Inspection·July 11, 2024

F 0684 03/31/24 Resident #1's pain level range was recorded as: 0-7/10. Level of Harm - Minimal harm or potential for actual harm Further record review of the facility's two (2) computerized Controlled Substance Utilization Record/Narcotic sign-off sheets only contained nurse signature-offs from 03/13/24 until 03/26/24 for only the generic Oxycodone with Acetaminophen Oral Tablet dosage 5-325 mg to be given one (1) tablet by mouth every six (6) hours (PRN) as needed for Pain, which was received by the facility on 03/13/24 and 03/23/24. Residents Affected - Few In contrast, record review of the (MAR) reflected that from 03/21/24 until 03/26/24, facility staff nurses documented as if Resident #1 was administered Percocet/generic Oxycodone with Acetaminophen oral tablet 7.5/325 mg give one (1) tablet by mouth one time a day for pain one (1) hour prior to Physical Therapy (PT). However, there was no current Orthopedic Surgeon's order in place signifying an increase for the Percocet to 7.5/325mg. Neither were there any corresponding Controlled Substance Utilization Record/Narcotic sign-off sheets to match or reflect those particular dates of service. It was noted that Resident #1 had two (2) scheduled visits in which he was seen by his Orthopedic surgeon: 1) Wednesday March 20th and 2) again on Wednesday March 27th. During a subsequent computerized record review of Resident #1's uploaded facility documentation, it was noted that there was an un-dated prescription from Resident #1's Orthopedic Surgeon for Percocet 7.5/325 mg one (1) tablet by mouth three times (TID) (PRN) as needed, non-acute pain which had not been uploaded by the facility until 03/26/24. On 07/11/24 at 3:20 PM, during an interview with Staff A, a Registered Nurse (RN), she revealed that she contacted Resident #1's PCP first, and she said that she was directed by the PCP to contact Resident #1's Orthopedic Surgeon to have him to write a prescription for an increase in the resident's Percocet pain management order. Staff A then explained that she then followed-up and called the Orthopedic Surgeon's office, prior to ending her work shift and she spoke with the office nurse there. She then proceeded to give the Orthopedic Surgeon's office nurse the facility's fax number. Next, Staff A said that she was told by the office that they would fax over the new increased Percocet pain medication order. Staff A stated that when she returned to work on the 25th that she did call the Orthopedic Surgeon's office again about the prescription. But, Staff A also admitted to this Surveyor that she did not follow-through to ensure that a prescription had been received back from Resident #1's Orthopedic Surgeon office. Staff A said that she had indicated, with a #9 indicator in the facility's MAR, that a nurses' note was written referencing the status of Resident #1's Percocet 7.5-325 mg tablet for that day. However, a side-by-side computerized record review conducted by Staff A and this Surveyor of the nurses' notes, did not reflect any entries pertaining to the Percocet 7.5-325mg tablet. Staff A ultimately acknowledged that she did not document any prior communication or conversation in the record, with Resident #1's PCP regarding the Percocet 7.5-325mg increase. There was no documentation in any of the facility's nurses' progress notes to indicate that a physician's order was ever obtained or secured from the Orthopedic Surgeon by Resident #1's nurse. On 07/11/24 at 3:43 PM an interview was conducted with Staff B, an RN, in which she acknowledged that she was following what had been previously recorded in the resident's MAR and she also said that she had indicated with a #9 that a nurses' note was written with regard to the Percocet 7.5-325mg tablet that day on the MAR, however, side-by-side computerized record review of the nurses' notes, did not reflect any entries pertaining to the Percocet 7.5-325mg tablet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 2 of 3 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 07/11/2024 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 Neither Staff C, an RN, nor Staff D, an RN were available for interview. But, during a side-by-side computerized record review with the DON, it was revealed that both nurses had signed off the MAR on Friday 22nd and Sunday the 24th of March in error with the resident not having been administered the Percocet 7.5-325mg tablet either day. In summary, there was no Controlled Substance Utilization Record for the dates-of-service (DOS) March 21st through March 26th due to the fact that there was no physician's order obtained, nor was there any documentation in the associated physician progress notes identifying an increase Percocet 7.5/325; this medication was not received according to the Narcotic sheet until March 26th. The DON further recognized and acknowledged after reviewing the MAR that on 07/12/24 at 4:20 PM there was a PCP order, but no prescription order from Resident #1's Orthopedic Surgeon to validate the increase in the Percocet dosage and further the Percocet 7.5-325mg tablet had been signed off as administered on both days by the nursing staff, when in fact, it should not have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105411 If continuation sheet Page 3 of 3