Inspection·May 11, 2023

F 0584 room [ROOM NUMBER]: Bathroom walls in disrepair and peeling paint. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: Offensive urine odor in room. Residents Affected - Some South Shower Room: Emergency call bell wrapped around wall hand rail and could not be activated, and sink vanity exterior in disrepair with wood splinters. Second Floor: room [ROOM NUMBER]: One of three room overbed lights not working; and window blinds broken and not functioning to open and close. room [ROOM NUMBER]: Room walls in disrepair and noted areas of peeling paint. room [ROOM NUMBER]: Room walls and bathroom walls in disrepair and areas of peeling paint. room [ROOM NUMBER]: Exterior of bathroom door in disrepair and require re-painting. room [ROOM NUMBER]: Room wall noted to have numerous large areas of black scuff marking, and bathroom walls in disrepair and areas of peeling paint. room [ROOM NUMBER]: Room ceiling damage. room [ROOM NUMBER]: Exposed electrical wiring on walls between room beds; and room walls in disrepair and noted areas of peeling paint. Hallway Clean Linen Cart: The exterior of the cart cover had numerous large tears. Second Floor Elevator: The handrail just outside of the elevator entrance was in disrepair and noted with sharp plastic edges. The 05/09/23 and 5/10/23 environmental tour findings were discussed with the Administrator on 05/10/23 at 2 PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 2 of 14 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 05/11/2023 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)

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 interview and record review, the facility failed to report an allegation of resident to resident misappropriation of funds/property in a timely manner for 1 of 1 sampled residents reviewed for abuse (Resident #11). The findings included: A review of the facility's policy Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, dated 11/2019, documented: All suspected cases of abuse or misappropriation of resident's property will be fully investigated by the Administrator, Abuse Coordinator, or designee. The findings should be reported to the appropriate governing agencies. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the event must be reported no later than 24 hours after the allegation is made. Record review revealed Resident #11 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact, and required limited one-person assist with activities of daily living. A further review of Resident #11's records revealed a progress note dated 05/03/23 at 7:08 PM documented: Resident took roommate's $10 and accused him of stealing his $100. Unable to redirect or educated due to language barrier. Spoke with (resident's representative), stated that he left $100 with resident a couple of weeks ago (broken down notes) and the next day resident informed him that the $100 is missing, also informed writer that resident is missing a gold ring. An interview was conducted with the Unit Manager (UM) on 05/10/23 at 1:20 PM. The UM stated she was the one who intervened with the incident that occurred with Resident #11 on 05/03/23. The UM stated the resident was very upset. The UM stated she did an incident report on 05/06/23. An interview was conducted with the Social Services Director (SSD) on 05/10/23 at 1:00 PM. The SSD stated she was made aware of the incident involving Resident #11 on 05/08/23 (5 days later) during morning meeting while reviewing incident reports, at which time the allegations were called in to the appropriate agencies. The SSD further stated the investigation into the allegations had not yet started. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 3 of 14 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 05/11/2023 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)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to take corrective actions addressing misappropriation of a resident's funds/property in a timely manner for 1 of 1 sampled residents reviewed for abuse (Resident #11). Residents Affected - Few The findings included: A review of the facility's policy Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, dated 11/2019, documented: Prevention of abuse will be accomplished by the timely reporting of the suspected abuse and a thorough investigation of these instances. The center has procedures to identify, correct, and intervene in situations in which abuse, neglect/misappropriation of resident property is most likely to occur. This includes an analysis of features of the physical environment that may make abuse/neglect more likely to occur, such as secluded areas of the center. Record review revealed Resident #11 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact, and required limited one-person assist