Health inspection·October 7, 2021

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few showed his BIMS score was 13, indicating he is cognitively intact. His MDS assessment also indicated his diagnoses included Bipolar Disorder and Psychotic Disorder and he had received an antipsychotic medication for all 7 days of the 7 day look back assessment period. Review of Resident #33's physician orders showed he received Seroquel from 03/06/20 through 04/24/20 for mood, 04/24/20 through 05/11/20 for psychosis, and from 09/21/20 through 06/09/21 for psychosis. He has been receiving Depakote for mood stabilization with an increase in dosage on 10/5/21. Other orders included: -Psych consult: increased yelling behaviors. Active 09/29/21 -Monitor and document behavior concerns using codes provided Behavior (beh) code: 0 no behavior 1 Fear/panic 2 Anger 3 Scream/yell 4 Danger/self/others 5 Delusions 6 Hallucinations 7 Sad/tearful 8 Emotion/Act Withdrawal 9 refusing care; Interventions: 1 Redirect 2-1on1 3 Ambulate 4 Activity 5 Return to room [ROOM NUMBER] Toilet 7 Give food 8 Give fluids 9 Change position 10 Encourage to rest 11 Back rub 12-PRN med (medication); Outcome: I-Improved S-Same W-Worse Side Effects: 0-None 1-EPS 2-Tard Dys 3-Hypotension 4-Inc beh. As needed related to BIPOLAR DISORDER, UNSPECIFIED (F31.9) Active 09/22/21 -Monitor and document behavior concerns using codes provided Behavior code: 0 no behavior 1 Fear/panic 2 Anger 3 Scream/yell 4 Danger/self/others 5 Delusions 6 Hallucinations 7 Sad/tearful 8 Emotion/Act Withdrawal 9 refusing care Interventions: 1 Redirect 2-1on1 3 Ambulate 4 Activity 5 Return to room [ROOM NUMBER] Toilet 7 Give food 8 Give fluids 9 Change position 10 Encourage to rest 11 Back rub 12-PRN med Outcome: I-Improved S-Same W-Worse Side Effects: 0-None 1-EPS 2-Tard Dys 3-Hypotension 4-Inc beh every shift for Psychotropic Medication use (lamictal seroquel) seroquel depakote Other Discontinued 06/09/21 -Psych consult iwth [Psychiatrist] for anger issues and cursing at caregivers. active 06/03/21, discontinued 08/24/21 -Psych consult and psychologist evaluation for depression active 05/11/20, discontinued 06/03/20 -Psych consult DX: Agitations / Yelling active 02/27/20, discontinued 05/27/20 Review of Resident #33's progress notes included: -10/05/21 at 17:22 hours (5:22 PM) - Behavior Note by the Psychiatrist included: Interval History: Re-evaluated today on the request of Nursing. It is reported that the patient has been yelling and screaming for no reason, and has been verbally abusive. Patient told me that he has been yelling and screaming because he does not get the help he needs at the time that he needs it, stated that it takes too long for staff to come to his bedside when he rings the cord bell. He stated that he has been frustrated. He stated Look at me , a Doctor, it is not a happy ending, I'm paralyzed, my children or grand children don't visit me, I'm all alone, the Depakote helps me Problem Pertinent Review of Symptoms / Associated Signs and Symptoms: Feelings of anxiety are denied. He specifically denies manic symptoms. No hallucinations, delusions, or other symptoms of psychotic process (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 2 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 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 0644 are reported. Level of Harm - Minimal harm or potential for actual harm Exam: [Resident #33] presents as calm, attentive, communicative, disheveled, normal weight, but looks unhappy. He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood presents as normal with no signs of either depression or mood elevation. Affect is appropriate, full range, and congruent with mood. A paranoid manner and other signs of paranoid process are present. Disorganized behavior has been observed. Suicidal ideas or intent are denied. Homicidal ideas or intentions are denied. Cognitive functioning was not formally tested today but appears clinically to be unchanged from previous examinations. Insight into problems appears fair. Judgment appears fair. A short attention span is evident. [Resident #33]'s behavior in the session was cooperative and attentive with no gross behavioral abnormalities. Residents Affected - Few Diagnoses: The following Diagnoses are based on currently available information and may change as additional information becomes available. Bipolar disorder, current episode depressed, severe, without psychotic features, F31.4 (ICD-10) (Active) Therapy Content/Clinical Summary: This session the patient's focus was on feelings of frustration. Coping with feelings of dependency was also discussed. Interpersonal problems were also discussed by the patient. Instructions / Recommendations / Plan: 1) Increase Depakote to 