Inspection·March 1, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/29/24 at 1:59 PM, when asked the process for providing resident showers, Staff A, Certified Nursing Assistant (CNA), explained there was a written shower schedule that was also documented on the large white board (pointing to the white board at the nurses' station that documented the Nurse and CNA room assignments), and that they could also provide showers if requested by a resident. When asked if she documented the provision of a shower, the CNA explained there was a shower book and they filled out a shower sheet. The CNA was asked to locate and provide the shower schedule, shower book and documented shower sheets for the month of February 2024 for Resident #51. During a side-by-side review of the three requested items, Staff A identified Resident #51 was scheduled for showers on Tuesday, Thursday, and Saturday during the 7 AM to 3 PM shift. The CNA found evidence of showers for Resident #51 dated Tuesday 02/13/24, Wednesday 02/21/24, Thursday 02/22/24, Saturday 02/24/24, Monday 02/26/24, and Tuesday 02/27/24. The weekend supervisor found documentation for three additional showers dated Thursday 02/01/24, Saturday 02/03/24, and Tuesday 02/06/24. The weekend supervisor explained the shower sheets were in the supervisor's office as they needed to be signed off by a supervisor. The weekend supervisor also stated there may be some additional shower sheets waiting to be uploaded into the EMR. During an interview on 02/29/24 at 2:32 PM, the Medical Records person stated there was no pending documentation for Resident #51. Documentation revealed Resident #51 received only 9 of the 13 scheduled showers, or of the 29 preferred daily showers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 2 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on 1 of 2 units/floors in the facility (2nd floor secured unit). This affected Residents #67, #24, #85, #51, #79, #57, #58, #68, #40, #31, #59, #32, #91, #28). The findings included: The following observations were made during environmental tours on 02/26/24 and 02/27/24 in the secured unit on the second floor of the facility (photographic evidence obtained): room [ROOM NUMBER]B - overbed light string was off; Resident's daughter stated the string pulls off very easily. The daughter must pull on the short little string to turn the light on or off. The toilet in bathroom has debris. room [ROOM NUMBER]A - Stained privacy curtains, bedside chairs, and linens. room [ROOM NUMBER]B - Rust on bottom rail of bed; light string missing from over-bed light and lying over bedside nightstand. room [ROOM NUMBER]B - Over-the-bed table with corner in disrepair. When asked how long it had been like that, Resident # 51 stated, Oh about 3 months or so. My previous roommate broke it. The table was also very wobbly. room [ROOM NUMBER] - Red splattering on window air conditioning unit; the over-the-bed table had one corner in disrepair; privacy curtain was stained. room [ROOM NUMBER]A - IV pole and bed rail near the tube feeding pole were soiled with tube feeding contents; the mattress near the tube feeding pole was splattered with residue from tube feeding contents. room [ROOM NUMBER] - Bed A's nightstand was missing strip along top edge. The bottom cabinet door was missing its knob, and the door was hanging crooked on its hinge. The bathroom toilet tank was missing its cover. room [ROOM NUMBER]A - Over-bed table's edge is separating from the table. The bathroom wall by handrail next to toilet had brown smudge which resembled feces. room [ROOM NUMBER]A - The over-bed table is starting to bubble and separate around edges. room [ROOM NUMBER]A - Over-bed table's corner is coming apart. Toilet brush was left lying on back of toilet tank lid. room [ROOM NUMBER]B - Over-bed table is separating around edges; The bathroom has strong urine smell. The floor around the toilet was soiled. room [ROOM NUMBER]A - Over-bed table is coming apart at the corner; the top drawer's bottom edging (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 3 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 on the nightstand is starting to come off along the left side corner. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]B - The side chair's seat is stained/dirty; The over-bed table is separated around edges and the bathroom toilet seat was soiled with feces. Residents Affected - Some room [ROOM NUMBER]B - Over-bed table edges are separating, with some edges missing; The side chair was soiled/stained. An interview was conducted with Maintenance Director on 02/28/24 at 3:12 PM, he stated that Angel rounds are completed each morning and if there are any environmental concerns, they are put in the maintenance logbook at the nurse's station and maintenance staff will check the logbook periodically (every 1-2 hours). Concerns will also be brought up at the morning meetings. On 02/29/24 at 2:36 PM, a tour was conducted with the Maintenance Director. He acknowledged the concerns presented to him during the tour of the above resident rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 4 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 2 of 32 sampled residents related to oxygen use for Resident #91 and discharge status for Resident #57. Residents Affected - Few The findings included: 1) Review of the record revealed Resident #91 was admitted to the facility on [DATE], was transferred to the hospital on [DATE], and returned to the facility on [DATE]. Review of the current orders documented to keep the resident's