with activities of daily living. A further review of Resident #11's records revealed a progress note dated 05/03/23 at 7:08 PM the documented: Resident took roommate's $10 and accused him of stealing his $100. Unable to redirect or educated due to language barrier. Spoke with (resident's representative), stated that he left $100 with resident a couple of weeks ago (broken down notes) and the next day resident informed him that the $100 is missing, also informed writer that resident is missing a gold ring. A telephone interview was conducted with Resident #11's representative on 05/10/23 at 11:00 AM. The representative confirmed he was notified of the incident that took place with the resident on 05/03/23. The representative stated he had not had any update of the allegations since then. The representative stated he believed the residents were still housed together. An interview was conducted with the Unit Manager (UM) on 05/10/23 at 1:20 PM. The UM stated she was the one who intervened with the incident that occurred with Resident #11 on 05/03/23. The UM stated the resident was very upset. An interview was conducted with the Director of Nursing (DON) on 05/10/23 at 1:30 PM. The DON acknowledged the residents should have been separated at the time of the incident. The DON confirmed the residents would be separated as soon as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 4 of 14 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 05/11/2023 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)

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, that the facility failed to provide services that included Speech Therapy, Dietary Services, Social Services, and Dental Services to ensure that 1 (Resident #122) of 9 sampled residents reviewed for nutrition maintained their ability to self feed independently. Residents Affected - Few The findings included: During the initial screening of Resident #122 on 05/08/23 at 10 AM, the resident was noted to be alert, oriented, and responding to the surveyors questions. The resident stated to the surveyor that he was admitted to the facility approximately one month ago. The resident further stated that the hospital lost his dentures upon discharge to the facility. He further stated that he has been in gum pain continuously when attempting to eat foods provided by the facility and has informed staff of the denture issue on a couple of occasions. During the observation of the lunch meal on 05/08/23 at 12:15 PM it was noted that the resident was served a No Added Salt diet that was not mechanically altered. Review of the resident's meal tray ticket on 05/08/23 documented only a No Added Salt diet. The resident was noted to state issues chewing the pork entrée and stated that his gums were in pain when chewing the pork. A review of the admission summary dated [DATE] documented that the resident was received from the hospital and is alert and oriented to time, person and situation. Resident has no teeth and stated that he had dentures but were thrown away at the hospital. No dentures were found amongst belongings on admission. Meals are to be chopped. On 05/09/23 at 10:00 AM, an interview was conducted with the Director of Social Services to discuss the denture issues with Resident #122. The Director stated that she had not been made aware that the residents' dentures had been lost at the hospital and was having difficulty with gum pain when chewing. The Director stated that mobile Dentistry is at the facility weekly and she will make an appointment for the resident to be seen this week. It was further stated that she did not know who would be responsible for the dentures, but the resident is Medicaid pending and the mobile dentist could work with the facility, Medicaid, and facility concerning the denture expense. It was further discussed with the Director that the denture, chewing and pain issues should have been brought to her attention earlier upon admission. Interview with the facility's Consultant Dietitian on 05/09/23 at 10:15 AM, revealed that she was aware of the chewing issues but thought that the Nursing and Social Services Department would intervene concerning the resident's denture issues. A review of Nutrition Dietary Notes dated 04/08/23 documented the resident to state loss of dentures while in the hospital and having some problems chewing. Follow up observation and interview with Resident #122 on 05/10/23 at 8:00 AM noted that the residents' diet had been changed to Dysphagia/Mechanical Soft. The resident stated that his diet was changed yesterday (05/09/23) and now it's so much easier to chew the foods that are being served and less gum pain. Resident # 122 further stated during the observation that his breakfast today was soft and easier to chew. He stated he was visited by Social Services on 05/09/23 and will have a dental/ denture consult this week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 5 of 14 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 05/11/2023 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)

