Inspection·February 2, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 01/30/23 at 11:30 AM, it was noted that all milk and juice portions were being served in proper reusable 4 ounce drinking cup. The FSS stated to the surveyor that the cups and lids were located in the dietary storeroom and had been available for the residents the entire time. 4) Observation conducted in the main kitchen on 01/30/23 (9 AM and 11 AM), 01/31/23 (7 AM and 11 AM), and 02/01/23 (7 AM and 11 AM) noted that numerous hundreds of food portions that included milk, juices, desserts, pureed foods, mechanically altered foods, soups, fresh and canned fruits were being served in disposable bowls, cups, disposable silverware, and soufflé containers. Upon interview with the FSS at the time of the observations, it was reported that the serving of foods is a daily kitchen process and that she was unaware that the continued serving of foods in disposable containers is a resident dignity issues. It was estimated with the Food Service Supervisor on 01/31/23 that each resident receives up to 5-7 disposable dishware per day (estimated 800- 1200 individual disposable dishware). 5) On 01/31/23 at 9:05 AM, a dining observation was conducted at the facility's Cambridge Unit. On 01/31/23 at 9:09 AM, observation revealed Staff H, Certified Nursing Assistant (CNA) delivered Resident #87's meal tray to her room, placed the tray on top of table and walked away from the resident to deliver more trays. On 01/31/23 at 9:37 AM, observation revealed Staff H feeding Resident #87, standing next to the resident rather than sitting. Consequently, an interview was conducted with Staff H who stated Resident #87 was a good eater and eats 100% of her meals. On 02/01/23 at 2:04 PM, an interview was conducted with Staff H, who stated that he is supposed to sit down while feeding a resident. Staff H added that it is tough to feed Resident #87 while sitting because it did not give the ability to feed the resident. Staff H added when you stand up is much easier to feed Resident #87. Staff H was asked if he had informed the Unit Manager regarding the difficulty feeding the resident while sitting, and he stated No. On 02/02/3 at 8:22 AM, an interview was conducted with Staff K who stated it was not appropriate to stand while feeding the resident. Staff K stated it is tough to feed Resident #87 while sitting because she moves a lot. Staff K was asked if she had communicated the issue to the Unit Manager and stated she sits down to feed the resident. On 02/02/23 at 8:47 AM, an interview was conducted with Staff M, RN-UM who stated she had not heard any issues from the CNAs having trouble feeding Resident #87 while sitting. On 02/02/23 at 9:20 AM, observation revealed Resident #87 lying in bed while beingfed by Staff H. Further observation revealed Staff H was standing while feeding the resident. Consequently, an interview was conducted with Staff H while feeding the resident and it was stated that the resident was almost done with her meal. Review of Resident #87's clinical record documented an initial admission to the facility on [DATE] and a readmission on [DATE]. The resident diagnoses included Alzheimer's, Schizophrenia, Seizures, Dysphagia, Hypothyroidism, and Adult Failure to Thrive. Resident #87's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident had short and long term memory problem and severely impaired for decision making. The assessment documented under Functional Status that the resident was total dependent on the staff for all ADL's (Activities of Daily Living). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 2 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6) On 01/31/23 at 9:16 AM, observation revealed 12 (twelve) residents in the skilled dining room and 2 two CNA's in the room delivering residents trays. At 9:19 AM, observation revealed Staff I, CNA started to feed Resident #95 while her table mate Resident #98 had her meal tray in front of her. Resident #98 needed assistance with feeding. Observation revealed from 9:19 AM to 9:30 AM Resident #98 was looking at Staff I, feeding her table mate Resident #95. At 9:30 AM, observation revealed Staff Z, CNA started to feed Resident #98, 11 minutes after her table mate (Resident #95) started to eat. Review of Resident #95's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Alzheimer's, Dysphagia and Nutritional Deficiency. Resident #95's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident had short and long term memory problem and severely impaired for decision making. The assessment documented under Functional Status that the resident was total dependent on the staff for all ADL's. Review of Resident #98's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Alzheimer's, Aphasia, Hemiplegia, Dysphagia and Nutritional Deficiency. Resident #98's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident had short and long term memory problem and severely impaired for decision making. The assessment documented under Functional Status that the resident was total dependent on the staff for all ADL's. On 01/31/23 at 9:21 AM, observation revealed Staff J, CNA setting up Resident #78's meal tray. Resident #78 was able to eat by herself. Resident 78's table mate, Resident #77 meal tray was on top of the table in front of the resident. Further observation revealed Resident #77 attempting to open the hot cereal bowl and was not successful. Observation revealed Staff J placed Resident #77's meal tray away on from her but still was left at the table. Resident #77 needed assistance with feeding. At 9:23 AM, observation revealed Staff J,CNA serving coffee to other residents in the dining room. At 9:24 AM, Staff J started to feed Resident #77 and at 9:25 AM, stopped feeding the resident to remove another resident from the dining room. Staff J returned to Resident #77 at 9:29 AM and proceeded to feed the resident. Resident #77 waited 8 minutes to be fed while her table mate, Resident #78, was eating. On 02/01/23 at 9:04 AM, meal trays arrived at the facility's Cambridge Unit. Observation revealed 12 residents sitting down in the skilled dining room. Observation revealed Resident #78 drinking coffee and eating a muffin. Resident #77 who needed assistance with dining was looking at her table mate eating and drinking. Further observation revealed Resident #77's meal tray was on top of the table to the side of the resident. Resident #77 was alert and looking and following with her eyes as the staff coming in to the room with trays. Resident #77 was asked if she was hungry and stated Yes. At 9:23 AM, Staff J, CNA started to feed Resident #77 and Resident #78 received her tray. Review of Resident #78's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Dementia, Diabetes Mellitus, Hemiplegia and Dysphagia. Resident #78's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive to total assistance from the staff for all ADL's. Review of Resident #77's clinical record documented an initial admission to the facility on [DATE] with a readmission on [DATE]. The resident's diagnoses included Parkinson's Disease, Alzheimer's, and Dysphagia. Resident #77's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 3 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident had short and long term memory problem and severely impaired for decision making. The assessment documented under Functional Status that the resident was total dependent on the staff for all ADL's. On 02/01/23 at 9:14 AM, observation revealed Resident #95's meal tray in front of her. Resident #95 needed assistance with feeding. Resident #95 was alert and looking to her table mate Resident #2, who was fed by Staff K, CNA. At 9:27 AM, further observation revealed Staff M, RN started to feed Resident #95. Resident #95 waited to be fed 13 minutes while Resident #2 was fed. Review of Resident #2's clinical record documented an initial admission to the facility on [DATE] with a readmission on [DATE]. The resident's diagnoses included Multiple Sclerosis, and Paraplegia. Resident #2's Minimum Data Set (MDS) comprehensive assessment dated [DATE] documented the resident had no cognition issues. The assessment documented under Functional Status that the resident was total dependent on the staff for all ADL's. Review of Resident #143's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Cerebral Edema, Malignant Neoplasm of the Brain and Seizures. Resident #143's Minimum Data Set (MDS) comprehensive assessment dated [DATE] documented the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff for all ADL's. On 02/01/23 at 9:18 AM, observation revealed Resident #143's meal tray on the table in front of her and not eating, and not been encouraged or cued by the staff to eat. At 9:29 AM, observation revealed Staff K sat down to feed Resident #143, 11 minutes after the tray was delivered to the resident. Resident #143 needed assistance with feeding. On 02/01/23 at 9:35 AM, observation revealed Staff H, CNA and Staff L, CNA passing tray meal trays to the residents in their room at the facility's Cambridge Unit. An interview was conducted with Staff Lwho stated that once they finished passing the room trays, then she will go to the dining room to help. On 02/01/23 at 2:04 PM, an interview was conducted with Staff H who stated they could not feed two residents at once and most of the time one resident had to wait to be fed while they are finishing with the other. On 02/02/23 at 8:22 AM, an interview was conducted with Staff K who stated that she works at the Cambridge Unit most of the time. Staff K stated that Resident #95 is usually fed by the hospice aide and the hospice aide was not there. Staff K stated it was not right for residents to be at the table while the table mate is fed. Staff K stated they did not have enough help. Staff K stated the residents had to wait until the room trays are passed and then they are fed. On 02/02/23 at 8:47 AM, an interview was conducted with Staff M, RN-UM who stated when the residents receive their meals they should be fed simultaneously. Staff M stated they are not short- staffed and that she will make sure the residents are fed at the same time. Staff M stated that most residents in the skilled dining room needed some type of assistance with eating. On 02/02/23 at 2:14 PM, an interview was conducted with Staff J, CNA who stated that it is a dignity issue when one resident is eating and the other resident at the same table is not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 4 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Based on observation, interview and record review, the facility failed to serve residents in a manner to enhance or maintain the dignity of the residents during dining. The findings included: Review of the facility's policy titled Dignity published on 11/30/22 documented Residents are treated with dignity and respect at all times .provided with a dignified dining experience .staff are expected to treat cognitively impaired residents with dignity and sensitivity . 