Health inspection·August 15, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm i. room [ROOM NUMBER]: Bathroom toilet requires re-caulking to the floor, room walls (3) damaged and in disrepair. And no over-bed light cord (W-bed). j. room [ROOM NUMBER]: Bathroom toilet required re-caulking to the floor, room floor stained throughout, bathroom toilet seat loose, and room walls damaged and in disrepair. Residents Affected - Some k. room [ROOM NUMBER]: Room floor stained throughout, bathroom floor stained, and toilet required re-caulking to the floor. l. room [ROOM NUMBER]: Bathroom floor stained and soiled throughout, air-conditioning unit not properly attached to the room walls, and toilet requires re-caulking to the floor. m. room [ROOM NUMBER]: Bathroom floor stained throughout, and toilet requires re-caulking to the floor. Community Shower Room: Room entry door damaged and in disrepair, and discolored/stained wall tiles (Shower Stall #1). n. Soiled Utility Room: Interior of Specimen Refrigerator was soiled. o. Housekeeping Storage Room: Soiled equipment and chemicals stored with clean resident toilet and paper towel rolls. p. Hallway Hand Rails: the wall mounted handrails between Rooms #13-21 were noted to have large areas of peeling paint and exposed bare wood surfaces. Following the tour, the environment findings were again confirmed with the Administrator who stated that facility staff are not reporting housekeeping and maintenance issues with the receptionist who is responsible for contacting the housekeeping and maintenance department for their attention to the specific issues. 2. Observation of the main dining room on 08/13/24 at 8:00 AM accompanied with the Administrator and Director of Housekeeping, the following observations were noted: a. Three of six dining room chairs were noted to be soiled and stained with a white substance. b. The exterior of the [NAME] cupboard was soiled and stained. c. Dining room walls (4) were noted to have large black markings in numerous areas of the room. d. Accumulation of dust and dirt on window sills and furniture. e. Floor areas around the dining room tables were noted to have numerous pieces of food debris and were not cleaned following the dinner meal of 08/12/24. f. Numerous room windows (20) were heavily soiled and were not being cleaned on a regular basis. g. The exterior of the suctioning machine located on a back table was noted to be dirt and dust laden. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105968 If continuation sheet Page 2 of 8 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 105968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VI at Lakeside Village 2782 Donnelly Drive Lantana, FL 33462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 h. Base boards throughout the dining room were soiled and stained. Level of Harm - Minimal harm or potential for actual harm i. Five of 10 light fixture were noted to be heavily soiled and had evidence of dead insects. j. The exteriors of 4 of 4 food tray tray stands were rust laden and required to discarded . Residents Affected - Some k. Soiled resident food trays were carried individually by staff uncovered through the dining room through the clean serving area, and into the kitchen. It was discussed with the Registered Dietitian that exposed soiled food trays are required to be covered at all times and not exposed to clean food preparation and serving areas. l. Observation of the dining room preparation area noted that soiled resident table linens (tabled cloths and napkins) are stored in uncovered barrels (2). m.) Observation of drinking glasses noted that the interiors of the glasses was covered with a white film (26 of 26 glasses). Following the tour, an interview was conducted with the Director of Maintenance who stated he only cleans the dining room floor and has no responsibility for the rest of the dining room issues. The Administrator confirmed all the surveyor findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105968 If continuation sheet Page 3 of 8 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 105968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VI at Lakeside Village 2782 Donnelly Drive Lantana, FL 33462 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to prepare food in a form designed to meet the resident's individual need for 1 of 1 sampled resident who had a physician ordered mechanical soft ground diet, Resident #23. The findings included: Record review revealed Resident #23 was admitted to the facility on [DATE], was recently hospitalized on [DATE], and was readmitted to the facility on [DATE], with a diagnosis of Pneumonia. The record revealed Resident #23 had other diagnoses that included Dysphagia (difficulty swallowing), muscle weakness, Dementia, and a history of Covid-19 and obesity. Review of the Minimum Data Set (MDS) significant change assessment, dated 06/15/24, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. This MDS assessment revealed Resident #23 had swallowing problems specified as holding foods in mouth / cheeks or residual food in mouth after meals. Review of Resident #23's care plan, last reviewed on 