F 0676 Review of the clinical record of Resident #122 on 05/8-10/23 noted the following: Level of Harm - Minimal harm or potential for actual harm Date of admission: [DATE] Residents Affected - Few Diagnoses: Aortic Stenosis, Long Term Use Anticoagulants, Asthma, Dizziness, Respiratory Failure, ASHD (Arteriosclerotic Heart Disease) and Muscle Weakness. Physician's Orders: 04/06/23 - No Added Salt (Regular Consistency Diet) 04/07/23 : Vanilla Shake BID (twice daily) 05/09/23: No Added Salt -Dysphagia Advanced Texture Diet (Downgraded Diet) Weight History: 05/10/23: 125 (Surveyor Requested Weighing) 05/02 = 126 04/18=125 04/11 = 122 BMI (Body Mass Index)= 19.2 (Underweight) Height = 68 MDS: 04/13/23 Sec B: Understood & Understands Sec C= BIMS = 13 (No Cognitive Impairment) Sec D: Mood: Feeling Down, Feeling Tired, Poor Appetite and Feeling bad about self Sec G: Eating: Supervision with meals/Set Up Current Care Plan: * Developed 04/07/23 Nutritional Problem: Poor Dentition, Low BMI (underweight) Approach: Serve Mechanically Altered Diet (Not Ordered) Upgraded 05/09/23 - Diet downgraded to Mechanically Altered Foods Further record review noted teh following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 6 of 14 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 05/11/2023 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)

F 0676 Nutritional/Dietary Note: 05/09/23 Level of Harm - Minimal harm or potential for actual harm RD (Registered Dietitian) discussed resident with Speech today. Resident now reporting having difficulty tolerating Regular Foods at times. Speech Therapy downgraded diet to Dysphagia Advanced to promote oral intake and tolerance due to dentures not in place, as he remains edentulous at this time. Communicated downgrade to dietary to ensure we will provide Dyspahgia advanced texture foods Residents Affected - Few Speech Language Pathologist (SLP) Evaluation and Plan of Treatment : 05/09/23 documented, today reported significant difficulty including recent aspiration while consuming a hot dog, continued difficulty masticating regular solids and interest in diet texture modification following education. Recommend: Soft & Bite Sized (Dysphagia Advanced Diet with compensatory swallowing strategies). Resident to be seen by SLP for swallowing dysfunction for 12 times in 30 days (Daily) FROM 05/09/23 06/07/23. Mobile Dental Services: 05/10/23 Documented screening of resident. Patient is fully edentulous upper and lower arches. Expresses interest in upper complete denture and denies interest in lower denture. Patient understands and wants to proceed with impressions. Dental Hygienist authorized to treat patient. Office will follow up for approval. During an interview conducted at the request of the Administrator on 05/10/23, it was discussed that the resident was admitted to the facility over 30 days ago (04/06/23) with missing dentures and gum pain when eating. The resident stated he informed staff of the issues, however no interventions were initiated. It was also noted that a Dietary Progress note dated 04/08/23 documented the resident to state issues with the chewing of foods and lost dentures. On 05/05/23 the surveyor brought the chewing and denture issues of Resident #122 to the attention of Social Services. It was not until then that the SLP became involved to assess the resident and downgraded the diet from regular texture to Dysphagia Advanced Texture Diet and then the Dental Consult for dentures was completed on 05/10/23. The resident stated to the surveyor on multiple occasions that the new Dysphagia Advanced Texture Diet is enabling him to eat pain free and looks forward to new dentures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 7 of 14 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 05/11/2023 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)