1). During an observation of lunch being served on to the residents in the dining room of the C-Wing (Rooms 300 to 332), on 01/30/23 12:48 PM, staff were observed removing the trays from the covered speed rack that was used to transport the meals from the kitchen to the units. Staff were noted to remove the tray from the speed rack and place the meal in front of the residents and remove the covers from the meal and the lids from the containers and open the cartons of various fluids. Once the staff had completed setting up the meals for the residents, staff would leave the entire meal on the tray that it was served on. During an observation of lunch being served to the residents in their rooms of the C-Wing, on 01/30/23 at 12:55 PM, staff were observed removing the trays from the covered speed rack that was used to transport the meals from the kitchen to the units. Staff were noted to remove the tray from the speed rack and place the meal in front of the residents and remove the covers from the meal and the lids from the containers and open the cartons of various fluids. Once the staff had completed setting up the meals for the residents, staff would leave the entire meal on the tray that it was served on. During an observation of lunch being served in the dining room on the B-wing (Rooms 200 to 232), on 01/30/23 01:14 PM, staff were observed removing the trays from the covered speed rack that was used to transport the meals from the kitchen to the units. Staff were noted to remove the tray from the speed rack and place the meal in front of the residents and remove the covers from the meal and the lids from the containers and open the cartons of various fluids. Once the staff had completed setting up the meals for the residents, staff would leave the entire meal on the tray that it was served on. During an observation of breakfast being served to the residents in their rooms on the C-Wing, on 01/31/23 at 9:05 AM, staff were observed removing the trays from the covered speed rack that was used to transport the meals from the kitchen to the units. Staff were noted to remove the tray from the speed rack and place the meal in front of the residents and remove the covers from the meal and the lids from the containers and open the cartons of various fluids. Once the staff had completed setting up the meals for the residents, staff would leave the entire meal on the tray that it was served on. During an observation of breakfast being served to the residents in their rooms on the C-Wing, on 02/01/23 at 9:04 AM, staff were observed removing the trays from the covered speed rack that was used to transport the meals from the kitchen to the units. Staff were noted to remove the tray from the speed rack and place the meal in front of the residents and remove the covers from the meal and the lids from the containers and open the cartons of various fluids. Once the staff had completed setting up the meals for the residents, staff would leave the entire meal on the tray that it was served on. During an observation of lunch being served to the residents in their rooms on the B-Wing, on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 5 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0550 Level of Harm - Minimal harm or potential for actual harm 02/01/23 at 1:11 PM, staff were observed removing the trays from the covered speed rack that was used to transport the meals from the kitchen to the units. Staff were noted to remove the tray from the speed rack and place the meal in front of the residents and remove the covers from the meal and the lids from the containers and open the cartons of various fluids. Once the staff had completed setting up the meals for the residents, staff would leave the entire meal on the tray that it was served on. Residents Affected - Some During an interview, on 02/01/23 01:21 PM , with Staff U, CNA (Certified Nursing Assistant) on the 200 unit, when asked about the policy for dignity during dining regarding the meals being served on the trays, Staff U replied, that's just the way that we do it. During an interview, on 02/02/23 at 1:18 PM, with Staff V, RN(Registered Nurse), when asked about serving lunch to the residents on the trays, Staff V replied, Usually we take the tray in and put the food on the table. During an interview, on 02/02/23 at 8:47 AM, with Staff M, RN/Unit Manager, Staff M stated the staff do not remove the tray, moving forward that will be corrected. Staff M further stated that staff do remove the meals from the trays in the main dining room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 6 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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, the facility failed to assess 2 of 2 sampled residents for self-administration of medications for Resident #79 to safely store, transport and administer mediations at dialysis, and for Resident #34 to safely to store, and administer medications in the resident's room. Residents Affected - Few The findings included: 1. Review of the Facility's Policy & Procedure for Self Administration of Medications, documented, in part: * Policy Heading: Resident have the right to self-administer medication if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. * The medication is appropriate for self-administration. * The resident is able to read and understand medication labels. * The resident can comprehend the medications purpose, proper dosage, timing, signs of side effects and when to report these to staff. * The resident has the physical capacity to open medication bottles, remove medication from a container, and ingest and swallow medication. * The resident can follow directions and tell time to know when to take the medication. * The resident is able to safely and securely store the medication. Record review for Resident #79 noted the resident had a diagnoses of End Stage Renal Disease and received dialysis three times per week on Monday, Wednesday, and Friday with a chair time of 11:30 AM and return times of 4:30 PM (to the facility). Review of current physician orders,, dated 12/14/22, included a summary of: Midodrine 10 mg HCL 10 mg give 1 tab every day shift every Monday, Wednesday, and Friday for Hypotension, send tablet with patient to dialysis to administer for SBP (systolic blood pressure) Less than 130. Review of the Medication Administration Records (MAR) for December 2022 and January 2023 noted documentation the dose of Midodrine was sent with the resident to dialysis. The nurse notes documented the Midodrine 10 mg dose was also sent with the resident to dialysis on scheduled dialysis days. Review of the clinical record noted that an assessment of Self Administration of Medications for Resident #79 was not conducted to ensure that the resident was safe to store, transport, and administer prescription medication. Interview conducted with the Director of Nursing on 02/01/23 noted that the clinical record of Resident #79 was reviewed and no assessment for self-administration of medication had been conducted for Resident #79. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 7 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview conducted with Resident #79 on 01/31/23 noted the resident to be alert, hard of hearing, and with some cognitive impairment. A follow-up interview was conducted with Resident #79 on 02/02/23 at 9 AM, who stated that on dialysis days he is given an envelope that he has been told is the medication to take to the dialysis center and that sometimes he puts the envelope in his pocket or in his wheelchair bag. The resident further stated he gives the envelope to staff at the dialysis center upon arrival. On 02/02/23 at 7:30 AM, the Director of Nursing submitted a Self-Administration of Medication Review that was conducted for Resident #79 which was dated 02/02/23. The review documented the following: * Resident unable to state the name of the medication and what it is used for. * Resident unable to correctly state what time the medication is to be taken. * Resident unable to correctly state the proper dosage of the medication. Under, Determination, it was documented, Resident has been evaluated and is Not Safe to self-administer medications. Review of Transfer Forms of Resident #79 from 12/14/22 to 01/30/23 noted documentation that the medication was administered only on 6 days of the 25 times the resident went to the dialysis center: 01/27/23, 01/25/23, 01/23/23, 01/20/23, 01/18/23, and 01/6/23. The total dialysis treatments for the same period of time was 25 sessions. 2) Review of Resident #34's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Fracture of Left Forearm with Subsequent Encounter for Closed Fracture, Displaced Fracture of Medial Malleolus of Right Tibia, Subsequent Encounter For Closed Fracture, Dislocation of Right Ankle Joint, Atrial Fibrillation, Essential Hypertension(I10), Major Depressive Disorder, Anemia, Insomnia, Glaucoma and Protein-Calorie Malnutrition. Review of Resident #34's Minimum Data Set (MDS) admissions assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10, indicating that the resident had moderate cognition impairment.The assessment documented under Functional Status that the resident needed from extensive to total assistance with ADLs (activities of daily living). Review of Resident 34#'s care plans on file revealed a lack evidence of a Self-Administration of Medications care plan. Review of Resident #34's physicians order dated 12/10/22 documented, Ascorbic Acid (Vitamin C) 500 mg daily. Physician order dated 01/05/23 documented Vitamin C chewable 500 mg one time a day and discontinued on 01/16/23. Review of Resident #34's clinical record revealed the file lacked evidence of a physicians order for Florastor, no physicians order for Refresh Optive- Lubricant eye drops, and no physician order for Acerola-Chewable Vitamin C. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 8 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #34's January 2023 Medication Administration Record (MAR) revealed no entry for Florastor or Refresh Optive- Lubricant eye drops. The MAR documented Ascorbic Acid (Vitamin C) 500 mg daily. On 01/30/23 at 12:43 PM, observation revealed Resident #34 in bed, in the presence of a visitor. The visitor introduced herself as the resident's daughter. A joint interview with the resident and the daughter was conducted. During the interview, observation revealed a full bottle of Acerola 500 mg (Vitamin C) chewable two bottle of Florastor ( a probiotic) and a box of Refresh Optive lubricant eye drops. An inquiry was made regarding the over the counter (OTC) medications in the room. The residents daughter stated that the Nurse Practitioner told her to get Florastor for Resident #34 to take daily. The daughter added that she obtained the Florastor at the pharmacy because it is an OTC and did not need a prescription. The residents daughter stated that the facility had Vitamin C in a tablet form and that she wanted Resident #34 to have Vitamin C chewable. The residents daughter stated regarding the Refresh Optive lubricant eye drops that it was prescribed by the Eye specialist and that she would not allow the nurses to put eye drops on Resident #34's eyes. During the interview, Resident #34 and the daughter were informed that the facility has to have a physicians order for the medications to be in the room and administered by her. Resident #34 replied those drops are just water and they don't need a prescription. On 2/01/23 at 2:43 PM, an interview was conducted with Staff B, Registered Nurse (RN) who stated that on 01/31/23, she saw Eye drops in Resident #34's room and spoke with the resident's daughter about it. Staff B stated the daughter told her that the eye drops in the room were her drops and that she will put them in a drawer if it was going to be trouble. Staff B stated that the resident's daughter stated she preferred the resident to have Vitamin C chewables. Staff B stated there was not an order for Vitamin C chewables and that the facility had to order them because they did not have in stock. Staff B stated if the resident wants to keep medications in the room they will give them a lock box. Staff B was apprised that on 01/30/23 an interview was conducted with Resident #34 and the daughter and they both stated that the eye drops were the resident's drops recommended but the eye specialist. Staff B was informed that there was also a bottle of Acerola -Vitamin C, two bottles of Florastor in the room during the interview. Staff B stated she did not know and did not see those bottle in the room. Staff B stated the resident was transferred to the hospital. On 02/01/23 at 2:45 PM, an interview was conducted with Staff N, RN who stated she administered Resident #34's morning medications today. Staff N stated the medications included Vitamin C and Florastor. Staff N was asked if she administered any eye drops to Resident #34 and stated No. Staff N stated she did not give the resident the facility's Vitamin C because the resident's daughter declined and gave the resident Vitamin C from a bottle the daughter had in the room. Staff N stated the daughter declined for resident to take Florastor from her. Staff N stated the daughter obtained the Florastor from a bottle she had in the room and administered to the resident in front of her. Staff N stated she did not have Vitamin C chewables. Staff N stated residents are not supposed to have medications in the room and added for some reasons she did not want to give them to the facility. Staff N stated that the daughter was aware that she was not allowed to have medications in the room but did not follow the rules. Staff N was asked if she had informed Staff B, RN of medications in Resident #34's room and stated she had not. On 02/01/23 at 3:40 PM, an interview was conducted with the MDS Coordinator who stated that Resident #34 was not assessed for Self-Administration of Medications therefore, there was not a care plan initiated for it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 9 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. 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 act on and resolve grievances voiced by the Resident Council, with the potential to effect residents in the facility that prefer meals in the Dining Rooms(s) and the timing of the meals being served. Residents Affected - Some The findings included: During an interview, on 01/30/23 at 11:59 AM, with Resident #13, when asked about dining, Resident #13 replied, We used to have dinner in the main dining room, but we don't anymore because there is not enough staff. I don't like eating dinner in my room. Lunch, we eat in the main dining room Monday through Friday. During a review of the Resident Council Meeting Minutes and the Menu Committee Meeting minutes, on 02/01/23 at 12:15 PM, the following grievance was noted: 09/15/22: - Main Dining Room is now open to residents for lunch only. - Main Dining Room is requested to be open for [NAME] Hashana dinner - Main Dining Room is to be served first before the units receive lunch trays Action taken 09/19/22, The Main Dining room is being served at the appropriate time of 12:30 PM. the council is in agreement with this time for lunch. Lunch trays continue to be served late. This issue will be addressed at the October menu meeting. October Menu Meeting 10/20/22, The committee would like to have the main dining open at 12:30 pm instead of 12:00pm to decrease their wait time for lunch to be served. Resident Council Meeting 11/17/22, Dining room meal serving time needs to improve. Menu Committee Meeting 12/22/22, the lunch meal time will go back to 12pm in the MDR (main dining room) instead of 12:30pm. During an interview with members of the Resident Council, on 02/01/23 at 1:37 PM, including Resident #13, with a Brief Interview for Mental Status (BIMS) score of 14 (cognition intact), Resident #91, with a BIMS score of 11 (cognition moderately impaired), Resident #28, with a BIMS score of 12 (cognition moderately impaired), Resident #27, with a BIMS score of 13 (cognition intact), and Resident #103, with a BIMS score of 12 (cognition moderately impaired), when asked about the timing of the meal service, all of the attendees agreed hat the timing of food was still a problem. Resident #13 stated, I think thing were on time today because the staff knows that the state is here. When asked about eating in the Main Dining Room for Dinner and eating in the Main Dining Room on the weekends, Resident #13 stated, We are supposed to be having dinner in the dining room Monday through Friday, but it's not happening. They tell us that there are staff problems not having enough people to clean up after and not enough staff in the kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 10 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0565 Level of Harm - Minimal harm or potential for actual harm During an interview, on 02/02/23 at 1:36 PM, with the Chef and the Regional Dietary Director, when asked about service in the Main Dining Room, the Chef stated, The people from Activities will come over and serve (in the Dining Room) had no knowledge of the concern. The Chef and the Regional Dietary Director stated that they had no knowledge of the concern with the residents wanting to eat dinner in the Main Dining Room. Residents Affected - Some During an interview, on 02/02/23 at 1:45 PM, with the Activities Director, when asked about the grievances by the Member of the Resident Council, the Activities Director stated that the Resident Council is still voicing that they would like to use the Main Dining Room for more than just lunch Monday through Friday and concerns regarding the timing of the meal service. During an interview, on 02/02/23 2:03 PM with the DON (Director of Nursing), when asked about the concerns voiced by residents about eating in the Main Dining Room, the DON replied, We were talking about that, We spoke with the residents and there were some of them that wanted to eat in their room so that they can go to bed. We know that there are some that definitely want to come. When asked about the concerns with the timing of the meals and being served late, the DON replied, With the previous Dietary Manager, we moved it from 12:00 to 12:30, we were working with the Resident Council President. When Resident #23 was the President, we pushed it to 12:30 and it was well. It was a request from her that we push it to 12:00 and she was good with that, and it worked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 11 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0584 Level of Harm - Minimal harm or potential for actual harm 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. Based on observations and interviews, the facility failed to maintain the facility's laundry services in a clean and sanitary manner. Residents Affected - Some The findings included: A tour of the laundry room was conducted on 02/02/23 at 11:00 AM with a fellow surveyor and Staff S, Laundry Aide and Staff T, Housekeeping Manager. The following areas of concern were observed, and photographic evidence was obtained: 1) In the dirty linen sorting area, it was observed that 2 of the 3 dirty laundry carts had interior build-up of dust, dirt, and debris; and the exteriors of the carts were worn, ripped, and rusty. This could potentially contaminate the soiled linens. 