Inspection·June 9, 2022

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on observation, interview and record review, the facility staff failed to identify resident to resident abuse and failed to report the abuse incident involving 2 of 2 sampled residents, Residents #139 and #78. Residents Affected - Few The findings include Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, reviewed 05/15/2020 and revised 08/10/2021 specifies the facility must: Identify, correct and intervene in in situations in which abuse is more likely to occur. It also affirms All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin; All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative; All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin will be immediately reported to the administrator and or director of nursing; The person(s) observing an incident of resident abuse or suspecting resident abuse will immediately report such incidents to their immediate supervisor and/or the charge nurse; The incident will be reported immediately to the administrator and the director of nursing; and finally, The facility must ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials in accordance with State law through established procedures'. On 06/06/2022 at approximately 11:30 AM, surveyor was present in the dining room during activities. Staff L, a CNA (certified nursing assistant) and Staff M, an activity assistant, were also present. Resident #78 was seated at the main table in her wheelchair next to Resident #139. Resident #78 was somewhat agitated and verbally lashing out in general, although her words were nonsensical. Resident #78 suddenly grabbed Resident #139's right wrist and the lower part of her hand. She was squeezing it tightly and did not readily let it go. Resident #139 was grimacing, and other residents began yelling for help. Staff M was able to separate the two residents. Resident #139 was visibly upset and rubbing her arm. Staff M then moved Resident #78 to the other side of Staff M's space so she was not sitting next to any other residents. Resident #78 remained upset and agitated and at 11:50 AM, she was taken back to her room by Staff L, a CNA. On 06/07/2022 at 9:00 AM, the progress notes for both residents were reviewed however there was no documentation of the event that occurred between them the previous day. On 06/07/22 at 9:40 AM, during an interview with Staff L, the CNA who was present the day before, she said she had informed the unit manager of the incident on 06/06/22. On 06/07/22 at 9:47 AM, during an interview with the Staff N, the Nurse/Unit Manager, she said she had been told the resident was agitated the day before but had not been informed of the physical assault, until then by the surveyor. On 06/07/22 at 12:45 PM, The Interim DON (Director of Nursing) and The Interim NHA (Nursing Home Administrator) were informed of the resident-to-resident abuse incident that had occurred the day before. They had not been informed prior to that time by facility staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105516 If continuation sheet Page 2 of 13 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 105516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409 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 0609 Level of Harm - Minimal harm or potential for actual harm On 06/08/22 at 5:00 PM, the Interim NHA presented documentation from the most recent in-service regarding identifying, reporting and preventing abuse in the facility, showing Staff L had attended and signed the attendance form. She also said Staff M, who has been employed at the facility since February of 2022, received the training during her new-employee orientation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105516 If continuation sheet Page 3 of 13 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 105516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review, the facility failed to follow the care plan in place to prevent resident to resident abuse involving 2 of 2 sampled residents, Residents #78 and #139. Residents Affected - Few The findings include On 06/06/2022 at approximately 11:30 AM, surveyor was present in the dining room during activities. Staff L, a CNA (certified nursing assistant) and Staff M, an activity assistant, were also present. Resident #78 was seated at the main table in her wheelchair next to Resident #139. Resident #78 was somewhat agitated and verbally lashing out in general, although her words were nonsensical. Resident #78 suddenly grabbed Resident #139's right wrist and the lower part of her hand and was squeezing it tightly. Resident #139 was grimacing, and other residents began yelling for help. Staff M was able to separate the two residents. Resident #139 was visibly upset and rubbing her arm. She did not attempt to strike back or retaliate in any way. Staff M then moved Resident #78 to the other side of Staff M's space so she was not sitting next to any other residents. Resident #78 remained upset and agitated and at 11:50 AM, she was taken back to her room by Staff L. At that time, Staff L, was asked if Resident #78 behaves like this often. Staff L stated, Not often, she only gets like this when she is tired. On 06/07/22 at 9:40 AM, during an interview with Staff