Inspection visit

Health inspectionDecember 15, 2022

BROOKWOOD GARDENS REHABILITATION AND NURSING CENTECMS #10555016 citations on this visit

16 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 16 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to treat residents with respect and dignity in a manner that promoted enhancement of quality of life that included; not providing drinking cups for approximately 77 residents, failed to provide dessert plates for approximately 78 resident. Failure to provide dining knives for residents on dysphagia diets, failure to allow 1 (Resident #95)out of 1 resident sampled for dialysis to sit in lobby area while awaiting transportation, and failure of staff to sit during the feeding of Resident #64. The findings included: 1) During the observation of the lunch meal on 12/12/22, breakfast and lunch meal on 12/13/22, and breakfast meal on 12/14/22 it was noted that cartons of milk were served on the tray however a drinking cup was not provided to these residents. During routine meal observations it was noted that residents were required to drink milk directly out of the carton. Residents were noted to issue grasping the cartons or spilling when drinking from the carton spout. Other residents were noted not to drink from the cartons at all. During the breakfast observation on 12/14/22 the surveyor requested the Certified Dietary Manager (CDM) to come onto the resident floors to observe the milk carton issue. The CDM stated that she was aware of the dignity issue and residents had never been provided a cup for their milk. The CDM stated that the dietary department did not have enough drinking cups available to provide residents with for the next meal and would have to order drinking cups. The CDM stated that disposable cups would be provided until the drinking cups were delivered, however the surveyor informed the CDM that disposable cups are also considered a dignity issues. Review of diet census noted that there were approximately 77 facility residents who were being served milk in cartons and were required to drink directly from the milk carton. 2) During the observation of the lunch meal on 12/12/22 at 11:30 PM in the main kitchen it was noted that the Pineapple Upside Down Cake was served to the residents in a plastic bag. Observation of the meal in the Assisted Dining Room on 12/12/22 noted that the 4 residents had to eat directly out of the plastics bag with their fingers and spilled the cake contents on the dining room table along with sticky fingers from the pineapple contents. Other residents were noted to take the cake out of the bag and place on the food plate on top of food items that had not been consumed. During a subsequent interview the CDM surveyor noted the dignity concerns related to serving residents the cake in plastic bags instead of on a dessert plate dish. it was estimated that there were approximately 78 facility residents who were served the cake dessert in plastic bags. 3) During observation of the lunch meal tray line in the main kitchen on 12/12/22 at 11:30 AM, it (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 30 Event ID: 105550 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was noted that residents on Mechanical Soft Dysphagia diet were not issued a knife on the food tray. Staff working on the tray line (Staff A, B, C, D) stated that these residents are on Mechanical Soft Dysphagia diet are served pureed food and only require a fork and spoon on the meal tray. Review of the approved menu noted that the Dysphagia diet included a Roll and Margarine with all meals that would require the use of a knife during the meal. During the review of the facility's Diet Census for 12/12/22 it was noted that 19 residents with physician ordered Dysphagia diets did not have a knife included on their food trays. 4) On 12/13/22 at 11:00 AM while at the 200 Nurses Station the surveyor was approached by Resident #95. The resident was alert and orientated x (times) 4 and asked the surveyor if he could help him with his dialysis issues. The residents stated that he has been residing at the facility for approximately 7 months and during this time there has been repeated issue with the timeliness of transportation to the dialysis center. The resident further stated that he wanted to wait in the lobby or outside entrance area on dialysis day on Mondays, Wednesdays, and Fridays with pick up time at 11:00 AM on these days. The resident stated he only wanted to wait in the lobby area for a short time (15 minutes) on these days, but staff would not allow him to wait and stated that he must go back to his room and sent him back to his room on numerous occasions. This issue was brought to the attention of the Social Services Director on 12/13/22 for review who stated to the surveyor that the resident was getting in the way of COVID screening in the lobby. The surveyor met with Resident #95 again on 12/14/22 and the resident stated that the chair he was given on one occasion broke and that there are plenty of chairs outside and away from the lobby testing area. On 12/15/22 at 10:45 AM the resident was observed sitting outside of the entrance area awaiting transportation to dialysis. The resident stated that staff had approached him on the morning of 12/15/22 and informed the resident that there were no issues with him waiting for dialysis transportation in the lobby or outside entrance area. 5) Review of the facility's policy titled Dignity with a revised date of February 2021 included: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are always treated with dignity and respect. When assisting with care, residents a\re supported in exercising their rights. For example, residents are provided with a dignified dining experience. Review of Resident #64's clinical records revealed the resident was admitted to the facility on [DATE] with a readmission on [DATE], diagnoses included Dementia, Anxiety, Schizophrenia, Review of Section C for cognitive status of the Minimum Data Set (MDS) dated [DATE] documented that Resident #64 had a Brief Interview for Mental Status of 9, which indicated that he was moderately impaired. Review of Section G for functional status of the MDS dated [DATE] documented that Resident #64 had a bed mobility, dressing, toilet use and personal hygiene self-performance of total dependence with support of one person assist. During an observation on 12/12/22 at 12:15 PM, Staff K, a Certified Nursing Assistant (CNA) was noted standing over Resident #64 feeding him. During an interview conducted on 12/12/22 at 12:20 PM with Staff K (CNA) when asked how long she has worked for the facility, she replied 7 months. When asked about standing to feed Resident #64, she stated that normally she sits to feed the resident but today she stood. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 2 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide 1 of 1 resident with an opportunity to be out of bed per resident's preferences. The findings included: On 12/12/22 at 01:48 PM, Resident #50 was observed in bed. The Resident stated that activities had not been around since he has been quarantined. I would love to have a book, but someone would have to read it to me because I can't turn the page. Resident #50, when asked about his understanding of isolation precautions, Resident #50 replied, I don't think that I have COVID, but they won't re-test me. I've had the vaccines and 3 boosters. I haven't had any symptoms of it at all. Resident #50 further stated that he had a wheelchair that staff would put him in, and his personal belongings prior to being moved his current room. Resident #50 stated that the wheelchair was not brought to current room and that he had not been out of bed since being on precautions. Resident #50 clinical records revealed the resident was admitted on [DATE] and most recently readmitted on [DATE] after being discharged to the hospital due to indwelling urinary catheter blockage. Review of the 5-day Minimum Data Sheet (MDS), dated [DATE], Resident #50 had a Brief Interview for Mental Status score of 14, indicating the resident is cognitively intact. The MDS documented that Resident #50 was dependent upon staff for all activities of daily living. Resident #50's diagnoses at the time of the assessment included: UTI (urinary tract infection) (last 30 days), Quadriplegia, MS (Multiple Sclerosis), Seizure disorder, Malnutrition, Stage 4 Pressure Ulcer sacral region, neuromuscular dysfunction of bladder, Epilepsy, Major depressive disorder, muscle spasm. Resident #50's orders included: order dated 12/07/2022 -Contact isolation and Droplet precautions for 10 days secondary to positive Covid-19. Resident #50's care plan, dated 12/08/22, documented, [Resident's name] has need for isolation related to active infectious disease: COVID positive. The goal of the care plan was documented as, Resident's isolation will reduce the spread of the infectious agent and minimize the transmission of the infection. With a target date of 01/08/23. Interventions to the care plan included: * Use principles of infection control and universal/standard precautions. * Use least restrictive isolation to prevent resident from experiencing mood distress. * Follow facility's Infection Control policies/procedures when cleaning/disinfecting room, handling soiled and/or contaminated linen, disinfecting equipment, etc. On 12/14/22 at 12:05 PM, during an observation of the room that Resident #50 was in prior to being moved, it was noted that there was a high-backed wheelchair and the resident's dresser was full of personal belongings. Staff L, a Certified Nursing Assistant confirmed that the wheelchair and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 3 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0561 personal belongings in the room belonged to Resident #50. 