Health inspection·April 19, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few offered and accepted clothing offered that was in the facility's clothing supply. It was also noted that the prior living residence of Resident #32 was contacted and would have the resident's clothing available for pick up today (04/18/23),, which the facility would do. On 04/18/23 at 11:30 AM, the Director Social Service approached the surveyor and showed a large bag of clothing that the facility had picked up at the resident's prior residence. The bag contained an assortment of pants, shirts, socks, undergarments, and other clothing. On 04/18/23 at 12:30 PM, observation of the resident noted the resident to be wearing fresh clean clothing. The resident expressed how happy he was to be able to obtain his clothing and to be able to stop wearing hospital gowns on a daily basis. 4. During observation of the lunch meal on 04/16/23 at 12:15, breakfast meal observation on 04/17/23 at 7:30 AM accompanied with the facility's Consultant Dietitian, and lunch meal observation of 04/17/23 at 12:30 PM in the Williamsburg Unit , it was noted that following the meal tray set up that all food lids, empty beverage cartons, carton lids, straw covers, and other trash were piled on the end of the residents' beds which was coming in touch with the bed covers and bed linens. This was noted to occur during the meal observations in resident rooms #100 through #119 and affected 19 facility residents, which included Residents #32 #66, #202, and #205. Based on observations, interviews, and record review, the facility failed to treat each resident with dignity equally for 21 of 34 sampled residents reviewed for dignity, as evidenced by: utilizing a gown as a clothing protector (Resident #58), lack of personal care request related to hair (Resident #97), not providing proper clothing (Resident #32), and for placing meal tray trash on residents' beds for resident rooms #100 through #119, which affected 19 randomly observed facility residents during meals (that included sampled Residents #32 #66, #202 and #205). The census at the time of the survey was 165. The findings included: Review of the facility's policy, titled, Resident Rights, with no date implemented and no revised date documented, in part: The facility will inform the resident both orally and in writing, in a language the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the [NAME] in the facility. All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation or gender identity or expression. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. 1. Record review for Resident #58 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Anxiety Disorder and Major Depressive Disorder. Review of the Minimum Data Set (MDS) for Resident #58 dated 01/17/23 revealed in Section C that a Brief Interview for Mental Status (BIMS) score could not be conducted due to the resident is rarely / never understood. Section G revealed Resident #58 required extensive assistance, with support of one person assist, for dressing, eating, toilet use and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 2 of 29 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 04/19/2023 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation conducted on 04/16/23 at 9:45 AM in the [NAME] dining room, some of the residents had a towel placed on their chest as a clothing protector. Resident #58 had a hospital gown draped across her chest as a clothing protector. During an interview conducted on 04/16/23 at 9:55 AM with Staff H, Certified Nursing Assistant (CNA), when asked why Resident #58 had a hospital gown draped around her chest, she stated we did not have any more bibs / towels. 2. Resident #97 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #97 had diagnoses that included Lupus, Heart Disease, Chest Pain, Dizziness, Blood Clots, COVID-19, Hypertension, and Insomnia. The Annual Minimum Data Set (MDS) documented on 03/02/23 that Resident #97 had a BIMS score of 14, indicating she was cognitively intact. For functional status, this MDS documented Resident #97 required extensive assistance of 1 staff member for personal hygiene. Review of Resident #97's care plans revealed there was a care plan in place regarding Resident #97 being at risk for altered skin integrity, but there was no care plan specifically regarding her hair. During the initial tour of the facility conducted on 04/16/23 at 10:41 AM, Resident #97 stated she had asked the staff multiple times to help her shave her head. Resident #97 said her hair was falling out because of her diagnosis (named) and it was very uncomfortable for her to have her hair the way it was. She stated wanted her head shaved because it would be more comfortable for her. An interview was conducted with Resident #97 on 04/18/23 at 9:43 AM. The surveyor immediately observed that her head was unshaved. The surveyor asked Resident #97 about her hair, who stated the staff still had not helped her shave it. The surveyor asked who she has been asking for assistance in this matter, and stated she had asked nurses and CNAs, and no one had helped her. An interview was conducted with Staff E, CNA and Staff M, Registered Nurse (RN) on 04/18/23 at 9:47 AM. Staff E and Staff M stated Resident #97 had not told them about wanting her head shaved. Staff E stated a beautician comes to the facility each week on Tuesdays and can help Resident #97 do her hair. The surveyor explained that Resident #97 did not want her hair done, she wanted her head shaved. Staff E and Staff M seemed confused by this and did not respond. The surveyor asked that one of the staff speak to the resident and the beautician regarding her concern. An interview was conducted with Resident #97 on 04/18/23 at 3:37 PM. The surveyor immediately observed that her head was still unshaved. Resident #97 stated the staff had not come to her room to discuss her head shave request. Resident #97 stated she was upset that the staff were not helping her with her request. An interview was conducted with the facility's Director of Nursing (DON) on 04/18/23 at 3:42 PM. The surveyor explained to the DON that Resident #97 was upset and depressed about this concern and that the staff were not helping her with her concern. The DON stated she had not heard of a concern or request from Resident #97 about having her head shaved. She said she would talk to Resident #97 now and help her complete this request. An interview was conducted with Resident #97 on 04/19/23 at 10:45 AM. The surveyor immediately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 3 of 29 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 04/19/2023 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observed that her head was still unshaved. Resident #97 stated that no staff had talked to her about shaving her head. Resident #97 stated she was becoming increasingly upset that the staff was not helping her with her request. An interview was conducted with the facility's DON on 04/19/23 at 12:16 PM. The DON stated she had told Staff N, RN, to shave Resident #97's head but did not know that the task had not been completed. The surveyor told the DON that Resident #97 was observed less than 2 hours prior and her head was not shaved and that this was unacceptable. The DON stated she was going to talk to the nurse immediately. An interview was conducted with Resident #97 on 04/19/23 at 1:35 PM. The surveyor immediately observed that her head was still unshaved but appeared to have been washed and combed. Resident #97 stated a nurse had come and helped her clean her hair and combed it and that she was more comfortable with this current solution but that she still wanted the hair shaved off for a long-term solution. An interview was conducted with the facility's DON on 04/19/23 at 1:42 PM. The DON said the staff had worked with Resident #97 and that the beautician would be at the facility on 04/25/23 to work with Resident #97 on a long-term solution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 4 of 29 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 04/19/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 4 of 4 residential living areas (Williamsburg, [NAME], Cambridge, and [NAME]); and failed to ensure it stored and processed linens in the laundry area in a proper manner. The findings included: During the resident screenings conducted on 04/16-17/23 and the