Inspection·January 21, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/20/22 at 1:14 PM, observation revealed the meals tray cart delivered to the [NAME] wing. At 1:37 PM, observation revealed Resident #50 in bed and without a meal tray. At 1:37 PM, observation revealed Staff R-CNA, feeding Resident #50's roommate. An interview was conducted with Staff R-CNA. Staff-R-CNA was asked about Resident's #50's meal tray, who stated that she will feed Resident #50 when she is finished with his roommate. She stated she had been feeding his roommate for the last 15 minutes and no one had come to feed Resident #50 and the third resident in the room (Resident #70). Staff R-CNA stated Residents #50 and #70 were 'feeders'. Staff R-CNA was asked if she was supposed to call the resident feeders and stated she did not do it in front of them. On 01/21/22 at 11:37 AM, an interview was conducted with Resident #50 who stated that he was upset that he did not get his lunch at the same time as his roommate got it (meal tray). 2. Review of Resident #70's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included, in part, Peripheral Vascular Disease, Diabetes Mellitus, Protein-Calorie Malnutrition, Muscle wasting, and Contracture of Right Knee and Gangrene. Review of Resident #70 Minimum Data Set (MDS) quarterly assessment, dated 11/02/21, documented a Brief Interview of the Mental Status (BIMS) score of 13/15, indicating that the resident had intact cognition. The assessment documented under Functional Limitation that the resident needed Extensive Assistance with most of his ADL's and limited assistance with eating. Further documentation review revealed the resident had highly impaired vision. Review of Resident #70's care plan, titled, ADL; s Self-care performance deficit initiated on 10/05/19 and revised on 07/23/20, documented an intervention that read the resident needed supervision with eating and was totally dependent on the staff for dressing, personal hygiene, oral care, toilet use and transfers. Review of Resident #70's Nursing quarterly and prn (as needed) data collection, dated 12/16/21, documented the resident needed limited assistance with eating. On 01/18/22 at 1:28 PM, observation revealed Resident #70 in bed with his head under the cover sheet. Further observation revealed Staff W-CNA and Staff Q-CNA in Resident #70's room and feeding his two roommates. An inquiry was made about Resident #70's meal tray and Staff Q-CNA stated the resident ate by mouth and was a 'feeder'. Staff W-CNA also stated Resident #70 was a 'feeder'. Staff Q-CNA stated that Resident #70 was blind and will be fed after one of them is done. Unable to conduct an interview with Resident #70 because he did not speak English. On 01/18/22 at 1:40 PM, observation revealed Staff Q-CNA delivered the meal tray to Resident #70. At 1:41 PM, Staff T, a Licensed Practical Nurse (LPN), came into the resident's room and stated, Is he a feeder. On 01/20/22 at 1:14 PM, observation revealed the delivered of the west wing meals tray cart. At 1:37 PM, observation revealed Resident #70 in bed with his head under the cover sheet. Further observation revealed Staff R-CNA feeding Resident #70's roommate (Resident #50). An interview was conducted Staff R-CNA who stated that she will feed Resident #70 when she is finished with his roommate. She stated she has been feeding the roommate for the last 15 minutes and no one had come to feed Resident #70. On 01/20/22 at 1:43 PM, observation revealed Staff R-CNA delivered Resident #70's tray and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 2 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 proceeded to feed him. Staff R-CNA stated the resident was blind and did not speak English. Level of Harm - Minimal harm or potential for actual harm On 01/20/22 at 2:45 PM, a joint interview was conducted with the Director of Nursing and Staff F, Registered Nurse (RN). They both were apprised of the findings during dining observations. Staff F-RN stated they have to feed all resident in a same room at the same time. Residents Affected - Few 3. Review of the record documented that Resident #89 was re-admitted to the facility on [DATE] with the diagnoses to included: Hyperlipidemia, Hypertension, Protein-Calorie Malnutrition and Schizoaffective Disorder. Review of Section C of the Quarterly Minimum Data Set (MDS), dated [DATE], documented that Resident #89 had a Brief Interview for Mental Status (BIMS) score of 02 of 15, indicating he was severely cognitively impaired. Review of the Care Plan, dated 12/17/21, documented Resident #89 had an actual decline in ability to feed himself. Review of the Certified Nursing Assistant (CNA) Tasks for Eating Self Performance, dated 12/31/21 01/19/22, documented Resident #89 mostly required total dependence on staff. During an observation conducted on 01/18/22 at 12:55 PM, Resident #89's roommate received his lunch meal tray. It was noted that Resident #89 was awake and seated in his bed with no lunch meal tray. During an observation conducted on 01/18/22 at 1:15 PM, Resident #89 was still awake and seated in his bed with no lunch meal tray. It was noted that at this time, Resident #89's roommate had finished eating his lunch. During an interview conducted on 01/18/22 at 1:18 PM, Staff C-CNA, was asked why Resident #89 had not yet received a meal tray. Staff C-CNA stated, When you have a feeder, you leave the tray on the cart until you can feed them. During an observation conducted on 01/18/22 at 1:20 PM, the Administrator delivered Resident #89's meal tray to his room. Staff C-CNA entered the room to provide him with feeding assistance. This showed that Resident #89's lunch had not been delivered until 25 minutes after his roommate's lunch was delivered. During an observation conducted on 01/20/22 at 8:38 AM, Staff E-CNA, was in the hallway with Staff D-CNA, passing out breakfast meal trays. Staff E-CNA pointed to Resident #89's room and stated to Staff D-CNA, he's a feeder. Staff D-CNA then entered Resident #89's room to deliver his meal tray and provide him with feeding assistance. During an interview conducted on 01/20/22 at 9:02 AM, Staff E-CNA was asked about referring to residents as feeders. Staff E-CNA acknowledged that residents should not be called feeders. Review of the In-Service, titled, Supervised Dining dated 11/05/21, documented the following objective: During dining, residents are to be assisted, no feeders. Further review showed that Staff E-CNA and Staff C-CNA had not attended this in-service. Review of the In-Service titled, Resident Rights dated 11/12/21, documented the following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 3 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 objective: Serve everyone together. Further review showed that Staff E-CNA and Staff C-CNA had not attended this in-service. 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: 105572 If continuation sheet Page 4 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the record documented that Resident #54 was re-admitted to the facility on [DATE] with diagnoses that included: Weakness, Difficulty in Walking, Major Depressive Disorder and Unsteadiness on Feet. Residents Affected - Few Review of Section C of the 5-Day Minimum Data Set (MDS) dated [DATE] documented that Resident #54 had a Brief Interview for Mental Status of 13, which indicated that he was cognitively intact. Review of Section G of the 5-Day MDS dated [DATE] documented that Resident #54 required extensive assistance with two person physical assist for bed mobility. Review of the Care Plan dated 09/22/21 documented that Resident #54 had an activities of daily living self-care performance deficit related to weakness and lack of coordination. Interventions were to keep call bell within reach while in room. During an observation conducted on 01/18/22 at 12:53 PM, Resident #54's call light was on the floor underneath his privacy curtain. Resident #54 stated that he wanted help opening his cup of ice cream and stated that he could not reach his call light. He then asked the surveyor to give him his call light. During an observation conducted on 01/20/22 at 8:41 AM, Resident #54's call light was on the floor underneath his bed. Resident #54 stated that he could not reach his call light and Obviously it's not where it's supposed to be. During an interview conducted on 01/20/22 at 3:36 PM, Staff A, Licensed Practical Nurse, stated that call lights were to be placed on the resident's bed within easy reach. He further stated that he checked the placement of call lights every time he went into a resident's room. When asked what it meant for call lights to be within reach, Staff A stated, Within reach would mean in their hands. If they have an emergency, they will need it. If not, they could fall. Based on observations, interviews and record review, the facility failed to keep call bells within reach for 3 of 45 sampled residents, Resdients #106, #57 and #54. The findings included: 1.Review of the record showed that Resident #106 was admitted to the facility on [DATE] with the following diagnosis: Muscle Wasting and Atrophy in right shoulder, Lack of coordination Review of Section C of the Minimum Data Set (MDS), dated [DATE], documented Resident #106 had a Brief Interview for Mental Status (BIMS), of 09 of 15, indicating the resident had moderate cognitive impairment. Review of Section G of the MDS, dated [DATE], documented Resident #106 required extensive assistance with two-person physical assist for bed mobility. Review of the Care Plan, dated 12/27/21, documented Resident #106 had an Activities of Daily Living (ADL) self-care Performance Deficit, with intervention documented to keep the call bell within reach while in room. During observation on 01/19/22 at 3:24 PM, Resident #106 was lying in bed. The resident's call bell was observed behind the rsident hanging off the right side of bed. When asked if he could reach the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 5 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few call bell, Resident #106 shook his head no and pointed to his right arm, indicating he could not move his arm. During an observation on 01/20/22 at 8:45 AM, Resident #106 was lying in bed. The call bell was observed hanging