Inspection·July 27, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lower leg. The surveyor was unable to see the left leg dressing date because he was sitting and facing the aide. The resident stated that he was taking blood thinners and his skin was thin from the blood thinners. The PA stated the resident loves to put bandages on his skin. The PA was asked to state the date on the resident's left lower leg and stated it was dated 07/19/23. On 07/26/23 at 9:33 AM, observation revealed Resident #5 in bed and he continued to have a right leg dressing dated 07/19/23 and had a dressing on his left lower leg dated 07/25/23. Subsequently, a joint interview was conducted with the resident and his PA. The PA stated that the nurse changed the resident dressing on his left leg but did not see the dressing on the right leg. During the interview, Staff E, Licensed Practical Nurse (LPN) came into Resident #5's room and stated she was there to say hello to the resident. Consequently, an interview was conducted with Staff E who stated that she did not do the resident's dressing change on 07/25/23. Staff E was apprised of the right leg dressing dated 07/19/23 and stated that the dressing was for protection maybe and offered to remove it. Observation revealed Staff E performed hand hygiene, donned gloves, and removed Resident #5's right leg dressing dated 07/19/23. Staff E, LPN stated the skin tear was healed. Observation revealed a small scratch like skin mark. The removed dressing had a piece of xeroform gauze in it. Staff E confirmed that the piece of xeroform gauze was in the dressing removed. 0n 07/26/23 at 9:43 AM, an interview was conducted with Staff B, Registered Nurse (RN) who stated there was nothing on Resident #5's right leg and added that all that the nurse needed to do was remove the dressing and discontinue the order. Staff B was apprised that the dressing on his right upper leg (thigh) and left lower leg, were dated 07/19/23 when the observation was made on 07/24/23. On 07/26/23 at 9:52 AM, a joint interview was conducted with Staff B, RN, Staff E, and the Assistant Director of Nursing (ADON). The ADON confirmed that Resident #5's physician order's frequency for the right leg and left leg was to be changed every third day and should have been changed on 07/22/23. Staff E confirmed that the right leg dressing was dated 07/19/23 and the left leg dressing was dated 07/25/23. The ADON was apprised that the right leg dressing was on for 7 days and the left leg dressing was changed 6 days rather than every third day as ordered. On 07/26/23 at 10:08 AM, a side by side review of Resident #5's clinical record was conducted with Staff B, RN/Unit Manager. Staff B confirmed that the resident's physician orders dated 07/16/23, included wound care orders dressing /ointment type: dry dressing: wound location and care instructions: cleanse healing skin tear left lower leg and right lower leg with normal saline, pat dry, apply xeroform gauze, cover with dry dressing every third day and prn (as needed) until resolved. Continued review revealed that Resident #5's wound care documentation for 07/22/23 documented skipped by the nurse on duty for the day. Staff B stated that the dressing change was not done on 07/22/23. Further review revealed that the resident's dressing changed on 07/25/23 was not documented. On 07/26/23 at 10:27 AM, an interview was conducted with Staff E, LPN who stated she took the physician orders for Resident #5's wound care for the right and the left leg, but that somehow did not prompt the nurses to do it. On 07/26/23 at 3:09 PM, an interview was conducted with the MDS Coordinator who stated that Resident #5's annual assessment dated [DATE] documented that the resident had skin tear (s) during the review. On 07/27/23 12:03 PM, surveyor was approached by the Director of Nursing (DON) who stated that the facility did meet with the managers and the wound care nurse, and that they were addressing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105668 If continuation sheet Page 2 of 7 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 105668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Manor 777 South Douglas Road Pembroke Pines, FL 33025 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 dressing change problem. The DON was apprised that Resident #5's dressing on both legs were in place for over 6 days and the physician orders were to change it every third day. The DON was informed that the dressings were dated 07/19/23 for both legs, and the left leg dressing was changed on 07/25/23 but the right leg dressing was not. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105668 If continuation sheet Page 3 of 7 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 105668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Manor 777 South Douglas Road Pembroke Pines, FL 33025 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the tube feeding regimen according to the Physician ' s orders for 1 of 2 sampled residents reviewed for tube feeding (Resident #66). The findings included: In an observation conducted on 07/25/23 at 7:30 AM, Resident #66 was noted with the tube feeding Isosource 1.5 (tube feeding formulary) running at 55 ml (milliliters) an hour. Closer observation showed that the tube feeding was started at 4:00 PM, the night before and was at the 800 ml mark out of a 1500 ml capacity bag. The tube feeding mark showed that 700 ml of tube feeding was infused during the night. In an observation conducted on 07/25/23 at 8:07 AM, the breakfast tray was brought into Resident #66's room. The breakfast tray showed a sliced cheese omelet, ground ham, white toast, and grits. Closer observation showed that the tube feeding was still running with Isosource 1.5 (tube feeding formulary) at 55 ml (milliliters) an hour. In this observation, Resident #66 said, I am not hungry. Upon continued observation at 8:18 AM, Resident #66's tube feeding was still running with Isosource 1.5 at 55 ml an hour. The breakfast tray was noted to be 100% untouched. At 8:50 AM, the tube feeding was still running in the room while Resident #66 was trying to eat her breakfast tray. Resident #66 ate a few bites of her breakfast tray. In an observation conducted on 07/26/23 at 8:13 AM, Resident #66 was trying to eat her breakfast tray in her room. Closer observation showed the tube feeding was still running at 55 ml an hour. The tube feeding bag was at the 800 ml mark out of a 1500 ml capacity bag. This showed that 700 ml of formulary was given instead of the 880 ml as ordered by the Physician. Continued observation at 8:22 AM showed that the tube feeding was turned off, and Resident #66 did not eat anything on her breakfast tray. At 8:40 AM, the breakfast tray was still 100% untouched. A record review showed that Resident #66 was readmitted on [DATE] with severe malnutrition and respiratory failure diagnoses. An order was noted for tube feeding continuously every 16 hours to start at 4:00 PM and stopped at 8:00 AM to provide 880 ml dated 07/14/23-diet order for mechanical soft ground dated 03/30/23. A nutrition progress note dated 06/06/23 showed that the tube feeding order meets 74% (percent) of Resident 66's daily caloric needs and 78% of Resident #66's daily protein needs. Resident #66 ' s estimated caloric requirements range between 1785 to 2024, and estimated protein needs range between 77 to 102 grams of protein. The care plan showed that Resident #66 is at risk of unintended weight loss in nutrition parameters due to total dependence on Enteral Feeding (delivering nutrition straight to your stomach or small intestines) for fluids and hydration. A caloric daily intake was conducted on 04/04/23 for the three daily meals, which showed that Resident #66 was eating 30% of her caloric needs and 38% of her protein needs. In an interview conducted on 07/26/23 at 12:10 PM with Staff A, Registered Nurse (RN), it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105668 If continuation sheet Page 4 of 7 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 105668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Manor 777 South Douglas Road Pembroke Pines, FL 33025 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm stated that Resident #66 tolerates her tube feeding well. The tube feeding runs from 4:00 PM the night before until 8:00 AM the next day for 16 hours. When asked why the tube feeding was running past 8:00 AM while Resident #66 was eating her meals, she said that the tube feeding pump would beep when it was done, and that is when she turned the tube feeding off. Staff A further reported that it is okay for the tube feeding to run while the Resident eats her meals. Residents Affected - Few In an interview conducted on 07/26/23 at 12:20 PM, Staff B Registered Nurse (RN) stated that it is not best practice to run tube feeding while a resident eats. She further said that the tube feeding should have stopped while Resident #66 was eating her lunch meals. In an interview with Staff D, Registered Dietitian, on 07/27/23 at 8:45 AM, stated that Resident #66 Tube feeding runs 16 hours starting at 4:00 PM and stopping at 8:00 AM running at 55 ml an hour. She adjusts the tube feeding based on how well the Resident eats, and Resident #66 sometimes fluctuates. She was only eating 10% to 30% of her meals for a while. This is why she based her needs from the tube feeding on the higher end of needs. She further stated that you should run the tube feeding at a different time than Resident #66 is eating her meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105668 If continuation sheet Page 5 of 7 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 105668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Manor 777 South Douglas Road Pembroke Pines, FL 33025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide food accommodating resident preferences, choices, and tolerances. The facility did not follow its menu regarding food portion sizes during multiple dining observations for Resident #74, Resident #148, Resident #14, Resident #55, Resident #20, and Resident #71. The findings included: A review of the facility's 4-week menu cycle revealed the following: Tuesday's menu showed lunch served was had roast beef (3 ounces), gratin potatoes, green beans, and a soft roll. For Wednesday, the menu showed lunch served was glazed pork loin, baked potato, and mixed vegetables. 