Inspection·October 6, 2022

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure care plan meeting were being held in a timely manner and the required IDT (Interdisciplinary Team) members participated in the care planning process for 7 of 13 reviewed, (Resident #2, #3, #11, #12, #16, #20, and #173). The findings included: 1) Record review for Resident #2 revealed the resident was admitted to the facility on [DATE], hospitalized on [DATE], and readmitted on [DATE]. A quarterly MDS was completed on 09/12/22. Further review of Resident #2's records revealed there were no care conference meeting record. 2) Record review for Resident #3 revealed the resident was admitted to the facility on [DATE]. A review of her MDS (Minimum Data Set) revealed that she had an annual review on 03/30/22, and a quarterly review on 06/29/22 and 09/28/22. A review of Resident #3 Care Plan IDT meetings revealed that her last care plan meeting was held on 03/16/22, she has not had one since. A review of the care plan conference record documents the following were in attendance: physical therapy, social services, activities, Director of Nursing (previous DON), and by telephone in attendance Resident #3's son and guardian. Further review revealed that there was no dietician or Certified Nursing Assistant (CNA) in attendance or notes that they were asked about this resident. 3) Record review for Resident#10 revealed the resident was admitted to the facility on [DATE]. A review of Resident #10's Care Plan Conference Record dated 04/20/22 does not document that an CNA or dietician were in attendance. A Care Plan Conference Record dated 07/29/22 does not document that a dietician was in attendance. No notes documented that the CNA or dietician were asked about the resident. 4) Record review for Resident #11 revealed the resident was admitted to the facility on [DATE]. A review of Resident #11's Care Plan Conference Record dated 05/18/22 documents that a CNA and dietician were not in attendance. A Care Plan Conference Record dated 07/29/22 does not show the dietician was in attendance. A Care Plan Conference Record dated 08/24/22 does not show the dietician was in attendance. There are no notes documenting the dietician or CNA were asked about the resident. 5) Record review for Resident #16 revealed the resident was admitted to the facility on [DATE], and her MDS was completed on 08/17/22. A review of her Care Plan Conference Record was dated 09/21/22, which was a month later. In attendance was a Registered Nurse (RN), rehabilitation, social service, and activities and by telephone was the resident's niece. Further review revealed that there was no dietician or CNA in attendance or notes they were asked about this resident. During an interview was scheduled on 10/06/22 at 9:43 AM with the Social Service Director, she stated the MDS Coordinator schedules the care plan meetings and sends us the schedule, then we do the meeting, and fill out the Care Plan Conference Record on who attends. The IDT is involved in meeting which consist of the Social Service Director, nurse, rehab services if the resident is in rehab, activities, and CNA. She stated that if they are not in the meeting then we talk to them. If they are in the meeting, then they sign the document that they were in it. A telephone interview was conducted on 10/06/22 at 11:55 AM with the MDS Coordinator to review the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 2 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Skilled Nursing Facility LLC 2090 N Congress Ave West Palm Beach, FL 33401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm care conference for Residents #2, #3 and #16. She does not see a CP conference meeting for Resident #2 and acknowledges she has been here since 06/01/22. She then reviewed Resident #3 and acknowledges that she does not see a care conference record since 03/22. She stated there should have been a couple more since then. She then reviewed Resident #16 and stated she does not know why her Care Plan Conference meeting was held late. Residents Affected - Some 6) Record review for Resident #12 revealed the quarterly care plan review was held on 08/24/2022 with interdisciplinary team (IDT) participation included: social services, activity, rehab, rehab aid, Assistant Director of Nursing (ADON), Physician, resident, and son (by phone). There was no evidence of dietary, Certified Nursing Assistant (CNA), and direct care nurse participation in this care plan review. On 10/06/22 at 12:01 PM, a phone interview was held with Staff D, MDS Coordinator, and she confirmed the findings. 7) Record review for Resident #173 revealed the admission care plan review was held on 09/14/2022 with IDT participation included: Resident #173, Director of Nursing (DON), social services, and speech therapy. On 10/06/22 at 12:08 PM, during the interview process, Staff D was made aware there was no evidence of direct care nurse, CNA, and dietary staff participation in this review. She acknowledged the findings. 