Inspection·August 10, 2023

F 0550 honest with you, I forgot what word to use. Level of Harm - Minimal harm or potential for actual harm On 08/07/23 at 2:51 PM, an interview was conducted with Staff B, CNA who confirmed that she called the residents feeders. Staff B stated she was supposed to say need assistance with meals. Residents Affected - Few On 08/09/23 at 8:29 AM, during an interview, the facility's weekend supervisor was asked to submit Assistance with Feeding policy and was apprised that a nurse and a CNA called residents feeders. The supervisor stated she will inform the Director of Nursing (DON). On 08/09/23 at 9:22 AM, surveyor was approached by the DON who asked why the request of the Assistance with Feeding policy. The DON was informed that a nurse and a CNA called the residents feeders. The DON stated that was an old term, longtime ago. The DON stated that the staff were using the wrong terminology. She further stated the staff have been educated, reeducated and she will continue to educate them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 2 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide 1 of 1 sampled residents (Resident #12) with reasonable accomodations of personal needs and room preferences. Residents Affected - Few The findings included: During the initial screening of Resident #12 on 08/07/23 at 9 AM, it was noted the resident wanted to speak to the surveyor concerning his room issues. The alert and oriented resident stated that he has an old bed, which does not raise high enough when receiving ADL (Activities of Daily Living) care from staff. He further stated that staff have to hover over him and almost lay on top of the bed during care. The resident stated that he has requested from nursing and maintenance numerous times over the past 2 months for a new bed that raises to a higher level. Resident #12 stated he was told there are new beds in the facility that raise to a higher level, but there was not a new bed available for him and he could not have a new bed. The resident also went on to state that his furniture is not placed correctly in his private room, that causes him to hit the dresser and walls. Observation on 08/07/23 noted that there were numerous large areas of damage to the room walls and the exterior of the room dresser was heavily damaged. On 08/08/23 during an observation of Resident #12 room with the Corporate Maintenance Director, the resident's room issues were confirmed. The Director stated that a new bed would be issued to the resident along with wall repairs, new dresser, wall hanging of the television , and new arrangement of the furniture. On 08/09/23 during an observation of the room of Resident #12 , it was noted that a new bed had been issued to the resident. The resident stated to the surveyor that the bed raises to a higher level during care and is very happy , but unhappy that it took the intervention of the surveyor to meet his needs. Further observation of the room noted that the holes had not been repaired, a new dresser had not been issued, the television was not hung on the wall and the room furniture had not been re-arranged to meet the needs of Resident #12. Review of the clinical record for Resident #12 noted the following: Date of re-admission: [DATE] Diagnoses: Paraplegia, Disorder of Nervous System, Contracture to R (Right) & L (Left) Hand and R & L Foot and Insomnia. MDS (MinimumData Set) quarterly assessment dated [DATE]: Section B: Understood & Understands Section C: BIMS (Brief Interview for Mental Status) score= 15 ( No Cognition Issues) Section D: No Mood Issues (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 3 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 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 0558 Section G: Extensive to Total Dependence Level of Harm - Minimal harm or potential for actual harm Section O: Special Treatment - IV Medication Section J: Health Conditions - Pain Residents Affected - Few Current Care Plan Review: Chronic Pain Impaired/Decreased Mobility Anxiety & Restlessness Extensive Assist with ADL (Activities of Daily Living) Care FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 4 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 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 - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to maintain a safe environment for the residents. Specifically, unlocked sharps container cabinets which were lacking the proper internal red box in Resident #152 and #136's rooms, and several additional resident rooms, which were easily accessible. The findings include: 1) During the initial tour of the facility conducted on 08/07/23 at 9:51 AM, in Resident #152's room, the surveyor observed an unlocked sharps container cabinet which was lacking the proper internal red box. Inside the unlocked sharps container cabinet, there were 4 used razors noted. A secondary tour was conducted on 08/08/23 at 9:55 AM, in Resident #152's room, the surveyor observed the sharps container cabinet remained unlocked and was still lacking the proper internal red box. Inside the unlocked sharps container cabinet, there remained the same 4 used razors. Review of Resident #152's record revealed she had a Brief Interview of Mental Status (BIMS) score of 12, which indicates she was moderately cognitively impaired. 