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: 105550 If continuation sheet Page 4 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 (200 Unit and 300 Unit) of 5 resident areas. The findings included: During the initial resident and room screenings conducted on 12/12/22 and the environment tour conducted on 12/13/22 at 1:00 PM accompanied by the Director of Maintenance, the following were noted: On the 200 Wing hallway floor outside of Rooms #201 to 204 it was noted that the wood laminate floor was buckling and curving upwards in 3 areas and was a potential fall/injury risk to residents. Observation of room [ROOM NUMBER] revealed three of the room walls were noted to be damaged and in disrepair, the bathroom walls were noted to have large black scuff areas, and the bathroom sink required recaulking. In room [ROOM NUMBER] the personal closet (1) was noted to have exterior damage, the over-bed table exterior was damaged and noted to have exposed sharp wood areas. The walls (3) in room [ROOM NUMBER] were damaged and in disrepair. room [ROOM NUMBER]: Seat cushion of room chair noted to have a large tear and over-bed table (1) exterior was damaged and not to have exposed sharp wood areas. room [ROOM NUMBER]: Over-bed tables (2) exterior was damaged and noted to have exposed sharp wood areas and room walls (2) were damaged and in disrepair. room [ROOM NUMBER]: Window blinds were damaged would not close. room [ROOM NUMBER]: Room walls were damaged and in disrepair and room windows soiled and required cleaning. room [ROOM NUMBER]: Room walls (3) damaged and in disrepair. room [ROOM NUMBER]: Room walls (2) damaged and in disrepair, and bathroom baseboards were falling off of walls. room [ROOM NUMBER]: Room walls (3) damaged and in disrepair, and room base boards damages and required replacement. room [ROOM NUMBER]: Room windows soiled and required cleaning. room [ROOM NUMBER]: Room entry door damaged and exposed sharp wood edges, and window curtains damaged and would not close. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 5 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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]: Large black scrapes to room wall, window shade damaged and would not close, and over-bed light cord wrapped around the light fixture. room [ROOM NUMBER]: Room walls (3) damaged and in disrepair, over-bed table exterior was damaged and noted to have exposed sharp wood areas, bathroom ceiling vent was dust laden, and room privacy curtain was heavily stained. room [ROOM NUMBER]: The seat cushion of the room chair was torn, and over-bed table exterior was damaged and noted to have exposed sharp wood areas. Observation of the 200 Activity Room: The activity tables (2) were noted to have large areas of peeling paint, two ceiling lights were not working, room baseboards were falling off of the wall, laminated floorboards were warped and buckling upwards, and room chair exteriors (3) were heavily worn. The 200 Unit's Shower room [ROOM NUMBER]: One of three ceiling lights not working, and wall shelf was rust laden. Observation of the 300 Unit revealed: room [ROOM NUMBER]: Room door handle falling off. room [ROOM NUMBER]: Room walls (2) were damaged and in disrepair. room [ROOM NUMBER]: Room walls (1) were damaged and in disrepair., window curtain damaged and would not close, and over-bed tables were worn and exposed sharp wood areas. room [ROOM NUMBER]: Window curtains were damaged and would not close. Community Shower Room: Toilet seat stained, toilet required recaulking/regrouting and the toilet floor grout stained. Following the tour, the Maintenance Director was interviewed sand noted that all nurses station (4) has a Maintenance/Housekeeping Logbook of which staff are to document maintenance/Housekeeping concerns. None of the issues observed were familiar to the Director. Following the interview, the Administrator was briefed on the observation tour and confirmed the tour findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 6 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 observations and record review, the facility failed to implement an accurate care plan for blood pressure management for 1 (Resident #23) out of 21 sampled residents. Residents Affected - Few The findings included: Review of the facility policy titled Medication Holds, dated April 2007 revealed the following: The attending Physician must provide an explicit order as to when to restart a medication that has been held, either at the time the order is given to hold the medication or subsequently. 1) During a medication administration observation opportunity and interview conducted on 12/13/22 for Resident #23's morning medication at approximately 9:40 AM. The Registered Nurse stated that the resident's vital signs had been taken prior to the observation and that the BP (Blood Pressure) was 93/50 and the Registered Nurse gave the ordered Lisinopril for a history of hypertension (high blood pressure). A review of Resident #23's physician orders revealed the order for the Lisinopril had no hold parameters from the physician in regard to low blood pressure. A review of Resident #23's medication administration record and vital signs record revealed that, on two separate occasions, the Lisinopril had been held by the staff for low blood pressures-on 12/08/22 Resident #23's blood pressure was 101/67 and on 12/09/22 Resident #23's blood pressure was 98/53. Further review of Resident #23's notes revealed there were no notes indicating the staff contacted the physician on 12/08/22 or 12/09/22 regarding holding the Lisinopril due to the low blood pressure readings. In fact, on 12/08/22, the note written stated, all prescribed medications administered as ordered. A review of Resident #23's Care Plans revealed a care plan was written on 05/04/20 (and last reviewed on 10/18/22) which stated the following: Resident is at risk for cardiac and cerebrovascular complications related to HTN [hypertension] and hyperlipidemia (high cholesterol). Along with this care plan was an approach which stated in part the following: observe for s/s [signs and symptoms] of sudden weakness or abnormal v/s [vital signs] and notify MD [doctor] if occur FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 7 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 Record review, interviews, and observations the facility failed to provide an ongoing activities program for 3 (Resident # 259, Resident # 105, and Resident # 50) of 3 residents reviewed for activities, out of the 9 residents that were on isolation precautions. Residents Affected - Few The findings included: The facility's policy, titled Coronavirus (COVID-19) - Resident Visitation, Dining, Activities with Effective date 07/07/20 and most recently revised on 08/26/22, did not address providing activities to residents in their rooms. During an interview, on 12/12/22 at 10:52 AM, Staff O, ADON (Assistant Director of Nursing) /Infection Preventionist when asked about residents that were on precautions, Staff O replied, when they come in from the hospital, we put them on droplet and contact precautions for 10 days, we do the COVID test on day 1 and day 3 and day 5. If they don't have any s/s of COVID after 7 days, we removed them from isolation. We do that because they are not fully vaccinated. During an interview, on 12/12/22 at 10:57 AM, when asked how activities are provided to residents on precautions, Staff P replied, therapy is done inside of the rooms until they are cleared to be outside, for Activities, they are given stuff to color, television, movies and music while they are on precautions. 1. During an observation and interview with Resident #259, via an interpreter, on 12/12/22 at 11:39 AM, Resident #259 stated that she had been in the facility for 3 weeks and was unable to bend her leg to get out of bed. The resident stated that with a wheelchair, she would be happy and that she had not been out of her room for 10 days or more. Record review of clinical records revealed Resident #259 was admitted to the facility on [DATE]. A progress note dated 12/09/22 timestamped at 12:16 documented resident as being alert and oriented x (times) 4. Resident #259's care plan, date 12/10/22, documented, Problem: At risk of decline in previous recreational interests/patterns due to depressive disorder. The goal of the care plan was documented as Resident will participate in preferred activities per scheduled times. Intervention to the care plan included: * Activities to invite, encourage, remind, and escort resident to activity programs consistent with resident interests daily for socialization. * Encourage resident to participate in group activities such as bingo, arts and crafts, and exercise. * Resident will receive Monthly Calendar with daily activities listed * Resident will receive one on one and talk oriented programming per rotating schedule. Resident #259's orders included: Non-COVID Isolation, Contact Precaution dated 12/08/22 with an end date of 12/09/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 8 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview, on 12/14/22 at 2:17 PM, with Staff M and Staff N, when asked about activities provided to Resident #259, Staff M replied, I saw her once since she got here for her intake assessment. Resident #259 did not have any orders for isolation precautions during the survey. 