Inspection·May 25, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER]: bathroom toilet requires re-caulking to the floor, over bed tables exterior were rust laden, and room baseboards were heavily soiled and stained. room [ROOM NUMBER]: The room walls were covered with black scuff marks, in disrepair and in need of re-painting. The exterior of the bathroom entry door was in disrepair and large sharp splinters of wood were exposed. room [ROOM NUMBER]: Large areas of black tile glue coming up between the floor tiles, and the room walls were covered with black scuff marks, in disrepair and in need of re-painting. room [ROOM NUMBER]: Exterior of room entry door was in disrepair, room walls were covered with large black scuff marks, in disrepair and in need of re-painting, bathroom walls in disrepair, and room base boards soiled and stained. room [ROOM NUMBER]: Large areas of black tile glue coming up between the floor tiles. room [ROOM NUMBER]: The floor area behind the d bed was noted to be heavily soiled and areas of dried brown matter, tube feeding pole noted to be heavily soiled and areas of dried brown matter. room [ROOM NUMBER]: The room dresser was noted to have missing drawer pull handles, room floor heavily soiled, and the room walls were covered with black scuff marks, in disrepair and in need of re-painting. room [ROOM NUMBER]: The room walls were covered with black scuff marks, in disrepair and in need of re-painting, bathroom toilet requires re-caulking to the floor, and the over-bed light cord was too short for resident use. room [ROOM NUMBER]: The room walls were covered with black scuff marks, in disrepair and in need of re-painting. room [ROOM NUMBER]: The room walls were covered with black scuff marks, in disrepair and in need of re-painting, and the over-bed light cord was too short for resident use. room [ROOM NUMBER]: Privacy curtain for D-bed would not provide full privacy, room walls were covered with black scuff marks, in disrepair and in need of re-painting. Large areas of peeling wall paper and exterior of over-bed tables were rust laden. room [ROOM NUMBER]: Exterior hole of bathroom entry door, numerous large holes to room walls, and stained privacy curtain. room [ROOM NUMBER]: The room walls were covered with black scuff marks, in disrepair and in need of re-painting, poor cable television reception. Main Hallway: The floor areas between rooms #101 through #119 (20 Rooms) were noted to be covered throughout with large black stains. Photographic Evidence Obtained of above findings. Second Floor: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 2 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 room [ROOM NUMBER]: Bar soap located in bathroom (2 non-related residents residing in room), non-labeled toothbrushes (4) and brushes combs located in bathroom. room [ROOM NUMBER]: The Formica exterior of the closet doors (3) was peeling off, room walls were covered with black scuff marks, in disrepair and in need of re-painting, large stains to room ceiling, and bathroom mirror exterior was black. room [ROOM NUMBER]; Dresser drawers would not close, the room walls were covered with black scuff marks, in disrepair and in need of re-painting, room [ROOM NUMBER]: The Formica exterior of the room closet doors (3) was peeling off. room [ROOM NUMBER]: Closet doors (2)were broken and would not close. room [ROOM NUMBER]: The room walls were covered with black scuff marks, in disrepair and in need of re-painting, the bathroom sink requires re-caulking to the wall, bathroom baseboards were soiled and stained black, and the bathroom toilet required re-caulking to the floor. Main Hallway: The corner of the wall area outside of room [ROOM NUMBER] was in disrepair and noted to have exposed sharp edges. Main Facility Hallway: The carpet area that extended from the First Floor Nurses Station, past the elevators, past the beauty shop, and up to the Main Dining Room was noted to be heavily stained and in need of replacement. Following the 05/23/23 environment tour, the findings were again confirmed with the Director of Maintenance and Director of Housekeeping. The findings were then reviewed with the facility's administration staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 3 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation of Resident #23 on 05/22 /23 at 8:30 AM noted the breakfast tray was delivered to resident's room and set up on bedside table. A Regular Diet was noted to be served. Residents Affected - Few Observation of the resident during the meal noted the resident was left to feed self. Continued observation noted that while trying to self-feed, the resident was spilling plate foods and drinks onto the front of himself. Continued observation noted the resident would pick up spilled foods (Pancakes, Scrambled Eggs) and place them in his mouth to eat. The resident expressed frustration and anger and said he would like more assistance and adaptive eating equipment. Review of the meal tray card noted no documentation of adaptive eating or drinking cups to be included on the meal tray. Following the observation, the surveyor requested the Skilled Therapy Director to evaluate / screen the resident for adaptive equipment (built-up silverware, Sippy cup and scoop plate). Review of clinical record of Resident #23 on 05/24/23 noted the following: Date of admission: [DATE]. Diagnoses included: Disorder of Muscles, Cerebral Palsy, Psychosis, Hypokalemia. Current Physician Orders included: 09/20/22 - Regular