environment tour conducted on 04/19/23 at 10 AM, accompanied with the Director of Maintenance and Corporate Director of Maintenance, the following was noted: 1. Williamsburg Unit: room [ROOM NUMBER]: Peeling room wallpaper, and damage and disrepair to room walls. room [ROOM NUMBER]: Exterior of room entry door in disrepair. room [ROOM NUMBER]: Exterior of entry door damaged and in disrepair. room [ROOM NUMBER]: Peeling room wallpaper, and damage and disrepair to room walls. room [ROOM NUMBER]: Peeling room wallpaper, and damage and disrepair to room walls. room [ROOM NUMBER]: Heavy urine odor in room and bathroom, small flying insects in bathroom, and peeling room wallpaper. room [ROOM NUMBER]: Dresser drawer broken and unable to open or shut and room walls damaged and in disrepair. room [ROOM NUMBER]: Room walls damaged and in disrepair, exterior of footboard (Bed A) was heavily worn, and room trash container was cracked and broken. room [ROOM NUMBER]: Peeling room wallpaper, and damage and disrepair to room walls, large room floor tile broken (1), and dresser drawer missing opening handle. room [ROOM NUMBER]: Peeling room wallpaper, and damage and disrepair to room walls. room [ROOM NUMBER]: Exterior of bathroom entry door was damaged and in disrepair. room [ROOM NUMBER]: Peeling room wallpaper, and damage and disrepair to room walls. room [ROOM NUMBER]: Peeling room wallpaper, and damage and disrepair to room walls, and bathroom walls in disrepair. room [ROOM NUMBER]: Room floor noted to have numerous stained areas, and peeling room wallpaper and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 5 of 29 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 04/19/2023 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 damage and disrepair to room walls. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: The entry door did not open all the way unless the door handle is pulled down. Residents Affected - Some room [ROOM NUMBER]: Peeling room wallpaper, and damage and disrepair to room walls, and exterior of room chair was heavily worn. Medical Supply Room: Room floor soiled with dirt and trash, room floor had numerous stained areas, and broken storage shelving (2). Physical Therapy Gym: The stabilizer bars of the parallel bars were loose and unsteady for resident use, the floor was soiled and covered with tree leaves that had blown in from the exit/entry door, exercise machines (2) were heavily soiled and not deep cleaned on a regular basis, and exercise mat noted to be covered with soiled sheet linen. Nurses Station: The ceiling mounted air-conditioning vent located oven the nurses station noted to be heavily soiled and covered in a black mold type substance. Clean Utility Room: Room cabinets noted to be water damaged, the ceiling vent noted to be heavily soiled and covered in a black mold type substance, and room floor heavily soiled. 2. [NAME] Unit: room [ROOM NUMBER]: Room entry door does not open all the way unless the door handle is pulled down. room [ROOM NUMBER]: German roach like insect ran across the floor towards the underside of the resident's bed with Certified Nursing Assistant (CNA) present. During an interview conducted on 04/16/23 at 10:40 AM with the CNA, he acknowledged an insect ran across the floor towards the underside of resident's bed in room [ROOM NUMBER]. When asked how or who he would report this to (the bug sighting incident), he stated he would tell the nurse or the Administrator. room [ROOM NUMBER]: Ceiling near the smoke detector had missing plaster. room [ROOM NUMBER]: Inside of the bathroom door and on the door jamb edge had dark marks and chipped wood leaving rough edges exposed. Photographic Evidence Obtained. room [ROOM NUMBER]: Threshold to the bathroom, the floor is coming up. Photographic Evidence Obtained. room [ROOM NUMBER]: Nightstand (next to the bed closest to the door) the laminate/wood on the top is chipped. Photographic Evidence Obtained. room [ROOM NUMBER]: Threshold to the bathroom floor is missing a piece of flooring, the bathroom ceiling tiles were stained, there is a hole in the wall above the baseboard located below the paper towel dispenser. Photographic Evidence Obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 6 of 29 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 04/19/2023 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 Level of Harm - Minimal harm or potential for actual harm [NAME] Dining Room: Entrance (furthest from the nursing station to the [NAME] dining room) had dark marks on the wall, red paint / nail polish on the floor near the window, and the door (closest to the nursing station) to the [NAME] dining room was chipped at the bottom. Photographic Evidence Obtained. 3. Cambridge Unit: Residents Affected - Some Nurses Station: Accumulation of dust on the ceiling at the air vents around the centrally located nurses' station on the Cambridge Unit Pantry: Drawers and cabinet damaged with an accumulation of debris under the cabinet. Pantry: Roach droppings and live and dead roaches observed underneath the microwave oven. Accumulation of debris under and behind water and ice dispensing machine. room [ROOM NUMBER]: Peeling / rubbed off paint outside of resident room's entry doorway. Second floor just opposite the main elevators: Chipped and stain running base board. Soiled Utility Room: Peeling / rubbed off paint on the outside door. room [ROOM NUMBER]: Chipped and peeling bottom lower portion of entry way door hinge. Second floor Activity Room storage doorway entry wall: scuff marks and peeling paint located just outside of the door. Second floor Activity Room: Scuff marks on both the back and side walls of the second floor. 4. [NAME] Unit: Medication Preparation Room: Dead roaches under refrigerator and under sink. room [ROOM NUMBER]: Live roaches noted. room [ROOM NUMBER]: Live roaches noted, and holes in the wall right side of A/C (air conditioner) unit. room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. There was also a large area of damage on the wall below the television of the A-bed. There were also stained ceiling tiles and a broken soap dispenser observed in the resident's bathroom. Photographic evidence obtained. room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. There was also a large stain on the privacy curtain between the residents' beds. There was also a large amount of black/gray mold-like matter on and surrounding the vent in the doorway of the room. Photographic evidence obtained. room [ROOM NUMBER] Peeling wallpaper noted behind both resident beds. There was also a large amount of black/gray mold-like matter on and surrounding the vent in the doorway of the room. The garbage can on the B-bed side of the room was lacking a garbage bag but there was garbage in the can. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 7 of 29 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 04/19/2023 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 Photographic evidence obtained. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. There was also a large amount of black/gray mold-like matter on and surrounding the vent in the doorway of the room. Residents Affected - Some room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. There was also a large amount of black/gray mold-like matter on and surrounding the vent in the doorway of the room. There was a raised toilet seat present in the resident's bathroom which had peeling paint and large areas that appeared to be rusty/rough and had the potential to cause a skin tear to a resident's legs. room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. There was also a large amount of black/gray mold-like matter on and surrounding the vent in the doorway of the room. There was also stained ceiling tiles and bubbled / peeling flooring behind the toilet observed in the resident's bathroom. There was also a stained and burned lamp shade observed on the B-bed side of the room. Photographic evidence obtained. room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. There was also bubbled / peeling flooring behind the toilet observed in the resident's bathroom. room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. room [ROOM NUMBER]- Peeling wallpaper noted behind both resident beds. Hallway: Outside of room [ROOM NUMBER], there were 4 stained/discolored ceiling tiles observed. Photographic Evidence