Inspection·July 28, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: Exterior of Wardrobe Closet (A-bed) was in disrepair and the two doors (2) would not shut. room [ROOM NUMBER]: Numerous electrical cords (5) and electrical power strips (2) on floor presented a potential safety and fall hazard. Residents Affected - Some room [ROOM NUMBER]: Room window curtains would not open and shut properly, and the exterior of the Wardrobe Closet (A-bed) was in disrepair and the two doors (2) would not shut. room [ROOM NUMBER]: Exterior of the Wardrobe Closet (A-bed) was in disrepair and the two doors (2) would not shut (B-bed). room [ROOM NUMBER]: Overbed pull light cord missing. room [ROOM NUMBER]: Bathroom floor noted to have numerous black stains. room [ROOM NUMBER]: Bathroom floor noted to have numerous black stains. room [ROOM NUMBER]: Room walls noted to have numerous and large black scuff marks. room [ROOM NUMBER]: Room walls noted to have numerous and large black scuff marks. room [ROOM NUMBER]: The Exterior of the Wardrobe Closet (A-bed) was in disrepair, the two doors (2) would not shut, and overbed light (B-bed) was not operational. Following the tours, the findings were confirmed with the Administrator. It was revealed that the facility has a computerized TELS system that staff are trained to enter for housekeeping and maintenance issues. It was noted that staff are not utilizing the system for reporting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 2 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 ensure residents received appropriate treatment and services to maintain or improve the ability to eat and to maintain nutrition status, for 1 of 4 sampled residents, Resident #48. Residents Affected - Few The findings included: Review of clinical record for Resident #48 revealed the following: Date Of admission: [DATE] with readmission on [DATE]. Diagnoses included: UTI {urinary tract infection), Sepsis, Covid-19, Atrial Fibrillation, and Calculus of Kidney. Current MD Orders included: 06/09/22 - No Added Salt Diet 05/30/22 - Nutritional treat 07/26/22 - Ensure Plus BID [twice daily] 07/27/22 - Hospice Consult 05/31/22 - Prosource ZAC 30 ml QD [daily] 06/07/22 - Ferrous Sulfate 3256 mg BID - Anemia Weight (wt) History as provided: 07/27=126 pounds (#) (surveyor requested weight) 07/12= 127# 06/17=132.8# 06/02=153.8# Height= 69 inches BMI [Basal Metabolic Index]=18.8 Review of Minimum Data Set (MDS) assessment, dated 06/04/22,00 for Significant Change: Sec B: Clear Speech / Understood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 3 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0676 Sec C: BIMS (Brief Interview for Mental Status) =12, indicating moderate cognitive impairment. Level of Harm - Minimal harm or potential for actual harm Sec D: No Mood Sec G: Eating =Supervision Residents Affected - Few Sec H: Indwelling Catheter / No toileting plan Sec K: Ht=69 [inches], Wt=154 [pounds/#] / On a wt gain plan Sec M: Yes -Pressure Ulcer (2) - Unstageable During observation of the lunch meal on 07/25/27 at 12:30 PM, it was noted that the lunch tray was served to the room of Resident #48. Further observation noted that the tray was put on the resident's over-bed table which was slightly out of the reach of the resident. The resident was noted to be lying in bed with confusion and trying to reach for food items on the meal tray. No staff were noted to come into the room to provide assistance or supervision for the resident to eat. The tray was removed without the resident eating any of the lunch meal. During observation of the breakfast meal on 07/26/22 at 8:30 AM, it was noted that the meal tray was served to the room of Resident #48. Further observation noted that the tray was left on the resident's over-bed table which was out of reach of the resident. During the observation the resident was requesting the surveyor to assist with eating. At no time during the observation was noted that staff members attempted to assist or supervise the resident with eating. The tray was removed by staff and noted zero intake of the meal. During observation of the breakfast meal on 07/27/22 at 8:05 AM, it was noted that the meal cart was delivered to the Wing of rooms #228-235. Further observation noted that there were no nursing staff available to pass the meal trays to the residents' rooms, but that the facility Dietitian and Physical Therapist had to pass the meal trays. Further observation noted the breakfast tray was not delivered to the room of Resident #48 until 8:45 AM. It was noted that the meal tray was placed on the resident's over-bed table which was slightly out of reach of the resident. Observation of