Diet 12/3/22 - ProSource 30 ml Daily - Supplement 12/01/22 - Vitamin C 500 mg BID 12/02/22 - Multivitamin with Minerals 05/29/15 - Vitamin D3 1000 Units 2 Tabs Daily. Review of current Minimum Date Set, dated 03/03/23, noted: Sec B: Understood & Understands Sec C: BIMS=10 [indicating moderate cognitive impairment] Sec D: No Mood Sec G: requires supervision Sec K: 65/149# [inches / pounds] Sec M : No Pressure Ulcers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 4 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Review of Weight History documented: Level of Harm - Minimal harm or potential for actual harm 05/04/23 = 146# 03/06/23 = 150 # Residents Affected - Few 11/02/22 = 154 # Height = 65 Body Mass Index = 24.3 Weight loss of 8 pounds since 11/02/22 through 05/04/23. Nutrition Note, dated 03/07/23 included: Able to feed self with some set up and assistance. Review of current Care Plan, dated 03/28/23, included: Nutritional Risk: Requires set-up with meals and adaptive utensils. It was noted that no adaptive equipment was assessed and implemented for Resident #23 during meal observations conducted on 05/22-23/23. On 05/25/23, the Director of Skilled Therapy submitted a Therapy Screening for Resident #23 that recommended and required the use of Built-up Utensils, Plate Guard, and Adaptive Drinking Cups. The director also submitted a physician order dated 05/24/23 that documented Patient to receive built-up handles for utensils, extended straw, cup lid with straw hole and plate guard. Before feeding, the resident should be upright at a 90-degree angle in bed or in wheelchair. Occupational Therapy evaluation and treatment 5 times per week times 2 weeks. It was also discussed during the 05/25/23 interview with the Director that staff are failing to report feeding issues to the Nursing Administration and the Skilled Therapy Department and there was the potential, Resident #23 could decrease the ability to self-feed. The Director could not give the surveyor a reason why Resident #23 had not been assessed for the adaptive equipment since admission of 09/07/20. Based on observations, interviews, and record review, the facility failed to provide the necessary care and services to maintain resident's independence with eating for 2 of sampled 13 residents reviewed for nutrition, Residents #23 and #104. The findings included: 1. Record review for Resident #104 revealed the resident was admitted to the facility on [DATE] with most recent readmission date of 05/18/23 with diagnoses that included: Multiple Sclerosis, Syncope and Collapse, Dysarthria and Anarthria, and Seizures. Review of the Minimum Data Set (MDS) for Resident #104, dated 04/20/23, revealed in Section C a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 5 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Brief Interview of Mental Status (BIMs) score of 14, indicating cognition is intact. Section G revealed for bed mobility and eating both had a self-performance of extensive assist with support of one person assist; and transfers, dressing and personal hygiene all had a self-performance of total dependence with support of two plus person assist. Review of the physician's orders for Resident #104 included an order dated 05/18/23 for Eval and treat - OT (Evaluation and Treatment - Occupational Therapy). Review of the physician's orders for Resident #104 included an order dated 05/18/23 for regular diet, regular texture. Review of the physician's orders for Resident #104 included an order dated 04/12/22 to 10/30/22 for Eval and treat - OT. Review of the care plan for Resident #104 dated 04/13/22 with a focus on Activity of Daily Living (ADL) self-care deficit, revealed an increased need for assistance during functional task related to weakness, decreased activity tolerance, dynamic balance, safety awareness, pain. The goals were to improve ADL self-performance. Interventions included: OT ADL Activities of Daily Living) training/adaptive equipment to improve self-care, home management training, meal preparation, safety procedures and/or instructions in use of assistive devices and/or technology. OT therapeutic exercises to develop strength, endurance, range of motion and/or flexibility. Review of the Nutrition Progress note for Resident #104 dated 04/13/22 included the following: the resident is awake and alert during RD (Registered Dietician) visit, reported having difficulty self-feeding as she is not able to use utensils secondary to her MS (Multiple Sclerosis. Requested finger foods, RD discussed with CDM (Certified Dietary Manager) to facilitate preferences. Able to consume fluids via straw. Preferences discussed with resident. She denied any chewing / swallowing difficulties. Denied any nausea / vomiting or diarrhea. Please refer to the completed assessment for further information. During an interview conducted on 05/22/23 at 10:20 AM with Resident #104, she stated her hands are very weak from MS and she has a hard time using her hands to feed herself. She stated she used to have big handles on her eating utensils before she went to the hospital recently. She said she returned to the facility from the hospital Thursday night (05/18/23) and since she had been back, she has not had the big handled eating utensils. When asked about the 8 cups of water on her overbed table, she said she must have those because they are a smaller size than the big Styrofoam cups, they usually hand out to everyone with water. She said the Styrofoam cups are too big and heavy for