Inspection·May 26, 2022

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some 1) Review of the record revealed Resident #5 was admitted to the facility on [DATE]. Review of the current quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was alert and oriented. During an interview on 05/23/22 at 10:48 AM, Resident #5 voiced concerns about the food, but that it had gotten better since the residents had voiced complaints. During a subsequent observation and interview on 05/23/22 at 12:32 PM, Resident #5 stated her lunch was okay, but the carrots were observed to be untouched. When asked about the carrots, Resident #5 stated she didn't like cooked carrots. When asked if anyone from the facility had spoken to her about her food preferences, she could not recall. When asked if she had participated in a care plan meeting, Resident #5 stated she could not recall. Review of the Care Plan Meeting dated 05/10/22 revealed the documented signature of Resident #5 and four other staff who were identified as the Director of Rehab (DOR), Social Services (SS), the Director of Nursing (DON), and a Certified Nursing Assistant (CNA). This Care Plan Meeting lacked documented evidence of participation by the direct care nurse and food and nutrition services. 2) Review of the record revealed Resident #35 was originally admitted to the facility on [DATE], with a documented re-admission on [DATE]. Further review revealed the most current quarterly MDS assessment was completed on 03/16/22. Review of the Care Plan Meeting dated 04/05/22 lacked documented evidence of participation by food and nutrition services. 3) Review of the record revealed Resident #42 was admitted to the facility on [DATE]. Further review revealed the most current comprehensive MDS assessment was dated 05/03/22. Review of the Care Plan Meeting dated 04/13/22 related to the resident's readmission, lacked any documented evidence of participation by the food and nutrition services. 4) Review of the record revealed Resident #52 was admitted to the facility on [DATE]. Further review revealed the comprehensive MDS assessment was dated 05/02/22. Review of the Care Plan Meeting dated 05/05/22 lacked any documented evidence of participation by the food and nutrition services. 5) Review of the record revealed Resident #7 was admitted to the facility on [DATE]. A Quarterly MDS assessment was completed on 01/31/22. Review of the Care Plan Meeting dated 02/16/22 lacked any documented evidence of participation by Food and Nutrition services or Social Services. 6) Review of the record revealed Resident #49 was admitted to the facility on [DATE]. A Quarterly MDS assessment was completed on 04/18/22. Review of the Care Plan Meeting dated 04/30/22 lacked any documented evidence of participation by Food and Nutrition services or Social Services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105835 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 105835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Trail Nursing and Rehab Center 4445 Pine Forest Dr Lake Worth, FL 33463 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some 7) Resident #27 was admitted to the facility on [DATE]. The Resident Brief Interview for Mental Status (BIMS) 03. On 5/24/22 at 3:30 PM, conduct a review of the Resident care plan conference records it was noted that the only staff that had participated in the conference on 3/18/22 was the floor Nurse and the Director of Nursing, and the Resident Representative. 8) Resident #30 was admitted to the facility on [DATE]. The Resident Brief Interview for Mental Status (BIMS) is 12. On 5/24/22 at 4:00 PM during a review of the Resident Care plan Conference record for 3/29/22. The documented staff that Participated at the conference were the Director of Nursing, the Floor Nurse and a Certified Nursing Assistant. The Resident Representative participated via phone. 9) Resident #32 admitted to the facility on [DATE]. The Resident Brief Interview for Mental Status (BIMS) is 15. On 5/25/22 conduct a review of the Resident documented Care Plan Conference record for 3/30/22, it revealed that the participating documented staff were the Director of Nursing, The floor nurse and a Certified Nursing Assistant. On 5/26/22 at 10:35 AM conduct an interview with the DON to inform her of the Care Plan Conference Participation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105835 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 105835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Trail Nursing and Rehab Center 4445 Pine Forest Dr Lake Worth, FL 33463 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, observation, record review and interview, the facility failed to ensure a safe environment for a resident diagnosed with Dementia (Resident #6). This failure affected 1 of 4 residents sampled for falls. The findings included: Facility Policy titled Falls and Fall Risk, Managing, revised 9/24/2021 reads: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Facility Policy titled Housekeeping and Environmental Services Policy and Procedure, revised June 2009, states: Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. Documentation