2) During the initial tour of the facility conducted on 08/07/23 at 10:08 AM, in Resident #136's room, the surveyor observed an unlocked sharps container cabinet which was lacking the proper internal red box. Inside the unlocked sharps container cabinet, there was a used blood glucose lancet noted. A secondary tour was conducted on 08/08/23 at 9:54 AM, in Resident #136's room, the surveyor observed the sharps container cabinet remained unlocked and was still lacking the proper internal red box. Inside the unlocked sharps container cabinet, there remained the same used blood glucose lancet. Review of Resident #136's record revealed she had a BIMS of 11, which indicates she was moderately cognitively impaired. Additional observations were conducted on 08/07/23 which revealed a total of 15 of the 35 rooms on the facility's [NAME] Wing had sharps container cabinets which were lacking the proper internal red box. Approximately half of these cabinets were unlocked but had no sharp objects present inside. During an environmental tour of the facility conducted with facility administration and maintenance on 08/08/23, these areas of concern were discussed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 5 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy reveiw, observations and interview, the facility failed to follow the Urinary Catheter Care policy, and failed to ensure staff provided urinary catheter care and peri care consistent with accepted standards of practice during Foley/peri-care provided for 1 of 1 sampled residents reviewed for urinary catheter care(Resident #142). The findings included: Review of the facility's policy, titled, Catheter Care, Urinary reviewed on January 2023 documented, in part the urinary bag must be held or positioned lower than the bladders at tall times to prevent urine in the tubing and drainage bag from flowing into the urinary bladder .be sure the catheter tubing and drainage bag are kept off the floor .empty the drainage bag regularly .empty the collection bag at least every eight (8) hours .wash the resident's genitalia and perineum thoroughly .with nondominant hand separate the labia of the female resident .maintain the position of this hand throughout the procedure .observe the urethral meatus .cleanse around the urethral meatus . Review of Resident #142's clinical record documented an admission on [DATE] with readmissions on 04/01/23, 04/28/23 and 06/27/23. The resident's diagnoses included Sepsis, Pressure Ulcer of Sacral Region, Stage 4, Recurrent, Mild Chronic Pain Syndrome, Obstructive and Reflux Uropathy, Dementia with Mood Disturbance, Neuropathy, Malnutrition, and Muscle Weakness. Review of Resident #142's Minimum Data Set (MDS) significant change assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 indicating that the resident had intact cognition. The assessment documented under Functional Status that the resident needed extensive assistance from the staff to complete the activities of daily living. Review of Resident #142's care plan titled Resident is at risk for complications including urinary infections related to need for indwelling catheter initiated on 06/14/23 and revised on 07/12/23, documented interventions that included: catheter care every shift, keep drainage bag from touching the floor, position drainage bag below level of the bladder. Review of Resident #142's physician order dated 06/27/23 documented, Foley Catheter Care every shift. Review of Resident #142's physician order dated 06/27/23 documented, Monitor Foley Catheter output every shift. On 08/07/23 at 10:50 AM, an interview was conducted with Resident #142 who stated that she had a Foley catheter for a longtime and was told they were going to remove but they had not. The resident added that the Foley bag was full. On 08/07/23 at 11:00 AM, observation revealed a urinary drainage bag full of dark amber urine (over 1,000 cc) and the bag was touching the floor. The bag had a privacy pouch covering the front of the bag only. On 08/09/23 at 8:44 AM, observation revealed Resident #142 in bed with her head down and feet up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 6 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 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 0690 Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the resident who stated she was in pain. The call device light was activated and the Wound Care Nurse (WCN) came in to the room and repositioned the resident. Further observation revealed Resident #142's urinary drainage bag was on the resident's right side of the bed facing the room door. The drainage bag had approximately 300 cubic centimeters (cc) of amber urine in it and the bag was touching the floor. The