Obtained. room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. There was also a large amount of black/gray mold-like matter on and surrounding the vent in the doorway of the room. Photographic evidence obtained. There was also bubbled/pealing flooring behind the toilet observed in the resident's bathroom. room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. There was also a large amount of black/gray mold-like matter on and surrounding the vent in the doorway of the room. room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. There was also a large amount of black/gray mold-like matter on and surrounding the vent in the doorway of the room. room [ROOM NUMBER]: Peeling wallpaper noted behind the A-bed. room [ROOM NUMBER]: Large amount of scratches and scuff marks located on the bottom half of the bedroom and bathroom doors. room [ROOM NUMBER]: Peeling wallpaper noted behind both resident beds. Medication Room: Room ceiling note a large amount of black/gray mold-like matter and staining on 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 8 of 29 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 04/19/2023 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 of the ceiling tiles and surrounding the ceiling vent. Photographic Evidence Obtained. Level of Harm - Minimal harm or potential for actual harm 5. In the Williamsburg Unit Pantry: the drawers and cabinet were damaged with an accumulation of debris under the cabinet. Residents Affected - Some 6. In the Employee Break Room: there was an accumulation of debris and dead roaches behind the reach-in refrigerator in the employee break room. 7. First floor laundry chute room: The auto closing external door to the laundry chute room was propped open with a plastic chair. 8. Review of the facility's policy, titled, Soiled Linen and Trash Containers with a reviewed/revised date of 04/19/23, included housekeeping personnel shall empty soiled linen and trash containers from soiled utility rooms into outside hazard rooms twice daily at designated times. Loose trash and linen should be appropriately bagged before placing into the large storage bins. Review of the facility's policy, titled, Handling Soiled Linen with a reviewed/revised date of 04/19/23, included, It is the process of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. Contaminated linen carts should be cleaned and disinfected whenever visibly soiled and according to schedule developed by the facility. Soiled linen shall be kept separate from clean linen. Review of the facility's policy, titled, Laundry with a reviewed/revised date of 04/19/23, included, Laundry will be removed from washers promptly and will not be left in the machines overnight. Whenever possible, the facility will leave the doors to washing machines open to air dry. During a laundry tour conducted on 04/19/23 at 7:35 AM with the Director of Maintenance, the following observations were made: a. Laundry room sorting area: There were overflowing bins and unbagged laundry. Photographic Evidence Obtained. b. Laundry drying room: There was 1 of 4 dryers was not in working order. c. Laundry drying room: The dryer drums of all 4 dryers had rust and melted debris. Photographic Evidence Obtained. d. Laundry drying room: The vents under all 3 dryers had lint / debris accumulation on the bottom of vent area on the sides and in the corners. Photographic Evidence Obtained. e. Laundry drying room: The bin for transporting the washed clothes to the dryer room had cloth and debris in the bottom of the bin. Photographic Evidence Obtained. f. Laundry drying room: The covered cart of clean laundry had a cover that was thread bare, and the Velcro tabs were worn and would not adhere. Photographic Evidence Obtained. g. Laundry drying room: There was clean wet laundry stored inside the broken dryer. Photographic Evidence Obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 9 of 29 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 04/19/2023 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 Level of Harm - Minimal harm or potential for actual harm h. Laundry storage room: The area furthest from entrance to laundry storage room had built up dust / debris on the floor and behind a control type of box. Photographic Evidence Obtained. i. Laundry storage room: Most of the clean laundry was not covered. There were numerous bags of clean laundry left open. There was clean laundry lying on the floor. Photographic Evidence Obtained. Residents Affected - Some j. Soiled Utility Room on [NAME] Unit: There were 2 trash bins with items (glass containers) stored under the sink. Photographic Evidence Obtained. k. Soiled Utility Room on [NAME] Unit: There was a yellow bin with a cloth, used gloves and debris in the bottom of the bin. Photographic Evidence Obtained. l. Soiled Utility Room on [NAME] Unit: There were bins overflowing with bagged dirty laundry. There were open bags of dirty laundry on the counter. Photographic Evidence Obtained. During an interview conducted on 04/19/23 at 8:00 AM with Staff P, Laundry Aide, who when asked about the dirty laundry bins, stated the night shift did not clean them. When she was asked if all the dryers were in working order, she stated, the 1 dryer had been broken since last year. When asked why clean wet linen was in the broken dryer, she stated we do not have enough bins to store the laundry, so we put it in the broken dryer to hold it. During an interview conducted on 04/19/23 at 9:15 AM with Staff Q, Laundry Aide, who when asked about residents soiled laundry, she stated she picks up the residents soiled laundry as follows: The [NAME] unit resident laundry gets picked up on Mondays and Wednesdays, it is always overflowing with resident soiled laundry placed on top of the bin cover and on the counters in the soiled utility room. The [NAME] unit resident laundry gets picked up on Tuesday and Thursdays and it also is always overflowing with resident soiled laundry placed on top of the bin cover and on the counters in the soiled utility room. The Cambridge unit resident laundry gets picked up on Tuesdays. The Williamsburg unit resident laundry gets picked up on Tuesdays and Fridays. When asked why some of the units have soiled residents' laundry outside of the bins, she stated they do not have enough bins for soiled resident laundry. 9. The exterior of the handrails on both sides of the corridor in the Cambridge (room [ROOM NUMBER]-248) and [NAME] (room [ROOM NUMBER]-270) Units were noted to be heavily worn, dirty, stained, and in disrepair. Photographic Evidence Obtained. One (1) ceiling tile immediately in front of the elevator bank on the 2nd floor was noted to be broken and in a state of disrepair. 10. [NAME] Unit: Two observations conducted on 04/16/23 and 04/17/23 in the Central Shower Room on the [NAME] Unit revealed a [NAME] Sharps wall cabinet with a glove opening in the bottom which was approximately 12 inches long by 3 inches wide (large enough for an adult hand to fit inside). The wall cabinet was missing the appropriate red sharps container box inside. Observed inside the wall cabinet were 7 used razors. Discussion with the facility's Director of Nursing (DON) at the time of observation revealed she did not know who was responsible for ensuring the proper red sharps container boxes were placed or replaced in the wall cabinets throughout the facility. A third observation of this shower room conducted on 04/19/23 revealed a staff member had placed a red sharps container box inside the wall cabinet appropriately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 10 of 29 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 04/19/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In the main hallway outside the [NAME] Dining Room and in front of the nursing station, there were 4 badly stained and discolored ceiling tiles. Inside the [NAME] Lounge Room, it was observed that one of the ceiling lights contained a large amount of black/gray matter on and surrounding the light fixture. Also noted in this room was a small end table with a drawer-the drawer-front was broken off and placed inside of the drawer. There was also a brown, roach-like insect approximately 1 inch long on the floor of the room. In the [NAME] Medication Room, there were multiple stained ceiling tiles present. There was also a large amount of black/gray mold-like matter on and surrounding the ceiling vent. In the [NAME] Unit Shower Room, the shower curtain on the second shower stall was heavily stained/dirty. 