2. During an interview, on 12/12/22 at 12:04 PM, with Resident #105, when asked about activities, Resident #105 stated that he would like to see other people (group activities) and that he preferred to eat in the dining room. Resident #105 further state that he had been in the room for 3 weeks. Resident #105 was admitted to the facility on [DATE]. According to an admission MDS, dated [DATE], Resident #105 had a BIMS score of 14, indicating that Resident #105 was 'cognitively intact'. The MDS documented that Resident #105 required assistance from staff for ADLs except for eating. Resident #105's diagnoses include but not limited to Fracture of parts of lumbosacral spine and pelvis, Muscle weakness, Dysphagia, Abnormalities of gait and mobility, Deep tissue damaged of right heel, deep tissue damage of left heel, Chronic respiratory failure, Hyperlipidemia, Congestive heart failure, Hypertension, Type 2 diabetes Mellitus, Peripheral vascular disease, and Benign prostatic hyperplasia Resident #105's orders included: Non-COVID Isolation: Multidrug-Resistant Organisms (MDRO) Isolation, Contact Precaution dated 11/16/22 with an end date of 11/25/22. Resident #105's care plan, that was initiated on 12/06/22, documented, [Resident's Name] is At risk of decline in previous recreational interests/patterns due to lumbar spine fracture. The goal of the care plan was documented as, Resident will participate in preferred activities per scheduled times. Dated 12/06/22 with a target date of 03/30/23. Interventions to the care plan included: * Activities to invite, encourage, remind, and escort resident to activity programs consistent with resident interests daily for socialization. * Encourage resident to participate in outside activities as tolerated and weather permitting. * Resident will receive Monthly Calendar with daily activities listed. * Resident will receive one on one programming per activity preference per rotating schedule During an interview, on 12/14/22 at 2:17 PM, with Staff M, Activities Assistant and Staff N, Activities Assistant, when asked about activities provided to Resident #105, Staff M replied, I have not seen him. I have not seen him for an assessment. I think [ staff name] did the assessment. Resident #105 did not have any orders documented for isolation precautions during the survey. 3. During an interview, on 12/12/22 at 1:48 PM, Resident #50, when asked about activities the resident stated that Activities had not been around since he has been quarantined. I would love to have a book, but someone would have to read it to me because I can't turn the page. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 9 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #50's clinical records revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] from a local hospital after being discharged due to indwelling urinary catheter blockage. Review of the resident's most recently completed assessment, a 5-Day Minimum Data Set (MDS), dated [DATE], documented Resident #50 had a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was 'cognitively intact'. The MDS documented that Resident #50 was dependent upon staff for all Activities of Daily Living (ADLs). Resident #50's diagnoses at the time of the assessment included: Urinary Tract Infection (UTI) last 30 days, Multiple Sclerosis Quadriplegia, Seizure disorder, Malnutrition, Stage 4 Pressure Ulcer sacral region, neuromuscular dysfunction of bladder, Epilepsy, Major depressive disorder, muscle spasm. Resident #50's orders included: Physician's order dated 12/07/2022-Contact isolation and Droplet precautions for 10 days secondary to Positive Covid-19. Resident #50's care plan, dated 05/26/22, documented, [Resident's name] is At risk or decline in previous recreational interests/patterns due to Multiple Sclerosis, Quadriplegia and Depression The goal of the care plan was documented as, Resident will participate in preferred activities per scheduled times. With a target date of 02/15/23. Interventions to the Care plan included: * Encourage resident to sign up and participate in book club and invite for happy hour celebrations. * Resident will receive fish aquarium visits and daily devotional per preference when available. * Resident will receive Monthly calendar with daily activities listed. * Resident will receive one on one programming with mobile karaoke and engage in conversation. During an interview, on 12/14/22 at 2:03 PM with Staff J, a Registered Nurse (RN), when asked about Resident #50 being out of bed and attending activities, Staff J replied, Mostly once a day, sometimes he would go to activities. He is a patient that required a lot of attention. Therapy was done in his room, PT, they tried to move his legs and knees He had treatment for muscle spasms. He would go to the dining room. During an interview, on 12/14/22 at 2:17 PM, with Staff M, Activities Assistant, and Staff N, Activities Assistant, when asked about activities provided to Resident #50, Staff M replied, He participated in coffee social and the garden club, I haven't seen him since he was moved. I am not sure of the last time that we have seen him. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 10 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, the facility failed to prevent new and worsening of pressure ulcers for 1 Resident #309 of 3 residents reviewed for pressure ulcers. Residents Affected - Few The findings included: 1) Resident #309 was investigated as part of complaint investigation #2022017052. In this complaint, it is stated by Resident #309's daughter that she was admitted to the facility with no pressure ulcers and left with multiple pressure ulcers. Resident #309 was admitted to the facility on [DATE] from a different facility. Resident #309 had a medical history significant for dementia, peripheral vascular disease, heart disease, anemia, diabetes. During the initial record review, it was documented in the discharge paperwork from the original facility that Resident #309 was receiving wound care three times per week for bilateral wounds to heels. Resident #309 was discharged from this facility to a different facility on 08/04/22. The admission Minimum Data Set documented that Resident #309 was dependent on staff for all activities of daily living. There was no admission assessment provided to the surveyor at the time of the survey for review, so there was no record of wounds present at the time of admission to this facility. Review of Resident #309's Care Plan revealed there was a care plan written on 10/19/20 regarding Stage 2 sacral ulcer with the following approaches educate resident/responsible party about: pressure injury etiology, primary risk factors, treatment and prevention; provide pressure relieving devices such as chair cushion; turning and repositioning every 2 hours as tolerated. An interview was conducted with Staff G, a Certified Nursing Assistant on 12/15/22 at 8:32 AM. Staff G stated she did work with Resident #309 during her stay at the facility and Staff G stated she did remember that Resident #309 had a small wound on her bottom. Review of the wound care notes provided by the facility documented three wounds that Resident #309 had during her stay at the facility. The documented wounds were a wound on the right heel, a wound on right calf, and a wound on the right lateral foot. A Nursing Note was written on 08/03/22 at 4:42 PM which documented a new left foot wound found during routine wound care done on that day. A Nursing Note was written on 08/04/22 at 9:30 AM which documented that Resident #309 left the facility in a wheelchair in the company of her daughter. An interview was conducted with Staff H, Social Services on 12/15/22 at 11:33 AM. The surveyor asked Staff H if the facility initiated the discharge for Resident #309 or if the family did. Staff H stated the family initiated the discharge. The surveyor asked how Resident #309 was transported to the new facility. Staff H stated the daughter rented a wheelchair accessible van and drove Resident #309 to the new facility herself after it was explained to her by the new facility that Resident #309's insurance would not cover an ambulance transport. The surveyor asked for a copy of the discharge instructions and education which were provided to Resident #309 and her daughter at the time of discharge. Staff H stated there was no copy of the discharge instructions to share as these had been sent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 11 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0686 to [ facility name]. Level of Harm - Minimal harm or potential for actual harm Due to the lack of documentation provided by the facility regarding the presence of a sacral wound and what education may have been given to Resident #309's daughter regarding the presence of wounds and pressure relieving measures and necessary perineal care during transport, it was determined that this complaint is substantiated. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 12 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 observations, interviews, and record review, the facility failed to provide appropriate care, properly assess, document, and notify physician of a change in condition in a timely manner for 1 (Resident #64) of 1 resident sampled for catheter care. The findings included: Review of the facility's undated policy titled Notification of Changes included: This facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status. Review of the facility's undated policy titled Protocol - When to Call the Doctor included the following: A guideline for types of situations which frequently require physician notification are as follows: Bleeding. It is the responsibility of the nursing staff to observe the situation, make an assignment, collect information, and notify the physician when indicated in accord with this protocol. The Nurse will: Recognize the situation, obtain appropriate information, Monitor the resident, and continue to obtain information about the situation and note any changes, Notify the physician of the situation in accord with this policy, Notify the Nursing Supervisor and other support staff as needed. Review of Resident #64' clinical records revealed the resident was admitted to the facility on [DATE] with a readmission on [DATE], diagnoses included Dementia, Anxiety, Venous Insufficiency, Schizophrenia, Pressure Ulcer of Right Heel Stage 3, Pressure Ulcer of Right Upper Back Stage 3, Pressure Ulcer of Left Upper Back Stage 3, Obstructive and Reflux Uropathy and Urinary Tract Infection. Review of the Minimum Data Set (MDS) dated [DATE] Section C for cognitive status documented that Resident #64 had a Brief Interview for Mental Status score of 9, which indicated that he was moderately impaired. Review of Section G of the MDS dated [DATE] documented that for bed mobility, dressing, toilet use, and personal hygiene Resident #64 had self-performance of total dependence with support of one person assist. Review of the Physician's Orders showed that Resident #64 had an order dated 09/25/2022 for Eliquis (apixaban) tablet; 5 mg (milligram): 1 tablet oral twice a day. There was an order dated from 10/21/2022 to 10/23/2022 to hold Eliquis (apixaban) tablet; 5 mg; 1 tablet oral twice a day. Physician order dated from 10/26/2022 to 10/29/2022 indicated to hold Eliquis (apixaban) tablet 5 mg, 1 tablet oral twice a day. Review of the Physician's Orders showed that Resident #64 had an order dated 09/26/22 for urinary catheter size 16Fr (16 French) for straight drainage. Review of the Physician's Orders showed that Resident #64 had an order dated 09/26/22 for side effects: bleeding precautions, monitor for signs and symptoms (S/S) of bleeding due to anticoagulant use - dark tarry stool, dark urine, nose bleeds, black gums/mucous membranes, vomiting or coughing up blood- report to physician if any noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 13 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 Review of the Care Plan for Resident #64 dated 09/05/22 with a problem of the resident is at risk for infection related to [] catheter with diagnoses of obstructive uropathy with a goal that in the event of infection early recognition of infection to allow for prompt treatment. Approaches included: Monitor for abdominal pain. Monitor characteristics of urine (odor, color, blood in urine). Keep resident comfortable, clean, and dry. Residents Affected - Few Review of the Care Plan for Resident #64 dated 09/05/22 documented problem indicated the resident presents with episodes of bowel incontinence. Resident uses adult briefs. Resident is at risk for urinary tract infection (UTI) and skin breakdown related to incontinence, with a goal that resident will be maintained clean and dry to minimize risk for UTI and skin breakdown daily through next review date. Approaches included: Check and change for incontinent episodes an apply moisture barrier ointment regularly. Observe for signs/symptoms (S/S) of UTI: fever, urine dark/cloudy/scant/strong odor, increased agitation/confusion, blood in urine and report to physician. Review of the Medication Administration Record (MAR) for Resident #64 revealed under side effects: bleeding precautions, monitor for signs and symptoms (S/S) of bleeding due to anticoagulant use - dark tarry stool, dark urine, nose bleeds, black gums/mucous membranes, vomiting or coughing up blood- report to physician if any noted. on 12/12/22 the nurse documented yes, the resident was monitored for bleeding, and no there were no blood. Review of the Nursing Progress Note for Resident #64 dated 10/21/22 included: Resident with the use of anticoagulant Eliquis was seen today for the wound care, the back dressing was removed, with heavy serosanguinous drainage noted, the wound was cleaned, and new dressing applied. Physician notified about the heavy exudate and new orders received to hold the anticoagulant (Eliquis) for two days. Review of the Nursing Progress Note for Resident #64 dated 10/26/22 included: Resident with the current use of anticoagulant Eliquis, was seen today by the wound care doctor, stage 3 pressure wound of the right upper back with moderate serosanguineous exudate, wound progress deteriorated. Second pressure wound of the left upper back Stage 3 deteriorated. Doctor recommendation of hold the use of the anticoagulant. Right heel evaluated upon admission as a blanchable redness was reclassified by the wound care doctor as stage 3 pressure wound of the right heel with light exudate. During an observation conducted on 12/12/22 at 11:30 AM, revealed Resident # 64's urinary catheter with hematuria (bloody urine) in the tubing and the drainage bag (Photographic Evidence Obtained). During an observation of urinary catheter care on 12/14/22 at 9:30 AM with Staff I, a Certified Nursing Assistant (CNA), it was observed that after providing catheter care for Resident #64, Staff I -CNA, failed to remove the adult brief that became wet during catheter care Staff I provided and was noted to have simply secured the wet brief to the resident. During an interview conducted on 12/14/22 at 11:30 AM, Staff J, a Registered Nurse (RN), when asked to come into Resident #64's room and verify if the resident's brief was wet, Staff J agreed the brief was wet and the resident should have been changed. When asked about Resident #64 having bloody urine, Staff J stated he was not aware. When Staff J was shown the photographic evidence of the bloody urine in the drainage bag for Resident #64 that was taken of 12/12/22 he agreed it was bloody, and he was taking care of the resident on 12/12/22 but the Certified Nursing Assistant did not notify him of the bloody urine. Staff J also stated he thinks the doctor is aware that the resident has bleeding, because the doctor held the resident's anticoagulant (Eliquis) previously for bleeding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 14 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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, record review and interview, the facility failed to ensure tube feeding was administered as ordered for 2 (Resident #62, and Resident #94) out of 4 sampled residents reviewed for tube feeding. There were 10 residents residing in the facility with orders for tube feeding at the time of the survey. The findings included: 1. During an observation conducted on 12/12/22 at 10:00 AM, Resident #62 was observed lying in her bed. Upon closer observation, it was revealed that the resident had Jevity 1.5 (formulary type) tube feeding that was started on 12/12/22 at 3:00 AM and was to be infused at 50 milliliters (mls) per hour (hr.) via feeding pump. The tube feeding was at the 950 mark out of a 1,000-milliliter capacity bottle (Photographic Evidence Provided). The tube feeding was not infusing. Record review for Resident #62 revealed that the resident was admitted to the facility on [DATE] with a recent readmission on [DATE], diagnoses included: Dysphagia Following Cerebral Infarction, Other Speech and Language Deficits Following Other Cerebrovascular disease, and Gastrostomy Status. Review of the Physician's Orders for Resident #62 revealed an order dated 07/23/21 for Enteral Feeding: Jevity 1.5 via PEG (percutaneous endoscopic gastrostomy) at 50 ML (milliliter)/Hour for 20 Hour Every Shift Day, Nights. Review of the Minimum Data Set (MDS) for Resident #62 dated 09/17/22 revealed in Section C for cognitive status documented a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate impairment. Review of Resident #62's Care Plan dated 11/27/2019 with the Problem: Resident has a need for use of a feeding tube related to dysphagia. Resident has the potential for complications secondary to using a feeding tube. Goal is for the resident to remain free of complications related to the use of a feeding tube as evidenced by no signs/symptoms of aspiration, no nausea/vomiting, no diarrhea, no abdominal distention. Approaches included: Administer tube feeding formula and flushes as ordered. Report significant weight changes to MD (Medical Doctor). Report complications/side effects of tube feeding to MD. Observe for the following: tolerance to feeding, lung sounds, bowel sounds, presence of abdominal distention, presence of drainage and or signs and symptoms of infection at tube site. Keep head of bed elevated at least 30 degrees while tube feeding is infusing. During an observation conducted on 12/12/22 1:45 PM, Resident # 62, she was lying in her bed, the resident had Jevity 1.5 (formulary type) tube feeding that was documented as started on 12/12/22 at 3:00 AM and was noted between the 900 to 950 mark out of a 1,000-milliliter capacity bottle (Photographic Evidence Provided). The tube feeding was not infusing. During an observation on 12/13/22 at 10:05 AM of Resident #62 sitting in a wheelchair, closer observation revealed the resident had Jevity 1.5 (type of formulary) tube feeding that was documented as started on 12/13/22 at 5:00 AM, the tube feeding was at the 950 mark out of a 1,000-milliliter capacity bottle (Photographic Evidence Provided). The tube feeding was not infusing. During an interview conducted on 12/13/22 at 12:50 PM, the Registered Dietician was asked about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 15 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 Resident #62's tube feeding. The Registered Dietician reported that the residents who are receiving enteral tube feeding should have the tube feeding off from 10:00 AM to 2:00 PM and the enteral tube feeding should be running all other times. The Registered Dietician stated that Resident #62's weight has been stable, so she did not feel there was any issue with the tube feeding. The Registered Dietician added that she does ask nursing staff about and if there are any issues with the tube feedings. The Registered Dietician agreed based on surveyor observations that the resident has not been getting the amount of tube feeding ordered. 