the resident noted some cognitive impairment and was asking the surveyor for assistance with eating. Further observation at 9:00 AM noted the tray still out of reach of the resident and the resident was noted attempting to grasp foods from the tray. At 9:10 AM, the Certified Nursing Assistant (CNA) pushed the over-bed table with the food tray in front of the resident. The resident was lying in the bed and required repositioning to attempt to eat. The resident was noted to try to grab food while laying in the bed. At 9:15 AM, the CNA removed the tray form the room of Resident #48 without anything eaten from the breakfast tray. The CNA stated the resident stated he was done with the meal. During an interview with the MDS Coordinator on 07/26/22 and 07/27/22 to discuss the status of Resident #48, it was revealed that she had not been made aware of the decline of the resident. Specifically, she had not been made aware by nursing that the resident's cognitive status had significantly declined along with Significant decline of Activities of Daily Living that included eating. The MDS Coordinator assessed the resident on 07/26/22 and 07/28/22 and agreed with the surveyor of the resident's decline in cognition and eating status and stated a Significant Change in the MDS should be completed. The resident was scheduled for discharge to a Hospice based facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 4 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0676 Level of Harm - Minimal harm or potential for actual harm The concern of the resident's failure to receive assistance with eating and the nutritional status was also discussed with the Director of Nursing (DON) on 07/26/22. The DON confirmed the surveyor findings that Resident #48 required extensive assistance with eating and was not getting the extensive assistance from staff during meals. It was also noted of a significant decline on the resident's cognition status. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 5 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 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** Based on observation, interview, record review and review of policy and procedure, the facility failed to provide care and services in accordance with activities of daily living, related to nail grooming, for 2 of 2 sampled residents observed for fingernail care, Resident #33 and Resident #85. Residents Affected - Few The findings included: Review of the facility policy and procedure on 07/27/22 at 2:00 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 Procedure 6. Carefully brush nails with nailbrush to remove dirt or clean with orange stick 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 facility's Certified Nursing Assistant (CNA) job description on 07/27/22 at 2:10 PM, revised 02/08, indicated: Job Summary: Provides basic nursing care to residents within the scope of the nursing assistant responsibilities and performs basic nursing procedures under the direction of the licensed nurse supervisor Personal Nursing Care Responsibilities: Assists residents with resident care including bathing, grooming, hygiene and . Resident #33 was re-admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Seizures, Atherosclerotic Heart Disease, Hypertension and Hereditary and Idiopathic Neuropathy. She had a Brief Interview Mental Status (BIM) score of 00 (severely impaired). Record review of the Resident #33's Monthly Certified Nursing Assistant (CNA) ADL (Activities of Daily Living) Flowsheet Record, dated 07/14/22 through 07/27/22, revealed that resident's (ADL)s for Personal Hygiene indicated that the resident required total assistance from staff. Further record review of the Minimum Data Set (MDS) sections A Identification Information and G Functional Status, dated 05/10/22, for Resident #33 indicated the resident was total dependence requiring full staff performance. In addition, (MDS) sections D Mood and E Behavior, dated 05/10/22, for Resident #33 indicated that the resident did not exhibit any mood or behaviors during the period reviewed. Record review of the Resident #33's care plan, initiated 05/20/21 and revised 06/01/21, indicated: Focus: Activities of Daily Living (ADL): Self-care deficit related to Seizures, Bipolar Disorder, Weakness, History of Cerebrovascular Accident (CVA) and Dysphagia. Interventions: .assist with daily hygiene, grooming, dressing, oral care and eating as needed. Goal: Will receive assistance necessary to meet (ADL) needs. During an initial observational tour conducted on 07/25/22 at 10:33 AM, Resident #33 was observed with long, sharp, jagged, unkempt fingernails on both hands. Photographic evidence was