500mg bid and 250mg at 2PM for Mood 2) Will monitor for response and side effects Return 1 month, or earlier if needed. -10/05/21 at 14:15 (2:15 PM) COMMUNICATION - with Resident Note Text: NHA [Nursing Home Administrator] approached room after hearing resident yelling nurse, nurse. When NHA came to room, nurse and two CNAs [Certified Nursing Assistants] were in room caring for the resident. NHA asked resident why he was yelling when staff was in the room helping him. Resident stated, State [AHCA] is here, so I will yell as much as I want. NHA asked resident if he had any concerns or needed any care. Resident stated that he does not need anything and has no concerns. -10/05/21 at 10:23 AM, Behavior Note by Nursing Note Text: staff reporting while giving care to resident today he told them he is a professional and has the right to tell lies He also reported he has the right to throw his diaper at people if he wants to. Resident seen by MD yesterday, will continue to monitor him for behaviors. -8/29/2021 23:26 Health Status Note: Note Text: Resident is using inappropriate language to CNA while receiving care. -6/7/2021 at 09:48 AM, Behavior Note [Psychiatrist] included: Interval History: Re-evaluated for increased agitation and aggressive behavior. Patient denied having been aggressive but impulsive during exam. Problem Pertinent Review of Symptoms / Associated Signs and Symptoms: [Resident #33] denies any problems associated with anger. Feelings of anxiety are denied. He describes no depressive symptoms. He describes no symptoms of mania. No hallucinations, delusions, or other symptoms of psychotic process are reported. Exam: [Resident #33] presents as irritable, inattentive, minimally communicative, casually groomed, hostile, and looks unhappy. but tense. Mood lability has been observed. His affect is congruent with mood. Disorganized behavior has been observed. Insight into problems appears to be poor. Judgment appears to be poor. A short attention span is eivdent. [Resident #33] displayed oppositional behavior during the examination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 3 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Diagnoses: The following Diagnoses are based on currently available information and may change as additional information becomes available. Bipolar disorder, current episode depressed, severe, without psychotic features, F31.4 (ICD-10) (Active) Therapy Content/Clinical Summary: This session the patient's focus was on feelings of frustration. Coping with feelings of dependency was also discussed. Interpersonal problems were also discussed by the patient. Instructions / Recommendations / Plan: 1) Increase Depakote to 250mg bid for Mood Stabilization. -06/02/21 Nursing Note, Note Text: Psych consult ordered with [Psychiatrist] for reports of resident exhibiting anger and making verbal derogatory remarks to CNA assigned to care for him. An interview with conducted with CNA-A, who was indicated as having been in the room during the incident described in the 10/05/21 COMMUNICATION note, at 10/06/21 on 2:14 PM. CNA-A stated she floats but is familiar with Resident #33. When asked if he has any behaviors, she stated he yells for help. There was even an incident where another resident called 911 because he was making too much noise. He requires total care. Review of Resident #33's Comprehensive Care Plans showed: -[Resident #33] has behavior problems related to yelling and rejecting care. [Resident #3] on two person assist with care related to behavior. Goals: Resident #33] will not harm themselves or others secondary to their behaviors through next review. Interventions include: Administer medications as ordered. [LPN,RN] Observe behavior episodes and attempt to determine underlying cause. [All] Psychological/psychtric consult as needed [LPN,RN,SS] Re-approach later if becomes agitated [All,CNA] Report changes in behavior status to physician/nurse [LPN,RN] An interview was conducted with the Administrator on 10/06/21 at 2:29 PM. She stated Resident #33 has not been evaluated for a Level II PASARR. 