Health inspection·June 23, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to provide respect and dignity in a manner and in an environment that promotes enhancement of quality of life that include, ensuring all residents are served proper drinking cups with meals; ensuring residents are served hot meals and/or bagged lunch on scheduled outpatient dialysis center appointments for 2 of 2 sampled residents reviewed for dialysis; and ensuring a residents' nails are not clipped over the lunch meal tray for 1 of 1 sampled residents (Resident #257), who was reviewed requiring fingernail care. The findings included: 1) During the observation of the breakfast meal on 06/21/22 at 8 AM noted that all facility resident's (94) received a carton of milk, carton of juice , and a majority received a nutritional liquid supplement. Further observation noted that none of the facility residents received a proper beverage cup for the residents to drink from. It was further noted that facility residents were required to drink directly from the beverage carton container. Upon interviews with random residents during the breakfast meal, it was stated that they would like a cup for their beverages. Following the observation, the Dietary Manager (DM) was interviewed in the main kitchen concerning the issues and to determine how many drinking cups were needed for resident meals. It was calculated by the DM that 114 drinking/beverage cups should be available for resident breakfast trays for the current census of 94 resident. An observation of the dietary supply of drinking cups noted that there were approximately only 40 cups in supply for resident meals. The DM stated that a sister facility would be contacted to provide additional cups. However, further observations conducted on 06/22/22 and 06/23/22 noted no additional cups were received. 2) During an observation of Resident #255 on 06/20/22 at 11 AM, it was noted that the resident was being readied to be taken for transport to the dialysis center. Further observation noted that a bagged lunch consisting of a Peanut & Jelly sandwich was ready to go with the resident. The resident was asked if she received an early hot lunch meal prior to leaving of which the resident replied no and further stated she would like a hot lunch meal prior to leaving for the dialysis center. Following the observation an interview was conducted with the 300 Unit Manager who stated that the resident's dialysis chair time was changed to 12:30 PM recently, but had not communicated with the dietary department for the request that Resident #255 receive an early lunch tray on dialysis days that include every Monday, Wednesday, and Friday. Additional observation conducted on 06/22/22 at 11 AM noted that the resident was sent a early hot lunch, however an observation of the lunch meal noted that the resident did not receive a wheat roll and brownie for dessert. 3) During an observation of Resident #30 on 06/22/22 at 9:35 AM it was noted the resident yelling for 30 minutes for staff assistance to be taken to the lobby for transportation to the dialysis Page 1 of 34 105852 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some center. Further observation noted staff ignoring the resident's request and the surveyor made the determination to wheel the resident to the lobby. While on the way to lobby the surveyor asked to see the resident's dialysis bagged lunch. The resident responded that numerous times she is not given a bagged lunch to take to dialysis and is tired of asking for the bagged lunch prior to leaving. She further stated that she gets hungry but doesn't care anymore. Upon arriving to the lobby it was noted that the transportation driver was waiting and stated that the resident is late and he was ready to leave. 4) During an observation of Resident #257 on 06/20/22, it was noted that the resident's fingernails on both hands were extremely long, dirty, black in color, and had sharp points on the ends of each nail. An interview with the alert and oriented resident at the time of the observation, revealed the resident requesting nail care numerous times on a daily basis. The resident asked the surveyor to assistance with the issues. The matter was brought to the attention of the 200 Unit Manager and Director of Nursing on 06/22-23/22. Observation of Resident #257 on 06/23/22 at 10 AM again noted that the resident had not received nail care and was becoming agitated with the lack of nail care. On 06/23/22 at 12:30 PM, a subsequent observation was conducted of Resident #257. The observation noted that a LPN (Licensed Practical Nurse), Staff F was with the resident, trimming the fingernails. Further observation noted that Staff F was trimming the nails over the resident's lunch food tray while the resident was self feeding. It was noted that the trimmed nails were falling directly onto the resident's food tray and food. The surveyor requested that Staff F cease trimming during the meal and request another lunch tray. The resident responded and stated, don't bother with another tray, as I'm happy they are finally trimming my nails. The matter was reported to the 200 Unit Manager who stated she would request a new lunch tray. A review of the clinical record of Resident #257 on 06/22/22 noted the current MDS (Minimum Data Set) assessment documented the resident's BIMS (Brief Interview for Mental Status) score as 15 (no cognitive impairement). * Photographic Evidence was obtained of the resident's 06/23/22 lunch tray. 105852 Page 2 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and interviews, the facility failed to honor 1 of 3 sampled residents' rights (Resident #52) to appeal discharge from skilled services (OT (Occupational Therapy & PT (Physical Therapy), by ensuring they received and signed the Notice of Medicare Non-Coverage (NOMNC). Residents Affected - Few The findings included: Resident # 52 began skilled services on 05/05/2022 and his therapy services were terminated on 06/08/2022. The facility initiated the discharge (d'c) with rehabilitation days remaining. However, review of the Notice of Medicare Non-Coverage (NOMNC) revealed that it was not signed by the resident or his authorized representative. The Social Worker wrote on the NOMNC that Resident #52's authorized representative (AR) was contacted on 6/6/2022 via telephone to let him know that the treatment would be suspended on 06/09/2022. During an interview conducted with the Social Worker (SW) on 06/22/22, at 3:02 PM, she reported that the resident's AR came to the facility for the discharge a few days prior to the discontinuation of the resident's skilled services, and on the day the resident was discharged from the facility. Yet, the SW did not provide the NOMNC to the AR. She said that she informed and explained to the AR his rights to appeal. She also said if she had given the NOMNC to the AR to sign when he came to the facility, it would have been too late. Review of the Social Worker's progress notes dated 06/06/2022 revealed that the AR was contacted via telephone and the right to appeal discontinuation of services were explained to him. The record showed that the AR expressed desire to appeal the decision to terminate services, so that his father could benefit from additional therapy days. However, the notes dated 06/09/2022 (Resident #52 d'c date) did not reflect that the resident appealed the decision. There was neither an indication that the SW assisted the resident with the appeal process. During an interview with the therapy department Team Leader (Staff M) on 06/23/22 at 2:30 PM, she reported that the resident did very well in therapy. She reported that Resident #52 was a trooper and met all the goals set, for both physical therapy (PT) and occupational therapy (OT). She explained that partial/moderate assistance meant that the resident required more assistance compared to supervision in which a resident would require standby assistance. However, the ideal task performance would be independent. The resident's record revealed that he was diagnosed of weakness, muscle wasting and atrophy, and unspecified fall, etc. The initial PT evaluation and treatment plan dated 05/06/2022 showed that the resident performed rolling from left to right while lying on his back with partial to moderate assistance. The goal was for him to independently perform that task. He performed lying to sitting on the side of bed with partial to moderate assistance. The intended goal was for him to accomplish this task with supervision. He transferred from bed to chair and vice-versa with partial to moderate assistance. The performance goal was with supervision. The last goal was for Resident #52 to ambulate up to 125 feet using two-wheeled walker with supervision or touching assistance in order to achieve independence at his house. Resident #52 met these PT goals except two others, a) timed up and go, the record revealed that the Resident was unable to participate. b) Resident #52 required cues and supervision to perform home exercise program (HEP). In all, Resident #52 could not perform all required task independently upon discharge. The discharge PT record showed that the resident destination was to 105852 Page 3 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0582 his home. Level of Harm - Minimal harm or potential for actual harm Review of the OT initial evaluation showed that Resident #52 performed the following tasks with partial to moderate assistance: Toilet transfer; lower body dressing and toileting and hygiene on 05/06/2022. Upon discharge from OT on 06/06/2022, the resident met the desired goals to perform these tasks with supervision or touching assistance. However, Resident #52 did not perform any of the tasks or goals independently. Residents Affected - Few The records failed to reflect that the resident's AR appealed the decision to suspend termination from therapy. as the AR intended. The Social Worker also failed to assist in the appeal process or provide records to indicate that the resident and his AR left fully satisfied with the services provided. 105852 Page 4 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that 2 of 3 sampled residents (Resident #14 and #151) received a copy of the Baseline Care Plan. The findings included: 1. On 06/20/22 at 1:35 PM, during an interview with Resident #14, he reported that he did not participate in any care plan meeting and no one discussed his plan of care with him. Review of the clinical record revealed that Resident #14 was diagnosed with the following: Other Symptoms and Signs Involving the Musculoskeletal System Right Artificial Knee Joint, Muscle Wasting And Atrophy, Difficulty In Walking, Complication Of Internal Left Knee Prosthesis, Left Artificial Knee Joint, and Osteoarthritis. Review of the Baseline care plan (CP) dated and completed on 6/11/2022 showed that it was initiated on 6/10/2022. The CP outlined all the required services Resident #14 was supposed to receive during his stay at the facility. Review of the Nurses Progress Notes dated 06/13/2022 revealed an entry that the Rehabilitation Unit Nurse Manager met with the resident to discuss the baseline care plan. The note revealed that Unit Manager reviewed medications, diet, Physical therapy, occupational therapy course of treatment with Resident #14 and the Resident was eager to get started. 