her to use with her hands because of the arthritis and MS. During an observation conducted on 05/22/23 at 1:00 PM of Resident #104's lunch meal tray, the resident did not have any built-up eating utensils on her meal tray. Photographic Evidence Obtained. During an observation conducted on 05/22/23 at 1:00 PM of Resident #104's eating cream of wheat with a regular spoon and had several spots on her chest of spilt cream of wheat and the cream of wheat was also on her chin. It was noted that the resident did not have any built-up eating utensils on her breakfast meal tray. During an interview conducted on 05/22/23 at 1:00 PM with Resident #104, she stated 'have you ever seen pasta with no sauce, and then said this is when I really need those big handled eating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 6 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 utensils, it is hard for me to feed myself.' Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 05/23/23 at 9:45 AM with the Director of Therapy who stated she has been the Director of Therapy for 3 months but has been employed with the facility for 19 years. She stated that if Resident #104 was seen by Occupational Therapy last year that was on a different system, and she does not have immediate access to those records and will have to locate them and she will get back to surveyor. Residents Affected - Few During an interview conducted on 05/24/23 at 10:49 AM with the Director of Therapy, when asked how long it takes for a resident to be evaluated once an order is written for an eval and treat for Occupational Therapy (OT), she stated it can up to 2 days; if this is an order for a new admission or a readmission, it is done the next day. When asked about Resident #104, she stated on 04/13/22, an eval was done and found that for eating, she was at the same level as setup. When asked if it is determined that a resident needs adaptive equipment with meals how is the kitchen made aware of this. She stated we would put an order in and then nursing signs off on the order and the order goes to the kitchen. When asked about the order written on 05/18/23, she stated the resident was a long-term care resident, and she would not be seen unless nursing sees a change in the resident. She verified that there was an active order dated 05/18/23 for Resident #104 for Eval and treat OT but she had never received the order. During an interview conducted on 05/25/23 at 8:30 AM with the Director of Therapy, she stated Resident #104 was screened by OT and they recommend the resident needed built up handles for utensils, plate, extended straw, and cup with top. She said that the OT also recommends that Certified Nursing Assistants (CNAs) make sure that the patient is positioned upright prior to eating. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 7 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the residents' environment remained free of accidents hazards due to excessive hot water temperatures on 1 (Wing C- 20 resident rooms) ) of 3 residential wings located on the first floor. The findings included: During the initial screening of residents on 05/22/23 at 10 :30 AM that located on the First Floor C Wing (Rooms #101 - #119), it was noted that the hot water temperature in the bathroom of room [ROOM NUMBER] was very hot to the touch. The surveyor asked the two residents (2) residing in the room if there were any issues with the hot water temperature and the response from both residents was no. At the request of the surveyor, a digital food thermometer from the dietary department was obtained. The thermometer was calibrated and the hot water temperature in the bathroom of room [ROOM NUMBER] was recorded at 119 degrees Fahrenheit (F). At the surveyor's request, additional rooms located on First Floor C Wing were taken accompanied with the facility's Certified Dietary Manager (CDM). The room hot water temperatures were recorded as follows: #103 = 125 F #106 = 138 F #112 = 120 F #119 = 99 F #122 = 122 F #127 = 125 F #133 = 124 F #134 = 123 F Community Shower Room = 125 F. Additional hot water temperatures taken on the first floor were noted to be at acceptable ranges from 105 110 degrees F. Following the temperature testing, the surveyor requested an interview with the Director of Nursing and Director of Maintenance. During the interview, it was noted that the Directors were not aware of the potential issues resulting from excessive Hot Water Temperatures located in the First Floor C Wing. The surveyor requested an immediate action plan to include the following: -Inform all nursing staff of the hot water temperature. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 8 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0689 Level of Harm - Minimal harm or potential for actual harm -In-service all nursing staff to not allow residents the use of hot water without staff supervision in the rooms and community shower areas. -Inform all alert and oriented residents of the hot water temperature and to not use without staff supervision. Residents Affected - Some -Empty the Hot Water Heater in the Mechanical Room to remove all hot water storage ( 1 hot water heater) and re-fill with cold water. -Contact outside plumbing vendor to assess the hot water issues ASAP. -Contestant monitoring and documenting of hot water temperatures throughout the facility until the issues had been resolved. An observation of the Mechanical Room conducted on 05/22/23 at 11:30 AM with the Director of