Health inspection·October 12, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility. She told the AD I know you give good care, that is why I am happy to be back. The AD said that she met with the Resident probably on the 5th of October. She said the resident did not make any request then. On 10/9/2023, I met with her and she told me when you have a private room in Cypress, I would like to move there. She said that Resident #110 did not make any other request. She did not ask her for a commode. She just wanted to move to Cypress because she was there before. I told her that when I find a private room, I will accommodate her, the SW said. On 10/10/23 at 2:48 PM, Employee (I) said that Resident #110 told her on the day of admission that she wanted a private room. She told Employee (I) that she did not get along with the roommate. Employee (I) said that Employee (H) told her that she had a private room the last time she was here and she would like to get a private room, in Cypress again. Employee (I) said that she relayed the information to the Contractor who recruited Resident #110 who, at that time, was acting as the admission Director. The Contractor said OKAY but, I am not sure what she did with that information. She said that the resident did not ask her for a commode or a recliner. I am not sure she spoke to the resident because she is mostly in the field. Employee (I) said that she told Resident #110 that residents leave the facility throughout the week, so it is likely that she could find another room. Employee (I) said that there were no private rooms available when she spoke to the Resident. An interview with the Consultant on 10/11/23 at 09:16 AM revealed that she spoke to the Resident at the hospital and did not make any promises, such as a private room. She said that knowing that there are but a few private rooms, she never promises or guarantees private room access to anyone, unless they need to be isolated. She said that she did not discuss recliner or commode with the resident. She said the need for a recliner or commode probably came after her admission to the facility. The interview with Employee (J) a Physical Therapist (PT) on 10/11/23 at 12:20 PM revealed that she had completed the initial PT assessment for the resident. Resident #110 had a fall and fractured her left Femur on 8/18/2023. She underwent surgery. On 9/27/2023 she fell at home and had a hip fracture revision. Resident #110 was admitted to the facility with partial 50% weight bearing. Resident #110 could not ambulate and required Moderate to Maximum assistance. Which meant that the resident required more than minimum assistance. Because she was non-weight bearing. She said that she did not discuss with the resident the need for using a commode. An interview with the Certified Occupational Therapy Assistant (COTA) Employee (K) on 10/11/23 at 12:29 PM revealed that she had completed the initial OT assessment for the resident and had made the recommendation for a commode on 10/4/2023 for the resident. Employee K said that she attempted to provide the commode because her Manager was not available, but she could not find one. Employee (L) a Physical Therapy Assistant (PTA) informed on 10/11/23 at 12:34 PM, that on Friday the 5th of October 2023, she discussed Resident #110's need to use a commode with the Resident's Nurse. She said that she was not sure who the nurse was. Employee (L) said that she also discussed with the Maintenance Director on Monday 10/4/2023; yet, they did not provide the commode. Review of the Minimum Data Set (MDS) showed that Resident #110 obtained a score of 15/15 on the brief interview for mental status (BIMS). This signifies that Resident #110's cognitive status was intact. She could make her needs known. Review of the Nursing Care Plan (CP) revealed the following: Potential alteration in comfort related to depression, fracture left hip, decreased mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 2 of 18 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 10/12/2023 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 0550 o Level of Harm - Minimal harm or potential for actual harm The resident will not have an interruption in normal activities due to pain through the review date. o Residents Affected - Few To show minimal/no side effects of medications taken The resident is at risk for constipation related to decreased mobility, pain [Bowel/Bladder]. o The resident will have a normal bowel movement at least every three days through the review date o Encourage Resident to sit on toilet to evacuate bowels if possible. o Follow facility bowel protocol for bowel management. The resident has an ADL self-care performance deficit r/t decreased mobility, Left Hip Fracture. [ADLs/Mobility] o The resident will improve the current level of function in ADL's through the review date. In all, although Resident # 110 had requested a commode and the facility, as evidence by interviews with three employees, was fully aware of the Resident's need to use one, it was not provided. The findings were discussed with the Administrator on 10/10/2023 and he informed that a commode would be immediately provided to Resident #110. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 3 of 18 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 10/12/2023 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 0572 Give residents a notice of rights, rules, services and charges. Level of Harm - Minimal harm or potential for actual harm Based on interviews and records review, it was determined that Residents' rights were not discussed and 3 of 3 sampled Residents (Residents # 4, 14, & 19) were not reminded of their rights during Resident Council meetings. Residents Affected - Few The findings included: On 10/12/23 at 11:10 AM an interview was conducted with the Resident Council President, Resident #43. She said that she was not sure whether she was the President. If they say that I am the President, then I must be. She could not recall whether they met monthly. The Activity Director, Employee (M) reported on 10/12/23 at 11:23 AM, that he has been working at this facility since January 2023. He said that he assists in setting up the Resident Council meeting every month and help facilitate the meeting. He reported that they did not discuss Residents' rights during the meeting. Review of the Resident Council minutes documented no Residents rights items discussed. The Minutes of the meetings documented that the Management team informed the resident council about the renovation that was happening in the building, from January 2023 to September 2023. This information was documented every month as old business. Resident #14 said on 10/12/23 at 11:45 AM, she attended Resident Council meeting monthly, but she did not recall residents' rights being discussed. Resident #4 informed on 10/12/23 at 11:58 AM that he did not recall residents' rights being discussed during Resident Council meetings. Resident #19 also said on 10/12/23 at 12:38 PM that he could not confirm or refute whether residents' rights were ever discussed. The findings were discussed with the Administration on 10/12/2023 and they informed that the situation will be remediated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 4 of 18 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 10/12/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and interviews, the facility failed to file a federal report for an allegation of injury of unknown origin immediately to the State Agency for 1 of 1 sampled resident (Resident #108). The findings included: Review of an incident report dated 6/26/2023 revealed that on 06/08/2023, on the 6:00 AM to 2:00 PM shift, Resident #108 sustained an injury which origin the facility could not explicitly determine. The record revealed that Resident #108 was diagnosed with: Unspecified Dementia; Unspecified Anxiety Disorder; Other recurrent Depressive Disorder; Poly Osteoarthritis; Glaucoma and Edema, among others. Review of the Minimum Data Set (MDS) documented that Resident #108 obtained a score of 3 out of 15 which is indicative of significant cognitive deficit. Further records review showed that Resident #108 was impulsive and used the bathroom for her toileting needs without using her call lights and waiting for assistance. Consequently, on 6/08/2023 while using the bathroom, Resident #108 sustained bodily injuries reported by the facility as follows: Per Supervisor's statement, while making rounds, she entered room [ROOM NUMBER]A and observed the Certified Nursing Assistant (CNA) changing soiled bed linens, resident noted on the toilet at this time on 6/8/23, 7am - 7pm shift. The Nurse reported no concerns voiced by resident, no events reported by floor staff and noted that resident often tries to self-transfer and independently propel herself to the nurse's station and to self-toilet without asking for assistance. Resident would also independently change her incontinent brief with available supplies in the room without activating the call light or asking for assistance. On 6/9/23, 6am - 2pm shift: Per CNA statement, while making rounds she observed resident with dark area to the left arm and discoloration to the left cheek. Observations were immediately reported to the nurse. On 6/9/23, 7am - 7pm shift: Per nurse's note; nurse was called to the room by assigned CNA, upon arrival resident noted with discoloration to left arm and slight discoloration to her left cheek. Resident denied any fall at that time, no other resident concerns were noted. Nurse notified MD and responsible party. Orders received to send resident to the local hospital for further evaluation and treatment. 6/10/23 PM Shift: Resident returned to facility. 