obtained of Resident #33's long, sharp, jagged and unkempt fingernails. During a second observation conducted on 07/25/22 at 1:58 PM, Resident #33 was again observed with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 6 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0677 long, sharp, jagged, unkempt fingernails on both hands. Level of Harm - Minimal harm or potential for actual harm During a third observation conducted on 07/26/22 at 9:58 AM, Resident #33 was observed with long, sharp, jagged, unkempt fingernails on both hands. Residents Affected - Few During a fourth observation conducted on 07/26/22 at 2:52 PM, Resident #33 was still observed with long, sharp, jagged, unkempt fingernails on both hands. During a fifth observational tour conducted on 07/27/22 at 9:44 AM, Resident #33 was again observed with long, sharp, jagged, unkempt fingernails on both hands. Resident #33's fingernail care was noted not to have been done, on the dates from 07/25/22 through 07/27/22, until after surveyor inquisition / intervention. An interview was conducted with Staff E, Certified Nursing Assistant (CNA) on 07/27/22 at 12:20 PM, who revealed that they had not provided fingernail care to Resident #33. She said that it is the responsibility of the CNAs to clean and trim the residents' fingernails. She further acknowledged that Resident #33's fingernails were long, sharp, jagged and unkempt. An interview was conducted with Staff F, a Registered Nurse (RN) on 07/27/22 at 12:25 PM, regarding Resident #33's long, unkempt nails and she also acknowledged that Resident #33's fingernails were long, sharp, jagged and unkempt. 2. Resident #85 was re-admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Chronic Kidney Disease, Dementia, Diabetes Mellitus Type II, Hypertension, Quadriplegia and Gastrostomy Status. She had a Brief Interview Mental Status (BIM) score of 00 (severely impaired). Record review of the Resident #85's Monthly (CNA) (ADL) (Activities of Daily Living) Flowsheet Record dated 07/14/22 thru 07/27/22 revealed that resident's (ADL)s for Personal Hygiene indicated that the resident required total assistance from staff. Further record review of the Minimum Data Set (MDS) sections A, Identification Information, and G, Functional Status, dated 06/29/22, for Resident #85 indicated that the resident was total dependence requiring full staff performance. In addition, (MDS) sections D Mood and E Behavior dated 06/29/22 for Resident #85 indicated that the resident did not exhibit any mood or behaviors during the period reviewed. Record review of the Resident #85's care plan, initiated 03/23/20 and revised 10/01/20, indicated Focus: Activities of Daily Living (ADL): Self care deficit related to physical limitations, Parkinson's Disease, Rhabdomyolysis, Alzheimer's/Dementia, Chronic Kidney Disease and Functional Quadriplegia. Interventions: .assist with daily hygiene, grooming, dressing, oral care and eating as needed. Goal: Will receive assistance necessary to meet (ADL) needs. During an observation conducted on 07/25/22 at 10:49 AM, Resident #85 was observed with long, sharp, jagged, unkempt fingernails on both hands. Photographic evidence was obtained of Resident #85's long, sharp, jagged and unkempt fingernails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 7 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0677 Level of Harm - Minimal harm or potential for actual harm During a second observation conducted on 07/25/22 at 1:58 PM, Resident #85 was observed with long, sharp, jagged, unkempt fingernails on both hands. During a third observation conducted on 07/26/22 at 10:06 AM, Resident #85 was observed with long, sharp, jagged, unkempt fingernails on both hands. Residents Affected - Few During a fourth observation conducted on 07/26/22 at 2:18 PM, Resident #85 was observed with long, sharp, jagged, unkempt fingernails on both hands. During a fifth observation conducted on 07/27/22 at 9:53 AM, Resident #85 was again observed with long, sharp, jagged, unkempt fingernails on both hands. An interview was conducted with Staff G, CNA on 07/27/22 at 12:28 PM, who acknowledged that the resident's fingernails were long, sharp, jagged and unkempt. She also stated that she had not mentioned Resident #85's current fingernail status to the resident's nurse. An interview was conducted with Staff F, RN, on 07/27/22 at 12:32 PM, regarding Resident #85's long, unkempt nails. Staff said that it is the responsibility of the nurses to trim the fingernails of residents who are Diabetic. She acknowledged that Resident #85's fingernails were long, sharp, jagged and unkempt. Resident #85's fingernail care was noted not to have been