Health inspection·January 13, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: The wall underneath the television had an unpainted white patch. The Environmental Services Director stated that the wall was spackled last week. He further stated that this was an ongoing issue and would be observed in multiple resident rooms. 3. Residents Affected - Few room [ROOM NUMBER]: The wallpaper was peeling from the wall located near the resident's bed. The stand for the overbed table was rusted. The dresser drawers had multiple scratches. The wall near the room door had an unpainted white patch. 4. room [ROOM NUMBER]: The wall near the bathroom door had an unpainted white patch. Black streaks were noted across the bathroom door. A chunk of wallpaper was missing from the wall near the closet. 5. room [ROOM NUMBER]: The wallpaper was peeling from the wall located near the resident's bed. Paint was missing from the wall near the bathroom door. 6. room [ROOM NUMBER]: The wall underneath the TV, the wall near the bathroom door, and the wall by the room door had unpainted white patches. 7. room [ROOM NUMBER]: The wall underneath the TV had an unpainted white patch. 8. room [ROOM NUMBER]: The wallpaper was peeling from the wall located near the resident's bed. 9. room [ROOM NUMBER]: The door to the room was chipped with missing pieces of wood. 10. room [ROOM NUMBER]: The wallpaper was peeling from the wall located near the resident's bed. 11. room [ROOM NUMBER]: The wallpaper was peeling from the wall located near the resident's bed. 12. room [ROOM NUMBER]: The door to the room was chipped with missing pieces of wood. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 2 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 13. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: The wall near the air conditioning unit had a hole. 14. Residents Affected - Few room [ROOM NUMBER]: The wall on the right side of the window had an unpainted white patch. Following the tour, the Director of Maintenance stated that nurses and certified nursing assistants were able to report maintenance issues using the TELS system (maintenance reporting system). He further stated that he would print a work order report each morning and would check the TELS system 2-3 times throughout the day. According to him, if he noticed additional issues, he would add them to his list. The Environmental Services Director stated that work orders were completed based on priority levels. He further stated that they were aware of the peeling wallpaper in resident rooms and that upper management was looking into remodeling the first floor and removing the wallpaper. The Director of Maintenance and Environmental Services acknowledged all findings and stated that the peeling wallpaper was an ongoing issue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 3 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to revise, follow, and update the care plan for eating assistance for 3 of 12 sampled Residents reviewed for nutrition (Residents #51, #86, and #75). The findings included: 1. Chart review showed that Resident #51 was admitted on [DATE] with diagnoses of cerebral infarction and anxiety disorders. A review of the Physician's orders showed that Resident #51 is on a Mechanical soft diet with ground meats which was dated 01/03/22. The care plan dated 11/23/21 showed that Resident #51 needs encouragement and assistance with his meals and fluids. The Minimum Data Set (MDS), Quarterly dated 11/11/21 showed that for section G, eating, Resident #51 needs supervision with set up only. Section C showed that he has a Brief Interview of Mental Status (BIMS) score of 06 which indicates the resident is cognitively impaired. In an observation conducted on 01/11/22 at 8:00 AM, the meal cart arrived on the unit. At 8:05 AM, the staff brought the breakfast tray into Resident #51's room. At 8:33 AM staff came into the room to assist Resident #51 with his breakfast meal (this was 28 minutes after the arrival of the tray). In an observation conducted on 01/13/22 at 7:55 AM, the tray was brought into Resident #51's room and was set up by staff. At 8:30 AM, the Resident was in his room with no assistance from staff and the breakfast tray was 100% untouched. In this observation, Resident #51 stated that he needs help with his meal, but the staff is serving other people. Continued observation at 8:35 AM, showed Staff F, Central Supply, assisting Resident #51 with his breakfast meal which was 40 minutes later. In this observation, Staff F reported that Resident #51 needs assistance with his meals. She further stated that he gets his Ensure Plus (nutritional supplement) once a day at 10:00 AM and that he usually drinks 100% of his shake. In an interview conducted on 01/13/22 at 9:10 AM, Staff E, Certified Nursing Assistant, stated that Resident #51 needs assistance with his meals. She further stated that she helped him with his meal this morning. In an interview conducted on 01/13/22 at 9:43 AM, the facility's Minimum Data Set Coordinator stated that for section G eating, she will review the electronic records and the Certified Nursing Assistant's documentation to see if residents need assistance with their meals or they are able to eat on their own. She said that sometimes there may be discrepancies in the documentation by the nursing team. When asked by the surveyor why was Resident #51 coded under section G, for eating as supervision only, she stated that Resident #51 was assessed in November and could have had recent changes in his eating abilities. 2. Chart review showed that Resident #86 was readmitted to the facility on [DATE] with diagnoses of heart disease and macular degeneration. Review of the care plan dated 12/01/21 revealed that Resident #86 is at nutritional risk due to disease process and significant weight loss. It further showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 4 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0657 that Resident #86 needs encouragement and assistance with her meals and supplements. Level of Harm - Minimal harm or potential for actual harm The Significant change MDS dated [DATE] showed that for section G, eating, Resident #86 needs extensive assist with 1 person assist. Section C for BIMS showed a score of 06 which is cognitively impaired. Residents Affected - Few In an observation conducted on 01/11/22 at 8:10 AM, the meal cart arrived on the unit. At 8:20 AM, the meal tray was brought into Resident #86's room and was placed at the side table. At 8:35 AM, the Resident was yelling in her room saying: I need help, I need help. In this observation, Resident #86 told the surveyor that she needs help with her breakfast meal. At 8:45 AM, Resident #86 continued yelling for help while staff observed outside her room. At 8:55 AM, the Clinical Dietitian was observed going into the room and asking Resident #86 what she needed. The Resident said that she needed help with her meal tray. During this entire observation, the meal tray for Resident #86 was untouched. In an observation conducted on 01/12/22 at 7:53 AM, the meal cart arrived on the unit. Resident #86 was observed with her meal at the side table. At 8:10 AM, the Resident was observed yelling from her room for help. At 8:32 AM, Staff E, Certified Nursing Assistant, was observed going into the room and saying, eat your food and walking out of the room leaving Resident #86 to eat on her own. Continued observation showed that at 8:45 AM, Resident #86's tray was over 90% untouched. In an interview conducted on 01/13/22 at 9:10 AM, Staff E stated that Resident #86 does not need any assistance with her meal and that she does not like it when staff comes into the room to help her with her tray. A review of the care plan dated 01/12/22 showed that Resident #86 is at nutritional risk and needs encouragement and assistance with her meals. In an interview conducted on 01/13/22 at 1:00 PM, with the Director of Nursing, he was told of the findings. 