oxygen saturation at 90% or greater as of 02/07/24. Although the orders lacked a specific order for as needed oxygen, review of the oxygen saturation levels from 02/07/24 through 02/13/24 in the vital sign section of the electronic medical record (EMR) documented oxygen use on 5 of those 7 days. Review of the current MDS assessment dated [DATE] lacked any documented oxygen use for Resident #91. Review of the corresponding care plan initiated 02/25/24 documented Resident #91 was at risk for altered respiratory status and to administer oxygen as ordered and to monitor the oxygen saturation level as needed. During an interview on 03/01/24 at approximately 1:00 PM, when asked about the lack of documented oxygen use in the current MDS assessment dated [DATE], the MDS Coordinator referred to the order to maintain the oxygen levels at 90% or greater and then referred to the February 2024 Medication Administration Record (MAR) that documented all of the oxygen saturation levels taken each of the three daily shifts were at or above 90%. The MDS Coordinator stated because the oxygen levels were at or greater than 90%, oxygen was not in use by Resident #91. The MDS Coordinator agreed there was no documentation on the MAR as to whether those oxygen levels were taken with or without oxygen. When shown the oxygen saturation levels in the vital sign section of the EMR, that documented the oxygen was used on 5 of the 7 days during the MDS 7 day look-back period, the MDS Coordinator stated he thought it was a documentation error. When asked if the vital signs were taken and documented by the licensed nurses or the certified nursing assistants, the MDS Coordinator stated it was completed by the licensed nursing staff. 2) On 02/28/24/ at 08:38 AM, a record review of the resident electronic medical recods revealed that Resident #96 was admitted to the facility on [DATE] and had a planned discharge home on [DATE]. The documentation in the resident's MDS was not accurate, as it documented that Resident #96 was transfered to the hospital. On 02/29/2024 at 8:56 AM, an interview was conducted with the MDS Coordinator. During this interview, the MDS Coordinator acknowledged the error regarding where the resident was discharged . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 5 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 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 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer 1 of 1 sampled resident for a Level II resident review, as indicated by the pre-admission screening and resident review (PASRR) Level I review completed by hospital staff (Resident #67). The findings included: Review of the record revealed Resident #67 was admitted to the facility on [DATE], transferred to the hospital on [DATE], and returned to the facility on [DATE]. Review of the PASRR Level I screen completed by the hospital on [DATE] documented by checkmark that Resident #67 had depressive disorder as documented in Section 1A, and was currently receiving services for MI (mental illness). Further review of this PASRR documented in Section II.1. there was an indication the individual had or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage. Section II. 3. A. documented the resident had received recent treatment for a mental illness with an indication of psychiatric treatment more intensive than outpatient care. Section II. 3. B. documented the resident had experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a resident treatment environment, or which resulted in interventions by housing or law enforcement officials. The directions on the PASRR Level I form documented, A Level II PASRR evaluation must be completed prior to admission if any box in Section 1.A. or 1.B. is checked and there is a 'yes' checked in Section II.1, II.2, or II.3, unless the individual meets the definition of a provisional admission or a hospital discharge exemption. Further review of this PASRR documented it was not a provisional admission. Section IV of this PASRR lacked documentation the resident may be admitted to the facility, as the section was left blank. Further review of the electronic medical record (EMR) lacked any documented Level II PASRR. Review of the current orders revealed Resident #67 was being administered Risperdal (an antipsychotic medication) every 12 hours for behavioral and psychological symptoms of dementia, Lorazepam (an antianxiety medication) twice daily for anxiety, and Benztropine (an anticholinergic antiparkinson medication used for tremors) at bedtime for extrapyramidal side effects (EPS/drug-induced movement disorders). Resident #67 was being monitored for psychotropic side effects and behaviors. A current care plan initiated on 07/29/22 and revised on 07/19/23 documented the resident had an aggressive history toward staff with multiple documented behaviors. During an interview on 02/28/24 at 11:08 AM, when asked if the PASRR Level I that was completed by the hospital on [DATE] indicated a need for a Level II, the Social Services Director (SSD) stated, I am not real familiar with the form. It is done by the Administrator or DON (Director of Nursing). During an interview on 02/29/24 at 9:43 AM, Administrator confirmed she was responsible for reviewing and completion of the PASRR forms. When asked about the Level II PASRR for Resident #67, the Administrator agreed a Level II should have been completed in January 2023, as indicated on the Level I completed by the hospital at that time. The Administrator stated it had been missed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 