done, on the dates from 07/25/22 thru 07/27/22; until after surveyor inquisition/intervention. On 07/27/22 at 1:30 PM, an interview was conducted with the Director of Nursing (DON) regarding both Resident #33's and Resident #85's fingernails being long, sharp, jagged and unkempt and she acknowledged that it is the responsibility of the (CNA)s to clean and trim the resident's nails; the nurse to trim fingernails if the resident is Diabetic. The (DON) further acknowledged that the resident's fingernails were long and that they should have been cleaned/trimmed/cut. There was no facility documentation in the licensed nurses' notes indicating that fingernail care was attempted and refused by either Resident #33 or by Resident #85. There was no facility documentation noted in the licensed nurses' notes to reflect that Resident #33 or Resident #85 exhibited behaviors of resisting any care, during the period reviewed. Resident #33's and Resident #85's fingernails were observed to be cleaned and trimmed after surveyor inquisition / intervention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 8 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 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 provide care and services to ensure orthotic devices were applied as ordered to ensure there was support and no decline in range of motion (ROM) for 1 of 1 sampled resident, Resident #55. The findings included: Record review on 07/27/22 revealed Resident #55 was admitted to the facility on [DATE] and had been in a different rehabilitation facility immediately after the stroke in October of 2021.The most recent comprehensive MDS (Minimum Data Set) assessment showed a BIMS (Brief Interview for Mental Status) exam score of 14 out of 15, which indicated little to no cognitive deficit. The relative diagnoses included Hemiplegia and Hemiparesis following cerebrovascular disease affecting the right / dominant side; Osteoarthritis; Muscle Weakness; repeated Falls; abnormalities of gait and mobility, foot drop, and Diabetes. On 07/25/22 at 11:09 AM, Resident #55 reported she has foot drop on the right side from a stroke last fall. She said there is a brace she is supposed to wear every day, but it rarely gets put on. On 07/26/22 at 3:19 PM, during a subsequent interview with Resident #55, she said the boot was applied to her right leg today by the therapy department because the CNA (Certified Nursing Assistant), won't do it. On 07/28/22 at 10:12 AM, during an interview with the Director of Rehabilitation (DOR), physical and occupational records were reviewed as well as the paper medical record. The DOR showed that Resident #55 began her therapy regimen within 48 hours of her admission and continued until 04/09/22 at which point her progress had reversed. On 07/21/22, therapy staff observed the resident to be very fearful of transferring. The resident had been readmitted to the rehabilitation (rehab) program and has been participating every day. The DOR said the resident has two orthotics for her right leg/foot. One is for wearing during rehab sessions and is more flexible. The other one is rigid and worn during bed rest to keep the ankle flexed at 90 degrees. The DOR remembered ordering both orthotics for this resident and showed the purchase of the bed rest AFO (ankle foot orthotic) device from 03/31/22. She further stated the orthotic device for use in bed is supposed to be put on and removed by the CNA. Review of therapy notes from 04/09/22 revealed nursing staff was trained to don and doff (put on and take off) the bed rest AFO with good understanding. The DOR contacted the physical therapist who informed her that the nursing staff members had been trained on 04/09/22 were Staff A and Staff S, both CNAs. Hand-written Discharge Physical Therapy Orders, dated 04/12/22, read: [NAME] R (right) AFO during evening ADLs (Activities of Daily Living) and doff during morning ADLs as tolerated and assess skin were found in the paper chart. There was no current or previous electronic order for the devices found in the MAR (Medication Administration Record), the TAR (Treatment Administration Record) or on the Task List or [NAME] for the CNAs to follow. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 9 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/28/22 at 10:40 AM, during an interview with resident in her room with the DOR present, the resident reported the orthotic was put on by therapy. She confirmed that between her therapy discharge in April and starting therapy again last week, no one was putting the AFO on her. On 07/28/22 at 11:32 AM, during an interview with Staff A, a CNA, she said if a [resident] is supposed to wear any type of device, the nurse or physical therapist will tell them and there should be an order for it. When asked how she would know she is supposed to put on or take off an orthotic, she said it should be on the [NAME] or the Task List. She agreed she would be able to document her actions there and she could also let the nurse know it was done. She verbalized if there is no order, she should not be doing it. On 07/28/22, during an interview with the DON (Director of Nursing), she confirmed the nurses and CNAs would need an order to don or doff any orthotic device and it should be on the [NAME] for the CNAs. The DON acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 10 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #352's, clinical record documented an initial admission to the facility on [DATE] with a readmission on [DATE]. The resident's diagnoses included Encephalopathy, Multiple Myeloma not having achieved remission Cancer, Sepsis due To Escherichia Coli (bacteria), Type 2 Diabetes Mellitus, Bacteremia, and Anemia In Neoplastic Disease. The resident's diagnoses list lacked a diagnosis to validate a clinical indication for the resident's foley/urinary catheter noted in place during the initial observation on 07/25/22. Review of Resident #352's wound care nurse Second Skin assessment note, dated 07/18/22, documented, .Foley catheter in place, clear yellow urine collection bag . The resident's Admission/readmission Evaluation dated 07/16/22 documented under clinical evaluation renal/urinary that the resident had a catheter #18 . Review of Resident #352's nurse's note, dated 07/27/22 at 8:08 AM, documented, .Patient pull out her foley catheter. patient denied pain and discomfort and patient will continue to monitor for void. Incoming nurse informed about patient status. Further record review revealed lack of communication with the resident's physician regarding the foley being pulled out. Review of Resident #352's Minimum Data Set (MDS) admission five (5) days assessment. dated 07/21/22. documented a Brief Interview of the Mental Status (BIMS) score of 3 of 15, indicating the resident had severe cognition impairment. The assessment documented under the Bladder and Bowel section that the resident did not have a foley / urinary catheter. Review of Resident #352's care plan lack documentation of a Foley / urinary catheter. Review of Resident #352's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2022 MAR/TAR lacked documentation of the resident's Foley / urinary catheter monitoring or care. Review of the resident's physician orders lacked a physician order for a Foley / urinary catheter. Further review revealed the lack of a physician order to remove Residents #352's foley / urinary catheter. On 07/25/22 at 11:20 AM, observation revealed Resident #352 in bed with a urine drainage bag hanging on the right side of the bed, facing the door. No privacy bag to cover the drainage bag was noted. Further observation revealed a pinkish, blood tinged color urine. An attempt was made to interview the resident but she was talking in a language the surveyor did not understand. During the observation, Resident #352 pulled her cover sheet down and pointed to the foley catheter. On 07/26/22 at 11:20 AM, observation revealed Resident #352 in bed and there was no urine drainage bag noted. The resident pulled her sheets up and the foley catheter was not in place. On 07/27/22 at 10:04 AM, observation revealed Resident #352 in the therapy room accompanied by Staff H, an Occupational Therapist-Student (OT-S). Observation revealed the resident did not have a Foley / urinary bag. An interview was conducted with Staff H, OT-S, who stated the resident was getting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 11 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0690 therapy in her room before and that they (staff) must have taken her Foley out yesterday (07/26/22). Level of Harm - Minimal harm or potential for actual harm On 07/27/22 at 10:16 AM, an interview was conducted with Staff I, a Registered Nurse (RN), who stated that she was monitoring Resident #352 for urine because the foley / urinary catheter was removed as per report from the evening nurse. Staff I was asked when the catheter was removed and stated she did not know when it was removed. Residents Affected - Few On 07/27/22 at 11:48 AM, an interview was conducted with Residents #352's Nurse Practitioner (NP) who stated the resident pulled her foley out and that the urinalysis came back positive for urinary tract infection (UTI). The NP was asked the reason / indication for the Foley and stated that the resident had urinary retention. On 07/27/22 at 3:46 PM, an interview