2. During an interview on 06/20/22 at 10:23 AM, Resident #151 reported that she did not have any care plan meeting, nor did she receive any copy of the Care Plan (CP). The Clinical record reveals Resident #14 was admitted to the facility on [DATE]. The Baseline CP was initiated on 06/08/2022 with an expected review date of 06/28/2022. Resident#14's admitting diagnoses included Chronic Obstructive Pulmonary Disease, Unspecified; Muscle Wasting And Atrophy, Falls; Dizziness and Giddiness; Atherosclerotic Heart Disease Of Native Coronary Arterys; Hyperlipidemia, and Hypothyroidism. The Minimum Data Set (MDS) assessment revealed the resident scored 15/15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. In an interview conducted with the Rehabilitation Nurse Unit Manager on 06/22/22 at 9:36 AM, she reported that that she usually completes the baseline CP's as soon as residents are admitted in her unit. She said that the CP are developed with the residents or their family members. When asked if she had discussed the CP with Resident #14 and #151 and had given them a copy of the plan, she responded that she did not know that the residents were supposed to have a copy of the baseline CP. She said that she will do that from now on. She added that she has been working at the facility for three weeks. No further explanation or information was provided during the exit meeting on 06/23/2022. 105852 Page 5 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) During an observation of Resident #257 on 06/20/22, it was noted that the resident fingernails on both hands were extremely long, dirty, black in color, and sharp points on the ends of each nail. An interview with the alert and oriented resident at the time of the observation revealed the resident requesting nail care numerous times on a daily basis. The resident asked the surveyor to assistance with the issues. The matter was brought to the attention of the 200 Unit Manager and Director of Nursing on 06/22-23/22. Residents Affected - Few Observation of Resident #257 on 06/23/22 at 10 AM again noted that the resident had not received nail care and was becoming agitated with the lack of nail care. On 6/23/22 at 12:30 PM, a subsequent observation was conducted of Resident #257. The observation noted that a LPN, Staff F was with the resident trimming the fingernails. Further observation noted that Staff F was trimming the nails over the residents lunch food tray while the resident was self feeding. It was noted that the trimmed nails were falling directly onto the resident;s food tray and food. The surveyor requested that Staff F cease triming during the meal and request an another lunch tray. The resident required don't bother with another tray as I'm happy they are finally trimming my nails. The matter was reported to the 200 Unit Manager who stated she would request a new lunch tray. A review of the clinical record of Resident #257 on 06/22/22 noted the current MDS documented the resident's BIMS score was 15 (no cognitive impairement). * Photographic Evidence Obtained Based on observation, interview and record review, the facility failed to identify the need for assistance with Activities of Daily Living (ADL) for fingernail care for 6 of 6 sampled residents reviewed for Activities of Daily Living, Resident #19, Resident #42, Resident #80, Resident #258, Resident #55 and Resident #257, as evidenced by the residents fingernails were observed to be unclean and in varying stages of excessive length. The findings included: Review of the facility policy for Nail Care states in part, 'Purpose: To provide for personal hygiene needs and prevent infection. Note: Precaution should be used when trimming nails of a patient with diabetes and should be done by a licensed nurse or physician. Procedure: Trim nails and file for smoothness, as needed.' Review of the facility policy and procedure on 06/22/22 at 2:22 PM for Nail Care provided by the Director of Nursing (DON) revised 01/2014 indicated Purpose: To provide for personal hygiene needs and prevent infection. Note: Precaution should be used when trimming nails of a patient with Diabetes and should be done by a licensed nurse or physician .9. Trim nails and file for smoothness, as needed Suggested Documentation: Completion of procedure. Unusual observations and/or complaints and subsequent interventions including communications with physician. Review of Nurse Supervisor Registered Nurse/Licensed Practical Nurse/Vocational Nurse Job Description on 06/22/22 at 2:22 PM revised 06/18 indicated Job Summary: Supervises nursing personnel to deliver nursing care and within the scope of practice coordinates care delivery, which will ensure that 105852 Page 6 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few patient's needs are met in accordance professional standards of practice through physician orders, center policies and procedures and federal, state and local guidelines .General Nursing Care Responsibilities: Demonstrates the ability to administer treatments timely and according to facility policy .Transcribes physician's orders to patient charts, cardex .treatment cards and care plans, as required. Charts progress notes in an informative, factual manner that reflects the care administered as well as the patient's response to care. Identifies and reports changes in condition to supervisor, physician and family. Accurately identifies skin changes and follows HCR Manor Care skin management protocols .Conducts frequent rounds to evaluate effectiveness of care delivery . 1) Review of the clinical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure, Diabetes, Depression and Chronic Obstructive Pulmonary Disease. On 06/20/22 at 2:35 PM, Resident #19 was observed in his room up in his wheelchair eating potato chips. Further observation revealed Resident #19's fingernails were long with an accumulation of a black substance underneath. Resident #19 was asked if he was ok with the length of his nails and the condition of them, to which he stated 'Yeah, they need to be cut, it's been a while, they grow fast.' On 06/21/22 at 11:22 AM, Resident #19 was observed in his room up in his wheelchair. The condition of his fingernails remained unchanged. On 06/22/22 at 10:45 AM, Resident #19 was observed in his room in bed asleep. His hands were above the covers revealing no change in the condition of his fingernails. On 06/22/22 at 11:50 AM, Resident #19 was not in his room. An inquiry was made to Registered Nurse (RN), Staff I where he might be to which she stated he may be in the main dining room or in activities. Staff I was advised the resident's fingernails have been observed to be long with a black substance underneath the nails for the past 3 days to which she stated, sometimes he is resistive to care. Staff I was advised there is no documentation in his clinical record documenting he is refusing to have his nails trimmed. Staff I stated she will tell the aide to cut them. On 06/23/22 at 11:30 AM, Resident #19 was observed in his room up in his wheelchair with an Occupational Therapist who was ready to take him to therapy. Resident #19's fingernails were observed to be trimmed and clean. Resident #19 commented, 'They feel good. I had a shower last night and my nails cut and I feel great.' Review of a Care Plan dated initiated on 07/08/21 documents under Focus: ADL (Activities of Daily Living) Self care deficit related to disease process, weakness, recent surgery. Goal: Will receive assistance as necessary to meet ADL needs. Intervention: Assist daily with dressing, grooming and hygiene. 2) Review of the clinical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease, Congestive Heart Failure, Depression and Arthritis. Further review of the clinical record revealed a Physician Order dated 04/26/22 to 'Keep patient's fingernails short.' On 06/20/22 at 10:15 AM, Resident #42 was observed in his room up in a wheelchair wearing shorts and a short sleeved shirt. Numerous scratches and scabs were observed on his legs and arms. An inquiry was made how these scratches and scabs came about, to which the resident stated he has a habit of 105852 Page 7 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0677 Level of Harm - Minimal harm or potential for actual harm picking and scratching at his arms and legs. Resident #42's fingernails were observed to be long with an accumulation of a black substance under his fingernails. On 06/21/22 at 9:52 AM, Resident #42 was observed in his room up in a wheelchair. The condition of his fingernails remained unchanged. Residents Affected - Few On 06/21/22 at 2:55 PM, Resident #42 was observed in his room up in a wheelchair eating cookies. The condition of his fingernails remained unchanged. On 06/22/22 at 10:16 AM, Resident #42 was observed in his room up in a wheelchair. The condition of his fingernails remained unchanged. His arms and legs remained with multiple scabs and scratches. On 06/22/22 at 11:54 AM, an interview was conducted with RN Staff I regarding trimming resident fingernails, to which she stated it is the Certified Nursing Assistants (CNA) responsibility to do that. An inquiry was made about Resident #42 to which she stated they have to keep his nails short as he likes to pick at his scabs. Staff I was brought into Resident #42's room and his fingernails were observed. Staff I concurred the resident's nails were long with a black substance underneath. Staff I asked the resident if it would be ok to cut his nails and he stated 'as long as she knows what she is doing' followed by a giggle. Resident #42 was agreeable to having his nails trimmed. On 06/23/22 at 11:10 AM, Resident #42 was observed in his room up in a wheelchair. His nails were observed to be trimmed and clean underneath. Resident #42 commented 'They did a good job, it feels good.' Review of a Care Plan dated initiated on 12/27/19 documents under Focus: ADL Self care deficit related to physical limitations. Goal: Will receive assistance as necessary to meet ADL needs. Intervention: Assist daily with dressing, grooming and hygiene. 