6 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the care plan for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #33). The findings included: Review of the record revealed Resident #33 was admitted to the facility on [DATE], transferred to the hospital on [DATE] and returned on 07/15/23. Review of the current Minimum Data Set (MDS) assessment dated [DATE] lacked any documented use of opioids (narcotic pain medications). Review of the current physician orders lacked any opioids, and indicated Tylenol was the only medication ordered for pain. Review of the current care plan initiated on 09/04/22 and revised on 02/07/23 documented Resident #33 was at risk for pain or discomfort related to (multiple diagnosis and conditions) . and oxycodone 5 milligrams being administered every eight hours as needed. This care plan also documented an intervention to administer Naloxone (a medication to reverse an opioid overdose) as needed. Further review of the record revealed the previously ordered oxycodone had been discontinued on 07/15/23. During an interview on 03/01/24 at about 1:00 PM, upon review of the current care plan related to pain management for Resident #33, the MDS Coordinator agreed the care plan had not been revised. The MDS Coordinator also agreed that the narcotic had been discontinued on 07/15/23. The MDS Coordinator had no reason for the failure to revise the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 7 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to provide an ongoing activity program based upon assessments, care plans, and personal preferences, for 2 of 2 residents who voiced concerns related to the lack of activities (Resident #51 and #9), and for 5 of 5 residents observed only in their rooms, with a lack of sensory stimulation, and or assessed as needing either one-to-one activities or friendly visits (Residents #79, #91, #37, #43, and #40). Residents Affected - Some The findings included: Review of the Activities Policy implemented 10/16/23 and revised 02/07/24 documented, 3. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include, as a minimum: . (The policy then describes multiple different types of activities provided by the facility.) This policy lacked any information for one-to-one or sensory type activities for the cognitively impaired residents. At the time of the survey, the facility lacked any written policy or procedure for one to one activities or friendly visits as documented in resident care plans. 1) Review of the record revealed Resident #51 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the Annual MDS assessment dated [DATE] documented it was very important for Resident #51 to participate in his favorite activities and to go outside. Review of a Quarterly Activity Evaluation dated 12/07/23 documented current interests for Resident #51 included books/newspapers/magazines, TV/movies, going outside, and sports. Review of the current care plan initiated on 06/02/22 and revised on 02/25/24 documented Resident #51 preferred to stay in his room watching TV/movies/news and socializing with peers/staff, and enjoys going outside when he chooses. Interventions included to provide the resident with the activity calendar, and to invite, escort, and encourage to attend activities. An additional intervention dated 06/05/23 included for staff to provide friendly visits daily for added socialization. During an interview on 02/27/24 at 11:09 AM, when asked if he participates in any of the activities at the facility, Resident #51 stated, What activities? When asked what he would like to do, the resident stated he enjoyed card games with a group. When asked if there were any card games or card groups at the facility, the resident stated he was not aware of any. An observation of the February 2024 Activity Calendar in the resident's room lacked any scheduled card games (Photographic Evidence Obtained). An observation of the February 2024 activity calendar posted in the common area of the second floor documented card games were scheduled for 02/10/24 at 11:00 AM (Photographic Evidence Obtained). During an interview on 02/29/24 at 2:10 PM, Staff E, Activity Assist assigned to the second floor, explained she had been a Certified Nursing Assistant (CNA) at the facility for about a year, and had joined the activity department about two weeks prior to the survey. Staff E confirmed she worked every other weekend, including the weekend of 02/10/24. When asked if the facility had the Card Games (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 8 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some activity on 02/10/24, Staff E stated she was not aware of any card games and had not organized any such activity. When asked what she had been doing in activities, Staff E explained she was assigned to the second floor and she had been doing the group activities. When asked if she had done any one to one activities for the residents in their rooms, Staff E stated only that she goes around and turns on the TVs about 2 PM each day. When asked specifically about Resident #51, Staff E stated when she was a CNA, she would sometimes take him outside after he ate lunch in the downstairs dining room. Staff E stated she hadn't done that for awhile. On 02/29/24 at 2:40 PM, the Activity Director, who had stated she was fairly new to the facility and was still learning the resident's names, and that she worked Monday through Friday, and her activity assistants would rotate weekends. The Activity Director was taken into the room