Maintenance, noted that the thermostat for the hot water thermostat was set at 140 degrees F. The Director stated that the hot water temperature should go down to acceptable levels once the water reaches the mixing valve. A review of the facility's Temperature Log for the Month of May 2023 noted recorded daily (5/1-19/23) hot water temperatures located in First Floor C wing from 110 - 114 degrees F. There were no recorded hot water temperatures above 114 degrees F. A review of the facility's Incident/Accident Logs and Resident Grievance Logs from March 2023 to present noted no incidents with skin burns from scalding hot water or resident complaints concerning excessive room and shower hot water temperatures. Individual interviews conducted with 5 alert and oriented residents residing on the First Floor C Wing did not voice issues with excessive hot water temperatures. On 05/22/23, the facility administration informed the surveyor that an outside Plumbing vendor was in the facility to address the hot water issues. The surveyor was informed that the hot water heater required a new mixing valve that would be installed on 05/23/23. On 5/23/23, the facility submitted a Plumbing repair bill form an outside vendor (Plumbing License #CFC 022540) that documented the following: -Replace Bad Domestic Hot Water Mixing Valve -New Electronic Controlled Mixing Valve -Emergency Call 5/22/23 -Materials & Parts, Installation An interview was conducted with the Plumbing Vendor on 04/23/23 who stated he could not pinpoint the day that the mixing valve failed to work but it could have been within the date of 05/22/23. Further review of hot water temperatures logs after the 05/22/23 issue was noted were reviewed. The review included temperatures taken hourly in different residents' rooms from 05/22/23 through the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 9 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0689 repair date of 05/23/22 noted comfortable hot water temperatures ranging from 104 -107 degrees F. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 10 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0692 Provide enough food/fluids to maintain a resident's health. 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 address significant weight loss in a timely manner for 1 of sampled 13 residents reviewed for nutrition, Resident #76. Residents Affected - Few The findings included: Record review for Resident #76 revealed the resident was admitted to the facility on [DATE], left the faciity on [DATE] and was readmitted to the facility on [DATE]. Diagnoses included: Aftercare Following Joint Replacement Surgery, Noninfective Gastroenteritis and Colitis, Abdominal Pain, Chronic Kidney Disease Stage 3, Type 2 Diabetes Mellitus, Presence of Cardiac Pacemaker, Alcohol Abuse, Gastroesophageal Reflux Disease without Esophagitis, Nausea, Localized Edema. Review of the Minimum Data Set (MDS) for Resident #76 with a date of 03/14/23 revealed in Section C a Brief Interview of Mental Status score of 10 indicating the resident had moderate cognitive impairment. Section G revealed for bed mobility, transfers, toilet use, and personal hygiene all had a self-performance of extensive assistance with support of two plus persons assist, eating had a self-performance of independent with support of 1 person assist. Review of the Physician's orders for Resident #76 revealed an order dated 04/16/23 for CHO (Carbohydrate) controlled, no added salt diet, regular texture. Review of the Physician's orders for Resident #76 revealed an order dated 04/16/23 for Nutritional Shake: no sugar added with meals for nutrition support. Review of the Physician's orders for Resident #76 revealed an order dated 04/16/23 for Glucerna Thera Shake one time a day for nutrition supplement. Review of the Care Plan for Resident #76 dated 03/10/21 and revised on 03/16/23 with a 'focus on Risk for altered nutrition related to history of ETOH (Alcohol) abuse, DM (Diabetes Mellitus), CAD (Coronary Artery Disease), and multiple food preferences. Misconceptions regarding appropriate food choices attempts to educate but resident not receptive. Sometimes the resident is resistant to care and being weighed. PO (oral) fluctuations-sign at times and fragile skin. Gradual weight loss trend March 2023. My goals were to tolerate diet and texture/consistency. Interventions included: Administer vitamin / mineral supplements as ordered. Encourage and assist as needed to consume foods and/or supplements and fluids offered. Honor food preferences. Monitor labs, skin, PO (oral), and hydration status PRN (as needed). Provide supplements as ordered. Provide therapeutic diet as ordered. Report signs or symptoms of diet and/or texture intolerance. Review weights and notify physician and responsible party of significant weight change.' On 02/03/23, the resident weighed 116.4 pounds and on 05/02/23, the resident weighed 103 pounds which indicated a significant weight loss of 11.51 % in 3 months. On 04/07/23, the resident weighed 110.2 pounds and on 05/02/23, the resident weighed 103 pounds which indicated a significant weight loss of 6.53% in 1 month. Record review revealed the resident is 5'7 (feet / inches) tall with a current weight of 103 pounds which gives him a Body Mass Index (BMI) of 16 indicating the resident is underweight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 11 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Nutrition Progress Note for Resident #73 dated 02/23/23 included: 