11. During a medication room observation conducted on 04/18/23 at 9:35 AM, the surveyor noted the ceiling in the Cambridge Medication Room had a large amount of black/gray mold-like matter and staining on 3 of the ceiling tiles and surrounding the ceiling vent. The surveyor immediately notified the facility's Assistant Director of Nursing (ADON), Corporate Nurse, and Maintenance staff who performed repairs on the ceiling and called a roof repair service. In the Cambridge Unit Shower Room, the first shower stall contained a cracked ceiling light. There was also a large amount of black/gray mold-like matter on and surrounding the vent in the ceiling of the shower stall. In the Cambridge Unit Clean Utility Room, there were multiple stained ceiling tiles present. There was also a large amount of black/gray mold-like matter on and surrounding the ceiling vent, and large scuff marks on the walls. 12. In the Williamsburg Medication Room, there were multiple stained ceiling tiles present. There was also a large amount of black/gray mold-like matter on and surrounding the ceiling vent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 11 of 29 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 04/19/2023 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide medically related social services in a timely manner for 1 of 2 sampled residents reviewed for social services (Resident #80). Residents Affected - Few The findings included: Resident #80 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #80 had a medical history significant for a Stroke, Heart Failure, Muscle Weakness, Hypertension, Atrial Fibrillation, Insomnia, Major Depressive Disorder, Paranoid Schizophrenia, Dementia, Blood Clot, Anxiety, and Chronic Pain. Review of Resident #80's Physician Orders revealed an initial order for a Psychiatric Consult was written on 12/28/22, despite Resident #80 being admitted in November 2022 with a significant psychiatric history. Review of the admission Minimum Data Set (MDS) of 11/17/22, documented in part: Under Section A for Identification Information, this MDS documented Resident #80 was not currently considered by the state Level II Preadmission Screening and Resident Review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition; Under Section I for Active Diagnoses, Resident #80 had a medical history significant for Anxiety, Depression, and Schizophrenia; Under Section C for Cognitive Pattern, a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment Under Section N for Medications, Resident #80 had received 5 days of antipsychotic medications since admission. This section also documented Resident #80 was receiving antipsychotic medications on a routine basis Under Section E for Behavior, Resident #80 displayed rejection of cares-behavior of this type occurred 1-3 days. Review of the Level I PASRR sent from the hospital on [DATE], when Resident #80 was admitted , revealed the PASRR was incomplete and did not contain the documentation of the above diagnoses. If these diagnoses had been documented properly, the resident would have received a Level 2 PASRR which would have led her to receiving psychiatric services sooner. Review of Resident #80's care plans revealed there was a care plan in place regarding Resident #80 being at risk for behavior symptoms related to her diagnosis of Paranoid Schizophrenia, that she refused treatment and medications, and that she used racial slurs toward staff members. There was no care plan in place regarding Resident #80 being under the care of a court appointed guardian. During the initial tour of the facility conducted on 04/16/23 at 11:13 AM, Resident #80 was screened related to a concern she had communicated to the surveyor. During the initial record review, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 12 of 29 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 04/19/2023 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 0745 surveyor noted Resident #80 was under the care of a court appointed guardian. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the resident's legal guardian on 04/18/23 at 2:07 PM. The guardian explained that Resident #80 required a guardian due to being an indigent, having no family, and having a declining health status. The guardian explained that he works at the Legal Aide office as a Social Worker. He explained that in order for a person to become a ward, a referral is filled out by a facility and the person is evaluated by 3 professionals and then a judge who determines (based on the evaluation) if the person meets the criteria. He said the guardianship protocol states a ward must be seen every 3 months but the Legal Aide protocol states they must see each ward every month, so he said he sees Resident #80 every month. Residents Affected - Few The guardian stated Resident #80 used to live at another facility and then was discharged to a local hospital. He said no one at the initial facility told him that Resident #80 had been sent to the hospital. When she was discharged from the hospital, Resident #80 was admitted to this facility because she did not want to go back to the other facility, but no one at this facility or the hospital had told him that Resident #80 was admitted to this facility. He said he did not know where Resident #80 was until she called him asking him to go to the initial facility to get her belongings for her. The guardian stated Resident #80 had a known history of Paranoid Schizophrenia. He stated Resident #80 called in lots of complaints and concerns to him, the police, the Department of Children and Families, and the Agency for Health Care Administration. He said all the reports are unfounded/not substantiated. The guardian stated Resident #80 was being followed by the Psychiatrist at the initial facility. He stated he did not know until January(2023) that the Psychiatrist was not seeing her at this facility. He said he told the Social Worker here in January that Resident #80 needed the Psychiatrist consult for care. He said he feels Resident #80's psychiatric issues were more substantial than her health diagnoses. An interview was conducted with Staff K, Social Worker on 04/19/23 at 1:43 PM. Staff K stated it is her job to review the PASRR sent from the hospital for all new admissions within 48 hours of admission. When asked if the PASRR from 11/13/22 appeared to be complete, Staff K answered that the PASRR was incomplete because it was missing the documentation of Resident #80's psychiatric diagnoses. When asked if a Level 2 PASRR should have been completed, Staff K answered that a Level 2 should have been completed. The surveyor asked if she had contacted Resident #80's guardian when she was admitted . Staff K stated she did not. An interview was conducted with the facility's Director of Nursing (DON) on 04/19/23 at 2:05 PM. The DON stated it is the responsibility of the admitting nurse to review a new resident's physician orders and then the DON and Assistant Director of Nursing (ADON) review the orders the next day to ensure if the new resident has orders for psychiatric medications. If they do, then a psychiatry consult is written. The DON stated she did not call Resident #80's guardian when she was admitted to the facility. The DON stated Resident #80 was not on psychiatric medications when she was admitted , but the admission MDS documented she was. Further review of Resident #80's physician orders revealed there was an order written from 11/13/22 to 01/31/22 for ARIPiprazole Oral Tablet 20 MG Give 20 mg by mouth at bedtime for Depression. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 13 of 29 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 04/19/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to be free of a medication error rate of 5% or more, and the medication error rate was 9.68 %. Three (3) medication errors were identified [NAME] observing a total of 31 opportunities, affecting Resdient #42 and a resident in room [ROOM NUMBER]. Residents Affected - Few The findings included: 1. A medication administration observation was conducted on 04/17/23 at 9:15 AM with Staff A, Registered Nurse (RN) for a resident in room [ROOM NUMBER]. Staff A gathered and administered the following medications: a. Aspirin 81 milligram (mg) 1 tablet given b. Docusate 100mg 1 capsule given c. Eliquis 5mg 1 tablet given d. Valsartan 80mg 1 tablet given e. Vitamin C 500mg 1 tablet given f. Vitamin D3 1000 international unit (iU) 1 tablet given. Review of the resident's physician orders and Medication Administration Record (MAR) revealed the resident should have received 2 tablets each for the Vitamin C 500mg and Vitamin D3 1000IU. 2. A medication administration observation was conducted on 04/18/23 at 9:15 AM with Staff B, Licensed Practical Nurse (LPN) for Resident #42. Staff B gathered and administered the following medications: a. Breo Ellipta Inhaler 100-25 1 puff administered b. Isosorbide Dinitrate 10mg 1 tablet given c. Furosemide 20mg 1 tablet given d. Vitamin C 500mg 1 tablet given e. Methenamine 1gm 1 tablet given f. Brimonidine Tartrate 0.2% Eye Drops 1 drop administered in each eye g. Naproxen 500mg 1 tablet given h. Potassium Cl ER 10 milliequivalent (mEq) 1 tablet given i. Vitamin D3 1000mg 1 tablet given (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 14 of 29 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 04/19/2023 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 0759 j. Xarelto 20mg 1 tablet given. Level of Harm - Minimal harm or potential for actual harm After entering the resident's room, Staff B gave the resident the medication cup containing the medication tablets and a bottle of water and then left the bedside to wash her hands in the bathroom. While Staff B was in the bathroom, the resident took the medication cup and tipped the tablets into her mouth. The resident then looked into the medication cup and saw 3 tablets remaining in the cup. She then tipped 2 of the remaining tablets into her mouth, the 3rd fell into the bedsheets (the Xarelto tablet). The resident did not notice this. When Staff B returned to the bedside, she began to administer the resident's eye drops, but the surveyor intervened and told Staff B about the Xarelto tablet that fell into the bedsheets. Staff B searched and eventually found the tablet tucked under the resident's comforter. Without surveyor intervention, Staff B would not have known that the resident did not ingest the Xarelto tablet. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 15 of 29 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 04/19/2023 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 - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure secure storage of medications in an unlocked Wound treatment cart; ointment in an unoccupied resident room; medications at the bedside for Resident #126, Resident #305, Resident #9, Resident #122; loose tablet on a medication cart; one (1) tablet disposed of into a garbage can; two (2) loose tablets in two (2) medication carts; and one (1) expired medication in a medication refrigerator. The findings included: Review of the facility policy and procedure on [DATE] at 1:30 PM, titled, Medication Storage, provided by the Director of Nursing (DON) reviewed 2022, documented in part, in the Policy Statement: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medications rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments .8. Unused Medications; The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. The medications are destroyed in accordance with our Destruction of Unused Drugs Policy. 1. During an observational tour conducted on [DATE] at 10:36 AM, it was observed that there was an unlocked, easily opened 5th drawer of the Wound treatment cart, located on the second floor of the Cambridge Unit. This cart was unsecured and accessible to other residents, staff members and visitors. The 5th drawer of the Wound care treatment cart contained a larger clear plastic bag with a package of twenty-four (24) individual packets of Selan Zinc Oxide ointment; all with expiration dates of 10/24. The treatment cart also contained wound care treatment medications for fifty-eight (58) residents residing on the Cambridge Unit. Photographic evidence was obtained. A brief interview was conducted with Staff G, Registered Nurse (RN) / Assistant Director of Nursing (ADON) for the 2nd floor Cambridge and [NAME] units, in which she was asked about the unlocked treatment cart. She stated it is supposed to be locked at all times, and that perhaps the medication cart maybe 'malfunctioning'. 2. During an observational tour on [DATE] at 11:32 AM of an 'un-occupied' resident room (# 226-A), it was observed there was a used, very visible container of OTC (over-the-counter) Vitamin A-D-E ointment located atop the bedside dresser with an expiration date of 01/24. The ointment was unsecured and accessible to other residents, staff members and visitors. Photographic Evidence Obtained. On [DATE] at 2:33 PM, the Vitamin A-D-E ointment was again noted to be very visible atop of the this 'un-occupied' resident's bedside dresser. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 16 of 29 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 04/19/2023 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 - Some 3. Resident #126 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Dementia, Anxiety Disorder, Major Depressive Disorder and Hypertension. He had a Brief Interview Mental Status (BIM) score of 9, indicating moderate impairment. On [DATE] at 12:04 PM, it was observed there was a used, very visible bottle of OTC Mylanta liquid antacid / anti-gas, with an expiration date of 09/24; a used very visible container of OTC Afrin nasal spray expiration date of 06/2024; a used visibly container of OTC Neo Synephrine nasal spray expiration date of 06/2024; and a very visible container of OTC Retaine MGD eye drop, single ophthalmic solution with no expiration date, located atop the Resident #126's bedside dresser, which were unsecured and accessible to other residents, staff members and visitors. On [DATE] at 2:35 PM, it was again observed that there was a used visibly sitting bottle of OTC Mylanta liquid antacid/anti-gas; a used very visible container of OTC Afrin nasal spray; a used very visible container of OTC Neo Synephrine nasal spray; and an OTC container of Retaine MGD eye drop, single ophthalmic solution, all left atop of Resident #126's bedside dresser. On [DATE] at 10:51 AM, it was still noted that there was a used, bottle of OTC Mylanta liquid antacid/anti-gas, a used container of OTC Afrin nasal spray, a used container of Neo Synephrine nasal spray and now there was observed to be an additonal bottle of OTC Mylanta liquid antacid / anti-gas, with an expiration date of 03/2024 located visibly in the bottom drawer of Resident #126's bedside dresser. 4. On [DATE] at 12:13 PM, during a second day observational hallway tour, it was observed that there was a very visible, unidentified, loose, white, oblong shaped pill sitting atop of the 'pull out' shelf of the Cambridge second floor's #3 medication cart which was unsecured and accessible to other residents, staff members and visitors. Photographic evidence was obtained. On [DATE] at 12:19 PM a brief interview was consecutively conducted with Staff F, RN, and with Staff B, Licensed Practical Nurse (LPN) / Charge Nurse (CN) of the Cambridge Unit second (2nd) floor, regarding the visible, unidentified, loose, white, oblong shaped pill sitting atop the 'pull out' shelf of the Cambridge second floor's #3 medication cart, as well as the other unsecured OTC medications. Staff F and Staff B both acknowledged that neither the OTC Mylanta liquid antacid/anti-gas bottles, OTC Afrin nasal spray, OTC Neo Synephrine nasal spray, OTC Retaine MGD eye drop, single ophthalmic solution, nor the loose, unidentified pill should have been left unsecured and accessible and all the medications should have been secured and/or discarded. Record review was conducted with Staff G, which noted that neither Resident #126's hard copy chart nor his computerized Point-Click-Care (PCC) medical record indicated the resident had any self-assessment completed in order for him to administer his own medications. There was no order on the Resident #126's Medication Administration Record (MAR) for this (OTC) medication to be administered to this resident. During an interview conducted on [DATE] at 10:05AM with Staff G, she acknowledged that neither the OTC Mylanta liquid antacid/anti-gas bottles, OTC Afrin nasal spray, OTC Neo Synephrine nasal spray, OTC Retaine MGD eye drop, single ophthalmic solution, nor the loose, unidentified pill should have been left unsecured and