of Resident #51. Upon arrival, Resident #51 stated he had seen that staff down in the dining room, but did not know she was part of the activity program. Resident #51 stated he only knew she was a lady who makes rounds in the dining room. When told she was the new Activity Director, Resident #51 became visibly upset and stated, If it says on that calendar that it's time for a walk or something, when I go to do it, they tell me it's canceled for whatever reason. Resident #51 stated they used to offer to take him outside after lunch, but they don't do that anymore. Resident #51 stated the new director would have to prove herself as he had lost confidence in the program. Review of the documented activities in the Tasks section of the electronic medical record (EMR) lacked any documented activities for the past 30 days, expect for four days of documented Television in Room. 2) Review of the record revealed Resident #79 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident was rarely understood and severely cognitively impaired. Review of the most current Activity assessment dated [DATE] documented Resident #79 was dependent upon staff to manage the television or radio, and would receive one to one staff visits for mental and social stimulation. Review of the current care plan initiated on 10/17/23 documented Resident #79 enjoyed watching the television, listening to music, and getting activities and family visits. An intervention included daily friendly visits for added socialization. Review of the Tasks section of the EMR for the past 30 days documented the television as the only activity on four days. Multiple observations throughout the survey and specifically on 02/26/24 at 4:23 PM, 02/28/24 at 9:42 AM, and on 03/01/24 at 10:12 AM, all revealed Resident #79 in her darkened and quiet room, in bed, with no television, radio, or any other type of sensory stimulation. 3) Review of the record revealed Resident #91 was admitted to the facility on [DATE]. Review of the current care plan initiated on 01/03/24 documented the resident was new to the facility, and enjoyed staying in room at times watching television/movies/news, going outside, enjoyed reading the Bible, surfing the web on his phone, and enjoyed attending group activities. This same care plan documented the resident preferred to pursue Independent activities and visits from family members. An additional intervention documented to provide with friendly visits daily for added socialization. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 9 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Multiple observations throughout the survey from 02/26/24 through 03/01/24 revealed Resident #91 in his room, always in bed, with no television or music playing. The resident was never observed doing anything but lying in bed with his eyes closed, except for during meals. The EMR lacked any documented evidence of any type of activity. Residents Affected - Some During an interview on 02/29/24 at 10:54 AM, the Activity Director explained she had looked through all the information in the activity department, but had not found any type of one to one resident list or book. The Activity Director stated there was documentation in the EMR for activities, but that she and her staff had not been doing any documentation. The Activity Director stated there were currently two activity aides, one assigned upstairs and one downstairs, who were responsible for both the group and individual activities. The Activity Director explained she had just made a list of residents who she had assessed as needing one to one activities for conversation or sensory stimulation, but again stated she had not been documenting the provision of activities. The Activity Director provided her one to one resident list, which did not include Resident #91. The list did include Resident #79 (example #2). During an interview on 02/29/24 at about 4:00 PM, the Medical Records person, who was the previous Activity Director, stated she did not have any type of one to one resident list or book, but stated she was told just to document the provision of activities in the EMR. The Medical Records person stated she left the activity department on 02/23/24. 7) Resident #40 was admitted to the facility on [DATE], and she is currently in Hospice. On 02/26/24 at 11:02 AM, Resident #40 was seen lying in bed on her right side. The Resident's eyes were open, but she was unresponsive to my Good Morning greeting or attempts to engage her in conversation. No music was playing in the room at this time. The television was not on. On 02/27/24 at 9:02 AM, Resident is seen with her eyes closed. She appears to be in some discomfort, showing restlessness. The nurse was notified by the surveyor of this observation. The Nurse later documented in her progress notes that the resident was very agitated and restless, and unable to verbalize needs .Orders given by hospice nurse to administer Buspar 5 mg PO [by mouth] twice a day, Lorazepam 1 mg PO every 6 hours PRN [as needed] for agitation [Name] made aware and gave consent to administer. Orders transcribed. No music was playing in the room, and the television was not on. On 02/28/24 at 9:55 AM, Resident was lying in bed on right side. Resident was resting peacefully. No music playing in her room. The television is not on. On 02/29/24 at 2:31 PM, Resident appears to be restless; she is laying uncovered in the bed. No music is playing in her room. Television is not on. A review of Resident #40's latest comprehensive Minimum Data Set (MDS) after a Significant