Inspection·February 1, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete incorrect button, then maintenance has to come and reprogram it. When asked if anyone else knew how to work the Smart TVs, the Administrator stated, not really. The Social Services Director (SSD) was walking by and was asked by the Administrator to try to fix the TV for Resident #80. When asked if she had received instructions on how to work the new Smart TVs, the SSD stated she had not. The SSD worked on the TV in Resident #80's room for about 10 or 15 minutes and stated she just kinda figured it out. The SSD explained that she was the young mind at the facility and gets asked to assist with all the technological stuff. Event ID: Facility ID: 105875 If continuation sheet Page 2 of 12 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 02/01/2024 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care and services as per resident choice for 1 of 2 sampled residents observed who received blood sugar level checks (Resident #10). The findings included: During a medication pass observation for Resident #10 on 01/31/24 at 11:38 AM, Staff A, Licensed Practical Nurse (LPN), gathered the supplies to obtain a blood sugar level, and entered the resident's room. When asked by the LPN which finger she wanted to use to obtain the blood sample, Resident #10 stated she didn't care which finger, but stated, Don't do it near the fingernail, it hurts, while demonstrating where not to put the lancet. The LPN then started toward the side of the resident's finger with the lancet and the resident stated, No not there. On the pad, demonstrating to the LPN exactly were on the pad of the finger she would prefer. The LPN stated she could not do it on the pad as that's where the nerves are and that would hurt. Resident #10 again stated, Not on the side. The LPN stated, Ok . right here, and placed the lancet on the side of the finger and immediately pricked the finger with the lancet before the resident was able to respond. The resident stated, That hurt, and you didn't listen to me. You're not the one that has to live with the pain. After the medication pass observation, Resident #10 explained that she was a seamstress all of her life and was used to pricks on the pad of her fingers. When asked how Staff A made her feel, Resident #10 stated, I understand the nurses didn't sew, but they need to listen to me. I know what I want. During an interview on 01/31/24 at 11:55 AM, when asked if she should have listened to the resident's request regarding obtaining the blood sample, and follow her request, the LPN stated, I agree. Review of the record revealed Resident #10 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, on a 0 to 15 scale, indicating the resident had some cognitive impairment. This MDS also revealed the resident received insulin injections 7 of 7 days during the look-back period. Review of the current Medication Administration Record (MAR) revealed the nurses were obtaining blood sugar levels three times daily. Review of the comprehensive assessment dated [DATE] documented all the decisions related to her Activities of Daily Living (ADLs) were very important to her. During an interview on 02/01/24 at 9:25 AM, when told of the observation during the medication pass with Resident #10 and Staff A, the Director of Nursing (DON) stated, (Name of Resident #10) is very particular. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 3 of 12 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 02/01/2024 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of the policy Oral Inhalation Administration revised January 2018 documented, Metered dose and Dry-Powder Inhalers: . K. Ask resident to breathe out as deeply as possible (do not exhale into inhaler). L. Position inhaler for administration: 1) If not using a spacer: a. Open mouth and position the inhaler one or two inches from mouth, OR b. Place inhaler mouthpiece under top teeth and above tongue with mouth/lips closed around the mouthpiece. M. Press down on inhaler once to release medication as resident starts to breathe in slowly through the mouth over 3 to 5 seconds. (Do not spray more than one puff at a time.) . P. If another puff of the same or different medication is required, wait at least 1-2 minutes between, then repeat procedures above. A medication pass observation was completed for Resident #81 on 01/30/24 at 9:26 AM with the Unit Manager, who was the direct care nurse for the shift. The Unit Manager obtained the resident's Albuterol inhaler, explaining the resident had her morning medications but requested the inhaler after breakfast. The Unit Manager handed the Albuterol inhaler to Resident #81 and stated, You know, two puffs. Hold it and exhale when you need. Resident #81 took the inhaler, put it in her mouth, exhaled into the inhaler, administered two quick puffs, and held her breath. The Unit Manager had to cue the resident to exhale, even though she had previously instructed her to hold her breath and exhale when needed. During an interview on 01/31/24 at 9:37 AM, when asked if she recalled the inhaler administration for Resident #81 from the previous day, the Unit Manager stated she did. When asked if she had administered the Albuterol for