6/11/23 AM Shift: Xray results reviewed- 2mm depressed minimally displaced fracture of left orbital floor. Facial bones are otherwise intact and in anatomic alignment. The Executive Director (ED) of the facility reported on 10/12/2023 at 3:13 PM, that he had investigated this incident to determine its root cause. The ED said that he interviewed the staff assigned to the resident the date of the incident. The assigned staff (Employee N) had reported that she was getting ready to provide morning care when she had found the resident in her wheelchair, at the beginning of her shift on 6/9/2023 with bruises on her left arm and discoloration on her cheek. Employee N said that she had immediately contacted the shift-nurse to report the incident. The Shift-Nurse (Employee O) reported on 6/9/2023 during the 7:00 AM-7:00 PM shift that she found the resident fully dressed and sat in her wheelchair fully dressed. Resident had a large hematoma on her left arm, which was hard on palpation, dark and grayish in color. She was also noted small skin discoloration on the left side of the Resident's eye. The Nurse documented that Resident #108 denied (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 5 of 18 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 10/12/2023 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 0609 any fall, any pain, and any physical abuse. Level of Harm - Minimal harm or potential for actual harm Interviews conducted with the employees assigned to care for the resident the day before the resident's injuries were identified on 6/9/2023 @ around 7:15 AM yielded no positive knowledge of an incident involving Resident #108. No employees reported having noted any bruises or facial discoloration on Resident 108 on 6/8/2023. Residents Affected - Few However, despite the inconclusive investigative report, the facility did not submit the federal report for an allegation of an injury of unknown origin to the State Agency. The findings of the complaint investigation were discussed with the Administrator on 10/12/2023 and he acknowledged the result. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 6 of 18 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 10/12/2023 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 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 accurately document a resident's discharge status for 1 of 3 residents reviewed for discharges (Resident #56). Residents Affected - Few Findings included: Record review noted that Resident #56 was not hospitalized as per discharge assessment, but was discharged home. Resident #56 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and limited 1 person assist for activities of daily. A review of Resident #56's progress notes revealed a Discharge summary dated [DATE] at 12:55 PM that documented the resident was discharged home with home health. A review of Resident #56's discharge assessment dated [DATE] documented the resident was discharged to hospital. An interview was conducted on 10/12/23 at 1:20 PM, with the MDS coordinator. The coordinator stated Resident #56 was discharged to home on 7/28/23, not transferred to the hospital, and the discharge assessment was coded wrong. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 7 of 18 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 10/12/2023 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide appropriate activities for 1 of 1 resident reviewed for activities (Resident #209). Residents Affected - Few The findings included: Resident #209 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment, and required extensive one-person assist with activities of daily living. Resident #209 was care planned for using an iphone, reading newspaper and listening to big band music, watching the news and other shows on Univision (Spanish speaking network). On 10/09/23 and 10/10/23 throughout the survey from 8:00 AM-4:00 PM, the resident was observed in her room laying in bed watching an English program on TV. Surveyor attempted to speak with the resident, and the resident responded that she does not speak English, only Spanish. On 10/11/23 at 11:00 AM, Resident #209 was observed in her room with a private duty aide that also spoke only Spanish, and they were both watching TV on the English TV channel. Record review did not document any one on one visit by the activities department for the resident. An activity progress Note dated 10/07/23 at 10:25 AM, documented: All information was obtained by the family representative. The resident mainly speaks Spanish. She enjoys the following activities: uses an iPhone, reads the newspaper, listens to big band music, watches the news and other shows on Univision. She needs encouragement/reminders to attend the following when available: Chair Exercise, Entertainment, Trivia, and Bingo. On 10/11/23 at 3:01 PM, an interview with Activities Supervisor was conducted. The supervisor stated that he communicates with the resident by using the application on his cell phone, Translate. He is aware that the resident does