off the right side of the bed between the chair and bed. When asked if he could reach the call bell, Resident #106 shook his head no and pointed to his right arm, indicating he could not move his arm. During an interview on 01/20/22 at 10:09 AM, Staff J, Certified Nursing Assistant (CNA), and Staff K-CNA were asked about placement of call bells for residents. Staff J-CNA replied, I place it in their good hand, or close to resident. Staff K-CAN agreed. Staff J-CNA and K-CNA were asked how often call bells are checked, both agreed call bells are checked anytime they enter the room. 2. Review of the record showed that Resident #57 was admitted to the facility on [DATE] with diagnoses to include: Hemiplegia and hemiparesis following Cerebrovascular Disease affecting left non-dominant side, Muscle Wasting and Atrophy in Left and Right Shoulders and Muscle Weakness. Review of Section C of the MDS, dated [DATE], documented Resident #57 had a BIMS, of 13 of 15, indicating the rsident was cognitively intact. Review of Section G of the MDS, dated [DATE], documented Resident #57 required extensive assistance with-one-person physical assist for Bed Mobility. Review of the Care Plan, dated 09/22/21, documented Resident #57 had ADL self-care Performance Deficit as evidence by a history of Cerebral Vascular Accident (CVA) with left Hemiplegia/Hemiparesis, Impaired mobility, and functional decline, with an intervention documented to keep call bell within reach while in room. During an observation on 01/18/22 at 10:09 AM, Resident #57 was in bed. The resident's call bell was observed on the floor underneath his wheelchair, next to his bed. Resident #57 stated he could not reach the call bell because he had a stroke and does not have enough strength. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 6 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 interviews and record review, the facility failed to provide shower assistance to 1 of 1 sampled resident (Resident #72) as indicated in the plan of care and as desired by the resident. The findings included: On 01/19/22 at 11:03 AM, Resident #72 stated she does not receive her scheduled showers despite her multiple concerns to staff, saying she had discussed this issue with everyone, but was often told the Hoyer lift did not work. Review of section G of the quarterly minimum data set (MDS), dated [DATE], and titled, Functional Status, documented that Resident #72 was totally dependent on staff and required 2+-persons extensive physical assistance for transfer, and 1-person extensive assistance for bed mobility, dressing, and physical assistance in part of her bathing. Review of the Nursing Plan of Care (CP), dated 12/28/21, revealed Resident #72 was incontinent of Bladder and Bowel; was at risk for falls or fall related injury because of Gait/balance problems; and outlined that Resident #72 was at risk or had actual limitations in range of motion as evidence by her need to wear a splint 3 hours per day and as per her tolerance level. It documented Resident #72 was able to sponge bathe herself and could transfer in and out of tub/shower but was unable to wash her back and hair. Review of the Activities of Daily Living (ADL) tasks log revealed Resident #72 was scheduled to receive a shower twice a week, every Wednesday & Saturday, between the hours of 7:00 AM -3:00 PM (day shift). The completed task document showed that the resident only received one shower a week (every Wednesday). There was no documentation or evidence that Resident #72 had refused showers on her other scheduled shower days. An interview with Staff Y, a certified nursing assistant (CNA), on 01/20/22 at 12:46 PM, revealed that she is familiar with Resident #72. Staff Y-CNA said that she usually bathed Resident #72 in bed. She said that at times the resident refused to take a shower. Staff Y-CNA said that Resident #72's shower days were on Sundays and Wednesdays, contrary to ADL shower/tasks log. Staff Y-CNA said Resident #72 occasionally refused her Sunday scheduled shower. Staff Y-CNA said she could not take the resident into the shower in the resident's room because the resident's wheelchair was too big. Staff Y-CNA also said when they tried to shower her in the main shower room, it is too difficult to reach all body parts since the resident cannot stand, so she concluded it is better to give her bed bath. Staff Y-CNA said when they take Resident #72 to the main shower room, water leaks from the Shower room into the resident's room leaving a trail of water on the floor, and it is very difficult. During an interview with the South Unit Manager (SUM), on 01/20/22 at 12:53 PM, she said that they had offered to take Resident #72 to the big shower room as her wheelchair cannot get into her personal shower room, but Resident #72 declined. The S-UM reported that the resident is bathed daily. The S-UM stated that she had observed the resident being bathe daily. The S-UM also said that they would have to get a Hoyer lift with a mesh in order to get Resident #72 to the main shower room and to prevent water spillage on the wheelchair and in the hallways. The S-UM added that she would discuss the matter with the Administrator because there are other residents who could benefit from using a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 7 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 mesh Hoyer lift. Level of Harm - Minimal harm or potential for actual harm Review of the completed ADL Care Task record revealed Resident #72 received daily baths as reported. There was no evidence that she received all scheduled showers as stipulated in the ADL task log. Residents Affected - Few Review of the grievance log, dated 05/12/21, showed that the resident was found in tears with concerns noted to a staff member that they have documented that she had refused to get out of bed to go to the shower when that was not the truth. She said that she wanted to have her showers as scheduled. The issue was then discussed and was, according to the grievance report, resolved. There was no further evidence provided as to how the issue had been resolved. A follow-up interview with Resident #72 on 01/19/22 confirmed that the issue was only resolved for a short while, but it now remains ongoing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 8 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to ensure 4 of 6 sampled residents, Resident #31, Resident #34, Resident #61, and Resident #72, or their representatives participated or were involved in their Care Plan development process. The findings included: 1. Review of the electronic census records showed that Resident #31 was admitted to the facility on [DATE]. The assessment, dated 10/29/21, document the resident's Brief Interview of Mental Status (BIMS) as 13 of 15, indicating the resident's cognition was intact. The initial minimum data set (MDS) revealed that Resident #31 was discharged and readmitted to the facility multiple times, with the last reentry on 11/16/21 but the initial MDS was completed on 10/29/21. Section G of the MDS revealed that resident #31 required extensive assistance for most activities of daily living (ADLs) including transfer and bed mobility and he was totally dependent on staff for locomotion on and off Unit. On 01/19/22 at 11:17 AM, Resident #31 stated he had not attended any care plan (CP) meetings about his care. He said that he did not meet with anyone or discussed any care needs with anyone. He also stated his therapy was discontinued and that he would like to have more sessions. Review of the Initial Care Plan (CP) completed on 12/9/21 revealed Resident #31 would receive all services encompassing nursing, activities, dietary and social services. The facility was not able to provide evidence that the resident or his legal representative participated or attended the CP meeting. The signing sheet could not be located. An interview was conducted with the Social Worker (SW) on 01/19/22 at 2:17 PM. The SW could not produce any evidence or confirmation that the resident attended the CP meeting. The SW reported that he has not yet met with Resident #31. The SW said that he was not present when Resident #37's initial CP was developed. During an interview with the Director Of Nursing on 01/19/22 at 2:03 PM, she reported that the minimum data set (MDS) Coordinator was out on sick leave, and that the records could not be immediately accessed. 2. Resident #34 was admitted to the facility on [DATE] and has remained in the facility since admission. His CP was noted to have been revised multiple times. The initial CP was completed on 02/24/21 and the subsequent quarterly reviews were completed on 05/23/21; 09/21/21, and 11/20/21. Review of the last quarterly dietary CP, dated 11/20/21, documented no food preference. On 01/18/22 at 1:56 PM, Resident #34 stated he has not attended or had a CP meeting. He said that he does not recall anyone meeting with him to discuss his care. Resident #34 stated he has had an ongoing issue with his food preference not being followed. During an interview with the Social Worker (SW) on 01/19/22 at 2:14 PM, he stated he is familiar (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 9 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the resident. The SW remarked that Resident #34 usually sits in the hallway, and he has spoken to him. He also stated Resident #34's CP was due to be updated on 01/28/22. During an interview with the DON on 01/20/22 at 10:09 AM, she stated the CP meetings are usually held with the MDS coordinator, the DON, the Activity Director and the residents and or their representatives. The DON could not, when asked, provide evidence that Resident #34 attended any CP meeting. During an interview with the MDS consultant on 01/21/22 at 10:08 AM, she stated she has been coming to this facility for nearly eleven months. She said that as consultant, she assisted in all spheres, including nursing and MDS. She confirmed she did not work with Resident #34. She was not able to provide any further information regarding Resident # 34 care planning attendance. 