Inspection·June 28, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that the resident was upset and spoke to her about it. The SSD said she did not document the room change yet but has a paper that was signed by herself on 06/22/23 that stated the resident was notified of the room change and the daughter was notified via telephone and the daughter was happy her mother would have a roommate. On 06/26/23 at 2:31 PM, this surveyor spoke via telephone with Resident #60's daughter. The daughter stated she was not aware that her mother had a room change until she was moved, and she was not happy about it. She stated her mother had been calling her 3-4 times a day asking when she will go back to her room. The daughter stated her mother was comfortable with the staff by her previous room and she feels very confused now. The daughter also stated that she called the Administrator to tell her that her mother was unhappy, and the Administrator stated that she spoke with the resident, and she was happy in the new room. Further interview with the resident's daughter revealed she felt the resident would not have been moved back to her previous rooom without surveyor's intervention. On 06/23/23 at 3:30 PM, an interview was conducted with the Administrator regarding the room change for Resident #60. The Administrator stated she needed to make a room change because they needed a room for a male admission. She was asked why a male resident could not have been put in an empty available room and she replied that she thought Resident #60 would be happy to have a roommate since she had not had one for a couple of months. On 06/27/23, Resident #60 was moved back to her previous room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105475 If continuation sheet Page 2 of 11 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 105475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace of Delray Beach Nursing and Rehabilita 5430 Linton Blvd Delray Beach, FL 33484 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow tube feeding physician orders for 2 of 2 sampled residents reviewed for tube feedings (Percutaneous Endoscopic Gastrostomy / PEG), Residents #48 and #62. The findings included: Review of the facility's policy, titled, Gastrostomy Tube / Feeding and Care, with a revised date of 08/20/22 included, in part: To provide nutrients, fluids, and medications, as per physician orders, to residents requiring feeding through an artificial opening into the stomach. A licensed nurse will review the physician's order for type of formula, concentration, rate of flow and method of administration. Label container with resident's name, flow rate, date, and time. Hang times: Record date/time container is hung. 1. Record review for Resident #48 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission date of 11/15/22, with diagnoses that included: Parkinson's Disease, Dysphagia Oropharyngeal Phase, Gastrostomy status, and Dementia. Review of the Minimum Data Set (MDS) assessment for Resident #48 dated 05/14/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 7 of 15, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #48 revealed an order dated 05/04/23 related to Dysphagia Oropharyngeal Phase to give Jevity 1.5 at 70 ml/hr (milliliters per hour) x 20 hours continuous feed daily via PEG (Percutaneous Endoscopic Gastrostomy). Flush 50 ml/hr x 20 hours water auto flush via PEG. Flush 100ml water before starting and stopping feeding. Turn off at 10:00 AM, turn on at 2:00 PM daily. Review of the Physician's Orders for Resident #48 revealed an order dated 11/28/22 for regular diet Pureed texture, Nectar consistency, and recreational snacks only 1 time per day. Record review for Resident #48 revealed no documentation of the amount of tube feeding the resident had actually received. Review of the Care Plan for Resident #48 revealed a care plan dated 06/28/22 with a focus on 'the resident required enteral feedings as the primary source of nutrition that puts the resident at risk for: Aspiration, Malnutrition, Dehydration, and Intolerance. Enteral feeding is related to: Parkinson's Disease, need for mechanically altered diet, Dysphagia, high BMI (Body Mass Index). Weight fluctuates related to edema to extremities.' The goals included: 'Enteral nutrition will meet 75% or more of estimated nutritional needs as evidenced by stable weight through the next review.' The interventions included: 'Assess oral intake through calorie count as ordered/needed. Elevate head of bed to prevent aspiration. Enteral nutrition per physician order. Monitor for complications including aspiration, diarrhea, respiratory infection, dehydration, abdominal pain, feeding tube displacement, nausea, vomiting, and abnormal lab values. Notify nurse or physician as indicated.' Observation was made on 06/25/23 