resident agreed with Foley Care observation. Residents Affected - Few On 08/09/23 at 8:47 AM, observation revealed Staff C, CNA came in to Resident #142's room. An interview was conducted with Staff C and agreed to do Foley and Peri Care at 10:00 AM. On 08/09/23 at 8:49 AM, observation revealed Resident #142's urinary drainage bag continue to be touching the floor. Observation revealed the WCN was in the resident's room and was apprised that observations revealed the resident's Foley bag was touching the floor on 08/07/23 and today (08/09/23). Observation revealed the WCN donned gloves and repositioned the bed, so the Foley bag did not touch the floor. During the interview, the weekend supervisor came into the room. Subsequently, a side by side reveiw of the photographic evidence taken on 08/07/23 of Resident #142's urinary bag touching the floor and full of urine, was shown to the WCN and the weekend supervisor. On 08/09/23 at 9:05 AM, observation revealed Staff C, holding Resident #142's urinary bag above the bladder level. Staff C was instructed by the surveyor to lower the urinary bag. Staff C stated, I know. The Assistant Director of Nursing (ADON) instructed the Staff C about the same. An interview was conducted with Staff C who stated that when she comes in the morning, if the urinary bag is full, she empties the bag. Staff C added that sometimes when she is doing care, she checks the bag and empties it. Staff C stated that she empties the residents Foley urinary bag at the end of the shift. On 08/09/23 at 10:18 AM, observation of Peri care/Foley care for Resident #142 performed by Staff C, and assisted by the ADON started. Observation revealed Staff C performed hand washing, donned gloves and removed the resident's brief. The Foley tubing was noticed to be anchored. Staff C pulled a wipe and wiped each outer/inguinal side of the resident's labia, then with a clean wipe, she wiped the middle area of the labia from top to bottom twice with the same wipe. Observation revealed Staff C did not separate Resident #142's labia to clean inner side of the labia. Staff C removed her pair of gloves, performed hand washing, donned gloves, rinsed and dried the area. Staff C then proceeded to clean the catheter tubing by wiping the tubing with one wipe with strokes from the point of insertion down twice with the same wipe and without turning the wipe to a clean side. Staff C was observed doing this same step one more time. Observation revealed the ADON was observing Staff C during this step. Staff C looked at the surveyor and stated she was done with the Foley care. Immediately following the Foley care, a joint interview was conducted with Staff C, and the ADON. Staff C was asked if she should separate the resident's labia to clean between the labia (inner/inside). Staff C stated she did it. Staff C was apprised she was observed cleaning the outer side and the middle, but that she did not separate the labia. The ADON was asked if she noticed the same as the surveyor did and stated she was not looking at that time. On 08/09/23 at 10:52 AM, an interview was conducted with the Director of Nursing (DON) who was apprised of the findings. The DON stated that maybe Staff C did not understand because of her language. Staff C was responding appropriately to questions asked. On 08/09/23 at 11:01 AM, a joint interview was conducted with the ADON and the DON. The ADON stated she was not looking when the CNA was cleaning the resident's labia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 7 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 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 0690 Level of Harm - Minimal harm or potential for actual harm On 08/09/23 at 11:21 AM, an interview was conducted with Staff C, CNA who stated she had been working in the facility for 20 years. Staff C stated that she emptied Resident #142 on 08/07/23 morning because the 11 PM - 7 AM shift did not empty it. Staff C stated the bag had 1,000 cc. A side by side review of the resident's urine record documented by Staff C confirmed that she documented a urinary output of 1,000 cc on 08/07/23 for her day shift. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 8 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the physician ordered gastric tube feeding for 2 of sampled residents (Resident's #16 and #45) were followed. The findings included: 1) During the review of the clinical record of Resident #16 on 08/07/23 the following were noted: Date Of admission: [DATE] - (Re-admission) Diagnoses; Alzheimer's, Dysphagia, Protein-Calorie Malnutrition, Iron Deficiency, Sacral Pressure Ulcer, and Dementia, Current Physician Nutritional Orders dated: 08/4/23 - Jevity 1.5 @ 65 ml/hr - X 20 hours - 1300 ml- with flush 55 ml X 20 hours - on at 2 PM and off at 10 am. 8/1/23 - Fe supplement Elix 5 ml BID (twice daily) 7/29/23 - Ascorbic Acid 2.5 ml BID - Fe def 6/8/23 - Prostat 30 ml BID via G tube 5/23/23 - Wt (weight) Loss due to edema 5/10/23 - MVI 5 ml Daily 5/6/23 - Folic Acid 1 mg via G tube 5/5/23 - NPO (nothing by mouth) - Dysphagia Weight History: 8/4/23 = 123# (pounds) 7/10/23 = 132.8# 5/23/23 = 139# 5/8/23 = 143 # 4/10/23 - 111.8 # Height = 60 (inches) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 9 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 BMI (Body Mass Index) = 24 Level of Harm - Minimal harm or potential for actual harm Current Quarterly MDS (Minimum Data Set) assessment, dated 06/30/23: Section B : No Speech, Rarely understood & no understands Residents Affected - Few Section C: No BIMS- Rarely understood Section D: No Mood assessm- never understood/understands Section G: Total ;Dependence Section K : 60/133 #, Weight gain /Feeding Tube Section M : Yes - Pressure Ulcer - Stage 4 Section O: Tube Feeding A review of the August 2023 MAR (Medication Administration Record) for Resident #16 on 08/09/23 noted that the Enteral Feed Order of Jevity 1.5 at 65 ml per hour X 20 hours via peg had been initialed as administered on 08/09/23 by Staff E. Review of Progress Note dated 08/04/23 noted the resident's current body weight of 123.4 # is down 9.4 # (14 %significant X 90 days, and up 12% significant in 180 days), Weight loss expected due to history of edema, Resident's son notified of weight change and requested Jevity 1.5 feeding be increased to 65 ML until 1300 ml infused, Auto Flush 50 ml to run alongside Start at 2 PM - feeding will provide 1950 cal, 83 gm Pro - 2080 free water. During a routine observation of Resident #16 on 8/9/23 at 8:30 am noted Jevity 1.5 infusing at 55 ml/hour. Further observation of the tube feeding label noted that the feeding was documented as hung on 8/09/23 and started at 6:50 AM, Further observation noted that there was over 400 ml left in the bag. Resident #16 was sleeping at time of observation. It was also noted that the tube feeding container was leaking at the tubing connection site. The feeding was noted to be dripping down the tubing and onto the floor. Directly following the surveyor's observation, an interview was conducted with the medication nurse on 08/09/23 at 9 AM concerning why the physician ordered tube feeding rate of Jevity 1.5 was not being administered. Staff E stated to the surveyor that she did not review the Medication Administration Record of Resident #16 she started the tube feeding at the incorrect rate of 55 ml per hour. Staff E stated the last time she worked the tube feeding administration rate was Jevity 1.5 at 55 ml per hour X 20 hours. It was also noted during the interview and observation, the tube feeding label of 55 ml had been covered over with black marker and a rate of 65 ml was written on the label. 2) Review of Resident #45's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Chronic Respiratory Failure, Pressure Ulcer of Sacral Region, Stage 4, Type 2 Diabetes Mellitus, Gastrostomy (Feeding tube), Dementia and Heart Failure. Review of Resident #45's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 10 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Brief Interview of the Mental Status (BIMS) score of 0, indicating that the resident had severe cognition impairment. The assessment documented under Functional Status the resident needed total assistance from the staff to complete the activities of daily living. Review of Resident #45's care plan titled Resident requires tube feeding initiated on 02/10/23 and revised on 05/25/23 documented an intervention that read .follow physician orders regarding nutrition order . Review of Resident #45's care plan titled Resident is at risk for complications related to PEG (tube feeding) tube placement initiated on 02/08/23 and revised on 05/25/23 documented an intervention that read .administer tube feeding as per MD order . Review of Resident #45's physician orders dated 07/03/23 documented Enteral feed order (tube feeding) every shift Jevity 1.5 at 70 millimeters (ml) per hour, 20 hours a day via PEG (on at 2:00 PM; off at 10:00 AM) with auto flush PEG tube with 55 ml/hour water. On 08/07/23 at 3:10 PM, observation revealed Resident #45 in bed with his eyes open. The surveyor attempted to interview the resident, who was not responding to questions asked. Continued observation revealed the resident had a Jevity 1.5 cal tube feeding formula bottle running at 70 ml per hour. The bottle label was dated 08/07/23, start time 0600 (6:00 AM). Further observation revealed the bottle had over 1500 ml (full bottle) of the formula remaining in the bottle, indicating that no feeding formula had been infused. The amount that the resident should have received from 6:00 AM to 10:00 AM was 280 ml and 70 ml from 2:00 PM to 3:00 PM for a total of 350 ml in five hours. Resident #45 had 350 ml of his feeding formula missing. (Photographic evidence obtained). On 08/08/23 at 9:10 AM, observation revealed Resident #45 in bed, with his eyes closed. Further observation revealed the same bottle formula (Jevity 1.5 cal) hanged on 08/07/23 (bottle label read 08/07/23 start time 0600 (6:00 AM) was connected and running at 70 ml per hour. The bottle had