not speak English, and he acknowledged that he did not invite the resident to participate in the activities program. The supervisor further acknowledged the resident's TV was on an English speaking channel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 8 of 18 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 10/12/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to obtain a physician's order for care of nasal steri-stips for 1 of 1 sampled residents observed, Resident #157. Residents Affected - Few The findings included: Review of the facility policy and procedure titled Wound Care provided by the Director of Nursing (DON) revised October 2010 documented in the Policy Statement: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident .Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e. wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason (s) why. 10. The signature and title of the person recording the data . Resident #157 was admitted to the facility on [DATE] with diagnoses which included Dementia, Alzheimer's Disease, Major Depressive Disorder, Atherosclerotic Heart Disease, Laceration without Foreign Body of Unspecified Cheek and Temporomandibular Area, Orthostatic Hypertension. He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). On 10/09/23 at 10:52 AM Resident # 157 was observed with a medium sized Band-aid to his forehead. And, two (2) un-clean steri-strips to the bridge of his nose with old-dried blood on top. Photographic Evidence Obtained. A brief interview was conducted on 10/09/23 at 10:57 AM with Resident #157 regarding the Band-aid and steri-strips, in which he stated that a picture accidently fell on his head, while at home prior to his facility admission three (3)-days ago; with no sutures necessary, and with no pain, at this time. On 10/10/23 at 10:10 AM and 2:13 PM, Resident #157 was still observed with two (2) un-clean steri-strips to the bridge of his nose with old-dried and crust-like blood on top. On 10/11/23 at 10:14 AM Resident still observed with two un-clean steri-strips to the bridge of his nose with old-dried and crust-like blood; with the edges beginning to un-ravel and lift off the un-addressed resident's skin. Computerized record review conducted of the resident's Physician's order form, did not show an order for nasal steri-strip care noted. There was no documentation in the nurses' progress notes to indicate that the resident's physician had been contacted for care instructions for the nasal bridge steri-strips, not-withstanding the fact that weekly skin checks had been ordered to be done on Tuesday nights. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 9 of 18 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 10/12/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further computerized record review of both the Nursing admission summary dated [DATE] by Staff A, Registered Nurse (RN), in which she had identified and documented that Resident #157 had an abrasion to the bridge of his nose with steristrips in place, and of the Nursing Advanced Skilled Evaluation by Staff B, RN, dated 10/08/23 in she documented that Resident #157's skin was warm and dry, skin color within normal limits (WNL), and turgor is normal, but with no documentation noting the two (2) steri-strips located on resident's nasal bridge with old-dried blood on top. Moreover, there was no further documentation reviewed to show or indicate contact of Resident #157's physician for follow-up care for the two (2) steri-strips located on resident's nasal bridge with old-dried blood on top which was observed un-addressed for three (3) days during the survey. There was also no care plan to address the nasal bridge steri-strip care. On 10/11/23 at 11:58 AM a brief interview was conducted with Staff C, Licensed Practical Nurse (LPN), in which she acknowledged that the steri-strips were covered with dried bloody drainage, and that there was no contact or communication made to the resident's physician as to the current status of the resident's skin and possible treatment orders. On 10/11/23 at 12:02 PM an interview was conducted with Staff D, RN desk nurse for Banyan unit in which she also acknowledged that the steri-strips were covered with dried bloody drainage and there was no communication made with the resident's physician as to the current status of the resident's skin and possible treatment orders. On 10/11/23 at 12:22 PM an interview was conducted with the ADON in which she acknowledged that the physician should have been contacted regarding the resident's current nasal bridge skin status. In fact, a physician's order to monitor steri-strip to nose bridge for signs/symptoms (s/s) of infection or active bleeding every shift until resolved, was not written, until after surveyor inquisition/intervention. The DON further recognized and acknowledged that on 10/11/23 at 12:25 PM that the physician should have been notified of the