Inspection·July 14, 2022

F 0550 feeding the resident and added it was hard to. Level of Harm - Minimal harm or potential for actual harm On 07/13/22 at 1:31 PM, observation revealed Resident #23 in her room in bed, being fed by Staff D, Personal Care Attendant (PCA). Staff D was standing next to the resident's left side and feeding her while standing. Observation revealed Staff D and Resident #23 were not able to make eye contact during the task. Continued observation revealed Resident #23 lifting her head to talk to Staff D. Further observation revealed no chairs in the room at the time of the observation. Residents Affected - Few On 07/13/22 at 1:42 PM, an interview was conducted with Staff E, a Registered Nurse (RN) who stated the CNAs and PCAs are supposed to sit down while feeding the resident. Staff E added it was more comfortable and that the staff can keep eye contact with the resident. On 07/13/22 at 4:30 PM, a joint interview was conducted with Staff D and the Director of Nursing (DON). Staff D was asked if she was to sit down or stand up while feeding a resident. Staff D stated that sometimes she stood up and sometimes she sat down. Staff D stated that she raised the bed to feed Resident #23 and did not sit down. The DON stated that the PCAs and CNAs are supposed to sit down while they are feeding the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 2 of 14 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 105827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Finnish-American Village 1800 South Drive Lake Worth, FL 33461 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. Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 (West Wing, South Wing, and East Wing) 3 residential wings. The findings included: During the Environmental Tour conducted on 7/13/22 at 10:15 AM, accompanied by the Director of Maintenance and Director of Housekeeping, the following were noted; East Wing: Room E-2 - Sink vanity exterior damaged and in disrepair. Room E-3 - Peeling paint in area ceiling area in bathroom, and bathroom ceiling vent was dust laden. Room E-4 - Room ceiling tiles (4) require replacement. Room E-6 - Room entry door in disrepair and noted to have sharp edges, bathroom wall had a large area of peeling paint, window blinds not working, and room sink was stained and soiled. West Wing: Room W-1 - Room chair exterior was heavily worn, and missing over-bed light cord (D-bed). Room W-3 - Bathroom toilet requires re-caulking to the floor. Room W-5 - Bathroom sink coming away from wall and requires repair and re-caulking. Room W-4 - Room entry door exterior was in disrepair, window blinds not working, and exterior of room sink vanity was heavily scuffed. Room W-6 - Exterior of room entry door was in disrepair, broken nightstand (C-bed), and over-bed light corn missing (A & B bed). Room W-7 - Room sink vanity exterior damaged and in disrepair. Shower Room - Exterior of entry door damaged and in disrepair, and ceiling vent was dust laden. South Wing: Room S-4 - Exterior of bathroom door was damaged and in disrepair. Room S-6 - Exterior of room chair was stained and heavily worn. Room S-8 - Exterior of room chair was stained and heavily worn. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 3 of 14 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 105827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Finnish-American Village 1800 South Drive Lake Worth, FL 33461 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 Room S-9 - The padding of the bed rails (left and right) were noted to be heavily worn and missing in places and were exposed down to the rails (Window bed). Dining Room Entry Door - The covering on the entry and exit door was porous and could not be properly sanitized on a daily basis to prevent spread of bacteria and germs. Residents Affected - Some Following the tour all observations were again confirmed with the facility Directors. The Directors stated that there is a maintenance log located at the nurses station for all housekeeping and maintenance issues to be documented by staff. The Directors further stated that the log is checked periodically throughout the day, however staff are not documenting issues. It was further stated that none of the issues from the tour were documented by staff in the log. All tour issues were discussed with the Administrator on 7/13/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 4 of 14 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 105827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Finnish-American Village 1800 South Drive Lake Worth, FL 33461 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to properly identify and treat a skin condition for 1 of 2 samples residents (Resident #33), reviewed for wounds. Residents Affected - Few The findings included: Review of the facility's policy titled Skin Integrity- Skin Tears revision date 12/09/21 documented .RN's and LPN's will participate in the management of skin tears and medical conditions by following physician orders, assessments of residents, and reporting changes in condition to the residents physician .modification of interventions .the attending physician will be notified of .lack of healing of any skin tears . On 07/11/22 at 9:29 AM, observation