was conducted with the facility's Director of Nursing (DON). The DON was apprised that on 07/25/22, Resident #352 showed the surveyor her Foley catheter and that on 07/26/22, the resident did not have the Foley catheter in place. The DON stated she did not see a physician order for a Foley / urinary catheter or an order to discontinue the foley catheter for Residents #352. During the interview, the DON stated that when they have a new admission that comes in with a Foley catheter, if appropriate, they will get a physician order for a voiding trial to discontinue the Foley on the same day or as soon as possible. The DON was apprised that the NP informed the surveyor that Resident #352's urine results came back positive for UTI today (07/27/22). The DON was apprised that the resident's MDS assessment did not capture that the resident had a Foley catheter and that a care plan related to the catheter was not initiated. On 07/27/22 at 4:36 PM, a side by side review of Resident #352's MDS five (5) days assessment, dated 07/21/22, Bladder and Bowel section, was conducted with Staff J, an MDS Coordinator. Staff J stated she completed the assessment by seeing the resident and reviewing the nurses notes. Staff J stated that she overlooked the record and did not code Resident #352's assessment for a Foley catheter. She stated that would have triggered a Foley catheter care plan. On 07/28/22 at 9:49 AM, an interview was conducted with Staff K, a Licensed Practical Nurse (LPN), who stated that Resident #352's Foley catheter was patent on Tuesday (07/26/22). Staff K added that the resident's family member requested the removal of the Foley and that she passed the request on to the evening nurse. Staff K stated she did not obtain a physician order for the removal of the Foley catheter. Staff K stated, today (07/28/22) she was informed that the Foley was removed after the voiding trial. Based on observation, record review, interview and policy review, the facility failed to obtain physician orders for a Foley catheter, failed to perform catheter care in a manner to prevent infection, and failed to maintain Foley drainage bags off the floor for 3 of 4 sampled residents reviewed for urinary catheters, Residents #19, #306 and #352. The findings included: Review of the facility provided policy, titled, Bed Bath, dated May 20, 2022, instructs the care provider to wash, rinse and dry the patient's abdomen and then groin and perineum, remove and discard gloves, perform hand hygiene, don new gloves, wet a clean washcloth and apply cleanser then wash, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 12 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0690 rinse, and dry the patient's legs. Level of Harm - Minimal harm or potential for actual harm Review of the facility provided policy titled Indwelling Urinary Catheter (Foley) Care and Management last revised on 11/19/2021, reads: don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI (Catheter Associated Urinary Tract Infection). Residents Affected - Few 1. Resident #19 was admitted to the facility on [DATE]. The first physician order to insert a Foley catheter was dated 07/07/21. The current physician order from 05/11/22 read: Maintain Foley catheter with 18F 10 cc balloon for Neurogenic Bladder. Additional relevant diagnoses included Urinary Tract Infection (UTI), Neuromuscular Dysfunction of bladder, Hemiplegia and Hemiparesis to right side following a stroke, BPH (Benign Prostatic Hyperplasia), and Urinary Retention. The most recent comprehensive assessment, dated 05/07/22, revealed the resident had a BIMS (Brief Interview of Mental Status) exam score of 14 out of 15 indicating little to no cognitive deficit. The resident required extensive physical assistance from one to two persons or was totally dependent for most ADLs (Activities of Daily Living) due to a stroke and limited independent abilities. On 07/25/22 at 9:22 AM, the urinary catheter bag for Resident #19 was observed resting on the floor. On 07/26/22 at 3:30 PM, the urinary catheter bag for Resident #19 was again observed resting on the floor. Photographic Evidence Obtained. On 07/26/22 at 4:12 PM, a bed bath with catheter care completed by Staff R, Certified Nursing assistant (CNA), was observed. During the bed bath, the order of washing occurred as follows: Staff R washed the resident's face and the front of his torso, added more soap to the basin of water and had the resident wash his hands in the water. She then washed his abdomen and groin, rinsed the washcloth in the water, washed the abdomen and groin again and then dried it. Using the same washcloth, after rinsing in the basin of dirty water, she washed