Inspection·August 12, 2024

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide an environment free of pests in 4 of 15 rooms on the 2 South Unit (room [ROOM NUMBER], #241, #250 and #251). Residents Affected - Few The findings included: Review of the second floor Maintenance Report Logbook, located at the nurse's station, revealed the following: - Concern regarding roaches in room [ROOM NUMBER]-A on 06/12/24, documented as 'fixed' on the same day. - Infestation of roaches in room [ROOM NUMBER] and 241 on 07/28/24 reported by staff. During a room-by-room tour on 08/12/24 at 10:05 AM, the following observations were made: In room [ROOM NUMBER], 2 (two) live juvenile roaches and multiple dead roaches were observed behind the [NAME]. There was also one dead juvenile roach observed on the resident's bed, while the resident was sleeping. In room [ROOM NUMBER], 2 (two) live and mature roaches were observed on the wall and floor behind vacant bed-A. In room [ROOM NUMBER], 2 (two) live juvenile roaches were observed on the floor in the shared bathroom, live and dead roaches in all stages of life were observed behind a nightstand to the left of the air conditioning unit, and dead roaches were observed by the window bed. In room [ROOM NUMBER], numerous live mature and juvenile roaches were observed behind a closet to the left of the air conditioning unit. Two (2) dead roaches were observed on the floor by the window bed. During a room-by-room tour, on 08/12/24 at 10:43 AM, accompanied by the Maintenance Supervisor and the Director of Nursing (DON), the concerns regarding pests were acknowledged and observed by both the Maintenance Supervisor and the DON. On 08/12/24 at 11:20 AM, the Administrator and the Social Services Manager were made aware of the concerns. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105659 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 08/12/2024 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)