accessible and all the medications should have been secured and/or discarded. The two (2) bottles of OTC Mylanta liquid antacid/anti-gas, OTC Afrin nasal spray, OTC Neo (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 17 of 29 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 04/19/2023 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 - Some Synephrine nasal spray and OTC Retaine MGD eye drop, single ophthalmic solution, were not all removed from Resident #126's bedside, until after surveyor intervention. On [DATE] at 10:15 AM, the DON further acknowledged the Wound Care treatment cart should be kept locked, the OTC medications should have been secured, and the loose, unidentified pill, should have been discarded, and this was not done. 5. During an observation conducted on [DATE] at 10:25 AM revealed Resident #305 lying in bed. Upon closer observation of the room, it was bserved that the nightstand next to the resident had a loose pill, 1 open bottle of artificial tears with an expiration date of [DATE], an unopened bottle of artificial tears with an expiration date of 08/22, Preparation H ointment with an expiration date of 12/24, Monistat with an expiration date of 09/24, and Vagisil cream with an expiration date of 01/25. Photographic Evidence Obtained. During an interview conducted on [DATE] at 10:30 AM with the Resident #305, she stated those medications, excluding the loose pill, are medications that she brought from home because she needs them occasionally. An interview was conducted on [DATE] at 10:40 AM with Staff I, Certified Nursing Assistant (CNA), who stated he has worked for the facility for 5 years. When asked about the medication at the bedside for Resident #305, he pointed to the pill and said 'that is a pill', and had no other comment. 6. During the initial tour of the facility conducted on [DATE] at 9:50 AM, the surveyor noted Resident #9 had a box of Lubricated Eye Drops in an open box sitting on top of the nightstand. A secondary observation was made on [DATE] at 11:00 AM of the eye drops remaining on Resident #9's nightstand. Review of the Significant Change Minimum Data Set (MDS) of [DATE] documented Resident #9 had a Brief Interview of Mental Status (BIMS) score of 10, indicating she had moderate cognitive impairment. Review of Resident #9's chart revealed there were no progress notes, assessments, or care plans written about Resident #9 being able to self-administer medications. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:00 PM. The surveyor informed the DON about the eye drops on Resident #9's nightstand who said she would make sure they were removed promptly. 7. During the initial tour of the facility conducted on [DATE] at 10:27 AM, the surveyor noted Resident #122 had a Ventolin Inhaler in an open box sitting on top of the nightstand. A secondary observation was made on [DATE] at 10:48 AM of the inhaler remained on Resident #122's nightstand. An Annual MDS documented on [DATE] that Resident #122 had a BIMS score of 15, indicating he was cognitively intact. Review of Resident #122's chart revealed there were no progress notes, assessments, or care plans written about Resident #122 being able to self-administer medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 18 of 29 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 04/19/2023 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 An interview was conducted with the facility's DON on [DATE] at 3:00 PM. The surveyor informed the DON about the inhaler on Resident #122's nightstand, who said she would make sure it was removed promptly. 8. A medication administration observation was conducted on [DATE] at 9:15 AM with Staff B, Licensed Practical Nurse (LPN). Staff B gathered and administered the following medications: Residents Affected - Some a. Breo Ellipta Inhaler 100-25 1 puff b. Isosorbide Dinitrate 10mg 1 tablet c. Furosemide 20mg 1 tablet d. Vitamin C 500mg 1 tablet e. Methenamine 1gm 1 tablet f. Brimonidine Tartrate 0.2% Eye Drops for 1 drop in each eye g. Naproxen 500mg 1 tablet h. Potassium Cl ER 10 milliequivalent (mEq) 1 tablet i. Vitamin D3 1000mg 1 tablet j. Xarelto 20mg 1 tablet. During the observation,upon entering the resident's room, Staff B placed the eye drops, inhaler, and medication cup on the resident's bedside table and then went into the resident's bathroom to wash her hands, leaving the medications unattended in the resident's room. The resident self-administered the medication tablets and while doing so dropped a tablet into her bed sheets. The surveyor intervened and told Staff B about the dropped tablet. Staff B retrieved the tablet and then left the room to place it into a medication cup in her medication cart, leaving the medications unattended in the resident's room again. After Staff B administered all the resident's medications, she and the surveyor returned to the medication cart. Staff B placed the eye drops and inhaler on the medication cart and then entered another resident's room to wash her hands, leaving the medications unattended again. When she returned to the medication cart, Staff B then returned the eye drops and inhaler to the cart. 9. A medication room observation was conducted on [DATE] at 11:10 AM with Staff M, Registered Nurse (RN) of the [NAME] Unit Medication Room. During this observation, a vial of Pneumovax 23 was found in the drawer of the medication refrigerator. This vial was not in a bag and did not contain a resident's name. This vial had an expiration date of [DATE]. The surveyor handed the vial to Staff M. Staff M said she would dispose of it. The surveyor informed the DON, Assistant Director of Nursing (ADON), and Corporate nurse of this expired vial. 10. A medication cart observation was conducted on [DATE] at 11:30 AM with Staff D, RN of his medication cart on the [NAME] Unit. During this observation, the surveyor found one oval shaped white (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 19 of 29 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 04/19/2023 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete tablet lying at the back of a drawer. Staff D stated he did not know where this tablet came from or which resident it belonged to. Staff D stated he would dispose of it in the Pill Buster. The surveyor infomred the DON, ADON, and corporate nurse of this tablet. 11. A medication cart observation was conducted on [DATE] at 11:40 AM with Staff O, RN, of the medication cart on the Williamsburg Unit. During this observation, the surveyor found a partial round white tablet lying at the back of a drawer. Staff O stated she did not know where this tablet came from or which resident it belonged to. Staff O stated she would dispose of it in the Pill Buster. The surveyor informed the DON, ADON, and corporate nurse of this tablet. Event ID: Facility ID: 105481 If continuation sheet Page 20 of 29 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 04/19/2023 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 observation, interview, and record review, the facility failed to follow the approved menu for Pureed Diets that included 16 of 16 aampled residents, Residents #10, #16 #18, #29, #31, #37, #63, #69, #72, #99, #121, #132, #137, #202, #212, and #299. The findings included: 1. During the review of the approved menu for the lunch meal of 04/16/23, the following documentation was noted: *Regular Diets - Fresh Potatoes and Onion (4 ounce serving portion) *Pureed Diet - Pureed Fresh Potatoes and Onions (#10 scoop portion) During the observation of the lunch meal in the main kitchen on 04/16/23 at 11:30 AM, it was noted that the Fresh Potatoes and Onions were prepared and located on the steam table for Regular Diet. Further observation noted that Pureed Fresh Potatoes and Onions were not prepared. Further observation noted that instant Mashed Potatoes were prepared for Pureed Diet. Interview with the Certified Dietary Manager (CDM) and facility's Registered Dietitan (RD) at the time of the observation noted that staff failed to review the approved menu for pureed diet. It was discussed with the CDM and that the following of approved menus and preparation of fresh foods for pureed diets increases the food palability, appearance, and acceptance of residents receiving Pureed Diets. A review of the Standardized Recipe for the preparation of Pureed Fresh Potatoes and Onions revealed documentation that fresh potatoes and onion be utilized for the pureed food. 2. During the review of approved menu for the breakfast meal of 04/17/23, the following documentation was noted: *Regular Diet - Confetti Eggs (#18 scoop portion) *Pureed Diet - Pureed Confetti Eggs During the observation of breakfast meal in the main kitchen on 04/17/23 at &;30 AM, it was noted that the Confetti Eggs were prepared for the Regular Diets. Further observation noted that Pureed Confetti Eggs were not prepared and Pureed Scrambled were to be served to Pureed Diets. Interview with the CDM at the time of the observation noted to state that staff failed to review the approved breakfast menu and failed to prepare the Pureed Confetti Eggs. It was discussed with the CDM and that the following of approved menus and preparation of fresh foods for pureed diets increases the food palability, appearance, and acceptance of residents receiving Pureed Diets. A review of the standardized recipe for Pureed Confetti Eggs noted documentation that all ingredients including [NAME] and Red Peppers be included in the preparation of the pureed eggs. 3. During the review of the approved menu for the lunch meal of 04/17/23, it was noted that Pureed Applesauce (#10 scoop portion) were to be served to Pureed diets. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 21 of 29 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 04/19/2023 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 FORM CMS-2567 (02/99) Previous Versions Obsolete During the observation of the lunch meal in the main kitchen on 04/17/23 at 11:30 AM, it was noted that Regular Applesauce was prepared for Pureed diets. Interview with the CDM at the time of the observation noted to state that she was unaware that the applesauce was to be pureed for the lunch meal. 4. During the review of the facility's diet census for 04/16/23 and 04/17/23, noted that there were 16 facility residents with physician orders for a Purred Diet. The 16 resident's included sampled Resident's #10, #16, #18, #29, #31, #37, #63, #69, #72, #99, #121, #132, #137, #202, #212, and #299. Event ID: Facility ID: 105481 If continuation sheet Page 22 of 29 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 04/19/2023 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation , interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for the food service safety. Residents Affected - Many The findings included; 1. During the initial kitchen / food service sanitation tour conducted in the main kitchen on 04/16/23 at 9 AM and accompanied with the Morning Cook, the following was noted: (a) Observation of the cooks 2-compartment preparation sink noted that the left side sink contained 6-5 pound cook portions of Pot Roast. Further observation noted that a small stream of warm water was running onto 2 portions of the beef. The right sink was noted to contained approximately 40 portions of commercially packaged raw fish. Further observation noted the fish was not being covered in cold running water. An interview conducted with the lunch cook at the time of the observation noted the surveyor to state the roast and fish were not being thawed according to regulation. It was discussed with staff that both the beef and fish need to be resting in cold water with run-over drain and also cold water running over the top of the beef and fish. It was also discussed that the internal temperature of the cooked beef and raw fish were not being maintained at the regulatory temperature of 41 degrees Fahrenheit (F) or below. The staff stated she was unaware of the regulatory thawing process and holding temperature cold foods. Photographic Evidence Obtained. (b) Observation of reach-in refrigerator #1 noted 2 sides to be rust ladened and the front was covered with large areas of dried food matter. Photographic Evidence Obtained. (c) Observation of the bench mounted commercial can open noted that the stem of the open part was rust ladened and the open blade was dull and covered with metal shavings. There was a potential that the shavings and rusted could end up in foods and result in food contamination. Photographic Evidence Obtained. (d) Observation of the 3-compartment sink noted that the food preparation equipment was being washed by dietary staff. Further observation noted that the third sink was not filled with a sanitizing chemical as per required regulation of a Quaternary, Iodine, or Bleach sanitizing chemical. The surveyor requested that all food preparation equipment be rewashed and sanitized as per regulation. Photographic Evidence Obtained. (e) Food preparation skillets / fry pans (2) were noted to have the exterior covered with black carbon residue and the interior coating of Teflon was being worn off. It was discussed that the Teflon and carbon could potentially result in food contamination. The surveyor requested that the skillets be discarded from use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 23 of 29 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 04/19/2023 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 Photographic Evidence Obtained. Level of Harm - Minimal harm or potential for actual harm (f) Observation of the dish machine room noted that the caulking on stainless steel dish runs were covered with a black moil type substance. The surveyor requested that the issue be reported to maintenance for repair. Residents Affected - Many Photographic Evidence Obtained. (g) Observation of the dish machine which was in operation noted that the entrance and exit dish curtains were covered with food slime and dried food matter. The surveyor discussed that the dish machine and curtains were not properly cleaned from use from the dinner meal service of 04/15/23. Photographic evidence obtained. (h) Observation of the dry / canned storage room noted that the entrance door was being held open by a soiled #10 can of sliced pears. It was discussed by the surveyor that foods cannot be stored directly on the floor. Photographic Evidence Obtained. (i) Observation of the food preparation and serving area noted that 4 soiled cleaning rags were being stored directly on food surfaces. Continued observation noted that the were no cleaning rag storage buckets that contained a chemical sanitizer. Photographic Evidence Obtained. (j) Five contains (1-2 pound) containers of Parsley Flakes, Oregano, Garlic Powder, Ground Nutmeg, and Ground Cinnamon were noted to be located on the cook's spice shelf. Further observation noted that the contained were not documented with an opening date as required by regulation. Photographic Evidence Obtained. (k) Observation of the dry foods / canned food storage room noted that there were 2 commercial storage rice bins located within the room. Further observation noted that the exteriors of both bins were covered with brown dried food matter. Photographic Evidence Obtained. (l) The wall area around the entrance door of the walk-in refrigerator was noted to be in disrepair and a large hole in the wall area was noted. The surveyor requested the matter be brought to the attention of the maintenance staff. Photographic Evidence Obtained. (k) The entry door of the walk-in refrigerator was noted to be rust laden and large areas of peeling paint. It was discussed by the surveyor that the rust and peeling paint could result in food contamination. Photographic Evidence Obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 24 of 29 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 04/19/2023 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 (l) During the observation of the kitchen exit door to the outside of the facility noted that the door was being held open with a #10 can of fruit, and 2 cases of Foam Hot Cups (each 40/25 count) were being stored directly on the soiled concrete pad. (m) During the observation tour, it was noted that numerous flying insects were located in the food storage area, food preparation areas, and food serving and distribution areas. Numerous observations noted the flying insects to land on clean food preparation surfaces and onto food located within these areas. 