2. During an observation on 12/12/22 at 11:15 AM of Resident # 94 lying in bed, closer observation revealed the resident had Jevity 1.5 formulary tube feeding that was documented as started on 12/12/22 at 3:00 AM and was at the 700-milliliter mark out of 1,000 milliliter-bottle capacity (Photographic Evidence Provided). The tube feeding was not infusing. Record review for Resident #94 revealed the resident was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses that included: Dysphagia Following Nontraumatic Subarachnoid Hemorrhage, Persistent Vegetative State, and Parkinson's Disease. Review of the Physician's orders for Resident #94 revealed an order dated 05/18/22 for Enteral Feeding: Formula Jevity 1.5 at 70 ml/hr. (milliliter/hour) for 20 hours Every Shift Days, Nights. Review of the Minimum Data Set (MDS) for Resident #94 dated 11/14/22 revealed in Section C for cognitive status indicated a Brief Interview of Mental Status (BIMS) score could not be obtained due to the resident is rarely/never understood. Review of Resident #94's Care Plan dated 05/06/22 with a problem of the resident is at risk for alteration in parameters of nutrition and hydration related to: total dependent on TF (tube feeding), increased kcal/pro (calorie/protein) needs for healing post-surgery and acute illness. Goal was for resident to remain well-nourished/hydrated and without complications through the next review date. Approaches included: Provide enteral feeds as ordered. Report complications/side effects of tube feeding to Physician. During an observation on 12/12/22 at 1:45 PM of Resident # 94 lying in bed, closer observation revealed the resident had Jevity 1.5 tube feeding that was documented as started on 12/12/22 at 7:00 AM and was at the 700-milliliter mark out of a 1,000-milliliter capacity bottle (Photographic Evidence Provided). The tube feeding was not infusing. During an observation on 12/13/22 at 10:00 AM of Resident # 94 lying in bed, closer observation revealed the resident had Jevity 1.5 tube feeding that was documented as started on 12/13/22 at 5:00 AM, the tube feeding was at the 850-milliliter mark out of a 1,000-milliliter capacity bottle (Photographic Evidence Provided). The tube feeding was not infusing. During an interview conducted on 12/13/22 at 1:00 PM, the Registered Dietician was asked about the tube feeding for Resident #94, the Registered Dietician stated that Resident #94 tube feeding would be off from 10:00 AM to 2:00 PM for activities of daily living (ADL) care. The Registered Dietician She agreed that based on the surveyor's observations the resident is not receiving the tube feeding amount as ordered by the physician. The Registered Dietician reported that the resident's weights fluctuate a little. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 16 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews the facility failed to secure medications at the bedside for Resident #86 and failed to refrigerate medications per facility policy. The findings included: Review of the facility policy titled Medication Storage, dated 03/28/18 revealed the following: Medications and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Medications shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubical, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medications requiring refrigeration must be stored in a refrigerator located in the medication room at the nurses' station or other secured location. Review of the pharmacy list titled Medications with Shortened Expiration Dates, undated revealed the following: Latanoprost Ophthalmic Solution-store unopened in refrigerator: Yes; refrigerate once opened: No. 1) During the initial tour of the facility conducted on 12/12/22 at 9:25 AM, it was observed by the surveyor that there was an open drawer in Resident #86's room. Observed inside the open drawer were three unidentified white tablets. Photographic evidence obtained. Review of Resident #86's medical records revealed there was no documentation of Resident #86 being assessed as safe to self-administer medications. A secondary observation was made on 12/13/22 at 9:12 AM. The white tablets were no longer present in the drawer. An interview was conducted with Resident #86 at that time. The resident stated she did not know what the white tablets were and did not know who removed them from her drawer. 2) During an observation conducted on 12/14/22 at 3:45 PM of a medication cart at the 200/300 Unit nurse's station with Staff E a Licensed Practical Nurse (LPN), the surveyor observed a bottle of Latanoprost Ophthalmic Solution which had a sticker on the bag which read refrigerate before opening. The surveyor asked Staff E if this medication should have been in the refrigerator. Staff E stated it did not have to be in the refrigerator because the drops were not open. The surveyor pointed to the sticker and asked again if the eye drops should be in the refrigerator and again Staff E stated the eye drops were not open, so they did not have to be refrigerated. The surveyor again pointed to the sticker and asked the nurse to clarify. Staff E then removed the eye drops from the medication cart and stated she would place them in the refrigerator. A second observation was conducted on 12/14/22 at 3:50 PM of a medication cart at the 300 North nurse's station with Staff F, LPN. There was a bottle of Latanoprost Ophthalmic Solution which had a sticker on the bag which read refrigerate before opening observed in this cart as well. The surveyor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 17 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 asked Staff F if this medication should have been in the refrigerator. Staff F stated that since the eye drops were open, they did not have to be refrigerated as this is the facility's policy. 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: 105550 If continuation sheet Page 18 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to provide a nourishing, palatable, well-balanced diet to meet the special needs of 1 (Resident #95) of 1 sampled dialysis resident. The findings included: On 12/13/22 at 9:00 AM, the surveyor was approached by Resident #95 while at the 200/300 Nurses Station. The resident who was alert and oriented times 3 asked if the surveyor would help with his issue with dialysis and his renal diet. Resident #95 stated to the surveyor that he has resided at the facility for the past 7 months and has had continued problems with diet and meals. The resident further stated that he leaves the facility on dialysis days (Mondays, Wednesdays, and Fridays) around 11:00 AM for the dialysis center which is approximately a 1.5-to-2-hour drive in the transport van. The resident was asked by the surveyor if he is given a bagged lunch to take to the dialysis center. The resident he only has been given a bagged lunch once or twice. and the few times a bagged lunch was provided by the facility it included snacks, chips, soda, and other foods that are not to be included on his diet. The resident stated that he constantly requests more fresh fruits and vegetables for the facility meals and bagged lunches, but this has not happened. The resident also stated that when he returns from dialysis his 5:00 PM facility dinner tray is located in the facility refrigerator and staff do not re-heat the foods in the microwave enough and the food is cold. Also, the condensation from the food lid gets all the foods wet and he does not eat the meal. During the review of the clinical record of Resident #95 on 12/13/22 it was noted that the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to End Stage Renal Disease, Dependence on Renal Dialysis, Heart Failure, and Anxiety Disorder. Review of current Physician orders include order dated 9/17/22 - Nepro-Vite and Folic Acid 0.8 mg (milligrams) QD (daily). Thiamine 100 mg QD. Order dated 11/11/22 - Renal Diet. Order dated 12/8/22 Dialysis M/W/F (Mondays, Wednesdays, Fridays)-Chair 1:25 PM Return 6:15 PM. Review of Quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident understood and understands. Section C for cognitive status documented a Brief Interview o Mental Status Score of 15 out of 15 indicating the resident is cognitively intact. Section D for Mood and Behaviors indicated the resident has no mood issues. Section G for functional status indicated the resident is Independent of Activities of