revealed Resident #33 sitting in a wheelchair in the dining room and speaking to the Minimum Data Set Coordinator (MDS). Further observation revealed the resident had a loose dry dressing on her left lower leg (LLL). On 07/11/22 at 9:35 AM, observation revealed Resident #33 in her room. Continued observation revealed the resident's loose dressing to her LLL was no longer in place. Further observation revealed that Resident #33's LLL skin was a dark purple color and approximately 5 inches long by 3 inches wide. On 07/11/22 at 10:37 AM, an interview was conducted with Resident #33 who stated that she did not remember what happened to her left leg. The resident stated that her left leg, where the skin discoloration and skin tear was located, hurts and that she took two Tylenol this morning. Resident #33 was asked if the staff were cleaning her wound and stated they used to clean her leg but were not doing it anymore. Review of Resident #33's clinical record documented an initial admission to the facility on [DATE], with no readmissions. The resident's diagnoses included Urinary Tract Infection, Metabolic Encephalopathy, Dorsalgia (back pain), Cardiomegaly, Atrial Fibrillation (A-Fib), Malnutrition, Muscle weakness, Cognitive Communication Deficit and Hypertension. Review of Resident #33's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 8 of 15, indicating that the resident has moderate to severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive to total assistance with her Activities of Daily Living (ADLs). Review of Resident #33's care plan for impaired circulation and potential alteration in tissue perfusion, initiated on 06/20/22, documented an intervention that read monitor, document, report to MD (doctor) any s/s (signs and symptoms) of skin problems, redness, edema, blisters, itching, bruises, skin lesions . Review of Resident #33's admission note dated 06/03/22 documented under skin condition three skin tears with dry dressing and one steri-strip to left lower leg . Review of Resident #33's documented the following physician orders: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 5 of 14 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 105827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Finnish-American Village 1800 South Drive Lake Worth, FL 33461 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 06/03/22 -weekly skin check every Wednesday. Level of Harm - Minimal harm or potential for actual harm 06/15/22 - Cleanse skin tears to left lower leg with normal saline/saline solution. Apply TOA, cover w/ gauze, wrap w/kerlix, secure w/tape and change daily until resolved every night shift. The physician order was discontinued on 06/28/22. Residents Affected - Few 07/11/22 cleanse reopening area to Left lower leg with Normal Saline, apply bacitracin, and cover with dry dressing every day shift. Review of Residents #33's weekly skin notes documented the following: 06/29/22 documented .skin tear to left lower leg (LLL) tx (treatment) in place . 07/06/22 documented . skin tear to LLL healing. 0 c/o (complaint) pain voiced . Review of Residents #33's skilled evaluation nurse note dated 07/11/22 at 11:47 PM, documented .skin .no new or worsening skin impairment .wound care n/a . Review of Residents #33's skilled evaluation nurse note dated 07/11/22 at 4:54 PM, documented .skin .no new or worsening skin impairment .wound care n/a . Review of Resident #33's Treatment Administration Record (TAR) for June 2022, documented that wound care to the resident's LLL started on 06/12/22 and was discontinued on 06/27/22. Review of Resident #33's Treatment Administration Record (TAR) for July 2022, documented that wound care to the resident's LLL was restarted on 07/12/22. On 07/12/22 at 3:26 PM, a side by side review of Resident #33's June 2022 TAR was conducted with the Director of Nursing (DON). The DON stated they had not consulted any wound care doctor for the residents left lower leg unhealed wound. The DON was asked if Resident #33 should have been seen by a wound care specialist and stated the resident should have. The DON was asked if any specialist had seen Resident #33 dark purple lower leg, and stated no. The DON stated that the resident had not had any special test done to check on her left lower leg dark colored skin but had been seen by Physiatrist and the Cardiologist. On 07/12/22 at 1:55 PM, wound care observation performed by Staff B, a Registered Nurse for Resident #33 was conducted. Observation revealed the resident's left lower leg skin was a dark purple color. There were multiple old scabs on the residents leg. Staff B commented that she did not normally work with Resident #33 and this was her first time seeing this wound. Staff B also stated that Resident #33's legs and feet were cold to touch, but when she asked the resident, she said she did not feel cold. Observation revealed the old dressing that was covering the wound, dated 07/11/22, was visibly soiled with drainage. When the old dressing was removed, it was observed that the wound was open (lacking a scab) and draining serosanguinous fluid. The wound edges were poorly defined and the wound appeared to be the size of a 50 cent piece. Staff B stated that the wound did not have the appearance of a pressure ulcer but rather it looked like a wound caused by venous insufficiency. On 07/12/22 at 3:41 PM, an interview was conducted with Staff B. Staff B stated that Resident #33 had mild tenderness during wound care today, on the residents left lower wound. Staff B stated that the wound looked like it was a peripheral problem and added that the resident's legs were cold. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 6 of 14 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 105827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Finnish-American Village 1800 South Drive Lake Worth, FL 33461 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few B was asked if she checked for pedal (foot) pulses and stated she did not check any pulses. Staff B added that the wound did not look like a regular wound and that the resident needed to be seen by the wound care specialist. Staff B stated she had never seen a wound like this before and again stated it did not look like a regular skin tear. Staff B was asked if she measured the wound and the dark purple surrounding area, and she stated that the wound was about 2 inches by 1.5 inches with light yellow sanguineous drainage. Staff B was asked if she had contacted the physician and stated she will contact the doctor when I get to it. On 07/12/22 at 3:45 PM, during an interview, the DON was asked if Resident #33 had been seen by a Podiatrist and stated that he did not see a podiatry note in the resident's chart. On 07/12/22 3:59 PM, an interview was conducted with the facility's Director of Social Services (DSS). The DSS stated that the podiatrist comes to the facility almost every month. A side by side review of the DSS Podiatrist list was conducted and revealed that Resident #33 had not been seen by the Podiatrist. On 07/12/22 at 4:45 PM, a side by side review of Resident #33's wound to her LLL was conducted with the DON. The superficial skin was opened, measuring approximately 2 inches long by 2 inches wide. The DON stated the wound had a slight drainage. The surrounding skin was dark purple color measuring about 5 inches long by 3 inches wide. On 07/13/22 at 8:39 AM, during interview, the DON submitted the Podiatrist notes dated 05/03/22. The note did not document/address Resident #33's LLL skin condition. On 07/13/22 at 8:50 AM, a joint telephone interview with the DON was made to the Podiatrist. The Podiatrist stated she did not see Resident #33 in June 2022. The Podiatrist stated she only does toenails, no wound care. On 07/14/22 at 7:02 AM, an interview was conducted with Staff F, a Licensed Practical Nurse. Staff F was asked of she provided wound care to Resident #33's LLL on 07/11/22, and stated she did not. Staff F stated the resident had bad bruises and they were putting gauze to protect her skin. Staff F did not remember the last time that she provided wound care for Resident #33. Staff F stated that the resident's skin had nothing open, just bad bruises. Staff F added the resident had a dark bruise on her leg and the skin was not open. Staff F stated she did not apply antibiotic to the LLL, and only put a dressing to protect the fragile skin. Staff F was asked where she documented the wound status, description, and measurement. Staff F stated the wound care doctor did that. Staff F was apprised that Resident #33 had not been seen by the wound care doctor and that she had an opened wound to her LLL, and had dark purple color skin surrounding the wound. On 07/14/22 at 7:41 AM, an interview was conducted with Staff E, a Registered Nurse (RN). Staff E stated she did Resident #33's LLL wound care dressing change on 07/13/22 and did not see any drainage. Staff E confirmed she did the resident's weekly skin check on 06/29/22 and 07/06/22. Staff E stated that she meant scabbing for healing. Staff E was apprised that the resident's LLL wound care was discontinued on 06/28/22 and that she documented treatment was in place. A side by side review of the resident's June 2022 and July TAR was conducted with Staff E. Staff E confirmed the treatment was discontinued on 06/28/22. On 07/14/22 at 8:12 AM, an interview was conducted with the DON, and he confirmed that Resident #33's physician order for LLL wound was discontinued on 06/28/22. He was apprised that the nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 7 of 14 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 105827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Finnish-American Village 1800 South Drive Lake Worth, FL 33461 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 documentation did not address the status of the resident's LLL skin discoloration, no pedal pulses documented and no measurements of the wound or the dark purple skin discoloration surrounding the wound. The DON was asked for the reason for discontinuation of the LLL wound care and he stated there was not documentation to support the discontinuation of the wound care, no documentation of the skin wound progress or the surrounding skin condition. Residents Affected - Few On 07/14/22 at 11:48 AM, an interview was conducted with the DON and he stated that he contacted the Medical Director/Attending Physician on 07/12/22 and ordered a wound care consult and ultrasound LLE. The DON added that the wound care