2) In the dirty linen sorting area, it was observed that 2 used isolation gowns were hanging on the wall on hooks, indicating the staff intended to re-use them. Staff T stated the staff members do re-use the isolation gowns. The surveyors explained that it is best practice for the staff members to wear new isolation gowns for each load of laundry to ensure they are not cross-contaminating loads. 3) In the dirty linen sorting area, it was observed that there was a wet, used mop head sitting in the bottom of a plastic garbage can. The surveyors explained that this can breed bacteria which can cause contamination in the facility. 4) When assessing the 2 washing machines, it was observed that 3 of 4 external filters on the 2 washing machines were dust and dirt laden. 1 of the 4 external filters was missing. Staff T stated she had attempted to clean the filter approximately 1 week prior to the survey, but it fell apart. It was noted by the surveyors that there was a sign directly under each of the filters which stated Clean filter daily. Staff T agreed the filters were not being cleaned regularly. 5) Observed in the clean linen area were 2 additional isolation gowns hanging on the wall on hooks, indicating the staff intended to re-use them. Staff T stated the staff members do re-use the isolation gowns. The surveyors explained that it is best practice for the staff members to wear new isolation gowns for each load of laundry to ensure they are not cross-contaminating loads. 6) Also observed in the clean linen area were 5 clean laundry carts, all of which had interior build-up of dust, dirt, and debris, and the exteriors of the carts were worn, ripped, and rusty. This could potentially contaminate the clean linens. Each of the clean laundry carts also had an inner bottom which was supposed to operate on a spring-system which, when working properly, would cause the inner cart bottom to raise up to assist the staff in the removal of the clean linens from the cart. In all of the clean laundry carts, this spring-system was broken, which caused the carts to not be in proper working order. This also caused the inner bottom to be loose, which made it possible for linens to become misplaced under the inner bottom. 7) When assessing the 3 dryers, it was observed that each of the internal dryer drums had a thick, heavy build-up of rust, black matter, and unidentified melted substances around the entire surface. This could potentially contaminate the clean linens. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 12 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 8) Also during the assessment of the dryers, it was observed that 1 of the dryer door gaskets was cracked and in disrepair, which created an uncleanable surface. This could also potentially contaminate the clean linens. 9) During the assessment of the clean laundry carts, it was observed that 1 of the cart covers had a large hole present at the top. This could potentially cause the clean linens to become contaminated during transport to the units for resident and staff use. An interview was conducted with a member of the corporate office after the tour of the laundry room was conducted. The areas of concern were discussed with this individual and he stated there were improvements already in the works. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 13 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide foot care to 2 of 2 sampled residents reviewed for foot care (Resident #39 and #78). Residents Affected - Few The findings included: 1) Review of Resident #39's , clinical record documented an initial admission on [DATE] and a readmission on [DATE]. The resident was under hospice care since 10/14/22. The resident diagnoses included Coronary Artery Disease (CAD), Atrial Fibrillation, Peripheral Vascular Disease (PVD), Diabetes Mellitus, Gout, Osteomyelitis of the lumbar sacral region and Stage IV Pressure Ulcer to the Sacrum. Review of Resident #39's Minimum Data Set (MDS) significant change assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 12 indicating that the resident was moderately impaired. The assessment documented under Functional Status that the resident needed extensive to total assistance from the staff for all activities of daily living (ADL). Review of Resident #39's care plan titled ADL initiated on 02/26/22 and revised on 10/27/22 documented that the resident needed extensive assistance with bathing and grooming. On 01/30/23 at 12:40 PM, an interview was conducted with Resident #39 who stated that he had asked the staff for his toenails to be cut and it had not been done. Observation of the resident's toenails revealed elongated toenails. Record review revealed a physicians order dated 04/21/22, Podiatry Consult as needed. Review of Resident #39's clinical record revealed no Podiatry consultation note on file. On 02/01/23 at 9:51 AM, a side by side observation of Resident #39's toenails was conducted with Staff B, Registered Nurse (RN). Staff B confirmed the resident toenails were elongated and stated that the resident needed to be seen by a Podiatrist. Staff B stated that a Podiatrist comes to the facility every six (6) weeks and some residents have to go out for the care. During an interview, Staff B stated that she did not see a Podiatry consult note in the resident's file. On 02/01/23 at 10:07 AM, an interview was conducted with Medical Record Coordinator who stated that she checked Resident #39's file back to 2021 and did not see a Podiatry consultation note. On 02/01/23 at 10:05 AM, an interview was conducted with the facility's Director of Social Services (DSS), it was revealed that the nurse requests Podiatry service for the resident and then she contacts the provider for consultation. The DSS stated that Resident #39 was not listed for Podiatry service in January 2023. The DSS stated the Podiatry group e-mails the completed consultation note to her, then she files them in the resident's paper record, not in the electronic record. On 02/01/23 at 12:36 PM, during an interview, the DSS stated that it was an oversight. The DSS stated that she had no record of Podiatry care provided to Resident #39. 2) Review of Resident #78's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident diagnoses included Cerebral Infarct, Occlusion Left Anterior (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 14 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Cerebral Artery affecting right dominant side, Dysphagia, Aphasia, Diabetes Mellitus (DM), Pulmonary Fibrosis, Hypertension, Dementia, Pacemaker, CAD, Anemia, Coronary Artery Disease (CAD), and Peripheral Vascular Disease (PVD). Review of Resident #78's MDS quarterly assessment dated [DATE] documented a BIMS score of 6, indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance to total assistance from the staff with her ADLs. Review of Resident #78's care plan titled, ADL, initiated on 03/24/22 and revised on 09/02/22 documented that the resident needed extensive assistance with bathing and grooming from the staff. Record review revealed a physician's order dated 09/21/21, which documented Podiatry Consult as needed. Review of Resident #78's clinical record on file contained a Podiatry consultation dated 07/27/22 that documented Nails are elongated & mycotic .Assessments: Onychomycosis, PVD, Non- Insulin DM, Hemiplegia .failure to debride nails/lesions can lead to complications due to systematic disease marked . failure to provide treatment is likely to result in medical complications . Podiatry consultation in chart noted 05/05/22. On 01/31/23 at 10:14 AM, a telephone interview was conducted with Resident #78's daughter who stated she told the nurse three times in the last three months that the resident's toenails needed to be done and they still have not be done. On 02/01/23 at 8:09 AM, observation revealed Resident #78 sitting in a recliner wheelchair and wearing non-skid socks. Resident was not interviewable. Consequently, a side by side observation of the resident's feet was conducted with Staff J, Certified Nursing Assistant (CNA). The review revealed resident's right foot with elongated nails and one jagged toe nail. The left foot revealed elongated nails. Staff J stated that the facility has a foot doctor that comes to see the residents. Staff J confirmed that Resident #78's toenails were long. On 02/01/23 at 10:16 AM, an interview was conducted with the DSS who stated that Resident #78 was scheduled to be seen by a Podiatrist on 01/22/23 but had marked on the January 2023 list that the resident was seen on 12/22/22. The DSS was asked to submit a copy of 12/22/22 Podiatry consultation note. The DSS stated she checked her e-mail from Podiatry and did not see a note for Resident #78's Podiatry visit on 12/22/22. The DSS stated that it was probably a name mix up. The DSS stated that they have two residents with unbelievable close names, same first name and last name very similar. The DSS believed the Podiatrist was referring to the other resident. On 02/02/23 at 8:37 AM, an interview with Staff K, CNA who stated she will tell the nurse or the Unit Manager when a resident's toenails are long. On 02/02/23 at 8:59 AM, an interview was conducted Staff M, Unit Manager who stated that she thought Resident #78 was seen every 2-3 months by the Podiatrist. Staff M stated she saw the resident's toenails on 02/01/23 and they are long. Staff M stated she asked DSS to call the Podiatrist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 15 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to 1) ensure expired supplements and medical/biologicals supplies were removed from 2 of 3 medications/supplements storage room reviewed (Cambridge Unit, [NAME] Unit, and the Biological Storage Room); 2) keep medications carts free from loose pills/tablets noted in the drawers for 2 of 4 medications carts reviewed; and 3) ensure that 1 of 3 treatment carts (Berkshire Unit) and 1 of 3 respiratory care carts were kept secure/locked. The findings included: Review of the facility's policy titled Storage of Medications published on 11/30/22 documented .Drugs and biologicals used in the facility are stored in locked compartments .Drugs and Biologicals are stored in the packaging, containers or other dispensing systems in which they are received .the nursing staff is responsible for maintaining medication storage .in a clean, safe and sanitary manner .outdated drugs or biologicals are returned to the dispensing pharmacy or destroyed .unlocked medication carts are not left unattended .medications are stored separately from food . Review of the facility's policy titled Disposal of Medications, undated, revealed the following: Expired, adulterated or unusable medications will be discarded via a drug destruction device such as Rx Destroyer or Drug Buster. When the destruction device is full it will be placed in the soiled utility room for disposal. 