approximately 150 ml left of the formula to be infused. The bottle was hanged for more than 24 hours. Photographic evidence obtained. On 08/10/23 at 8:38 AM, an interview was conducted with the facility's Dietitian. The Dietitian stated Resident #45 was a tube feeder. The Dietitian was apprised that she was labeling the resident. The Dietitian replied the resident was on enteral feeding. The Dietitian stated the resident was getting Jevity 1.5 cal at 70 ml per hour for 20 hrs a day, on at 2:00 PM and comes off at 10:00 AM. The Dietitian stated that Resident #45 formula volume infused was supposed to be 1400 ml in 20 hours. Subsequently, a side by side review of photographic evidence was conducted with the Dietitian. The Dietitian confirmed the formula bottle was full on 08/07/23 at 3:10 PM. The Dietitian stated that 630 ml of the feeding formula should have been infused. On 08/10/23 at 9:45 AM, a joint side by side review of Resident #45's tube feeding photographic evidence taken on 08/07/23 and 08/08/23 related to the resident's tube feeding formula was conducted with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The DON stated that she did not know what happened on 08/07/23 and his tube feeding delay. The ADON was apprised that Resident #45 did not receive his tube feeding as per physician's order on 08/07/23. On 08/10/23, the surveyor attempted to interview Staff A regarding Resident #45's tube feeding, however, she was not available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 11 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/10/23 at 10:45 AM, an interview was conducted with Staff F, Licensed Practical Nurse (LPN) who stated she stopped Resident #45's tube feeding at 10 AM and will resume the current hanging bottle at 2:00 PM. Staff F added that the bottle was good for 24 hours. Staff F was asked about the formula volume infused during her shift and stated that the machine volume was not cleared. Staff F added that at the end of the shift she multiples the rate by the hours infused and documentd it. Staff F, LPN stated there were no issues with Resident #45's tube feeding or the machine functioning. On 08/10/23 at 11:12 AM, an interview was conducted with Staff G, CNA who stated that she does Resident #45's care after the feeding is stopped at 10:00 AM and she will not need to have his tube feeding stopped during her shift. Staff G stated there were no issues with the feeding pump and the resident did not have any vomiting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 12 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, policy and record review, the facility failed to ensure pharmaceutical services provided the accurate administing of all drugs, as evidened by failure to administer scheduled medications in a timely manner for 6 of 7 sampled residents (Residents #2, #63, #97, #103, #116, and #121). The findings included: The facility's policy, titled, Administering Medications revised April, 2019 and reviewed January 2023 revealed Medications are administered in accordance with prescriber orders, including any required time frame. 1. Resident #2 was admitted to the facility on [DATE] with Multiple Sclerosis, Cerebral Palsy, Diabetes Mellitus. On 08/03/23, the resident was placed on droplet and contact precautions. On 08/08/23 at 11:12 AM while interviewing Staff D, Licensed Practical Nurse, (LPN) this surveyor observed a cup with medications in it on the top of the medication cart. Staff D stated they were the 9:00 AM medication for Resident #2. She stated she was not yet finished with her 9:00 AM medication pass. Seventeen (17) medications were due at 9:00 AM for Resident #2 and 3 medications were due to be given at 10:00 AM. 9:00 AM scheduled medications included: Senna S tablet give 2 tablets 2 times a day was given 11:17 AM next dose due 5:00 PM Klonopin tablet 0.5mg give 0.25 mg once a day was given 11:29 AM Eliquis 5 mg two times a day was given 11:26 AM next dose due 5:00 PM Potassium tablet once a day was given 11:19 AM Omeprazole tablet delayed release 2 times a day was given 11:19 AM next dose due 5:00 PM Metformin HCL tablet 2 times a day was given 11:17 AM next dose due 5:00 PM Methenamine Hippurate tablet 2 times a day was given 11:18 AM next dose due 5:00 PM Furosemide 20 mg once a day was given 11:26 AM Levetiracetam 1500 mg 2 times a day was given 11:26 AM next dose due 5:00 PM Thera-M tablet once a day was given 11:17 AM Cranberry capsule once daily was given 11:17 AM Prozac once a day given 11:19 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 13 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 UTI-Stat Liquid two times a day given 11:28 AM next dose due 5:00 PM Level of Harm - Minimal harm or potential for actual harm Carbamazepine suspension 2 times a day given 11:29 AM next dose due 5:00 PM Fosfomycin Tromethamine Packet once daily given 11:46 AM Residents Affected - Few Nifedipine ER tablet extended release once daily given 11:46 AM Lidocaine patch topically daily given 11:46 AM 10:00 AM medication: Prednisone 1 tablet 2 times a day given 11:17 AM next dose due 5:00 PM Vitamin C one time a day was given 11:17 AM Zinc once daily was given 11:17 AM On 08/09/23 at 8:45 AM, an interview was conducted with the Director of Nurses (DON). This surveyor explained to the DON the lateness of the medications given to Resident #2 on 08/08/23 and asked for a medication administration audit report for the Resident #2 and the 6 additional residents on transmission based precaution who were all located in the 200 unit and given medication by Staff D. On 08/09/23, she presented the reports of the 7 residents on transmission based precautions for 08/08/23. 