3. On 01/19/22 at 10:26 AM, Resident #61 stated that she had not attended or participated in a CP meeting. On 01/19/22 at 2:16 PM, the interim SW said that he has not met with the resident. On 1/19/22 at 2:03 PM, during an interview with the DON, she stated the MDS Coordinator was out on sick leave. she was going to try to access the records. Review of the CP Signing sheet provided on 01/20/22 revealed that the resident signed it, but it was not dated. During a follow-up interview with Resident #61 on 01/21/22 at 11:45 AM, she reported that she was given a CP meeting form to sign yesterday 01/20/22. She said signed it but did not date it because she did not attend the CP meeting. 4. On 01/19/22 at 11:03 AM, Resident #72 stated she has not participated in any CP meeting. She said that she has a power of attorney (POA), and that she too did not participate in any CP meeting. Resident #72 voiced concerns that her shower scheduled was not being followed. On 01/19/22 at 2:14 PM, the interim SW was asked whether he was familiar with Resident #72's care planning and replied that he was not. He said that he recently joined the company and was not present during the resident's care plan development. Review of the CP sign in sheet, dated 12/2/21, revealed that the resident had signed the document as well as the DON, the social worker, and the Activity Director. During an interview with the Resident on 01/21/22 at 11:41 AM, she stated that she did not attend the CP meeting but had received the form on 01/20/22 and had signed it. She reiterated that she did not attend the CP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 10 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to develop a communication deficit care plan and interventions for 1 of 1 sampled resident in the [NAME] wing, Resident #101, reviewed for communication. The findings included: Review of Resident #101's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident's diagnoses included, in part, Neuropathy, Dysphagia (Difficulty swallowing), Cognitive Communication Deficit, Hypertension, Diabetes Mellitus, History of Falls, Subluxation(dislocation) of Right Shoulder, and Unsteadiness on Feet. Review of the facility-provided list documented Resident #101 as a non-English speaking resident and only spoke in her foreign language. Review of the resident's Admission/readmission: Data Collection/Baseline Care Plan tool, dated 12/08/21, documented the information to complete the assessment tool was provided by the resident's representative that included: .the resident required a translator to assist with communication; primary language [documented] .the resident was at risk for falls .skin color, temperature and turgor(elasticity) was normal .risk of wound .needed assistance of 2 for transfers and bed mobility . Review of the most recent Minimum Data Set (MDS) admissions assessment, dated 12/14/21, documented that Resident #101 had clear speech, was understood and able to understand other, had no cognitive impairment. The assessment coded that the resident did not need or want an interpreter to communicate with the healthcare staff. The resident's functional status was documented as requiring expensive assistance from the staff for most of his activities of daily living (ADLs) including bed mobility, transfers, bathing, and toilet use. The assessment documented the resident was at risk of developing pressure ulcers and did not have a pressure ulcer at the time of the assessment. Further review revealed the assessment was completed with the participation of a family / significant other. Review of Resident #101's comprehensive care plans did not include a communication care plan. The resident's care plan, titled, PAIN, initiated on 12/09/21 and revised on 01/18/22, included interventions to .Observe / report to Nurse any signs or symptoms of non-verbal pain as .facial expressions- grimaces .protective body movements or postures .rubbing / massaging a body part / area. On 01/18/22, an interview was attempted with the Minimum Data Set- Clinical Reimbursement Specialist (CRS), who completed Resident #101 assessment, but she was not available. On 01/18/22 at 11:42 AM, observation revealed Resident #101 in bed in supine position and leaning over to her right side. An interview was conducted with the resident in [her language] because she stated she did not speak nor understand English. On 01/18/22 at 1:22 PM, observation revealed Staff S, a Certified Nursing Assistant (CNA), delivered Resident #101's lunch tray. She started to reposition the resident and the resident was talking to her in [her language]. Staff S-CNA was asked if she understood what the resident was saying and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 11 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 stated she did not understand / speak her language and left the room. Level of Harm - Minimal harm or potential for actual harm On 01/18/21 at 1:23 PM, observation revealed Staff T, a Licensed Practical Nurse (LPN) came in the room and started to talk to Resident #101 in English. Further observation revealed the resident stated in [in her language], what did you say. Staff T-LPN was not able to communicate in the resident's language and did not have a communication board. Staff T-LPN continued to speak English to the resident and offered coffee. Observation revealed the resident stated No and with a loud speaking tone, the resident told Staff T-LPN, I have told them many times that I don't drink coffee. Observation revealed Resident #101 raised her sheets up and down very fast, irritated, looked at Staff T-LPN and said in in her language, How many times do I have to tell you that I do not drink coffee. Observation revealed Staff T-LPN attempting to said words in the resident's language, but the resident was not able to understand her. Further observation revealed there was no communication board noted in the room. Residents Affected - Some On 01/19/22 at 10:13 AM, observation revealed Resident #101 in bed being assisted with breakfast by the Speech Therapist (ST) and the Occupational Therapist (OT). During an interview, the ST stated the resident is being evaluated because she had a visual deficit. During an interview, the ST stated she spoke a little of the resident's language. On 01/19/22 at 4:20 PM, an interview was conducted with Staff L-CNA. She stated she works day shift (7:00 AM to 3:00 PM) and does the residents' morning care, assists them with their meals, turns them every 2 hours if needed, changes their adult brief and checks their bottom every 2 hours for any skin opening. Staff L-CNA stated that today (01/19/22), it was the first time she was assigned to take care of Resident #101. Staff L-CNA was asked if she spoke the resident's language and stated she (herself) understood it a little and added that the resident understood a little English. Observation revealed Staff L-CNA asked the resident if she was hungry in English. Resident #101 responded I don't understand in her language. Observation revealed Staff L-CNA attempted to say a word in the resident's language and Resident #101 stated in her language that she did not know what she (Staff L-CNA) was saying. Staff L-CNA was asked about a communication board to help with the language communication and stated that they used that sometime, but she did not see one in her room. On 01/19/22 at 4:44 PM, a joint interview was conducted with Staff N-LPN and Staff F, a Registered Nurse (RN). Staff N-LPN stated she used the basic language of Resident #101, but the resident says dolor (pain) and never had complained pain to her. She added that the resident was on scheduled medications for pain. Staff N-LPN stated that if she was thirsty, she said agua (water) and added that they usually found someone who spoke the language. She added they had a therapist and a CNA that spoke the resident's language. Staff N-LPN stated Resident #101 did not have a [language] speaking CNA assigned to her. Observation from 01/18/22 to 01/20/22 revealed Resident #101 did not have a [language] speaking CNA assigned to her. On 01/19/22 at 4:50 PM, a side-by-side check of the resident sacrum area and right heel was conducted with Staff F-RN and the Director Of Nursing (DON). During the check, the resident was asking in [language] what are you going to do. The DON and Staff F-RN were not able to communicate with the resident in her language. Observation revealed the resident looked frightened, resisted to be turned and stated in [language], I am going to fall. They asked the surveyor to translate. Observation revealed the lack of a communication board in the resident room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 12 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 01/19/22 at 5:09 PM, during an interview, the DON and Staff F-RN were informed that Resident #101 was rubbing her stomach area while Staff L-CNA and Staff M-CNA were turning her approximately one hour ago and they did not acknowledge the resident protective body movements and were not able to communicate with the resident, and they did not have a communication board. On 01/20/22 at 10:34 AM, an interview via a telephone call was conducted with Resident #101's representative. The representative stated that Resident #101 had been at the facility for over a month and that she would be staying at the facility. He added the resident needed care that they can't provide. He helped the resident with meals because she can't see, and her appetite was poor which he told the nurses on 01/18/22. He stated he had told the nurses that he was worried that they can't communicate with her because she did not speak English and added she understand very few words in English. He added that Resident #101 gets frustrated and nervous because of the language barrier. On 01/21/22 at 7:17 AM, an interview was conducted Staff O-RN. He stated he was a fulltime employee and works the night shift. Staff O-RN was asked how he communicated with Resident #101 and assessed her pain. He stated that the resident usually sleeps all night and will not be disturbed. On 01/21/22 at 10:37 AM, an interview was conducted with Staff T-LPN. She stated that some residents had a communication book but did not know if Resident #101 had one. On 01/21/22 at 10:56 AM, an interview in the resident's language was conducted with Staff G-RN. He stated he worked in the South wing and spoke fluently [language] and when they need a translator, they will call him. Staff G-RN stated he recalled Resident #101 because she had been admitted to his wing and only spoke her language. Staff G-RN stated he was away for two weeks and was not aware if the facility had a translation service. On 01/21/22, at 2:15 PM during an interview, the DON was asked about the facility's ways to communicate with residents who did not speak English. The DON stated that they had Google translate and staff members that speak other than English like Creole and Spanish. She stated she had not heard any resident complaints regarding language barrier. The DON stated Resident #101 has now a communication package in her room. The DON was apprised of observations during staff members and Resident #101 interaction and the staff were not able to understand the resident and did not offer a communication board or use other ways to understand her. The DON was apprised that the resident was irritated and frustrated because she did not understand what they were saying. On 01/21/22 at 2:34 PM, a side-by-side review of Resident #101 care plan was conducted with the DON. The review revealed the lack of a care plan related to communication due to language barrier. 