1) On 01/31/23 at 11:53 AM, a side by side review of the facility's Cambridge Unit's medication/supplements storage room was conducted with Staff O, Licensed Practical Nurse (LPN). The review revealed 10 container of Pulmocare 1.5 cal with an expiration date on 02/2022 and 4 Pulmocare 1.5 cal with an expiration date on 11/2022. Staff O confirmed the expiration dates and stated that between the Unit Manager and the nurses, they were supposed to check for expiration dates. On 01/31/23 at 12:05 PM, a side by side review of the facility's [NAME] Unit's medication was conducted with Staff B, RN. The review revealed an opened and undated bottle of Reguloid (Natural Psyllium powder) inside the medication cabinet. Staff B stated an opened medication bottle was not supposed to be in the cabinet and the bottle needed to have a date written when it was opened. Staff B stated she will call the pharmacist to check if the bottle needed to be stored in the medication cart or the cabinet. Staff B then added that the Reguloid bottle did not need to be dated because it was not expired. Staff B was asked to check with the facility's pharmacist and get back with an answer to the surveyor. Continued side by side review with Staff B, RN of the [NAME] Unit's biologicals storage room revealed multiple expired laboratory tubes, foley catheters and culture swabs. During the review, Staff B stated she checks medical supplies and laboratory tubes for expiration dates and that she was planning to get rid of the laboratory tubes but had not done so. The following expired medical/biologicals supplies were found in the biological storage room: -Four (4) Urological Foley Catheter 24 French (size) with an expiration date on 12/15/21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 16 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0761 -Two (2) Urological Foley Catheter 20 French with an expiration date on 01/21 Level of Harm - Minimal harm or potential for actual harm -Three Universal Viral Transport for Viruses, Chlamydiae, Mycoplasmas, and Urea-plasmas swabs with an expiration date on 12/31/22, two (2) with an expiration date on 07/31/22, and one (1) with an expiration date on 04/21. Residents Affected - Some - Four (4) Vacuette (blue/black top) blood containers with an expiration date on 06/30/19, and eight (8) with an expiration date on 06/12/19 - Sixteen (16) BD Vacutainer (blue top) blood containers with an expiration date on 04/30/21, and one (1) with an expiration date on 12/16. - Six (6) Vacuette (purple/black top) blood containers with an expiration date on 04/12/22, four (4) with an expiration date on 02/07/20, three (3) with an expiration date on 01/11/20, and one (1) with an expiration date on 07/31/19. - Eight (8) Vacuette (red/yellow/black top) blood containers with an expiration date on 01/05/22, and six (6) with an expiration date on 06/11/20. - One(1) Vacuette (red/black top) blood containers with an expiration date on 04/07/22, three (3) with an expiration date on 12/06/21, and one (1) with an expiration date on 02/11/20. On 01/31/23 at 3:09 PM, a side by side review of the facility's Berkshire Unit's medication storage room was conducted with Staff R, RN. The review revealed a Kangaroo- Gastrostomy Feeding Tube with an expiration date on 10/01/22. Staff R confirmed the expiration date. Staff R stated that Central supply staff was supposed to check for expiration dates. 2) On 01/31/23 at 3:14 PM, a side by side review of the facility's Berkshire Unit's medication cart #2 was conducted with Staff W, RN. The review revealed one (1) loose round white pill inside cart drawer #2. Staff W confirmed the loose pill and stated it is easy for the pills to come off the package. On 01/31/23 at 3:45 PM, a side by side review of the facility's Berkshire Unit's medication cart #1 was conducted with Staff X, LPN. The review revealed three (3) loose pills, one white round, one light yellow round and one [NAME] color inside the cart second drawer. Staff X stated she checked the cart previously and there was not one loose pill. Staff X added she did not know what happened. On 02/01/23 at 7:49 AM, an interview was conducted with the facility's Central Supplies Coordinator who stated that ultimately she was responsible of checking the storage rooms for expired items. The Central Supplies Coordinator was apprised of expired items in the supplements and medication rooms. On 02/01/23 at 7:50 AM, an interview was conducted with the facility's Director of Nursing (DON) and was apprised of observations and findings. The DON stated she discarded the expired items. 3) On 02/02/23 at 1:40 PM, observation revealed an unsecured/unlocked treatment cart at the facility's Berkshire unit (Photographic evidence taken). Consequently, Staff Y, RN who was at the medication cart across from the cart was called to review the cart. Staff Y confirmed the treatment cart was unlocked and added that it is supposed to be locked. Staff Y stated she had not used anything from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 17 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0761 the cart today. Level of Harm - Minimal harm or potential for actual harm On 02/02/23 at 1:56 PM, an interview was conducted with Staff Q, RN who stated that he gave a treatment to a resident and locked the treatment cart. The treatment cart contained the following medications to include: zinc oxide, Fluocinonide external cream and Vitamin A & D ointment. Residents Affected - Some 6) During a tour of the facility conducted on 01/30/23 at 4:25 PM, the surveyor observed an unlocked respiratory treatment cart on the 412-421 hallway near the nurse's station. At 4:50 PM, an unknown staff member came to the cart to retrieve medications for a resident and locked it when she walked away. The surveyor inquired to Staff B, Unit Manager for the staff member's name but Staff B could not provide the name, stating it was a new employee and she could not remember what her name was. 7) A medication administration observation was conducted on 01/31/23 at 8:45 AM with Staff C, Registered Nurse. During the medication administration, Staff C left the resident's prescription eye drops unattended at the bedside when she went to wash her hands and obtained clean gloves for the administration of the eye drops. Also during the medication administration, the resident refused her Miralax (a powder medication which is mixed with water for administration that is used to aid in digestive health). After exiting the resident's room, Staff C set the refused Miralax into the garbage can on the side of the medication cart. Staff C did not pour the medication out into a Drug Buster bottle or into the garbage can, but rather set the full cup into the garbage can. 8) A medication administration observation was conducted on 02/01/23 at 8:15 AM with Staff D, Licensed Practical Nurse. While Staff D prepared the resident's medications, the surveyor noted an open, half consumed water bottle inside one of the drawers of the medication cart. After the medication administration, the surveyor observed Staff D place the used blood pressure cuff back into the medication cart without cleaning it first. The surveyor proceeded to interview Staff D about these two observations. When questioned about the proper procedure for cleaning a blood pressure cuff, he hesitantly stated he should have cleaned the blood pressure cuff after it was used on the resident and before it was returned to the medication cart. When questioned about the water bottle, he hesitantly replied I'm sorry and promptly threw the bottle into the garbage can on the side of the medication cart. 9) An observation was conducted on 02/01/23 at 8:36 AM in which Staff F, Licensed Practical Nurse, left her medication cart unlocked and unattended in the hallway outside of room [ROOM NUMBER]. This was also observed by Staff G, Risk Manager. Staff G promptly locked the medication cart while Staff F was in a resident's room administering medications. When Staff F returned to the medication cart, Staff G reminded her that the medication carts should be locked when not in use. 10) A medication administration observation was conducted on 02/01/23 at 8:42 AM with Staff F, Licensed Practical Nurse. This medication administration was also observed by Staff G, Risk Manager. While preparing the resident's medications, Staff F dropped a medication tablet. She picked up the medication tablet and bent down toward the garbage can on the side of the medication cart. Staff F then looked back at Staff G who stated, don't you have a bottle of med buster in your cart?. Staff F stated she did not know. Staff F then proceeded to look in the drawers of her medication cart until she found the Drug Buster bottle. Please note, it appeared to the surveyor during this interaction that Staff F did not intend to dispose of the medication tablet properly. During the medication administration, the resident refused her Metamucil (a powder medication which is mixed with water for administration that is used to aid in digestive health) along with Eldertonic (a prescribed liquid multivitamin supplement) and Pro-Stat (a prescribed liquid protein supplement). After exiting the resident's room, Staff F looked to Staff G and inquired of the proper way to dispose of the refused Metamucil, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 18 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Eldertonic, and Pro-Stat. Staff G told Staff F it was fine to put