'weight obtained for the month, 116.4 and indicates a significant weight gain of 7.7% vs last month. [the resident] recently readmitted with weight loss and now has regained weight which is beneficial. Provisions meeting needs, rec [recommend) to proceed and will f/u [follow-up] prn.' Review of Nutrition Progress Note for Resident #73 dated 03/16/23 included: [the resident] presents for an annual evaluation. Weight review indicates a gradual weight loss trend with no significant changes within the past 6 months. BMI (Body Mass Index) is below range at 17.5. Patient has fracture and surgery in past quarter which may have accounted for some weight loss related to healing process. He is on a regular, CHO (carbohydrate) controlled, NAS (no added salt) diet with a varied intake of 50-75% daily average, able to feed himself with some set up assistance. NSA (no sugar added) shakes TID (three times a day) remain in place for po (oral) support. Labs noted, monitored by medical team. Skin fragile, no areas of concern. Will add Glucerna Shake QD (daily) for additional support and will follow up prn (as needed).' Review of Nutrition Progress Note for Resident #73 dated 05/22/23 included: 'Resident visited today due to previously noted weight loss, re-weigh was requested, and resident had refused. Educated on the importance of weight trending, stated he needs to gain some weight. Food preferences reviewed, no recent change in appetite. My only complaint was that sometimes he gets reflux, typically avoids foods with tomato products and gravies. Accepts NSA shake, prefers them over the Glucerna shakes. Resident requested for me to come back next week to further discuss food preferences, did not want me to change too many food items at this time. RD [registered dietician] will follow up per resident request.' During an observation conducted on 05/22/23 at 11:40 AM of Resident #76 revealed the resident lying in bed wearing a hospital gown looking extremely thin. An interview was conducted on 05/23/23 at 10:30 AM with the Registered Dietician who stated he has been with the facility for 13 months. When asked what would be considered a significant weight loss, he stated it would be 5% or greater in 1 month, 7.5% or greater in 3 months or 10% or greater in 6 months. When asked how he would know if a resident had a significant weight loss, he stated the resident would be flagged in the electronic medical record (EMR) under weights. When asked what he would do for a resident with significant weight loss, he said typically he would see the resident the same day the resident was flagged in the EMR for significant weight loss, and he would order weekly weights. First, he would go over the resident's food preferences (likes and dislikes), next he would offer/order nutritional supplements (Boost or Ensure). Typically, the nutritional supplement(s) will be ordered for 1-2 times per day based on the caloric needs of the resident. The Nurse Practitioner (NP) would already have been notified and he would discuss with the NP consideration of an appetite stimulant. When asked about Resident #76, he stated he was waiting for an updated weight and the resident has refused weights in the past. The RD stated he saw the resident yesterday (05/22/23) and was educated on the importance of weight trending and the need to be reweighed weekly. The RD did a partial update of food preferences partially because the resident requested for RD to come back and see him next week. When asked why it took almost 3 weeks (20 days) from the time the resident's significant weight loss was identified until he saw the resident, he did not have an answer. When asked why he did not speak to the NP to discuss considering an appetite stimulant, he said he was going to follow up with the resident next week before contacting the NP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 12 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's Policy & Procedure for Fluid Restriction, (Implemented 12/22/22 and Revised 5/23/23), noted the following: Residents Affected - Few Policy: it is the policy of the facility to ensure that fluid restrictions will be followed in accordance to the physician's orders. Compliance Guidelines: #4: Water will not be provided at the bedside unless calculated into the daily total fluid restriction. During the observation of the breakfast meal on 05/23/24 noted Resident's #92's meal tray ticket to document a diet of Carbohydrate Controlled - Fluid Restriction Diet. Further observation of the meal ticket did not document what and how much fluid to be served on the breakfast tray. Interview with the alert and oriented resident on 05/23/23 noted the resident to state 'I want coffee with my breakfast meal and milk for my cereal.' A 16-ounce Styrofoam cup of water was noted at the bedside of which the resident stated she 'receives daily and drinks from it as needed'. Resident #92 also stated she not been been provided a lunch / snack-to-go bag to take to dialysis (3 times a week) for months. The resident stated she becomes hungry during the 4-5 hour dialysis treatment and the transportation. A review of the clinical record of Resident #92 noted the following: Date of admission: [DATE] Diagnoses: End Stage Renal Disease. Current Physician orders included: 10/25/22 - Carbohydrate Controlled , High Protein- Renal Diet. 05/11/23 - Fluid Restriction (FR) 1200 ml /24 hours - 120 ml Every 3 shifts. 