at 12:10 PM of Resident #48 lying in bed. Upon closer observation, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105475 If continuation sheet Page 3 of 11 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 105475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace of Delray Beach Nursing and Rehabilita 5430 Linton Blvd Delray Beach, FL 33484 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident had a bottle of Jevity 1.5 (formulary type) of tube feeding hung at the bedside labeled as started on 06/22/23 at 5:00 AM. The tube feeding was at the 750 mark out of a 1,000 milliliter (ml) capacity bottle and was not infusing, indicating there was 750 mls remaining in the bottle. An observation was made on 06/26/23 at 9:30 AM of Resident #48 lying in bed. Upon closer observation, the resident had a bottle of Jevity 1.5 (formulary type) of tube feeding hung at the bedside labeled as started on 06/26/23 at 4:00 AM and was at the 400 mark out of a 1,000 milliliter (ml) capacity bottle and was not infusing, indicating there was 400 mls remaining in the bottle). During an interview conducted on 06/26/23 at 1:30 PM with the Licensed Dietician, who has been working at the facility for the past 5 weeks, and with Licensed Dietician Nutritionist (LDN), who has been working at the facility for the past 5 weeks, revealed that both staff members stated that as they were reviewing weights for residents, they identified that the residents' weights were not performed consistently the same way each time the resident was being weighed, meaning the resident may be weighed with Hoyer lift one time then weighed while in a wheelchair another time. At the time of discovering this inconsistency with the weights, they were unable to determine if residents with weight loss or significant weight loss were accurate. They put a Quality Assurance Performance Improvement plan for weights in place and it is currently in process. When asked about Resident #48, as to whether a tube feeding bottle that was started at 5:00 AM and was off at 10:00 AM (5 hours), that was to run at 70mls per hour, how many milliliters should be in the bottle after 5 hours, they stated there should be 650mls remaining in the bottle, which indicated the resident had received less than the amount they should have received. They both acknowledged that the resident received less than the amount they should have. During an interview conducted on 06/27/23 at 9:50 AM with Staff E Registered Nurse who stated she has been working at the facility for 19 years. When she was asked about residents who are receiving tube feeding if it is documented anywhere in the chart how much tube feeding the resident actually received, she stated we do not document the total volume infused. Most residents who have tube feeding have orders to stop the tube feeding at 10:00 AM and restart the tube feeding at 2:00 PM and we just document that on the MAR (Medication Administration Record. When asked if she verifies that the resident has received the correct amount of tube feeding, she said she does not really check to verify if the total volume infused, but maybe she should start checking. She said if a tube feeding pump keeps beeping, we remove the pump from use and central supply would send a new one. During an interview conducted on 06/27/23 at 9:58 AM with Staff C Licensed Practical Nurse (LPN) who when asked about residents who are receiving tube feeding if it is documented anywhere in the chart how much tube feeding the resident actually received, she stated for most residents who are receiving tube feeding, there is an order to restart the tube feeding at 2:00 PM and at that time they clear the machine and put a new bottle of tube feeding up. When we stop the tube feeding at 10:00 AM, we check to make sure the total volume has infused but do not document this anywhere. The nurses always keep an eye on the pump to make sure it is plugged in. She stated she does not look at the machines every day unless something is wrong like it is beeping. She said sometimes a nurse may start the tube feeding a little late, when that happens, they run the tube feeding until the total amount has infused. We know the total amount to be infused because it is on the order. During an interview conducted on 06/27/23 at 3:40 PM with Staff D Licensed Practical Nurse (LPN) who when asked about residents who are receiving tube feeding if it is documented anywhere in the chart how much tube feeding the resident actually received, he said no, we just make sure the pump is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105475 If continuation sheet Page 4 of 11 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 105475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace of Delray Beach Nursing and Rehabilita 5430 Linton Blvd Delray Beach, FL 