Health 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. Page 1 of 9 105466 105466 01/27/2022 Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn, bathroom sink exterior had areas of black stains, over-bed table exterior was pitted and rusted, bathroom ceiling vent dust laden, room base boards had large areas of black stains, and use of hand bar soap in bathroom (no resident name). room [ROOM NUMBER] - The exteriors of the room entry door were damaged and heavily worn, bathroom floors were soiled and stained, and landing/fall mat was heavily soiled and stained. room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn, and room based boards not to have large areas of black stains. room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn, 3 dresser drawers did not close and remain open, large black marks/streaks to room floor, and the entrance threshold to room was in disrepair and was a trip/fall hazard. South Shower Room - Two large ceiling tiles were noted to have black stains, and 1 of 3 ceiling lights was not working. Clean Linen Cart - The nylon cover had numerous large tears. Corridor Door - The 2 doors located at the half point of the corridor were noted to be damaged and had large worn area. Corridor Ceiling Vent - The commercial air vent was noted to be black dust laden. 2 North Unit (rooms 229-244): room [ROOM NUMBER] - The exteriors of the room entry door were damaged and heavily worn, and bathroom sink had areas of black stains. room [ROOM NUMBER] - The exteriors of the bathroom entry door were damaged and heavily worn. room [ROOM NUMBER] - The exteriors of the room entry door were damaged and heavily worn. room [ROOM NUMBER] - Large area of wall damage between D & W beds, and bathroom sink had numerous exterior small cracks. room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn. room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn, the room entry floor threshold was damaged and was a trip/fall hazard, and room floor had numerous large black markings. room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn and bathroom wall require repainting. room [ROOM NUMBER] - The exteriors of the room entry door were damaged and heavily worn, and bathroom walls require repainting. 105466 Page 2 of 9 105466 01/27/2022 Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER] - The exteriors of the room entry door were damaged and heavily worn, the exteriors of the bathroom doors were damaged and heavily worn, and portable commode seat was rust laden. room [ROOM NUMBER] - The exteriors of the bathroom doors were damaged and heavily worn, 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, pervasive and offensive urine odor in bathroom, the toilet requires recaulking to the floor, bathroom base boards were black stained, and 1 of 2 bathroom wall lights not working. room [ROOM NUMBER] - large hole in room wall near air-conditioning unit, bathroom walls require repainting, and damage areas to room walls. Corridor Smoke Doors - The 2 doors were noted to have exterior damage and were heavily worn. Following the tour, a summary interview was conducted with the Director and findings of the 01/26/22 tour were confirmed. It was also noted that there is a housekeeping/maintenance logbook located at the second-floor nurses station for which staff are to report any housekeeping/maintenance issues. Review of the logbook noted that the items noted during the tour were documented. Note: During the Long Term Care Survey of 01/27/22 it was noted that no residents resided on the first floor due to water damage and subsequent remodeling by the facility. 105466 Page 3 of 9 105466 01/27/2022 Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary care and services to ensure that a resident's abilities of independent eating do not diminish for 6 of 11 sampled residents (Residents #5, #10, #12, #14, #44, and #201). Residents Affected - Some The findings included: 1) During the observation of the breakfast meal on 01/26/22, it was noted that the food cart was delivered to the 2 South Wing at 7:40 AM. Continued observation noted that all breakfast trays were delivered to resident rooms by 7:50 AM. Further observation noted that meals were delivered, opened and set up for residents on the over-bed tables for Residents #5, #10, #12, #14, #44, and #201. It was noted from 7:50 AM through 8:30 AM, that the residents sat sleeping in front of their meal tray without assistance or supervision from staff. It was noted that the meals were removed after 8:35 AM from the resident rooms without any intake. 