these into the garbage can. Staff F proceeded to set the refused medication and supplements into the garbage can on the side of the medication cart. She did not pour the medication and supplements out into a Drug Buster bottle or into the garbage can, but rather set the full cups into the garbage can. An interview was conducted on 02/02/23 at 2:22 PM with the facility's Director of Nursing and Assistant Director of Nursing regarding these concerns. Both the Director of Nursing and Assistant Director of Nursing agreed these liquid medications and supplements were disposed of incorrectly and should have been poured into bottles of Drug Buster. Event ID: Facility ID: 105476 If continuation sheet Page 19 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, it was determined that the approved menu was not followed for physician ordered Purred Diet, Chopped Diet, and Ground Diet which effected 8 of 8 sampled (Resident #10, #14, #70, #81, #87, #92, #98, and #213). The findings included: 1) During the review of the approved menu for the lunch of 01/30/23 noted the following to be served to residents with a physician ordered Pureed Diet and Ground Diet: * 3 ounces Pureed Fish * 4 ounces Pureed beets * Pureed Garlic Bread * Tomato Puree 3 ounces Ground Fish 4 ounces Ground Beets Observation of the tray line assembly of the lunch meal in the main kitchen on 01/30/23 at 11:30 AM, noted the following: * Pureed Fish - unavailable and not prepared for the lunch meal * Pureed Beets - unavailable and not prepared for the lunch meal * Pureed Garlic Bread - unavailable and not prepared for the lunch meal * Tomato Puree (smooth consistency) - unavailable and not prepared got the lunch meal * Ground Fish - unavailable and not prepared for the lunch meal * Ground Beets - unavailable not prepared for the lunch meal The facility's Registered Dietitian who was supervising the 01/30/23 lunch tray line was informed by the surveyor of the missing pureed and ground foods that were documented on the approved lunch menu. The Dietitian had to inform the cook to prepare the pureed and ground menu foods. It was noted that this delayed the food tray line and lunch serving times up to 30-45 minutes for 01/30/23. 2) During a review of the approved menu for the lunch and dinner meal of 01/30/23 and breakfast 01/31/23, the following were noted: * Four ounces of Pears were to be served to Regular Diet, Ground, Chopped Diet, Pureed diet, and Carbohydrate controlled diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 20 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the approved menu for the dinner meal noted for Canned Pears to be served again for Chopped Diet, Ground Diet, Pureed Diet, and Carbohydrate Controlled Diet. Interview with the facility's Registered Dietitian conducted on 1/30/23 noted that there was an error in the preparation of the approved menu to ensure that a variety of foods are included on the facility menu. 3) During the review of the approved menu noted that regular consistency Oatmeal was to be served to residents with physician ordered Pureed diet. Observation of the breakfast tray line on 01/31/23 at 7:30 AM also noted the regular Oatmeal was being served for Pureed diets. A review of the facility Diet manual for Pureed Diet noted documentation that all cooked cereal (wheat, Oatmeal, Rice) requires to be pureed. The surveyor informed the Dietitian of the documentation included in the facility's Diet Manual. The Dietitian stated that there was an error in the preparation of the approved breakfast menu and required correction. 4) During the review of the approved menu for the lunch meal of 01/31/23, it was noted that a 4 ounce portion of Roasted Potato was to served for all Regular/No Added Salt Diets, and Carbohydrate Controlled/No Concentrated Sweet Diets (CCHO/NCS). It was also noted that a 4 ounce portion of Mashed Potato be served for Ground diet and Pureed diet. During the observation of the lunch meal on 1/31/23 at 11:30 AM noted the following: (a) Observation of the Roasted Potatoes noted that the potatoes were mashed together in a large pan and could not be identified as Roasted Potatoes. The surveyor requested the FSS observe the potatoes and stated that the recipe directions was not being followed. (b) Observation of the Mashed Potatoes noted that instant mashed potatoes were prepared in place of the fresh potatoes prepared for the Roasted Potatoes. Interview with the FSS at the time of the observation noted that she was unaware that the mashed potatoes were to be prepared with fresh potatoes. The facility's Registered Dietitian who was supervising the 01/30/23 lunch tray line was informed by the surveyor of the missing pureed and ground foods that were documented on the approved lunch menu. The Dietitian had to inform the cook to prepare the pureed and ground menu foods. It was noted that this delayed the food tray line and lunch serving times up to 30-45 minutes for 01/30/23. 5) During a review of the approved menu for the lunch and dinner meal of 01/30/23 and breakfast 01/31/23, the following were noted: * Four ounces of Pears were to be served for Regular Diet, Ground, Chopped Diet, Pureed diet, and Carbohydrate controlled diet. Review of the approved menu for the dinner meal noted Canned Pears to be served again to Chopped Diet, Ground Diet, Pureed Diet, and Carbohydrate Controlled Diet. Interview with the facility's Registered Dietitian conducted on 01/30/23 noted that there was an error in the preparation of the approved menu to ensure that a variety of foods are included on the facility menu. * During the review of the facility Diet Census for 01/30/23, the following were noted: (a) Mechanically Altered Pureed Diet: Total physician ordered was 13 facility residents which included sampled Resident's #10, #78, #87, and #92. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 21 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0803 Level of Harm - Minimal harm or potential for actual harm (b) Mechanically Altered Chopped Diet: Total physician ordered was 25 facility residents which included sampled Resident's #14, and #213. (c) Mechanically Altered Ground Diet: Total physician ordered was 11 facility residents which included sampled Resident's #70, #81, and #98. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 22 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 prepare food by methods that conserve nutritive value, flavor, and appearance for physician ordered Pureed Diets which included 13 facility residents (Sampled Resident's #10, #78, #87, and #92). Residents Affected - Some The findings included: 1) Review of the: Facility Standardized Recipe for Roasted Red Potatoes, documented the following: (a) Cut potatoes into wedges, slightly boil or steam potatoes before placing in roasting pan. (b) Bake at 375 F for 30 minutes until tender and lightly browned. (c) For Pureed: Measured desired servings into food processor. Blend until smooth. Add liquid for thinning and commercial thickener if product needs thickening. During the review of the approved menu for the lunch meal of 01/31/23, it was noted that a 4 ounce portion of Roasted Potatos was to be served for all Regular/No Added Salt Diet, and Carbohydrate Controlled/No Concentrated Sweet Diet (CCHO/No Concentrated Sweets). It was also noted that a 4 ounce portion of Mashed Potatoes be served for Ground Diet and Pureed Diet. During the observation of the lunch meal on 1/31/23 at 11:30 AM noted the following: (a) Observation of the Roasted Potatoes noted that the potatoes were mashed together in a large pan and could not be identified as Roasted Potatoes. The surveyor requested the Food Service Supervisor (FSS) observe the potatoes and stated that the recipe directions was not being followed. (b) Observation of Mashed Potatoes noted that instant mashed potatoes were prepared in place of the fresh potatoes prepared for the Roasted Potatoes. Interview with the FSS at the time of the observation noted that she was unaware that the mashed potatoes were to be prepared with fresh potatoes. 2) Review of facility Standardized Recipe: Scrambled Eggs (a) Combine milk and eggs, beat lightly. (b) Do not overcook. (c) If eggs must be held for a period of time., place in lightly oiled steam table pan in 250 degree F oven. Eggs for longer than 15-20 minutes will discolor. (d) Pureed Eggs - Measure number of desired servings into food processor. Blend until smooth. Add liquid if product needs thinning or add commercial thickener if product needs thickening. During the review of the approved menu for the breakfast meal for 02/1/23, it was noted that a #16 scoop of Scrambled Eggs was to be served to Regular Diet, Chopped Diet, and Carbohydrate Controlled/No Concentrated Sweets Diet (CCHO/NCS). During the observation of the lunch meal on 01/31/23 at 11:30 AM noted the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 23 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of resident trays leaving the kitchen were noted to have scrambles eggs that were green and grayish in color. Further observation noted that the eggs in the pan located on the steam table were also green and graying in color. Interview conducted with the Certified Dietary Manager confirmed the surveyor's observation and the Certified Dietary Manager (CDM) was requested to stop serving the off color scrambles eggs and prepare a new pan. Subsequent interview with the Corporate Food Service Director on 01/31/23 noted that the eggs were held too long at too high of a temperature, causing the off color appearance. The Director stated that a new pan of eggs was prepared and the cooks have been in-serviced on proper preparation of scrambled eggs. Photographic evidence obtained. 