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 interview and record review, the facility failed to acquire lab results prior to administering an anticoagulant (blood thinner) to 1 of 5 sampled residents reviewed for unnecessary medications (Resident #24). Residents Affected - Few The findings included: Record review revealed Resident #24 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. A review of Resident #24's physician orders revealed an order dated 04/02/23 for Warfarin 5 milligrams (mg) every evening (6:00 PM) for Atrial Fibrillation. Resident #24 was care planned for anticoagulant therapy. Interventions included to administer as ordered and labs as ordered. Further review of Resident #24's orders revealed an order dated 04/15/23 for PT/INR (blood clotting labs) on 04/16/23. A review of Resident #24's Medication Administration Record (MAR) revealed Warfarin 5 mg was administered on 04/16/23 at 6:00 PM. A review of the PT/INR labs drawn on 04/16/23 at 9:50 PM results revealed critically high at 9.3 (range of 2-3.5 is recommended for a standard anticoagulation therapy) The resident had a high chance of bleeding. A review of Resident #24's orders revealed an order dated 04/17/23 to hold Warfarin until INR is less than 3. PT/ INR every day until INR is less than 3. An interview was conducted with the Unit Manager (UM) on 05/09/23 at 2:30 PM. The UM stated if a physician orders labs in which the dosage of medication is determined by, such as a PT/INR, the medication is held until the results are received. The UM further stated Resident #24's Warfarin 5 mg should have been held on the evening of 04/16/23 until the lab results were received. The resident should not have been administered Warfarin on 04/16/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 8 of 14 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 05/11/2023 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to respond to a urine culture results in a timely manner for 1 of 1 sampled residents reviewed for Urinary Tract Infection (UTI) (Resident #24). The findings included: Record review revealed Resident #24 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. A further review of Resident #24's records revealed a progress note dated 04/12/23 at 11:58 PM, documented: During round resident was observed using urinal dark brownish urine smell fish like noted. MD made aware order was received for urine analysis and culture. Fluids encouraged no complaint voiced per patient. Will continue to monitor. A review of Resident #24's progress note dated 04/18/23 at 11:12 AM documented: MD made aware of (resident) appearing confused and urine culture results and ordered Augmentin 875-125 mg (antibiotic), 1 tab every 12 hours for 10 days for UTI (Urinary Tract Infection). First dose administered and resident tolerated well. A review of Resident #24's urinalysis result revealed collected time 04/13/23 at 2:00 AM, and reported on 04/15/23. The urinalysis was positive for a UTI. An interview was conducted with the Unit Manager (UM) on 05/09/23 at 2:30 PM. The UM acknowledged Resident #24 did not receive treatment for his UTI until he became symptomatic with confusion, 3 days after the results of the UTI was received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 9 of 14 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 05/11/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, observation and record review, the facility failed to accurately document controlled mediations for 3 of 5 residents (Resident #41, Resident #115, and Resident #132). Residents Affected - Few The findings Included: The facility's policy and procedure titled, 7.0 Best Practices for Medication Dispensing: Scheduled II Narcotics has a subsection H. Dispensing of Controlled Dangerous Substances (CDS). The subsection has a numbered list of entries. Entry #5 states When a CDS medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the inventory sheet the date of administration, the quantity administered, the amount of medication remaining, and his/her initials. 1. On 05/10/23 at 12:10 PM, a side-by-side review of Controlled Medications, for the first floor Medication Cart #1, was conducted with Staff A, a Registered Nurse (RN). Staff A was instructed to pull a card of controlled medications for two residents, one at a time, to be checked against the Controlled Medication Log. Resident #115's card was the second card reviewed. Resident #115's medication was labeled as follows: Oxycodone/APAP (Percocet) 5/325mg tab (tablet) give 1 tab by mouth every 6 hours as needed for non-acute pain. The medication dose times were checked and recorded based upon the Controlled Medication Log. The number of tablets remaining corresponded with what was recorded on the log. A comparison of the Medication Administration log for May 2023 for Resident #115 was made against the electronic health record, which is Point Click Care (PCC). The following discrepancies were found: On 05/04/23 at 0435 (4:35 AM) 1 tablet was removed from the card and documented on the Control Log, but not in PCC. The same discrepancy was found for 05/08/23 at 1900 (7:00 PM) and on 05/09/23 at 1630 (4:30 PM). On 05/05/23 a tablet was removed and recorded on the Control Log at 0900 (9:00 AM), however, the earliest entry on PCC was 1345 (1:45 PM). 