3. Review of the record showed that Resident #75 was re-admitted to the facility on [DATE] with the following diagnoses: Sarcopenia, Muscle Weakness, and Cognitive Communication Deficit. Review of Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #75 had a Brief Interview for Mental Status score of 10, which showed that he was moderately cognitively impaired. Review of Section G of the Quarterly MDS dated [DATE] documented that Resident #75 required extensive assistance with one person physical assist for eating. Review of the Care Plan dated 11/30/21 documented that Resident #75 had an activities of daily living self-care deficit related to physical limitations and weakness. Interventions were to assist with daily hygiene, grooming, dressing, oral care and eating as needed. During an observation conducted on 01/11/22 at 8:08 AM, Resident #75 was observed sitting in his bed with his breakfast tray on his overbed table. Closer observation showed that his breakfast tray was untouched. When asked if he was hungry, Resident #75 nodded his head yes. When asked if he needed assistance with his meals, Resident #75 did not answer and looked at the surveyor. During an observation conducted on 01/11/22 at 8:28 AM, Staff O, Certified Nursing Assistant (CNA), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 5 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few entered Resident #75's room and began to provide him with feeding assistance. When asked, Staff O stated that she usually helped Resident #75 with his meals. Staff O stated, He usually needs help with breakfast because he is sleepy. Resident #75 waited for 20 minutes for staff to assist him with his meal. During an observation conducted on 01/12/22 at 7:42 AM, Resident #75's breakfast tray was delivered to his room. At 7:54 AM, Resident #75 was seated in his bed and his breakfast tray appeared untouched on his overbed table. When asked if he was hungry, Resident #75 did not answer and looked at the surveyor. During an observation conducted on 01/12/22 at 8:04 AM, Staff I, CNA, entered Resident #75's room and removed his breakfast tray. This showed that although Resident #75 required assistance with meals, staff had not entered Resident #75's room until 22 minutes after his meal tray was delivered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 6 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of the record showed that Resident #75 was re-admitted to the facility on [DATE] with the following diagnoses: Sarcopenia, Muscle Weakness, and Cognitive Communication Deficit. Residents Affected - Few Review of Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #75 had a Brief Interview for Mental Status of 10, which showed that he was moderately cognitively impaired. Review of Section G of the Quarterly MDS dated [DATE] documented that Resident #75 required extensive assistance with one person physical assist for personal hygiene. Review of the Care Plan dated 11/30/21 documented that Resident #75 had an activities of daily living self-care deficit related to physical limitations and weakness. Interventions were to assist with daily hygiene, grooming, dressing, oral care and eating as needed. During an observation conducted on 01/10/22 at 11:15 AM, Resident #75's fingernails were long and went past his fingertips. Closer observation showed that there was brown residue underneath his nails. When asked if he wanted his nails cut, Resident #75 stated, Yes. During an observation conducted on 01/10/22 at 1:07 PM, Resident #75's fingernails were still long and past his fingertips. Closer observation showed that there was still brown residue underneath his nails. During an observation conducted on 01/11/22 at 1:10 PM, Resident #75's fingernails were still long and past his fingertips. Closer observation showed that there was still brown residue underneath his nails. During an observation conducted on 01/12/22 at 7:54 AM, Resident #75's fingernails were still long and past his fingertips. Closer observation showed that there was still brown residue underneath his nails. During an interview conducted on 01/12/22 at 10:32 AM, Staff I, Certified Nursing Assistant (CNA), stated that she had worked in the facility for 15 years. She stated that CNAs were responsible for cleaning/cutting residents' fingernails. When asked how often nails were cleaned/cut, she did not specify a timeframe and stated that it was done when she asked activities for nail clippers. She further stated that she did not document fingernail grooming. Staff I then entered Resident #75's room with two surveyors and acknowledged that Resident #75's fingernails were long. When asked about the brown residue underneath his nails, she stated, They're not dirty. She further stated that Resident #75's fingernails were cut about 1 month ago and she acknowledged that they needed to be trimmed. Based on observations, interviews, and record reviews the facility failed to provide fingernail grooming for 5 of 34 residents observed (#90, #15, #16, #79, #75), and the facility also failed to provide showers for Resident #119. Findings included: Review of facility policy titled Nail Care with a revised date of 01/2014 revealed the purpose is to provide for personal hygiene needs and prevent infection. Note: precaution should be used when trimming nails of a patient with diabetes and should be done by a licensed nurse or physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 7 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procedure #9 Trim nails and file for smoothness, as needed. Suggested documentation: completion of procedure. Review of Job Description for Nurse Aide with most recent revision of 02/2008 revealed in section titled personal nursing care responsibilities; assist residents with resident care including bathing, grooming, hygiene, and placement of adaptive equipment. In section titled documentation revealed accurately documents information in the clinical record as required by the patient's condition. Review of facility policy titled Bathing with a most recent revised date of 07/2016 revealed the purpose is to cleanse skin and promote circulation. Procedure #11 revealed clean and trim nails as needed (only a licensed nurse can perform nail cutting on a diabetic patient). Suggested documentation: document in plan of care (POC) the care provided. 1. Record review for Resident #15 revealed the resident was admitted on [DATE] with a readmission on [DATE], diagnoses included Cerebral Infarction, Muscle Wasting and Atrophy, Anxiety Disorder, Convulsions, Type 2 Diabetes Mellitus. The quarterly minimum data set (MDS) dated [DATE] revealed in section C a brief interview of mental status (BIMS) score of 11 indicating moderate cognitive impairment, section G revealed for personal hygiene self-performance of extensive assistance with support of one-person physical assist. The resident's care plan revised on 04/12/21 with a focus on activities of daily living (ADL) self-care deficit related to physical limitations, Cerebral vascular accident (CVA), and left side weakness, with a goal of will receive assistance as necessary to meet ADL needs. Interventions included assist with daily hygiene, grooming, dressing, oral care and eating as needed, assist to bathe/shower as needed. An observation was made on 01/10/22 AT 2:10 PM of Resident #15's fingernails extending past the edge of her fingers. During an interview conducted on 01/10/22 at 2:10 PM with Resident #15, she stated she wants her nails cut, but nobody has the time. 2. Record review for Resident #16 revealed the resident was admitted on [DATE] with readmission on [DATE], diagnoses included Type 2 Diabetes Mellitus, Anxiety Disorder, Dementia without Behavioral Disturbance, Adult Failure to Thrive. The quarterly MDS dated [DATE] revealed in section C a BIMS score of 13 indicating intact cognitive response, section G revealed personal hygiene self-performance of extensive assistance with support of one- person physical assist. The resident's care plan with a revision date of 10/21/21 had a focus on ADL self-care deficit related to physical limitations, weakness, requires assistance with all ADL's, transfers, and wheelchair (w/c) mobility, with a goal of will receive assistance necessary to meet ADL needs. Interventions included assist to bathe/shower as needed, assist with daily hygiene, grooming, dressing, oral care and eating as needed. On 01/10/22 at 4:00 PM an observation of Resident #16's fingernails extending past the end of her fingers. During an interview conducted on 01/10/22 at 4:00 PM with Resident #16, when she was asked about her fingernails, she stated that she likes them much shorter, but nobody will cut them. 3. Record review for Resident #79 revealed the resident was admitted on [DATE], with diagnoses that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 8 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included Muscle Weakness and Obesity. The admission MDS dated [DATE] revealed in section C a BIMS score of 13 indicating intact cognitive response, section G revealed personal hygiene self-performance of extensive assistance with support of one-person physical assist. The care plan dated 11/15/21 with a focus on ADL self-care deficit related to physical limitations, and weakness, with a goal of will receive assistance necessary to meet ADL needs. Interventions included assist with daily hygiene, grooming, dressing, oral care and eating as needed, assist to bathe/shower as needed. On 01/10/22 at 4:10 PM an observation was made of Resident #79's fingernails extending beyond the tips of her fingers. During an interview on 01/10/22 a 4:10 PM with Resident #79 she stated she has been asking for her fingernails to be cut for the past month and the staff say they will come back, and they never do. 4. Record review for Resident #90 revealed the resident was admitted on [DATE] with a most recent readmission on [DATE] with diagnoses that included Bacturia, Chronic Kidney Disease, Dementia without Behavioral Disturbance, Cognitive Communication Deficit. The quarterly minimum data set (MDS) dated [DATE] revealed in section C that a brief interview for mental status (BIMS) was not conducted due to resident is rarely/never understood, section G revealed eating had a self-performance of extensive assistance with support of one-person