3) During the observation of the lunch meal in the main kitchen on 1/30/23 at 11:30 AM, the pureed food plates being served to the residents were observed. The observation noted that the pureed meatball, pureed spaghetti, and pureed vegetables were spread out across the plate and running into each other across the entire surface of the plate. It was also noted that a red sauce was poured all over the mixture of the pureed meatballs (brown), spaghetti (white), and vegetable (green). Interview with the Corporate Food Service Director at the time of the observation noted to state the appearance of the pureed plate was unattractive and unacceptable in appearance. It was also discussed that if the pureed mixture is running all over the plate it could mean that the pureed foods are being watered down/thinned and potentially affecting the nutritional value of the pureed foods. The Corporate Director stated that the cooks would be in-serviced on proper preparation of pureed foods. The photos of the pureed foods were shared with the Administrator on 01/30/23. * Photographic evidence Obtained 4) Continued observation of the pureed meals for breakfast meal of 01/31/23, lunch meal of 01/31/23, breakfast meal of 02/1/23, and lunch meal of 02/1/23, continued to note the pureed foods (pureed pancakes, pureed entrée, pureed starch, and pureed vegetables to be excessively thin, spread out combining with each other on the plate, and unappetizing in appearance. On 02/01/23 the photos of the pureed meals were again shared with the Corporate Director who stated that the appearance of the pureed foods were unacceptable. The pureed food photos were also shared with the Administrator on 02/01/23. Photographic evidence obtained. 5) It was also discussed with the Corporate Director on 02/01/23 that plate garnishes are not being used for pureed breakfast meals. Specifically observations of breakfast pureed plates on 01/31/23 and 02/01/23 were only brown in color and required pureed colored garnishes to increase appearance. The director stated that the dietary department is required to provide garnishes for all resident food plates. however, the garnishes are not being prepared and served. Photos of the pureed foods were provided to the Director for review. 6) During the observation of the lunch meal in the main kitchen on 01/30/23 at 11 AM, it was noted that the Garlic Rolls prepared as per the approved menu were burned while cooking in the oven. The surveyor requested that the Garlic Bread not be served to the facility residents. Observation noted that regular bread was substituted for the Garlic Bread however, a pat of margarine was not provided. 7) During the observation of the food tray line in the main kitchen on 01/30/23 at 11:30 AM, it was noted that regular meat sauce (1-2 ounces) was being poured over the pureed meatballs and pureed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 24 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0804 Level of Harm - Minimal harm or potential for actual harm pasta. Further observation noted that the meat sauce contained large pieces of meat within. Review of the approved menu for the lunch meal of 01/20/23 noted that a Tomato Puree was to be served over the pureed meatballs and pureed pasta. The surveyor made the facility's Registered Dietitian aware of the issues and requested that the regular meat sauce cease to be served with the pureed meatballs and pasta, and to prepare the Tomato Puree as stated on the approved pureed menu. Residents Affected - Some * During the review of the facility's Diet Census for 01/30/23 noted that there were 13 residents with physician ordered Pureed Diets. This included sampled Residents #10, #78, #87, and #92. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 25 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 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. Based on observation, interview, and record review, it was determined that the facility failed to follow physician ordered Fluid restriction for 1 (Resident #79) 5 sampled residents reviewed for nutrition. Residents Affected - Few The findings included: Review of facility policy for Restricted Fluids , noted the following: * Guidelines: 1) Follow specific instructions concerning fluid restrictions. 2) Record fluid intake on the intake output record. 3) Document the amount of fluids consumed by the resident during the shift. 4) Report information in accordance with facility and professional standards of practice. Review of the clinical record of Resident #79 on 01/31/23, revealed the following: 11/27/21 - Renal Diet - End Stage Renal Disease 11/29/21 - Sugar Free Prostat 30 ml TID (Three Times Daily) in beverage of choice 12/1/21 - Nepro 8 oz TID 11/29/21 - Fluid Restriction 1500 cc - Dietary 1020, Nursing = 480 11/30/21 - Fluid Restriction Day = 240 cc /Shift, Eve =120 cc/ Night Shift = 120 cc Dialysis M/W/F chair Time = 11:30 AM - Return 4:30 PM, WT before and after During the observation of the breakfast meal on 02/01/23 it was noted the food tray served to the room of Resident #79. Review of the meal tray ticket noted documentation of: * No Added Salt Diet * Low Potassium * No Concentrated Sweets * * 1500 cc Fluid Restriction Further review of the meal tray ticket noted the following was to be served: * 4 ounces Apple Juice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 26 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 * 4 ounces Almond Milk Level of Harm - Minimal harm or potential for actual harm * 4 ounces Coffee Residents Affected - Few Further observation conducted on 02/01/23 of the breakfast tray noted that the 4 ounces of milk and 4 ounces of Coffee were not located on tray. The surveyor informed Staff M that the fluid restriction was not being followed, specifically the fluids that were supposed to be provided on the tray were not included on the tray. A second observation conducted on 02/1/23 at 11 AM noted the resident to state he was ready to be transported to dialysis. Further observation noted that the resident was drinking an 8 ounce container of Nepro Carbsteady supplement, and was also noted that his bagged lunch contained 2 - ounce Nepro supplement. The resident stated he likes the supplement and drinks numerous containers (4-5) throughout the day. At the request of the surveyor the residents' meal tray tickets were obtained and reviewed. The review noted the following fluids to be served: Breakfast = 240 cc fluids (milk, juice, coffee) Lunch = 120 cc of fluids (cranberry juice) Dinner = 120 cc of fluids (cranberry juice) A review of the January 2023 Medication Administration Record (MAR) of Resident #79 noted that the physician's order for the Fluid Restriction for Nursing documented the Day Shift of 240 cc, Evening Shift of 120 cc, and Night Shift of 120 cc. Further review of the MAR noted no documentation of the amount of fluid the resident consumed during the 3 shifts. During a meeting with the facility's Registered Dietitian on 02/01/23, the resident fluid restriction was reviewed and it was noted that the 1500 cc physician ordered Fluid Restriction was not being followed for both the dietary and nursing department. Further discussed that the dietary fluids being provided did not meat the breakfast and dinner allotment on meal trays and far exceeded the lunch fluid allotment for lunch meals on dialysis days. It was also discussed that the fluid assessment did not contain documentation of Npepro supplement was part of the 1500 cc Fluid Restriction and also failed to document if the fluids being provided with the Sugar Free Prostat were also a part of the Fluid Restriction. The Dietitian submitted to the surveyor a physician order dated 02/01/23 that documented The Fluid Restriction was increased to 1650 cc/24 hours. Further documented that the nursing fluid allotment was changed to 480 cc with medications and 480 Nepro, and 90 cc SF Prostat every 24 hours. The dietary fluid allotment was changed to 600 cc every 24 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 27 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 - Many 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, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards that include: failure to maintain refrigeration units, failure to ensure washing in the 3-compartment sink, failure to maintain and clean ceiling and light fixtures, and failure to clean and sanitize commercial food preparation equipment. The findings included: 1) During the initial kitchen/food service sanitation tour conducted on 01/30/23 at 9 AM, accompanied with the Food Service Supervisor (FSS), the following were noted: (a) Observation of the walk-in freezer noted that thermometer gauge to be 40 degrees F and also noted that the entry/exit door was ajar and would not close tightly and noted a heavy, large build-up of ice around the entire door threshold area. The FSS stated that the door is new, however, it has not been able to shut for weeks. Further stated that the issues had been reported to maintenance but has not been addressed. The surveyor informed the FSS that the internal thermometer should be held at 0 degrees F or below as per regulation and also requested the daily thermometer log for the month of January 2023. The surveyor was informed that the log could not be located and as a result requested that the Maintenance Department be notified of the temperature, ice build-up, and door issues. Upon entering the walk-in unit, it was noted that foods located within the unit were beginning to become soft to the touch of the outside packaging. Interview with the Director of Maintenance following the observation noted to state he was not aware of the freezer issues and stated that a refrigeration company would be notified for assessment and repair and if the issues persists the facility would rent a refrigeration truck for frozen food storage until the unit was properly repaired and temperatures are maintained, as per regulation. On 1/31/23 at 7 AM the Director of Maintenance submitted documentation to the surveyor that included the following: * The temperature gauge was broken and replaced with a new new gauge. * The door heating element was repaired to ensure that there was no build-up of ice around the threshold. * The door closure mechanism required repair. * Continued documentation noted upon repair completion, the unit temperature was recorded at 5 degrees F and was dropping. * Temperature observation conducted on 02/01/23 noted that the internal temperature of the walk-in freezer was -5 degrees F. (b) Observation of the 3-compartment