specialist was notified but had not come to see the resident. Review of Resident #33's ultrasound of the Left Lower Extremity dated 07/13/22 results received on 07/14/22 documented, Occlusion of the dorsalis pedis artery. Slow flow velocity of the posterior tibial artery suggesting ischemia . On 07/14/22 at 12:38 PM, a telephone interview was conducted with Resident #33's attending physician via the DON's cell phone. The attending confirmed that Resident #33 was previously on the Assisted Living side of the facility, she was sent out to the hospital, and then came back to the facility nursing home side. The attending stated she thinks the leg wound came from the resident's wheelchair back in May 2022. The attending physician stated that wound care was being done and that the wound was doing better. She stated she thinks the scab over the wound must have re-opened but that wound care has been restarted by the facility now. The attending was informed that during the initial tour in the morning of 07/11/22, Resident #33's left lower leg wound dressing was not in place and there was drainage noted coming from the wound. She was further informed that upon record review, it was noted that there was no active order for wound care to be done for Resident #33. The wound was measured to be about 2 inches by 2 inches. Further record review revealed there was no documentation regarding the wound showing improvement. There was also no documentation regarding why wound care was discontinued. There was an order placed on 06/28/22 to discontinue wound care, but no wound care or nurses note regarding the wound status. Weekly skin notes were reviewed and continued to document tx in place despite there being no active wound care order. The attending physician then stated she was not sure why there was a lack of thorough documentation regarding the status of the resident's wound. Not sure why documentation was unclear. The attending stated the facility ordered a vascular study to assess Resident #33's vascular status so that more interventions can be done for this wound. The attending was apprised that Resident #33's leg was a dark purple color and that the facility nurse who performed wound care on 07/12/22 verbalized multiple times that the resident's legs and feet were cold to the touch. The attending stated that a Vascular doctor will be consulted now that the vascular study has been done. The surveyor explained the concern is that the wound care was stopped without proper documentation, that there was no follow up from any physician, and now the resident's leg has gotten worse, and it took the surveyor to intervene before the facility made any changes to Resident #33's plan of care. The attending stated she will discuss further with the facility's DON to see how to improve the care for Resident #33. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 8 of 14 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 105827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Finnish-American Village 1800 South Drive Lake Worth, FL 33461 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that include, maintenance of refrigeration units, and maintenance of air-conditioning vents. The findings included: During the kitchen/food service observation tour conducted on 7/11/22 at 9:10 AM, accompanied with the Dietary Manager (DM), the following were noted: (a) Observation of walk-in refrigerator #1 noted that the majority of the floor area (6 X 4') was heavily pitted and had a large area of rust. It was discussed with the DM at the time of the observation that the unit is very old, and the floor is in need of replacement. (b) Observation of the [NAME] reach-in refrigerator #1 noted that the there was an excessive build-up and dripping of condensation with the interior of the unit. It was noted that there was a large pan inside to collect the dripping condensation however it was so excessive that the dripping was going onto individual juice being stored within the unit. It was discussed with the DM at the time of the observation that there was a potential for the juice to become contaminated from the condensation and the unit should not be used until repairs can be made. (c) Observation of True reach-in refrigerator #2 noted that 3 of 3 shelves revealed a build-up of rust and there was a collection of condensation in the bottom interior of the unit. (d) Observation of the roll up dietary door to the dining room area, revealed a visible build up of dust around the opening chain/gear unit. The unit is located above the stream table and food preparation surface. It was discussed with the DM at the time of the observation that there was a high potential for the dust/dirt to fall into the steam table foods. Surveyor requested proper cleaning prior to the next meal service. (e) Observation of the 3 wall mounted air-conditioning vents located above the steam tables noted that the wall areas surrounding the vents was crumbling and in disrepair. It was discussed with the DM at the time of the observation that small pieces of wall could become loose and fall into steam table foods resulting in food borne contamination. The surveyor requested that the issues be repaired prior to the next meal service. (f) Observation of the