2. Resident #63, a dialysis resident, had Sevelamer Carbonate oral packet 2.4 grams (GM) ordered for 7:30 AM. It was to be given with meals. It was administered at 10:40 AM on 08/08/23. The next dose of Sevelamer Carbonate oral packet 2.4 grams was scheduled for 12:30 PM and was given at 2:38 PM. Eldertonic Oral Liquid which is an appetite stimulant to be given before meals at 4:30 PM was given at 8:38 PM by Staff H, a registered nurse (RN). Sevelamer Carbonate oral packet 2.4 grams which was scheduled for 5:30 PM with a meal was given at 8:38 PM. 3. Resident #97, a resident who had a cerebral infarction, was given Eliquis 2.5mg at 8:38 PM by Staff H which was scheduled for 5:00 PM. 4. Resident #103, a resident with hypertension, was given Amlodipine 10mg for hypertension at 11:00 AM by Staff D. It was scheduled for 9:00 AM. Atenolol 50mg due at 9:00 AM was given at 11:07 AM by Staff D. 5. Resident #116, a COVID positive resident, was given Cefedinir capsule 300 mg for the COVID infection at 11:48 AM instead of the scheduled 9:00 AM dose, by Staff D. Decadron tablet 6 mg for inflammation was given at 11:48 AM instead of 9:00 AM, by Staff D. Apixaban 5 mg used to prevent blood clots, was given at 12:25 PM instead of 9:00 AM, by Staff D. Gabapentin for neuropathy (nerve pain) was given at 12:25 PM instead of 9:00 AM by Staff D. Baclofen 5 mg for spasms was given at 12:48 PM instead of 9:00 AM, by Staff D. 6. Resident #121, a resident with Diabetes Mellitus, was given Glipizide 5 mg at 12:45 PM, instead of 9:00 AM, by Staff D. Glipizide is an oral diabetes medication. Two other medications for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 14 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm diabetes, Alogliptin Benzoate tablet given at 12:46 PM and scheduled for 9:00 AM, and Januvia tablet was given at 2:20 PM and were scheduled for 9:50 AM. After review of this report, this was further discussed with the DON on 08/09/23 at 1:00 PM who stated she had begun inservices with the nurses and already had inserviced Staff D. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 15 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 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 special physician ordered eating utensils for 1 of 1 sampled residents to assist when consuming meals (Resident #60). Residents Affected - Few The findings included: During the observation of the lunch meal in the Main Dining Room on 8/7/23 at 12:15 PM, it was noted that the meal ticket for Resident #60 documented weighted utensils with all meals . Further observation noted that weighted utensils (fork, knife and spoon) were not provided with the lunch. It was noted that only a non-weighted built-up fork was provided, with a non-weighted built-up spoon still wrapped in plastic and no adaptive knife. Resident #60 was noted to have only the use of the right hand and could have benefited from a weighted spoon and knife. During the observation the surveyor requested the Director of Therapy to view the associated issues of the adaptive utensils. The Director confirmed the findings of the surveyor and stated that Resident #60 was assessed for weighted utensils with meals and was receiving only a non-weighted built-up fork with meals. During an interview with Resident #60, following the lunch meal observation, he was noted to state that he could benefit from the weighted utensils and would try the weighted knife and spoon. A review of the clinical record of Resident #60 revealed the following: Date of admission: [DATE] Diagnoses: Cerebral Palsy, Bipolar Disorder, Dementia, and Hemiplegia. Current Physician Orders: MD (medical doctor) Orders: 11/02/20: Weighted utensils and scoop dish during every meal 08/03/20 - Regular Diet 11/22/22 - Nutritional Treat BID (twice daily) L & D (lunch & dinner) Weight History: 8/4/23 =144.8 # (pounds) 6/12/23=143# 12/14/22 =140# BMI (Body Mass Index)=22 Ht (height) = 68 (inches) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 16 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 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 Current MDS (Minimum Data Set) assessment review noted the following: Level of Harm - Minimal harm or potential for actual harm 6/30/23 - Quarterly Sec B: Understood 7 Understands Residents Affected - Few Sec C: BIMS (Brief Internew for Mental Status) Score = 14 (Cogntively