08/05/24, revealed the resident was at nutritional risk related to Dysphagia. The approach in the care plan noted that the resident's diet was upgraded from a pureed diet to a mechanical soft diet with ground meat. Review of Resident #23's physician diet order dated 07/04/24 listed the current diet order consistency was Mechanical Soft Ground. This diet order was signed by the physician on 07/05/24. Photographic Evidence Obtained. Observation in the main dining room on 08/13/24 at 1:36 PM revealed Resident #23 was served shredded pork. The meat had stringy pieces that were mostly 1/4-1/2 inches long. Resident #23 was observed with prolonged chewing. Photographic Evidence Obtained. The surveyor then went to the kitchen and requested a portion of ground meat from the cook, Staff D. Staff D explained that each plate was prepared to order. Staff D then used a chopping knife and chopped up the meat finely. He gave the plate to the surveyor to observe. This plate remained in the kitchen. Observation at this time revealed Staff B, the Food Service Manager (FSM), entered the food preparation area and he was made aware of the concern about the food texture. The surveyor then requested Staff B to go to the dining room to observe Resident #23's plate. In an interview at the dining room table on 08/13/24, at 1:50 PM, Staff B was asked to describe the prepared pork entrée that was on the resident's plate. Staff B stated the pork on Resident #23's plate was of a chopped texture, and clarified that it was not ground. In an interview in the dining room on 08/13/24 at 2:05 PM, the Registered Dietitian (RD), verified that Resident #23's diet order was for foods to be prepared with a mechanical soft ground texture. The RD explained, They don't do therapeutic (ground) diets here. They do regular, salt free pack, the chopped consistency or what we are calling mechanical soft, and we also do puree. The surveyor requested that the RD provide a copy of the diet manual that included a description of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105968 If continuation sheet Page 4 of 8 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 105968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VI at Lakeside Village 2782 Donnelly Drive Lantana, FL 33462 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 0805 Level of Harm - Minimal harm or potential for actual harm foods served on a mechanical soft ground diet. The RD provided a sheet of paper that listed Food items not allowed on mechanical soft diet. Specific breads, cereals, desserts, vegetables, potatoes, and fruits were listed. There was no mention of any meat items. This sheet had no identifying headings that referred to the name of a diet manual or the source of this listing. Residents Affected - Few Photographic Evidence Obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105968 If continuation sheet Page 5 of 8 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 105968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VI at Lakeside Village 2782 Donnelly Drive Lantana, FL 33462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. The findings included: 1. During the initial tour of the Main Kitchen on 08/12/24 at 9:05 AM, and accompanied by Staff B, the facility's [NAME] Supervisor, and Staff C, the Registered Dietitian (RD), the following was observed: a. A used serving spoon for the breakfast sweet potatoes rested on top of the plastic wrap that partially covered the sweet potatoes. There were plastic spoons observed in an uncovered metal tin, and placed on top of the steam table used on the tray line. The surveyor informed Staff B about the concerns of contaminated serving utensils and contaminated plastic utensils. b. Staff B was observed taking temperatures of foods on the steam table and did not sanitize the thermometer prior to taking the temperature of the sweet potatoes. Staff B was made aware of some possible risks associated with cross contamination. c. Staff C, RD, placed test strips for sanitizer into bucket #1 and bucket #2. The sanitizing solution in bucket #1 and bucket #2 did not meet the requirement for Ammonium compound to be 150 - 200 parts per million. The result of bucket #1 was a yellow color on the test strip, which indicated that there was no sanitizer (O parts per million) mixed into the solution. The result of bucket #2 was a light green color (100 parts per million) on the test strip, which indicated the sanitizing solution was too weak. d. The plastic container of thickener powder had no date written on the container nor on a label on the container. The container of thickener had dried food stuck to the exterior of the container. e. A metal screen like fixture with tiny holes, approximately 18 inches from the ceiling, and located in between the steam table and the oven exhaust, had many dark spots all over the surface. Staff B was made aware that this fixture needed to be clean to maintain sanitary conditions for food service. f. The walk-in refrigerator #8 had no thermometer inside the refrigerator. An empty thermometer clip was observed affixed to the wall inside the refrigerator close to the door. When surveyor questioned Staff B about where the thermometer was, Staff B said that there used to be a thermometer right here. Staff B pointed to the empty clip to the left of the entry door of the refrigerator. g. The cottage cheese best if used by date was 08/3/24. The Hummus use by date was 07/09/24. h. The fan covers on the upper back wall were dusty. Groupings of black specs were observed on the walls located between and around the fans. A concentration of black speck-like debris was observed sprinkled on the ceiling of the refrigerator in the area located on the rear walls near the fans. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105968 If continuation sheet Page 6 of 8 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 105968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VI at Lakeside Village 2782 Donnelly Drive Lantana, FL 33462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many i. A cycle run of the dishwasher was performed. This dishwasher was a low temperature dishwasher and depended on the regulated sanitizer concentration of 50 parts per million (ppm) of chlorine to sanitize the dishes, glasses, and utensils adequately. The RD used a test strip to test the sanitizing solution. The test strip turned a pale lavender color which indicated a concentration between 0-10 ppm chlorine. The measured amount of sanitizing solution failed to meet the required 50 ppm chlorine. The RD used a second test strip and placed it on a cup that was wet from the dishwasher. The test strip turned a pale lavender color which indicated a concentration between 0-10 ppm chlorine. The test strip again failed to show the required amount of sanitizing solution. j. The clean side of the dishwasher run had residual pieces of food. k. The garbage pail was filthy with splattered food on top of garbage lid and on the exterior of the garbage pail. One half of plastic lid was missing. l. The Southbend oven had a build-up of grease on the interior and exterior surfaces. The top of the oven had food crumbs, dust, and stuck on residue. The oven drip trays were ladened with burned grease. m. The Hoshizaki reach-in refrigerator #5 had a puddle of water on the floor close to and under the unit. The surveyor made Staff B aware that this indicated a functional problem with this refrigerator. n. A drawer of knives and a drawer containing cooking spoons, spatulas, scoops, and whisks was dirty. The knives were removed from the drawer by the RD and they were sent to be washed. The empty drawer revealed a dirty paper with debris that lined the drawer. o. The [NAME] boiler was observed in use boiling soup. It was filthy with residual dried on food on exterior sides of the boiler. p. The ice machine was located in an area for dirty containers, bowls, pans, and garbage. q. A dirty, used apron hung in an area, located near the ice machine and the garbage. r. The food mixer was dirty with residual flour and dried on batter. s. The soda dispenser was rusty. t. A rack of uncovered trays was in the hallway next to the entry door of the kitchen. Photographic Eveidence Obtained of above findings. The findings were reviewed with Staff B and Staff C who agreed with these findings and communicated findings with sanitation of kitchen to the administrator. 2. During a follow-up visit to the kitchen on 08/12/24 at 11:30 AM, Staff B, the [NAME] Supervisor, was asked to take the temperatures of the foods prepared for lunch. The temperature of the broccoli did not meet the regulatory required temperature of 135'F (degrees Fahrenheit) or above. The temperature of approximately 20 portions of cooked broccoli was 122'F. The temperatures of 2 cold foods: cottage cheese, and shrimp salad, were not held at the required temperature of 41'F or below. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105968 If continuation sheet Page 7 of 8 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 105968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VI at Lakeside Village 2782 Donnelly Drive Lantana, FL 33462 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many temperature of the cottage cheese in the fruit and cottage cheese plate measured 49'F. The shrimp salad measured 75'F. Photographic Eveidence Obtained of above findings. 3. During a follow-up visit to the kitchen on 08/14/24 at 11:36 AM, an interview with the RD revealed she thought the problem with the concentration of the dishwasher's sanitizing solution was because of a clogged tube that ran from the bucket of the sanitizer solution to the dishwashing machine. The RD showed the surveyors the bucket and the connecting tube to the dishwasher. The RD ran the dishwasher twice, and then she performed testing for adequate sanitizer strength. She touched three separate test strips to wet spots on cups that had gone through the dishwashing machine. All three test strips produced a pale lavender color which indicated a concentration between 0-10 ppm chlorine. The sanitizing solution failed to meet the requirement of 50 parts per million of chlorine. Photographic Eveidence Obtained of above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105968 If continuation sheet Page 8 of 8