walk-in refrigerator (milk storage #2) noted that the entrance area had a missing plate and that the entire floor of the unit was pitted and rust laden. It was discussed with the DM at the time of the observation that the unit is very old and floor replacement is necessary. (g) Observation of the walk-in freezer #2 noted that the entire door gasket (3 feet) was failing off from the unit. It was discussed with DM at the time of the unit that the missing gasket could result in the temperature not being maintained at the regulatory temperature of 0 degrees F or below. The surveyor requested that a new door gasket be installed, and the temperature of the unit be monitored for compliance throughout the day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 9 of 14 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 105827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Finnish-American Village 1800 South Drive Lake Worth, FL 33461 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 0812 Level of Harm - Minimal harm or potential for actual harm (h) Observation of the ceiling lighting units (4) noted that the light covers were soiled and dust laden. It was noted that the light units are located directly over food preparation and serving areas. It was discussed with the DM that the dust/dirt could potentially fall from the light fixtures (4) into foods resulting in food contamination. The surveyor requested that the light fixtures be properly cleaned prior to the next meal service. Residents Affected - Some (i) Observation of the kitchen floor in the food preparation/serving area noted that there was a hole in the floor tile (1.5 inches deep/3 inches wide. It was discussed with the DM at the time of the observation that bacteria/viruses can become trapped in the hole and spread out into the entire kitchen area by staff constantly walking over the hole. Following the kitchen/food service observation tour the findings were reviewed with the Administrator on 7/11/22. Note: Photographic evidence obtained on 7/11/22 of examples: (a), (b), (c), (d), (e), (f), (g), (h) , (i), and (j). 2) During the observation of the lunch meal in the Main Dining Room on 7/11/22 at 12 PM and breakfast meal in the Main Dining Room on 7/12/22 at 8 AM, it was noted that the ALF residents eat their meal prior to the nursing home residents. Further observation noted that the dining room chairs were not sanitized prior to the seating of the nursing home residents. It was noted that 40 dining room chairs were not properly cleaned and sanitized prior to the nursing home residents seating. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 10 of 14 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 105827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Finnish-American Village 1800 South Drive Lake Worth, FL 33461 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) On [DATE] at 10:25 AM, during an interview with Resident #38 it was noted that the call bell was broken off and missing. (Photographic evidence taken) Resident #38 was admitted on [DATE] with diagnoses that include heart disease and Parkinson's. A minimum data set (MDS) resident assessment done [DATE] stated the resident is cognitively intact and has a functional status of being able to eat with supervision. Residents Affected - Some 7) On [DATE] at 10:52 AM Resident #37's call bell was noted to be missing. (Photographic evidence taken) The resident was noted to adjust her blanket and was able to answer a few questions appropriately. Resident #37 was admitted on [DATE] with diagnoses that include stroke and dementia. A MDS assessment done [DATE] stated the resident has severe cognitive impairment requiring extensive assistance to total care for all activities. On [DATE] at approximately 12:30 PM Staff A, LPN was notified of missing call bells in Resident #38 and Resident #37's room. He stated he would follow up. On [DATE] at 8:30 AM, it was noted the call bells in Resident #38 and Resident #37's room had been replaced but were nonfunctioning. 8) On [DATE] at 8:30 AM, it was noted the call bell for Resident #35 was nonfunctional. Record review for Resident #35 reveals an admission date of [DATE] with diagnoses that include Parkinson's and Alzheimer's. A MDS assessment on [DATE] documented severe cognitive impairment with a functional ability requiring supervision only to eat and walk the halls. 9) On [DATE] at 8:30 AM, it was noted the call bell for Resident #41 was nonfunctional. Record review for Resident #41 reveals an admission date of [DATE] with diagnoses that include Parkinson's and Alzheimer's. A MDS assessment on [DATE] documents severe cognitive impairment with a functional ability requiring supervision only to eat and walk in room. 10) On [DATE] at 8:30 AM, it was noted the call bell for Resident #5 was nonfunctional. Record review for Resident #5 reveals an admission date of [DATE] with diagnoses that include Parkinson's and heart disease. A MDS assessment on [DATE] documents moderate cognitive impairment with a functional ability requiring extensive assistance for all activities. 