his legs, washed the groin again and then only the penile meatus and the catheter tubing at the point of entry in the urethra. She then changed the water in the basin and got a new washcloth. She washed the resident's back then the buttocks, rinsed the washcloth in the basin and washed the buttocks again. After the resident turned to the other side, she used the same washcloth and water to wash the back, gluteal cleft (space between butt cheeks), perineum, and then the buttocks again. She then applied barrier cream to the buttocks, gluteal cleft, and scrotum. Wearing the same gloves used to apply barrier cream, she lifted the urinary catheter tubing out of the way while she secured his brief. When asked how many washcloths she used she said three, it's in the basket and motioned to the hamper in the bathroom. The surveyor inspected the hamper which was completely empty. She was able to produce two wash cloths from the laundry bundle and said, two, one for top and one for bottom. On 07/27/22 at 3:32 PM, Resident #19's urinary catheter bag was again observed resting on the floor. Photographic evidence obtained. Staff A, a CNA, was asked to come to the room to observe. She confirmed that the bag should not be on the floor. 2. Resident #306 was recently admitted to the facility on [DATE] after treatment of a UTI and with an indwelling urinary catheter. Relative diagnoses included Neuromuscular Dysfunction of the bladder and a sacral wound infection (Stage IV). The most recent comprehensive assessment, dated 06/23/22, revealed a severe cognitive deficit. The resident was hospitalized for a procedure and returned to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 13 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0690 Level of Harm - Minimal harm or potential for actual harm the facility on [DATE] with an indwelling urinary catheter. Review of the resident's medical record did not reveal any current order for a urinary catheter. On 07/26/22 at 1:25 PM, Resident #306's urinary drainage bag was observed resting on the floor. Photographic Evidence Obtained. Residents Affected - Few On 07/27/22 at approximately 3:30 PM, Resident #306's urinary drainage bag was again observed resting on the floor. Photographic Evidence Obtained. Staff B, CNA, was asked to come to the resident's room to observe. She confirmed urinary bag was on the floor and it should not be. It was also noted that the bag had approximately 800 ml of urine in it and had not been emptied by the assigned CNA who had left for the day. On 07/27/2022 at 3:20 PM during an interview with Staff B, CNA, she agreed that catheter care is done with every episode of incontinence, and it is not ok to let the drainage bag touch or rest on the floor. She also said it was not ok to use the same washcloth to wash the legs after washing the groin. On 07/27/22 at 3:47 PM, during an interview with the Director of Nursing, (DON) regarding urinary catheters, she said the process for a patient {resident} that is admitted with a catheter included trying to obtain an order [physician order] for a voiding trial to discontinue the catheter. She confirmed that a physician's order is necessary to insert or keep an indwelling urinary catheter. She said there should be a place on the TAR (Treatment Administration Record) to document findings about the catheter. There should be an order that specifies Maintain Foley catheter with the size and diagnosis. If a catheter needs to be inserted or discontinued there should be a separate order. The DON agreed there should be an item on the Task list or Kardex about catheter care for the CNAs. When asked to show a current order for Resident #306 to have the indwelling catheter, she was unable to find one. The only order identified was started on 06/28/22 and discontinued on 07/03/22. The DON then agreed that the Foley drainage bags should not be on the floor and acknowledged the issues with orders and the bags on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 14 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0698 Provide safe, appropriate dialysis care/services 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 record review and interview, the facility failed to ensure residents received services consistent with professional standards of practice that included review and clarification of physician ordered medications, for 1 of 1 sampled resident, Resident #53, reviewed for dialysis. Residents Affected - Few The findings included: Review of the clinical record of Resident #53 on 07/26/22 noted the following: Date Of admission: [DATE] Diagnoses included: End Stage Renal Disease, Dependence of Renal Dialysis, DM 2 and Cognitive