2. During the second follow-up to the main kitchen on 04/16/23 at 11:30 AM accompanied with the Certified Dietary Manager (CDM), the following were noted: (n) During the second follow-up tour, it was noted that clean silverware was not being stored in a sanitary manner. Specifically, 4 cylinders of clean silverware were stored with the eating portion in the up position. Staff were noted to be handling the silverware (forks, knives, and spoons) by the eating portion. The surveyor requested the CDM to view the issues and requested the silverware be rewashed and sanitized and stored properly prior to the next use. Photographic Evidence Obtained. 3. During a third follow-up conducted in the main kitchen on 04/18/23 at 7:30 AM, and accompanied with the CDM, the following were noted: (o) Numerous flies were again noted in the tray line serving area. Flies were noted to be landing on prepared foods located within the area. The surveyor requested that the CDM notify the administration of the pest control issues. Photographic Evidence Oobtained. (p) During the observation of the tray assembly line, it was noted the diet aides were whipping water off of resident trays with a soiled cleaning rag. The surveyor requested that this procedure cease immediately. It was discussed with the CDM at the time of the observation that the soiled rag was spreading bacteria onto each resident tray. On 04/16/23 and 04/18/23, the photographic evidence was shared with the Administrator to confirm the observation findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 25 of 29 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 04/19/2023 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to dispose of garbage and refuse properly. The findings included: Residents Affected - Some During observation of the facility's dumpster / refuse area on 04/16/23 at 10:30 AM, it was noted that there were 2 commercial dumpster's (1-garbage / refuse and 1 cardboard / paper waste) located in the courtyard outside of the dietary department. Further observation of the garbage / refuse dumpster noted that door to the unit was not closed and the interior of the dumpster was filled with open bags (10) and exposed garbage food/trash waste. The unit was noted to be full of flying insects and the smell was overwhelming. Photographic Evidence Obtained. Observation of the cardboard / paper dumpster also noted that the the unit was full of open garage and expose garbage waste. The administrator and Director of Maintenance were notified that the garbage storage area was not being maintained in a sanitary condition to prevent the harborage and the feeding of pests. Photographic Evidence Obtained. It was also discussed that there was the potential health threat from exposed rotting garbage / trash and insect infestation. The administrator stated that he was unaware of the condition of the garbage refuse area and the Director of Maintenance was unaware what facility department was responsible to maintain the garbage refuse area in a clean and safe condition. Photographic evidence was shared with the administrator on 04/16/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 26 of 29 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 04/19/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to screen for eligibility to receive pneumococcal immunization and failed to offer pneumococcal immunization for 1 of 5 sampled residents reviewed for immunizations, Resident #300. Residents Affected - Few The findings included: Record review for Resident #300 revealed the resident was admitted to the facility on [DATE]. There was no Pneumococcal screening for Resident #300. There was no documentation of the Pneumococcal vaccine offered to Resident #300. During an interview conducted on 04/19/23 at 11:00 AM with the Infection Preventionist revealed she started working at the facility during the end of November 2022 as the Infection Preventionist. When asked about immunizations being offered to residents, she stated all residents are screened on admission and readmission for Pneumococcal, Influenza and Covid immunization, and based on the screening, the immunizations are then offered to each resident if applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 27 of 29 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 04/19/2023 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 observation, interview and record review, the facility failed to have an effective pest control program, as evidenced by observations of live and dead roaches in multiple areas of the facility. Residents Affected - Some The findings included: During an observation on 04/16/23 at 10:37 AM in room [ROOM NUMBER], a Germán roach-like insect ran across the floor towards the underside of the resident's bed with Staff I, Certified Nursing Assistant (CNA), present. During an interview conducted on 04/16/23 at 10:40 AM with Staff I, he acknowledged an insect ran across the floor towards the underside of resident's bed in room [ROOM NUMBER]. When asked how or who does he reports the bug sighting incident, he stated he would tell the nurse or the Administrator. On 04/16/23 at 2:14 PM, during an interview with the resident in room [ROOM NUMBER], when asked about the presence of pests, the resident replied, roaches the size of elephants in the closet. At the conclusion of the interview, with Resident #13's permission to tour her room, live roaches, in all stages of life and too numerous to count, were observed behind a 4-drawer dresser to the resident's right side of the bed. A review of the 'Service Request Log' located at the nurse's stations revealed that there were sightings of roaches in the Cambridge Pantry as recently as 02/01/23. During a tour of the unit pantries, on 04/17/23 at 7:51 AM, accompanied by the Maintenance Director, the following were noted: a. In the Cambridge Unit Pantry, roach droppings and live and dead roaches were observed underneath the microwave oven. b. In the Medication Prep Room on the [NAME] Unit, there was an accumulation of dead and mature roaches and roach droppings noted under the upright reach in refrigerator / freezer and under the hand washing sink. c. During an observation of the Employee Break Room, on 04/17/23 at 9:56 AM, there was an accumulation of debris and dead roaches in all stages of life and too numerous to count behind the upright reach in refrigerator/freezer in the employee break room. d. During an interview with members of the Resident Council, on 04/17/23 at 3:05 PM, when asked about the presence of pests, the resident who resides in room [ROOM NUMBER] stated that he sees roaches, almost every day in the ceiling, on the walls of room. At the conclusion of the meeting, this surveyor arrived to room [ROOM NUMBER] and upon entering the room, the resident pointed out a live and mature roach-like insect crawling on the floor between the beds and under the nightstand. Further inspection of the area around the nightstand revealed live roaches in all stages of life and too numerous to count on the floor and wall behind the nightstand, on the wall where the privacy curtain between the beds meets the wall. Live roaches were also observed in the corner of the room by the window bed where pictures were stored. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 28 of 29 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 04/19/2023 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 - Some e. On 04/17/23 at 4:18 PM, live roaches in all stages of life and too numerous to count, were observed in room [ROOM NUMBER] behind the nightstand. f. During an interview, on 04/18/23 at 12:18 PM, with Staff B, Licensed Practical Nurse since 2017, when asked about the presence of roaches, Staff B replied, sometimes in the patient's rooms, during the day, not as much. I tell the Administrator and the UM [unit manager]. When asked of the most recent sighting, Staff B replied, a week ago in the pantry (Cambridge on the Cambridge Unit). Review of the Pest control service reports revealed the following: *On 03/03/23, Treated kitchen areas with gel bait throughout for heavy German roach activity .also treated all pantry areas, German roach activity was seen in pantry areas. The report documented that there were 40 German roaches noted. *On 03/10/23, German roaches were found in employee break areas .German roaches were found behind fridge areas of the pantry. The report documented that there were 50 German roaches noted. *On 03/17/23, documented activity in the kitchen as well as area being in need of cleaning. The facility did not provide reports and invoices for the month of April 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105481 If continuation sheet Page 29 of 29