2) During the observation of the lunch meal on 01/26/22, it was noted that the food try cart was delivered to the 2 South Wing and all resident lunch trays were delivered to the rooms by 12:05 PM. It was noted again that the lunch trays were delivered to the bedside tables of Residents #5, #10, #12, #14, #44, and #201. Observation of these resident from 12:05 through 12:30 PM noted that no staff assisted or supervised these residents with their meals. It was noted that the residents sat seated and sleeping in front of their lunch trays. At 12:35 PM the surveyor requested the administrator to observe the issue. The administrator confirmed the surveyor's findings that meal trays are served to rooms of Residents #5, #10, #12, #14, #44, and #201. and these residents failed to receive any necessary assistance or supervision with their meals. 3) During the observation of the breakfast meal on 01/27/22 from 8:05 AM through 8:30 AM, it was noted that the trays were set up on over-bed tables in front of Residents #5, #14, and #44. It was noted that the residents were sleeping and had not consumed any of the breakfast foods. Also noted no supervision or assistance with meals given to these residents. 4) Interview with Administrator on 01/27/22 concerning the 01/26/22 meal observations noted to state that the issues to ensure that residents are receiving assistance and supervision with meals is being discussed and will take a few days of nurse staffing to correct the issue. 5) A review of the clinical records of Residents #5, #10, #12, #14, #44, and #201 on 01/26/22 and 01/27/22 noted the following: Resident #5: admission Date: 2/20/18 Current Diagnoses: Heart Disease, Muscle Weakness, Need For Personal Care, and Dysphagia MDS (Dated 1/17/22) : BIMS Score = 10, Section G (Eating) = *Supervision With Meals 105466 Page 4 of 9 105466 01/27/2022 Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

F 0676 Section K = Mechanical Soft Diet . Level of Harm - Minimal harm or potential for actual harm Care Plan: Nutritional Status (Revised 01/25/22) = * Assist with Meals Resident #10: Residents Affected - Some admission Date: 11/03/08 Current Diagnoses: Type 2 DM, Hypokalemia, Need For Assistance With Care, Major Depressive Disorder, Dysphagia, and Protein -Calorie Nutrition. MDS (10/31/21) : Section C BIMS = Resident Rarely Understood, Section G = *Supervision With Meals, Section K Therapeutic Diet. Care Plan: (Revised 1/25/22: * Assist With Meals, Encourage Resident To Eat Slowly Resident #12: admission Date: 09/30/14 Current Diagnoses: Dysphagia, Diabetes Type 2, Need For Assistance, and Dehydration. MDS (11/7/21) Sec C: BIMS= 10, Sec G =* Supervision with Meals, Sec K: Therapeutic Diet Care Plan : 11/17/21 * Maintain Weight * Monitor Intake of Food * Observe For Dehydration Resident #14: admission Date: 08/10/21 Current Diagnoses: *Eating Disorder, * Protein-Calorie Malnutrition, * Nutritional Anemia, * Symptoms and Signs Concerning Food and Fluid Intake, * Disorder of Electrolyte and Fluid Balance, and * Dysphagia, * Vitamin B-12 deficiency, MDS: 11/14/21: Sec C: BIMS = 10, Sec G =Supervision With Eating, Section K = 72/145#, BMI = 21.26 Progress Notes: 105466 Page 5 of 9 105466 01/27/2022 Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

F 0676 1/17/22 : 25% intake of breakfast, refused lunch and supplement Level of Harm - Minimal harm or potential for actual harm 11/18/21: Continues with steady weight loss 11/18/21: Continues with poor intake Residents Affected - Some 10/18/21: Significant weight Loss with 5% X 30 days and history of weight loss. Nutritional Progress Note: 11/17/21 * Ideal Body Weight = 178 # * BMI = 19.7 * Meal Intake = 25% Care Plan: 1/14/22 - Nutritional Status * NO Further Weight Loss * Decreased Intake * Encourage of room dining Resident #44: admission Date: 01/06/20 Current Diagnoses: Dementia, Cognitive Deficit, Need For Assistance With Care, Anemia, Hypomagnesemia, Dysphagia, and Anorexia. MDS: 12/26/21 Sec C: Rarely understood Sec G: * Extensive Assist With Meal Progress Note; 12/27/21: Daughter informed that resident is not eating much of meals. Daughter states she will bring in Boost supplement. Care Plan: Nutritional Status 1/7/22 * Resident will consume more than 50% of meals ** No approach documented for extensive Assist with Meals * Provide ADL Dining Care 105466 Page 6 of 9 105466 01/27/2022 Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

