Health inspection·May 10, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on [DATE]. Resident #702's medical record also revealed his religion preference is Judaism. Further review showed Resident #702's hospital medical record dated 04/27/2023 also revealed the resident's religion preference is Jewish. Review of Resident #702's Initial Nutrition Assessment, dietary Nutrition Risk assessment dated [DATE] revealed that Resident #702 is alert and oriented times 3 (AAOx3) and able to report food preferences at time of interview. Further review of Resident #702's updated initial nutrition assessment, the dietary nutrition risk assessment dated [DATE] revealed that Resident #702 is alert and oriented times 3 (AAOx3) and able to report food preferences at time of interview. Review of Resident #702's Minimum Data Set (MDS) dated [DATE] revealed that the Resident Brief interview for Mental Status Score was 15, indicating the resident is cognitively intact. Review of Resident #702's Interdisciplinary Care Plan dated 04/28/2023 showed: Resident personal food preferences will be honored through next review date; however, there was no mention on the resident's likes or dislikes of food. Review of Resident #702's nutritional food preferences revealed, No Concentrated Sweets (NCS), low fat low cholesterol diet, Fluid Rest. 1000 ml/day (milliliters/day) (780 ml diet, 220 ml NURS) No pork/chicken/ham/bacon . Turkey bacon ok. On 05/09/23 at 12:34 PM, during an interview with Resident #702's private duty aide (PDA) #2, PDA #2 stated, When he first came, they gave him pork when he first came; they fixed it. He doesn't eat bacon. On 05/10/23 at 12:14 PM, when asked Resident #702 if he eats bacon, Resident #702 replied, no pork, no chicken, no bacon pork, no bacon turkey, I'm Jewish. No bacon at all. On 05/10/23 at 12:19 PM, during an interview with Staff F, a Registered Dietitian regarding Resident #702's food preferences, Staff F stated, He follows kosher but not strict diet. He doesn't eat pork but eat turkey bacon. I talked to the daughter he doesn't eat chicken, but he can eat stew chicken. They have a selective menu, and they choose from that menu for the week. They can choose whatever they want to eat. On 05/10/23 at 12:30 PM, further interview with Resident #702 in front of the two Dietitians, Staff F and Staff G regarding his food preferences, Resident #702 stated that he does not want bacon at all. Resident #702 stated, No chicken bacon, no turkey bacon, no pork. On 05/10/23 at 12:33 PM Staff H, Certified Nursing Assistant for Resident #702 stated, He cannot eat pork, but he can eat chicken. When showed the food card from Resident #702's food tray during the lunch time, Staff H read it and stated, Oh!!!. Staff H was unaware that Resident #702 did not eat chicken and was also unaware if Resident #702's food preferences was related to his religion. On 05/10/23 at 12:37 PM, interview with Staff I, Resident #702's Registered Nurse (RN) revealed that she was aware that Resident #702 is Jewish. Staff I stated that when she receives the resident for the first time, she asked for the food preferences. Staff I then stated, I remember exactly for preferences for breakfast. I remember he asked for cut of cheese, fruits, and apple sauce. I don't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105719 If continuation sheet Page 2 of 9 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 105719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palace at Kendall Nursing and Rehabilitation Cente 11215 SW 84th Street Miami, FL 33173 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete remember exactly bacon. I know he always has a private aide, and the private aide always helps him get the food. The private aide is very aware of what he wants. I don't remember exactly if he eats the bacon. It was in the menu, basically they probably served him the bacon. If he as a Jewish person requested not to eat bacon, he is supposed not to have it in the menu. On 05/10/23 at 12:46 PM, when asked Staff J, RN Manager about receiving any complaint regarding Resident #702's food preferences, Staff J stated, Never, never. I never received any complaint from the family. After they received the food tray card, they reviewed it, and they went and corrected it. I guess they gonna have to go and update it. Event ID: Facility ID: 105719 If continuation sheet Page 3 of 9 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 105719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palace at Kendall Nursing and Rehabilitation Cente 11215 SW 84th Street Miami, FL 33173 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 accurately code the Minimum Data Set (MDS) assessment for two (Resident #13, and Resident #195) out of 3 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS section O for Special Treatments, Procedures, and Programs. Oxygen therapy for Resident #13 and Hospice care for Resident #195. There were 172 residents residing in the facility at the time of this survey. Residents Affected - Few The Findings Included: During observation on 05/07/23 at 09:00 AM, resident #13 was observed in the wheel chair eating breakfast, oxygen (02) was running via nasal canula (NC). On 05/08/23 at 08:24 AM, the resident was observed in bed asleep, the 02 was running at 2 