resident's steri-strip nasal bridge skin status; this was not done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 10 of 18 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 10/12/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor and intervene for a resident identified with significant weight loss for 1 of 2 residents reviewed for nutrition (Resident #35); and failed to identify significant weight loss for 1 of 2 residents reviewed for nutrition (Resident #53). Residents Affected - Few The findings included: 1. Resident #35 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and required extensive one-person assist with activities of daily living. The assessment further documented Resident #35 had weight loss, and was not on a prescribed weight loss regimen. A review of Resident #35's care plan revealed a care plan, revised 07/10/23, for nutritional problem or potential nutritional problem related to cognitive functions, history of weight loss, and needs assistance with meals. An intervention included to observe for/record/report to physician signs and symptoms of malnutrition such as significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Registered Dietician to evaluate and make diet change recommendations as needed. A review of Resident #35's progress notes revealed a dietary note dated 03/10/23 at 1:53 PM that documented a significant weight change review. The resident had a significant weight loss x 3 months (12/24/22 resident weight 97 lbs, 03/03/23 resident weight 89.6 lbs= 7.6%). The Registered Dietician (RD) recommended to supplement an appetite stimulant and add fortified foods at breakfast/dinner to increase nutrient intake. RD made nursing aware of appetite stimulant recommendation, and dietary manager made aware of adding fortified foods at breakfast/dinner. RD to follow for oral intakes, weights, skin, labs, and plan of care. A review of Resident #35's orders revealed the resident was ordered to receive Megace (an appetite stimulant) one time a day for poor appetite for 30 days on 04/10/23 (one month after RD recommendation). Further record review revealed there was no order for fortified foods for breakfast/dinner. Resident #35's nutritional status was not addressed again until a dietary progress note, dated 07/05/23 at 1:56 PM, documented a significant weight loss with the resident weight at 82 lbs on 07/04/23. The RD documented Resident #35 was receiving fortified foods at breakfast/dinner. The RD recommended adding an appetite stimulant and assistance with meals to aid in increasing meal intakes. Record review revealed an order dated 07/05/23 for Resident #35 for Megace one time a day for supplement for 30 days. Further review of the resident's orders revealed an order dated 07/05/23 for fortified foods at breakfast and dinner (initially recommended by RD on 03/10/23), and to assist with meals. A review of the Certified Nurse Assistant (CNA) documentation for the task of eating, revealed Resident #35 was eating independently with help to set up frequently. An interview was conducted with the facility's RD on 10/11/23. The RD stated she had started at the facility on 09/19/23, and had not reviewed Resident #35 as of yet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 11 of 18 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 10/12/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Resident #53 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact, and required extensive two-person assist with activities of daily living. A review of Resident #53's care plan revealed a care plan for the resident being at nutritional risk dated 09/19/23. During record review it was noted that resident #53 had weight loss of 5.45 % in less than a month (09/19/23 weight 220 lbs, 09/29/23 weight 208. lbs, 10/06/23 weight 208 lbs= 12 lbs). Review of the resident chart for documentation revealed there are no intervention for the resident's weight loss, or even any acknowledgement of the resident's weight loss. On 10/11/23 at 2:30 PM an Interview with the registered dietician(RD) was conducted. The RD acknowledged Resident #53's weight loss, and the lack of intervention in response to the weight loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 12 of 18 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 10/12/2023 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 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 review of policy and procedure, observation, interview and record review, it was determined that the facility failed to 1) Follow the physician's order for Oxygen Therapy Administration for 1 of 6 sampled residents observed for Oxygen, Resident #158; and 2) Failed to obtain a physician's order for administration of Oxygen for 1 of 6 sampled residents observed for Oxygen, Resident #109. Residents Affected - Few The findings included: Review of the facility policy and procedure on 10/11/23 at 1:23 PM titled Oxygen Administration provided by the Director of Nursing (DON) revised October 2010 documented in the Policy Statement: The purpose of this procedure is to provide guidelines for safe Oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for Oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident .Assessment: Before administering Oxygen, and while the resident is receiving Oxygen therapy, assess for the following: 1. Signs or symptoms of Cyanosis 2. Signs or symptoms of Hypoxia . 