Change (Hospice) on 06/08/23, the MDS documents under section for Activity Preferences that it very important to listen to music I like; and Somewhat important to keep up on news and have newspapers, books and magazines, and do things with groups of people. A review of the Care Plan completed on 12/28/23 documents for Activities: Resident prefers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 10 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 independent activities. Resident to receive friendly visits 3-5 times a week for added socialization. Level of Harm - Minimal harm or potential for actual harm On 02/29/24 at 10:50 AM, an interview was conducted with the Activities Director, she stated, I just started this job on the 6th of this month. My aide started on the 8th. We have been doing just basic activities to get to know the residents since starting. We have just started the 1:1 visits. There are 3 activities personnel; 2 upstairs and 1 downstairs. Residents Affected - Some On 02/29/24 at 1:15 PM, the Activities Director stated, I have done some 1:1 activities with this resident. We are trying to do hand massages with her as a calming activity. Activity Director confirmed that there was no documentation recording the days, times, and type of 1:1 activities being done with the residents requiring 1:1 visits. Interview with the previous Activity Director on 02/29/24, who is now working in Medical Records, confirmed that any documented 1:1 activity should have been documented in the electronic record under Tasks. Review of the electronic Activity Task Sheet shows no group, independent or 1:1 activities done with Resident #40 from 02/06/24 to 02/29/24, except for television on 02/15/24, 02/17/24, 02/20/24 and 02/21/24. 4) Resident #37 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and was dependent on activities of daily living. Resident #37 was care planned for memory problems due to Dementia. The resident enjoys staying in her room at times or in the lounge area watching TV/movies/news/listening to music/socializing with peers/staff, attending Ice cream socials, going outside with peers and during family visits, getting her nails done by her daughter or staff, and BINGO/Word games/Game shows especially Jeopardy. Her Representative brought her a stuffed animal, her bunny, which she loves to hold and play with throughout the day when she chooses to. Interventions included: Provide materials to utilize in room when requested, and Provide with activity calendar, invite and encourage to attend activities daily, respect wishes to decline participation. Resident #37 was observed throughout the survey 02/26/24 and 03/01/24 in bed without any activities provided. 5) Resident #43 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, and was dependent on activities of daily living. Resident #43 was care planned for none verbal and stay in his room watching TV and getting daily chronicle read to him. Interventions included: Provide with activity calendar, also get room visits 3-5 per week from activities. Resident #37 was observed throughout the survey 02/26/24 and 03/01/24 in bed without any activities provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 11 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6) On 2/26/24 at 11:00 AM, a review of the resident Electonic medical records revealed that Resident #9's Brief Interview for Mental Status (BIMS) was 08 out of 15. She was admitted to the facility on [DATE]. On 02/26/24 at 4:16 PM, the resident was observed in her room. The resident had been seen in her room most of the day. During an interview with Resident #9, she stated that she needed someone to transport her to Activities, and she was bored. The Resident's Care Plan Interventions documented: Provide materials to utilize in room when requested. The resident will be assisted to activities of choice, and verbalize satisfaction with activity plan and social interaction. On 02/28/24 at 9:20 AM, the Activities Director was asked about the activities for Resident #9. The Activities Director stated that she did not have any knowledge or documentation regarding Resident #9's participation in any specific activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 12 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 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 0698 Provide safe, appropriate dialysis care/services 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 observation, interview, and record review, the facility failed to coordinate care between the facility and dialysis for 1 of 2 residents reviewed for dialysis (Resident #29). Residents Affected - Few The findings included: 1) Resident #29 was admitted to the facility on [DATE], with diagnoses included End Stage Renal Disease. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and was receiving Hemodialysis. Resident #29 as care planned for at risk for complications related to hemodialysis. Dialysis Days: M-W-F in house. An intervention included collaborate care services with dialysis center. A review of the facility's Dialysis Resident Communication Report from 01/29/24 until 02/28/24 revealed no documentation in the Dialysis Center Staff section of the Communication Report revealed no documentation of any medicine given in dialysis, except on 02/28/24 (Wednesday), where it was documented Heparin and Micera (medicine to increase Red Blood Cells) 50 micrograms (mcg) was given. A review of Resident #29's orders revealed an order dated 02/22/24 for Micera 100 mcg at dialysis every other Wednesday. 