11) On [DATE] at 8:30 AM, it was noted the call bell for Resident #40 was nonfunctional. Record review for Resident #40 revealed an admission date of [DATE] with diagnoses that include fractured femur with repair and Alzheimer's. A MDS assessment on [DATE] documents moderate cognitive impairment with a functional ability requiring supervision only to eat and walk in room. On [DATE] at 8:45 AM, an observation with a second surveyor was conducted, who verified the call bells for Residents #38, #37, #35, #41, #5, and #40 were not functioning. On [DATE] at 9:00 AM Staff A, LPN confirmed Residents #38, #37, #35, #41, #5, and #40 call bells failed to respond when activated. Resident #37's call bell cord had been replaced on [DATE] but fell apart upon examination by Staff A (Photographic evidence taken). He stated they had a problem with one of the call bells on Sunday, but he thought it was fixed. He is unaware of a routine process for checking that call bells work. They usually find out the bell does not work when a resident complains. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 11 of 14 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 105827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Finnish-American Village 1800 South Drive Lake Worth, FL 33461 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 12) On [DATE] at 12:30 PM, the facility Administrator identified Resident #27 as having a nonfunctioning call bell. Record review reveals Residents #27 has an admission date of [DATE] with diagnoses that include urinary tract infection and dementia. A MDS assessment on [DATE] documents moderate cognitive impairment with a functional ability requiring supervision only to eat. Based on observations, interviews, and record reviews, the facility failed to ensure that the call light systems were working properly throughout the facility for 13 out of 43 residents (Resident #16, 243, 2, 24, 31, 37, 5, 41, 40, 35, 38, 42, 27). The findings included: Review of the facility policy titled Call Lights, undated, revealed the following, Staff will report problems with a call light or the call system immediately to the supervisor and/or Maintenance Director and will provide immediate or alternative solutions until the problem can be remedied. The Maintenance Department will conduct monthly audits of all call lights to ensure functionality. Ensure the call system alerts staff members directly or goes to a centralized staff work area. 1) On [DATE] at 9:00 AM, Resident #16 was observed lying in bed with her call light lying next to her left hand. Upon further investigation, the surveyor found this call light to be non-functioning; the surveyor pressed the button on the call light and no alert or alarm sounded in the room or at the nurse's station and no light came on above the room door. Resident #16 was admitted to the facility on [DATE]. According to an Annual Minimum Data Set (MDS) done on [DATE], Resident #16 had a Brief Interview of Mental Status (BIMS) score of 3, which shows cognitive impairment. For functional status, Resident #16 required set up assistance for meals. Further observation of Resident #16 revealed she was alert and able to communicate with staff and was able to feed herself after her meal trays were set up by a staff member. This functional status indicated she was able to use a call light. 2) On [DATE] at 9:00 AM, Resident #243 was observed sitting in her wheelchair next to her bed with her call light lying on the bed in front of her. Upon further investigation, the surveyor found this call light to be non-functioning; the surveyor pressed the button on the call light and no alert or alarm sounded in the room or at the nurse's station and no light came on above the room door. Resident #243 was admitted to the facility on [DATE]. According to an admission MDS done on [DATE], Resident #243 had a BIMS score of 15, which shows she was cognitively intact. For functional status, Resident #243 required set up assistance for meals. Further observation of Resident #243 revealed she was able to fully interact with staff, propel herself around the facility in her wheelchair, and enjoy her meals in the main dining room. In an interview with Resident #243 on [DATE] at 9:00 AM, she stated she did not notice the call bell was not working. This functional status indicated she was able to use a call light. 3) On [DATE] at 9:05 AM, it was revealed that the room of former Resident #2, who had previously resided in this room, had passed away during the evening of [DATE]. The surveyor attempted to use the call light that was lying across the bed and found it to be non-functioning; the surveyor pressed the button on the call light and no alert or alarm sounded in the room or at the nurse's station and no light came on above the room door. Resident #2 had been admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 12 of 14 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 105827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Finnish-American Village 1800 South Drive Lake Worth, FL 33461 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some According to a Quarterly MDS done on [DATE], Resident #2 had a BIMS score of 3, which shows cognitive impairment. For functional status, Resident #2 required extensive assistance of one staff for eating her meals. Earlier observations of Resident #2 made on [DATE] at 9:09 AM, 11:50 AM, and 2:00 PM revealed her grandson was present at her bedside. In an interview conducted on [DATE] at 11:50 AM, her grandson stated that Resident #2 was on hospice, and he knew she would pass soon. This functional status indicated Resident #2 was unable to use the call light, but the presence of family at the bedside indicated they would be able to use the call light on Resident #2's behalf. Also, a new resident could be admitted to this bed and have this non-functional call light. 