3. Signs or symptoms of Oxygen toxicity . 4. Vital signs 5. Lung sounds. 6. Arterial blood gases and Oxygen saturation, if applicable; and. 7. Other laboratory results ., if applicable Documentation: After completing the Oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The date and time the wound care was given. 3. The rate of Oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5) The reason for p.r.n. administration. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason (s) why and the intervention taken. 9. The signature and title of the person recording the data . Review of the facility policy and procedure on 10/11/23 at 1:38 PM titled Administering Medication provided by the Director of Nursing (DON) revise April 2019 documented in the Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders. Review of the facility policy and procedure on 10/11/23 at 1:54 PM titled Physician Orders provided by the Director of Nursing (DON) revised November 2014 documented in the Policy Statement: The purpose this procedure is to establish uniform guidelines in the receiving and recording of physician orders. Supervision by a Physician 1. Each resident must be under the care of a Licensed Physician authorized to practice medicine in this state and must be seen by the Physician at least every 60 days. 2. A current list of orders should be maintained in the clinical record of each resident. 3. Orders must be transcribed into the EMR. 4. Physician Orders/Progress Notes must be reviewed with each resident visit. 1) Resident #158 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Anxiety Disorder, Hypertension, Atrial Fibrillation and Gastro-esophageal Reflux Disease (GERD). She had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). On 10/09/23 at 12:21 PM Resident #158 was observed with Oxygen infusing continuously via nasal cannula at four (4) liters via concentrator; with an oxygen saturation reading of: 96-97% on room air (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 13 of 18 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 10/12/2023 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 0695 and Oxygen. Photographic Evidence Obtained. Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 10/09/23 at 12:25 PM with Resident #158, she confirmed that she has had a diagnosis of End-stage COPD since 2009. The resident indicated that she has been able to tolerate four (4) liters of oxygen since her admission to this facility on 09/25/23. The resident was not noted to be in any acute distress or exhibiting any shortness of breath (SOB), at the time. The resident also stated that she routinely uses her oxygen everyday (24/7) and has done so for over 3-4 years, normally on three (3) liters; even though it is currently set at four (4) liters per minute. Resident #158 also further self-professed that she self-medicates and takes two (2) puffs, at a time, 4-5 times per day of her un-ordered prescription Albuterol inhaler, which she keeps at her bedside, often in her shirt pocket or atop her overbed table. Photographic Evidence Obtained. Residents Affected - Few On 10/10/23 at 10:40 AM and at 2:23 PM, Resident #158 was still observed with Oxygen infusing continuously via nasal cannula at four (4) liters via concentrator; with an oxygen saturation reading of: 96% on room air and Oxygen. On 10/11/23 at 10:25 AM Resident #158 was still observed with Oxygen infusing continuously via nasal cannula at four (4) liters via concentrator; with an oxygen saturation reading of: 96% on room air. Computerized record review conducted Resident #158's Treatment Administration Record (TAR) dated 09/26/23 documented to administer two (2) L/min via nasal cannula (NC) Oxygen as emergency measure only if O2 sat < 88 percent every day and night shift (with parameters). Resident #158's oxygen saturations were being recorded from 9/26/2023 until 10/10/23 with a normal range of: 94%-97% @ 4 liters/minute on both room air and Oxygen via nasal cannula; the physician's orders were not carried out as ordered. Further computerized record review of the nurses' progress notes dated from 09/25/23 to 10/07/23 all recognize and document that the resident was on and receiving Oxygen via nasal cannula with an Oxygen saturation normal limit range of 94%-97%; with no notation that these were communicated to the resident's physician. The facility has been administering Oxygen to Resident #158, for over two (2) weeks, without