L, who witnessed and assisted with the incident the day before, said Resident #78 is known to be aggressive at times and stated, she will grab at anything within her reach, even if it is a chair. While speaking, Staff L demonstrated grabbing an imaginary item in front of her and shook it twice, imitating the resident's actions. She also said Resident #78 is known to be aggressive and combative with the staff. On 06/07/22 at 9:47 AM, during an interview with Staff N, the Unit Coordinator, she said she knows the resident can be aggressive saying said the resident has been physically resistant and possibly even combative with staff trying to provide care. On 06/07/22 at 10:20 AM during an interview with Staff M, the Activity Assistant, she was asked about Resident #78's behaviors and the incident the day before. She responded, Oh yes! Thats what she do. Thats why she have one to one [sitter]; she can grab anyone, even staff. She also mentioned a previous incident with Resident #78 where a nurse had been wearing long sleeves and was somehow assaulted by Resident #78 to the extent that the nurse was bleeding from the arm when she pulled up her sleeve. She further said, she get really upset, she always have one to one. She need a lot of attention. Review of Resident #78's chart revealed the following diagnoses: Unspecified dementia with behavioral disturbance, Unspecified psychosis not due to a substance or known physiological condition, Pain, Dysphagia (difficulty swallowing), Seizures and a History of Falls. The resident currently takes Aricept (for dementia) and Seroquel (an antipsychotic). The most recent comprehensive assessment on 04/08/22, showed a BIMS (Brief Interview for Mental Status) score of 00 out of fifteen points indicating the most severe cognitive deficit possible. Review of Resident #78's care plan showed focus categories of including but not limited to: The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105516 If continuation sheet Page 4 of 13 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 105516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident is Dependent on Staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits (initiated 01/11/21) with an intervention of low activity intolerance and needs redirection at all times (initiated 04/21/22). A second focus reads: Resident has a behavior problem of increased anxiety with agitation, screaming and yelling at others. The goal is Resident will not experience behaviors that are harmful to self and others through next review date (initiated 07/06/21 and last revised 03/10/22). The relevant interventions listed include: Anticipate the resident's needs and Intervene as necessary to protect the rights and safety of others, Remove from situation and take to alternate location as needed. Both interventions were initiated on 07/06/21 for this resident which indicates a known behavior or risk to others. Review of the record for Resident #139 showed receiving hospice care. The most recent comprehensive assessment on 05/11/22 showed her BIMS score was unable to be assessed due to her complete cognitive deficit. She has diagnoses of dementia without behavioral disturbance, generalized anxiety disorder, depression, and unspecified psychosis not due to a substance or known physiological condition. She does not take an antipsychotic medication. Review of her care plan did not reveal any indication of agitation or aggressive behaviors however, one careplan read, The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and immobility, (Initiated on 07/12/2021). Resident is not able to make her own decisions or physically move herself away from any hazardous situation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105516 If continuation sheet Page 5 of 13 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 105516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3). Facility Policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management, dated 04/19/2022 states A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; Measures to maintain and improve the resident's tissue tolerance are implemented in the plan of care. Record review revealed Resident #89 was admitted to the facility on [DATE], with diagnoses that include, cerebral vascular accident (Stroke) with right hand contracture (A condition of shortening and hardening of muscles and other tissues often leading to deformity and rigidity of joints), and heart disease. The facility resident assessment documented that Resident #89 is severely cognitively impaired and totally dependent on staff for all activities of daily living. On 06/08/2022 at 10:40 AM during a wound care observation with Staff Z, a RN (Registered Nurse), Resident #89's left-hand splint was removed. The left thumb, 4th and 5th fingernails were noted to be sharp and long, extending approximately ½ inch past the fingertips. The right-hand splint was removed by the nurse revealing gauze in the palm of the hand with dime sized yellow drainage. The right palm had a pea size open wound where the 4th and 5th fingernails were pressing into the skin underneath the gauze. The right 2nd, 4th and 5th fingernails were noted to be sharp and long extending approximately 1/3 inch past the fingertips. Staff Z stated he needs