33484 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 0693 running at the rate that is on the order. Level of Harm - Minimal harm or potential for actual harm 2 Record review for Resident #62 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dysphagia Pharyngoesophageal Phase and Encounter for Attention to Gastrostomy. Residents Affected - Few Review of the Minimum Data Set (MDS) for Resident #62 dated 05/25/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 13 of 15, indicating an intact cognitive response. Review of the Physician's Orders for Resident #62 revealed an order dated 06/14/23 for Regular diet Pureed texture, and Thin consistency. Review of the Physician's Orders for Resident #62 revealed an order dated 06/15/23 every evening shift Jevity 1.5 at 45ml/hour x 14 hours/day (on at 4:00 PM, off at 6:00 AM) with 30ml water flush every hour. Record review for Resident #62 revealed no documentation of the amount of tube feeding the resident actually received. Review of the Care Plan for Resident #62 revealed a care plan dated 05/19/23 with a focus on the resident is at risk for compromised nutritional status related to: Dysphagia; mechanically altered diet; GT feeding. The goals included: Resident will experience no further weight loss by the next review. The interventions included: Prescribed diet is: Regular puree. Weigh the resident monthly as ordered. On 06/25/23 at 1:30 PM, an observation was made of Resident #62 sitting in her wheelchair. Upon closer observation, it was revealed the resident had a bottle of Jevity 1.5 (formulary type) of tube feeding that was labeled as started on 06/25/23 at 6:00 AM and was at the 800 mark out of a 1,000 milliliter (ml) capacity bottle. The tube feeding was not infusing. On 6/26/23 at 9:35 AM, an observation was made of Resident #62 sitting in wheelchair, upon closer observation, it was revealed the resident had a bottle of Jevity 1.5 (formulary type) of tube feeding that was labeled as started on 06/26/23 at 5:00 AM and was at the 1,000 mark out of a 1,000 ml capacity bottle. The tube feeding was not infusing. An interview was conducted on 06/26/23 at 1:30 PM with the Licensed Dietician, who has been working at the facility for the past 5 weeks, and with the Licensed Dietician Nutritionist (LDN), who has been working at the facility for the past 5 weeks. When asked about Resident #62 if a tube feeding bottle that was started at 4:00 AM and was observed 9:30 AM (5.5. hours) that was to run at 70mls per hour how many milliliters should be in the bottle after 5.5 hours, they both stated there should be 615mls remaining in the bottle. When they were informed that the resident had 800mls in the bottle, they both acknowledged the resident received less than the amount they should have. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105475 If continuation sheet Page 5 of 11 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 105475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace of Delray Beach Nursing and Rehabilita 5430 Linton Blvd Delray Beach, FL 33484 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to administer timely and to monitor effectiveness of pain medications for 2 of 2 sampled residents reviewed for pain, Residents #313 and #314. Residents Affected - Few The findings included: Review of the facility's policy, titled, Pain Management Program with a revised date of 02/07/23, included: the purpose was to establish a program which can effectively manage pain in order to remove adverse physiological and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological wellness. The guidelines have a goal of the facility to facilitate resident independence, promote resident comfort, preserve, and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program. Documentation of assessments and the resident's response to the pain management plan will be made with each assessment. Pain control will be addressed during routine medication passes. 1. Record review for Resident #313 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Fracture of Unspecified Part of Neck of Left Femur, Strain of Muscle, Fascia and Tendon of Lower Back, Unspecified Injury of Head, Contusion of Right Hand, and Fall from Bed. Review of the Minimum Data Set (MDS) assessment for Resident #313 dated 06/29/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 13 of 15 indicating an intact cognitive response. Review of the Physician's Orders for Resident #313 revealed an order dated 06/24/23 for Tramadol HCL 50mg, give 1 tablet by mouth every 8 hours as needed for pain. Review of the Medication Administration Record (MAR) for Resident #313 from 06/22/23 to 06/25/23 revealed the resident was administered Tramadol 50mg on 06/24/23 at 5:20 PM for a pain level of 3 of 10; and was administered Tramadol 50mg on 06/25/23 at 8:11 PM for a pain level of 6 of 10. There was no documentation of the effectiveness of the medication for these administrations. Review of the Progress Notes, Forms, and/or Treatment Administration Records (TAR) for Resident #313 revealed there was no documentation of the effectiveness of the administered Tramadol on 06/24/23 or 06/25/23. Electronic record review for Resident #313 revealed, under the vitals tab, the resident had the following pain scores documented: On 06/24/23 at 12:50 PM, the resident had a pain score of 3. On 06/24/23 at 7:20 PM, the resident had a pain score of 3. On 06/24/23 at 8:34 PM, the resident had a pain score of 3. On 06/24/23 at 8:43PM, the resident had a pain score of 0. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105475 If continuation sheet Page 6 of 11 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 105475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace of Delray Beach Nursing and Rehabilita 5430 Linton Blvd Delray Beach, FL 33484 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 0697 On 06/25/23 at 8:11 PM, the resident had a pain score of 6. Level of Harm - Minimal harm or potential for actual harm On 06/25/23 at 8:16 PM, the resident had a pain score of 0. Residents Affected - Few Review of the Medication Administration Record for the month of June 2023for Resident #313 revealed the resident was Administered Tramadol HCL 50mg on 06/24/23 at 7:20 PM and again on 06/25/23 at 8:11 PM. Review of Care Plan for Resident #313 dated 06/23/23 with a focus on the resident has pain and/or is at risk for pain related to disease process, femur fracture, injury to head, history of falls, OA (Osteoarthritis) osteoporosis, GERD (Gastro Esophageal Reflux Disease). The goal was for the resident to not have an interruption in normal activities due to pain through the review date. The interventions included: Administer analgesia medication as per orders. Evaluate the effectiveness of pain interventions and notify the physician if interventions are unsuccessful. Monitor/record pain level as indicated. During an interview conducted on 06/25/23 at 11:33 AM with Resident #313 and her daughter present revealed the resident's daughter stated that her mother complained of acute pain yesterday morning after the aides cleaned her and had rubbed the area on her left hip (resident is status post left hip fracture). The daughter said it was around 10:00 AM that she had asked for Tramadol for the pain, the nurse said she had to call the doctor for the order, and they did not bring the tramadol into her until 5:00 PM and by then her mother had been lying still since 10:00 AM and no longer had any pain at that time. An interview was conducted on 06/27/23 at 9:50 AM with Staff E, Registered Nurse, who stated she has worked at the facility for 19 years. When she was asked if a resident has pain and what she does, she stated she would medicate the resident per the doctor's orders. If the resident does not have any pain medication ordered, then she would let the doctor know the resident has pain and get an order for pain medication. The doctor will then send a scrip to the facility (by fax), we send the script (by fax) to the pharmacy, then the nurse calls the pharmacy to make sure they received the script, and the pharmacy will give an authorization so that we can get the medication from the E-kit (emergency medication kit) as long as the medication is in the e-kit. During an interview conducted on 06/27/23 at 9:58 AM with Staff C, Licensed Practical Nurse (LPN), who when asked if a resident has pain what does she do, she stated for any resident who tells us they have pain she would first try repositioning the resident to see if that helps with their pain. Next, she would see if the resident had any pain medication ordered and if it is due to be given. If the resident does not have an order for any pain medication, she would call the doctor to get an order based on the pain scale the resident stated. The doctor has to fax the script directly to the pharmacy or if the doctor is in the facility, they will write a script. Then we would contact the pharmacy to get authorization to go into the E-kit to get the medication to give to the resident. During an interview conducted on 06/27/23 at 3:40 PM with Staff D, LPN, who when asked if a resident has pain what does he do, he stated if a patient had pain, he would ask the resident to rate the pain on a scale of 0 to 10, if the resident has pain medication ordered, he will give the medication. If the resident does not have any pain medication ordered, he will call the doctor to request a PRN (as needed) order for pain medication. The doctor then faxes the script to the facility or pharmacy and then he would contact the pharmacy to get authorization to get the medication from the