Daily Living (ADL) and Eats independently. Section O for Special treatments indicated the resident is on Sec O: Dialysis Treatment. The MDS also indicated no weight loss. During an interview with the Social Services Director on 7/14/22, the Social Services Director confirmed that the resident is not receiving a bagged lunch to take to take to the dialysis center. The Social Services Director stated that the resident was refusing the bagged lunch that was provided by the dietary department. On 12/14/22 at 11:00 AM, the resident was noted to be waiting in the outside front entrance. The resident stated he had finally been given a bagged lunch to take to dialysis that contained foods that were allowed in his renal diet. Observation of the bagged lunch noted: tuna fish sandwich, fig [NAME] bar, grapes, saltines, and apple juice. The resident expressed his joy that a proper bagged lunch was finally. provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 19 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 012/15/22 at 10:00 AM the resident was seen by the surveyor and noted to state that upon returning from dialysis at 7:00 PM the dinner meal was again served to him cold. During an interview with the Certified Dietary Manager and the facility's Consultant Dietitian on 12/15/22 it was revealed that the resident bagged lunch items were reassessed and will include foods Resident #95 is requesting that include fresh fruits and vegetables. It was also noted that the dietary department is open until 8:00 PM nightly and will serve a fresh dinner meal to Resident #95 upon returning from dialysis. Event ID: Facility ID: 105550 If continuation sheet Page 20 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, it was determined that the approved facility menu was not followed for a potential 103 residents (Regular and Therapeutic Diets) and 27 residents (includes sampled Resident #14, Resident #20, and Resident #28) with physician ordered pureed diet. The findings included: 1) During the review of the 12/12/22 approved lunch meal the following was noted: Italian Sausage (Regular and Therapeutic Diets) Dinner Roll with Margarine Pureed Dinner Roll with Margarine Thin Crust Pizza (Entree Substitute) Pureed Cheese Ravioli (Pureed Entree Substitute) Marinated [NAME] Bean Salad (Dysphagia Vegetable Substitute) Pureed Marinated [NAME] beans (Substitute vegetable) Tossed Salad with Dressing (Regular Entree Substitute) During the observation of the lunch tray in the main kitchen and interview with the Certified Dietary Manager (CDM) on 12/12/22 at 11:30 AM, it was revealed that, Shredded Roast Pork substituted for Italian Sausage. The CDM stated that the pork was not ordered in time or was not available for delivery. *The Dinner Roll with Margarine was not ordered and served. There was no regular bread or pureed bread prepared or served. The CDM stated that the cook forgot to review the menu to be prepared and served. *Thin Crust Pizza was not prepared or served. The CDM stated that the cook (Staff A) failed to read and follow the approved lunch menu. * Pureed Cheese Ravioli was not prepared or served; it was noted that there was no alternate pureed entrée available. The CDM stated that the cook (Staff A) failed to review and follow the approved lunch menu. * Marinated [NAME] Bean Salad was not prepared or served. It was noted that there was no alternate Dysphagia vegetable prepared or served. The CDM stated the cook (Staff A) failed to review and follow the approved lunch menu. * Pureed Marinated [NAME] Beans were not prepared or served. There was no alternate pureed vegetable prepared or served. The CDM stated that the cook (Staff A) failed to prepare review and follow the approved lunch menu. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 21 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some * Tossed Salad with Dressing was not prepared or served. There was no alternate salad prepared or served. The CDM stated the cook (Staff A) failed to review and follow the approved lunch menu. Review of the Diet Census for 12/12/22 noted that there were 27 residents with physician ordered pureed diet. Included in the 27 residents was sampled 3 residents (Resident #14, Resident #20, and Resident #28). 2) During the review of the approved menu for the lunch meal of 12/12/22 it was noted that a minimum 3-ounce portion of the Roast Pork was to be served as a standard portion. During the observation of the lunch tray line service in the main kitchen on 12/12/22 at 11:30 AM it was noted that the [NAME] (Staff A) was not utilizing portion control serving equipment and noted to be serving the entree with tongs and estimating the portion size. The surveyor requested a weighing of the Roast Pork entree. At the request of the surveyor 2 portions of the pork entree were weighed utilizing the facility's calibrated portion control scale. The weighing of the Pork entree was recorded at only 2.3 -2.5 ounces. The surveyor informed the CDM that the portion being served did not meet the documented required portion on the approved lunch menu. 3) During the review of the approved breakfast meal for 12/13/22, the following were noted: Biscuit (1) for Regular and Dysphagia Diets. Pureed Biscuit (1) During the observation of the breakfast meal service on 12/13/22 at 7:30 AM, the following were noted: * Croissants were substituted for biscuits. The CDM stated that the biscuits were not ordered or not available. Observation of the breakfast meal noted that the croissants were already purchased and prepared. However, the cook (Staff A) put them in the oven to reheat and burned many of the croissants that were noted to be still served to the residents. * Pureed Croissants were not prepared and served. Pureed bread was prepared and served. The CDM stated that the cook (Staff A) should have realized that pureed croissants should have been prepared and served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 22 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, record review, and interview, it was determined that the facility failed to prepare food in a form designed to meet the needs of residents with physician ordered thickened liquids that included 26 facility residents and included sampled Resident #10, Resident #42, Resident #64, and Resident #70. The findings included: 1) Review of the approved menu for the breakfast meal of 12/13/22 noted documentation of 8 ounces of milk be served for regular and therapeutic diets. During the observation of the breakfast meal in the main kitchen on 12/13/22 at 7:30 AM, it was noted that residents on physician ordered thickened liquids tray cards that documented 8 ounces of thickened milk (Nectar and Honey Consistency) were not receiving an 8-ounce portion of thickened milk. Interviews with Staff A, B, C who were working on the tray line stated that the thickened milk has not been available for some time. Interview with the Certified Dietary Manager (CDM) at the time of the observation noted that the thickened milk (both Nectar and Honey) is purchased pre-thickened in 8-ounce carton portions. The CDM further stated that the thickened milk has not been available for delivery since August 2022. Further interview with the CDM confirmed that residents with physician ordered thickened liquids have not had the required 16 ounces (2-eight ounce serves = approximately 300 calories and 16 grams Protein) per day for 5 months. It was also discussed with the CDM that the facility had liquid thickener in bulk and in individual packets in the kitchen supply and that the milk could have been thickened daily to be served to the residents for the past 5 months. The CDM stated she did not think of thickening milk in house on a daily basis. Interview with the Administrator and Consultant Dietitian on 12/13/22 revealed that they were unaware of the issue and had not been notified by the CDM of these critical nutritional issues. A review of the facility's diet census for 12/13/22 noted that there were currently 26 residents with physician ordered thickened liquids of which included Resident #10, Resident #42, Resident #64, and Resident #70. 2) During the observation of the breakfast meal on 12/14/22 it was noted the resident's meal tickets documented 8 ounces of Thickened Milk on the meal tray. Further observation noted that residents on physician ordered thicken liquids were served milk in a 5-ounces cup. The surveyor went to the main kitchen to weigh at portion of thickened milk that was designated for serving. During the weighing request it was noted that the kitchen was without basic food measuring devices that included an 8-ounce measuring cup (no measuring cups for food preparation as per standardized recipes) and the milk was measured in an 8-ounce ladle and was measured at 4 ounces. The surveyor informed the CDM that the portion did not meet the approved menu portion and was not nutritionally adequate. 