to call regarding nail care. A skin assessment dated [DATE] by Staff Y revealed no documentation of any hand wounds. Physician's orders dated 04/19/2022 documented, restorative nurse program for application of right and left palm protectors 6 to 8 hours a day as tolerated. A physician's order on 05/27/2022 reads Cephalexin (antibiotic) 500 milligram two times a day for cellulitis (skin infection) right hand for 7 days. A progress note dated 05/27/2022, by Staff X, a LPN (Licensed Practical Nurse) documented, Writer observed right hand palm with splint applied with odor noted. Lower forearm with edema, elevated on pillow. Writer removed splint and open area with moderate amount of drainage noted. Wound care consult. Area cleansed with soap and water. Thoroughly dried. Calcium alginate applied with 4X4 gauze and secured with kerlix wrap. MD made aware. [sic] A progress note dated 05/26/2022, by the facility wound care nurse documented, Pt [patient] referred to wound care for impairment to right palm. Right palm noted with 3 separate wounds; Proximal- measuring 0.5cm X 0.5cm Stage III Pressure; Medial- measuring 0.5cm X 0.5cm Stage III Pressure; Distal- measuring 0.5cm X 0.5cm Stage III Pressure; Peri-wound has maceration; drainage noted; palm has foul odor. Hand is swollen; unable to determine pain level when touched. Pt has right hand contracture; wounds are determined to have developed from pt's [patients] fingers piercing her skin in the palm. Area cleansed with soap and water, dried thoroughly. NP [nurse practitioner] made aware verbally. Recommended to start abt [antibiotic] therapy for what appears to be cellulitis. Recommended that tx [treatment] be Calcium Alginate and Kerlix daily. OT [occupational therapy] consult for splint revision. Pt [patient] remain at high risk for skin integrity compromise due to disease process [sic]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105516 If continuation sheet Page 6 of 13 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 105516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A progress note dated 05/27/2022 by the facility wound care nurse documented, Conversation today morning with the ADON [Assistant Director of Nurses] and the restorative team; it was reiterated that it is important to properly inspect the pt's [patients] extremities before donning any equipment and also upon removal. It was further discussed that each restorative aid should promptly report any skin impairment and document what they see and to whom the report was given. Recommend that OT [occupational therapy] f/u [follow up] for splint review. [sic] On 06/08/2022 at 11:13 AM, the wound care nurse stated the wound started initially a palm trauma from fingernails, she stated Restorative Care handles the nail trimming and she has had extensive conversation with them regarding the importance of the care. The wound care nurse then went with the surveyor to assess Resident #89. Upon examination the wound care nurse concurred the fingernails were long and sharp. During follow-up record review, it was noted a care plan initiated on 06/08/2022 for Resident #89 documented, keep nails trimmed to prevent fingernails from digging into the palm of her hands. Futher review revealed there was no evidence of a care plan initiated for pressure ulcer/injury noted for Resident #89. Based on observation, record review and interview, the facility failed to invite alert residents to care plan meetings affecting 2 of 35 sampled residents whose care plans were reviewed (Residents #25 and #33); and failed to update the care plan to reflect needs of the residents for 3 of 35 sampled residents (Residents #127, 116 and 89). The findings included: 1. Resident #25 has diagnoses that includes End Stage Renal Disease, Spinal Stenosis, and Muscle Weakness. His Brief Interview for Mental Status (BIMS) score is 15, indicating intact cognition, per his annual Minimum Data Set (MDS) assessment with reference date (ARD) of 03/15/22. A review of the resident's profile reveals he is his own responsible party and care conference person. On 06/06/22 at 12:04 PM, Resident #25 was interviewed. Resident #25 was asked if he had attended the interdisciplinary care plan meetings. Resident #25 replied that he does not receive invitations to the meetings and thinks they are on his dialysis days. An interview was conducted on 06/08/22 at 2:22 PM with Staff A, MDS Coordinator, regarding the invitation for Resident #25 to the care plan meeting. Staff A stated alert residents are given an invitation delivered to their room, A copy of the invitation for Resient #25 was requested, however, Staff A could not locate it. Staff A further stated the meetings are held on Tuesdays and Thursdays but they can change the day if the resident is not available. Further record review of Resident #25's care conference revealed it was conducted on 03/29/22. 