01/21/22 at 3:30 PM, an interview was conducted with the facility's contracted Clinical Reimbursement Consultant (CRC). She stated she was covering for the facility's CRS. She stated that if a communication barrier was not identified during the assessment, a communication care plan will not be initiated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 13 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide toenail grooming for 2 of 6 sampled residents reviewed for Activities of Daily Living (ADL), Residents #95 and #57. Residents Affected - Few The findings included: 1. Review of the record showed that Resident #95 was admitted to the facility on [DATE] with diagnoses that included: Abnormalities of Gait and Mobility and Type 2 Diabetes Mellitus. Review of Section C of the Minimum Data Set (MDS), dated [DATE], documented Resident #95 had a Brief Interview for Mental Status (BIMS) of 00, which indicated that the resident was severely cognitively impaired. Review of Section G of the MDS, dated [DATE], documented that Resident #95 required limited assistance with one-person physical assist for personal hygiene. Review of the Physician's Orders (POS) showed that Resident #95 had a physician order dated 12/10/20 for Podiatry services as needed. Review of the care plan, dated 12/21/21, documented that Resident #95 has an Activity of Daily Living (ADL) Self Care Performance Deficit, with intervention that included Personal Hygiene - 1 person assist. During an observation on 01/18/22 at 9:49 AM, Resident #95 was observed lying in bed. The resident said that his toenails were long, and it's been more than one month since they were trimmed. The resident removed the bedsheet and it was observed that his toenails extended past the tips of his toes. The resident was asked if he wanted them trimmed and he said sure. During an interview on 01/21/22 at 9:28 AM, Staff H, Certified Nursing Assistant (CNA), was asked who was responsible for trimming toenails. She stated, They have doctor or something like that, private people cut toenails. Staff-H was then asked what she would do if resident's toenails needed trimming. Staff H-CNA replied, We tell the nurse, verbally. Staff H-CNA stated that toenails are checked every time care is provided, including bathing and showering residents. During an interview on 01/21/22 at 9:50 AM, Staff Z, Registered Nurse (RN), stated normally, they call the doctor to trim toenails. Staff Z-RN said doctors are responsible for coming in and providing toenail care. When asked how often the residents' toenails were checked, he stated there is no time to check, only if we happen to find it, or if the resident reports it to me. When asked what he would do if a resident's toenails needed to be trimmed, he stated that he would inform Staff I, RN/Unit Manager and she would contact the doctor to come. Staff Z-RN then went into Resident #95's room with the surveyor and was asked what he thought of Resident #95 toenails. Staff Z-RN agreed that Resident #95's toenails were long and needed to be seen by the Podiatrist to have them trimmed. He further stated, if they're normal, we can do the toenails, but if it's fungal like than we can't, and he needs the doctor. During an interview on 01/21/22 at 10:02 AM, Staff I-RN stated that Podiatrist comes to the facility every Wednesday. When asked who is responsible for checking toenails, she stated that all staff were responsible and that they would report it to her or the resident's nurse. She stated that any residents that needed their toenails trimmed would have their names placed in the Podiatry Consult (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 14 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few book. Staff I-RN reviewed the Podiatry Consult book with the surveyor and stated that Resident #95 was not listed. She then stated that Resident #95 was transferred from the [NAME] Wing and he may have been in the Podiatry Consult book on that Wing. Staff I-RN also stated the Podiatrist writes their notes in the physical chart at the Nursing Station. Staff I-RN reviewed the physical chart for Resident #95 with the surveyor and stated there were no Podiatry notes for Resident #95. Staff I-RN stated she needed to check with Medical Records to see if they had any Podiatry notes for Resident #95. Review of Podiatry Consult Book, dated 06/18/21 to 01/18/22, showed Resident #95 was not listed for a consult. During an observation of the [NAME] Wing Nursing Station 01/21/22 at 10:09 AM, two surveyors were unable to locate a Podiatry Consult book on the [NAME] Wing Station. During an interview on 01/21/22 at 10:11 AM, Staff F, RN/Unit Manager (RN-UM), was asked about the location of the [NAME] Wing Podiatry Consult book. Staff F-RN-UM replied, Podiatry Consult Book? I don't think we have one. On 01/21/22 at 3:30 PM, Staff I-CNA approached the surveyors to inform them that after checking with Medical Records, there were no Podiatry notes for Resident #95. 2. Review of the record showed that Resident #57 was admitted to the facility on [DATE] with diagnoses that included: Hemiplegia and hemiparesis, Muscle Wasting and Atrophy and Muscle Weakness. Review of Section C of the MDS, dated [DATE], documented Resident #57 had a BIMS, of 13 of 15, indicating that the resident was cognitively intact. Review of Section G of the MDS, dated [DATE], documented that Resident #57 required extensive assistance with-two-person physical assist for Personal Hygiene. Review of the Physician's Orders showed that Resident #57 had an order dated 08/05/20 for Podiatry services as needed. Review of the care plan, dated 09/22/21, documented that Resident #57 had an ADL Self Care Performance Deficit with interventions that included: Assist as needed to perform ADL functions including but not limited to Personal Hygiene; Check nail length and trim and clean on bath day and as necessary; and Report any changes to the nurse. During an interview on 01/19/22 at 10:21 AM, Resident#57 stated he informed the physical therapist about his long toenails, and she told him they have the foot doctor, and they would come back for that. During an observation on 01/20/22 at 8:51AM, Resident #57's toenails were thick and past the tips of his toes to the point where they were deformed and curved. During an interview on 01/21/22 at 10:02 AM, Staff I-CNA, reviewed the Podiatry Consult book and stated that Resident #57 was not listed. She then stated that Resident #57 was also transferred from the [NAME] Wing, and he may have been in the Podiatry Consult book on that Wing. Staff I-CNA reviewed the physical chart for Resident #57 with the Surveyor, but she stated there were no Podiatry notes for Resident #57. Staff I stated she needed to check with Medical Records to see if they had any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 15 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 0677 Podiatry notes for Resident #57. Level of Harm - Minimal harm or potential for actual harm Review of Podiatry Consult Book, dated 06/18/21 to 01/18/22, showed Resident#57 was not listed for a consult. Residents Affected - Few During an observation on 01/21/22 at 11:19 AM, Resident #57 toenails were still thick and past the tips of his toes to the point where they were deformed and curved. On 01/21/22 at 3:30 PM, Staff I-CNA approached the surveyors to inform them that after checking with Medical Records, there were no Podiatry notes for Resident #57. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 16 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 record review, observations, and interviews, the facility failed to identify and prevent the development of a right heel pressure ulcer observed during care for 1 of 1 sampled resident, Resident #101, reviewed for pressure ulcer. Residents Affected - Few The findings included: Review of the facility's policy, titled, Standard-Notification of Resident/Patient Change in Condition, with no effective or revision date, documented the facility clinicians will notify the resident / resident representative immediately, if there is a crucial / significant change in the resident's condition .notify the physician if there is a significant change in condition, regardless of the time of day .document the nurses notes, the time of notification . Review of Resident #101's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident's diagnoses included, in part, Neuropathy, Dysphagia (Difficulty swallowing), Cognitive Communication Deficit, Hypertension, Diabetes Mellitus, History of Falls, Subluxation(dislocation) of Right Shoulder, and Unsteadiness on Feet. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/14/21, documented that Resident #101 had no cognitive impairment, required expensive assistance from the staff for most of his activities of daily living (ADLs) including bed mobility, transfers, bathing, and toilet use. The assessment documented the resident was at risk of developing pressure ulcers and the resident did not have a pressure ulcer at the time of the assessment. Review of Resident #101's Treatment Administration Record (TAR) for December 2021 documented treatments, dated 12/08/21 and completed on 12/15/21, as to apply skin prep wipe to heels daily very shift for 7 days for preventive measure. Notify MD (doctor) of changes. May continue if needed. Review of the resident's TAR for January 2022 lacked evidence of the administration for pressure ulcer care or preventive measures. Further review revealed no active physician orders for pressure ulcer care or wound healing supplements. Review of Resident #101's Medication Administration Record (MAR) for January 2022 lacked evidence of the administration for pressure ulcer care or preventive measures. Further review revealed no active physician orders for pressure ulcer care or wound healing supplements. Review of the resident's Admission/readmission: Data Collection / Baseline Care Plan Tool, dated 12/08/21, documented the information to complete the assessment tool was provided by the resident's representative, in part as follows: .the resident required a translator to assist with communication; primary language Spanish .the resident was at risk for falls .skin color, temperature and turgor(elasticity) was normal .risk of wound .needed assistance of 2 for transfers and bed mobility . Review of Resident #101's Certified Nursing Assistant's (CNAs) daily tasks included: float heels .monitoring: protective body movements or posture-bracing, guarding, rubbing/massaging a body part/area .skin observations . Review of the resident's CNAs bathing task from 01/08/22 to 01/18/22 documented Resident #101 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 17 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 total dependence on the CNA for that task. Level of Harm - Minimal harm or potential for actual harm Review of the resident's CNAs Turn and Reposition task from 01/08/22 to 01/18/22 documented Resident #101 was turned and reposition on every shift. Residents Affected - Few Review of the resident's CNAs skin observation task from 01/08/22 to 01/09/22 documented Resident #101 had no scratched, red area, discoloration, skin tear or open area on either shift. Review of the resident's CNAs skin observation task from 01/10/22 to 01/18/22 documented Resident #101 had red area on every shift. Review of Resident #101's Skin Check Weekly and as needed tool, dated 01/05/22 and 01/12/22, documented the resident had no new areas of skin impairment. Review of Resident #101's Skilled Evaluation tool, dated 01/09/22 and 01/10/22, documented under body system baselines that the resident was confused .not able to understand and be understood when speaking .skin warm and dry and color within normal limits .communication was verbal . urinary incontinence .wearing adult brief .was on a turn schedule; .under 'Skin Note', it was noted that the box was left blank, and no documentation was provided. Review of Resident #101's Skilled Evaluation tool, dated 01/11/22, documented under body system baselines that the resident was alert, oriented to place, person, and time communicated verbally, speech is clear, is able to understand and be understood when speaking .skin warm and dry and color within normal limits .peri care (washing the genitals and anal area) provided; .under 'Skin Note', it was documented that the skin remains intact. Review of Resident #101's Skilled Evaluation tool, dated 01/12/22, documented under body system baselines that the resident was alert, oriented to place, person, and time communicated verbally, speech is clear, is able to understand and be understood when speaking .skin warm and dry and color within normal limits .peri care provided; .under Skin Note, it was documented wound located to left buttock under treatment as ordered .general / narrative note documented .routine care by staff as ordered Review of Resident #101's Skilled Evaluation tool, dated 01/13/22, documented under body system baselines that the resident was alert, oriented to place, person, and time communicated verbally, speech is clear, is able to understand and be understood when speaking .skin warm and dry and color within normal limits .peri care provided; .under 'Skin Note', it was documented skin intact Review of Resident #101's Skilled Evaluation tool, dated 01/14/22, 01/15/22, 01/16/22, 01/17/22, 01/18/22 and 01/19/2,2 documented under body system baselines that the resident was alert, oriented to place, person, and time communicated verbally, speech is clear, is able to understand and be understood when speaking .skin warm and dry and color within normal limits .peri care provided; .under Skin Note, it was noted that the box was left blank, and no documentation was provided. Review of Resident #101's care plan, titled, WOUND RISK: The resident is at Risk of developing a wound, initiated on 12/08/2021; and revised on 01/18/2022 with a documented intervention that read, floats heels and Encourage / remind / assist to turn / reposition as needed or requested. On 01/18/22 at 11:42 AM, observation revealed Resident #101 in bed in supine position and leaning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 18 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few over to her right side. An interview was conducted with the resident in Spanish because she stated she did not speak or understand English. When asked if she had any concerns or complaints, the resident stated she was having a very bad pain in her right heel. She was asked if she told the nurse and stated she had not told anyone yet because nobody had asked and that she did not speak English to tell them. Resident #101 allowed the surveyor to look at the right heel. Observation revealed resident's heels were rubbing against the mattress, with no pillows and no heel protectors. The right heel had an approximately quarter size redness with a two centimeters necrotic tissue in the center and skin peeling off around it. The resident stated the staff did not put heel protectors on while she is in bed. During the interview, the resident was asked if she had a bed sore on her heel and stated she did not know that. On 01/18/22 at 1:13 PM, observation revealed Resident #101 in bed lying over her right side with her heels rubbing against the mattress. On 01/18/22 at 3:33 PM, observation revealed Resident #101 in bed lying over her right side with her heels rubbing against the mattress. On 01/19/22 at 8:45 AM, observation revealed Resident #101 in bed lying over her right side with her heels rubbing against the mattress. On 01/19/22 at 2:30 PM, observation revealed Resident #101 in bed lying over her right side with her heels rubbing against the mattress. On 01/19/22 at 4:16 PM, observation revealed Resident #101 in bed leaning over her right side. No heel protectors noted. On 01/19/22 at 4:20 PM, an interview was conducted with Staff L, a Certified Nursing Assistant (CNA). Staff L-CNA stated she works the day shift (7:00 AM to 3:00 PM) and does residents' morning care, assist them with their meals, turns them every 2 hours if needed, changes their adult brief and checks their bottom every 2 hours for any skin opening. Staff L-CNA stated that today (01/19/22), it was the first time she was assigned to take care of Resident #101. Staff L_CNA was asked if the resident had any pressure ulcer and stated she was not able to tell. Staff L-CNA stated she (herself) understood a little Spanish and added that the resident understood a little English. Observation revealed Staff L-CNA asked the resident if she was hungry in English. Resident #101 responded I don't understand in Spanish. On 01/19/22 at 4:35 PM, a side-by-side observation with Staff L-CNA and Staff M-CNA of Resident #101's skin check was conducted. The check revealed a white gauze type dressing on the resident's sacrum area dated 01/19/22. Further review revealed the resident's right heel with necrotic tissue, redness and skin peeling off around it. Staff L-CNA was asked if the resident was supposed to wear heel protectors and she stated that she was not sure. On 01/19/22 at 4:44 PM, a joint interview was conducted with Staff N, a Licensed Practical Nurse (LPN) and Staff F, a Registered Nurse (RN). Staff N-LPN was asked if she checked Resident #101's skin. She stated she did not because she did not have anything schedule related to resident, no skin assessment, no skin care to do. She added she did not have any physician orders related to her skin. She added everything they do was scheduled. Staff F-RN stated Resident #101 did not have any physician orders to do pressure ulcer care. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 19 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 Level of Harm - Minimal harm or potential for actual harm stated the resident did not have a special mattress. During this interview, Resident #101 right heel wound was shown to Staff N-LPN. Staff N-LPN placed her right hand over her mouth and opened her eyes wide. She stated she was not aware of the resident's right heel wound or of her sacrum dressing, dated 01/19/22. Staff F-RN was apprised that Resident #101's MDS assessment documented that she had a pressure reducing device in bed. Staff F-RN stated the resident did not have a special mattress. Residents Affected - Few On 01/19/22 at 4:58 PM, during the joint interview with Staff F-RN and Staff N-LPN, the Director of Nursing (DON) joined the interview. The DON stated that she was made aware of Resident #101's sacrum wound this morning (01/19/22). She was not informed of the resident's heel condition. The DON stated she communicated with the physician but has not gotten around to enter the orders in the computer. The DON stated she did the sacrum dressing this morning, stated she applied honey to the sacrum wound. Consequently, a side-by-side check of the resident's sacrum area and right heel was conducted with Staff F-RN and the DON. During the check, the resident was asking in Spanish what are you going to do? The DON and Staff F-RN were not able to communicate with the resident in Spanish. Observation revealed the resident looked frightened and stated in Spanish, I am going to fall. They asked the surveyor to translate. There was not a communication board in the resident room. On 01/19/22 at 5:09 PM, during an interview, the DON and Staff F-RN were apprised that Resident #101 complained of pain to the right heel on 01/18/22 during the surveyor's interview and right heel pressure ulcer was noted on 01/18/22. On 01/20/22 at 10:34 AM, an interview via a telephone call was conducted with Resident #101's representative. The representative stated that Resident #101 had been at the facility for over a month, and she was going to stay at the facility. He added the resident needed care that they can't provide. He helped the resident with meals because she can't see, and her appetite was poor which he told the nurses on 01/18/22. He was asked if he has seen the resident's legs being elevated on pillows or having any heel protectors and stated he had not. He stated last night (01/19/22) he was called by the facility to let him know that the resident had an injury / sore on her back and that they started treatment. He was asked if she has had bed sores before and stated that a week ago the resident complained of pain on her buttock. He added they checked her and was told that she did not have anything on her buttock. He added that on 01/19/22, they got her out of bed to a chair and she was complaining of back pain. The resident's representative stated that Resident #101 wears an adult brief a diaper, has Diabetes and Hypertension. He added that she resists to be turned because she can't see, her eyesight was bad and she is afraid that she might fall. He continued to say that the resident presses on her heel when in bed and told him that she keeps her legs bend because of pain. He stated the facility scheduled a meeting for 01/25/22. On 01/20/22 at 11:32 AM, attempt was made to interview Staff O-RN via telephone. A telephone call was made to Staff O-RN, a recorded voice message was activated, and a message was left to call back. On 01/20/22 at 12:15 PM, an interview was conducted with Staff R-CNA who stated she works the evening shift (3:00 PM to 11:00 PM). Staff R-CNA stated she checked on the residents every 2 hours, clean and change their adult brief, bathe them if needed. She stated if the resident's skin breakdown or had discoloration, she will inform the nurse right the way. She stated she had not taken care of Resident #101. On 01/20/2022 at 3:30 PM, an interview was conducted with Staff U-LPN who stated she works the evening shift and that she did not do residents skin checks and added those are done on other shifts. She stated that she did not check Resident #101's skin and was not aware of her skin breakdown / (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 20 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 wounds. Level of Harm - Minimal harm or potential for actual harm On 01/21/22 at 7:08 AM, an interview was conducted with Staff V-CNA. She stated she floats to all the facility's wings. She stated she changes the resident's adult brief every 4 hours and will report to the nurse if their skin is red or any changes on their skin color. She stated she did not recall taking care of Resident #101, it was not her assigned area. Residents Affected - Few On 01/21/22 at 7:17 AM, an interview was conducted Staff O-RN. He stated he was a fulltime employee and works the night shift (11:00 PM to 7:00 AM). Staff O-RN stated he had 37 residents assigned to him and his duties were to check on every resident, and to check the Medication Administration Records (MAR) to see if there was an order to be given / administered. He added that he administers, and documents medications and treatments provided such as wound care. He stated he currently had three residents that required wound care on his shift. He stated that he does skin assessment as assigned, and if a CNAs sees skin issues, they will come to him, and he will then assess. He stated he did not speak Spanish but understand few words. He stated Resident #101 knew a few words in English, like thank you. Staff O-RN stated that on (01/19/22) Tuesday night to Wednesday, Staff P-CNA who work the night shift, told him that she saw a wound on Resident #101's back. He added that he then cleaned the wound with normal saline solution and placed a temporary dressing. Staff O-RN stated that when the DON came on Wednesday morning, he reported to her and together they checked the wound in the back. The DON told him she would get a physician order. He was asked if he knew about the resident's right heel pressure ulcer and stated he was not notified by Staff P-CNA about the heel and that he was not aware of a heel pressure ulcer. Staff O-RN was asked regarding his documentation related to the resident's back wound findings and care provided. He replied he did not document what he saw or did for the resident on 01/19/22 and was waiting on the DON. He was asked to describe the wound appearance and stated, 'the sacrum surrounding area looked like there was something there before, skin was black and opened'. He stated at night, they don't want to disturb the residents, but anytime the CNA sees something they report it to him. He stated the wound was avoidable and that it did not happen overnight. On 01/21/22 at 10:37 AM, an interview was conducted with Staff T-LPN. She stated she works the day shift and floats through all wings. An inquiry was made regarding her medicating Resident #101 for pain on 01/18/22 at 12:23 PM. She stated the resident's son told her she was complaining of pain. Staff T-LPN added that the resident was rubbing her right thigh and pointed that the pain was at her thigh. She stated she assessed her right thigh for swelling but did not check her right heel. Staff T-LPN was apprised that Resident #101 had a pressure ulcer on her right heel. She stated she was not aware of the resident's pressure ulcer. Staff T-LPN stated that if a skin assessment popped up in the computer, she would do the whole head to toe assessment and would take the residents socks off. On 01/21/22, multiple calls were placed to Staff P-CNA assigned to Resident #101 on night shift and received no return call by the end of the survey time. On 01/21/22 at 1:28 PM, a telephone interview was conducted with Staff Q-CNA. She stated she took care of Resident #101 on 01/18/22. She stated she saw a bandage on the resident's bottom but did not see anything else. Staff Q-CNA's voice was hoarse and was unable to get more details. On 01/21/22 at 1:35 PM, an interview was conducted with the DON. She stated that Staff O-RN, when she was rounding on 01/19/22 (Wednesday) morning, informed her that Resident #101 had a wound to the sacrum area. The DON added she went into the resident's room, looked at the wound, call the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 21 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete physician, obtained an order for treatment, and provided the care / treatment. The DON stated the sacrum wound had yellow tissue at the base of the wound, no drainage, no odor, and unable to stage the wound, because of the yellow slough. The DON reported the resident right heel wound measurements were 2.0 centimeters (cm) (length) by 2.0 cm (width) and the depth was unable to determine, the wound was classified as a Deep Tissue Injury (DTI). The DON reported Resident #101's sacrum wound measurements as: 3.5 cm (length) by 4.0 cm (width) and the depth unable to determine. The DON was asked if the resident's wound was avoidable and stated she was [AGE] years old who had poor nutrition (meals average intake for most time 50 to 75%), had poor appetite, with confusion at times, and had a medical diagnosis of Diabetes Mellitus, Hypertension and Neuropathy. The DON was asked what Preventive Measures the facility had in place to prevent Resident #101's development of pressure ulcer. The DON stated the following: turning and repositioning; Physical, Occupational and Speech therapy and Med pass (liquid supplement) ordered on 12/10/21. The DON stated the resident was care planned for at risk for developing wounds on 12/08/21. Event ID: Facility ID: 105572 If continuation sheet Page 22 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to assess 1 of 1 sampled resident, Resident #368, for chest and stomach pain, as evidenced by not following the facility's set protocols; and failed to ensure that care was provided in a timely manner. Residents Affected - Few The findings included: Review of the facility's Pain Management protocol, effective October 2021, revealed the following needed to be completed: 1. Collect data on the intensity of the resident's pain. 2. Identify the current analgesic regimen 3. Analyze the reported pain severity on the current regimen. Review of the electronic clinical record revealed Resident #368 was admitted to the facility on [DATE] with diagnoses that included Adult Failure to Thrive; Unspecified Lack of Coordination; Other Idiopathic Peripheral Autonomic Neuropathy; Chronic Kidney Disease; Type 2 diabetes Mellitus; and Hypertension. The resident was admitted to the Covid unit for observation. Review of the resident's assessment documented the resident tested positive on 01/04/22, was asymptomatic and was placed on contact precautions. Section C of the MDS, dated [DATE], under Cognitive Patterns, revealed Resident #368 obtained a score of 13/15, indicating cognition was intact. He had only missed the current year by 1 year and missed the current month by 6 days. In Section G, it was noted that the resident required extensive assistance for all activities of daily living (ADLs) and he was totally dependent for Bathing requiring 2 persons physical assist. In section I, there was no evidence of a psychiatric disorder recorded. Review of the Physicians' Orders (POS) revealed that on 01/04/22, there was a physician order for 100 mg of Docusate Sodium Tablet ordered to be given by mouth two times a day for constipation. There was also an order for Dulcolax Suppository (Bisacodyl) that read, 'Insert 10 mg of Dulcolax Suppository rectally every 24 hours as needed for Constipation -Administer Daily if no results from MOM (milk of Magnesia). Active since 1/3/2022 at 23:44 PM.' On 01/19/22 at 09:55 AM, Resident #368 stated that he had to dial 911emergency twice, because he had respectively experienced chest pain and severe stomach pain. The resident said that on multiple occasions, he activated his call light, and no one came. His family member present during