Resident #81 before, the Unit Manager stated she had on many occasions. The Unit Manager explained she had learned from the resident's son, that prior to admission, resident #81 was independently administering her own medications, including the inhaler. The Unit Manager stated upon admission to the facility, she tried to administer the inhaler to the resident several times, but the resident would not allow it. The Unit Manager stated she spent a lot of time trying different times to get the resident to wait between puffs, but she would not follow her instructions. The Unit Manager agreed the technique used by the resident was not correct. When asked she if had documented anything related to the provided instructions, attempted education, and or discussion with the resident's son, the Unit Manager stated she believed she did a while ago. Review of the record revealed Resident #81 was admitted to the facility on [DATE]. The record revealed the order for the Albuterol inhaler, but lacked any order to self-administer. The record also lacked any progress note related to the use of the inhaler, attempted instructions and or education, or discussion with the resident's son. 4) Review of the policy Oral Medication Administration revised April 2018 documented, Procedures: I. Chart medication administration on Medication Administration Record immediately following each resident's medication administration. Review of the record revealed Resident #17 was admitted to the facility, late in the day on 01/01/24. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This MDS lacked any documented behaviors of refusal of care and indicated the resident had medications to include insulin and antidepressants. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 4 of 12 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 02/01/2024 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 Review of the January 2024 Medication Administration Record (MAR) revealed the following: Level of Harm - Minimal harm or potential for actual harm a) On 01/08/24 at 6:45 AM the record lacked any blood sugar level. Residents Affected - Some b) On 01/11/24 at 9:00 AM the record lacked the administration of amlodipine and lebetalol (medications for elevated blood pressure levels), citalopram (a medication for depression), famotidine (a medication for heartburn), aspirin (a medication for the prevention of blood clots), and metformin (a medication for elevated blood sugar levels). During a side-by-side review of the record and observation of the medication bubble packs (the packaging of the medication by the pharmacy) for Resident #17 on 01/31/24 at 5:12 PM, the Consultant pharmacist and Director of Nursing (DON) agreed with the lack of documented administration as noted above. The DON confirmed with the pharmacy that the medications for Resident #17 were scheduled to start on the morning of 01/02/24, and were delivered to the facility in time for the morning medication pass on 01/02/24. The following inconsistencies were noted between the January 2024 MAR and the actual number of medications administered (Photographic Evidence Obtained): a) Staff documented the administration of the Atorvastatin (a medication for elevated lipids) 29 times, with only 28 pills popped or removed from the bubble pack. b) Staff documented the administration of the amlodipine 28 times, with only 27 pills removed from the packaging. c) Staff documented the administration of the Citalopram 28 times, but 31 pills were removed from the two packages. 5) Review of the January 2024 Medication Administration Records (MARs) revealed Resident #25 had two orders for the pain medication Tramadol. One order was for 25 mg (milligrams) of Tramadol to be administered routinely at 9 AM and 6 PM. The MAR documented administration of the 25 mg twice daily, except for the 6 PM dose on 01/08/24, which was left blank. The second order was for 50 mg of Tramadol to be administered every 6 hours as needed for pain. The January 2024 MAR lacked any documented administration of the 50 mg tablets to Resident #25. Review of the corresponding Medication Monitoring/Control Records lacked any documented removal of the routine Tramadol on 01/30/24 for either shift, but documented removal of the 50 mg tablets of Tramadol on 01/30/24 at 9:30 AM and 6:30 PM. During an interview on 02/01/24 at 12:40 PM, the Director of Nursing (DON) agreed with the inconsistencies with the Tramadol. During an interview on 02/01/24 at 1:44 PM, the Unit Manager, who was one of the nurses who pulled the 50 mg Tramadol from the medication cart on 01/30/24, explained Resident #25 had complained of increased pain on that date, so the larger dose was given. When asked to review the MARs for the documentation of the Tramadol administration, the Unit Manager agreed she had documented the Tramadol incorrectly. Based on observation, interview, and record review, the facility failed to ensure competent nursing staff as evidenced by the failure to: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 5 of 12 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 02/01/2024 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 - Some 1) Document the antibiotic stop-date for 1 of 1 sampled resident receiving antibiotic