02/24/23: Dialysis days M/W/F - 9:45 AM Pick-up. Review of the Current Minimum Data Set, dated [DATE] included: Sec B: Understood 7 Understands Sec C: BIMS = 14 (No cognitive impairment) Sec D: No Mood Issues Sec G: Eat = Extensive Assist (Note 5/24/23 - 05/23/23 Noted Resident #92 able to eat independently with set up) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 13 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0698 Sec K: 70/253#, Therapeutic Diet Level of Harm - Minimal harm or potential for actual harm Sec M: No Pressure Sores Review of the current Care Plan, dated 03/27/23 incldued: Residents Affected - Few 1) Dialysis * No update of physician ordered 1200 ml Fluid Restriction on 05/11/23 * No update to not provide fluids at bedside * No documentation to provide meal bag M/W/F for Hemodialysis treatment. 2) Nutritional Status * No update of physician ordered 1200 ml Fluid Restriction on 5/11/23 * No update to not provide fluids at bedside * No documentation to provide meal bag M/W/F for Hemodialysis treatment Review of Fluid Restriction Worksheet dated 05/11/23 noted the following: -Physician ordered 1200 ml Fluid Restriction -Nursing Allotment : 200 ml; Fluids on all shift (days, evenings, and nights) -Dietary Allotment: 600 ml - Breakfast 240 ml (Coffee), Lunch 120 ml (juice) and Dinner 240 ml (4 oz milk, and juice. During an interview with the facility's Registered Dietitian and review of the resident's meal tray tickets, it was confirmed that no fluids were included for the 3 meals and the physician order for 1200 ml Fluid Restriction was not being followed. It was also discussed that the 200 ml of fluids are allotted for the 11 PM to 7 AM shift, but the resident is sleeping and the fluids could be utilized for the meals or added to the 7AM-3PM or 3PM-11PM shifts. It was also discussed that according to facility Fluid Restriction Policy dated and revised 05/23/23 documented that water will not be provided at the bedside unless calculated into the total daily fluid restriction. The surveyor requested that the physician ordered 1200 ml fluid restriction be recalculated. The Dietitian stated that he was unaware that fluids were being provided daily at the resident's bedside and also unaware that a lunch / snack-to-go bag was not being sent with the resident on dialysis days. Interview with the facility's Certified Dietary Manager (CDM) on 05/23/23 at 9:00 AM revealed that a lunch / snack-to-go bag, that included the resident's food preferences and fluids allotted as per the physician ordered fluid, were not being sent with the resident on dialysis days. The CDM was also not aware that fluids were being provided daily at the resident's bedside. On 05/23/23, the facility's Registered Dietitian submitted a new Fluid Restriction Worksheet dated 05/23/23. A review of the worksheet noted the following changes: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 14 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0698 Level of Harm - Minimal harm or potential for actual harm *The total amount of allotted fluid for Nursing was changed from 600 ml to 300 ml per day (120 ml on each of the 3 nursing shifts *The total amount of allotted fluids for Dietary was changed from 600 ml to 840 ml per day for Breakfast (B) 360 ml (8 oz coffee, and 4 oz juice), Lunch (L) 240 ml (2 -4 oz cranberry juice). Residents Affected - Few * The B/L/D (Dinner) meal tray tickets were changed to reflect fluids to be provided for the meals of breakfast = 360 ml, lunch =240 ml, and Dinner 240 ml. On 05/24/23 at 10 AM, a follow up interview and observation was conducted with Resident #92. The interview noted that she hand been provided a lunch bag for dialysis that contained 8 ounces of Cranberry Juice, 1/2 meat sandwich, and graham crackers. The resident further stated that this was the first time in months that a bagged snack / lunch bag had been provided to take with her to the dialysis treatment. Based on observations, interviews, and record review, the facility failed to provide fluid management for 1 of 2 sampled residents reviewed for dialysis (Resident #92) and failed to provide snacks-to-go for 2 of 2 sampled residents for dialysis (Residents #92 and #115). The findings included: 1. Record review for Resident #115 revealed the resident was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Systematic Lupus Erythematosus, and Dependance on Dialysis. Review of the Minimum Data Set (MDS) for Resident #115 dated 02/26/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 13 indicating an intact cognitive response. Section G revealed for Bed mobility, Dressing, and Personal hygiene that all had a self-performance of extensive assistance with support of one person assist, eating had a self-performance of independent with support of setup help only. Review of the Physician's orders for Resident #115 revealed an order dated 11/19/22 for 'CHO Controlled Hi Pro Renal (Carbohydrate Controlled High Protein Renal) diet. Regular texture for diet.' Review of the Physician's orders for Resident #115 revealed an order dated 03/08/23 that the resident is to have 'dialysis on days: MF (Mondays and Fridays). Dialysis chair time is 8:30 AM, catheter site right upper chest. Snack to-go one time a day every Monday and Friday.' Review of the Care Plan for Resident #115 with an initiated date of 11/21/22 and a revised date of 02/28/23, had a focus on 'nutritional status as evidenced by Lupus, Anemia, Underweight, CVA (Cerebral Vascular Accident), CKD (Chronic Kidney Disease) and on HD Hemodialysis), need for therapeutic diet and fragile