of a process to provide safety during mopping the floor in a resident's room was not noted in the housekeeping policy and procedures provided by the facility. On 05/23/2022 at 10:02 AM Resident #6 was observed in bed with a cast on her right wrist. She stated that she fell and broke her wrist and that is why she has a cast. She said she does not remember anything about when it happened. She went on to say she does not know why she is here and wants to see her children. On 05/24/2022 at 11:03 AM Resident #6 was noted wandering in the hallway without shoes or socks. A staff member redirected her back to her room stating, you need to put shoes on. Record review for Resident #6 reveals she was admitted on [DATE] with diagnosis that include dementia (brain dysfunction marked by memory disorders, personality changes and impairment in judgement), progressive neuropathy (nerve damage) and hypertension. Psychiatric evaluation on 02/22/2022 states Resident #6 has advanced dementia with periods of confusion. Care plans initiated 02/16/2021 and reviewed 05/12/2022: A) titled Behavior, states to approach in a calm manner and intervene as needed to protect the rights and safety of others; B) titled Cognitive Loss/Dementia, documents resident as having short term memory problems and states to minimize changes in caregivers, allow for choices, be alert for triggers, balance the amount of stimuli, allow adequate rest between stimulating events; C) titled Falls, documents resident is at high risk for falls related to dementia and poor safety awareness. The fall care plan lists approaches as: Keep room free from clutter; Keep call light within reach when resident is in room; Keep bed in lowest position; Therapy to screen for service; Medication review as needed. Document for Resident #6 titled: Therapy Screening of Resident Falls states, Date of Fall: 4/24/22, Date of Screen: 4/25/22, Circumstance of Fall: Resident's roommate/husband notified nurse his wife had fell and hurt her hand. Results of Screen: Resident's room was recently mopped, and floor was wet with wet floor signs in place. Encourage resident to be out of room during housekeeping. Physicians progress notes dated 04/25/2022 and 05/03/2022 documents Right Distal Radius Fracture (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105835 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 105835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Trail Nursing and Rehab Center 4445 Pine Forest Dr Lake Worth, FL 33463 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 0689 (broken wrist). Level of Harm - Minimal harm or potential for actual harm On 05/26/2022 at 10:35 AM, Staff A stated she was not in the room when Resident #6 fell. She said the resident's husband came out and said my wife fell. Staff A went to the room, assessed the resident, and called the doctor. She said the resident had no recall of what happened. Staff A stated she thinks there was a wet floor sign at the door but was unsure. Residents Affected - Few On 05/26/2022 at 2:42 PM the Director of Nurses stated that as follow-up after the fall she had a meeting with the Director of Housekeeping. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105835 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 105835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Trail Nursing and Rehab Center 4445 Pine Forest Dr Lake Worth, FL 33463 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) During an interview on [DATE] at 2:51 PM, Resident #5 stated she told facility staff she wanted to be seen by the eye doctor for a routine visit, and she was unsure when the eye doctor would do the visit. Review of the record revealed Resident #5 was admitted to the facility on [DATE]. Review of the current quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was alert and oriented. Further review of the record revealed an order dated [DATE] that documented, Eye exam with Mobile eye care due to complaint of 'eye squinting'. Review of the paper chart located at the nurse's station lacked any evidence the appointment for the Mobile Eye was made or completed. During an interview on [DATE] at 1:41 PM, Staff A, a Licensed Practical Nurse (LPN), stated that vision and dental services come to the facility when there are enough residents who need them. The LPN stated the Director of Nursing (DON) would have more information. During an interview on [DATE] at 1:44 PM, the DON stated that Social Services (SS) keeps track of those appointment. The surveyor asked to speak with Social Services. On [DATE] at 1:49 PM the surveyor was approached by the Previous Nursing Home Administrator (NHA), who was assisting with the survey process, and was informed the facility uses mobile services for eye and dental concerns. The Previous NHA stated she could provide evidence of who has been seen by Mobile Eye in the past three months, or who was currently on their list to be seen. On [DATE] at 2:40 PM, the previous NHA provided a list of residents that revealed Resident #5 had been seen by Mobile Eye on [DATE]. When asked why there was no progress note or evidence of the completed visit in the medical record, the Previous NHA explained that all their physician consults, like dental services and Mobile Eye, are kept in separate binders in the offices. The consultant's progress notes are not accessible to staff when these offices are locked, and the residents' medical records are not complete. 