properly and effectively following the physician's prescribed order. On 10/11/23 at 12:03 PM a brief interview was conducted with Staff C, Licensed Practical Nurse (LPN), in which she acknowledged that the resident uses Oxygen continuous at four (4) liters of Oxygen. But, the orders are not being followed properly. On 10/11/23 at 12:08 PM an interview was conducted with Staff D, RN desk nurse for Banyan unit in which she also acknowledged that the resident uses Oxygen continuous at four (4) liters of Oxygen and she added that the physician's orders should always be followed. On 10/11/23 at 12:25 PM an interview was conducted with the ADON which she acknowledged that the resident uses Oxygen continuous at four (4) liters of Oxygen and she added that the physician's orders should always be followed. A new order was not written and a pulmonary consult was not performed, until after surveyor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 14 of 18 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 10/12/2023 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 0695 intervention. Level of Harm - Minimal harm or potential for actual harm The DON further recognized and acknowledged that on 10/11/23 at 12:30 PM the physician's orders must always be obtained and ordered prior to administration of Oxygen therapy; this was not done. Residents Affected - Few 2) Resident #109 was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure, Asthma, Unspecified Systolic Congestive Heart Failure, Presence of Cardiac Pacemaker, Diabetes Mellitus Type II, Nonrheumatic Aortic Valve Stenosis, Hypertension and Glaucoma. Resident #109's cognitive status described as awake, alert and oriented x2. On 10/10/23 at 12:36 PM, during an observational tour, Resident #109 was observed sitting up in her room in her wheelchair next to her Oxygen machine, which was not currently attached and infusing; with Oxygen signage visibly posted outside of the resident's doorway. When questioned about the Oxygen, Resident #109 stated that she had been using her Oxygen two (2) liters and then it was later reduced to one (1) liter constantly and consistently for the past four (4) days, since admission to the facility on [DATE]. During a brief interview with the resident's nurse Staff E, an RN, she also acknowledged that the resident had been on Oxygen and that the Oxygen machine had remained at the resident's bedside to be used as needed (PRN). Computerized record review of the physician's orders for Resident #109 did not document any orders for Oxygen for this resident. Neither the Medication Administration Record (MAR) nor the TAR reflected any Oxygen administration for this resident. 10/10/23 02:36 PM Resident sitting up in her room in her wheelchair watching T.V.; with her Oxygen machine remaining in her room next to her bed. 10/11/23 at 11:03 AM Resident sitting up in her room in her wheelchair watching T.V.; with her Oxygen machine remaining in her room next to her bed. Computerized record review of the nurses' notes dated 10/07/23 through 10/09/23 revealed that the nurses had been documenting Oxygen usage by this resident. Both the Cardiovascular care plan dated 10/07/23, and the Asthma care plan dated 10/07/23 both documented to assess Heart Rate (HR)/Blood Pressure (BP)/Respiration and give Nebulizer Treatments and Oxygen therapy as ordered. However, there was no physician's order in the record prescribing Oxygen administration for this resident. On 10/11/23 at 11:48 AM a brief interview was conducted with Staff E, Registered Nurse (RN), in which she acknowledged that the resident was on Oxygen therapy and she uses it as she needs it, and there was no current order on record for this. On 10/11/23 at 11:50 AM an interview was conducted with Staff D, RN desk nurse for Banyan unit in which she also acknowledged that the resident was on Oxygen therapy and there was no current order on record for this. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 15 of 18 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 10/12/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm On 10/11/23 at 12:05 PM an interview was conducted with the ADON which she acknowledged that the resident was on Oxygen therapy and there was no current order on record for this. A new Oxygen order was not written and a Pulmonary consult was not performed, until after surveyor intervention. Residents Affected - Few The DON further recognized and acknowledged that on 10/11/23 at 12:15 PM that an order was required for the resident's Oxygen therapy administration; this was not done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 16 of 18 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 10/12/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure that it 1) secured prescription insulin medication following a Glucometer Observation for 1 of 1 sampled residents observed during a Medication Administration Observation, Resident #213. And, 2) failed to secure an order for self-medication of a prescription inhaler medication for 1 of 1 residents observed with an inhaler, Resident#158. The findings included: Review of the facility policy and procedure on 10/11/23 at 2:15 PM titled Medication Labeling and Storage provided by the Director of Nursing (DON) revised February 2023 documented in the Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation: Medication Storage 4. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 5. Medications are stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems 1) Resident #213 was admitted to the facility on [DATE] with diagnoses which included Hypertension, Acute Kidney Failure, Gastroesophageal Reflux Disease (GERD). Resident #213 is described as: Alert & Oriented x3. On 10/09/23 at 11:54 AM Staff F, a Licensed Practical Nurse (LPN), was observed during a Glucometer Observation for Resident #213. Subsequently, the nurse also performed an Insulin Medication Administration for Resident #213. Staff F, was observed placing Resident #213's Insulin pen containing Novolin R insulin in a tray in the chair near the doorway and then leaving the medication to walk over to the bathroom (more than 10 feet away) to wash her hands for over two (2) minutes; leaving the medication unattended, un-secured, and out of her line of sight. Photographic Evidence Obtained. During a brief interview conducted on 10/09/23 at 11:58 AM with Staff F, she acknowledged that she should not have left the medication unattended. On 10/11/23 at 12:26 PM an interview was conducted with Staff G, RN Supervisor, in which she acknowledged that the medication must always remain in the nurses' line of sight. On 10/11/23 at 12:34 PM an interview was conducted with the Assistant Director of Nursing (ADON) which she acknowledged that the medication must always remain in the nurses' line of sight. 2) Resident #158 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Anxiety Disorder, Hypertension, Atrial Fibrillation and Gastro-esophageal Reflux Disease (GERD). She had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). During a brief interview conducted on 10/09/23 at 12:25 PM, with Resident #158, she was asked about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 17 of 18 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 10/12/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her Respiratory health status, she voluntarily revealed to this surveyor that she self-medicates and takes two (2) puffs at a time 4-5 times per day, of her un-ordered prescription medication: Albuterol Sulfate HFA Inhalation aerosol inhaler, which she demonstrated that she keeps at her bedside in her shirt pocket; it was un-secured and accessible to other residents, staff members and visitors. Photographic Evidence Obtained. On 10/11/23 at 10:21 AM during subsequent room tour, it was now observed that the un-ordered prescription Albuterol Sulfate HFA Inhalation aerosol inhaler, was sitting in plain sight atop Resident #158's overbed table; still un-secured and accessible to other residents, staff members and visitors. An interview was conducted on 10/11/23 at 12:15 PM with Staff C, Licensed Practical Nurse (LPN), regarding the prescription inhaler medication voluntarily observed in Resident #158's shirt pocket and she acknowledged that the medication container should not have been there. During an interview conducted on 10/11/23 at 12:18 PM with Staff D, RN desk nurse for Banyan unit, she indicated that this resident was not authorized to self-administer any of her own medications and neither was she assessed to be able to do so. An interview was conducted on 10/11/23 at 12:27 PM with the Assistant Director of Nursing (ADON) in which she acknowledged that prescription inhaler medication should not have been there. Side-by-side record review was conducted with Staff D, RN desk nurse for Banyan unit, indicated that neither Resident #158's hard copy chart nor her computerized Point-Click-Care (PCC) medical record indicated that the resident had any self-assessment completed in order for her to be able to administer her own medications. There was no order on Resident #158's MAR for this prescription medication to be administered to this resident. Resident #158 was not assessed to be able to administer the inhaler medication, and neither was a physician's order written for the Albuterol Sulfate inhaler medication to be administered as needed, until after surveyor intervention. On 10/11/23 at 1:27 PM, the DON further acknowledged and recognized that the resident's medications must always remain in the sight of the nurse, at all times and that the OTC and prescription medications should not have been left at either of the resident's bedsides, and that all medications should be kept locked and secured, at all times; this was not done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 18 of 18