Inspection·January 27, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 2 resident units on the second floor (North and South). The findings included: During the initial environment tours conducted throughout the day on 01/24-25/22, and the tour conducted on 01/26/22 at 9:45 AM accompanied with the Director of Maintenance, the following were noted: 2 South Unit (Rooms 201-216): room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn, room sitting chair had stained seat cushion, and the exterior of the nightstand had exposed areas of raw wood. room [ROOM NUMBER] - The exteriors of the room entry door were damaged and heavily worn, bathroom toilet requires recaulking to the floor, over-bed table exteriors (2) were rust laden. room [ROOM NUMBER] - Landing/fall mat (W-Bed) was heavily soiled. room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn, large holes (2) in room wall near air-conditioning unit, and bathroom sink was rust laden. room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn, and the exteriors of the room entry door were damaged and heavily worn. room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn, and room floor was soiled with dust, dirt, and debris. room [ROOM NUMBER] - The exteriors of the room entry door were damaged and heavily worn, and the bathroom walls paint was bubbling up from the surface. room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn, bathroom walls had large areas of bubbling from surface, and portable commode seat was rust laden. room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn, dresser drawers did not shut (1 of 2), and room ceiling tiles (3) stained and in need of replacement. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 105466 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 105466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461 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)