physical assistance. The care plan with a revision date of 12/30/21 had a focus on ADL self-care deficit related to physical limitations, history of Polio with left side weakness, left foot drop, impaired cognition with a goal of will receive assistance necessary to meet ADL needs. Interventions included ADL Assist: transfer with mechanical lift with two-person assistance, assist to bathe/shower as needed, assist with daily hygiene, grooming, dressing, oral care and eating as needed. On 01/10/22 at 3:50 PM an observation was made of Resident # 90's unkept hair and long nails with brown substance under them. 5. Record review for Resident #119 revealed the resident was admitted on [DATE] with diagnoses that included Cerebral Infarction Muscle Wasting and Atrophy, Retinal Detachment with Retinal Break, Left Eye, Type 2 Diabetes Mellitus. Quarterly Minimum Data Set (MDS) dated [DATE] revealed in section C a brief interview for mental status (BIMS) with a score of 14 indicating intact cognitive response, section G revealed personal hygiene self-performance is extensive assistance with support of one person physical assist, bed mobility was self-performance of extensive assistance with support of one person physical assistance, transfers self-performance was extensive assistance with support of 2 plus persons physical assistance, dressing self-performance was extensive assistance with support of one person physical assistance. The annual MDS dated [DATE] revealed in section F that it is very important for resident to choose between tub bath, shower, or sponge bath. Review of the resident's care plan did not reveal any care plan for hygiene or bathing/showering. Record review of documented tasks revealed that resident received a tub bath on 12/13/21, a bed bath on 12/20/21 and a bed bath on 12/27/21. For 3 weeks in the month of December 2021 the resident did not receive a shower twice a week as scheduled. During an interview conducted on 1/10/22 at 10:15 AM with Resident #119 he stated that he is supposed to get a shower twice a week and he only gets one shower once a week and that has been for about a year. During an interview conducted on 01/11/22 at 3:45 PM with the Director of Nursing when asked who is responsible for fingernail care he stated the certified nursing assistants (CNA), when asked where (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 9 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few they document that they have provided care for the resident he stated he would have to get back to the surveyor. During an interview conducted on 01/12/22 at 9:30 AM with Staff V certified nursing assistant, when asked who is responsible for performing nail care for the residents, she stated the residents sometimes go to the beauty parlor or the nurse does it if the resident is diabetic. During an interview conducted on 01/12/22 at 9:32 AM with Staff W Registered Nurse, when asked who is responsible for resident's fingernail care, she stated she was not sure she would have to ask the unit manager. During an interview conducted on 01/12/22 at 12:20 PM with Staff X certified nursing assistant, (CNA) when asked who is responsible for resident's fingernail care she stated the CNA and the nurse is responsible to cut the nails, if she cuts the resident's fingernails, she tells the nurse so the nurse can document it in the resident's record. During an interview conducted on 01/12/22 at 12:45 PM with Staff Z certified nursing assistant, when asked who is responsible for the resident's fingernail care, she stated everybody is, the CNA and the nurse. She said she is unable to document fingernail care provided in the electronic medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 10 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide activities for 3 of 3 residents observed (#119, #82, and #43). Residents Affected - Few Findings included: Review of the facility policy titled Activity and Recreation Program Provision dated July 2019 revealed the use of structure in providing an activity and recreation program is vital to patient enjoyment and engagement. The structural components for providing a successful recreation program include preparation, presentation, closure, and evaluation. Before each program, it is necessary to plan appropriate set-up and preparation. The program may be listed on the center calendar, posted daily, as well as being posted on the in-room calendar. Preparation steps may include setting up supplies or audio-visual equipment. When working with patients who are experiencing sensory and cognitive losses, the program should enhance their abilities, as well as the activity and recreation staff offering structure and direction for the group. The activity and recreation department evaluates program services on an ongoing basis. The successful outcomes are evaluated in several ways: responses of patients during activities, comments during Resident Council meetings, and interviews during individual patient contact. 1. Record review for Resident #82 revealed the resident was admitted on [DATE] with a recent readmission on [DATE] and diagnoses included Unspecified Bipolar Disorder, Anxiety Disorder, Dementia with Behavioral Disturbance, Type 2 Diabetes Mellitus. The quarterly minimum data set (MDS) dated [DATE] revealed in section C a brief interview of mental status (BIMS) score of 15 indicating intact cognitive response. The resident's care plan with a revision date of 12/03/2021 with a focus on enjoys/enjoyed activities such as pet [NAME], CBS news, game/ talk shows, traveling, biking, swimming, blackjack/poker card game, gardening, oldies music. Staff does friendly room visits, participates in monthly lunch express, word search for stimulation, Jewish service. Goal included will actively participate in activities that promote socialization with peers consistent with likes and interests at least 3 times weekly as tolerated. Interventions included Encourage participation in individual activities of interest for socialization i.e., monthly lunch express, morning coffee, outdoor/ weekly service, provide local newspaper / magazines, word search for leisure activities as needed/requested / accepted / tolerated. During an interview conducted on 01/10/22 at 1:23 PM with Resident # 82 he stated they have not had a movie in 2 years, they say the machine has been busted. 2. Record review for Resident #119 revealed the resident was admitted on [DATE] with diagnoses that included Cerebral Infarction Muscle Wasting and Atrophy, Retinal Detachment with Retinal Break, Left Eye, Type 2 Diabetes Mellitus. The quarterly Minimum Data Set (MDS) dated [DATE] revealed in section C a brief interview for mental status (BIMS) with a score of 14 indicating intact cognitive response. The resident's care plan with revised date 09/20/21 with a focus on Enjoys/Enjoyed activities such as drawing, cooking, movies, traveling, [NAME] news, exercise, phone / computer/ music. Resident made aware of events calendar, use of library, outdoor patio. Alert X 3 express preference to be independent in own daily leisure activities such as use of phone, watching TV, use of computer, goes out of room independently. Goal included will actively participate in independent leisure activities of choice daily as tolerated. Interventions included Assist in planning and/or encourage to plan own leisure time activities of choice, provide monthly events calendar to accommodate participation in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 11 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0679 activities of choice. Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 1/10/22 at 10:15 AM with Resident #119 he stated the activities calendar is not correct, they never have the ice cream social, and they are supposed to have a nightly movie, but the VCR has been broken for quite a while. Residents Affected - Few During an interview conducted on 01/11/22 at 1:40 PM with the Director of Activities when asked if they provide activities for residents who do not leave their room or are cognitively impaired, she stated they provide a 1:1 with hand lotion and music. When asked how often a resident is seen in that situation she stated once a week for 15 minutes. When asked about the nightly movie at 7:00 PM on Channel 2, she said the front desk receptionist selects a movie and inserts it into the DVD player in the electrical room. When asked if there has been a night that the movie was not played, she stated no. During an interview conducted on 01/11/22 at 1:45 PM with the Business Office Manager she stated that either the front desk receptionist or herself put the DVD into the DVD player nightly, but they have not put it in because the DVD player has been broken for 2-3 months. When asked to see the DVD player, together we went to the electrical room and discovered that there was no DVD player. During an interview conducted on 01/12/22 at 9:15 AM with the Director of Activities she stated that the activity DVD player has been used by the human resources (HR) department for orientation. When asked how long the orientation has been going on she replied it is ongoing for the past 2-3 months and maintenance department brings the DVD player back every evening when the HR department is done with it. She then went on to say the residents may have felt like it was 2-3 months, but it really was not. They see the movie every night because maintenance puts the DVD player back in the electrical room each evening. During an interview conducted on 01/12/22 at 12:30 PM with the Director of Maintenance, he stated he picks up the DVD player every day in the morning from HR and brings it to the electrical room, he stated HR then takes the DVD player for orientation and he will bring it back to the electrical room either later that night or the next morning. 