liters per minute (LPM) via NC, the call light was on the bed. On 05/09/23 at 09:30 AM, the resident was observed in bed asleep, the 02 was running at the correct rate. Review of the medical records for Resident #13 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Palliative Care, Chronic obstructive pulmonary disease, unspecified and Shortness of breath. Review of the Physician's Orders Sheet for May 2023 revealed, Resident #13 had orders that included but were not limited to: 01/30/2023-oxygen (O2) @ at 2 Liters per minute (LPM) via NC continuously every Shift, Change Oxygen tubing and/or mask, and ensure equipment is functioning properly weekly and as needed once a day on Tuesdays and Ensure red Oxygen sign is in place outside the door of resident room at all times, while O2 tank/concentrator is in room every Shift. Record review of Resident # 13's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) is 4, indicating the resident is cognitively impaired. Section G for functional status documented the resident requires extensive assistance with one person assistance for Activities for Daily Living (ADLs). Section H for Bowel and Bladder documented Resident is always incontinent of bowel and bladder. Section J for Health Conditions documented Resident experienced no shortness of breath. Section K for Nutritional Status documented resident has no unknown weight loss/gain. Section N for Medications documented resident received diuretics and opioids in the last 7 days and Section O for Special Treatments, Procedures, and Programs documented resident received hospice care in the last 14 days, Oxygen therapy not coded. Record review of Resident #13 's Care Plans Dated 01/20/2023 revealed: Resident at risk for altered airway clearance related to Shortness of Breath. Interventions including: Oxygen via nasal canula as prescribed, ensure red Oxygen sign is in place outside the door of resident room at all times, while O2 tank/concentrator is in room, and change Oxygen tubing and/or mask, and ensure equipment is functioning properly weekly and as needed. Interview on 05/09/23 at 07:46 AM the Registered Nurse MDS (Staff A), when asked to check the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105719 If continuation sheet Page 4 of 9 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 105719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palace at Kendall Nursing and Rehabilitation Cente 11215 SW 84th Street Miami, FL 33173 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 Level of Harm - Minimal harm or potential for actual harm orders to verify the resident is on continuous oxygen, Staff A confirmed the order, surveyor had Staff A check the last two Quarterly MDS's on record dated 04/24/23 and 02/01/2023, Section O for treatments, programs, and procedures. Staff A confirmed the resident was not coded for oxygen therapy on the two quarterly MDS assessments. Staff A stated she will look into what happened with the resident's MDS and get back to the surveyor. Residents Affected - Few Interview on 05/09/23 at 10:55 AM Staff A stated, we looked at the resident's MDS, made the necessary corrections and resubmitted the MDS today. Received all documentation requested. Review of the facility's policy and procedures titled, Scope of Assessments and Re-assessments revision date 12/06/2021 states: The facility assesses and reassesses its residents according to applicable law/regulation and facility policy. Procedure 1-By the time all discipline-specific assessments and the MDS have been completed, the following information will be collected and documented: a. Current diagnosis, pertinent history, medication history, current medication, and current treatments. Record review of Resident #195 revealed, the resident was admitted on [DATE] under Hospice. Medical diagnoses included but were not limited to; heart failure, encounter for palliative care, acute embolism, and thrombosis of deep veins of bilateral lower extremity (03/15/2023), Status post thrombectomy (03/30/2023). The current Physician Orders included code status, Do Not Resuscitate. The Minimum Data Set, dated [DATE] for a significant change in Status. In Section C, the brief interview of mental status score was 12 meaning the resident was moderately impaired. In Section G, bed mobility was extensive assistance by one-person physical assist. Transfer was total dependent with two-person physical assistance. Eating was supervision with setup assistance. Toilet use was total dependent with one-person physical assistance. In Section O, while a resident, it stated that Resident #195 received no cancer treatments, no oxygen therapy, no for intravenous medications, transfusions, dialysis, hospice, isolation or quarantine. Resident #195 has been admitted under hospice since 7/15/22. In the care plan, Problem/Need documents, Resident #195 had a diagnosis of end stage heart failure. Receiving palliative care under hospice. Further decline is expected and unavoidable as end stage disease progresses. Date open 4/13/23. The goal stated, resident will have all psychosocial needs met by next review date. Interventions included were contact hospice and medical doctor regarding resident's status. Next review date 7/13/23. On 05/10/23 at 10:06 AM, in an interview with the MDS coordinators Staff A, Registered Nurse & Staff E, Registered Nurse. When asked Is the resident on hospice?, Has the resident been a resident here at the facility?. Staff A stated Yes, resident #195 is currently in hospice and has always been on hospice. I see that there this no check next to hospice care. I'll look into it, and I'll get back with you. On 05/10/23 at 11:00 AM, Staff A reports, We submitted a data entry error [5/10/23 10:19 AM] and here is correction page. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105719 If continuation sheet Page 5 of 9 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 105719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palace at Kendall Nursing and Rehabilitation Cente 11215 SW 84th Street Miami, FL 33173 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an accurate receipt of administration of controlled medications and failed to store medications for 1 out of 5 carts checked. The findings included: On 05/09/23 at 11:22 AM, during an observation with Staff C, Licensed Practical (LPN) of cart number three on the third floor. A purple pill which was Levothyroxine 75 mg was found on the bottom of the drawer below the resident's medication blister packs. Staff C placed the medication in a drug buster container and shook the bottle. During the review of the controlled medication record book for resident #176's Hydrocodone 10-325 mg (milligram) tabs controlled medication record. The record bood documented there were 28 tablets remaining, but in the blister pack there were 27. Staff C corrected the sheet that it was 27 remaining. At 5/9/23 8:51 AM, Staff had given a Hydrocodone tab to resident #176. On 05/09/23 at 01:27 PM, during an interview with Staff C, LPN. Staff C was asked, What is the facility's policy and procedure regarding the controlled medication count? Staff C stated, Everyone knows that once the narcotic medication is given. The nurse must write down that it was given to the resident on the narcotic count sheet. It's unacceptable. I feel very bad that it has happened. On 05/10/23 at 11:08 AM, during an interview with Staff C, LPN. Staff C was asked, What in-services and educations were given to staff about controlled medications? Staff C stated, We do several in-services during the year for different topics including narcotics. They did an in-service with narcotics with everyone yesterday. They are on top of in-services for narcotics all the time. I have worked here for several years. When I give the narcotic, I immediately sign for it in the narcotic count sheet in narcotic book. In the in-service, I was told, when you take it out, you scan and sign out the narcotic out immediately. Make sure the amount remaining is the same in the blister pack. The supervisors and the nurses do an extra counting of narcotics during the day. This didn't have to happen. This error. On 05/10/23 at 10:45 AM, in an interview with Staff D, Registered Nurse, Unit Manager. When Staff D was asked, What is the facility's policy regarding controlled medications? Staff D stated, When you give the controlled medications, click on that medication in the electronic health record to sign for it, and administer it to the resident. On the narcotic sheet, sign that the medication is given. If you give the medication, you sign for it. We have 2 shifts. The narcotics are counted between oncoming/offgoing nurses. Record review for Resident #176 revealed, the resident was admitted on [DATE]. Medical diagnoses included encounter for palliative care and primary diagnosis of degenerative disease of nervous system. Hydrocodone-acetaminophen - Schedule II tablet. Dosage is 10-325 milligrams for 1 tablet and to be given orally two times a day for pain. In the Minimum Data Set, dated [DATE], brief interview of mental status is a 2 meaning severe cognitive impairment. In Section I, active diagnosis is Arthritis, Non-Alzheimer's Dementia, pressure ulcer of sacral region, stage 4 and osteoarthritis, unspecified site. In Section N, opioids were given in the last 7 days. In section O, hospice care and 3 days of active range of motion are ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105719 If continuation sheet Page 6 of 9 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 105719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palace at Kendall Nursing and Rehabilitation Cente 11215 SW 84th Street Miami, FL 33173 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete In review of the Policies and Procedure titled, Narcotics: Control of Medication. Page 1 of 5. Effective 2017. Reviewed December 2022. In section, 4. Administration of Medication. When a medication is administered, the licensed nurse administering the medication enters the following information on the medication administration record (MAR) and accountability record for controlled substances. Date and time administration (MAR, accountability record), amount administered (MAR, accountability record), and remaining quantity (accountability record). Initials of the nurse administering the dose, completed after the medication is administered (MAR, accountability record). Event ID: Facility ID: 105719 If continuation sheet Page 7 of 9 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 105719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palace at