skin. Goals were to experience no significant weight change. Interventions included: Administer vitamin/mineral supplements as ordered. Bagged meal on Hemodialysis Days. Encourage and assist as needed to consume foods and/or supplements and fluids offered. Honor food preferences.' During an interview conducted on 05/23/23 at 8:30 AM with Resident #115, she stated she goes to dialysis Mondays and Fridays, she leaves at 8:00 AM and returns approximately 1:30 PM. When asked if she eats breakfast before she goes to dialysis, she stated no, she just has a cup of tea. When asked if they send a snack with her to dialysis, she said no. She said they used to send a tuna sandwich with her, but she does not eat tuna, if they could send a turkey or ham sandwich, she would eat it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 15 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few When asked how long ago the facility stopped sending a snack with her to dialysis, she said it stopped around January or February of this year, probably February. An interview was conducted on 05/23/23 at 10:50 AM with the facility's Registered Dietician (RD) who stated he has been with the facility for 13 months. He stated he typically would talk to the dialysis center once a month and chart on the dialysis resident monthly. The RD stated he would periodically address with a dialysis resident about the bag lunch or snack-to-go to make sure they are receiving them. When asked about Resident #115, he stated she is not a high-risk patient and would not typically discuss her bag lunch / snack-to-go. When the RD was informed that Resident #115 had said she used to receive a bag lunch / snack-to-go of a tuna fish sandwich but did not want tuna fish and subsequently has not received a bag lunch / snack-to-go since January/February 2023, he stated he was not aware of the situation. The RD verified in the Nutrition Management Program that there were no food preferences / dislikes listed. The RD added that typically a dialysis resident should be offered a bag lunch / snack-to-go that they can take with them to dialysis. An interview was conducted on 05/23/23 at 12:15 AM with the Certified Dietary Manager (CDM) who stated he has been working at the facility for 23 years. When asked how the kitchen knows who the dialysis residents are and when they need a bag lunch / snack-to-go and on which days, he stated the list was posted on the wall in the kitchen but today he took the list down to update it. He reprinted the old list that included Resident #107 M, F @ Breakfast. When asked to explain what this meant for Resident #107, he stated the resident goes out to dialysis on Mondays and Fridays and she needs a snack to go after breakfast had been served. He acknowledged there were no food preferences or dislikes on the list for the residents. When asked who is responsible to ensure a resident who leaves the facility for dialysis receives a bag meal or snack-to-go, he stated it is the responsibility of both the Dietician and CDM. The Dietician will update the food preferences / dislikes and the CDM will make sure the resident gets a meal before leaving for dialysis and resident receives a snack-to-go to dialysis. When asked when Resident #115 normally received a breakfast tray on non-dialysis days, he stated he believes it should be between 7:30-7:50 AM, and Resident #115 would get an early breakfast tray on the days she leaves for dialysis and her food preferences / dislikes have been updated. The CDM stated he just spoke to the resident, and she was not liking what was on the early breakfast tray and would just take some ginger tea. The resident would get a snack-to-go that is provided with the early breakfast tray on the dialysis days. The snack-to-go would be prepared the night prior to dialysis. When asked if the resident had been receiving a snack-go-on prior to leaving for dialysis, he stated he is not 100% sure that a snack-to-go was made up for the resident and/or if the resident received it or had refused it. They will now be keeping a log to track the snacks-to-go to ensure the snacks are prepared and given to the residents on their dialysis days. An interview was conducted on 05/23/23 at 2:20 PM with Staff A, Certified Nursing Assistant (CNA), who stated she has worked at the facility for 26 years. When asked if Resident #115 receives a breakfast tray before going to dialysis on Mondays and Fridays, she said 'yes, but she does not eat it, she only takes juice and tea'. When asked if she gets a snack-to-go bag to take with her to dialysis, she said 'yes but she does not take it because it has tuna fish. She said the resident does not like fish'. During an interview conducted on 05/23/23 at 2:30 PM with Staff B, Registered Nurse (RN), who was asked if Resident #115 receives a breakfast try before dialysis on Mondays and Fridays, he stated she does but she does not really eat breakfast. When asked if the resident receives a snack-to-go bag to take to dialysis, he said sometimes. When asked what is usually in the bag, he stated sometimes it is tuna fish or egg sandwich. He stated she does not like fish. When asked if he offers the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 16 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0698 resident something else if they give her tuna fish, he said I don't offer anything. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 17 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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 provide adaptive equipment for eating and drinking as ordered for 2 of 13 sampled residents reviewed for nutrition, Residents #126 and #132. Residents Affected - Few The findings included: 1. During the observation of the lunch meal on 05/22/23 at 12:30 PM, it was noted that Resident #126 had 1 Proval Cup (Adaptive Drinking Cup) included on the meal tray. Further observation noted that there were 3 fluids (coffee, milk, and water) on the tray but none of the fluids were poured into Proval Cup. It was also noted there were 4 bottles of water and juices on the overbed table. The resident was noted to attempt to drink fluids from the regular drinking container but had issues grasping and swallowing. During a second observation conducted on 05/23/23 at 8:15 AM, it was noted that 4 beverages (water, juice, milk, coffee) were on the meal tray and only 1 Proval Cup provided on the tray. An interview conducted with the Certified Dietary Manager (CDM) on 05/23/23 at 10:00 AM revealed the Proval Cup is an adaptive Drinking Cup used for swallowing / dysphagia issues and that a cup is required for each beverage provided on the meal trays. The CMD stated that the in-room water should be poured into a Proval Cup. It was also noted that the facility failed to have a sufficient supply of Proval cups to meet resident specific needs for some time. An interview conducted with the Director of Skilled Therapy on 05/23/23 at 2:00 PM also confirmed that the Proval Cup is a specific drinking cup used for swallowing issues that included dysphagia. It was also noted that 1 Proval Cup was to be provided for each tray beverage and that fluids located in the room should be in the Proval Cup. The Director stated that she had not been made aware there was an insufficient supply of Proval Cups in the facility to meet the needs of the residents who require them for swallowing. Record review for Resident #126 revealed the following: Date of admission: [DATE] Diagnoses included: Dysphagia, Failure, ASHD (Atherosclerotic Heart Disease), Symptoms Involving Musculoskeletal System. Review of Current Physician orders documented: 03/23/23 - Mechanical Soft Diet 03/23/23 - All liquids via Provale cup (5 cc - adaptive drinking cup). Review of Weight History included: 05/03/23 = 165 # (pounds). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 18 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0810 04/05/23 = 168 #. Level of Harm - Minimal harm or potential for actual harm 02/03/23 = 178#. 01/15/23 = 186#. Residents Affected - Few This indicates a 21-pound weight loss. Review of Current Minimum Data Set, dated [DATE], included: Sec B: Understood & Understands Sec C: BIMS (Brief Interview for Mental Status) score =14 Sec D: No Moods Sec G : Eat = Supervision Sec K: No Swallow Disorder, 67 (inches)-168 # Mechanical Altered Diet. Review of Current Care Plan dated 05/10/23 included: 1) Nutritional Status A review of the interventions failed to document the need for adaptive drinking equipment (Provale Cup) and Assistance / Supervision with eating. The Nutrition Note dated 05/10/23 failed to note documentation of the physician ordered fluids via Provale Cup and the assessed need for supervision / assistance with meals. 2. During the observation of the breakfast meal on 05/24/23 at 8:15 AM, it was noted that Resident #132's meal tray card documented to include 'Proval Cup for beverages'. Further observation noted that only 1 Proval Cup was provided for the 4 tray-beverages that included milk, orange juice and water. Further observation noted that Resident #132 was able to feed self with set up and supervision but could not drink from the regular drinking cups. A second observation conducted of Resident #132 on 05/24/23 at 7:45 AM noted that a Provale cup with water was at the resident's bedside. An interview was conducted with the Director of Skilled Therapy on 05/23/23 at 1:00 PM who stated that a cup is required for each beverage on the meal tray and a cup with liquid is required at the bedside. Interview with CDM on 05/23/23 noted the facility does not have enough cups to be able to provide for the in-room water and for each beverage included on meal tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 19 of 20 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 105496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isles of Boynton Nursing and Rehab Center 3001 South Congress Avenue Boynton Beach, FL 33426 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 0810 Review of the clinical record of Resident #132 on 05/23/23 noted: Level of Harm - Minimal harm or potential for actual harm Date of admission: [DATE] Diagnoses included: Hemiplegia and Hemiplegia, Lack of Coordination Disorder of Muscle, Residents Affected - Few Current Physician orders included: 04/19/23: No Added Salt, Mechanical Soft Diet 04/19/23: All Liquids via 5 cc Provale Cups. Review of Current Minimum Data Set, dated [DATE] documented: Sec B ; Understands 7 Understood Sec C: Unable to obtain BIMS score (indicates severe cognitive impairment) Sec D: No Mood Issues Sec G: Eat = Extensive Assist Sec K: No Swallow Issues, 66/152# - Mechanical Altered Diet. Review of current Care Plan dated 03/28/23 noted: 1) Nutritional Status -Review of interventions noted no documentation of extensive assistance with eating and the need for a Proval cup (adaptive drinking cup) with liquids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105496 If continuation sheet Page 20 of 20