e-kit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105475 If continuation sheet Page 7 of 11 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 105475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace of Delray Beach Nursing and Rehabilita 5430 Linton Blvd Delray Beach, FL 33484 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review for Resident #314 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung, Secondary Malignant Neoplasm of Brain, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct, Other Pancytopenia, and Unspecified Injury of Head. Review of the Minimum Data Set (MDS) assessment for Resident #314 dated 06/24/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognitive response. Review of the Physician's Orders for Resident #314 revealed an order dated 06/22/23 for Tramadol HCl Tablet 50 MG Give 1 tablet by mouth every 4 hours as needed for moderate and severe pain. Review of the Physician's Orders for Resident #314 revealed an order dated 06/23/23 to monitor and record pain level every shift for pain management. Pain scale: mild pain 1-3, moderate pain 4-6, severe 7-10. Review of Medication Administration Record (MAR) for Resident #314 from 06/22/23 to 06/25/23 revealed the resident had a pain level of 0. Review of the Medication Administration Record (MAR) for Resident #314 from 06/22/23 to 06/25/23 revealed the resident was not administered any Tramadol. Review of the Progress Notes, Forms and revealed no documentation of pain. Electronic record review for Resident #314 revealed, under the vitals tab, the resident had only a pain score of 0 documented. Review of the Care Plan for Resident #314 dated 06/23/23 with a focus on the resident who has pain and/or is at risk for pain related to disease process, neoplasm of lung, neoplasm of brain, Urinary Tract Infection. The goals included: The resident will not have an interruption in normal activities due to pain through the review. The interventions included: Administer analgesia medication as per orders. Evaluate the effectiveness of pain interventions and notify physician if interventions are unsuccessful. Monitor/record pain level as indicated. During an interview conducted on 06/25/23 at 10:02 AM with Resident #314 who stated she had a lot of pain last night and asked for Tramadol. She said she has cancer, and she was on Tramadol at home, the nurse last night told her she would have to call the doctor to get an order for Tramadol. The resident stated she did not get any Tramadol last night. When asked if she had received any Tramadol today, she said no just Tylenol. The resident stated I just want to get strong so I can do a few little things for myself. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105475 If continuation sheet Page 8 of 11 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 105475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace of Delray Beach Nursing and Rehabilita 5430 Linton Blvd Delray Beach, FL 33484 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 Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review; it was determined that the facility failed to ensure pharmacitical services were provided that ensured the accurate administration of medications per the physician orders, for 1 of 29 opporunities observed duringa medication observation, affecting Resident #86. The findings included: A review of the facility's Policy, titled Administering Medications dated 2001 and revised in December 2012 revealed Medications ordered for a particular resident may not be administered to another resident and the individual administering the medication will record in the resident's medical record .the dosage. 1. On 06/27/23 at 8:45 AM, a medication observation pass was conducted with Staff D, Licensed Pratical Nurse /LPN, for Resident #86. Resident #86's blood pressure and pulse were taken. The blood pressure was recorded as 133/56 and a pulse of 56. Staff D was observed preparing the resident's medication to include 9 oral medications. The pill count was confirmed to be 9 with Staff D. Staff D was observed entering Resident #86's room and proceeded to administer the oral medications. On 06/27/23 at 10:00 AM, the medications for Resident # 86 were reconciled to the Medication Administration Record (MAR). The Physician's order for Resident #86's medication for Amlodipine 5 milligrams (mg) ( a medication for blood pressure) was to give 2 tablets by mouth one time a day for Hypertension. Hold for SBP (systolic blood pressure) <110 and HR (heart rate) <60. Staff D did not follow the Physician's orders for Resident #86. Amlodipine should have been held due to a HR of 56 to follow the Physician's order. This was discussed with the Director of Nurses (DON) on 06/27/23 at 2:00 PM who acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105475 