial investigation to collect facts about the fall related incident. Information needed: date/time of fall; resident's description of fall; timely notification of provider and family; vital signs; current medications; resident assessment; environmental factors; care plan interventions. Documentation and Follow Up: determine the need for ongoing monitoring; complete an incident report; complete internal and external notification and reporting requirements; detailed progress note including results of the post fall evaluation; refer resident for further evaluation by physician; implement ongoing communication plan; refer to interdisciplinary treatment team to review and modify Care Plans; communicate to all shifts that the resident has fallen and is at risk for recurrent falls. 1) Resident # 19 was admitted to the facility on [DATE]. She had a medical history significant for falls, dementia, depression, and atrial fibrillation. According to a 5-day Minimum Data Set (MDS) done on 04/05/22, Resident #19 had a Brief Interview of Mental Status (BIMS) score of 5, which shows moderate cognitive impairment. For functional status, this MDS showed Resident #19 was totally dependent on 2 staff members for transferring from her wheelchair to her bed. During review of Resident #19's Care Plans, it was noted that she had care plans in place regarding her fall risk status and the fact that she was noncompliant with asking for assistance with transferring from her wheelchair to her bed. Written interventions included reminding staff to assist the resident with ambulation and transfers, ensure her call light is available, evaluate the environment to identify factors known to increase risk of falls, encourage physical activity for strengthening and improving her mobility, ensure she is wearing appropriate footwear when ambulating or up in her wheelchair, keeping her bed in the lowest position, and keeping the room and floor free from spills or clutter. Resident #19 also had a care plan in place regarding her use of an anticoagulant for her atrial fibrillation. During review of Resident #19's physician orders, the surveyor noted she was prescribed multiple medications which could cause her to be at increased risk for falls including one for Parkinson's disease, one for dementia, two for depression, two for hypertension, and one anticoagulant for atrial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 3 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Delray South 1717 Homewood Blvd Delray Beach, FL 33445 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 0689 fibrillation. She did have appropriate orders in place for hospice care. Level of Harm - Minimal harm or potential for actual harm During review of Resident #19's notes, the surveyor found that Resident #19 had suffered multiple falls since her admission. Residents Affected - Few An Incident Note was written on 04/22/22 at 6:40 PM which stated the resident was found lying on her side on the floor at the foot of her bed. There was a Fall Risk Evaluation completed on 04/22/22, however, there was no Neurological/Vital Sign Check documented following this fall. There were notes written on 04/22/22 at 10:21 PM, 04/23/22 at 2:41 PM, and 4/24/22 at 1:27 PM regarding follow-up evaluations of Resident #19 following this fall. These notes document that Resident #19 had no issues following this fall. An Initial Neurological/Vital Sign Check was documented on 05/31/22, indicating the resident suffered a fall on that day, however, there was no Incident Note written that day regarding a fall. There were no continuing checks documented on that day or the following days. There was a Health Status Note written on 06/02/22 which stated it was a post fall day 2 evaluation of Resident #19. This note stated Resident #19 had no issues following a fall. While the survey team was on site, Resident #19 suffered a fall on 06/08/22 at 2:00 PM. There was a Health Status Note written that day at 2:48 PM which stated Resident #19 fell in her room and complained to staff that she hit her head. The note also stated that the Hospice doctor and Resident #19's son were contacted. The note clarified that Resident #19's son did not want her sent to the hospital. Neurological/Vital Sign Checks were documented beginning on 06/08/22 following this fall; however, the surveyor noted that the last documented assessment was completed on 06/09/22 at 9:15 AM. There was no Fall Risk Evaluation documented on 06/08/22 following this fall. The surveyor interviewed Resident #19 multiple times on 06/08/22 following her fall. She told the surveyor that she was trying to get into bed from her wheelchair and caught her knee on the side of the bed, which caused her to lose her balance and fall. She stated that her head hurt but that she was feeling ok. An interview was completed with the facility's DON on 06/09/22 at 12:20 PM. The DON stated that for any fall that was unwitnessed by staff or that resulted in the resident hitting their head, the facility's policy instructs the staff to document a Fall Risk Evaluation and Neurological/Vital Sign Checks for 3 days (an initial check, then every 15 minutes for 2 times, then every 30 minutes for 3 times, then hourly for 2 times, then every 2 hours for 2 times, then every 4 hours for 4 times, then every shift for the next 2 days). The DON also said each shift writes follow up notes for 3 days evaluating the resident's level of consciousness and pain level. She said the