1. Resident #74 was admitted to the facility on [DATE] with a diagnosis of Stroke and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview of Mental Status (BIMS) score of 09, indicating mild to severe cognitive impaired. The diet order showed a mechanical soft cardiac heart healthy dated 10/2/122. In an observation conducted on 07/25/23 at 8:07 AM, Resident #74 was eating his breakfast meal. Closer observation revealed a meal ticket, documenting 6 ounces of grits, 2 ounces of eggs, ground ham, and a slice of white bread. Further observation revealed Resident #66's tray did not have the 6 ounces of grits as noted on his meal ticket. 2. Resident #148 was admitted to the facility on [DATE] with a diagnosis of Diabetes and Severe Obesity. The MDS assessment dated [DATE], showed a BIMS score of 15, indicating cognitively intact. Diet order noted for cardiac heart-healthy carbohydrate control dated 07/24/23. In an observation conducted on 07/25/23 at 8:44 AM, Resident #148 was in his room with a breakfast tray. His meal ticket showed a diet for cardiac carbohydrates controlled with eggs, white toast, coffee, and sugar packets. In this observation, Resident #148 stated that they gave him sugar packets on his tray and that he has diabetes. A review of the facility's week-at-a-glance menu breakdown showed that on the carbohydrate-controlled diet, sugar substitutes would be provided instead of sugar packets. 3. Resident #14 was admitted to the facility on [DATE] with diagnoses of Dementia and Parkinson's disease. The MDS dated [DATE] lacked documentation of a BIMS score. The order noted for regular diet dated 03//02/22. In an observation conducted on 07/24/23 at 12:15 PM, Resident #14 was noted with a lunch tray. Closer observation showed a regular diet meal ticket with 3 ounces of roast beef. The lunch plate was noted with two round slices of roast beef. In an interview conducted on 07/25/23 at 3:50 PM, Staff C, Registered Dietitian, stated that for the lunch menu, the roast beef is sliced and placed on the scale to ensure that each slice is 3 ounces. When asked by the surveyor of why some residents received two round pieces of roast beef and some residents received one portion, she said that they might be less than 3 ounces, and if they looked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105668 If continuation sheet Page 6 of 7 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 105668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Manor 777 South Douglas Road Pembroke Pines, FL 33025 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 0806 smaller, they would provide two pieces. Level of Harm - Minimal harm or potential for actual harm 4. Resident #55 was admitted to the facility on [DATE] with a diagnosis of Anemia and Diabetes. The MDS assessment dated [DATE] with a BIMS score of 14, which is cognitively intact. Diet order for cardiac, carbohydrate controlled dated 03/01/22. Residents Affected - Few In an observation conducted on 07/24/23 at 12:10 PM, Resident #55 was noted with her lunch tray. Closer observation showed a lunch plate that consisted of 1 slice of round roast beef and potatoes. The meal ticket showed Resident #55 has a cardiac carbohydrate-controlled diet with 3 ounces of roast beef. 5. Resident #20 was admitted to the facility on [DATE] with diagnoses of Diabetes and Hypertension. The MDS assessment dated [DATE] with BIMS score of 13, indicated the resident cognitively intact. Diet order noted for carbohydrate control diet dated 03/01/22. In an observation conducted on 07/24/23 at 12:13 PM, Resident #20 was noted with her lunch tray. Closer observation showed a lunch plate that consisted of 1 slice of round roast beef. The meal ticket showed that Resident #20 has a carbohydrate-controlled diet with 3 ounces of roast beef. Another observation was conducted on 04/26/23 at 8:12 AM, Resident #20 was eating her breakfast meal. The meal ticket showed a diet for carbohydrate control with 4 ounces of juice and sugar substitute. Closer observation showed 4 ounces of juice on the breakfast tray and 8 ounces of regular hot chocolate. 6. Resident #71 was admitted to the facility on [DATE] with a diagnosis of Dementia and Kidney Stones. The MDS assessment dated [DATE] has a BIMS score of 08, indicating moderate to severe cognitive impairment. Diet order noted for a regular diet; send side gravy/sauce with the meal and omit the baked ham and roast pork dated 02/11/23. In an observation conducted on 07/25/23 at 12:25 PM, Resident #71 was noted in the room with his lunch tray. The tray showed a tuna sandwich and one soft roll. Closer observation showed a meal ticket for a tuna salad sandwich, soft roll, and ½ cup of mixed vegetables, which was not on the tray. In an interview conducted on 07/25/23 at 3:50 PM with Food Service Director, it was stated that there is one staff member that is assigned to the tray line to ensure that the appropriate food items are placed on the correct diet trays. Any food items listed on the meal ticket will be on the tray unless the resident request something different it will write in pen on the meal ticket. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105668 If continuation sheet Page 7 of 7