2. On 05/10/23 at 1:00 PM, a side-by-side review of Controlled Medications, for the first floor Medication Cart #2, was conducted with Staff B, a Licensed Practical Nurse (LPN). Staff B was instructed to pull a card of controlled medications for two residents, one at a time, to be checked against the Controlled Medication Log. Resident #132 and Resident #41 had their medications reviewed. Resident #132's medication was labeled as follows: Oxycodone/APAP (Percocet) 5/325mg tab (tablet) give 1 tab by mouth every 8 hours as needed for non-acute pain. The current bubble card was delivered on 04/15/23. This card was reviewed and reconciled for April and May. When comparing the Control Log to entries on PCC the Control Log had an entry on 04/24/23 for 0900 (9:00 AM) without a corresponding entry on PCC. 3. Resident #41's medication reviewed was ordered as Oxycodone/APAP 10/325mg give 1 tab by mouth every 6 hours as needed for non-acute pain. On 5/5/23 the Control Log has a removal time of 0900 (9:00 AM) but an administration time of 1345 (1:45 PM) on PCC. On 05/10/23 at 2:30 PM, the Director of Nursing (DON) was informed of the discrepancies. The DON agreed that there was an issue with documenting Controlled Medications appropriately at the correct time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 10 of 14 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 05/11/2023 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure medication error rates were not 5% or greater. The facility had a medication error rate of 13.79%. Four (4) medication errors were identified while observing a total of 29 opportunities, affecting Resident #21. Residents Affected - Few The findings included: A medication administration observation was conducted on 05/09/23 at 9:06 AM with Staff Z, an agency nurse. Staff Z gathered medications for Resident #21. Staff Z admitted to not having a multi-vitamin, a stool softner, and a calcium pill on hand as ordered for Resident #21. Staff Z continued to administer the remainder of the medications due to the resident at that time. Staff Z was observed handing a nasal inhaler to the resident, without any instructions. Resident #21 was observed instilling 2 sprays of the nasal spray in each nostril. An interview was conducted with the Director of Nursing (DON) on 05/09/23 at 12:30 PM. The DON stated Staff Z was an agency nurse who informed her of missing medications for Resident #21. The DON stated the medications were over the counter, and in stock. The DON stated the agency nurse had gone home for the day, and another nurse assumed her assignment and would administer any missing medications not given by Staff Z. An interview was conducted with the Unit Manager (UM) on 05/09/23 at 2:00 PM. The UM stated she assumed Staff Z's assignment , and administered all missing medications to all residents. A review of Resident #21's Medication Administration Record (MAR) was conducted on 05/10/23 at 9:00 AM. The resident was not administered a multi-vitamin, a stool softner, and a calcium pill on 05/09/23. no correlating documentation was found. Furthermore, and order for Fluticasone (nasal spray) 1 puff each nostril daily was revealed. An interview was conducted with the DON on 05/10/23 at 10:00 AM. The DON acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 11 of 14 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 05/11/2023 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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician prescribed fluid restrictions for 3 (Resident #133, #119, and #276) of 3 sampled residents. The findings included: Review of the facility's Nutritional Services and Nursing Services Procedure (October 2019:- Page 15 of 43) noted the following: Policy: Fluid Restitutions shall adhere to a structured and planned allotment of fluids as prescribed by the physician. Policy Interpretation and Implementation: #4: Water pitchers will be removed from the resident's room. Beverage preferences will be obtained and reflected on the resident's meal ticket/tray card. #7: Nursing services will maintain documentation of fluids accepted with meals and medications. #8: Compliance or failure to follow physician orders shall be documented in the medical record as deemed necessary and communicated to the physician in a timely manner. 