resident's doctor and the family are notified by the staff after a fall. The staff and Risk Manager conduct an investigation regarding what lead up to the fall. Interventions are added into the resident's care plan regarding fall prevention. She said falls are discussed monthly at the Quality Assurance and Performance Improvement (QAPI) meetings to determine if there are fall trends noted in the facility and the staff is educated regarding fall prevention tactics. When asked specifically about Resident #19's Fall Risk Evaluation not being done for the fall on 06/08/22, she stated the staff has 24 hours to complete the evaluation. However, when the surveyor checked the chart on 06/09/22 at 3:00 PM, this evaluation still had not been documented. When asked about the previous two falls with incomplete documentation, she stated she did not know why the documentation was incomplete, but that she was going to follow up with her staff regarding all three falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 4 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Delray South 1717 Homewood Blvd Delray Beach, FL 33445 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2) Resident #52 was admitted to the facility on [DATE]. He had a medical history significant for falls, dementia, and atrial fibrillation. Resident #52 was diagnosed with COVID-19 on 06/08/22 after being tested early that morning by a night shift nurse. According to a Quarterly Minimum Data Set (MDS) done on 05/06/22, Resident #52 had a Brief Interview of Mental Status (BIMS) score of 3, which shows severe cognitive impairment. For functional status, this MDS showed Resident #52 required extensive assistance of 1 staff member for transferring from his bed to his chair and for walking. During review of Resident #52's Care Plans, it was noted that he had care plans in place regarding his fall risk status and the fact that he and his wife were noncompliant in asking staff for assistance when transferring and walking. Written interventions included for the staff to explain to him why this behavior is inappropriate, anticipate and meet his needs, assess for triggers that perpetuate behavior, determine and address causative factors of the fall, ensure his call light is within reach and encourage him to use it, educate him and his wife about safety reminders and what to do if a fall occurs, keeping his floors free from spills and clutter, keeping the bed in the lowest position, and following the facility's fall protocol. Resident #52 also had a care plan in place regarding his use of an anticoagulant for his atrial fibrillation. During review of Resident #52's physician orders, the surveyor noted that he was prescribed multiple medications which could cause him to be at increased risk for falls including one for overactive bladder, one for hypertension, one for dementia, and one anticoagulant for atrial fibrillation. There was an order written on 06/08/22 to place Resident #52 in droplet isolation for his new diagnosis of COVID-19. During review of Resident #52's notes, the surveyor found that Resident #52 had suffered two falls in the month of June. A Health Status Note was written on 06/04/22 at 1:30 PM which stated Resident #52 was found sitting on the floor of his room. The note documents Resident #52's wife was present in the room and that she told the staff Resident #52 stepped away from his walker and fell. There were no Fall Risk Evaluation or Neurological/Vital Sign Checks completed following this fall. There was a Health Status Note written on 06/05/22 at 2:05 PM, but this is the only post-fall evaluation that is documented. While the survey team was on site, Resident #52 suffered a fall on 06/08/22 at 12:15 PM. An Incident Note was written on 06/08/22 at 2:33 PM which states Resident #52 was found lying on the floor in front of his recliner chair and that he told staff he lost his balance, but offers no other information regarding the fall. This note does state that the Nurse Practitioner and Resident #52's wife were notified of the fall. Neurological/Vital Sign Checks were documented beginning on 06/08/22 following this fall; however, the surveyor noted that the last documented assessment was completed on 06/09/22 at 5:31 AM. There was no Fall Risk Assessment documented on 06/08/22 following this fall. An interview was completed with the facility's DON on 06/09/22 at 12:20 PM. When asked specifically regarding Resident #52's fall on 06/04/22, the DON stated she remembered that he was walking in his room with his wife present and fell after stepping away from his walker. She said Resident #52's wife has been educated by the staff multiple times since his admission to not allow him to walk without a staff member present, but the wife continues to allow and encourage him to walk independently (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 5 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Delray South 1717 Homewood Blvd Delray Beach, FL 33445 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from staff. The DON stated she did not know why the documentation regarding this fall was incomplete. When asked specifically about the fall on 06/08/22, she stated Resident #52 had been moved into a new room on the COVID-19 hallway that day. She said he fell due to the increased confusion from the COVID-19 and being in a new environment. She stated the staff has 24 hours to complete a Fall Risk Evaluation. However, when the surveyor checked the chart on 06/09/22 at 3:00 PM, this evaluation still had not been documented. 