therapy (Resident #130); 2) Document medication administration for 5 of 5 sampled residents chosen for unnecessary medications (Residents # 12, #4, #13, #81, and #26); and follow blood pressure parameters for 1 of 5 sampled residents (Resident #4); 3) Ensure resident was educated to the proper technique of inhaler administration for 1 of 6 observed for medication administration (Resident #81); 4) Accurately document the number of medications administered as evidenced by inconsistencies between the January 2024 MAR and the actual number of medications administered for 1 of 6 sample residents for medication administration (Resident #17); and 5) Document the accurate dosage of Tramadol for 1 of 2 sampled residents for narcotic administration (Resident #25). The findings included: 1) Resident #130 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection (UTI). On 01/26/24, the Resident's physician prescribed Cefuroxime Axetil Oral Tablet 500 MG; Give 1 tablet by mouth one time a day for UTI. There was no stop date included on the physician's order. Usage longer than 14 days increases risk for C-Diff. Recommended twice daily. A review of the Facility's Antibiotic Stewardship Policy and Procedure states: 9. The Prescribers will document dose, duration, and indication for all antibiotic prescriptions. On 01/31/24 at 4:00 PM, an interview was conducted with Consultant Pharmacist, he stated, I have not reviewed this resident's record as of yet, since he just was admitted a few days ago, but when reviewing for antibiotic stewardship, I look at right antibiotic, right duration, and if the antibiotic was actually started when prescribed. The Pharmacist agreed that the antibiotic order should have included a stop date. During an interview with the Director of Nursing (DON)on 01/31/24 at approximately 5:00 PM, the DON confirmed that the doctor verbally told her to give Resident #130 the prescribed antibiotic until 02/02/24. When she added the antibiotic into the electronic record, she failed to put the end date in the eMAR, but she was aware of the end date. 2a) Resident #12 was admitted on [DATE] with diagnoses which included Vascular Dementia, Diabetes, Bipolar Disorder, Neuropathy, Paranoid Schizophrenia, Major Depressive Disorder, Adjustment Disorder, Convulsions, Irritable Bowel Syndrome, Pain, Constipation, and Hypertension. Resident cognition is moderately impaired, with a Brief Interview for Mental Status (BIMS) score of 10 out of 15. A review of the electronic Medication Administration Record for December 2023 and January 2024 showed the following missing documentation: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 6 of 12 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 02/01/2024 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 Famotidine 20 mg once daily for GERD. There were no staff initials showing administration of this medication at 6 AM on 12/29/23 and 01/08/24 Colace 100 mg twice daily for bowel management; hold for loose stools. There were no staff initials showing administration of this medication at 9 PM on 12/24/23 Residents Affected - Some There were no staff initials showing the monitoring of targeted behaviors related to antidepressant use each shift for the night shift on 12/10/23 and 01/12/24 2b) Resident #4 was admitted on [DATE] with diagnoses which included Parkinson's, Muscle Weakness, Major Depressive Disorder, Dysphagia, Deep Vein Thrombosis and Acute Embolism, Hypertension, Dry Eye Syndrome, and Chronic Pain. Resident was cognitively intact with a BIMS of 15 out of 15. A review of the electronic Medication Administration Record for January 2024 and December 2023 showed the following missing documentation: Linzess 290 mcg once daily; There were no staff initials showing administration of this medication at 6 AM on 01/19/24 and on 12/19/24. Sinemet CR 50/200 mg once daily for Parkinson's. There were no staff initials showing administration of this medication on 01/21/24, 01/25/24, 12/21/23, and 12/31/23. Apixaban 5 mg twice daily for anticoagulant. There were no staff initials showing administration of this medication at 5 PM on 01/25/24 and 12/31/23. Entacepone 200 mg twice daily for Parkinson's. There were no staff initials showing administration of this medication at 5 PM on 01/25/24 and 12/31/23. Hydralazine HCI 25 mg, 1/2 tab, for Hypertension. There were no staff initials showing administration of this medication at 5 PM on 01/25/24 and 12/31/23. Systane Ultra Solution 0.4-0.3%, Instill 1 drop in both eyes for dry-eye syndrome. There were no staff initials showing administration of this medication at 9 PM on 01/21/24, 4 PM and 9 PM on 01/25/24; and at 9 PM on 12/21/23, 4 PM and 9 PM on 12/31/23. Carbidopa-Levodopa 25/100 mg 5 times a day for Parkinson's. There were no staff initials showing administration of this medication at 9 PM on 01/21/24; 5 PM and 9 PM on 01/25/24; at 9 PM on 12/21/23; 2 PM, 4 PM and 9 PM on 12/31/23. The order for Hydralazine HCl Tablet 25 MG, 1/2 tablet by mouth two times a day for Hypertension, had parameters which called for staff to hold for Systolic Blood Pressure (SBP) less than 110. These parameters were not followed by staff at 5 PM on 01/05/24, 8 AM & 5 PM on 01/06/24; and at 5 PM on 01/21/24 when this medication was initialed as being given by the nurse when SBP was less than 110. 