4) During an interview on [DATE] at approximately 11:00 AM, when asked where the consents and information related to each resident's flu and pneumonia immunizations were maintained, the Director of Nursing (DON) stated, In a binder here in my office. When asked if a copy was also maintained as part of the resident's medical record, the DON stated it was only kept in the binder. The DON also explained that the COVID-19 vaccination and testing information for each resident was not maintained in the resident's medical record. Based on interviews and record reviews, the facility failed to maintain accurate and complete resident records for 8 of 18 sampled residents whose records were reviewed regarding: 1) Advance Directives (Residents #4, #11, and #42); 2) Accuracy of MDS records (Resident #7 and #11); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105835 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 105835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Trail Nursing and Rehab Center 4445 Pine Forest Dr Lake Worth, FL 33463 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 0842 3) Physician consults (Resident #5); Level of Harm - Minimal harm or potential for actual harm 4) Immunization Information; 5) Neuro-checks (Resident #6), and Residents Affected - Few 6) Wound Care (Resident #53). The findings included: The facility's Advanced Directives Policy (revised [DATE]) states: 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his family members, about the existence of any written advance directives. 4. Information about whether the resident has executed an advance directive shall be displayed prominently in the medical record. 1a) Resident #4 was admitted to the facility on [DATE] with diagnoses documented on Face Sheet which included Atrial Fibrillation, Diabetes, Malnutrition, Pressure-induced deep tissue damage of left and right heels, Adult Failure to Thrive, Dysphasia, Muscle Weakness, ADHD, Depression, Hypertension, Suicidal Ideations. Resident #4's record contained a yellow Do Not Resuscitate (DNR) order dated [DATE] and signed by Resident's physician. A bright orange sticker with DNR printed on it was placed on the resident's binder to show Resident as being DNR. Resident #4's Face Sheet documented resident is DNR. However, the Physician Order Sheet (POS)for [DATE] and [DATE] both document the resident's Advance Directive as being Full Resuscitation. On [DATE] at 09:25 AM, Resident #4, who has a BIMS (Brief Interview for Mental Status) score of 15 out of 15, was asked if he expressed his wish to his physician or this facility's staff regarding his Advanced Directives. The resident replied that he didn't understand the question. The question was rephrased and Resident #4 was asked if he had made his wish known if he wanted CPR, or not, if something should happen in order to save his life. The resident stated that he would want the staff to do CPR on him. On [DATE] at 09:38 AM when asked what Resident #4's advance directive was, Staff A (licensed practical nurse) stated, He is a DNR I asked where she found this information. She stated, It is listed on his face sheet, and he has the yellow paper in his file. When pointing out the statement ,full resuscitation documented on the Physician Order Sheet under Advance Directives, she seemed surprised and concerned and said, Oh my, I will have to ask about this. On [DATE] at approximately 10:00 AM, the Director of Nursing (DON) approached the surveyor and stated that Resident #4 had been admitted to the facility severely depressed, and he had tried to commit suicide. This resident had expressed his wish not to be resuscitated. The DON showed me a doctor's order, written on [DATE], which documented, .Resident is stable and wishes to remain at facility w/DNR status. The DON was informed of my conversation with the resident where he expressed his wish to receive CPR, should it be necessary. The DON stated she would have another conversation with the resident to find out if his advance directives should be changed. 