the interview, confirmed that her father had called her twice asking her to call the facility's main line to request for help for him. She said when no one answered the phone, she left her house and came to the facility after her father activated the National Emergency Number (911), to see what was going on. In a follow-up interveiw with the resident on 01/20/22 at 11:12 AM, he reiterated and expounded on his previous claim and stated that prior to his admission to the facility, he was hospitalized from [DATE] to 01/03/22, and was discharged back to the facility on [DATE]. He said on the night of his arrival to the facility, he had severe chest pain and had activated his call light, and no one responded to the call. After 2 hours, since no one answered, he said, he called 911. Resident #368 said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 23 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the nurse did not come to his room until after the Paramedics arrived. The resident also added that the nurse never asked him about his pain level instead and was not pleased that he had called 911. Resident #368 further stated that while the paramedics were with him assessing him, he felt better and rescinded his option to go back to the hospital because he did not want to worry his children. Resident #368 said that on January 8, 2022, he had severe stomach pain and no one came to his rescue after he activated the call light. He then called his family member to request her assistance. The daughter tried reaching the office for nearly two hours and no one answered, so he again called 911. When they arrived, they (the paramedics and the nurse) told him that it was wrong for him to call 911. He told them, 'When you feel that you are dying and no one comes to your rescue for nearly 2 hours, isn't it right to call 911.' He added that the facility's action to not answering his call light was 'criminal'. He said that he did not want to create any problems and did not file any complaint, but that no one came to speak to him or see him regarding that matter. He said as of 01/19/21, he has not yet seen a physician. Review of the Medication Administration record (MAR), dated 01/03/22 through 01/06/22, revealed that no medication was administered to the resident for pain. There was no documentation of the resident's pain scale level and no evidence that a new order was received or given by the resident's physician. Review of the Nursing Progress Notes (NPNs), dated 01/04/22 documented that Resident #368 had initiated a 911 call at 3:05:54 AM. The NPNs revealed that the emergency call was made subsequent to the resident experiencing chest pain. Review of the nursing notes revealed the nurse documented the following: 'Resident called out to EMS to be transferred out of the facility back to the hospital. The resident was evaluated and assessed for any arrhythmias or shortness of breath (SOB), none detected. The resident was informed / explained the usage of 911 when there is an emergency. Resident voiced and nodded to understanding. After responders left, Resident placed call to family member to see if he can get discharged from this facility to home or hospital. This writer (the nurse) tried making resident as comfortable as possible and tend to need in a timely manner. Will continue to monitor for any changes. Call bell and bed control within reach.' Another progress note, dated 01/08/22, documented by Staff W, a registered nurse (RN), documented the fact that Resident #368 had complained of stomach pain / constipation. The note showed that stool softener was administered, and the resident was advised to wait about half an hour for the medication to become effective. Before the expiration of the allotted time, the resident called 911 emergency for assistance. The paramedics arrived at the facility and evaluated the resident and determined that his call to emergency was not a valid one and as a result left the facility without transporting him to the hospital. During an interview on 01/20/22 at 11:20 AM with Staff X, a Licensed Practical Nurse (LPN), she said she did not questioned Resident #368 about the extent of his pain. To her knowledge, the resident did not use the call light and when she entered the room, she saw the resident's family member was in the room. She said that the resident wanted to leave the facility. She said that she had not reviewed the chart at that time, when the resident arrived at the facility. She also stated the resident voiced concerns to leave the facility. Staff X-LPN said she was working in the South Wing Unit, and that Resident #368 had complained that no one was there to care for him. She tried to get him a snack, then she gave him a cup of water and a bottle of Resource, which he drank. He did not complain of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 24 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 0697 pain thereafter. Staff X-LPN said that she reported the issue to the South Unit Manager. Level of Harm - Minimal harm or potential for actual harm During an interview with the South Unit Manager (SUM) on 01/20/22 at 10:40 AM, she confirmed that Staff X-LPN, who usually worked at night (11:PM to 7:00 AM shift), informed her the resident had called 911. The SUM said that she had spoken to Resident #368, but she did not document it. She said that she remembered telling the resident to let them know if he needed anything. The SUM stated she did not recall what the resident reported to her. She said that she did not remember the resident complaining to her about his call light not being answered. The SUM said that she is sure that she had a discussion with the resident regarding calling 911, but she did not keep any documentation of it. Residents Affected - Few The SUM also stated when residents complain of chest pain, their protocol is to send the resident out to the hospital after conducting a full assessment. She said that staff should not rely on vital signs because they do not know what is going on internally. The SUM also said that the paramedics did not leave any documents. The only documentation they would have had is if the resident was transferred to the hospital would be a transfer form. The SUM said she would ask the resident if he still had pain, inquire about the last time he had a bowel movement, assess to see if a fleet enema would be necessary since he had complained of stomach pain. After reviewing the medication administration records (MAR), she stated that she has no idea why the other medications ordered for constipation were not administered. Review of the hospital transfer / discharge information, dated 01/03/22, revealed the resident had a bowel movement at 22:06 hours (10:06 PM) and on the 01/04/22 at 12:47 hours (00:47 AM), at 14:50 hours (2:50 PM) and at 21:52 hours (9:52 PM). During an interview with the Director of Nursing (DON) on 01/20/22 at 11:26 AM, she explained the facility's protocol and policy regarding pain assessment. She reported that if the resident complains of pains, they have to notify the residents' physicians and then follow their recommendations. She said the nurses must assess the patient, the assessment would entail asking the resident if they have pain, observed for face grimacing, and whether they are clutching to body parts. The nurse must ask what the pain scale is; where is the pain; what makes it worse or better and has anything helped you in the past for that pain; and then the resident would tell them whether the pain is new or usual and provide pertinent information on how it usually is resolved. The DON stated that when she spoke to the resident on the morning of 01/04/22 at approximately 7:00 AM, the resident confirmed that he had called 911 because he was in a new environment and was anxious and wanted to go back home. the DON stated that they do not keep a log of the incoming and outgoing calls to the facility, so she could not confirm the resident's claim. The DON did confirm that the resident was admitted to the isolation unit for observation. Review of the care plan (CP) documented that Resident #368 had an ADL Self Care Performance Deficit, in which he would be able to help with some ADLs but needed physical help from staff to help complete tasks; and that staff should encourage the resident to participate at highest level and provide assistance required to complete task and document. The following was noted: -BED MOBILITY: Extensive Assist of 2 to turn and/or reposition -TRANSFER: Assist of 1 staff participation with transfers. -LOCOMOTION: Electric Wheel Chair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 25 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 0697 -PERSONAL HYGIENE: Assist of 1 Level of Harm - Minimal harm or potential for actual harm -DRESSING: Assist of 1. -EATING: set up Residents Affected - Few -TOILET USE: Assist of 2 -Toileting: Bathroom -CONSTIPATION: The resident had a potential for constipation r/t Immobility, -Effective Bowel regimen -Maintain Normal Bowel Pattern -Minimize/eliminate constipation; and Observe / report to nurse/MD PRN [as needed] for signs and symptoms of complications related to constipation: Complaints of difficulty passing stools, Abnormal grunting with passing of stools, Abdominal distension, vomiting, small loose or stools, fecal smearing, Bowel sounds, Diaphoresis, Abdomen: tenderness, guarding, and rigidity. -Administer medications as ordered. Refer to POS for current order -Review medications for side effects of constipation. Keep physician informed of any problems. -Review of the Progress notes dated 1/3/2022 to 1/8/2022 revealed Resident #368's physician was not notified regarding complaints of chest and stomach pains. Review of the January 2022 MAR revealed that the resident's pain level was not documented. The order read, 'Monitor pain every shift and record pain number on a 0-10 scale.' From 01/04/22 to 01/08/22, all staff documented a pain level of zero. After review of the policy for Pain Management and further interivew with the DON on 01/20/22 at 11:26 AM, the DON confirmed that staff did not follow the facility's protocol as stipulated in the guidelines. The record showed that stafff did not follow the protocol / policy and this was confirmed by the DON. There was