2. A review of Resident #88's clinical record was conducted beginning on 10/05/21. Observations of Resident #88 showed she resided on the locked unit and is not interviewable. She was observed both in her room and ambulating the hallways. Resident #88 was admitted to the facility on [DATE] and has diagnoses including: -Unspecified Dementia with Behavioral Disturbance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 4 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 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 0644 -Schizoaffective Disorder, Unspecified Level of Harm - Minimal harm or potential for actual harm -Unspecified Psychosis not due to a substance or known physiological condition -Major Depressive Disorder, single episode, unspecified Residents Affected - Few Review of Resident #88's physician orders showed: -Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG Give 1 capsule by mouth in the morning related to Schizoaffective Disorder, Unspecified Active 8/5/2021 -Seroquel Tablet 25 MG Give 25 mg by mouth two times a day for schizoaffective disorder Active 7/6/2021 -Remeron Tablet 15 MG Give 1 tablet by mouth at bedtime for depression Active 8/10/2020 -Monitor and document behavior concerns using codes provided Behavior code: 0 no behavior 1 Fear/panic 2 Anger 3 Scream/yell 4 Danger/self/others 5 Delusions 6 Hallucinations 7 Sad/tearful 8 Emotion/Act Withdrawal 9 other(describe) Interventions: 1 Redirect 2-1on1 3 Ambulate 4 Activity 5 Return to room [ROOM NUMBER] Toilet 7 Give food 8 Give fluids 9 Change position 10 Encourage to rest 11 Back rub 12-PRN med Outcome: I-Improved S-Same W-Worse Side Effects: 0-None 1-EPS 2-Tard Dys 3-Hypotension 4-Inc beh as needed for behavior monitoring Remeron - Seroquel - Depakote Active 9/27/2021 Record review showed Resident #88 is followed by a Psychiatrist. Review of Resident #88's admission PASARR, dated 03/28/18 from the discharging hosptial, showed no mental health diagnoses were indicated. Section II did not indicate any behaviors. An interview was conducted with the Administrator on 10/6/21 at 2:29 PM. She stated a request for a Level II evaluation has not been made for Resident #88. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 5 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure timely assessment, treatment, and notification to the physician and resident representative of a new skin impairment for 2 of 3 sampled residents reviewed for skin issues (Residents #18 and #65). Residents Affected - Few The findings included: 1. Review of the record revealed Resident #18 was admitted to the facility on [DATE] and moved to her current room on 08/04/20. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #18 had a Brief Interview for Mental Status (BIMS) score of 7, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. During an observation on 10/04/21 at 11:16 AM, Resident #18 was sitting up in her wheelchair at bedside. A gauze boarder dressing dated 09/29/21 was noted to the resident's left outer lower leg. When asked about the area, Resident #18 was unable to recall what happened. During a subsequent observation on 10/05/21 at 11:27 AM, the same gauze dressing dated 09/29/21 remained on the resident's left leg. On 10/06/21 at 9:39 AM, a new dressing dated 10/05/21 was noted at the same location on Resident #18's left leg. Review of the current physician orders, the treatment administration record (TAR) for September 2021, the progress notes, and the assessments, lacked any documented evidence of any skin impairment to the left lower leg as of the date on the gauze dressing, 09/29/21. Further review of the progress notes revealed a note by the Wound Care Nurse dated 10/05/21 at 12:24 PM, that documented she observed a skin tear to the resident's left leg, with a small amount of drainage, and a beefy red wound bed. The note documented the Wound Care Nurse called the physician, received a telephone order for treatment to the skin tear, and notified the resident's representative. Review of the current care plans for Resident #18 documented, as of 03/31/20, with the most current revision on 07/25/21, that Resident #18 was at risk for an alteration in skin integrity related to immobility and the use of blood thinning medications. One of the interventions was to observe for signs and symptoms of alteration in skin and report. During an interview on 10/06/21 at 11:24 AM, the Wound Care Nurse was asked how she identified the skin tear on the left lower leg of Resident #18 on 10/05/21. The Wound Care Nurse stated it was brought to her attention by one of the corporate nurses, that she was not aware of the skin tear previously, and agreed the date on the gauze dressing she removed was 09/29/21. When asked the process if a nurse identifies a new area of skin impairment, the Wound Care Nurse explained the nurse should notify the physician for an order, notify the family, and complete a change in condition assessment or progress note. The Wound Care Nurse stated she would also expect the nurse to either notify her directly of the new area or through a supervisor, so that she can do weekly measurements and follow the progress. The Wound Care Nurse also explained the standard protocol for a skin tear would be to provide a physician ordered treatment three times weekly, unless the skin tear was really bad. The Wound Care Nurse was asked to provide any written protocol or policy related to identification of a new skin impairment or any related to skin tears. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 6 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a subsequent interview on 10/06/21 at 1:51 PM, the Wound Care Nurse stated there was no written policy or protocol as requested. Final review of the record revealed the order, dated 10/05/21, for the skilled nurse to cleanse the left lower leg with normal saline, pat dry, apply adeptic (a non-adherent mess-like dressing), then calcium alginate with silver, and cover with a dry dressing, three times a week. The skin grid form, dated 10/05/21 and completed by the Wound Care Nurse, documented the skin tear was 2 centimeters (cm) long by 2 cm wide by 0.3 cm deep. 2. Review of the record revealed Resident #65 was admitted to the facility on [DATE]. Review of the current Annual MDS assessment documented the resident had a BIMS score of 7, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. During an observation on 10/05/21 at 12:05 PM, a gauze boarder dressing, that was peeling off around the edges, was noted on the right forearm of Resident #65. The gauze dressing was dated 09/08/21. During a subsequent observation on 10/06/21 at approximately 9:20 AM, the same gauze dressing dated 09/08/21 was noted on the right forearm of Resident #65. During an interview on 10/06/21 at 10:43 AM, Staff B, the Registered Nurse (RN) assigned to care for Resident #65, stated she was not aware of any skin impairment for the resident. The RN was also asked about the facility process for weekly skin checks, and Staff B explained the computer prompts the nurse when the weekly skin check is due for each resident, and then the nurse is to do a head to toe skin assessment and document the findings on the weekly skin evaluation form in the computer. When asked the process if she would identify a new area of concern, Staff B stated she would put in a Risk Management note into the computer, call the physician and the family, and would notify the Wound Care Nurse. When asked if there was any Risk Management note in the computer for Resident #65 for the past month, the RN reviewed the electronic record and stated there was not. During the continued interview on 10/06/21 at 10:48 AM, the surveyor asked to do an observation of Resident #65 with the nurse. Staff B confirmed the dressing on the right forearm of Resident #65, and agreed with the date of 09/08/21. The RN removed the dressing and noted a dried scab approximately 0.5 cm long. The Regional Nurse arrived in the room, observed the area and stated, Oh, It's a pinpoint area. The surveyor questioned her as to the size, and the Regional Nurse did not comment. During an observation on 10/06/21 at 2:13 PM, the Wound Care Nurse observed the area on the right forearm of Resident #65 with the surveyor. A 2 cm healed skin tear was noted, with a 0.5 cm dried scab. Review of the weekly skin assessments documented on 08/31/21 that the resident's skin was intact, and then lacked a weekly skin assessment for two consecutive weeks. The weekly skin assessment dated [DATE] documented the resident's skin was impaired with documented skin tears to her left and right lower legs but none to the right arm, and then documented on 09/28/21 that the resident's skin was intact. Review of the current physician orders documented as of 03/31/21, to complete weekly skin check evaluations every evening shift on Tuesday. The current orders lacked any treatment order for the resident's right forearm. Review of the September 2021 treatment administration record (TAR) lacked any documented care to the resident's right forearm. This TAR documented all weekly skin evaluations were completed, as evidenced by a checkmark, but two corresponding weekly skin assessments on 09/07/21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 7 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 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 0684 and 09/14/21 were not completed. Level of Harm - Minimal harm or potential for actual harm Review of the current care plans, initiated on 09/27/18 and revised on 09/10/21, revealed Resident #65 was at risk for an alteration in skin integrity related to impaired mobility and incontinence, and a history of pressure injury. Interventions included to observe for signs and symptoms of alteration in skin and report, and to do skin checks as per facility protocol. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 8 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 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, record review and policy review, the facility failed to ensure the provision of pain medications for 1 of 2 sampled residents, Resident #63, reviewed with complaints of poor pain management. Residents Affected - Few The findings included: Review of the policy Medication Shortages/Unavailable Medications effective 12/01/07, with the most current revision dated 01/01/13 documented, Procedure: 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. This policy described what the nurse should do depending upon the time of day the inadequate supply was identified, including the use of the Emergency Medication Supply, an emergency delivery, or use of a back-up third party pharmacy. The policy further described should a medication not be available by any method the physician should be notified. The policy further documented, 8. When a missed dose is unavoidable, facility nurse should document the missed dose and the explanation for such missed dose on the MAR (Medication Administration Record) and in the nurse's notes per facility policy. Such documentation should include the following information: 8.1 A description of the circumstances of the medication shortage; 8.2 A description of pharmacy's response upon notification; and 8.3 Action(s) taken. This policy lacked any specific information related to controlled medications and the facility lacked any other policy related to unavailable controlled medications. During an interview on 10/05/21 at 9:09 AM, Resident #63 voiced concerns related to not receiving her pain medications as ordered, stating the staff had blamed it on the pharmacy. Review of the record revealed Resident #63 was admitted to the facility on [DATE]. Review of the current admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS also documented current diagnoses to include cancer and chronic pain, which the resident rated as frequent pain at a 5, on a 0 to 10 scale. Current physician orders included a Fentanyl patch of 75 mcg/hr (micrograms/hour) to be applied to the skin every three days. Review of the Medication Administration Records for Resident #63, since her admission date of 08/25/21 through 10/06/21, revealed the following: On 08/26/21 and 09/13/21, the Fentanyl patch was not administered as indicated by a 9 documented on the MAR. The nine indicated to refer to the progress notes, which lacked any documented reason for the lack of administration. On 09/19/21, the MAR was left blank for the administration of the Fentanyl patch and the progress notes lacked any documented reason for the lack of administration. On 09/22/21, the MAR documented 9 indicating the Fentanyl patch was not administered. The corresponding progress note simply documented, on order. On 09/28/21, the MAR documented 9 indicating the Fentanyl patch was not administered. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 9 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 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 corresponding progress note at 8:30 PM documented in route from pharmacy. The record lacked any documented evidence of the receipt of the patch or the provision of the Fentanyl patch. During an interview on 10/07/21 at 1:52 PM, the Director of Education, who was the interim Clinical Director at the time of survey entrance, was made aware of the failure to provide the Fentanyl pain patch as ordered. During a side-by-side review of the MARs and progress notes for Resident #63, the Director of Education agreed with the findings and had no explanation for the failure. During an interview on 10/07/21 at 3:15 PM, Staff G, a Registered Nurse (RN), one of the nurses who failed to administer the Fentanyl patch, stated the issue was getting a prescription from the physician, in order to get an authorization from pharmacy, to get it out of the emergency supply. Review of the Omni Inventory, (the medication storage and dispensing system used by the facility), revealed the facility had three 75 mg (milligram) Fentanyl patches available at the time of the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 10 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to provide evidence that annual competency evaluations were conducted for 4 of 4 sampled certified nursing assistants (CNAs), CNA-1, CNA-2, CNA-3, and CNA-4. Residents Affected - Few The findings included: The facility's employees list was reviewed and four CNAs who have been employed with the facility for over a year were reviewed. CNA-1, CNA-2, CNA-3 and CNA-4's files were included in the review. CNA-1 had a hire date of 09/29/2018. CNA-2 had a hire date of 11/13/1995. CNA-3 had a hire date of 09/25/2000. CNA-4 had a hire date of 03/03/1993. A request was made on 10/06/21 to review the last annual competency evaluations for the four sampled CNAs, CNA-1, CNA-2, CNA-3 and CNA-4. On 10/07/21, the facility provided packets of tests completed by the sampled CNAs involving topics such as Abuse/Neglect and Emergency Preparedness. The facility did not provide evidence of annual job specific skills evaluations. An interview was conducted with the Director of Education on 10/07/21 at 3:14 PM. She stated the facility does not have a policy regarding conducting annual competency evaluations. She explained a performance evaluation is completed upon hire and additional training is provided if needed based on observations. An interview was conducted with the Regional Registered Nurse on 10/07/21 at 3:25 PM. The Regional Registered Nurse provided copies of general annual job evaluations but was unable to provide evidence of skills evaluations. She stated the facility was conducting annual competency evaluations but stopped. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 11 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility failed to properly store medications for 1 random observation (Resident #2); and failed to dispose of expired medications in 3 of 4 medication storage areas, Carts #1 and #2 on the 200 Wing. The findings included: 1. A review of the facility policy, Nursing- Medications, storage of, dated 10/14 and revised 12/20, documented medications should not be kept at bedside. A interview was conducted with Resident #2 on 10/04/21 at 10:00 AM. A medicine cup containing 5 pills and another medicine cup with 30 milliliters of fluid were observed on Resident #2's bedside table. Resident #2 stated they were her medications, and she was supposed to take them. An interview was conducted with the Unit Manager (UM), a Registered Nurse, on 10/04/21 at 10:05 AM, at Resident #2's bedside. The UM stated she left the resident's medication at bedside because the resident wasn't ready to take the medications. The UM then proceeded to administer Resident #2 the medications. 2. Review of the policy, titled Palm Garden Nursing Storage of Medications: Effective Date October 2014, Revision Date December 2020, revealed: The purpose of this procedure is to ensure the medications are stored in a safe, secure, and orderly manner. General Guidelines #3: No discontinued, outdated, or deteriorated medication are available for use in this facility. All such medications are destroyed. On 10/05/2021 at 9:50 AM, during a medication pass observation with Staff B, (a Registered Nurse / RN), a Wixela inhaler ordered to be administered twice a day was removed from Cart-#1 on Wing 200, for administration to Resident #15. Staff B noted the medication was labelled expired on 09/23/21 (photographic evidence obtained). Staff B stated expired medications are not supposed to be on the cart. There was no replacement of the Wixela inhaler found on the cart. When asked if Resident #15 has been receiving her scheduled doses of Wixela, Staff B stated yes. On 10/05/21 at 1:00 PM, during the medication Cart-#2 review on Wing 200 with Staff C, (a Licensed Practical Nurse / LPN), the following expired medications were found in the cart (photographic evidence obtained): Levemir Insulin, labelled expired on 09/23/21 for Resident #95; Humulin R Insulin, labelled expired on 09/30/21 for Resident #95; and Latanoprost Eye Drops, expired on 09/3/21 for Resident #25. Staff C verified the medications were expired and no replacements were found in the cart. When asked if Resident #95 has been receiving his scheduled doses of Levemir and Humulin R Insulin, Staff C stated yes. When asked if Resident #25 has been receiving his scheduled doses of Latanoprost Eye Drops, Staff C stated yes. On 10/05/21 at 13:18 PM, the Regional Director of Clinical Services RN (Staff D) stated that the medication carts are checked every Friday for outdated medications and that expired medications are not to be in the medication carts. On 10/05/21 at 3:15 PM, during an inspection of the medication storage room with Staff E, (RN), an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 12 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm expired insulin injection pen and an unlabeled open vial of sterile water for injection was found in a drawer containing sterile intravenous tubing packs (photographic evidence obtained). Staff E verified the expired medication findings and stated they should not be there. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 13 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dental services for 1 of 1 sampled resident, Resident #63. Residents Affected - Few The findings included: Review of the record revealed Resident #63 was admitted to the facility on [DATE]. Review of the current admission Minimum Data Set (MDS) assessment, dated 09/01/21, documented Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same assessment documented Resident #63 had broken natural teeth. A current care plan, dated 08/31/21, documented Resident #63 had unavoidable weight loss related to cancer. This care plan also documented the resident's diet was mechanically altered in texture to ease in chewing. During an observation and interview on 10/05/21 at 10:05 AM, when asked about any dental needs, Resident #63 stated and revealed she had all broken teeth, due to her multiple chemotherapy and radiation treatments. The resident explained in the past (prior to admission) she couldn't afford any treatment or afford to have them pulled out. When asked if anyone from the facility had addressed her broken teeth or dental services with her, Resident #63 stated they had not. The resident further explained that because of her broken teeth she has to have ground up food (a mechanically altered diet). During an interview on 10/07/21 at 12:34 PM, the Social Services Assistant, explained she started in this department on 08/13/21. The Social Services Assistant explained the Social Services Director had just quit. When asked about dental services, the assistant stated the only dental service visit since she started was this past Tuesday, 10/05/21. When asked when the previous dental services were provided, the SSD stated in June of 2021, but was unsure why. The assistant explained she had called their dental service representative recently to get services re-started. The assistant explained the dentist would usually come once a month, but was also available as needed. When asked if Resident #63 was seen during the 10/05/21 visit by the dentist, the assistant stated she was not, but she could be put on the list and seen next week, as the dentist would be returning to see a couple of residents he had missed this week. When asked if she was aware that Resident #63 had broken teeth, she stated she was not. When asked if the resident could be seen by this dental service with her Medicaid pending status, the assistant stated she could be. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 14 of 15 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 105607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of West Palm Beach 300 Executive Center Drive West Palm Beach, FL 33401 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 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 interview and facility menu review, the facility failed to provide an alternative menu for 5 of 5 sampled residents reviewed for food, Residents # 12, 57, 29, 103, and 364. Residents Affected - Few The findings included: 1. An interview was conducted with Resident #12 on 10/05/21 at 10:00 AM. Resident #12 stated he had an issue with the facility's menu not having a variety. The resident stated he has no say in the selection of his meals. The surveyor asked Resident #12 if the facility had an alternative menu to select from. Resident #12 replied there was no alternative menu, but he could order a grilled cheese sandwich or a chef salad if he did not want what was on his tray. 2. An interview was conducted with Resident #57 (Resident #12's roommate) on 10/05/21 at 10:10 AM. Resident #57 stated if he did not like a meal that was sent, he would order a chef salad. Resident #57 stated he was not aware of an alternative menu, but knew he could order a chef salad. An interview was conducted with the registered dietician (RD) on 10/07/21 at 11:00 AM. The RD stated the facility did have an alternative menu. The RD stated she had a copy of the menu in her office. The RD further confirmed the alternative menu was not posted anywhere where the residents could view it. The RD provided a copy of the A La Carte menu that listed: baked chicken, chef salad, ham and cheese sandwich, turkey sandwich, fruit plate with cottage cheese, and grilled cheese. 3. On 10/04/21 at 12:47 PM, interview with Resident #29 revealed he did not like the food that he received, which was pork, for lunch. He said after he told them he did not eat pork, Resident 29, during the lunch observation, expressed that he did not like the foods that he was offered and he did not did not see anything on the menu that he would like to eat. The resident had wanted Glucerna. 4. On 10/04/21 at 4:17 PM, during an interview with Resident #103, the resident expressed, 'it would be nice if she had a menu to choose my meals.' 5. On 10/05/21 at 11:22 AM, during an interview with Resident #364, the resident expressed being not happy with his meals, and stated, there is no variety. On 10/07/21 at 11:56 AM, an interview was conducted with the RD, who stated that its the facility practice to have the 'Ala cart menu posted at the Nurses Station'. Observation and continued interview revealed the menu was not posted at either of the nurses station. The resident expressed she did not know about the ala cart menu. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105607 If continuation sheet Page 15 of 15