3. Review of the facility's policy titled, Activity/Recreation Evaluation dated July 2019, documented the following: (1) Review of the clinical record to obtain medical, mental, and functional information as well as prognosis or discharge plans. During an observation conducted on 1/11/22 at 1:00 PM, Resident #143 was observed lying in bed. During an observation conducted on 1/12/22 at 9:00 AM, Resident #143 was observed lying in bed A review of the record showed that Resident #143 was admitted to the facility on [DATE] with the following diagnoses: lack of coordination, muscle wasting/atrophy, dementia, psychosis, anxiety, catatonic disorder, altered mental status. A review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that a Brief Interview for Mental Status (BIMS) was not conducted as the resident is rarely/never understood. A review of Section F of the MDS dated [DATE] documentation indicated that it was not that important for residents to have books and that it was not very important to do things with groups of people. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 12 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0679 It further documented that it was very important for Resident #143 to do her favorite activities. Level of Harm - Minimal harm or potential for actual harm Review of the One-to-One Activity/Recreation Program Documentation Form dated January 10, 2022, documented that Resident #143 participated in: The ONE-TO-ONE ACTIVITY/RECREATION PROGRAM , completed by Staff R. Residents Affected - Few During an interview conducted on 1/12/2022 at 3:30 PM with Staff R, Activities Assistant, she was asked as to what type of exercise is performed with Resident #143, she said we don't do anything. A review of the Care Plan Dated 12/28/21 documented that Resident #143 enjoyed using the computer, baking desserts and cookies, flower gardening, word search, and walking/exercise. Interventions were to provide supplies/materials for leisure activities as needed/requested, i.e., word search and magazines. During an interview conducted 1/12/2022 at 11:00 AM, with Staff Q, private aide, she stated that she works with Resident #143 from 9:00 AM to 2:00 PM Monday through Friday. When asked about Resident #143 she stated that she was not able to do any gardening, use the computer, or do puzzles or word searches anymore. She also said she has never seen the Activities personnel come into the room to provide activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 13 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow the Tube Feeding regimen as per the Physician's orders for 1 of 2 residents reviewed for tube feeding (Resident #114). The findings included: Record review showed that Resident #114 was readmitted on [DATE] with a diagnosis of type 2 diabetes, hemiplegia, and hypertension. A review of physicians' orders showed an order for tube feeding Glucerna 1.5 running at 50 ml an hour until 1000 ml is infused. It further showed to start at 4:00 PM which was dated 03/20/21. In an observation conducted on 01/10/22 at 10:10 AM, in Resident #114's room, a tube feeding formula (Glucerna 1.5) was noted on hold. Closer observation showed that the tube feeding bottle was at the 500 milliliters (mL) mark out of a 1000 ml bottle (photographic evidence obtained). The bottle showed a start date of 01/09/22 at 4:00 PM. The tube feeding bottle running at 50 ml an hour until 1000 ml infused should have been at the 100 ml mark at 10:00 AM the next day. In another observation conducted on 01/10/22 at 1:20 PM, in Resident #114's room, the tube feeding bottle was at the 450 ml mark which showed that only 50 ml was infused from 10:00 AM to 2:00 PM. In an observation conducted on 01/11/22 at 8:14 AM, in Resident #114's room, the tube feeding bottle was noted at the 750 ml mark out of 1000 ml bottle. The bottle showed a start date 01/10/22 at 11:00 PM. The tube feeding running at 50 ml an hour until 1000 ml infused should have been at the 550 ml mark as per physician's orders (photographic evidence obtained). An observation conducted on 01/11/22 at 2:20 PM showed that the tube feeding is at the 500 ml mark on the 1000 ml bottle. The tube feeding was dated 01/10/22 with a start time of 11:00 PM. The tube feeding which started at 11:00 PM the day before should have been at the 250 ml mark. In an interview conducted on 01/11/22 at 2:22 PM, with Staff D, Registered Nurse, she stated that Resident #114 is tolerating the tube feeding well and that it was already running this morning when she came in. She further stated that it is always running when she comes in the morning since they always start it at 4:00 PM the day before. Review of the care plan intervention dated 12/23/21, included to Administer tube feeding formula, hydration, and flushes per order, for Resident #114. In an interview with the Corporate Dietitian, on 01/13/22 at 11:20 AM, she stated that most of the tube feeding orders in the facility do not have a start time and are expected to run until all needed tube feeding provided. When asked as to why Resident #114 tube feeding was not provided according to Doctor's orders, she did not know. She further stated that they may have stopped the feeding if Resident #114 was not tolerating their tube feeding. A review of the progress notes did not show any notes that Resident #114 is not tolerating the tube feeding and a review of the Medication Administration Records for the month of January 2022 showed that the staff had indicated Resident #114 received the tube feeding as per Physicians orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 14 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 - Few 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** 5. During an observational screening tour conducted on [DATE] at 10 AM of Resident #13's room in the facility's locked [NAME] unit, it was noted that Resident #13 had an expired/used tube of prescription Permethrin cream 5% with expiration date [DATE], at her bedside, in plain sight, located in a plastic box, located inside of her room in which the door is kept open and accessible to visitors and other wandering residents, in the unit. Resident #13 was originally admitted to the facility on [DATE] with diagnoses which included Dementia, Hypertension and Gastro-Esophageal Reflux Disease (GERD). She had a Brief Interview Mental Status (BIM) score of 10 (moderately impaired). Photographic evidence was obtained of the tube of prescription Permethrin cream 5%. On [DATE] at 1:16 PM Resident #13 was observed ambulating on her own in the hallway, she was observed/noted scratching herself and when asked about this she stated that she is itching all of the time, all over with a rash. And, she added that there is a white tube of cream in her room that is rubbed on her when she itches. On [DATE] at 1:22 PM, it was noted that the expired/used tube of prescription Permethrin cream 5% expiration date [DATE] which was still there in plain sight at the resident's bedside in a plastic box, accessible to other residents and visitors. On [DATE] at 11:59 AM an interview was conducted with Staff G, a Certified Nursing Assistant (CNA), in which she acknowledged that the cream medication tube did have Resident #13's name on the label and Staff G, a (CNA), stated that it should not have been left there and should have been disposed of. On [DATE] at 12:06 PM During an interview conducted with Staff H, a Licensed Practical Nurse (LPN), in which she stated that she was not aware of the medication being left at the bedside. However, she also acknowledged that the cream medication tube did have Resident #13's name on the label, and Staff H, an (LPN) also stated that it should not have been left there and should have been disposed of. On [DATE] at 12:18 PM An interview was conducted with the (DON) regarding the tube of prescription Permethrin cream 5% with an expiration date of [DATE], left in plain sight at the resident's bedside, and he acknowledged that it should not have been left there and should have been disposed. Based on observations, interviews, and record reviews the facility failed to secure 2 of 5 medication carts while unattended, facility failed to ensure that bedside medications were secured for 2 Residents (#85 and #59), facility failed to ensure that bedside medications were secured and discarded for Resident #13, the Nursing Center should ensure that drugs and biologicals for expired or discharged residents are stored