2. Resident #33 was admitted to the facility on [DATE] and has diagnoses that include Syncope, Hypertension and History of Falling. She has a BIMS score of 13, per admission MDS with an ARD of 03/17/22. This indicates that she is cognitively intact. On 06/07/22 at 10:55 AM, Resident #33 was interviewed. She was asked if she attended her care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105516 If continuation sheet Page 7 of 13 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 105516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete meetings and she replied that she does not know about any care plan meeting. She stated that she is her own responsible party. Record review of her care plan conference revealed it was conducted on 03/31/22. Interview on 06/08/22 at 2:22 PM with Staff A, MDS Coordinator, revealed she could not find a copy of the invitation to Resident #33's care plan meeting. Event ID: Facility ID: 105516 If continuation sheet Page 8 of 13 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 105516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to provide activities listed, according to the scheduled activities calendar for 2 of 3 sampled residents, reviewed for activities (Residents #25 and #33). Residents Affected - Few The findings included: Review of the facility's policy titled Therapeutic Activities Program, revised on 04/01/22, reveals The facility should implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well -being and independence. 1. On 06/07/22 at 9:03 AM Resident #25 was interviewed andasked if he attends activities. He stated that there are no activities for him here (facility). He wishes they had activities for people that are alert. Resident #25 has diagnoses that include End Stage Renal Disease, Spinal Stenosis, and Muscle Weakness. His Brief Interview for Mental Status (BIMS) score is 15, per annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/15/22. This indicates that he is cognitively intact. An observation was made of a May 2022 activities calendar on his wall. During an interview with the acting Director of Nursing (DON) on 06/08/22 at 9:22 AM, an inquiry was made regarding what is available for alert residents. He stated that they planned a trip for the residents but the outside transportation did not show up and the trip had to be canceled. Further interview revealed the facility has a bus, but no driver and they are actively looking to hire a driver. When they have a driver, they plan on making trips to Walmart, dollar store and sight seeing trips. Interview with Activity Director on 06/08/22 at 10:37 AM, who has been employed at the facility for 2 days, discussed it was regarding the activity calendar and the number of activities listed on the calendar and how all those activities can be done. The Activity Director stated she was wondering too how all of the activities listed would get done. She stated on 06/07/22, 2 of the 8 activities listed on the calendar were actually conducted. She has 2 assistants and one to be hired. One of the assistants spends the day in the memory unit doing activities and the other assists with the long term care unit. She stated there are word games listed on the activities calendar, American Flag Mining and CLAWS Categories for alert residents. American Flag Mining and CLAWS are listed one time each on the calendar. 2. On 06/06/22 at 10:43 AM Resident #33 was interviewed about activities. She stated that there are few activities. She would love to be outside and go on an outing but there is nothing like that available. She stated that she doesn't think all of the activities on the calendar are being done because she wasn't notified that they were being done. She stated she walks around the facility on her own and sits outside on the patio. Resident #33 was admitted to the facility on [DATE] and has diagnoses that include Syncope, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105516 If continuation sheet Page 9 of 13 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 105516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Hypertension and History of Falling. She has a BIMS score of 13 per admission MDS with an ARD of 03/17/22. This indicates that she is cognitively intact. 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: 105516 If continuation sheet Page 10 of 13 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 105516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the accuracy of the electronic medication administration records (eMAR) for 4 of 5 sampled residents reviewed for unnecessary medications (Residents #115, #116, #127, and #371). The findings included: Facility policy regarding Nursing Documentation (reviewed 05/05/20 and revised 05/07/21) documents, This facility will ensure nursing documentation is consistent with professional standards practice, the state nurse act, and any state laws governing the scope of nursing practice. Paragraph #3 under INTRODUCTION, it states: Federal regulations require that long-term care facilities maintain clinical record for each resident and that these records contain sufficient information to identify resident. These records must also be complete, accurate, readily accessible, and systematically organized and must provide documentation of the resident's assessments and the care plan and services provided. Under IMPLEMENTATION, bullet #12 states: Document information as soon as possible to ensure information accuracy and reflect ongoing care. Delayed documentation increases the potential for omissions, error, and inaccuracy due to memory lapse. 