3) Review of the clinical record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses to include Bipolar Disorder, Dementia and Blindness to the Left Eye. On 06/20/22 at 11:05 AM, Resident #80 was observed in his room in bed. His fingernails were observed to be long with an accumulation of a black substance underneath his fingernails. An inquiry was made if he was ok with the length of his fingernails to which he stated, 'I don't think I have a choice.' On 06/21/22 at 9:50 AM, Resident #80 was observed in his room in bed finishing up eating breakfast. The condition of his fingernails remained unchanged. On 06/21/22 at 3:00 PM, Resident #80 was observed in his room in bed eating cookies. The condition of his fingernails remained unchanged. On 06/22/22 at 10:15 AM, Resident #80 was observed in his room up in a chair. The condition of his fingernails remained unchanged. On 06/22/22 at 11:55 AM, (after observing Resident #42's fingernails), Staff I was requested to observe Resident #80's fingernails in the room next door. Upon observation, Staff I concurred his nails were long and dirty and needed to be trimmed. Staff I asked the resident if they can cut his nails to which he agreed without hesitation. Outside of the resident's room, Staff I stated Resident #80 105852 Page 8 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few can be combative at times. Staff I was advised there is nothing in the resident's record documenting he refuses to have his nails trimmed. On 06/22/22 at 1:20 PM, an interview was conducted with CNA Staff N and an inquiry was made about cutting resident's fingernails, to which she stated the aides do the nails and sometimes the nurses. She stated with Resident #80 he fights me. An inquiry was made where she documents Resident #80 resists nail care, to which she stated grufffly 'I don't document that anywhere.' On 06/23/22 at 11:35 AM, Resident #80 was observed in his room up in a chair sleeping. His fingernails were observed to have been trimmed and cleaned. Review of a Care Plan date initiated on 03/20/15, documented under Focus: ADL Self care deficit related to disease process - physical limitations and impaired cognition - assist resident daily with ADLs as needed. Goal: Will receive assistance necessary to meet ADL needs. Intervention: Assist resident with daily hygiene, grooming, dressing as needed. 4) Review of the clinical record revealed Resident #258 was admitted to the facility on [DATE] with diagnoses to include endocarditis, chronic kidney disease and diabetes. On 06/21/22 at 1:55 PM, an interview was conducted with Resident #258 in his room. His fingernails were observed to be long and jagged. An inquiry was made if he was ok with the length of his nails to which he stated he has not been home since May 13 as he has been in the hospital and now is in rehab, so he has not been able to trim his nails. He further stated he does not like the length of his fingernails however he does not have a choice. An inquiry was made if any staff have offered to trim his fingernails to which he stated 'No.' On 06/22/22 at 1:35 PM, an interview was conducted with Resident #258 in his room. The condition of his fingernails remained unchanged. On 06/22/22 at approximately 2:00 PM, an interview was conducted with the Director of Nurses (DON) who was apprised of the length and condition of the fingernails for Resident #19, Resident #42, Resident #80 and Resident #258. The DON indicated she would address this. On 06/23/22 at 12:00 PM, an interview was conducted with Resident #258 in his room. His fingernails were observed to have been trimmed. Resident #258 stated, 'They cut them yesterday, they feel good.' Review of a Care Plan dated initiated on 06/06/22 documents under Focus: ADL Self care deficit related to disease process; ADL self care deficit as evidenced by decreased strength, functional mobility, endurance. Goal: Will receive assistance necessary to meet ADL needs. Will improve ADL self performance. Intervention: Assist daily with dressing, grooming and hygiene. 5) During an initial observational tour conducted on 06/20/22 at 12:00 PM, Resident #55 was observed with long, dirty, sharp, jagged, and unkempt fingernails on both hands (Photographic evidence obtained). Resident #55 was originally admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Osteoarthritis and Hypertension. He had a Brief Interview Mental Status (BIMS) score of 15 (cognitively intact). On 06/20/22 at 12:03 PM, during a brief interview with Resident #55, he stated that he does not 105852 Page 9 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0677 Level of Harm - Minimal harm or potential for actual harm like his fingernails like this. He added that he told a staff member about them some time ago, but nothing happened with it. During a second observational tour conducted on 06/20/22 2:47 PM, Resident #55 was still observed with long, dirty, sharp, jagged and unkempt fingernails on both hands. Residents Affected - Few During a third observational tour conducted on 06/21/22 10:39 AM, Resident #55 was still observed with long, dirty, sharp, jagged and unkempt fingernails on both hands. During a fourth observational tour conducted on 06/22/22 at 10:43 AM, Resident #55 was still observed with long, dirty, sharp, jagged and unkempt fingernails on both hands. Record review of the Resident #55's Monthly (CNA) certified nurses' assistant (ADL) (Activities of Daily Living) Flowsheet Record dated 06/08/22 thru 06/22/22 revealed that resident's (ADL)s for Personal Hygiene required a range of limited assistance to extensive assistance to total dependence. Record review of the Resident #55's Care plan initiated 06/07/22 indicated Focus: Activities of Daily Living (ADL) Self-care deficit related to disease process, recent fall, pain. Interventions: He requires assistance with daily dressing, grooming and hygiene. Goal: Will receive assistance necessary to meet (ADL) needs. Nonetheless, Resident #55's fingernail care had not been done, on the dates from 06/20/22 thru 06/22/22; until after surveyor inquisition/intervention. Further record review of the Minimum Data Set (MDS) as sections A, C and G dated 05/11/22 for Resident #55 indicated that the resident required extensive assistance with personal hygiene. An interview was conducted with Staff A, a Certified Nursing Assistant (CNA) on 06/22/22 at 11 AM, in which she revealed that she had not provided fingernail care to Resident #55, and she acknowledged that the resident's fingernails were long, sharp, dirty, untrimmed, and unkempt. An interview was conducted with Staff B, a Registered Nurse (RN) on 06/22/22 at 11:15 AM, regarding Resident #55's long, unkempt nails and she also revealed that she had not provided fingernail care to Resident #55. Staff B also acknowledged that Resident #55's fingernails were long, sharp, dirty, untrimmed and unkempt. Side-by-side computerized record review of the facility's computerized nursing progress notes from 06/06/22 thru 06/22/22, conducted with Staff C, a Registered Nurse/Unit Manager)/(RN/UM), of the Progressive and Traditional units did not indicate or document any refusals for fingernail care by the resident. An interview was conducted with Staff D and Staff E, Activities Assistants on 06/22/22 at 11:19 AM in which they both stated that their department has been doing fingernail cleaning, polishing, filing and some trimming for all the residents in the facility by either one (1) of her two (2) activities assistants. However, they added that their department is not allowed to cut any of the resident's fingernails. They further added that if their staff were to see a resident with long, dirty fingernails that they would alert the nursing staff or Management of the wing or unit involved and let them know to follow-up with the resident. The Activities Assistants also acknowledged that Resident #55's fingernails were all long, sharp, dirty, untrimmed and unkempt. On 06/22/22 at 11:59 AM, an interview was conducted with Staff C, regarding Resident #55's 105852 Page 10 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fingernails being long, sharp and untrimmed and she also acknowledged that the resident's fingernails were long and that they should have been cleaned/trimmed/cut. On 06/22/22 at 12:30 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #55's fingernails being long, sharp and untrimmed and she acknowledged that the resident's fingernails were long and that they should have been cleaned/trimmed/cut. 105852 Page 11 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

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 record review and interview, the facility failed to ensure that 1 of 1 sampled residents (Resident #255), reviewed for dialysis, received treatment and care in accordance with professional standards of practice that includes medications administered, as per physician orders. Residents Affected - Few The findings included: During the review of the clinical record of Resident #255, it was noted an admission date of 06/07/22 with diagnoses of End Stage Renal Disease, Dependence on Dialysis and DM-2. Further review of physician orders noted 06/08/22, Sevelamer 800 mg (2 Tabs) Phosphorus Binder- Three time per day for Kidney Disease. Further review of the record and interview with the Unit Manager on 06/21/22 noted that the resident's dialysis days are scheduled for Monday, Wednesday,and Friday. Upon admission the resident's original chair time was scheduled for 10:30 AM and was changed on 06/15/22 to 12:30 PM. The resident returns from dialysis days during the late afternoon hours of 4-5 PM. A review of the June 2022 - Medication Administration Record (MAR) for Resident #255 noted the scheduled administration of the Sevelamer including dialysis days was 9 AM, 1 PM, and 5 PM. Further review of the June 2022 MAR noted that the 1 PM dose of Sevelamer was documented as administered on 06/08/22, 06/13/22, 06/15/22, 06/17/22, and 06/20/22. The 1 PM schedule dose for 6/10/22 was left blank with no further documentation. An interview with the Unit Manager on 06/21/22 revealed that the resident is not in the facility for the administration of the 1 PM dose of Sevelamer on Monday, Wednesday, and Friday . It was also noted that the resident was not within the 1 hour prior and after the scheduled dose. The Unit Manager went on to state the nurses are documenting administration of the Sevelamer when the resident is not in the facility and are required to notify the the DON (Director of Nursing) and attending physician of clarification of the 1 PM and obtain new orders. Review of MDS dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 10, indicating moderate cognitive impairment; and Activities of Daily Living (ADL's), requiring extensive assistance, 64inches in height and 136 pounds, and at Risk for Pressure Ulcers. On 06/21/22 the 300 Unit Manager submitted to the surveyor a clarification of the Sevelamer 800 mg - 2 tabs to be changed to Twice Per day (BID - 8 AM & 5 PM) on dialysis days. 105852 Page 12 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure splint devices were applied, as recommended for 1 of 2 sampled residents reviewed for Position/Mobility, Resident #301, as supported by no evidence bilateral hand palm guards were applied for Resident #301. The findings included: Review of the facility Restorative Nursing Guideline policy states in part, 'Overview: Restorative nursing care includes nursing interventions that help to maintain the patient's highest level of function and prevent unnecessary decline in function. Restorative nursing programs are individualized to specific patient needs and have many tangible positive effects including - preventing further decline Patients may enter a restorative nursing program in several ways including after discharge from a skilled physical, occupational or speech rehabilitation program.' Review of the clinical record for