separately, away from use, until destroyed or returned to the Pharmacy; and the Nursing Center should destroy or return all discontinued, outdated/expired, or deteriorated drugs or biologicals in accordance with Pharmacy return/destruction guidelines. Findings included: Review of policy titled Medication Administration: Self-Administration of Medications dated 11/2017 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 15 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 - Few revealed the decision to allow a patient to self-administer medications is subject to periodic assessment by the intradisciplinary team (IDT)based on changes in the patient's medical and decision-making status. Medications, if stored at the patient's bedside, are to be secured in a locked storage unit until use. Review of policy titled Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles with the most recent revision date of 08/2018, revealed the Nursing Center should ensure that only authorized Nursing Center staff, as defined by the Nursing Center, should have possession of the keys, access cards, electronic codes, or combinations which open drug storage areas; (2) the Nursing Center should ensure that all drugs and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room, inaccessible by residents and visitors; (3) the Nursing Center should ensure that drugs and biologicals have not been contaminated or deteriorated and are stored separate from other medications until destroyed or returned to the supplier; (12) for bedside medication storage the Nursing Center should not administer/provide bedside drugs or biologicals without a prescriber order and documented evaluation of approval by the Interdisciplinary Care Team and Nursing Center administration: and the Nursing Center should store bedside drugs or biologicals in a locked compartment within the resident's room. In addition, the policy included the Nursing Center should ensure that drugs and biologicals for expired or discharged residents are stored separately, away from use, until destroyed or returned to the Pharmacy; and the Nursing Center should destroy or return all discontinued, outdated/expired, or deteriorated drugs or biologicals in accordance with Pharmacy return/destruction guidelines. 1. Record review for Resident #59 revealed the resident was admitted on [DATE] with a readmission on [DATE], diagnoses included Malignant Neoplasm of Larynx, and Anxiety Disorder. The quarterly minimum data set (MDS) dated [DATE] revealed in section C a brief interview of mental status (BIMS) score of 15 which indicated intact cognitive response. The care plan revised on [DATE] with a focus on at risk for alteration in skin integrity related to impaired mobility, psoriasis, with a goal of decrease/minimize skin breakdown risks. Interventions included Provide preventative skin care routinely and prn. Administer treatment per physician orders. Review of the resident's record revealed there was no Self-Administration of Medications form completed which is used to document patient assessment, interdisciplinary team (IDT) review, and patient acknowledgement of self-administration. During an observation on [DATE] at 10:20 AM of Resident #59's bedside table drawer, Resident #59 had a medicated cream for Clobetasol 0.05% in the drawer of the nightstand, the resident allowed surveyor to take a picture but not touch the cream. During an interview conducted on [DATE] at 10:20 AM with Resident #59 he stated he uses the cream for his psoriasis. During an interview conducted on [DATE] at 2:30 PM with the DON he stated that Resident #59 never had an assessment for self-administration of any medication. 2. Record review for Resident #85 revealed the resident was admitted on [DATE] with a readmission on [DATE], diagnoses included Muscle Weakness and Obesity. The quarterly MDS dated [DATE] revealed in section C a BIMS score of 15 which indicated intact cognitive response. The care plan with a focus on bowel elimination alteration; constipation related to medications with a goal of will have bowel movement at least q 3 days. Interventions included administer medications per physician order and observe effectiveness, notify physician of any changes in bowel function, record bowel movement (BM) and report abnormalities, report signs and symptoms (S&S) constipation such as abdominal cramping, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 16 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 - Few diarrhea, nausea, and vomiting (n/v), no BM for 3 days. Review of the resident's record revealed there was no Self-Administration of Medications form completed which is used to document patient assessment, interdisciplinary team (IDT) review, and patient acknowledgement of self-administration. On [DATE] at 2:20 PM an observation was made of Resident #85's room, there were two (2) medications (sleep aid and anti-diarrheal) at the bedside (photographic evidence obtained). During an interview conducted on [DATE] at 3:00 PM with Resident #85 he stated he has over the counter medications in his room and that is because they will not give him medication sometimes. He said he can leave on his scooter and get what he wants. During an interview conducted on [DATE] at 2:30 PM with the DON he stated that Resident #85 never had an assessment for self-administration of any medication. 3. On [DATE] at 10:52 AM an observation was made of keys left on medication cart located between room [ROOM NUMBER] and 206, there was a resident sitting in a wheelchair in the hall one room away from the medication cart. During an interview conducted on [DATE] at 10:54 AM with Staff S Registered Nurse (RN) when asked if the keys on top of the medication cart were the keys to open the medication cart, she replied yes. When asked why she left the keys to the medication chart on top of the medication cart, she replied I thought they were in my pocket. 4. On [DATE] at 11:20 AM an observation was made of a medication cart left unlocked and unattended with 2 residents sitting in wheelchairs close by on the second floor. During an interview conducted on [DATE] at 11:22 AM with Staff T RN when asked why she left the medication cart unlocked and unattended she stated she had something sticky on her hand and did not want to touch the lock and she went into a residents bathroom to wash her hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 17 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 observations, interviews, and record review, the facility failed to follow the approved menu and approved portions for 24 residents on pureed diets, which included 8 sampled residents (Resident #90, Resident #109, Resident #59, Resident #604, Resident #45, Resident #22, Resident #88, Resident #145). The findings included: Review of the approved lunch menu for pureed diets for 01/12/22 documented that the following was to be served: #12 scoop (2.5 ounces) of pureed squash casserole and ½ cup of rosy applesauce. During an observation of the lunch tray line conducted on 01/12/22 at 11:24 AM, accompanied by the Food Service Director (FSD), it was noted that pureed cauliflower had been substituted for the pureed squash casserole. It was further noted that a #16 scoop (2 ounces) was used to plate the pureed cauliflower. This showed that residents on pureed diets were receiving a 2 ounce portion of pureed cauliflower instead of a 2.5 ounce portion. The FSD acknowledged that the approved portion sizes for the pureed diets were not being followed and stated that a #12 scoop should have been used. When asked about the rosy applesauce, Staff L, Diet Aide, stated that it was not on the menu for today and that pureed strawberry rhubarb pie was to be served. The FSD reviewed the menu with the surveyor and confirmed that pureed strawberry rhubarb pie was not on the approved pureed menu and that rosy applesauce was to be served. The FSD acknowledged that the approved lunch menu for the pureed diets was not being followed. Review of the facility diet census dated 01/12/22 documented that 24 residents were on pureed diets, which included Resident #90, Resident #109, Resident #59, Resident #604, Resident #45, Resident #22, Resident #88, Resident #145 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 18 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 observations, interviews, and record review, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions and failure to maintain adequate holding temperatures. The findings included: During the initial tour of the kitchen conducted on 01/10/22 at 8:44 AM, accompanied by Staff J, Cook, Regional Registered Dietitian (RD), and Food Service Director (FSD), the following was noted: 1. During the breakfast tray line, Staff M, Diet Aide, placed her bare hands in her pockets. She then removed her hands from her pockets and proceeded to touch clean utensils and place them on meal trays without performing hand hygiene. Staff N, Diet Aide, was observed grabbing a plate of food with her bare hands to place on the meal tray. It was noted that her thumb had touched the top of the plate. 