1) Resident #115 was admitted to the facility on [DATE] with diagnoses which include Displaced Intertrochanteric Fracture of L (left) Femur, Hyperlipidemia, Major Depressive Disorder, Anxiety, COPD, GERD, and Constipation. A review of Resident #115's eMAR for June 2022 showed documentation concerns for the following medications and monitorings: a) Tramadol HCl Tablet 50 MG, 1 tab to be given by mouth every 8 hours for Pain (06/01/22). There was no documentation showing administration of medication for 8:00 AM dose on 06/03/22. b) Levothyroxine Sodium Tablet 50 MCG, 1 tablet by mouth one time a day for low thyroid hormone (04/28/21). There was no documentation showing administration for 6:00 AM dose on 06/03/22. c) Movantik Tablet 25 MG, 1 tablet by mouth one time a day for OIC [opioid induced constipation] (10/25/21). There was no documentation showing administration for 6:00 AM dose on 06/03/22. d) Monitoring each shift for side effects related to use of anti-depressant, Bupropion. There was no documentation showing monitoring was done for night shift on 06/02/22. 2) Resident #116 was admitted to the facility on [DATE] with diagnoses which include Parkinson's Disease, GERD, and Syncope and Collapse. A review of Resident #116's eMAR for June 2022 showed documentation concerns for the following medications: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105516 If continuation sheet Page 11 of 13 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 105516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a) Midodrine HCl Tablet 10 MG, 1 tablet by mouth every 8 hours for hypotension; hold for SP>120 (12/26/21). There was no documentation showing administration of medication for 6:00 AM dose on 06/04/22 and 06/05/22. There was also no documentation showing that Systolic Pressure of 124 at 6:00 AM on 06/07/22 was held because it exceeded parameters. 3) Resident #127 was admitted to the facility on [DATE] with diagnoses which include Cerebral Infarction, Encephalopathy, Acute Respiratory Failure, Congestive Heart Failure, Chronic Kidney Disease Stage 3, Attention Deficit Disorder, Major Depressive Disorder, Hypertensive Urgency, Atrial Fibrillation, Hypothyroidism, Anemia, GERD, Altered Mental State, Hypokalemia, and Coronary Artery Disease. A review of Resident #127's eMAR for June 2022 showed documentation concerns for the following medications: a) Levothyroxine Sodium Tablet, 100 mcg by mouth one time a day for Hypothyroidism (12/30/21). There was no documentation showing administration of medication for 6:00 AM dose on 06/04/22 and 06/05/22. 4) Resident #371 was admitted to the facility on [DATE] with diagnoses which included Sepsis due to staphylococcus, Pyelonephritis, UTI (Urinary Tract Infection), Abdominal Hernia, Muscle Weakness, Pleural Effusion, Hypertension, GERD (Gastroesophageal Reflux Disease), Osteoarthritis, Pleural Effusion, Hypokalemia, Hypomagnesemia, BPH (Eenign Prostate Hypertropy), Constipation, E-Coli infection, Toxic Encephalopathy, Dementia, Coronary Artery Disease, Psychosis A review of Resident #371's eMAR for June 2022 showed documentation concerns for the following medications and monitorings: a) Vancomycin HCl Solution 1000 mg/10 ml, Use 1 gram intravenously every 24 hours for Ecoli, Staph infection until 06/16/2022 (06/01/22). There was no documentation showing administration of medication on 06/04/22. b) Observe site before and after administration of intermittent medications and during dressing changes. Confirm observation every shift (06/01/22) - There was no documentation of observations being completed by night shift on 06/03/22. c) Observe every shift with intermittent therapy or when not in use (06/01/22). There was no documentation of observations being completed for night shift on 06/03/22. d) Midline Catheter - Change administration set every 24 hours intermittent. Label with date/time/initials. Change sterile end cap on intermittent set after each use (06/02/22). There was no documentation that administration or sterile end cap was changed and labeled on 06/03/22 or 06/04/22. e) Monitor for s/s (signs and symptoms) infiltration/extravasation at a frequency based on therapy and resident condition every shift (06/01/22). There was no documentation showing monitoring was done for night shift on 06/03/22. f) Vitals signs to be recorded each shift (06/01/22). Vital signs were not recorded for night shift on 06/03/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105516 If continuation sheet Page 12 of 13 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 105516 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm g) Flush midline to RUA [right upper arm] with 10 ml NS [Normal Saline] before/after medication every 24 hours (06/01/22). There was no documentation showing that flush to midline was completed on 06/04/22. h) Pain level every shift; Document pain scale 0-10. There was no documentation showing pain level was checked for night shift on 06/03/22. Residents Affected - Few i) Oxygen at 2 liters/minute continuously per nasal cannula; document every shift (06/01/22); and Oxygen Saturation rates per shift. There is no documentation showing Oxygen is being administered or saturation rates being checked for night shift on 06/03/22. Class III FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105516 If continuation sheet Page 13 of 13