Resident #301 revealed she was admitted to the facility on [DATE] with diagnoses to include Cerebral Vascular Disease, Dysphagia (inability to swallow), Gastric Feeding Tube, Aphasia (inability to speak), Alzheimer's Disease and Depression. On 06/20/22 at 11:50 AM, Resident #301 was observed in her room in bed. Both hands were observed to be severely contracted in a clenched position. There were no splints in place or visibly observed in the resident's room. Resident #301 was unable to communicate verbally to express her needs, however she did follow movement around the room with her eyes. On 06/20/22 at 2:30 PM, Resident #301 was observed in her room in bed. No splints were observed on her bilateral hand contractures. On 06/21/22 at 10:05 AM , Resident #301 was observed in her room in bed. No splints were observed on her bilateral hand contractures. On 06/21/22 at 3:05 PM, Resident #301 was observed in her room in bed. No splints were observed on her bilateral hand contractures. In a conversation with Resident #301's roommate, her roommate stated she told the nurse Resident #301 has been coughing a lot today and the nurse arranged for the resident to be seen by the physician at 5:30 today. Review the electronic medical record revealed a Medical Practitioner Internal Medicine Note dated 06/21/2022 at 7:34 PM, documenting in part under the assessment of Resident #301's extremities Bilateral foot drop, wrist/hand contractures, generalized atrophy. On 06/22/22 at 10:20 AM, Resident #301 was observed in her room in bed. No splints were observed on her bilateral hand contractures. The resident's feet were observed not covered by the blankets at this time, which revealed the resident had a pronounced bilateral foot drop. There were no preventative or comfort devices observed for her feet. On 06/22/22 at 4:35 PM, an interview was conducted with Registered Nurse (RN) Staff I after an observation of a medication pass with Resident #301. An inquiry was made about Resident #301's bilateral hand contractures and what measures are in place related to the contractures. Staff I stated the 105852 Page 13 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident moved to this unit less than a month ago from the subacute unit on the other side of the building and she is now a long term resident on this unit. Staff I stated Resident #301 has been contracted since she moved here from the other unit. Review of the clinical record revealed a Care Plan documenting: Resident may need assistance with bed mobility and transfers; uses a wheelchair for mobility and mechanical lift for transfers. Shows on [NAME]. (The [NAME] is a guide for the Certified Nursing Assistants (CNA) to be informed of the resident specific care each particular resident requires.) Interventions included: Palm guards bilateral at night; assist to put on and remove in AM. Review of the [NAME] for Resident #301 documented - Palm guards bilateral at night; assist to put on and remove in AM. Further review of the [NAME] revealed no evidence of documentation by the CNAs the bilateral palm guards were being applied. Review of the May 2022 and June 2022 Medication Administration Records (MAR) and Treatment Administration Records (TAR) revealed no evidence of documentation the bilateral palm guards were being applied. On 06/23/22 at 9:24 AM, an interview was conducted with Occupational Therapist (OT), Staff M in the presence of the Director of Nursing (DON) and in inquiry made about the assessment of the bilateral hand contractures of Resident #301. In reviewing the electronic therapy charting, Staff M stated the resident was evaluated on 06/06/22 by Occupational Therapy, Physical Therapy and Speech Therapy and they picked her up for 2 weeks to see if she could progress or participate to improve her quality of life. Staff M stated the resident suffered a profound stroke and due to her medical condition there was little progress and she was referred to restorative nursing. Staff M stated the resident is nonverbal however can communicate with her eyes and the contractures were giving her pain so the palm guards were recommended. An inquiry was made how long the palm guards should be applied to which Staff M stated she should wear them all the time and only take them off for hygiene to check the skin to ensure no skin breakdown. She stated the palm guards would provide comfort and they did not want her to decline any further. A request was made for a copy of the OT Discharge Summary to show the resident was referred to Restorative Nursing Services. Staff M stated they do not document on the Discharge Summary a referral to restorative, they do a separate document which they put in the resident's chart. OT Staff M stated she does not have a copy of the referral, however it should be in the resident's record. On 06/23/22 at 9:40 AM, an inquiry was made to the DON who is responsible for overseeing the Restorative Nursing Program to which the DON stated when a resident goes off therapy they go to restorative floor maintenance and the CNAs will do for example range of motion or extension with the resident while providing care, however there is not a dedicated restorative program. A request was made to review Resident #301's record for documentation of the application of the bilateral palm guards. The DON reviewed the residents Physician Orders and there was no order for the palm guards. The DON reviewed the TARs and there was no documentation of the palm guard, then stated there would be no documentation on the TAR, that is for the nurse and the CNA does not document on the TAR. The DON found the application of the palm guards at night on the CNA [NAME] as a CNA task however was unable to find the documentation the palm guards were being applied. The DON stated she will have to check with Minimum Data Set (MDS) Licensed Practical Nurse (LPN), Staff K to show her where the CNAs document the application of the palm guards. On 06/23/22 at 9:50 AM, a recap was versed with the DON and Staff M in which there was no Physician 105852 Page 14 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Order for the palm guards as recommended by OT; there was no documentation on the MAR or TAR the palm guards were being applied; the palm guards were documented on the [NAME] however there was no evidence of documentation by the CNAs they were being applied; Staff M stated she recommended the palm guards at all times except for hygiene however the [NAME] states apply at night. Staff M stated at this time she recommended they be put on at night as a trial. The DON asked how long a trial would be to which no definitive answer was provided by Staff M. A request was made for documentation of the trial application of the palm guards however she was unable to find any documentation. On 06/23/22 at 10:00 AM, Resident #301's paper clinical record was reviewed with the DON revealing a paper double copy original Physician Orders Occupational Therapy form dated 05/24/22. The order written by Staff M documented for 'Palm Guard to bilateral hands at night. Remove during the day. Frequency 7 days a week. Precautions: Check skin AM bilateral hands. This order was signed under Signature of Nurse Noting Order, however there was no physician signature confirming the order. Further the double copy form was still intact indicating it had not been forwarded to the next level for processing. On 06/23/22 at 10:05 AM, Resident #301's room was checked with the DON for the presence of the palm guards. As the DON was searching in the resident's closet, Staff M arrived to the room and located the palm guards inside the second drawer of the night stand. The faux sheepskin palm guards looked clean and barely used. An inquiry was made to Staff M how they educate the CNAs on how to apply the palm guards to which she stated they discuss with nursing in the morning meeting and educate them and the day shift passes it on to the evening and night shifts. A request was made for documentation of who and when they educated on the application of the palm guards. Staff M stated she will look for it. The documentation was not forthcoming. On 06/23/22 at 10:17 AM, an interview was conducted with CNA, Staff H who had Resident #301 on her assignment. Staff H confirmed she cares for Resident #301 often but her assignment changes once in a while. An inquiry was made to Staff H if she removed the bilateral palm guards from Resident #301's hands this morning when she started morning care to which Staff H stated Resident #301 did not have any splints to remove this morning and she has never seen the resident wearing splints. On 06/23/22 at 10:18 AM, the DON was informed Staff H did not remove palm guards from Resident #301's hands this morning and stated she has never seen splints on this resident. The DON had no comment. On 06/23/22 10:19 AM, an interview was conducted with RN, Staff C, Unit Manager regarding Resident #301's palm guards. Staff C stated if it is on the care plan then it would populate to the [NAME]. In reviewing the [NAME], she pointed out the palm guards at night and remove in the morning. She stated it is on the [NAME] for the CNAs to see so they know what to do for the resident. A request was made to show where the CNAs document the application of the palm guards. Staff C stated she was not familiar with where the CNAs document so she enlisted the assistance of CNA, Staff J to show where they would document the application and removal of the palm guards. On 06/23/22 at 10:25 AM, after several minutes of clicking from one screen to another on the CNA [NAME] Task screen, Staff J was unable to locate a section for the evening or night shift to document the application of the palm guards or the day shift for the removal of the palm guards. MDS LPN,Staff K arrived to the nursing station and joined in the search. She stated the recommendation goes from the care plan and is generated to the [NAME] however in this instance there is no pencil icon on the [NAME]. Staff K explained the pencil signifies that documentation is required for this task and 105852 Page 15 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0688 Level of Harm - Minimal harm or potential for actual harm since there was no pencil next to the application of the palm guards, there will be no place for the CNAs to document that task. Staff K stated it is more of a 'for your information' and is not a signable task. There was no evidence of documentation the bilateral hand palm guards were being applied as recommended on 05/24/22 for contracture management. Residents Affected - Few 105852 Page 16 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to appropriately assess and manage pain for 1 of 1 residents reviewed for Pain Management, Resident #258, as evidenced by Resident #258 expressing little to no relief of pain with the current pain management regimen. Residents Affected - Few The findings included: Review of the facility policy for Pain Management Guidelines states in part, 'Purpose: To describe the process steps required for interventions to prevent and or manage both acute and chronic pain. Guidelines: Pain is a highly subjective and personal experience which is impacted by one's previous experiences with pain as well as by cultural and spiritual beliefs. Pain is evaluated and documented - Before and after administration of PRN (as needed) pain medication; Prior to initiating therapy interventions; Prior to initiating wound care treatments; Using an appropriate pain scale, determined by nursing. Numeric Rating Scale: Used for patients whose cognitive functioning ranges from intact to mildly or moderately impaired. Patients are asked to choose a number from 0 (indicating no pain) to 10 (indicating worst pain imaginable). Pain scores of 4-7 twice in a seven-day period or those who have a single score of 8, 9 or 10 are reported to the medical practitioner for consideration of treatment adjustment. If a patient has had a recent musculoskeletal surgery, has an open wound requiring treatment, the medical practitioner should be contacted to evaluate need for routine pain medication until a more comprehensive evaluation can be completed.' Review of the clinical record revealed Resident #258 was admitted to the facility on [DATE] with diagnoses to include endocarditis, osteomylitis to the left foot, chronic kidney disease, chronic obstructive pulmonary disease and diabetes. Further review of the clinical record revealed Physician Orders to change the wound vac dressing to mid sternum every Monday, Wednesday and Friday in addition to would care to the left foot ulcer 3 times daily. Further, as of 06/20/22, the frequency of the mid sternum wound care was changed to daily. Additionally, the resident is receiving intravenous antibiotics every 24 hours via a long term intravenous catheter to his left upper arm and has a Foley urinary catheter with care being rendered every shift. In an interview conducted with Resident #258 in his room on 06/21/22 at 1:55 PM, he stated he had quadruple bypass surgery in March 2022 and had gone to therapy for a couple weeks thereafter. He stated on 05/13/22 he developed chest pain and ended up in the Emergency Department where he was admitted to the hospital and had 2 surgeries to remove the sternal plate in his chest which was infected from the bypass surgery. He further stated he has osteomylitis, an infection, of his left foot, and he has had multiple surgeries for that. While being on intravenous antibiotics for 6 weeks he subsequently developed kidney failure requiring dialysis 7 days a week for 6 weeks before his kidneys returned to functioning. He stated he now has a Foley catheter in as he was unable to urinate independently. Further, he stated he had a wound vac to his chest wound discontinued yesterday however he still feels swelling of his chest. He stated he has dressing changes to his chest wound and left foot wounds daily in addition to having physical therapy (PT) and occupational therapy (OT) 5 days a week. An inquiry was made if he is having any pain at this time to which he stated his pain level right now is 7 out of 10. He stated he gets a pain pill in the morning and one in the early evening but he has to ask for it as the nurses do not routinely offer it to him. Resident #258 also stated they put on a Lidocaine patch to his chest everyday but it does not do any good as far as the pain goes. An inquiry was made how he is doing in therapy to which he stated it is not going well, he can only walk a couple of steps and cannot sit up for extended periods due to the pain. A further inquiry was made 105852 Page 17 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few if the pain pill he is currently receiving is effective in managing his pain to which he stated 'No, I have pain all the time and being in pain I don't feel like doing much.' During the interview, Resident #258 was attempting to change positions in bed and in doing so, he was observed to be grimacing with every movement. Review of the clinical record revealed Resident #258 was admitted to the facility on [DATE] and a Physician Order was not received until 06/04/22 for Nucynta 100 milligrams, give 2 tablets by mouth every 4 hours as needed for pain. Further review of the record documented on the June 2022 Medication Administration Record (MAR), Resident #258 did not receive anything for pain until 06/05/22 at 3:15 AM. On 06/06/22 the resident received one dose at 6:30 AM. Further review of the MAR revealed on 06/06/22, the Nucynta dose was decreased from 2 tablets by mouth to 1 tablet my mouth every 4 hours as needed for pain. Review of the MAR revealed the administration of an average of 2 pain pills daily from 06/07/22 through 06/21/22 with the exception of 06/08, 06/09 and 06/16 where he only received one pain pill. On 06/10 there is no documentation he received any pain medication. Review of the June 2022 MAR under 'Pain evaluation every shift (every day, evening and night shift) for Monitoring of Patient's Pain level' documents from 06/04/22 through the night shift on 06/21/22, of the 54 day, evening and night shifts, only 14 nurses documented the resident was experiencing pain with a pain level of 3 to 8 out of 10. For 40 of the 54 shift pain assessments, the nurses documented Resident #258 had a zero for pain. Review of the Physical Therapy Evaluation and Plan of Treatment note dated 06/04/22 documents under Pain: Patient has pain that interferes/limits functional activity? = Yes. Pain Intensity = 7/10. Review of the Physical Therapy Treatment Encounter Note for 06/04/22 documents Pain Intensity = 7/10. Barriers Impacting Treatment: Pain, 7, comorbidities, drain, ulcers of feet. Review of the Occupational Therapy Evaluation and Plan of Treatment dated 06/06/22 documents under Pain: Patient has pain that interferes/limits functional activity? = Yes. Patient has pain that interferes with sleep? = Yes. Pain Intensity = 7/10, Constant; Location: Chest at incision. What exacerbates pain? Movement. Review of an Occupational Therapy Treatment Encounter Note dated 06/08/22 documents Pain Intensity = 5/10; Constant; Location: Chest at incision. What exacerbates pain? = Movement. Review of an Occupational Therapy Treatment Encounter Note dated 06/09/22 documents Pain Intensity = 7/10; Constant; Location: Chest at incision. What exacerbates pain? = Movement. Review of the Physical Therapy Treatment Encounter Note for 06/11/22 documents Pain Intensity = 6/10. Barriers Impacting Treatment: Pain, >6, sternal precaution, decreased activity tolerance, drain, Foley. Review of the Physical Therapy Treatment Encounter Note for 06/13/22 documents Pain Intensity = 6/10. Response to Session Interventions: Low activity tolerance also presents with dizziness with sitting up unable to tolerate sitting up more than 10 minutes. Review of an Occupational Therapy Treatment Encounter Note dated 06/14/22 documents Pain Intensity = 7/10; Constant; Location: Chest at incision. What exacerbates pain? = Movement. 105852 Page 18 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Physical Therapy Treatment Encounter Note for 06/14/22 documents Pain Intensity = 7/10. Response to Session Interventions: Patient reports constant thoracic pain require more assist with all functional mobility. Review of the Physical Therapy Treatment Encounter Note for 06/15/22 documents Pain Intensity = 7/10. Barriers Impacting Treatment: Pain. Review of an Occupational Therapy Treatment Encounter Note dated 06/15/22 documents Pain Intensity = 7/10; Constant; Location: Chest at incision. What exacerbates pain? = Movement. Review of the Physical Therapy Treatment Encounter Note for 06/16/22 documents Pain Intensity = 7/10, constant. What exacerbates pain? Sitting, Movement, Prolonged Activity. Review of an Occupational Therapy Treatment Encounter Note dated 06/16/22 documents Pain Intensity = 7/10; Constant; Location: Chest at incision. What exacerbates pain? = Movement. Review of the Physical Therapy Treatment Encounter Note for 06/17/22 documents Pain Intensity = 7/10, constant. What exacerbates pain? Sitting, Movement, Prolonged Activity. Review of an Occupational Therapy Treatment Encounter Note dated 06/17/22 documents Pain Intensity = 7/10; Constant; Location: Chest at incision. What exacerbates pain? = Movement. Review of the Physical Therapy Treatment Encounter Note for 06/20/22 documents Pain Intensity = 6/10; Constant. What exacerbates pain? Sitting, Movement, Prolonged Activity. Review of the Physical Therapy Treatment Encounter Note for 06/20/22 documents Pain Intensity = 7/10; Constant. What exacerbates pain? Sitting, Movement, Prolonged Activity. On 06/22/22 at 1:35 PM, an interview was conducted with Resident #258 in his room. When asked, Resident #258 stated his pain level is 6 out of 10 at this time. He stated he received a pain pill a couple of hours ago, but it is not working very well. After review of the Pain Evaluation monitoring on the MAR where the nurses documented Resident #258 had zero pain during 40 day, evening and night shift assessments, an inquiry was made to Resident #258 if he had at any time since his admission on [DATE], expressed to the nurses he was not experiencing any pain, to which he adamantly stated he has been in pain since he got here. Resident #258 continued to exhibit nonverbal signs of pain when attempting to reposition himself in bed. Review of a Care Plan date initiated on 06/06/22 documents, 'Focus: May have pain related to disease process, recent surgery, wound, neuropathy, back pain, muscle spasms. Goal: Pain or analgesia will not affect participation in activities of choice or daily care. Interventions: Administer pain medication per physician orders; Encourage/Assist to reposition frequently to position of comfort. Implement non-pharmacological interventions - therapy, exercise, therapeutic modalities, relaxation techniques, counseling, warm/cool compress, positioning, to assist with pain and monitor for effectiveness.' On 06/23/22 at 10:30 AM, an interview was conducted with Physical Therapy Assistant (PTA) Staff G who works with Resident #258, with the Director of Nursing (DON) and OT Staff M also present for the interview, and an inquiry made as to Resident #258's progress in therapy. PTA Staff G confirmed Resident #258 was experiencing pain during therapy sessions in addition to episodes of dizziness. An 105852 Page 19 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few inquiry was made if the PT and OT sessions are coordinated at the same time each day to which she stated the sessions are at different times, there is no set schedule. She stated she ensures the resident has received pain medication prior to the session. An inquiry was made if the resident is receiving pain medication prior to therapy and he is still experiencing pain at a level of 6 to 7 out of 10, is the pain management effective to which she had no comment. The DON stated at this time, they will arrange a consult with the physician for coping skills; they will have the Social Worker conduct a resident evaluation; they will speak to the resident to ensure he voices he needs something for pain; and she will call the physician to get a scheduled pain medication and use the PRN (as needed) pain medication for breakthrough pain. OT Staff M further stated if a resident is having pain, they will not want to do much and will not benefit from therapy. She further stated they can coordinate therapy and separate the sessions to have PT in the morning and OT in the afternoon. Review of a Nursing Progress Noted dated 06/23/2022 at 11:42 AM states in part, 'Unit manager called nurse practitioner in re: to patient's complaint of pain. N.P. asked unit manager to follow up with pain M.D. Unit manager called pain M.D in re: to patient's pain. Pain MD ordered Neurontin 100 mg tid (3 times daily). Pain MD also stated I will be in to see patient tomorrow and further assess patient' On 06/23/22 at 12:00 PM, an interview was conducted with Resident #258 in his room When asked, Resident #258 stated his pain level is about 7 out of 10 at this time. He stated he received a pain pill a couple of hours ago. An inquiry was made if he has been to therapy yet to which he stated he had not. An inquiry was made if he gets a pain pill prior to therapy and he stated he was not sure. Resident #258 continued to exhibit nonverbal signs of pain when attempting to reposition himself in bed. On 06/23/22 at 1:00 PM, an interview was conducted with the DON who stated they have contacted Resident #258's Physician and received an order for Neurontin 3 times daily for additional pain management. She stated Resident #258 will receive the first dose today. 