sink noted that staff were using the rinse and sanitizing sinks to clean food preparation equipment. Further observation noted that the staff had not filled the wash sink. The surveyor requested that the wash sink be filed and utilized prior to continued use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 28 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 - Many The surveyor also requested that all food preparation equipment be rewashed ,rinsed, and sanitized as per regulation. (c) Observation of the 3-compartment sink room noted that the equipment storage shelves (2) were heavily soiled and contained areas of dried food matter. Further observation noted that clean food preparation equipment was being stored directly on soiled shelving. The surveyor requested to the FSS that the shelving be cleaned and sanitized, and the equipment be rewashed and sanitized. (d) Numerous ceiling tiles (20) located over food preparation and serving areas were noted to be soiled, stained, and areas of dried food matter. The surveyor stated to the FSS that the soiled ceiling tiles could result in food contamination and should be replaced next time the department is closed. (e) Observation of the dish machine room noted the ceiling tiles and light fixtures were soiled, rust laden, and areas of dried food matter. The surveyor stated to the FSS that the tiles and light fixture could result in contamination of clean dishware and required replacement the next time the department is closed. (f) Observation of the bench mounted commercial can opener was noted to have dried food matter around the blade and housing area. The surveyor requested that the can open be cleaned and sanitized prior to the next use. (g) The shelving (3) located within Reach-in Refrigerator #1 was noted to be rust laden. The surveyor stated to the FSS that the rusted shelving could result in food contamination and food should not be stored on and under the shelving until replacement. (h) Observation of the walk-in refrigerator noted that the interior and exterior of the entry door had large areas of peeling paint and rust . It was noted that 2 of the interior walls of the refrigeration unit also had large areas of peeling paint and rust. The surveyor informed the FSS that there was potential for food contamination from the peeling paint and rust. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 29 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain resident's private health information in a secure manner and the facility failed to follow physician's orders for Resident #415. The findings included: 1) An observation was conducted on 02/01/23 at 8:36 AM in which Staff F, Licensed Practical Nurse, left the computer on top of her medication cart open with resident information visible along with a piece of paper containing resident information left face-up on her medication cart in the hallway outside of room [ROOM NUMBER]. This was also observed by Staff G, Risk Manager. Staff G promptly covered the computer screen with the piece of paper while Staff F was in a resident's room administering medications. When Staff F returned to the medication cart, Staff G reminded her that the computer screens need to be turned off and any papers should be left face-down. Staff F acknowledged her, saying I should have minimized it (regarding the computer screen). 2) During a medication administration observation conducted on 02/01/23 at 8:42 AM with Staff F, Licensed Practical Nurse, it was noted that when Staff F and the surveyor entered the resident's room to administer the medications, Staff F left a piece of paper containing resident information, face-up on her medication cart in the hallway outside of room [ROOM NUMBER], despite having just been reminded by Staff G to ensure resident information is not visible as it is a HIPAA violation. 3) An observation was conducted on 02/01/23 at 9:40 AM of a piece of paper containing resident information left face-up on a medication cart on the 412-421 hallway. Further observation and interviews revealed the medication cart and paper containing resident information belonged to Staff D, License Practical Nurse. Staff D acknowledged he should not have left the paper face-up on his medication cart as this is a HIPAA violation. 4) During a tour of the facility conducted on 02/02/23 at 8:07 AM, the surveyor observed a piece of paper containing resident information left face-up on a medication cart in the hallway outside of room [ROOM NUMBER]. Further observation and interviews revealed the medication cart and paper containing resident information belonged to Staff Q, Registered Nurse. Further observation revealed Staff Q exit the room and continue to the next resident's room to administer medications. After acknowledging the surveyor was present and prior to entering the next room, he turned his paper face-down. 5) During the initial tour of the facility conducted on 01/30/23 at 10:15 AM, Resident #415 complained to the surveyor that she needed to have her lung drained. She stated she had lung cancer, and her lung was supposed to be drained every other day. Resident #415 further stated her lung had not been drained since 01/26/23 and she was feeling very short of breath, despite being on oxygen at 5 liters via nasal cannula. An interview was immediately conducted with Staff A, Registered Nurse who was assigned to care for Resident #415 on 01/30/23. The surveyor asked Staff A if she was aware of Resident #415's lung issue and presence of the pleurX catheter (a specialty catheter inserted into a person's chest to allow for drainage of accumulated fluid-usually used in the presence of lung cancer or advanced heart failure). Staff A stated she was not aware that Resident #415 had a pleurX catheter. The surveyor then asked Staff A who at the facility would be responsible for draining a pleurX catheter. Staff A stated she did not know but she would find out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 30 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #415 was admitted to the facility on [DATE]. Resident #415 had a medical history significant for Chronic Obstructive Pulmonary Disease, Pneumonia, Stage 4 Right-sided Lung Cancer, Fluid Accumulation on the Right Lung, Blood Clots, Shortness of Breath, Atrial Fibrillation, Chronic Pain, and Anemia. An admission Minimum Data Set was In Progress at the time of the survey. It was documented that Resident #415 was fully mentally intact. Review of Resident #415's Care Plans revealed there was a care plan in place regarding Resident #415 having a pleurX catheter, initiated on 01/28/23. This care plan documented proper care and management for the pleurX catheter and that it should be drained every other day. Review of Resident #415's physician orders revealed there were orders in place regarding proper care and management for the pleurX catheter and that it should be drained every other day. These orders were all written on 01/28/23. Review of the Treatment Administration Record revealed documentation by the staff that on 01/30/23 and 02/01/23, the pleurX catheter had been drained. However, on 01/28/23, NA is documented, indicating the catheter was not drained on the day the physician wrote the order. Review of Resident #415's progress notes revealed an initial Skilled Nursing Note was written 01/27/23 at 7:21 PM. In this note, the admitting nurse documented the presence of the pleurX catheter and that it had been drained on 01/26/23. It should be noted that there were no further notes written from 01/27/23 to 01/30/23 documenting the presence of the pleurX catheter, care for the catheter site, or drainage of the catheter. An interview was conducted with Resident #415 on 01/30/23 at 4:20 PM. Resident #415 stated someone (she could not say who) had come and drained her lung, after the initial interview and after surveyor intervention. Resident #415 said she felt like her breathing was better and that she felt less short of breath. The surveyor then interviewed Staff B, Unit Manager. Staff B stated it was the wound care nurse who drained Resident #415's pleurX catheter and that she had written a note with the procedural details. Secondary review of Resident #415's progress notes revealed an initial Skin/Wound Note had been written on 01/30/23 at 3:52 PM which stated, she does have a hx [sic: history] of stage 4 lung cancer she has a right chest pleurx it was drained 300cc [sic: milliliters] today it will be drained again Wednesday. Please note, the pleurX catheter was not drained and this note was not written until after surveyor intervention. Further review of Resident #415's progress notes conducted on 02/01/23 at 9:03 AM. This review revealed a Nursing Note had been written on 02/01/23 at 8:25 AM. This note documented Resident #415 complained to staff that morning of worsening shortness of breath after the wound care nurse drained her pleurX catheter. This note also documented Resident #415 requested to be sent to the hospital and that her oxygen saturation had decreased to 89% despite being on oxygen and she required an additional nebulizer medication treatment. A Skin/Wound Note was written on 02/01/23 at 1:56 PM which documented the nurse drained 250 milliliters from Resident #415's lung that morning and that Resident #415 had no signs or symptoms of respiratory distress at the time of the procedure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 31 of 32 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 105476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Boca Raton Rehabilitation and Nursing Ce 6363 Verde Trail Boca Raton, FL 33433 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 0842 Level of Harm - Minimal harm or potential for actual harm An observation was conducted on 02/01/23 at 12:18 PM of Resident #415's family members in her room collecting her belongings. A conversation was overheard between the family members and Staff B, Unit Manager. The family members told Staff B that Resident #415 wound not be returning to the facility when she was released from the hospital. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105476 If continuation sheet Page 32 of 32