2) Resident #29 was also care planned for at risk for alteration nutrition/hydration. Nepro 1.8 at 60ml/hr x 18 hrs (on at 6P off at 12P). This provides 1944 kcals, 87 gms pro, 785ml free H2O (plus 630ml flushes). She also receives Liquid protein supplement BID for an additional 200 kcals 30 gms pro daily for stage 4 sacrum wound. An interview was conducted with Staff Z, a Registered Nurse on 03/01/24 at 11:00 AM. Staff Z stated Resident #29 get disconnected from tube feedings prior to going to dialysis at approximately 7-8 AM on Mondays, Wednesday, and Friday. Staff Z stated the resident is not reconnected to tube feedings until 6 PM that evening. (tube feedings off for approximately 4 hours early). 3) Further record review for Resident #29 did not reveal any communication with facility Dietitian and dialysis Dietitian. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 13 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Potential for minimal harm Based on record review and interview, the facility failed to state in their admission Agreement (pg. 15, Item #26) that Arbitration is not a requirement for admission or a requirement to continue to receive care at the facility. This affects all current residents who have signed the admission agreement, 100 out of 100 residents. Residents Affected - Many The findings included: A review of the facility's 'Arbitration Agreement Program Guide' and 'Arbitration Agreement' was completed on 02/28/24. The separate 'Arbitration Agreement' and 'Arbitration Program Guide' contained all required regulatory language. However, within the admission Agreement (Agreement between the Facility and Resident/Representative) there is a paragraph on page 15 (Item #26) which states: WAIVER OF RIGHT TO JURY TRIAL. BY SIGNING THIS AGREEMENT RESIDENT AND RESPONSIBLE PARTY ARE WAIVING (A) THE RIGHT TO A JURY TRIAL FOR ANY CLAIM(S) BROUGHT HEREIN AND (B) INSOFAR AS THE ARBITRATION AGREEMENT IS EFFECTIVE ARE AGREEING TO ARBITRATE CLAIMS PROVIDED FOR THEREIN INCLUDING ANY AND ALL CLAIMS ARISING OUT OF OR RELATED TO THE FACILITY SERVICES PROVIDED HEREUNDER TO RESIDENT, INCLUDING, SPECIFICALLY, RESIDNT'S MEDICAL CARE AND TREATMENT. Even if the resident/representative chooses not to sign the separate 'Arbitration Program Guide' and 'Arbitration Agreement,' because the above paragraph is contained within the admission Agreement (Resident Contract), each resident/representative seeking admission to the facility is being required to sign an arbitration agreement as a condition of admission and/or as a requirement to receive care and services at the facility. Nowhere in this paragraph does it inform the resident/representative that they are not required to agree to this Arbitration Agreement as a condition for admission or to receive care and services, nor does it give the resident/representative the right to rescind the agreement within 30 days of signing it. On 02/28/24, an email was sent to the Executive Director informing her of the concern with the Arbitration paragraph (Item #26) on page 15 of the admission Agreement. It was also brought to her attention, in person, on 02/29/24 at approximately 11:30 AM. She stated she would inform the corporate office of the concern. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 14 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of the Oxygen Management Policy revised 05/04/23 documented, 5. Care of Concentrator: c. Nurse responsibilities: i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Residents Affected - Few Review of the record revealed Resident #91 was admitted to the facility on [DATE], was transferred to the hospital on [DATE], and returned to the facility on [DATE]. Current physician orders dated 02/07/24 documented to keep oxygen saturation at 90% or greater, and to administer Ipratropium-Albuterol nebulizer treatment every 6 hours. Review of the oxygen saturation levels obtained by the nurses, documented Resident #91 utilized oxygen on 13 of 22 days from 02/07/24 through 02/29/24. Review of the current care plan initiated on 02/22/24 documented to change oxygen tubing per facility protocol and or physician order, and as needed. Observations on 02/26/24 at 10:13 AM, 02/26/24 at 3:49 PM, and 02/27/24 at 10:48 AM revealed oxygen tubing that was not dated in any way (Photographic Evidence Obtained). Resident #91 was using the oxygen at 2 to 3 liters/minute. A nebulizer machine was noted on the resident's bedside night stand, with tubing running from the machine into the closed top drawer. Resident #91 gave permission to look in the top drawer. The mask was noted in a clear plastic bag and no date was noted (Photographic Evidence Obtained). An observation on 02/28/24 at 11:52 AM revealed the oxygen tubing had been removed, and the concentrator was no longer in use. The nebulizer tubing remained in the closed top drawer. During an interview on 03/01/24 at 10:11 AM, when asked the process for maintaining the oxygen and nebulizer tubing, Staff D, Licensed Practical Nurse (LPN) explained it was done weekly be the night shift. An observation with Staff D revealed the same nebulizer tubing in the top drawer of the bedside night stand of Resident #91. Upon observation, the LPN was unable to find a date on the tubing or bag. Upon closer observation, the mask was noted with small brown debris inside. The LPN confirmed she had used the mask earlier that day, did not notice the lack of any date, and agreed it needed to be changed. Based on observation, interview, and record review, the facility failed to follow infection control practices after wound care for 1 of 2 sampled residents observed for wound care (Resident #43); Failed to follow best practice to prevent transmission of blood-borne pathogens using the ultra-mist machine for 1 of 1 sample residents with specialized wound care (Resident #43); and failed to maintain clean oxygen tubing for 1 of 2 residents reviewed for respiratory care (Resident #91). The findings included: A review of the facility's policy Wound Cleansing and Dressing, revised on 9/25/23, documented: Cleanse the wound using normal saline or wound cleanser. Change gloves and perform hand hygiene as needed to prevent contamination. Apply new dressing after cleansing the wound. 