Intact) Sec D: No Mood Issues Sec G : Eat - Independent Sec K : No Swallow /68/142# Sec M: No Pressure Ulcer Review of current care plan dated 07/06/23 noted: * Nutritional Risk - Weighted Utensils and scoop dish during every meal Review of Occupational Therapy Plan of Care dated 11/12/20 and submitted by the Director of Therapy on 08/08/23 noted documentation indicating, Resident #60 discharge is self feeding requiring modified independence utilizing adaptive utensils of weighted fork/spoon and scoop dish to self feed without spillage in the LTC (long term care) environment of this facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 17 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 food service safety that include: ensure dish-machine is sanitizing dishware as per regulatory requirement, ensure the expired foods were discarded from the food supply, ensure that policy regarding left-over foods is followed, ensure exhaust hoods are cleaned and serviced on a regular basis, and ensure that food preparation equipment are cleaned and sanitized on a regular basis. The findings included: Review of the facility's Food Storage Policy and Procedure noted the following: * Foods are covered , labeled and dated. * Potentially hazardous foods are discarded after 7 days of preparation or after thawing if not cooked. During the initial kitchen/food service observation tour conducted on 08/07/23 at 9 AM, and accompanied with the Certified Dietary Manager (CDM), the following were noted: (a) Observation of the dish room noted that the staff were utilizing the machine for resident dishes. The CDM stated that the dish machine was a high temperature machine, and the surveyor requested a temperature test. Following 3 test, the machine failed to reach a final rinse temperature of a minimum of 180 degrees F. Dietary staff in the room stated that the machine is a low temperature machine and 3 test were conducted and failed to reach the regulatory chemical (bleach) levels. Following the chemical testing, staff attempted to prime the chemical sanitizing agent and further testing noted the machine passed the chemical test. Following the testing it was discussed with the CDM that the machine must pass the chemical testing prior to washing. It was also discussed that the dish machine should not require priming the chemical sanitizer. (b) Observation of the walk-in refrigerator noted that the entry door gaskets were in disrepair and had large tear areas. It was discussed with the CDM that the torn gaskets could potentially effect the temperature of the unit. Photographic Evidence Obtained. (c) During the observation of the walk-in refrigerator it was noted that there were two 5-pound containers of Cottage Cheese with manufacturers expiration dates of 07/28/23. The CDM stated that the containers of cottage cheese should have been removed and discard by the expiration date. The CDM further stated the Food Left Over Policy was not being followed. Photographic Evidenced Obtained. (d) During the observation of the walk-in refrigerator it was noted that there was approximately 20 pounds of defrosted raw chicken located on the bottom food storage shelf. Further observation noted that the label date on the chicken was 7/26/23. It was discussed with the CDM that the raw chicken had been in the refrigerator for 13 days and should not be prepared for resident consumption. The CDM also stated that the Food Left Over/Thawing Policy was not followed. Photographic Evidence Obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 18 of 19 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 105505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Margate Health and Rehabilitation Center 5951 Colonial Drive Margate, FL 33063 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 (e) During the observation of the dish machine room, the following were noted: Level of Harm - Minimal harm or potential for actual harm < The interior of the dish machine hood exhaust was heavily rust laden. < Two of two ceiling vents were noted to be rust laden. Residents Affected - Some < Soiled cleaning cloths (3) were noted to be hanging from clean dish storage shelves. Photographic Evidence Obtained (f) Observation of the tray assembly line noted that the exterior of the entire 15 feet of the tray line was heavily soiled and rust laden. Photographic Evidence Obtained. (g) The door gaskets of Reach-in refrigerator #1 were noted to be laden with a black mold type substance. It was discussed with the CDM that the unit is not being properly cleaned and sanitized on a regular basis. (h) Observation of the main hood system noted that the inside of the hood had a build-up of dirt and dust. It was discussed with the CDM that the hood unit should be listed on the preventative maintenance log for proper cleaning. Photographic Evidence Obtained On 08/07/23 the sanitation issue and photographs were reviwed and confirmed with the Administrator FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105505 If continuation sheet Page 19 of 19