no additional information provided up to the exit meeting on 01/21/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 26 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 observations, interviews, and record review, the facility failed to follow the approved menu and approved portions for 15 residents on pureed diets, which included 10 sampled residents (Resident #50, Resident #83, Resident #89, Resident #49, Resident #24, Resident #105, Resident #31, Resident #96, Resident #70, Resident #57). The census at the time of the survey was 117. The findings included: Review of the approved lunch menu for pureed diets for 01/19/22 documented that the following was to be served: #12 scoop (2.5 ounces) of pureed brown sugar coffee cake and #8 scoop (4 ounces) of pureed oatmeal. During an observation of the breakfast tray line conducted on 01/19/22 at 7:25 AM, accompanied by the Certified Dietary Manager (CDM), it was noted that pureed brown sugar coffee cake had been substituted for pureed bread. When asked about the pureed brown sugar coffee cake, Staff B-Cook, stated, I wasn't sure if I would have enough pureed cake so I substituted with pureed bread. It was further noted that a #16 scoop (2 ounces) was used to plate the pureed bread. This showed that residents on pureed diets were receiving a 2 ounce portion of pureed bread instead of a 2.5 ounce portion. The CDM acknowledged that the approved portion sizes for the pureed diets were not being followed and stated that a #12 scoop should have been used. When asked about the pureed oatmeal, Staff B-Cook stated that grits were to be served instead. When asked why grits were being served instead of the pureed oatmeal, the CDM acknowledged that the approved pureed menu was not followed and stated, I don't know why she did that. I'm packing my sh*t up and leaving. Review of the facility diet census dated 01/19/22 documented that 15 residents were on pureed diets, which included Resident #50, Resident #83, Resident #89, Resident #49, Resident #24, Resident #105, Resident #31, Resident #96, Resident #70, Resident #57. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 27 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included failure to maintain sanitary conditions and failure to maintain adequate holding temperatures. The findings included: A. During the initial tour of the kitchen conducted on 01/18/22 at 8:50 AM, accompanied by the Certified Dietary Manager (CDM), the following were noted: 1. A face shield was observed on the floor of dishwashing area. When asked, the CDM was unable to specify if the face shield was used/dirty. 2. A personal phone charging cable was observed on top of the food preparation table in the back area. 3. A sanitation bucket filled with sanitizing solution was stored next to containers of brown sugar and thickener powder. The CDM acknowledged that chemicals should not be stored on the same shelf as food products. 4. The steamer was leaking water onto the floor. The CDM stated that it must have started leaking today. 5. One light bulb in the food preparation area was out. The CDM stated that it must have gone out today. 6. One light bulb in back food preparation area was out. The CDM stated that it must have gone out today. 7. In the dry storage area, one 6.63 pound can of diced beets was dented. 8. The reach-in freezer was observed with plastic garbage (empty Gatorade bottle and plastic lids), yellow residue, and red residue. 9. In the walk-in refrigerator, about 7 boxes of food were stored directly on the floor. The CDM stated that the boxes were delivered yesterday and that he had not had a chance to put them away. 10. The floor underneath the shelving in the walk-in refrigerator was observed with plastic garbage and a moderate amount of brown residue. 11. In the walk-in freezer, about 8 boxes of food were stored directly on the floor. The CDM stated that the boxes were delivered yesterday and that he had not had a chance to put them away. 12. In the walk-in freezer, one bag of sausage patties and one bag of waffles were missing labels identifying the use by dates. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 28 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete B. During an observation of the breakfast tray line conducted on 01/19/22 at 7:25 AM, the following was noted: At the request of the surveyor, the CDM calibrated the facility's digital thermometer to check the temperature of the hardboiled eggs in the hot holding unit. The temperature test revealed that the hardboiled eggs were at 127 degrees Fahrenheit (F). The CDM acknowledged that the hardboiled eggs were not at the regulatory temperature of 135 degrees F or above. He further stated that the hardboiled eggs needed to be removed from the breakfast tray line. Event ID: Facility ID: 105572 If continuation sheet Page 29 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that the resident's written plan of care included both the most recent hospice plan of care and a description of the services furnished by the facility for 1of 1 sampled resident, reviewed for Hospice services, Resident #63. The findings included: Review of Hospice Agreement for Nursing Facility Services revealed this agreement for Nursing Facility Services (agreement) is entered into and effective as of 12/16/21, by and between Hospice and Facility for location set forth on Appendix A (Facility). Definitions: Facility Plan of Care means a written care plan established, maintained, and modified (as necessary) by Facility for each Residential Hospice Patient in accordance with applicable laws, rules, and regulations, this Agreement, and Hospice policies and procedures, and which sets forth the Facility Services that Facility has determined to be appropriate for the Residential Hospice Patient, Hospice Plan of Care means a written care plan established, maintained, and modified (as necessary) for each Hospice Patient by the applicable Interdisciplinary Team which includes an assessment of the Hospice Patient's needs, an identification of the Hospice, Services appropriate to meet the needs of the Hospice Patient and his/her family, and details concerning the scope and frequency of such Hospice Services. Facility Obligations: Facility Plan of Care for each Residential Hospice Patient, Facility will develop a Facility Plan of Care which is consistent with his/her Hospice Plan of Care. Facility will furnish Hospice a copy of each residential Hospice Patient's Facility Plan of Care. Agreement signed by Hospice General Manager on 12/20/21 and Facility Nursing Home Administrator on 12/16/21. Record review for Resident #63 revealed the resident was admitted on [DATE] with most recent readmission on [DATE] with diagnoses that included: Encounter for Palliative Care, Schizophrenia, Major Depressive Disorder, Adult Failure to Thrive, and Traumatic Subdural Hemorrhage without loss of Consciousness Sequela. The significant change minimum data set (MDS), dated [DATE], revealed in Section C the brief interview for mental status (BIMS) could not be completed due to the resident is rarely / never understood, Section O revealed while he was a resident, he was on hospice care. There was a physician order, dated 11/01/21, to admit to hospice due to failure to thrive. Review of Resident #63's care plan revealed there was no hospice care plan. Review of the progress note, dated 10/15/21, revealed spoke to resident's brother to discuss pending Hospice admission. The brother stated he is having consents mailed to him by Hospice. Social Service Director (SSD) questioned if he would be able to receive them via email, the brother laughed and said he is disabled and does not have email, then mentioned having an email account attached to his phone. SSD informed him those consents could also be sent that way and he could even sign them from his phone most times. The brother disregarded the recommendation saying he'll wait for the mail. SSD asked if he would be okay with hospice reaching out and seeing if there was anyway of facilitating the process on their end for him. He thanked the SSD and said that would be fine. SSD reached out to Hospice and asked that they please reach out as soon as possible (ASAP). SSD will continue to monitor and follow up as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 30 of 31 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 105572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pompano Health and Rehabilitation Center 51 W Sample Road Pompano Beach, FL 33064 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview conducted on 01/20/22 at 4:23 PM with the Assistant Director of Nursing (ADON), when asked if staff communicates with hospice, she stated they talk in person when the hospice nurse comes once a week, and they give report to each other. If any concerns or changes in condition the facility staff call the hospice. During an interview conducted on 01/20/22 at 4:30 PM with Staff F, Registered Nurse (RN), when asked how staff communicate to hospice a change in condition or a concern for a resident who is on hospice, she stated they call hospice or if the hospice nurse is in the facility making a visit, they inform them in person. During an interview conducted on 01/21/22 at 9:21 AM with the Clinical Reimbursement Consultant (CRC). When asked about process for minimum data set (MDS), she stated when someone comes in, they have an admission assessment and then reassessments are done after that. A significant change assessment is done when the resident is admitted to hospice or discharged from hospice. The CRC said that the care plan that would be triggered by significant change due to hospice admission would be the care plan with a focus on terminal care. Review of Resident #63's care plan with the Clinical Reimbursement Consultant revealed there was no terminal care plan now or ever. There was no integration of hospice care on the facility care plan for Resident #63. The CRC then had the Director of Nursing (DON) come in and review Resident #63 record to locate a hospice care plan or a terminal diagnosis care plan and she was unable to find any. The DON and the CRC agreed there should be a hospice care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105572 If continuation sheet Page 31 of 31