4) On [DATE] at 9:10 AM, Resident #24 was observed sitting in her wheelchair next to her bed with her call light lying on the bed in front of her. Upon further investigation, the surveyor found this call light to be non-functioning; the surveyor pressed the button on the call light and no alert or alarm sounded in the room or at the nurse's station and no light came on above the room door. Resident #24 was admitted to the facility on [DATE]. According to a Quarterly MDS done on [DATE], Resident #24 had a BIMS score of 1, which shows cognitive impairment. For functional status, Resident #24 required total dependence of one staff for eating her meals. Further observations of Resident #24 revealed she was able to be helped into her wheelchair with staff assistance and go to the main dining room for her meals. This functional status indicated she may be able to use a call light. 5) On [DATE] at 9:15 AM, Resident #31 was observed lying on his bed with his call light next to him. Upon further investigation, the surveyor found this call light to be non-functioning; the surveyor pressed the button on the call light and no alert or alarm sounded in the room or at the nurse's station and no light came on above the room door. Resident #31 was admitted to the facility on [DATE]. According to a Quarterly MDS done on [DATE], Resident #31 had a BIMS score of 3, which shows cognitive impairment. For functional status, Resident #31 required supervision for eating his meals. Further observation of Resident #31 revealed he was able to transfer himself from his bed to his wheelchair, propel himself around the facility in his wheelchair, feed himself his meals, make phone calls to his family, and use his call light. In an interview with Resident #31 on [DATE] at 9:15 AM, he stated he did not notice the call light was not working. This functional status indicated he was able to use a call light. The observations of these non-functioning call lights were verified by a second surveyor on [DATE] at 9:35 AM. An interview was conducted with the facility's Administrator on [DATE] at 10:15 AM. He stated he was unaware of the call lights not working until the surveyors brought it to the staff's attention. The Administrator also verified there was no documentation in the maintenance log of non-functioning call lights. He said the maintenance staff was made aware of the issue and were working on fixing or replacing each of the non-functioning call lights. The surveyors stressed that an action plan needed to be in place for checking on all residents until the call lights were all confirmed to be working properly. The Administrator brought to the surveyors the facility's policy on call lights and maps of the facility (dated [DATE], [DATE], and [DATE]) showing the monthly audits of the call light system were being conducted properly. The Call Light Plan, dated [DATE] was also provided which stated the following: Plan: Residents who reside in the rooms listed above will have their rooms monitored by staff every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 13 of 14 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 105827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Finnish-American Village 1800 South Drive Lake Worth, FL 33461 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 0919 Level of Harm - Minimal harm or potential for actual harm 10 minutes until the call light has been deemed working. Monitoring will include a visual and asking if the resident requires any assistance. The call light will be deemed in working order after it is properly lighting up in the hallways and sounding at the nurse's station. This will be confirmed by 2 independent staff members. An audit of all call lights in the Nursing Facility will take place immediately following the assessment and repair of the call lights listed previously. Residents Affected - Some Call Light Audit Results: All call lights mentioned in the initial Call Light Plan were reviewed and tested by the facility staff and found that four of the call lights were not in working order; these call lights were immediately replaced and retested. The other reported call lights were in working order when tested. An independent audit was conducted by 2 other staff members of all call lights in the resident room, bathroom and its subsequent ringing at the nurse's station. This audit found that the call light in room E3B was not in working order. This call light was replaced and tested and is now in working order. On [DATE] at 2:30 PM and on [DATE] at 12:00 PM, the surveyor rechecked all of the previously non-functional call lights on the [NAME] hallway and confirmed that each one was in working order prior to exiting the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105827 If continuation sheet Page 14 of 14