Kendall Nursing and Rehabilitation Cente 11215 SW 84th Street Miami, FL 33173 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain communication with hospice to ensure continuation of care for 1 (Resident #7) out of 5 residents reviewed for hospice care, as evidenced by no updated hospice communication notes available in Resident #7's medical records. This had the potential to affect the 38 residents receiving hospice care in the facility at the time of this survey. The findings included: During Observation on 05/07/23 at 08:54 AM, Resident #7 was in bed being fed by a Certified Nursing Assistant, a unilateral floor mat was at the beside. On 05/08/23 at 08:24 AM, Resident #7 was in bed asleep, no distress was noted. On 05/09/23 at 12:04 PM, resident #7 was in bed awake watching Television, no distress was noted. Record review of the facility's hospice notes revealed, the most recent documentation available for Resident #7: was on 4/3/23-Focus visit plan completed, 4/5/23 -nursing comprehensive assessment was completed. Review of the medical records for Resident #7 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Do Not Resuscitate (DNR), Diet- No restrictions, Honey Thick, Pureed. Review of the Physician's Orders Sheet for May 2023 revealed, Resident #7 had orders that included but not limited to: Encounter for palliative care. Record review of Resident #7 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Resident's Brief Interview for Mental Status Score-unable to be determined. Section G for Functional Status documented resident is total dependence with two-persons assistance for Activities of Daily Living. Section H for Bowel and Bladder documented resident is -always incontinent of bowel and bladder. Section J for Health Conditions documented no shortness of breath and no schedule or as needed pain medications received in the last 5 days. Section K for Nutritional Status documented no unknown weight loss/ gain. Section N for Medications documented resident received anticoagulants and antibiotics in the last 7 days. Section O for Special Treatments, Procedures, and Programs documented resident received hospice care in the last 14 days. Record review of Resident # 7's Care Plans Reference Date 03/14/2023 revealed: Resident has a diagnosis of End Stage Cerebral Atherosclerosis, receiving Palliative care under hospice. Interventions up to and including: Contact Hospice and Physician regarding resident's status, discuss plan of care with all individuals concerned, provide palliative care and other modalities of treatment necessary as affirmed by individuals concerned. Review of the facility's hospice contract revealed on 10/10/2002-[Vi .] Hospice contract was signed with [Vi .] as general manager and facility's Chief Financial Officer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105719 If continuation sheet Page 8 of 9 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 105719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palace at Kendall Nursing and Rehabilitation Cente 11215 SW 84th Street Miami, FL 33173 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/09/23 at 08:10 AM with the Registered Nurse Unit 1 nursing Manager (Staff B) stated, hospice nurses come to the facility at least twice a week, the hospice staff sign in at the front desk, we communicate about the resident's care needs, the hospice staff leave their notes in the hospice binder located at the nurse's station. When a resident has to be placed on hospice initially, social services take care of coordinating the care with the hospice team. Surveyor and Staff B reviewed the hospice binder, the last nursing comprehensive assessment was completed on the resident on 04/05/2023, and on 4/3/23-last Focus visit plan completed. Interview on 05/09/23 at 08:21 AM with the Hospice Registered Nurse it was reported, right now we have about 38 residents here on hospice care, we have three (3) hospice nurses assigned to this facility and we come here almost every day, we leave our patient notes here almost every day, we complete the hospice notes, take it to the office, discuss the resident in our meetings, the physician signs, coordinate the care plan and then we bring a printed copy back to the facility. The notes get updated weekly-Tuesday to Tuesday. I will check with the hospice nurse that is assigned to this resident to see where the notes are. Review of the contract between [Vi .] Hospice and the facility documented the following: In section 2.10-facility shall prepare and maintain complete and detailed medical records for each hospice patient receiving inpatient services hereunder in accordance with prudent record keeping procedures and applicable laws, rules, and regulations. Facility personnel shall make a signed record entry each time any inpatient services are rendered. Such medical records shall include progress notes and clinical notes describing all inpatient services provided, and a copy of each hospice patient's plan of care. Review of the facility's policy titled, End of Life Care revision date May 3, 2015, states: End of life may include addressing the clinical, psychosocial, and spiritual concerns of the resident and their family or loved ones. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105719 If continuation sheet Page 9 of 9