1) A wound care observation for Resident #43 was conducted with the Wound Care Nurse (WCN) on 02/28/24 at 11:50 AM. The wound care nurse cleaned the resident's sacral wound as ordered. The WCN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 15 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few continued wound care with the same gloves on. The WCN dressed Resident #43's wound, and continued to reposition the resident in bed, touching tube feeding pole/pump, etc with the same gloves on and no hand hygiene. An interview was conducted with the WCN on 02/29/24 at 12:00 PM. The WCN acknowledged she did not remove her gloves and perform hand hygiene after she cleaned Resident #43's wound. 2) A review of the facility's policy Ultra Mist Therapy, revised on 02/07/24, documented under cleaning the Ultra Mist System: Do not sterilize the treatment wand including tip with steam, ETO, radiation, gas/plasma, or cold sterilant. May clean and sanitize with regular cleaning materials unless in an isolation room. Disinfect with approved disinfectant if in isolation. Wound care treatment was observed on Resident #43 on 02/28/24 at 11:40 AM. Staff Z, a Physical Therapist (PT), was observed bringing an Ultra Mist System (special wound care equipment that uses ultrasound and Normal Saline mist to aid in the healing of a pressure ulcer) in the resident's room. Along with the system, Staff Z brought in a red biohazard bag, and donned protective eye glasses and a mask. Staff Z explained sometimes the wounds treated can be bloody. Staff Z proceeded to place a disposable applicator on the treatment wand. Staff Z provided treatment with the applicator close to the wound for 4 minutes. Staff Z stated the Ultra Mist System was new to the facility, approximately 3 months, and therapy was trained on how to use it. After treatment of Resident #43's sacral wound, Staff Z stated she was going to wipe the system down with alcohol pads. Staff Z proceeded to grab a container of hand disinfective wipes, and wipe the machine down. Staff Z stated that was what she was trained to do. Further observation of the hand disinfective wipes container revealed the wipes contained 70% alcohol. An interview was conducted with the Nursing Home Administrator (NHA) on 02/28/24 at 3:00 PM. The NHA stated alcohol wipes should not be used to disinfect the Ultra Mist System. The NHA stated bleach wipes should be used to disinfect the machine. An interview was conducted with the NHA and Director of Nursing on 02/29/24 at 10:00 AM. The NHA stated she misspoke when she stated alcohol should not be used to disinfect the Ultra Mist System. The NHA stated she reached out to the company and the company stated via email that 70% alcohol wipes are approved options as indicated on our IFU (instructions for use). The use of certain chemicals can affect the plastic on the Ultra Mist System and can void the warranty of the product. The recommendation is often to use 70% alcohol wipes as they are often on hand, they have less abrasive smell and more likely to be tolerated by the patient population, it removes the variation of needing to dilute the concentration of bleach per the manufacturer's recommendations, some facilities have various types and the concentration can vary, this extra step can lend to confusion in the dilution process. Facilities and clinicians have preferred to not choose this method as the 70% alcohol wipes are equally as effective. The patient is not in contact with the ultra mist device, and there is a single use, per patient disposable component provided for the purpose of sterility. This company does not support the position that the facility should specifically be using bleach to wipe down the Ultra Mist System, and support and further recommend the 70% alcohol option due to the reasons stated above. A review of the Ultra Mist System Instructions for use manual documented to use germicidal wipes for cleaning/disinfecting. An interview was conducted with the Infection Control Preventionist (ICP) on 02/29/24 at 2:00 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 16 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The ICP stated the nurses clean all equipment such as glucometers (machine to measure blood sugars), as well as medicine carts with bleach wipes. The ICP further stated all nurses carts are stocked with bleach wipes only, because she did not want them to confuse them with the alcohol wipes. The ICP stated she did not know that they were using alcohol wipes to disinfect the Ultra Mist System. The ICP stated alcohol wipes were not appropriate for the facility's setting/population. The ICP stated alcohol was not effective on Multiple Drug Resistant Organism infections such as C-Diff, or any blood borne pathogens. The ICP stated she ordered some Sani -Wipes which contain some bleach, but was less caustic to disinfect/clean the Ultra Mist System. The facility had 3 residents with current orders for the Ultra Mist System. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 17 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain resident care equipment in a safe and sanitary condition related to specialized mattress and wheelchairs for 7 of 32 sampled residents (#24, #68, #40, #32, #91, #21, #28). Residents Affected - Some The findings included: 1) Review of the record revealed Resident #28 was admitted to the facility on [DATE] with a large pressure injury to his sacrum. This wound healed and re-opened in June 2023. Review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was totally dependent on staff for all activities of daily living and had two pressure injuries. Review of the orders documented the initiation of a low airloss specialty mattress as of 10/14/22. This order documented to check for placement and settings every shift. During an observation on 02/26/24 at 11:28 AM, Resident #28 was noted in bed, lying on a specialty air mattress. Observation of the specialty air mattress pump control unit revealed clear packing-type tape wrapped around the cord where it attached to the machine, and the tape continued around the entire machine (Photographic Evidence Obtained). On 02/28/24 at 2:36 PM, the specialty air mattress pump control unit remained the same, with the clear tape wrapped around the machine in the same manner. Staff B, the assigned Certified Nursing Assistant (CNA), who had also worked on Monday 02/26/24, was asked to come to the resident's room, and stated she had not noticed the tape wrapped around the air mattress control unit. The CNA stated she would now report it to a supervisor. Staff F, assigned Licensed Practical Nurse (LPN) on Tuesday 02/27/24 and 02/28/24, was unaware of the tape wrapped around the control unit. The Assistant Director of Nursing (ADON)/second floor supervisor was unaware of the tape wrapped around the control unit. The Administrator arrived at the resident's room and stated she was unaware of the situation. The Administrator explained that any needed maintenance would be logged into the maintenance book at the nurses' station. Review of the maintenance book from December 2023 to the present lacked any documented maintenance concerns for Resident #28. When asked about any type of rounds by the managerial staff, the ADON stated they do daily Angel Rounds for each resident. During an interview on 02/28/24 at 3:12 PM, the Maintenance Director stated he was unaware of the need for a new mattress or control unit for Resident #28 until today, after surveyor intervention. When asked the process for maintenance concerns identified by staff, the Maintenance Director explained all concerns should be documented in the maintenance books located at each nurses' station, and he or his staff will check the books every 1 to 2 hours throughout the day. The Maintenance Director confirmed they do Angel Rounds each morning, and again any concerns would need to be logged in the maintenance books. The director also stated the staff report concerns during the morning meetings. Review of the documented Angel Rounds for Resident #28 revealed they were completed daily by the Director of Rehab (DOR), with the last one completed on Friday 02/23/24. There were no documented concerns for Resident #28. The Director of Rehab was asked to go into the resident's room with the surveyor on 02/29/24 at approximately 3:00 PM. When asked what he observes during his Angel Rounds, the Director of Rehab explained he looks at both the resident and the room to identify any potential needs. The DOR confirmed an observation of the bed, mattress, and specialty air mattress control unit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 18 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460 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 0908 Level of Harm - Minimal harm or potential for actual harm would be part of his routine. The DOR stated he did not see any tape on the specialty air mattress control unit during his rounds on 02/23/24. 2) The following observations were made during environmental tours on 02/26/24 and 02/27/24 in the secured unit on the second floor of the facility (photographic evidence obtained):. Residents Affected - Some room [ROOM NUMBER]B - Wheelchair stained; rust on bottom rail of bed; room [ROOM NUMBER]A - IV pole contained much rust. room [ROOM NUMBER]A - IV pole and bed rail near the tube feeding pole were soiled with tube feeding contents; the mattress near the tube feeding pole was splattered with residue from tube feeding contents. room [ROOM NUMBER]A - The resident's reclining wheelchair's footrest is observed to be lopsided, tilting downward on the left side. room [ROOM NUMBER]B - The vinyl on the resident's wheelchair arms is partially missing. room [ROOM NUMBER]B - The vinyl on the wheelchair arms is cracked and coming off. An interview was conducted with Maintenance Director on 02/28/24 at 3:12 PM, he stated that Angel rounds are completed each morning and if there are any environmental concerns, they are put in the maintenance logbook at the nurse's station and maintenance staff will check the logbook periodically (every 1-2 hours). Concerns will also be brought up at the morning meetings. On 02/29/24 at 2:36 PM, a tour was conducted with the Maintenance Director. He acknowledged the concerns identified and presented to him during this tour. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105659 If continuation sheet Page 19 of 19