2. During the breakfast tray line, a plate of eggs, bacon, and toast was observed on the counter above the hot holding unit when the surveyors entered the kitchen. At the request of the surveyors, Staff J calibrated the facility's metal stemmed thermometer to check the temperature of the eggs. When asked what temperature the thermometer should be calibrated to, Staff J stated that it needed to be calibrated to 40 degrees Fahrenheit (F). The thermometer reached 40 degrees F and Staff J stated that the thermometer was ready to use. The surveyor informed Staff J that the thermometer needed to be calibrated to 32 degrees F. Staff J then calibrated the facility's metal stemmed thermometer to 32 degrees F and checked the temperature of the eggs, which were noted at 110 degrees F. This showed that the eggs were not at the regulatory temperature of 135 degrees F or above. Staff J stated that the plate had just been placed on the counter right before the surveyors had entered the kitchen. 3. A personal cell phone was observed on a shelf of the hot holding unit. Staff J stated that the cell phone belonged to her and that she placed it there because it had fallen out of her pocket. 4. A personal umbrella was observed on the shelf above the preparation table in the back area. Staff J acknowledged that personal items should not be stored above the preparation table as they have the potential to contaminate food items. 5. The curtains on the dishwashing machine were observed with a moderate amount of white residue. When asked how often they were cleaned, Staff J stated, They don't clean them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 19 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 6. Level of Harm - Minimal harm or potential for actual harm One opened 8 ounce bottle of water was stored on top of the dishwashing machine. 7. Residents Affected - Many One pair of disposable gloves was stored on top of the clean end of the dishwashing machine. Staff J stated that the gloves were dirty. 8. The dishwashing machine was observed with a leak with water pooling onto the floor below. Staff J stated that she did not know the dishwashing machine was leaking. 9. Four crates used for storing clean dishes were observed on the floor underneath the dishwashing machine. Staff J stated that there had not been a steady kitchen manager and that they did not have any dollies to store the crates. She acknowledged that the crates should not have been stored on the floor and stated, They should be on the cart. 10. The floor of the walk-in refrigerator was observed with a moderate accumulation of debris. Staff J stated that the floor needed to be deep cleaned. 11. In the walk-in refrigerator, one pan of brown sauce was missing a label identifying the product. Staff J stated that she was unable to identify the product and agreed that it needed to be labeled. 12. In the walk-in refrigerator, one pan containing a brown chopped item was missing a label identifying the product. 13. Two large, opened chunks of meat were missing labels identifying the product and use by dates. Staff J was unable to tell when the meats were opened and acknowledged that they needed to be labeled. 14. The floor of the walk-in freezer was observed with a broken tile and with a moderate amount of brown residue and debris. 15. In the walk-in freezer, one bag of chicken tenders was left open. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 20 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 16. Level of Harm - Minimal harm or potential for actual harm In the walk-in freezer, one bag of broccoli was missing a label identifying the use by date. 17. Residents Affected - Many In the dry storage area, one disposable glove was stored on top of a container of rice. When asked, the Regional RD stated that the glove was dirty. 18. In the dry storage area, two, 50 ounce cans of Campbell's Tomato Soup were observed with dents. 19. In the dry storage area, one package of brownie mix was left open and one 16 ounce package of corn starch was left open. 20. In the chemical storage area, a personal coat and a coat for the walk-in freezer were stored on a shelf containing chemicals. Closer observation showed that plastic aprons were left uncovered and stored on top of a box in the chemical storage area. The FSD then asked the kitchen staff if the plastic aprons were used for cleaning or cooking. He then noted that Staff J was wearing a plastic apron while working on the breakfast tray line. The FSD and Regional RD acknowledged that the uncovered plastic aprons were at risk for contamination. Following the tour, the FSD and Regional RD acknowledged all findings. During an observation of the breakfast tray line conducted on 01/11/22 at 7:26 AM, accompanied by Staff K, Cook, it was noted that sliced pears were stored in a hotel pan on top of a utility cart. At the request of the surveyor, Staff K calibrated the facility's metal stemmed thermometer to check the temperature of the sliced pears. The temperature test revealed that the sliced pears were at 72 degrees F. Staff K acknowledged that the sliced pears were not at the regulatory temperature of 41 degrees F or below. He further stated that the pan of sliced pears needed to be stored on top of more ice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 21 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of facility policy and procedure for Laundry Services provided by the Director of Nursing (DON) reviewed 07/2021, revealed that soiled linen has been shown to be a source of large numbers of pathogenic organisms. The risk of actual disease transmission is negligible if handled, transported and laundered in a manner that minimizes exposure or contamination and avoids transfer of microorganisms. Techniques minimizing potential healthcare associated and occupational risks associated with soiled linen handling include: use containers for wet laundry collection made of impervious material to prevent soaking or leakage of fluid to exterior Linen Handling Practices: place soiled linen in a bag at the site of use Bags and containers of soiled linen are considered contaminated Sorting of linen is most likely associated with infection transmission due to: Other infractions of precautions Store linen in a protected area until distributed for patient use. Residents Affected - Few During a Laundry Room tour conducted with the Director of Housekeeping and Laundry on 01/11/22 at 10 AM, 1) it was noted/observed in the dirty side laundry sorting room, that there were two (2) open bags of resident clothing, from the facility's [NAME] unit, sitting on top of two (2) closed personal clothing bins. These open bags were identified as being handled in an unsecured/un-contained/disorderly manner; there was no one noted in the room sorting out this linen at the time and there was no way to determine how long this linen had been kept there previously. 2) Next, in the washing room, it was noted that there was a clear open, dirty bag of resident laundry left on top of a regular top loading washing machine, next to a batch/stack of exposed/contaminated, unboxed gloves. Photographic evidence obtained of laundry sorting room, open bags of resident clothing and dirty bag of resident laundry/bedding, next to a batch/stack of exposed/contaminated, unboxed gloves. During an interview conducted on 01/11/22 at 10:45 AM, the Housekeeping Director acknowledged that the clothing bags should have been closed and placed inside of the bins and not exposed. The Housekeeping Director also acknowledged that the unboxed gloves should be/are normally kept, inside of a clean box on top of the shelf, and not next to dirty resident clothing. On 01/11/22 at 12:28 PM an interview was conducted with both the Administrator and with the (DON) in which they both acknowledged the existence of the open dirty resident laundry clothing bags in the sorting area. They also acknowledged that the contaminated/un-boxed gloves should not have been left lying on top of the machine, in the wash area, next to a bag of open, dirty resident bedding/clothing; this was not done. Based on observations, interviews, and record review, the facility staff failed to follow infection control isolation precautions for positive COVID-19 Resident (#22); the facility failed to assure that isolation precautions were being followed for Resident with Clostridium Difficile colitis (C.Diff) (Resident #76); facility failed to ensure that orders were provided for PICC line on Resident #90, and the facility failed to properly contain dirty laundry in the sorting room. The findings included: A review of the CDC guidance, titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, which was updated Sept. 10, 2021, showed the following: Health Care Professional (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 22 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0880 goggles or a face shield that covers the front and sides of the face). Level of Harm - Minimal harm or potential for actual harm <https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html> Residents Affected - Few A review of facility's policy titled Personal Protective Equipment Usage guide dated 09/28/21 showed that staff would use Personal Protective Equipment (PPE) for donning and doffing. It further showed that an N-95 respirator mask would be used when providing care or services for confirmed residents with COVID-19. It further showed that a full-face shield and a disposable gown must be used when providing care or services to confirmed COVID-19 residents. 