1) During the observation of the Lunch meal on 05/08/23 at 12:30 PM, it was noted the meal tray was served to the room of Resident #133. A review of the resident's meal/tray ticket noted Fluid Restriction (1200 cc) , 8 ounces of water with meals, and Carbohydrate Controlled and Renal Diet. It was noted that there was 8 ounces of water included on the meal tray. The resident was noted to be alert, oriented , and spoke only Spanish. The resident stated to the surveyor that she goes to dialysis on Monday, Wednesday and Friday, but did not know if she was on a physician ordered fluid restriction. Observation of the resident's room noted a 16 ounce Styrofoam container of ice water on the over-bed table and three 12 ounce bottles of water on the night stand, next to the resident's bed. The resident further stated that she is given the Styrofoam container of water each shift by the staff and drinks from it throughout the day. She explained that the bottled water is also for whenever she wants additional fluids to drink. On 05/08/23 at 2 PM, the surveyor requested that the facility's Registered Dietitian to observe the room of Resident #133. The observation noted the Dietitian to state that the resident has a physician ordered fluid restriction as part of dialysis treatment and further stated that the fluids other than those included on the meal tray, should not be in the room. The Dietitian stated that she would obtain new physician order to restrict additional fluids in the room. The surveyor requested the facility's Policy & Procedure for resident Fluid Restriction. A review of the policy noted that #4 - water pinchers will be removed from the resident's rooms and that #7 - nursing services will document fluid accepted with medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 12 of 14 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 05/11/2023 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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the May 2023 Medication Administration Record for Resident #133 noted the physician's order for the fluid restrictions per 7 A - 7 P. However, there was no documentation of the fluids that the resident consumed during the nursing shifts. It was further discussed with the facility's Dietitian that the policy and procedure for Resident Fluid Restrictions, #4 and #7, was not being followed. Review of the resident's clinical record Date Of admission: [DATE] Diagnoses: Fractured Right Femur, End Stage Renal Disease, DM (Diabetes Mellitus) 2, Dependent on Dialysis, and Morbid Obesity Current Physician orders noted: 05/09- No large cups at bedside 05/09 - 1200 ml Fluid Restriction 04/26/23 - 1200 ml Fluid Restriction 04/26/23- CCD /Renal Dyspahgia Advanced (Mechanical Soft) Current MDS (Minimum Data Set) assessment: 05/02/23 Sec C: BIMS (Brief Interview of Mental Status)=12 No Cognitive Impairment Sec G: Supervision with Eating 2) Following the observation, interviews, and record review concerning the fluid restriction of Resident #133, a review of the facility's Diet Census dated 05/09/23 was conducted. The review noted that documentation for Resident #119 and #276 had current physician orderes for a Fluid restriction. Observation, interview, and record review of these residents noted the following: (a) Observation of Resident #119 on 05/09/23 at 10 AM accompanied with the Consultant Dietitian noted a large Styrofoam container (16 ounces) of ice water at bedside on overbed table. The resident stated to receive ice water daily and drinks as needed . The Dietitian stated that the resident has a current physician ordered fluid restriction for dialysis purposes and the water container should not be located within the room. Review of record of Resident #119: Date Of admission: [DATE] Diagnoses: Fractured Right Femur, End Stage Renal Disease Current Physician Orders: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 13 of 14 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 05/11/2023 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)

F 0808 05/09- No large cups at bedside (Following the 5/9/23 observation) Level of Harm - Minimal harm or potential for actual harm 05/09 - 1200 ml Fluid Restriction 04/26/23 - 1200 ml Fluid Restriction Residents Affected - Some 04/26/23- Carbohydrate Controlled Diet /Renal Dyspahgia Advanced (Mech Soft) Current MDS: 05/02/23 Sec C: BIMS=12 (NO Cognitive Impairment) Sec G: Supervision With Eating (b) Observation of Resident #276 on at 11 AM and 05/09/23 at 10 AM noted large Styrofoam container that contained ice water located on the resident's on overbed table. The resident was noted to state he receives the large container of ice water daily and drinks from as needed. The facility's Dietitian stated the resident has a current fluid restriction order due to Congestive Heart Failure and that the container of water should not be served to the resident. Review of the clinical record of Resident #276 noted: Date Of admission: [DATE] Diagnoses: Respiratory Failure, Congestive Heart Failure and Hypokalemia Current Physician Orders: 05/09/23 - No large cups at bedside (Following 05/09/23 Observation) 05/09/23 - Fluids restriction 1, of 500 ml Current MDS: 04/30/23 Sec C: BIMS=9 Sec G: Extensive Assist With Eating Current Care Plan CP: 04/07/23 * Alteration in Nutrition Updated 04/25/23 - Fluid Restriction 1500 cc for increased hydration needs ** NO fluids at bedside FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105466 If continuation sheet Page 14 of 14