3) During the observation of the facility's thickened liquids on 12/13/22 it was noted that there were 4 residents with physician orders for Honey Thick Might Shakes (Liquid supplement). Further investigation noted that the facility purchases only Nectar Thick Mighty Shakes and does not purchase Honey Thick Might Shakes. it was also noted that the Nectar Shakes were being administered to the 4 residents on the Honey Thick Liquids. Interview with the CDM on 12/13/22 revealed that the facility's Consultant Dietitian had approved the use of Nectar Thick Milkshakes for Honey Thick Milkshakes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 23 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with the Consultant Dietitian denied giving approval and stated she was unaware the Nectar Thick Milkshakes were being administered in place of Honey Thick Milkshakes and was also discussed the potential possibility of aspiration. The Dietitian stated that all residents with physician ordered Honey Thick Milkshakes would immediately be served Pudding in place of the Nectar Milkshakes. Review of the facility's diet census for 12/13/22 noted that the 4 residents with physician ordered Honey Thick Milkshake included: Resident # 10, Resident #42, Resident #64, and Resident #70. Event ID: Facility ID: 105550 If continuation sheet Page 24 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, it was determined that 13 out of 13 facility residents that included Resident #10, Resident #14, Resident #20, and Resident #28, were not being served Fortified Foods (high calorie and high protein) with meals as per Dietitian assessment and attending physician orders. The findings included: Review of the facility's Fortified Food Program noted: The diet is important to ensure that calorie and protein needs are met by serving nutrient dense foods. The goal of the fortified food program is to be able to provide a higher calorie and higher protein food item to residents if the intake of regular foods or beverages are not able to meet estimated nutritional needs. A fortified food program may be used in the nutritional rehabilitation of individuals with poor nutritional status due to prolonged illness, burns, malnutrition, decreased intake of foods or fluids or significant weight loss . Fortified hot cereal at breakfast can be served in place of regular hot cereal or cold cereal .Fortified mashed potatoes can be served in place of the starch at lunch and dinner .Fortified pudding parfait can be served in place of the sweet dessert at lunch and or dinner. During the observation of the lunch tray line service in the main kitchen on 12/12/22 it was noted that numerous resident meal tray tickets documented a portion of Fortified Foods to be served. Observations of these resident food trays noted that a portion of Fortified Foods was not included on the trays. Interview with the Certified Dietary Manager (CDM) stated that the lunch Fortified Food to be served was fortified mashed potato (high calorie-protein ingredients). The [NAME] (Staff A) was interviewed by the surveyor and CDM at the time of meal observation and noted to state that he did not know what Fortified Foods were, unaware of how to prepare Fortified Foods, and has never prepared Fortified Foods. Staff working on the tray line (Staff B and AC) confirmed the cook's statements to the surveyor. It was also discussed with the CDM at the time that Fortified Foods are assessed and ordered by the Dietitian and Physician to provide additional calories and protein to underweight and malnourished residents. It was also discussed that the cook (Staff A) was also preparing and serving the breakfast meal and there was the potential that Fortified Foods were not being prepared or served for breakfast meals on a daily basis. Review of the diet census for 12/13/22 noted that there were currently 13 residents with physician ordered Fortified Foods that included Resident # 10, Resident #14, Resident #20, Resident #28, and Resident #64. Interview with the Consultant Dietitian on 12/14/22 noted that she was unaware that the dietary department was not preparing and serving Fortified Foods as per nutritional assessment and physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 25 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. As evidenced by failure to ensure cold food holding temperatures at 41 degrees Fahrenheit (F) or below, failure to ensure the proper cleaning of food preparation equipment, failure to ensure maintenance of light fixture, exhaust hoods, and vents to prevent food contamination, failure to handle silverware in a sanitary manor, failure to ensure leftover foods are dated, labeled and failure to ensure the maintenance of refrigeration units and shelving and failure to prevent contamination of potentially hazardous foods prepared and provided in bagged lunches for resident going out of the facility for dialysis. The findings included: 1) During the initial kitchen sanitation tour conducted on 12/12/22 at 9 AM accompanied with the Certified Dietary Manager (CDM), the following were noted: (a) Observation of the walk-in refrigerator it was noted that the outside exterior required repair repainting and the door gasket was torn and laden with mold type matter. The interior temperature of the unit was noted to be 50 degrees F. It was discussed with the CDM that the torn gasket could be contributing to the temperature internal temperature above regulatory requirement of 41 degrees F or below. (b) Observation of the walk-in refrigerator it was noted that left over foods were not labeled and dated as per requirement. It was noted that there were pans designated by the CDM as Tuna Fish Salad and Soup that was not labeled nor dated as a leftover. (c) Observation of reach-in refrigerator #1 noted that the 2 interior shelves were rust laden. (d) The light fixture and the ceiling air-conditioning vents located oven the food preparation area was heavily soiled laden with mold like substance. (e) Silverware located on the tray line was noted to be handled by staff in an unsanitary manor. It was noted that staff were handling the silverware by touching eating portion instead of the handles and potentially contaminating the silverware. (f) The pots and pans storage shelving (8 shelves) were noted to be heavily laden with rust. It was discussed with the CDM that the rust is falling off into the clean pans and required replacement of the shelving. (g) Observation of the dry storage room noted that there was a #10 can of pears (1) that contained a large dent. The surveyor request that the can be removed from the shelf to ensure non-use. (h) Observation of the sanitation buckets noted that 1 of 2 buckets failed to maintain the required chemical level. The test strip noted no evidence of chemical in the bucket solution. (i) The ceiling light fixture located directly above the food preparation area was noted to be heavily cracked and broken. It was discussed with the CDM that pieces of fixture could potentially fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 26 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 into foods. Level of Harm - Minimal harm or potential for actual harm (j) A commercial food storage container was noted to contain Food Thickener (5 pounds). Further observation noted that the scoop and handle was embedded directly into the thickener. The surveyor informed that the thickener was contaminated and required to be discarded. Residents Affected - Many (k) The convection oven was noted to have a heavy build-up of burned food and carbon. The CDM stated that the scheduled cleaning of the ovens each weekend was not being done. (l) Room walls located near the dish room entrance were noted to be heavily damaged and missing tiles. It was discussed with the CDM that the damaged wall areas are breeding areas for bacteria growth. (m) Three large cooking skillets/pans were noted to have the exterior covered with heavy layers of carbon and in the interior and the surface was wearing off with each use. The surveyor requested that the pans be replaced. (n) The dish machine hood ventilation system was rust laden. It was discussed with the CDM that rust could potentially fall onto clean dishes. (o) The ceiling air conditioner vent located in the dish room was noted to be rust laden. (p) The caulking located around the 3 compartment sinks was noted to be a black mold type matter. The surveyor requested the caulking to be replaced prior to the next use. (q) The slicer was noted to have large areas of food on the exterior. The surveyor requested that the slicer be properly cleaned prior to the next use. 2) During a follow-up observation of the main kitchen on 12/13/22 at 7:00 AM, food temperatures were being taken with the facility's calibrated thermometer. The findings noted that cold foods/beverages were not being held at the regulatory minimum temperature of 41 degrees F or below as per the following: Individual Milk Portions (30) = 47 degrees F Individual Thickened Liquid Portion (20) = 46 degrees F Individual Apple Juice Portions (30) = 47 degrees F Individual Cranberry Juice Portions (30) = 48 degrees F 3) During an observation of residents by the lobby/reception area waiting to be taken to dialysis, on 12/15/22 at 9:53 AM. it was noted that the resident's lunch provided by the facilty to take with the residents, consisted of an egg salad sandwich, applesauce, ginger ale and commercially processed fig cookie. it was noted that there was no ice pack in the soft sided cooler that was provide to the resident and no other cooling medium to keep the potentially hazardous foods at a safe temperature. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 27 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and interview, the facility failed to ensure an effective Quality Assessment and Assurance (QAA) committee as evidenced by not implementing corrective plans of action for correcting repeated deficiencies related to labelling and storage of drugs and biologicals, infection control and sanitary food handling. Cross reference F761 Label/Store Drugs & Biologicals; Cross reference of F880 for Infection Prevention and Control and F812 for Sanitary Food Handling. The facility had deficient practice identified at 761 during the last recertification survey with exit date of 04/22/2021. The facility was cited F880 during an infection control survey conducted in 2020 and during the recertification survey with exit date of 4/22/2021. The facility was cited F812 during the recertification survey conducted in 2019 and during the last recertification survey with exit date of 04/22/2021. The facility was also QAA was cited during the last recertification with exit date of 04/22/2021. The findings included: During an interview conducted on 12/15/22 at 1:30 PM with Administrator. It was revealed the committee includes Director of Nursing Services, Medical Director, Nursing Home Administrator, Governing Body, Heads of departments and Certified Nursing Assistant. The committee meets monthly (3rd Friday) and quarterly the pharmacist attends. The facility is working with [company name] due to the outbreak of covid. They were ready to end the program, and she asked for it to be extended due to an outbreak with a resident recently. The facility is working on Pressure ulcers and to decrease amount of high risk and in house acquired pressure ulcers, educate Certified Nursing Assistants (CNAs) and assessing Nutrition needs. For activities the facility is doing more movement type of activities (working with physical therapy). The facility is working on reducing unnecessary Antipsychotics. trying to reduce unnecessary. Improving documentation and access to historical data due to transitioning from one corporation to another. The facility is working on weight loss, activities addressing hydration, dietary ensure preferences are assessed and looked at supplements and snacks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 28 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3). Resident #50 was admitted to the facility on [DATE] and most recently readmitted on [DATE] after being discharged to the hospital due to urinary catheter blockage. Residents Affected - Some Review of the 5-day Minimum Data Sheet (MDS), dated [DATE], Resident #50 had a Brief Interview for Mental Status score of 14, indicating the resident is cognitively intact. The MDS documented that Resident #50 was dependent upon staff for all activities of daily living. Resident #50's diagnoses at the time of the assessment included: UTI (urinary tract infection) (last 30 days), Quadriplegia, MS (Multiple Sclerosis), Seizure disorder, Malnutrition, Stage 4 Pressure Ulcer sacral region, neuromuscular dysfunction of bladder, Epilepsy, Major depressive disorder, muscle spasm. Review of Resident # 50's physicians orders dated 12/07/2022 indicated: Contact isolation and Droplet precautions for 10 days secondary to Positive Covid-19. Review of Resident #50's care plan, dated 12/08/22, documented, [Resident] has a potential risk for complications r/t (related to) an active infection of COVID-19. The goal of the care plan documented: Resident will not demonstrate s/s (signs and symptoms) of active COVID-19 infectious process through the next review date. Target Date: 01/08/23. Interventions to the care plan included: Monitor appetite and PO (by mouth) fluids intake. Monitor vital signs as per MD (Medical Doctor) orders. Maintain appropriate PPE (Personal Protective Equipment) use according to state requirement availability. Educate resident/family on proper hand washing, social distancing, reason for possible future isolation, and visitor limitation as indicated. Labs as ordered, report abnormal labs results to MD ASAP. Isolation as warranted per resident's condition. Resident #50's care plan, dated 12/08/22, documented, [ Resident] has need for isolation related to active infectious disease: COVID positive The goal of the care plan was documented as, Resident's isolation will reduce the spread of the infectious agent and minimize the transmission of the infection. With a target date of 01/08/23. Interventions to the care plan included: Use principles of infection control and universal/standard precautions. Use least restrictive isolation to prevent resident from experiencing mood distress. Follow facility's Infection Control policies/procedures when cleaning/disinfecting room, handling soiled and/or contaminated linen, disinfecting equipment, etc. A progress note, dated 12/07/22 at 11:47 AM, documented, Resident tested positive for COVID 19 today . MD and family notified .Resident moved to the covid unit in order to avoid further spread of virus. On 12/14/22 at 12:50 PM Staff L, CNA was observed in resident's room seated next to the resident's bed and assisting the resident with eating in the manner of physically feeding the resident. It was noted that Staff L was not wearing a gown, gloves, or face shield/goggles. When Staff L was asked of his awareness of Resident #50 being on contact and droplet precautions due to being confirmed positive for COVID 19, Staff L stated that he was aware. When asked why he was not wearing appropriate Personal Protective Equipment, Staff L stated that he just 'did not think about it.'. Based on observations, interviews, and record review the facility failed to have a facility-wide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 29 of 30 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Infection Prevention and Control Program (IPCP) that is current and reviewed at least annually. The facility failed to use appropriate hand hygiene practices when providing catheter care for 1 resident sampled for catheter care (Resident #64) and failed to appropriately use Personal Protective Equipment (PPE) while providing feeding assistance to a resident on isolation precautions for 1 resident sampled for isolation precautions (Resident #50). Residents Affected - Some The findings included: Review of the facility's policy titled Infection Prevention and Control Program with a revised date of October 2018 included the following: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and in an integral part of the quality assurance and performance improvement program. The infection prevention and control program are coordinated and overseen by an infection prevention specialist (Infection Preventionist). Review of the facility's undated policy titled Hand Hygiene included: When to wash hands or use alcohol-based hand rub - before applying and after removing gloves. 1 During an interview conducted on 12/15/22 at 7:20 AM with Director of Nursing/Infection Control Preventionist/Registered Nurse, when asked for a copy of their facility-wide Infection Prevention and Control Policy (IPCP), she provided the facility policy titled Infection Prevention and Control Program with a revised date of October 2018 (There was no reviewed dates). During an interview conducted on 12/15/22 at 1:30 PM with the Administrator, when asked about the facility's facility-wide Infection Control Policy with a revised date of October 2018, she said the policy should have been reviewed since then. 2) During an observation of urinary catheter care on 12/14/22 at 9:30 AM with Staff I Certified Nursing Assistant (CNA), while providing care for Resident #64 Staff I - CNA removed her gloves a total of 5 times and only washed her hands 1 time after removing her gloves, Staff I also touched her shirt with her right hand before putting on a new pair of gloves. The remaining 4 other times she removed her gloves and failed to wash or use any hand sanitizer and then proceeded to put on a new pair of gloves. Staff I was observed each time after putting on a new pair of gloves, she touched various items (blanket, privacy curtain, over-the-bed table, bed control) before touching the resident. During an interview conducted on 12/14/22 at 9:48 AM, Staff I was asked how long she has worked for the facility, she replied 4 years. When asked about washing hands or using hand sanitizer in between removing gloves and putting on new gloves, Staff I stated: washed my hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 30 of 30

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Citations

16 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Epotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0561GeneralS&S Dpotential for harm
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
0584GeneralS&S Epotential for harm
F584 - Safe Environment
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.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0679GeneralS&S Dpotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
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.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0800GeneralS&S Dpotential for harm
F800 - Food and nutrition services
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0805GeneralS&S Epotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0867GeneralS&S Epotential for harm
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0808GeneralS&S Epotential for harm
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

FAQ · About this visit

Common questions about this visit

What happened during the December 15, 2022 survey of BROOKWOOD GARDENS REHABILITATION AND NURSING CENTE?

This was a inspection survey of BROOKWOOD GARDENS REHABILITATION AND NURSING CENTE on December 15, 2022. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BROOKWOOD GARDENS REHABILITATION AND NURSING CENTE on December 15, 2022?

Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·December 15, 2022