105852 Page 20 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On [DATE] at 10:00 AM, during an initial resident observation tour on the 500 unit, Registered Nurse (RN) Staff L was observed at her medication cart parked outside of room [ROOM NUMBER] and 503. On top of the medication cart were 2 clear medication cups, one labeled with black marker 507A and the other labeled with black marker 507B. She was observed to be preparing the medications for the residents in 507A and 507B at the same time. Once she had finished with the preparation, she placed the 2 medication cups and 2 medication patches on a Styrofoam tray and proceeded to push her medication cart down the hallway towards room [ROOM NUMBER]. At this time, an inquiry was made of RN Staff L if she had just prepoured medications for the 2 residents in room [ROOM NUMBER] at the same time. Without hesitation RN Staff L stated 'If the residents in the same room are in isolation I prepour the medications, that is how it is done.' She further stated 'It saves time because you would have to put a gown on and take it off twice, this way you only have to gown up once.' RN, Staff L was advised the residents in room [ROOM NUMBER] are not in isolation. Staff L checked her resident list and when identifying the residents in room [ROOM NUMBER] were not in isolation, shrugged her shoulders and went to carry on pushing her medication cart down the hallway. Staff L was stopped and asked if prepouring medications was a safe practice of medication preparation and administration, to which she shrugged her shoulders again and kept on pushing her cart to room [ROOM NUMBER]. Upon arriving at room [ROOM NUMBER], she proceeded into the resident's room with the tray containing the 2 medication cups and medication patches without stopping to think that she should not be proceeding with this medication pass. 4) On [DATE] at 10:55 AM, an interview was conducted with Resident #39 in her room sitting up in a wheelchair. Resident #39 stated she does not walk very well anymore however she can get herself around in the wheelchair. Observed on her dresser was a bottle of prescription labeled Azelestine nasal spray and a Flovent respiratory inhaler. An inquiry was made if she uses these medications, to which she stated she usually takes them once in the morning and once in the evening. An inquiry was made how these medications got here, to which she stated she was not sure. An inquiry was made if the nurse left them behind, to which she stated she was not sure. She stated she believed she has not taken them yet today. She then further stated They shouldn't be there should they? On [DATE] at 12:58 PM, an observation of Resident #39's room revealed the 2 medications had been removed off the dresser. An inquiry was made to the resident when and who took the medications, to which she stated she was not sure. Review of the clinical record for Resident #39 revealed no documentation of an assessment Resident #39 could store medications at her bedside or self administer medication. 5) On [DATE] at 11:20 AM, an interview was conducted with Resident #11 in her room. Observed sitting on top of her over bed table next to the television remote was a pill cup containing a large whitish pill. An inquiry was made if that was her pill and what it was for. Resident #11 stated it was for her stomach. An inquiry was made if the nurse left it at her bedside and she confirmed the nurse did. Also observed on her over bed table was an Albuteral respiratory inhaler with the resident's name on it but no directions for use. The date on the inhaler read [DATE] however it was unclear if this was the date of delivery or the expiry date. Resident #11 stated she uses the inhaler 3 to 4 times a week as needed. 105852 Page 21 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the clinical record for Resident #11 revealed no documentation of an assessment Resident #11 could store medications at her bedside or self administer medication. On [DATE] at 1:45 PM, the Director of Nursing (DON) was apprised of the observation of medications being left at Resident #39 and Resident #11's bedside in addition to observation of the RN prepouring medications for 2 different residents at the same time. The DON was informed the reason RN Staff L stated she was prepouring the medications for these 2 residents was because they were on isolation in the same room, however they were not on isolation. The DON shook her head and stated, 'She used the excuse to prepour her medications because the residents were in isolation? That is not right. She should know better, you do not prepour medications.' Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to ensure that it 1) secured and locked the un-ordered expired over-the-counter prescription medication for 1 of 1 residents, Resident #96, 2) failed to ensure that it secured and locked an un-ordered over-the-counter (OTC) and an expired prescription medication for Resident #9, 3) failed to secure prescription medications left at the bedside for Resident #11 and 4) for Resident #39. And, 5) Licensed nurse was observed pre-pouring medication on unit on [DATE] for a resident, during an observational room tour. The findings included: 1) During an initial observational tour conducted on [DATE] at 10:53 AM, Resident #96 was noted to have a half-used tube of prescription Triamcinolone Acetonide Cream 0.1% (expiration date of 03/23 with the name of a different resident who expired in the facility over two (2) months ago back on [DATE]), in Resident #96's bathroom, on a shelf, unlocked, unsecured, visible and easily accessible to other residents, employees and visitors. Resident #96 was originally admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Residual Schizophrenia, Type 2 Diabetes Mellitus, Anxiety Disorder and Bipolar Disorder. She had a Brief Interview Mental Status (BIMS) score of 15 (severely impaired, moderately impaired or cognitively intact). Photographic evidence obtained of Resident #96's half-used tube of prescription Triamcinolone Acetonide Cream 0.1%, on her bathroom shelf. During a brief interview with Resident #96 on [DATE] at 10:55 AM, the resident stated that she did not know that it was even there. During a second observational tour conducted on [DATE] at 2:52 PM, Resident #96 still noted to have a half-used tube of prescription Triamcinolone Acetonide Cream 0.1%, in her bathroom, on a shelf. During a third observational tour conducted on [DATE] at 10:19 AM, Resident #96 still noted to have a half-used tube of prescription Triamcinolone Acetonide Cream 0.1%, in her bathroom, on a shelf. During a fourth observational tour conducted on [DATE] at 2:26 PM, Resident #96 still noted to have a half-used tube of prescription Triamcinolone Acetonide Cream 0.1%, in her bathroom, on a shelf. During a fifth observational tour conducted on [DATE] at 10:38 AM, Resident #96 still noted to have a half-used tube of prescription Triamcinolone Acetonide Cream 0.1%, in her bathroom, on a shelf. An interview was conducted on [DATE] at 11:20 AM with Resident #96 's nurse, Staff B, a Registered Nurse (RN), regarding the half-used tube of prescription Triamcinolone Acetonide Cream 0.1% observed 105852 Page 22 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on Resident #96's bedside table and she acknowledged that the cream medication tube not prescribed for this resident should not have been there. She also indicated that this resident does not self-administer any of her own medications and neither was she assessed to be able to do. Side-by-side record review was conducted with Staff C, a Registered Nurse/Unit Manager (RN/UM), of the Progressive and Traditional units in which it was noted that neither Resident #96's hard copy chart nor her computerized Point-Click-Care (PCC) medical record indicated that the resident had/contained any self-assessment completed in order for her to be to administer her own medications. There was no order on the Resident #96's Medication Administration Record (MAR) for this prescription medication to be administered to this resident. 