If continuation sheet Page 9 of 11 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 105475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace of Delray Beach Nursing and Rehabilita 5430 Linton Blvd Delray Beach, FL 33484 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to provide foods that were prepared in a sanitary manner in accordance with professional standards. Residents Affected - Some The findings included: 1. During the initial kitchen tour, on 06/25/23 at 8:53 AM, accompanied by the Food Service Director (FSD) and Staff A, [NAME] the following were noted: a. The air conditioning unit was not working in the kitchen, and the facility had been using portable units to cool the kitchen. The portable units required water to be plumbed to them. The water that was plumbed to the portable units was the cold water from the hand washing sink, located at the end of the production area where meals are plated from the hot holding unit. Due to the units being plumbed to the hand washing sink, the sink was rendered unusable due to only having hot water. The facility converted a food prep sink at the coffee / beverage station into a designated hand washing sink by installing a soap dispenser and paper towel dispenser on the wall over and next to the sink. The designated hand washing sink that was next to the coffee / beverage station was observed to have a bucket that contained cloudy liquid (sanitizer, according to staff) and towels that were being used to sanitize food and non-food contact surfaces in the basin of the sink. The hand washing sink was the only working hand washing sink due to the air conditioning not working in the kitchen. b. Coffee pots were stored directly under the hand soap dispenser that was mounted to the wall at the hand washing sink. c. Staff A, Cook, dropped a pan of sliced ham on the floor and some of the ham in the pot had spilled over onto the floor. Staff A picked up the pieces of ham from the floor with her gloves hands and placed the pieces of ham in the trash receptacle at the end of the food assembly line area. Staff A then proceeded to wrap a full size 2 inch deep pan of the ham without changing gloves and performing hand hygiene until surveyor intervention. d. There was an accumulation of rust on the vents in the exhaust over the cooking equipment. e. There was an accumulation of residue on the lids and exterior of the ice machines. f. The floor drain under the three compartment sink was overflowing onto the floor. g. The surface on the top of the toaster was peeling. h. There was an accumulation of residues on the wall behind the tables in the food preparation area by the ice machines. i. There was an accumulation of food residues on the blade to the counter mounted manual can opener. j. Accumulation of ice from the cooling units directly over and on a box of commercially processed whip cream in the walk in freezer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105475 If continuation sheet Page 10 of 11 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 105475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace of Delray Beach Nursing and Rehabilita 5430 Linton Blvd Delray Beach, FL 33484 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some k. The floor inside of the entrance to the walk in cooler was damaged to a point that exposed the raw concrete underneath the tiles. At the conclusion of the initial kitchen tour, the FSD acknowledged understanding of the concerns. 2. On 06/26/23 at 6:55 AM, during an observation in the kitchen, accompanied by the FSD, the hand washing sink located at the coffee / beverage station had a bucket of cloudy liquid and there were numerous used cups, utensils and towels in the basin of the sink. At the time of the observation, the FSD was made aware and instructed staff to stop using the sink for food and drink preparation. 3. During the follow up kitchen tour, on 06/27/23 at 11:07 AM, accompanied by the FSD and Staff A, Staff B (Cook), was observed picking up an object from the floor. The cook placed the object in the waste receptacle and continued through the kitchen. The [NAME] was instructed to wash her hands prior to continuing work. The [NAME] proceeded to the hand washing sink that was not in use, turned on the water and ran her hands under the water and then turned off the water and dried her hands. The [NAME] then proceeded again through the kitchen until being prompted by the surveyor to properly wash her hands with soap at the working hand washing sink. The [NAME] then exited the kitchen to retrieve an empty food trolley so that staff could place meals in it for the residents. At the time of the observation, the FSD acknowledged understanding of the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105475 If continuation sheet Page 11 of 11