1b) Resident #11 was admitted to the facility on [DATE] with diagnoses which include Diabetes, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105835 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 105835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Trail Nursing and Rehab Center 4445 Pine Forest Dr Lake Worth, FL 33463 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Hypertension, Alzheimer's, Depression, and Manic Depression. The resident's Face Sheet documents that this resident does NOT have Advance Directives in place. A review of the Physician Order Sheet (POS) documents Full Code under Advance Directives, but the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form documents under Section H. ADVANCE CARE PLANNING that Resident #11 has an Advance Directive and a DNR. A review of Resident 11's medical chart revealed a signed and witnessed Health Care Advance Directive, including Living Will, Health Care Surrogate Designation and Durable POA, dated [DATE], which outlines specific instances when resident refuses life-prolonging procedures to be done. Photographic evidence obtained. On [DATE] at approximately 3:00 PM, the DON was shown Resident #11's Face Sheet, Physician Summary Orders, and the Resident's signed Advanced Directives to show her that the Face Sheet erroneously stated Resident #11 had no Advance Directives in place. The surveyor also showed her the Physician Summary Orders which documented that Resident #11 was Full Code, even though the Resident has a signed, legally drawn Advance Directive which limits the use of life-prolonging procedures in certain specified circumstances. In response, the DON acknowledged that the wishes of the resident and family needed to be further investigated to make sure the Resident's advance directives were carried out as intended, and that these directives were clear to staff. 1c) Review of the paper chart revealed Resident #42 was originally admitted to the facility on [DATE], with a current readmission on [DATE]. Further review of the record revealed a Full Resuscitate order on a previous readmission Physician Order Sheet (POS) dated [DATE]. The current [DATE] POS lacked any documented code status. The paper record did contain a yellow copy DNR order executed on [DATE]. Other documents included a base line care plan dated [DATE], a Social History, Assessment and Discharge Plan done with the resident's original admission, and the face sheet, all of which documented a DNR status. The inside of the binder cover also contained a DNR sticker. During an interview on [DATE] at 11:20 AM, Staff B, a Licensed Practical Nurse (LPN), was asked the code status for Resident #42. The LPN opened the paper chart and looked at the face sheet for a couple of minutes. The LPN was unable to find the documented Do Not Resuscitate (DNR) on the bottom of the face sheet. This was pointed out by the surveyor. The LPN did see the DNR sticker on the inside of the binder cover. The LPN was not sure of the code status. The surveyor then pointed out the yellow DNR paperwork, the lack of a DNR order on the [DATE] POS, along with the Full Resuscitate order on the handwritten [DATE] POS. The LPN agreed with the contradictory status and stated, Maybe (name of DON) can clarify it. On [DATE] at 11:25 AM, the contradictory documentation related to the code status for Resident #42 was brought to the attention of the DON, who agreed with the concern. 2a) Resident #4 was admitted to the facility on [DATE] with diagnoses documented on the Face Sheet which included Atrial Fibrulation, Diabetes, Malnutrition, Pressure-induced deep tissue damage of left and right heels, Adult Failure to Thrive, Dysphasia, Muscle Weakness, ADHD, GERD, Depression, Hypertension, Suicidal Ideations. Diagnoses listed on POS only included A-Fib, Hypertension, Diabetes, Neuropathic Nerve, and Pancreatitis. A review of the Resident's Care Plan, dated [DATE] and revised [DATE], contained a plan of care for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105835 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 105835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Trail Nursing and Rehab Center 4445 Pine Forest Dr Lake Worth, FL 33463 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CHF (Congestive Heart Disease) and COPD (Chronic Obstructive Pulmonary Disease). There is No diagnosis of CHF or COPD documented on the MDS, the Resident's Face Sheet or the Physician's Order Summary (POS). 2b) Resident #7 was admitted to the facility on [DATE] with diagnoses which include Alzheimer's, Psychosis, Major depressive disorder, Anxiety, Dementia without behaviors, Hypothyroidism, COPD, Osteoarthritis. A review of Resident #7's MDS, dated [DATE] and [DATE], had resident coded with having a Limb Restraint, used while in bed, less than daily, during both MDS observation dates. A review of Resident #7's Care Plan showed no plan of care for Limb restraints, nor were any limb restraints observed in use on this resident. On [DATE] at 9:45 AM, the Director of Therapy, and Director of Nursing, confirmed that Resident #7 does not have any restraints in place. On [DATE] at 10:50 AM, the former Administrator stated that MDS nurse corrected the error regarding 'restraints' on the [DATE] and [DATE] MDS reports. The corrected copies were provided for review. 5) On [DATE] at approximately 11:00 AM, a review of resident records revealed no documentation of neuro-checks for Resident #6 or wound care notes for Resident #53 within these residents' medical records. Upon inquiry, the staff nurse informed this surveyor that neuro-checks and wound care notes are kept in the Director of Nursing's (DON) office, not in the resident's charts. Upon request, the DON provided the documents for Resident #6 and #53. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105835 If continuation sheet Page 9 of 9