2) During an initial observational tour conducted on [DATE] at 12:30 PM, Resident #9 was noted to have a used bottle un-dated over-the-counter Lidocaine 4% and Menthol 1% pain relief cream and Major Carbamide Peroxoide 6.5% prescription ear drops bottle with an expiration date of [DATE], for wax buildup, on his bedside table, unlocked, visible and easily accessible to other residents, employees and visitors. Resident #9 was originally admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Chronic Viral Hepatitis C, Major Depressive Disorder, Anxiety Disorder, Hypertension and Anemia. He had a Brief Interview Mental Status (BIMS) score of 15 (cognitively intact). (Photographic evidence obtained of Resident #9 bottle un-dated (OTC) Lidocaine 4% and Menthol 1% pain relief cream and expired Major Carbamide Peroxoide 6.5% prescription ear drops). During a brief interview with Resident #9 on [DATE] at 12:35 PM, this surveyor inquired of Resident #9, regarding the prescription and (OTC) medications on his bedside table, Resident #9 stated that he rubs the cream on his right shoulders, but it does no good. However, he says that the ear drops do help. During a second observational tour conducted on [DATE] at 2:54 PM, Resident #9 still noted to have a used bottle un-dated over-the-counter Lidocaine 4% and Menthol 1% pain relief cream and expired Major Carbamide Peroxoide 6.5% prescription ear drops bottle, on his bedside table. During a third observational tour conducted on [DATE] at 10:57 AM, Resident #9 still noted to have a used bottle un-dated over-the-counter Lidocaine 4% and Menthol 1% pain relief cream and expired Major Carbamide Peroxoide 6.5% prescription ear drops bottle, on his bedside table. During a fourth observational tour conducted on [DATE] at 2:02 PM, Resident #9 still noted to have a used bottle un-dated over-the-counter Lidocaine 4% and Menthol 1% pain relief cream and expired Major Carbamide Peroxoide 6.5% prescription ear drops bottle, on his bedside table. During a fifth observational tour conducted on [DATE] at 10:43 AM, Resident #9 still noted to have a used bottle un-dated over-the-counter Lidocaine 4% and Menthol 1% pain relief cream and expired Major Carbamide Peroxoide 6.5% prescription ear drops bottle, on his bedside table. An interview was conducted on [DATE] at 11:31 AM with Resident #9's nurse, Staff B, a Registered Nurse (RN), regarding the (OTC) pain cream medication and the prescription ear drops observed on Resident #9's bedside table and she acknowledged that the (OTC) and prescription medications should not have been there. She also indicated that this resident does not self-administer any of his own medications and neither was he assessed to be able to do. 105852 Page 23 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on [DATE] at 12:04 PM with Resident #9's nurse, Staff C, an (RN)/(UM), of the Progressive and Traditional units regarding the (OTC) pain cream medication and the prescription ear drops observed on Resident #9's bedside table and she also acknowledged that the medication bottle should not have been there. There was no order on the Resident #9's Medication Administration Record (MAR) for this over-the-counter (OTC) and prescription medication to be administered to this resident. In fact, the prescription tube of medication, prescription eye drops and (OTC) bottle of Lidocaine cream were not removed from these resident's bedsides, until after surveyor inquisition/intervention. On [DATE] at 12:35 PM, the Director of Nursing (DON) further acknowledged and recognized that the (OTC) and prescription medications should not have been left in the resident's bathroom nor on the resident's bedside. Review of facility policy and procedure on [DATE] at 2:35 PM for Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles provided by the (DON) revised date 08/2018 indicated Applicability: This section sets for the procedures relating to the storage and expiration dates of drugs, biologicals, syringes and needles. Procedure: The Nursing Center should ensure that all drugs and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room, inaccessibility by residents and visitors The Nursing Center should ensure that drugs and biologicals: .Have not been contaminated or deteriorated and are stored separate from other medications until destroyed or returned to the supplier 12. Bedside Medication Storage: The Nursing Center should not administer/provide bedside drugs or biologicals without a prescriber order and documented evaluation of approval by the Interdisciplinary Care Team and Nursing Center administration. The Nursing Center should store bedside drugs or biologicals in a locked compartment within the resident's room [ROOM NUMBER]. The Nursing Center should ensure that drugs and biologicals for expired or discharged residents are stored separately, away from use, until destroyed or returned to the Pharmacy 105852 Page 24 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to provide sufficient staff to carry out the functions of the food and nutrition service, for 94 of the facility's 94 residents. Residents Affected - Some The findings included: 1) Observation of the lunch meal in the main kitchen on 06/22/22 at 11:30 AM noted non-kitchen staff working within the department that included the Director of Medical Records and a CNA. Interview with the Dietary Manager at the time of the meal observation noted to state that the dietary department has been down 2 diet aide positions for some time and often requires staff from other departments to be scheduled in the kitchen on a regular basis. It was also noted that the dinner cook was rescheduled to the breakfast and Lunch meal service on 06/22/22. Further observation of the 06/22/22 lunch meal noted that foods were not prepared on time and the meal service scheduled to start on 11:05 AM did not begin until 12:05 PM. The resident dishes were not finished washing until 12 PM. The lunch meal was delayed for over 90 minutes. 2) During the observation of the breakfast meal in the main kitchen on 06/23/22 it was noted the the Dietary Manager (DM) was performing the cooks duties. Interview with the DM at the time of the observation noted to state the the breakfast cook and a diet aide had called in sick for 06/23/22. The DM stated that the department was already down 2 full time diet aide positions for months. Further observation of the breakfast meal on 06/23/22 noted that meal service was delayed for up to 90 minutes. During the review of the dietary staffing and interview with the Dietary Manager on 06/23/22 noted that the department is to be scheduled daily with the following staff: 1 AM [NAME] 1 PM Cook 2 AM Diet Aides 2 PM Diet Aides Observation of the the meal service on 06/22/22 and 06/23/22 noted that the department was staff with only 1 cook per day and 2 diet aides per day. 4) During the observation of the lunch tray line assembly in the main kitchen on 06/22/22, it was noted there were staff working in the kitchen who were not dietary personal. Specifically the Medical Records Director and a CNA were working in the kitchen for the lunch meal preparation and service. Interview with the Dietary Manager at the time of the observation revealed that the kitchen is down 2 full times position and the dinner cook needed to be scheduled for the breakfast meal preparation . Further Observation noted that the 06/22/22 lunch tray assembly line began at 12:05 PM. A review of the Meal Tray Delivery Form and observation of meal tray carts noted the following: Hall 100: Scheduled delivery time documented as 11:05 PM - Actual delivery time was recorded at 105852 Page 25 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0802 12:30 PM Level of Harm - Minimal harm or potential for actual harm Hall 500 - Scheduled delivery time documented as 11:45 AM - Actual delivery time was recorded at 1:10 PM Residents Affected - Some Hall 600 - Scheduled delivery time documented as 12:15 PM - Actual delivery time was recorded at 1:30 PM Hall 700 - Scheduled delivery time documented as 12:25 PM - Actual delivery time was recorded at 1:45 PM * Further observation of the lunch meal in the Hall 700 noted that the last tray served to the residents was recorded at 2:05 PM, and the last resident to finish the lunch meal was recorded at 2:40 PM. 5) During the observation of the breakfast meal in the main kitchen on 06/23/22 at 7:30 AM, it was noted during an interview with the Dietary Manager (DM) that the breakfast cook and a dietary aide had called in sick for 06/23/22. The DM stated that the department was already down 2 full time diet aide positions for some time. Observation noted that the breakfast tray line began at 7:55 AM. A review of the Meal Delivery Times Form and observation of the breakfast meal service for 06/23/22 noted the following: Hall 100- Scheduled meal delivery time documented as 7:15 AM - Actual delivery time was recorded at 8:05 AM Hall 200 - Scheduled delivery time documented as 7:25 AM - Actual delivery time was recorded at 8:13 AM Hall 300 - Scheduled delivery time documented 7:35 AM - Actual delivery time was recorded at 8:25 AM Hall 500 - Scheduled delivery time documented as 7:55 AM - Actual delivery time was recorded at 8:30 AM Hall 600 - Scheduled delivery time documented as 8:05 AM - Actual delivery time was recorded at 9:02 AM Hall 700 - Scheduled delivery time documented as 8:15 AM - Actual delivery time was recorded at 9:20 AM * Further observation of the breakfast meal on Hall 700 noted that the last tray delivered to the residents was recorded at 9:45 AM and the last resident finished the meal at 10:15 PM. The cart with the soiled dishes was schedule to be picked up at 9:25 AM, however the cart was returned to the kitchen at 11:15 AM. 105852 Page 26 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determine that the facility failed to provide food prepared by methods that conserve nutritive value, flavor, appearance, and is palatable, attractive, and appetizing temperatures for for all 94 facility resident's that included interviews conducted with 4 (Resident's #93, #251, #256, and #257) of 4 interviews conducted with additional residents. Residents Affected - Some The findings included: 1) During the review of the grievance Logs from January 2022 through May 2022 noted the following resident food grievances: January 2022 = 3 total grievances including: Poor food quality Failure to food preference No meal alternatives available Incorrect food consistency February 2022 = 13 total grievances including: Poor food appearance Poor food quality taste (3) Food preference not followed (5) Cold food temperatures (2) Late tray service Therapeutic diet not followed Assistance with eating Incorrect diet consistency March 2022 = 7 total grievances including: Food Preference not followed (4) Insufficient portion sizes Poor Food quality 105852 Page 27 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0804 Poor food taste Level of Harm - Minimal harm or potential for actual harm Kosher meal not available April 2022 = 4 total grievances including: Residents Affected - Some Insufficient portion sizes Food preferences not followed NO condiments served with foods Cold food temperatures resident not receiving a meal tray Poor food quality Poor appearance of foods Incorrect food consistency May 2022 - 5 total grievances including: Cold food temperatures Food preferences not followed Poor food quality Therapeutic diet not followed No food alternatives Poor appearance of food Incorrect food texture/consistency Poor menu variety of foods 2) Observations and interview conducted with Resident's #93, #251, #256, and #257 on 06/20-23/22 concerning food issues noted the following: Resident #93: During observation of the breakfast meal on 06/22/22 at 8:15 AM, it was noted that the meal was brought into the room of Resident #93 and placed on the overbed table and was not set up for the resident. The CNA stated to the surveyor that the resident does not like to eat the breakfast meals until latter around 10-10:30 AM. It was noted that the resident was sleeping at the time of the observation. A second observation conducted on 06/22/22 at 10:45 AM noted that the resident was eating the breakfast meal which was the same meal that was delivered at at 8:15 AM. It was noted that the resident was eating the egg entree, hot cereal, bacon, toast at room temperature. It was also noted that the resident was drinking from a carton of milk that was also at room temperature. The 105852 Page 28 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility's Regional Dietitian who was in the room at the time of the observation stated that dietary