3) Record review revealed Resident #18 was admitted to the facility on [DATE], with diagnoses included dementia. A comprehensive assessment dated [DATE] documented Resident #18 had severe cognitive impairment, and required extensive one to two-person assist with activities of daily living. The assessment further documented the resident had 2 or more falls with injury. Resident #18 was care planned for at risk for falls dated 12/30/21. The goal was for Resident #18 to be free of falls. Interventions included: assist resident with ambulation and transfers, utilizing therapy recommendations, ensure call light is available to resident, evaluate fall risk on admission and as needed, evaluate resident's environment to identify factors known to increase risk of falls, offer to assist to the bathroom before dinner, review medications for drugs that increase the risk of falls, and utilize devices as appropriate to ensure safety (ie. Bed mats, sensor alarms, etc.). A care plan dated 02/25/22 documented Resident #18 had an actual fall. Interventions included: continue interventions on the at-risk plan, for no apparent acute injury, determine and address causative factors of the fall, Frequent rounding during hours of sleep, frequent rounds in the morning, monitor/document /report as needed for 72 hours to MD for signs and symptoms of pain, bruises, change in mental status, new onset confusion, sleepiness, inability to maintain posture, or agitation. A review of Resident #18's record revealed the resident had falls on 01/14/22, 02/11/22, 02/25/22, 05/02/22, 05/04/22, and 05/12/22. Further review of the resident's record did not reveal a Fall Risk Evaluation, or documentation that the resident was monitored for 72 hours post falls. Furthermore, there was no documentation of frequent monitoring for Resident #18. An interview was conducted with the Director of Nursing (DON) on 06/09/22 at 12:00 PM, and was informed of the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 6 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Delray South 1717 Homewood Blvd Delray Beach, FL 33445 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the correct fluid amount as per the Physician's order for 1 of 1 resident reviewed for Fluid Restriction (Resident #414). The findings included: A record review showed that Resident #414 was admitted on [DATE] with type 2 diabetes and muscle weakness diagnoses. Further review of the physicians' orders showed an order for Fluid Restriction of 1500 milliliters (ml) per day; Nursing: 150 ml day and evening, 0 ml nights, Dietary: 720 ml breakfast; 240 ml lunch and dinner, which was dated 05/28/22. The facility's clinical dietitian wrote an order dated 06/01/22 for 8 ounces (240 ml) of Glucerna (a nutritional supplement) once a day. Labs taken on 05/31/22 showed that Resident #414 had a lab result of 41 on his GFR (glomerular filtration rate, which measures how well your kidneys filter blood). This placed Resident #414 at stage 3 chronic kidney disease. The Minimum Data Set (MDS) dated [DATE], under section C, showed that Resident #414 had a Brief Interview of Mental Status (BIMS) score of 15, which indicates he is cognitively intact. A progress note dated 05/27/22 showed that new orders were received for 1500 ml Fluid Restriction and that Resident #414 was made aware of the new orders. In an observation conducted on 06/07/22 at 12:11 PM, Resident #414 was noted eating his lunch meal in his room. Closer observation showed that a lunch tray consisted of 6 ounces of water and about 5 ounces of soup, totaling 11 ounces (330 ml) of fluids. The meal ticket did not show that Resident #414 was on Fluid Restriction. This exceeded the allowable maximum of 240 ml for lunch per the physicians' order. In an observation conducted on 06/07/22 at 5:45 PM, Resident #414 was in his room eating his dinner meal. Closer observation showed a tray consisting of 6 ounces of water, 4 ounces of juice, and about 5 ounces of chicken soup, totaling 15 ounces (450 ml) of fluids. The meal ticket on the tray did not show that Resident #414 was on a Fluid Restriction. In this observation, Resident #414 reported that he did not know he was on any Fluid Restriction and said, staff does not know anything about me. This exceeded the allowable maximum of 240 ml for dinner per the physicians' order. In an observation conducted on 06/08/22 at 8:00 AM, Resident #414 was noted in his room, waiting for his breakfast meal. Closer observation showed 16 ounces of water in a white Styrofoam cup at the bedside. Resident #414 stated that the water was brought to him this morning. In an observation conducted on 06/08/22 at 8:45 AM, Staff B, Certified Nursing Assistant (CNA) was observed bringing the breakfast tray to Resident #414 in his room. Closer observation showed a breakfast tray with the following fluids: 10 ounces of coffee and 4 ounces of water. The meal ticket on the tray did not show that Resident #414 was on any Fluid Restriction. In this observation, Staff B was asked if she brought the 16 ounces of water this morning, and she said no. When asked if she knew (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 7 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Delray South 1717 Homewood Blvd Delray Beach, FL 33445 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that Resident #414 was on a Fluid Restriction, she said no and stated, I do not know