8) Record review for Resident #20 revealed the quarterly care plan review was held on 07/29/2022 with IDT participation included: social services, activity, ADON, Power of Attorney (POA) and Physician. There was no evidence of dietary, and direct care nurse participation in this care plan review. During the phone interview process with Staff D, on 10/06/22 at 12:13 PM, she confirmed the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 3 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Skilled Nursing Facility LLC 2090 N Congress Ave West Palm Beach, FL 33401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure on going activities for Resident#16 for 1 of 2 reviewed for activities. Residents Affected - Few The findings included: Observations of Resident #16 were made on 10/03/22 12:29 PM, in bed with her blinds open and TV on. On 10/04/22 at 12:25 PM Resident #16 was observed in bed with a book on tape on. On 10/05/22 at 2:30 PM, resident observed in room sitting in her chair, starring at the walls. On 10/05/22, and 10/06/22 music was playing in the dining/activity room. Resident #16 was not observed outside of her room while activities were going on in the dining/activity room. Review of Resident#16 records revealed she was admitted on [DATE] with diagnoses to include Encephalopathy, Parkinson's Disease, Altered Mental Status, and Dysphagia. A review of the resident's care plan dated 08/15/22 for Activities document the resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations, and she is assisted with all meals and ADL's. Her interventions include: All staff to converse with resident while providing care. Invite resident to out of room programs. Provide activities calendar of events. Encourage family involvement. Talking book, music, and TV on for socialization was added to the care plan on 10/05/22. Resident#16's MDS (Minimum Data Set) dated 08/17/22, documented resident is not interviewable and does not have a BIMS (Brief Interview for Mental Status) score. Her activity preferences completed with family members, documented that listening to music, doing things with a group of people, going outside for fresh air, and attending religious services are somewhat important to her. During an interview on 10/06/22 at 9:27 AM with the Activities Director, she was asked about Resident #16, she stated I do room visits, radio, talking books and TV for socialization. She comes out of her room but not this week. When asked why she has not been out this week she did not have an answer. The CNA (Certified Nursing Assistant) brings her out of her room. I sit and talk to her, put the talking book on at same time, I do massage her hands. Sometimes she will give me eye contact. Today is nail day so I will be bringing her out to get nails done. She doesn't respond. When asked for documentation on what activities she has done with her, the Activities Director stated she does not document anywhere what activities she has done with her. During an interview on 10/06/22 at 10:00 AM, with the DON (Director of Nursing), stated she will go in her room and talk to her when she can. The DON acknowledges that the resident would benefit being out of her room, and going outside would be good stimulation for her. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 4 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Skilled Nursing Facility LLC 2090 N Congress Ave West Palm Beach, FL 33401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview the facility failed to follow their policy related to weights for Resident #16 who had a significant weight loss, for 1 of 1 resident sampled for nutrition. Residents Affected - Few The findings included: Review of Resident #16 records revealed the resident was admitted to the facility on [DATE] with diagnoses to include Encephalopathy, Parkinson's Disease, Diabetes, Weakness, Dysphagia, Muscle Wasting and Atrophy, Altered Mental Status and Other Signs and Symptoms concerning Food and Fluid Intake. A review of the Physician's Orders revealed the resident was on Furosemide Tablet 20mg, to give 1 tablet by mouth one time a day for fluid retention, dated 08/13/22. Might Shake 120 ml one time a day for nutrition support, start date 09/15/22 and discontinued 09/16/22. Ensure 8 oz one time a day for nutritional support order date 09/17/22. A review of Resident #16 weights revealed she has been weighed only three times since admission, with the last weight at request of surveyor. On 08/13/22 the resident weighed 148 lbs. and on 09/09/22, the resident weighed 134 lbs., which was a -9.46 % loss. A reweigh was not conducted. On 10/06/22 the weight was 140 lbs. A review of the Care Plan dated 08/15/22 documents the resident has nutritional problem or potential nutritional problem related to symptoms and signs concerning food and fluid intake, diabetes, encephalopathy, hypercholesterolemia, Parkinson's disease, dysphagia. Her interventions included monitor/record/report to physician as needed, signs/symptoms of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. A review of the facility Policy & Procedures for Weight Management document the following: 1. All residents admitted to the facility will be weighed according to the following schedule,day one on admission, day two and then weekly X four. 2. All residents will be weighed on a monthly basis unless otherwise ordered by the physician or deemed necessary by the dietician and or the IDT team. 3. Monthly weight will be completed by the 5th of each month and Dietary will evaluate all weights by the 7th of each month. 4. A re-weight will be obtained for any weight change of +/- (3) lbs. from the previous weight unless other parameters have been ordered by the physician. 5. All re-weight will be obtained immediately. The re-weight process will be visualized by a licensed nurse. 6. All weights documented in EMR. 11. The physician and the resident or resident representative will be notified by the resident's nurse of any significant unexpected and or unplanned weight changes. The nurse will document the notification in the resident's EMR by completing the SBER-change in condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 5 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Skilled Nursing Facility LLC 2090 N Congress Ave West Palm Beach, FL 33401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Review of the Policy and Procedures for Weight Management revealed the facility did not weigh Resident #16 weekly for four weeks, weights not completed by the 5th of each month, the dietician did not evaluate the resident's weights until 09/14/22 after significant weight loss, re-weights were not completed for the weight loss and the nurse did not document in the EMR (Electronic Medical Record) that the physician and family was notified of unexpected weight loss. Residents Affected - Few During an interview on 10/05/22 at 12:09 PM and again at 12:33 PM with the Regional Dietician he stated that the dietician that wrote notes on Resident #16 is no longer in this facility. He was asked what does monitoring weights means? He stated that we are checking weights when they come in, typically we would get weekly weights done. Once we recognized weight loss the dietician will put a note and give a supplement. He stated that he spoke to the DON (Director of Nursing), who told him that the resident has improved intake, and was recieving feeding assistance. Weights will fluctuate because she is on Lasix. During an interview on 10/06/22 at 9:53 AM with the DON, she stated the resident was admitted from the hospital, where she was on antibiotics and IV fluid. She stated weights are done on admission and weekly. She acknowledges she has only had two weights. She stated that resident was puffy in feet when she came in, she was on Lasix 20mg. She is assisted with her meals. The DON acknowledges that there is no note by the nurse of notification of the physician or family member. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 6 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Skilled Nursing Facility LLC 2090 N Congress Ave West Palm Beach, FL 33401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, record review, interview, and policy review, the facility failed to ensure 1 of 2 sampled nurses (Staff C, a Licensed Practical Nurse/LPN) was competent in following policy and procedures during the medication pass observations for 2 of 4 sampled residents (Residents #19 and #9). Staff C failed to document the administration of medications at the time the medications were actually given to Residents #19 and #9, thus failing to ensure the safe delivery of medications. Staff C also failed to administer the medications for Resident #19 at the scheduled time. The findings included: Review of the policy Medication Administration (not dated), described the process of documentation during a medication pass to include the following: Procedure: B. 9. Click on the eMAR that says Prep (after removing the medication from the container and checking the label and order three times). B. 13. After the medication has been taken, return to cart and document Given. B. 14. The (sig) document Complete. A medication pass observation for Resident #19 was made on 10/05/22 beginning at 3:59 PM with Staff C, a Licensed Practical Nurse (LPN). The LPN obtained the following medications from the medication cart and administered them to the resident: Systane lubricant eye drops Carbidopa-Levodopa (a medication for Parkinson's disease) 25-100 mg (milligrams), one tablet Eliquis (a blood thinner) 5 mg, one tablet Hydralazine (a blood pressure medication) 25 mg, 1/2 tablet During the continued observation on 10/05/22 at 4:12 PM, Staff C obtained the following medications from the medication cart and administered them to Resident #9: Furosemide (a diuretic medication for excess fluid) 40 mg, one tablet Oxcarbazepine (a medication for seizures) 150 mg, one tablet Humulin 70/30 insulin, 25 units Staff C continued her evening medication pass. Upon surveyor reconciliation of the medications for both Residents #19 and #9 on 10/05/22 at 4:45 PM, it was noted none of the medications provided during the medication observation had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 7 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Skilled Nursing Facility LLC 2090 N Congress Ave West Palm Beach, FL 33401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 documented as provided on the electronic Medication Administration Record (eMAR). Level of Harm - Minimal harm or potential for actual harm During an interview and side-by-side review of the eMAR for Resident #9 on 10/05/22 at 4:59 PM, it was noted the two pills and insulin that were given earlier by Staff C, were still in yellow, indicating they were not given but due to be given. Staff C stated, I thought I signed them out. That is strange. The LPN proceeded to sign out the medications for Resident #9. When asked to pull up the eMAR for Resident #19, the LPN noted the medications that she had given earlier where also not signed out and again stated, That is strange. The LPN was made aware that those particular medications given to Resident #19 at about 4 PM, were not due until 6 PM. These medications were still in white, indicating it was not time to administer them, thus the reason she was unable to sign them out as administered. Residents Affected - Few During the continued interview, when asked if failure to sign out a medication at the time of administration could lead to a possible medication error should she forget and administer them a second time, or should she get replaced by another nurse, Staff C agreed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 8 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Skilled Nursing Facility LLC 2090 N Congress Ave West Palm Beach, FL 33401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observations and interview, the facility failed to ensure garbage and refuse were disposed of properly. Residents Affected - Many The findings included: During a kitchen tour on 10/05/22 at 7:55 AM, a tour of the garbage dumpster was completed with the Dietary Manager and the Certified Dietary Manager (CDM). The garbage trash compactor door was open, gloves, masks, plastic food bag of chips were observed behind dumpster. During an interview on 10/06/22 at 8:00 AM with the Dietary Manager, she acknowledged the garbage around the trash compactor yesterday. She stated that the trash compactor is used by the whole facility. Photographic evidence obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 9 of 9