was not made aware of the resident's request for a late breakfast and stated that the tray should have been removed refrigerated and reheated. The resident stated to the surveyor and the facility's Registered Dietitian that every breakfast meal is eaten cold. Resident #251: Interview noted the resident to state the food here is absolutely terrible, every meal is a mystery. poor quality, poor appearance, poor temp, no alternatives, and no selective menu. I only eat the [NAME] bran for breakfast meal here, I won't eat anything else. I have asked to see a Dietitian or food service rep several times but have not seen one. Review of current MDS dated [DATE] documented BIMS (Brief Interview for Mental Status) score of 14 (No cognitive impairemt) Resident #256- Interview with resident noted to state that the facility food is terrible and I keep telling them it's terrible on a daily basis. Meals are often served late, food is cold. food appearance, and food quality is poor. I don't eat beef and they send it to me every lunch and dinner meal. The food portions are too small and I'm loosing weight. Review of clinical record of Resident #256 noted admission date of admission date of 05/23/22 with diagnoses of Muscle Wasting, COPD (Chronic Obstructive Pulmonary Disease), Abdominal; Pain, GERD (Acid Reflux), Constipation, and CHF (Congestive Heart Failure). Current physician duet order dated 05/23/22 for No Added Salt and Megestrol (Appetite Stimulant -06/5/22). Current MDS dated [DATE] documented the resident's BIMS score was 14 (No cognitive impairment) Resident #257: Interview noted resident to state that food preferences are never followed especially for the breakfast meal. Stated the food is poor quality and the kitchen often runs out of food. I have requested to see a dietary representative to voice my concerns on a daily basis but I have not seen one. Review of clinical record of Resident #257 noted admission date of 6/15/22 with diagnoses of Liver Disease, Type 2 Diabetes, Muscle Wasting, Ascites, and GERD. Current physician diet order dated 06/15/22 was CHO (Carbohydrate) Controlled. Review of current MDS dated [DATE] documented the resident's BIMS score of 15 (No cognitive impairment). 3) During the observation of the meal service in the main kitchen and interview with the Dietary Manager (DM) on 06/21-23/22 the following were noted: Breakfast Meal conducted 06/21/22 at 7 AM: A standardized recipe was not utilized for the preparation of Confetti Eggs. The peppers and onions were not incorporated in the eggs as per the recipe. Hash [NAME] Potatoes were not prepared as per the approved menu. The DM stated that the Hash [NAME] Potatoes were not ordered and no substitute was prepared for the breakfast meal. No garnish included as per the approved menu. Lunch Meal conducted on 06/21/22 at 11:30 AM: A 10 pound cook Roast Beef was left out art room temperature for over 1 hour during the meal service was requested by the surveyor to be discarded. The Steak Fries were not completely cooked throughout and were noted to be soggy and greasy. The dessert of Apple Crisp was unrecognizable. NO garnish 105852 Page 29 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0804 utilized as per the menu. No garnish included as as per the approved menu. Level of Harm - Minimal harm or potential for actual harm Breakfast Meal conducted on 06/22/22 at 7 AM: Residents Affected - Some Stewed prunes were not prepared as per the approved menu and prune juice was substituted. The standardized recipe was not utilized for the preparation of Scrambled Cheese & Eggs that included 1 pound-14 ounces of shredded cheese. Interview with the cook revealed only 8 ounces of shredded cheese was used for the preparation of the Scrambled Eggs & Cheese. A pureed scrambled egg was utilized fro pureed duets that did not contain and cheese. Only half a slice of toast was served and review of the menu documented 1 whole slice of Wheat Toast. The pureed bread was not the proper consistency and noted to be in a liquid unrecognizable form. No garnish included as per the approved menu. Lunch Meal conducted on 06/22/22 at 11:30 AM: The [NAME] Supreme Sauce was not prepared for the Chicken Supreme until 12 PM which was after the start of the meal service. There were no Pineapple Cubes prepared for the Cardiac and CHO Cardiac therapeutic diets. No garnish included as per the approved menu. 105852 Page 30 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview, and record review, the facility failed to ensure the residents receive at least three meals daily, at regular times comparable to normal mealtimes in the community. The findings included: 1) During the observation of the lunch tray line assembly in the main kitchen on 06/22/22, it was noted there were staff working in the kitchen who were not dietary personal. Specifically, the Medical Records Director and a CNA were working in the kitchen for the lunch meal preparation and service. Interview with the Dietary Manager at the time of the observation revealed that the kitchen is down 2 full times position and the dinner cook needed to be scheduled for the breakfast meal preparation . Further observation noted that the 06/22/22 lunch tray assembly line began at 12:05 PM. A review of the Meal Tray Delivery Form and observation of meal tray carts noted the following: Hall 100: Scheduled delivery time documented as 11:05 PM - Actual delivery time was recorded at 12:30 PM Hall 500 - Scheduled delivery time documented as 11:45 AM - Actual delivery time was recorded at 1:10 PM Hall 600 - Scheduled delivery time documented as 12:15 PM - Actual delivery time was recorded at 1:30 PM Hall 700 - Scheduled delivery time documented as 12:25 PM - Actual delivery time was recorded at 1:45 PM * Further observation of the lunch meal in the Hall 700 noted that the last tray served to the residents was recorded at 2:05 PM, and the last resident to finish the lunch meal was recorded at 2:40 PM. it was estimated with the Dietary Manager on that the late meals effected at least 50 of the facility residents and that the lunch meal times were not according to comparable lunch community times. 2) During the observation of the breakfast meal in the main kitchen on 06/23/22 at 7:30 AM, it was noted during an interview with the Dietary Manager (DM) that the breakfast cook and a dietary aide had called in sick for 6/23/22. The DM stated that the department was already down 2 full time diet aide positions for some time. Observation noted that the breakfast tray line began at 7:55 AM. A review of the Meal Delivery Times Form and observation of the breakfast meal service for 06/23/22 noted the following: Hall 100- Scheduled meal delivery time documented as 7:15 AM - Actual delivery time was recorded at 8:05 AM Hall 200 - Scheduled delivery time documented as 7:25 AM - Actual delivery time was recorded at 105852 Page 31 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0809 8:13 AM Level of Harm - Minimal harm or potential for actual harm Hall 300 - Scheduled delivery time documented 7:35 AM - Actual delivery time was recorded at 8:25 AM Hall 500 - Scheduled delivery time documented as 7:55 AM - Actual delivery time was recorded at 8:30 AM Residents Affected - Some Hall 600 - Scheduled delivery time documented as 8:05 AM - Actual delivery time was recorded at 9:02 AM Hall 700 - Scheduled delivery time documented as 8:15 AM - Actual delivery time was recorded at 9:20 AM * Further observation of the breakfast meal on Hall 700 noted that the last tray delivered to the residents was recorded at 9:45 AM and the last resident finished the meal at 10:15 AM. The cart with the soiled dishes was schedule to be picked up on 9:25 AM, however the cart was returned to the kitchen at 11:15 AM. The issues concerning the late meal service was discussed and confirmed with the Administrator on 06/22/22 and 06/23/22. It was determined that the late meal effected at least 50 of the facility residents and that the breakfast meal was not comparable to community breakfast times. 3) Individual interviews conducted with Resident's #30, #251, #252, #256, #255, #257 on 06/20-06/23/22 noted voiced complaints of meals consistently served late. 105852 Page 32 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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. Residents Affected - Some The findings included: 1) During the initial Kitchen/Food Service observation tour conducted on 06/20/22 at 9 AM, accompanied with the Dietary Manager (DM) the following were noted: (a) The floor area leading up to the entry door of the dietary department was heavily soiled, with presence of garbage and trash. This was discussed with the DM that food carts and staff entering into the kitchen are tracking in the dust and dirt from the soiled floor. (b) There were numerous open food trays with visible trash/garbage sitting within the entry area of the kitchen. It was discussed with the DM that all garbage and refuse must be covered at all times to prevent the potential of food borne contamination and illness. (c) The food preparation floor and serving areas were noted heavily soiled with dust, dirt, trash , and garbage. It was discussed with the DM that the kitchen floor is not being cleaned on a regular basis. (d) The door gasket of the milk refrigerator were torn and rusted and required to be replaced. (e) The ceiling mounted air intake vent located in the food serving areas was dust laden and was potentially contaminating food during the serving process. (f) The interior of the hood exhaust system, located directly above the dish machine, was noted to have a large area of dried white matter and also noted that there was a build-up of brown oil condensation along the exterior edge that was dripping. 2) Observation of the Main Kitchen on 06/21/22 at 7:30 AM, accompanied with the DM noted the following: (g) Food temperatures were taken with the use of the facility's calibrated bayonet thermometer and noted that cold foods were not being held at the regulatory temperature of 41 degree F or below as per the following: * Quart Scrambled Egg Mix = 60 degrees F. The surveyor requested that the product be discarded. 3) Observation of the Lunch meal in the main kitchen on 06/21/22 at 11:30 AM, accompanied with the DM noted the following: (h) Ten pound Cooked Roast Beef was noted to be thawing at room temperature. The DM was informed that the regulatory process for thawing meats was to be only under cold running water or in the refrigerator. 4) During the observation of the breakfast meal in the main kitchen on 06/22/22 at 7:30 AM, 105852 Page 33 of 34 105852 06/23/2022 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0812 accompanied with the DM, the following were noted: Level of Harm - Minimal harm or potential for actual harm (i) Temperature of foods were taken with the facility's calibrated thermometer anf noted hot foods were not being held at the required 135 F or greater, as per the following: Residents Affected - Some Individual Pancakes = 120 F Pureed pancakes = 100 F Pureed Sausage =115 F SB6 Sausage = 115 F 105852 Page 34 of 34