anything about the Resident. I just brought the breakfast tray. Resident #414 received about 30 ounces (900 ml) of fluids this morning, exceeding the allowed maximum of 720 ml as per order. A review of the Care Plan dated 05/20/22 showed Resident #414 was at risk for nutrition and hydration and observed and encouraged fluids intake. Further review did not show that Resident #414 was placed on fluid Restriction. A review of the facility's Clinical Dietitian's assessment and progress note did not show that Resident #414 was on a fluid restriction, and no mention was made regarding the GFR lab on 05/31/22. In an interview conducted on 06/08/22 at 1:14 PM, the facility's Clinical Dietitian stated when someone is on fluid restriction, the nurse that oversees the resident will let the Dietary Manager know of the order for the fluid restriction. The Dietary Manager will then let her know of the order for the fluid restriction. She gets a particular form that shows how many fluids are allocated for Nursing and how many fluids are allocated for Dietary. The form is given to the Dietary Manager, who provides it to the kitchen. The Clinical Dietitian said that when she writes a recommendation for nutritional supplements, she will ensure that it is included in the total count of the fluid restriction. When asked by Surveyor if she knew that Resident #414 was on a fluid restriction, she said no. In an interview conducted on 06/08/22 at 1:24 PM, the facility's Dietary Manager stated that any order for fluid restriction is placed in the electronic system. Nursing will send her a message on a written communication sheet letting her know of any residents on a fluid restriction. Once she gets it, she breaks it down to determine who gets what and puts it on the diet order for the staff to know. That is then generated on the meal ticket since they can add special comments on the diet meal tickets. The Dietary Manger reported that she was aware that Resident #414 was on a fluid restriction and that it was posted on a sheet of paper next to the tray line. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 8 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105411 B. Wing (X3) DATE SURVEY COMPLETED A. Building 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Delray South 1717 Homewood Blvd Delray Beach, FL 33445 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions during lunch observation, and failure to date and label all food items in the central kitchen. The findings included: During the initial tour of the kitchen conducted on 06/06/22 at 9:00 AM, accompanied by the facility's Executive Chef, the following was noted: 1. A take-out white container was noted in the food production area, which was not dated (the date the food was made or used by date) or labeled with the food item in the container. 2. The Tray Line's counter was noted with multiple black disposable gloves that were not in a box and were improperly stored. 3. Three large round garbage bins in the food production area, with no lids and debris exposed. 4. The reach-in refrigerator in the food production area was noted with multiple salad containers and multiple dressing containers that had no food labeling or dates. 5. A large white box of young chicken was noted in the walk-in refrigerator. Closer observation showed a date of 05/22/22 on the box, and the chicken pieces were very soft to the touch. 6. Two large metal containers were noted in the walk-in refrigerator that was not labeled or dated. 7. A large metal container noted with red cabbage that was not labeled or dated. 8. A large white plastic container with diced carrots was not labeled or dated. 9. A yellow Gatorade bottle was ¾ empty in the walk-in refrigerator. 10. Two 1/6 size 6 inches stainless steel containers were noted in the walk-in refrigerator; closer observation showed that they were not labeled or dated. All above observations with photographic evidence obtained. 11. In an observation conducted on 06/07/22 at 12:03 PM in the dining room, the satellite kitchen was observed for meal plating for all 3 units. Staff E, Dietary Aide, was kept behind the tray line waiting for Staff F, Dietary Aide, who was reading the meal tickets on the other side of the tray line. Staff G, Dietary Aide, was noted setting up the meal trays with drinks, supplements, and desserts and then passing on the trays to Staff F. Staff F took the trays from Staff G and read the meal tickets to Staff E. Continued observation showed Staff E plating the food choices on a plate and giving it to Staff F to place on the meal trays. During this observation, Staff F was noted touching the food plates and soup cups with her bare hands as she placed them on the tray. Staff F was also plating the silverware on each tray with her bare hands. At times she was observed reaching for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 9 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Delray South 1717 Homewood Blvd Delray Beach, FL 33445 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete reach-in refrigerator for any missed food items and placing them on the meal trays. Staff F was observed setting up 8 trays and placing them in the meal cart. During the entire duration of this observation, Staff F did not practice hand hygiene or wash her hands between meal trays. In an interview conducted on 06/08/22 at 5:00 PM, with the facility's Administrator and the Director of Nursing they were informed of the findings. Event ID: Facility ID: 105411 If continuation sheet Page 10 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Delray South 1717 Homewood Blvd Delray Beach, FL 33445 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the required specialized Rehabilitative Services for 1 of 4 residents reviewed for Rehabilitation Services (Resident #414). Residents Affected - Few The findings included: A record review showed that Resident #414 was admitted on [DATE] with type 2 diabetes and muscle weakness diagnoses. Order noted to admit Resident to skilled nursing facility on 05/19/22. Another order dated 05/20/22 showed for Occupation Therapy (OT) and Physical Therapy (PT) to evaluate and treat. Further review showed that Resident #414 was placed on isolation for COVID-19 from 05/28/22 to 06/07/22. In an observation conducted on 06/08/22 at 10:00 AM, Resident #414 was noted in an isolation room for positive COVID-19. In this observation, Resident #414 stated that he had been in this room for days and that no therapy was provided to him while here. He further said that he is here for skilled therapy and that to be in isolation for COVID-19, he could have done it at home instead of staying in the facility for isolation. A review of the OT and PT past treatments showed that Resident #414 received OT and PT from admission date to 05/27/22 and therapy stopped from 05/27/22 to 06/07/22 for OT and PT. Further review showed that OT and PT resumed on 06/07/22 after Resident #414 was out of isolation for COVID-19. The Minimum Data Set (MDS) dated [DATE], under section C, showed that Resident #414 had a Brief Interview of Mental Status (BIMS) score of 15, which indicates he is cognitively intact. In an interview conducted on 06/08/22 at 10:24 AM with the Rehab Director, she stated that all therapy sessions stop when residents are in isolation for Positive COVID-19. The CNA assigned to the resident that day will provide the therapy by following the home exercise program given to the resident. This includes the upper and lower range of motion exercises done with the residents. When asked where it is documented that the staff provided the daily exercises, she did not know. She further stated that Resident #414 was on Physical Therapy (PT) and Occupational Therapy (OT) 5 times a week. His initial PT and OT evaluations were done on 05/20/22, and the therapy was provided on the following days: 05/20/22, 05/21/22, 05/23/22, 05/24/22, 05/25/22 for PT, and OT was provided on 05/20/22, 05/22/22, 05/23/22, 05/25/22 and 05/26/22. According to the Rehab Director, they are told on the daily staff meeting of any residents in isolation for COVID-19. In an interview conducted on 06/08/22 at 10:30 AM, Staff D, Certified Nursing Assistant (CNA), stated that she has 5 residents in the COVID-19 positive unit today. She reported that she oversees providing daily care and grooming as needed. Staff D said that residents who are positive for COVID-19 do not get any therapy from OT or PT and that she provides 15 minutes a day of daily range of motion exercises. It is documented in the facility's electronic system under the section called Tasks. She will document her daily sessions which is done 7 times a week. Staff D confirmed that therapy is not proving in-room therapy when a resident is placed in isolation for COVID-19. In an interview conducted on 06/08/22 at 10:44 AM, Staff C, Certified Nursing Assistant (CNA), stated that Rehab is not providing therapy for any residents that are COVID-19 positive and are on isolation. She said she would provide treatment for the residents in isolation with 20 minutes daily on a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 11 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbey Delray South 1717 Homewood Blvd Delray Beach, FL 33445 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few range of motion. When asked if it is documented anywhere that she provides a range of motion exercises to the residents, she said no, there is no place to record for her. Staff C further reported that she would tell the Rehab department if she provided any range of motion exercises. In an interview conducted on 06/08/22 at 11:03 AM, the Director of Nursing, stated that any residents in isolation who are on PT and OT will get their daily therapy sessions at the end of the day. This way, the therapist can avoid cross-contamination with other residents who are not COVID-19. The therapy sessions are documented under the Rehab electronic system, and some of the therapy notes can be seen in the facility's electronic system. When asked by the surveyor if the therapists are aware that they need to provide therapy for COVID-19 positive residents, she said yes. In a subsequent interview conducted on 06/08/22 at 11:20 AM with the Director of Nursing, she again stated OT and PT therapy needs to be done for all residents, including positive COVID-19 residents. She expects treatment to be done by the therapist assigned to the residents at the end of the day. Surveyor stated that Rehab is not providing therapy for any residents on COVID-19 isolation, and she said: that is unacceptable and that she will talk to the Rehab Department. In this interview, she acknowledged that Resident #414 did not have any therapy exercises provided while in isolation. In an interview conducted on 06/09/22 at 2:00 PM, with the facility's Administrator and the Director of Nursing they were informed of the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 12 of 12