1. Record review showed that units 200-219 had 20 residents total, with 1 resident on Airborne/Contact Isolation for positive COVID-19 and another resident on Contact Isolation for Methicillin-Resistant Staphylococcus aureus (MRSA). Unit 220-228 had 15 residents in total, with 1 resident in Airborne/Contact Isolation for positive COVID-19 and another resident in Contact Isolation for MRSA. Further record review showed there were 5 residents positive for COVID-19 in the facility at the time of the survey. In an observation conducted on 01/10/22 at 10:00 AM, a yellow sign was present on Resident #22's door for Airborne and Droplet Precaution .The sign stated the following: wash hands with water before donning PPE and again when leaving the room; put on N-95 or higher-level respirator mask before room entry; make sure eyes are covered before room entry and wear a protective gown and gloves. In an observation conducted on 01/10/22 at 1:21 PM, Staff A, Certified Nursing Assistant (CNA), was observed donning, but not securing, an isolation gown on hallway 220-228 and proceeded to grab a meal tray out of the meal cart that was located in the hallway. Another staff member said that Resident #22 is located in hallway 200-219. Staff A walked down the hallway in the untied isolation gown with the meal tray towards Resident #22's room. The surveyor observed Staff A entering the room with the isolation gown from earlier (which had fallen down to her hands due to not being tied--photographic evidence obtained). She was also observed with no gloves or face shield and just a regular surgical mask. Staff A did not perform hand hygiene before entering Resident #22's room. Staff A moved the Resident's tray table and positioned the meal tray in front of her. Staff A was observed leaning on the Resident's bed and touching the Resident's bedding with the isolation gown around her wrists. Staff A then removed her isolation gown and exited the room without performing hand hygiene. In an observation conducted on 01/11/22, 08:25 AM, Staff C, Certified Nursing Assistant (CNA), was observed exiting another resident's room and entering Resident #22's room. She donned gloves and an isolation gown without practicing hand hygiene before walking into the room. Staff C adjusted the height of the bed and placed the breakfast tray on the bedside table. Staff C then removed her gloves and put on new gloves without practicing hand hygiene, and proceeded to assist Resident #22 with the breakfast meal. In an interview with Staff A conducted on 01/10/22 at 3:01 PM, she reported receiving education on infection control last week. For any COVID-19 positive residents, she was told that she needed to put on a surgical mask, N-95 mask, and wash her hands before going into the Resident's rooms. When asked by the surveyor about the donning steps for personal protective equipment (PPE), she stated that the gloves go on first, the mask, and then the gown. According to Staff A, residents on isolation will have a yellow or a red sign on the door indicating that precautions need to be used. If a resident has both the yellow and the red signs, she needs to use higher precautions. Staff A further stated that she does not know which residents are positive for COVID-19. She works in different units and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 23 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is never assigned to the same unit. When asked about the doffing of PPE, she said, I take off all of my PPE, and I go to the bathroom outside of the room to wash my hands. In an interview with Staff B conducted on 01/10/22 at 03:10 PM, she stated she is usually assigned to hallway 220-228. She stated she is unsure what the different isolations signs mean about what to wear for each kind of isolation. She said, If you see the signs, you need to have precautions before you come .When she saw the signs, she said she put all the personal protective equipment (PPE). When asked about education on infection control, she said there was education on infection control last week, on the computer, the education was on infection and how to wash your hands every 15 minutes before you go inside the room. When asked about donning order for PPE, she stated, before going into the room, you put on the gloves first, the masks, and the gown, and then wash your hands before coming into the room. In an observation conducted on 01/12/22 at 08:29 AM, Staff E, CNA, was observed outside an isolation room. Closer observation showed airborne and contact isolation on the door. She was observed putting on a gown walking into Resident #22's room putting on a pair of gloves inside the room without practicing hand hygiene, and stepping outside the room. Staff E then took a meal tray from the metal cart in the hallway wearing the same gloves and gown that she had previously donned and proceeded to walk back into Resident #22's room. A record review was conducted on 01/12/22 at 11:48 AM for Resident #22. It was noted that she is positive COVID-19 from 01/05/22. Resident #22 was moved to a private room and was placed on Airborne and Contact isolation on 01/05/22. In an interview conducted on 01/12/22 at 3:20 PM, the Director of Nursing stated that any COVID-19 positive residents are placed in isolation-airborne and droplet precaution. Staff is expected to wear a face shield, N95 mask, surgical mask, and a gown before entering the resident's room. They are expected to take off the PPE before leaving the room and practice hand hygiene. In this interview, he was told of the observations conducted on infection control. 2. Review of facility policy titled Midline/PICC Dressing Change dated January 2009 revealed measure and document the circumference in cm of the mid-upper portion of the upper extremity with the catheter present, as needed, to detect and monitor possible retrograde edema of the arm. Compare the measurement to the baseline mid -upper arm circumference done at the time of insertion. Procedure #26 revealed label dressing with date, time, and initials of the person performing the dressing change. Documentation revealed record on medication administration record, treatment administration record, or progress notes. Record review for Resident # 90 revealed the resident was admitted on [DATE] with a most recent readmission on [DATE] with diagnoses that included Bacturia, Chronic Kidney Disease, Dementia, Cognitive Communication Deficit. The quarterly minimum data set (MDS) dated 11//30/21 revealed in section C that a brief interview for mental status (BIMS) was not done due to resident is rarely/never understood, section G revealed personal hygiene self-performance of total assistance with support of one-person physical assistance. readmission assessment dated [DATE] revealed patient alert responsive to tactile stimuli. Midline on right upper extremity intact patent; site clean and dry. Skin dry buttocks with redness and both reddened. Bilateral lower extremities and left upper extremity are swollen but peripheral pulses are present. No orders for midline/picc to right upper extremity. Order dated 12/29/21 for Normal Saline Flush Solution 0.9 % (Sodium Chloride Flush) Use 10 cc intravenously every 8 hours for patency. Last order for intravenous medication was 01/03/22 Zosyn Solution (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 24 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0880 Level of Harm - Minimal harm or potential for actual harm intravenously every 8 hours for bacteriuria until 01/03/2022. Order dated 01/11/22 to discontinue peripherally inserted intravenous catheter. On 01/10/22 at 3:50 PM an observation was made of Resident # 90's peripherally inserted central catheter (PICC) line located in her right arm dated 12/24 (photographic evidence obtained). Residents Affected - Few During an interview conducted on 01/10/22 at 1:24 PM with Staff Y Licensed Practical Nurse (LPN) when asked if Resident #90 is on any antibiotics, she stated no. When asked if Resident #90 had a PICC line, she stated she was unsure she had not checked yet this shift. When asked how often the dressing for a PICC line should be changed she stated every 7 days or as needed. The nurse then stated she was going to check on the PICC line right away. During an interview conducted on 01/11/22 at 3:45 PM with the DON, he stated that the PICC line for Resident #90 was removed this afternoon. During an interview conducted on 01/12/22 at 3:00 PM with the DON when asked if there is a policy on how often a picc line dressing should be changed, he stated there is no policy it gets changed however the doctor orders for it to be changed. 