F 0676 Resident #201: Level of Harm - Minimal harm or potential for actual harm admission Date: 01/12/22 Diagnoses: Malaise, Diabetes Type 2, and GERD, Residents Affected - Some MDS: 1/19/22 Sec C: BIMS = 13 Sec G: Supervision with Eating Section K: Therapeutic Diet Progress Notes: 1/27/22 - States appetite is minimal, 1/26/22 - Abnormal lab Potassium level 1/20/22- will recommend Med Pass daily to supplement protein intake, 105466 Page 7 of 9 105466 01/27/2022 Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, it was determined that the facility failed to prepare, distribute, and serve food in accordance with professional standards for food safety that include: holding foods at regulatory temperatures of 41 degrees F or below, or 135 degrees F or above. The findings included: 1) During the initial dietary/food service observation tour conducted on 01/24/22 at 9:15 AM, accompanied with the Dietary Manager, the following were noted: During the observation it was noted that foods were being stored in the steamer, however the steamer was not on. The lunch cook (Staff A) stated that the foods were lunch menu items and had been prepared hours earlier and being held in the steamer while the unit was off. At the requested of the surveyor the temperatures of the foods were taken utilizing the facility's calibrated digital thermometer. The temperatures of the foods were recorded as per the following: Pureed Capri Vegetables (20 servings) = 125 F Italian Sausage Links (10 pounds) = 118 F Pureed Italian Sausage = 120 F Milk (1/2 gallon) = 90 degrees F The surveyor informed the cook (Staff A ) that perishable hot foods must be held at 135 degrees or greater at all times. It was also discussed that food cannot be held in the steamer and foods (vegetable/pureed vegetables) should not be prepared and held for hours prior to meal service. 2) During a second revisit to the dietary department on 01/24/22 at 11:30 AM, temperatures of foods were taken with the facility's calibrated food thermometer. During the temperature testing it was noted that 3 Ham sandwich platters were sitting out at room temperature on the tray line. The temperature of the ham sandwiches were recorded at 57 degrees F . The surveyor informed the DM that the regulatory temperature was 41 degrees F or below. The surveyor requested that the ham sandwiches be discarded and re-made and held at regulatory temperature. * A review of the facility's Diet Census for 01/24/22 revealed that the inappropriate food temperatures had the potential to effect 46 of the facility's 47 residents, which included sampled Residents #201, #23, #21, #5, #25, #12, #44, #36, #302, #10, #251, #22, and #11. 105466 Page 8 of 9 105466 01/27/2022 Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on facility policy, observation, interview, and record review, the facility failed to properly screen 66 out of 103 employees on 3 days for signs and symptoms of illness prior to their work shift. Residents Affected - Some The findings included: Review of Facility Policy Titled Coronavirus (COVID-19)-Screening Stakeholders and Return to work, Last Revised:12/27/2021 documents under Guidelines: 2) Stakeholders are screened at the start of each shift for fever (in addition symptoms screening). Stakeholders' temperatures will be checked during this screening. On 01/24/2022 at 9:00 AM the surveyor upon entering the facility, during the illness screening process, observed incomplete entries on the Screening Log dated January 22, 2022. When asked if all employees are required to be screened and complete the Screening Log prior to beginning their shift, the Facility Administer stated yes. On 01/25/2022 at 8:30 AM the surveyor upon entering the facility, during the illness screening process, noted incomplete entries on the Screening Log dated January 24, 2022. Copies of the Screening Log and a list of the employees who worked for the last three days was requested from the business office manager. During an interview on 01/25/2022 at 10:52 AM, Staff D stated she did not do the illness screening prior to beginning work. During an interview on 01/25/2022 at 10:52 AM, Staff E stated she did the illness screening prior to starting her shift but forgot to fill out the log. During an interview on 01/25/2022 at 1:00 PM the Signature Care Consultant stated that an investigation was initiated into the employees complying with the facility illness screening protocol. During an interview on 01/26/2022 at 1:30 PM the Director of Nurses and Assistant Director of Nurses stated that the broken check-in computer and building construction caused the staff to enter through a different door which contributed to the lack of screening. A worksheet provided by the facility documenting staff who worked and staff who completed the illness screening prior to starting their shift for 01/23/2022-1/25/2022 revealed 66 of 103 illness screenings were missing. 105466 Page 9 of 9