2c) Resident #13 was admitted on [DATE] with diagnoses which included Insomnia, Chronic Kidney Disease, Anemia, Atrial Fibrillation, Sarcopenia, Glaucoma, Hypothyroidism, Major Depressive Disorder, Anxiety, Hypertension, Arthritis, and Coronary Artery Disease. Resident was moderately cognitively impaired with a BIMS of 9. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 7 of 12 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 02/01/2024 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 A review of the electronic Medication Administration Record for January 2024 and December 2023 showed the following missing documentation: Trazodone HCl Oral Tablet 50 MG Give 1 tablet by mouth at bedtime for Depression. There were no staff initials showing administration of this medication at 9 PM on 01/21/24, 01/25/24, 12/21/23 and 12/31/23. Residents Affected - Some Temazepam Oral Capsule 15 MG Give 1 capsule by mouth at bedtime for Insomnia. There were no staff initials showing administration of this medication at 9 PM on 01/21/24, 01/25/24, 12/21/23 and 12/31/23. Pro-Stat Oral Liquid Give 30 ml by mouth two times a day for wound healing. There were no staff initials showing administration of this medication for PM 01/25/24 and PM on 12/31/23 Levothyroxine Sodium Oral Tablet 50 MCG Give 1.5 tablet by mouth one time a day related to Hypothyroidism. There were no staff initials showing administration of this medication at 6 AM on 01/08/24 and on 12/08/23. Latanoprost Ophthalmic Emulsion 0.005 % Instill 1 drop in both eyes at bedtime related to Glaucoma. There were no staff initials showing administration of this medication at 9 PM on 01/21/24, 01/25/24, 12/21/23 and 12/31/23. Buspirone HCl Oral Tablet 15 MG Give 1 tablet by mouth three times a day for Anxiety, Hold for sedation. There were no staff initials showing administration of this medication at 9 PM on 01/21/24 and 01/25/24, 2 PM on 12/31/23, 9 PM on 12/21/23 and 12/31/23. Morphine Sulfate (Concentrate) Oral Solution 100 MG\5ML Give 0.25 ml by mouth two times a day for Pain. There were no staff initials showing administration of this medication at 9 PM on 01//21/24, 01/25/24, 12/21/23 and 12/31/23. Zofran Oral Tablet 4 MG Give 1 tablet by mouth three times a day for Nausea. There were no staff initials showing administration of this medication at 9 PM on 01//21/24, 01/25/24, 2PM on 12/31/23, 9 PM on 12/21/23 and 12/31/23. Behaviors were not initialed by staff as being monitored for Evening shifts on 01/08/24, 01/23/23, 01/25/24 and Night shifts on 01/12/24; Evening shifts on 12/08/23, 12/23/23, and 12/31/23. Side Effects for Psychotropic medications not initialed by staff as being monitored for Evening shift on 01/08/24, 01/23/23, 01/25/24 and Night shift on 01/12/24; Evening shift on 12/08/23, 12/23/23, and 12/31/23; Night shift on 12/12/23 and 12/31/23 2d) On 01/31/24 at 8:45 AM, a review of the electronic Medication Administration Record (eMAR) for Resident #26 noted that on 01/25/24 there was no documentation on the eMAR that the resident received her Duloxetine HCL oral capsule delay release sprinkle 60 MG given 2 times daily for depression, or her Tamsulosin HCL oral capsule 0.4 MG by mouth 2 times daily for overactive bladder. The resident's eMAR, (electronic MAR) contained no documentation to explain why the medication was not given. There was also no documentation in the Resident's progress notes to explain why the medication was not provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 8 of 12 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 02/01/2024 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 01/31/24 at 10:14 AM, the DON stated that the resident refused her medications (Duloxetine HCL and Tamsulosin HCL), and she did not remember to document the information. On 01/31/24 at 4:00 PM, the Pharmacist stated in response to his actions when reviewing the MARS: If I found any holes in the MAR, I would tell (DON). I would not necessarily note it in my notes. I expect them to deal with the issue right away, so I don't always put it in my notes When I notify (DON), she will look at it, confirm the information, and identify the staff member involved. Sometimes you can isolate the issue to one particular staff. I did note that there were issues in December and January regarding Behavior and side effect monitoring which I reported to the DON. Event ID: Facility ID: 105875 If continuation sheet Page 9 of 12 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 02/01/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and policy review, the medication error rate was 7.14 percent. Two medication errors were identified while observing a total of 28 opportunities, affecting 2 of 7 residents observed (Residents #8 and #4). Residents Affected - Few The findings included: Review of the policy Eye drop administration revised April 2018 documented, Procedure: . F. With a gloved finger, gently pull down lower eyelid to form pouch, while instructing resident to look up. Place other hand against resident's forehead to steady. Hold inverted medication bottle between the thumb and index finger, and press gently to instill prescribed number of drops into pouch near outer corner of eye. H. While the eye is closed, use one finger to compress the tear duct in the inner corner (inner canthus) of the eye for 1-2 minutes. This reduces systemic absorption of the medication. Alternatively, the resident may keep his/her eyes closed for approximately three minutes. 