3. Record review for Resident #76 revealed the resident was admitted on [DATE] with readmission on [DATE]. Diagnoses included Cirrhosis of Liver, Enterocolitis due to Clostridium Difficile, Anxiety, Thrombocytopenia, Metabolic Encephalopathy. Significant change MDS dated [DATE] revealed in section C a BIMS score of 15 indicating intact cognitive response. Order dated 01/09/22 for Contact precaution for c-diff. Admit/Readmit note dated 01/09/22 included Patient diagnoses (Dx): C-diff, Diarrhea, abdominal ascites and pneumothorax on right side, patient on contact precaution, right lower abdomen drainage removed dry dressing in place incision site measured 1cm,no drainage noted, all medication verified with doctor patient able to ambulate without complaint of discomfort, will continue monitor patient behavior. Care plan initiated 01/10/22 with a focus on infection of gastrointestinal tract (GI) tract C-diff with a goal of resident's infection will be resolved without complications. Interventions included administer medication per physician orders, maintain contact isolation for Clostridium difficile, obtain Labs as ordered and notify physician of results, record temperature as clinically indicated. On 01/10/22 at 10:00 AM an observation was made of Resident #76's door to his room which did not have any precautionary signs or a cart for personal protective equipment. The resident was not in the room. During an interview conducted on 01/10/22 at 3:15 PM with Resident #76 when asked if he was told he should not leave his room, he responded nobody told him he could not or should not leave his room. During an interview conducted on 01/11/22 at 1:30 PM with Staff U certified nursing assistant (CNA), when asked if a resident is on contact isolation what would she expect to see and do, she stated there would be a sign on the door and a cart outside of the room with personal protective equipment and the resident would get their meals served with disposable containers and cutlery. She stated she would wear a mask, gown, face shield, hair covering and gloves before going into the room and she would remove the personal protective equipment in the room and wash her hands, then as she exits the room, she would use hand sanitizer. During an interview conducted on 01/11/22 at 1:30 PM with Staff X CNA, when asked if a resident is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 25 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0880 Level of Harm - Minimal harm or potential for actual harm admitted with C-diff what would she expect to see or do, she said there would be a contact precaution sign on the door and a personal protective equipment (PPE) cart just outside of the room. Before she would enter the resident's room she would have on her mask, a gown, face shield and gloves. She would remove the gown and gloves before leaving the room and wash her hands in the room. She also stated the resident's meals would come in disposable containers and with disposable plastic utensils. Residents Affected - Few During an interview conducted on 01/12/22 at 9:32 AM with Staff W Registered Nurse, when asked if a resident is admitted with C-diff what she would expect to see or do, she stated there would be a contact precaution sign on the door and a PPE cart next to the door. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 26 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to have an effective pest control program. Residents Affected - Many The findings included: 1. In an interview conducted on 01/10/22 at 10:46 with Resident #61, she said can you move the blanket, I think I have something on my feet. In this interview, an alive roach was noted crawling across Resident's #61 feet (Photographic evidence Obtained). Record review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #61 had a Brief Interview of Mental Status (BIMS) score of 07 which is cognitively impaired. 2. In an interview conducted on 01/10/22 at 11:00 AM, with Resident #18, she stated that they have bugs and roaches in their room, and it is always a problem. She did not remember when the last time someone came into the room to spray for bugs. Record review of the Quarterly MDS dated [DATE] showed that Resident #18 had a BIMS score of 10 which is slightly cognitively impaired. 3. In an interview conducted on 01/10/22 at 10:45 AM with Resident #35, he stated that there are roaches in his room and on his bed and that he has not seen anyone in his room to spray for bugs. In this interview, several bugs (resemblance ants) and several bugs (resemble roaches) were observed running on the wall and on the floor (Photographic evidence obtained). Record review of the Quarterly MDS dated [DATE] showed that Resident #35 had a BIMS score of 14 which is cognitively intact. An interview conducted on 01/12/22 at 1:25 PM, with the facility's Maintenance Director, stated that the pest control company is scheduled to come once a week and as needed. At each of the nurse's stations, there is an Ecolab binder that all sighing of bugs and issues are reported. When the pest control company comes in, they will check the binders to see where to spray and what rooms to visit during their routine visit. He further reported that an invoice for all visits is kept at the Ecolab binder that is in the lobby. The Maintenance Director said that since he had so many responsibilities, the pest control task was given to the Housekeeping Director one year ago. In this interview, the Ecolab book at the lobby was reviewed for visits receipts and the following dates were noted: 03/03/21, 07/01/21, 07/01/21, 10/11/21, 10/26/21, and 11/03/21. When asked as to where the rest of the receipts for the weekly visits he is did not know. A review of the Service Request Log taken from the Ecolab binders showed the following dates of request/problem: multiple rooms and locations reported on 01/05/22 which was only addressed on 01/11/22 which was 6 days later. In an interview conducted on 01/12/22 at 1:42 PM, the facility's Housekeeping Director stated that he took over the responsibility of pest control a year ago. The pest control company has been coming once a month and recently they have been coming 3 times a week. He further stated that all pest control issues are in the Ecolab binder on the floors and that the pest control company will look at the binders on each visit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 27 of 28 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 105481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yamato Nursing and Rehabilitation Center 375 NW 51st Street Boca Raton, FL 33431 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 5. During an interview conducted on 01/10/22 at 10:30 AM with Resident #59 he stated he has had live roaches on the floor, going up the wall, they have been in his nightstand drawer, on his bed and even in his hair. He stated the roaches had a nest in the phone at his bedside which he made the staff put the phone onto the floor. He does not know if they sprayed for the roaches. 6. On 01/10/22 at 2:20 PM an observation was made in Resident #85's bathroom of a large bug resembling a roach in the bathroom moving about on the floor. The resident had a bottle of roach powder on a table in his room (photographic evidence obtained). During an interview conducted on 01/10/22 at 3:30 PM with Resident #85 when asked about possibility of bugs in his room he stated he had roaches, but he bought some roach powder to take care of them. 7. During an interview conducted on 1/10/22 at 10:15 AM with Resident #119 he stated that he has had roaches on his floor, walls, over bed tray, and bed, they spray and do not follow up and that has been in the last month or so. He stated it is an ongoing problem since as long as he has been here. 8. During an interview conducted on 01/10/22 at 10:45 AM with Resident #76 he stated that he had bugs in his room about a month ago. He stated that they come and go. 4. During the initial tour of the kitchen conducted on 01/10/22 at 8:44 AM, accompanied by Staff J, Cook, the following was noted: a. A trail of several small, black pests that resembled ants were observed crawling on the shelf that was located above the preparation table in the back area. Staff J acknowledged the surveyor's observation. b. A trail of several small, black pests that resembled ants were observed crawling along the top edge of the dishwashing table. Closer observation showed that there were also several small flying pests that resembled fruit flies in the dishwashing area. Staff J acknowledged the surveyor's observations and stated that she did not know how often pest control came out. During an interview conducted on 01/12/22 at 1:25 PM, the Director of Maintenance stated that the kitchen staff were to report pest sightings in the pest sighting log located in the Williamsburg nursing station. Review of the pest sighting log from the Williamsburg nursing station showed that pests sightings in the kitchen were last documented on 12/08/21. During an interview conducted on 01/12/22 at 1:50 PM, the Environmental Services Director stated that pest control came out to the kitchen once per month. He further stated that they could come out more often if something was reported. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 28 of 28