1) During a medication administration observation for Resident #8 on 01/30/24 at 11:12 AM, the Unit Manager, who was also the direct care nurse for the shift, obtained the resident's artificial tears from the medication cart. The Unit Manager proceeded to administer one drop directly into the tear duct (inner corner) of each eye. 2) During a medication administration observation for Resident #4 on 01/31/24 at 9:23 AM, the Unit Manager obtained the resident's medications from the medication cart, to include Systane eye drops. Upon administration of the medication, the Unit Manager placed the eye drops directly into the resident's tear ducts. During an interview on 01/31/24 at 9:37 AM, when asked the technique for eye drop administration related to where in the eye the drops should be placed, the Unit Manager explained she tries to put the drops in the corner pocket, pointing to the inner most aspect of her eye, to allow the medication to distribute over the eye. When asked about the tear duct, the Unit Manager stated she was not sure, explaining that she obtained her license during the pandemic and did not get very much clinical time. Review of the record revealed Resident #4 had a current Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating she was cognitively intact. During an interview on 02/01/24 in the afternoon, when asked if she feels the eye drops were helping her dry eyes, Resident #4 stated she did not, further explaining that her eyes remained dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 10 of 12 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 02/01/2024 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 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, the facility failed to prepare and serve food in a sanitary manner affecting all residents who eat their meals in the facility. Residents Affected - Many Findings include: Observations made during the initial tour of the main kitchen at 9:10 am on 01/29/2024, accompanied by the dietary manager. The following was observed: 1) The oven and stove was very dirty with grease and baked on food. (2) The flat top grill is dirty, stained with food and grease. (3) The test strips for determining the PPM for the sanitizing red bucket and the sanitizing sink had a expiration of November 2021. (4) The shelving under the steam table was very dirty with grease and food. (5) The janitor closet was dirty and the brooms and dust pan was stored on the floor of the janitors closet instead of hanging on the wall. (6)The top shelves in the dry storage room had boxes packed to the ceiling. There was no red line painted on the wall to indicate how high the boxes can be stored (7)There was a bag of yellow left open on the shelf, in the dry storage room. (8) There was a plastic bag of foam disposable plates open on the shelf, in the dry storage room. At 11:30 am on 01/29/2024 during an interview with the Certified Dietary Manager, he acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 11 of 12 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 02/01/2024 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Potential for minimal harm Based on record review and interviews, the facility failed to ensure the Binding Arbitration Agreements complied with all regulatory requirements. This affected all residents who signed the facility's current arbitration agreement. Residents Affected - Many The findings included: On 01/29/24 at 9:30 AM, during entrance conference with the Administrator, she verified that all residents have entered into an arbitration agreement, as it is a part of their admission packet. She confirmed that no residents at this time have resolved a dispute using arbitration. On 01/29/24, a copy of the Alternative Dispute Resolution Agreement, which was included in the Facility's admission Packet, was provided for review. During review of the Arbitration Agreement, the following concerns were noted: 1) The facility agreement does not specifically state that the resident/representative acknowledges that he/she understand the agreement. 2) The agreement states that any Party has three (3) days from execution of the Agreement to cancel or rescind any portion by timely delivering such notice in writing to the other Party(ies). Regulation specifies that the Agreement must explicitly grant the resident/representative the right to rescind within 30 days of signing it. The Administrator was informed of these concerns with the Arbitration Agreement in writing (via email) on 01/29/24 at 3:30 PM. No response or further information was provided. Three alert and oriented residents attending the Resident Council Meeting on 01/31/24 at 2:30 PM were asked if they recall signing the Arbitration Agreement during Admission. None of the 3 residents knew what the agreement was or remembered signing it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105875 If continuation sheet Page 12 of 12