Impairment. Current Physician Orders included: Dialysis: Monday / Wednesday / Friday (M/W/F) - leave facility at 5:30 AM - Chair time 6 AM. Interview with medication nurse on 07/26/22 confirmed the resident's dialysis days and schedule as M/W/F, leaves facility between 5:00-5:30 AM on these days and returns at approximately 1:00 PM. Review of current physician ordered medications and review of July 2022 Medication Administration Record (MAR) noted numerous doses of medications not administered, due to the resident being at dialysis, that included the following: a. Allopurinol (Gout) 100 mg QD [daily] - Review noted the medication was not administered on 7/3, 7/11, 7/15, and 7/25/22, and documentation noted that the resident was not in the facility for the scheduled 9:00 AM dose. b. [NAME] Thyroid (Hypothyroidism) 30 mg - give 1 table every Monday / Wednesday, and Friday - Review noted the medication was not administered on 7/3, 7/11, 7/15, and 7/25/22, and documented that the resident was not in the facility for the scheduled 9:00 AM dose. c. Omeprazole (GERD) 20 mg - Review noted the medication was not administered on 7/3, 7/6, 7/11, 7/13, 7/15, 7/18/, 7/20, and 7/25/22, and documented that the resident was not in the facility for the scheduled 7:30 AM dose. d. Isosorbide Dinitrate (Angina) 30 mg BID [twice daily] - Review noted that the mediation was not administered on 7/4, 7/11, 7/15, and 7/25/22, and documented that the resident was not in the facility for the scheduled 9:00 AM dose. e. Memantime HCL (Dementia) 5 mg BID - Review noted that the medication was not administered on 7/3, 7/11, 7/15, and 7/25/22, and documented that the resident was not in the facility for the scheduled 9:00 AM dose. f. Calcium Acetate (Calcium Supplement) 667 Three time per day [TID]- Review noted the medication was not administered on 7/6, 7/11, 7/15, and 7/25/22, and documented that the resident was not in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 15 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0698 facility for the scheduled 9:00 AM dose. Level of Harm - Minimal harm or potential for actual harm g. Refresh Solution (Dry Eyes) 1 drop three time per day - Review noted the medication was not administered on 7/3, 7/11, 7/15, and 7/25/22, and documented the resident was not in the facility for the scheduled 9 AM dose. Residents Affected - Few h. Humalog Insulin Inject as per Sliding Scale - Review noted the blood glucose was not taken and insulin not administered as per sliding scale on 7/1, 7/3, 7/6, 7/11, 7/13, 7/15, 7/18, 7/20, 7/22, and 7/25/22, and documented that the resident was not in the facility for 6:30 AM dose. i. Ventolin HCL (SOB) 2 Puffs 4 times per day - Review noted the medication was not administered on 7/11, 7/15, and 7/25/22, and documented the resident was not in the facility for the 9:00 AM dose. Following the medication review, an interview was conducted with the Director of Nursing (DON) on 07/26/22 to discuss the missing medication administrations. It was revealed during the interview that the nursing department failed to contact the attending physician to inform the physician of the dialysis days and times and to obtain new orders to ensure that prescribed medication doses were not being missed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 16 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliations were accurate for 2 of 9 sampled residents reviewed during the controlled substance record review at the facility's unit one and unit two, for Residents #93 and 82. The findings included: Review of the facility's policy, titled, Medication Reconciliation, provided by the Director of Nursing (DON), did not address controlled substance reconciliation. Review of the facility's policy, titled, Medication Administration: Medication Pass, documented .under administer medication .document initials on MAR (Medication Administration Record) for each medication administered. 1. On 07/26/22 at 2:07 PM, a side by side review of the facility's unit two medication cart and its controlled substance record for Resident #93, was conducted with Staff I, a Registered Nurse (RN). The resident's controlled substance record for Clonazepam 0.5 mg (milligrams) twice a day daily as needed for anxiety, documented that one tablet was removed from the controlled locked box on 06/26/22 at 1700 hours (5:00 PM) and on 06/28/22 at 1700 hours. Review of Resident #93's Medication Administration Record (MAR) for June 2022 revealed that Clonazepam 0.5 mg tablets was not documented as administered on 06/26/22 at 1700 hours (5:00 PM) and on 06/28/22 at 1700 hours. On 07/26/22 at 3:01 PM, during an interview, Staff L, Licensed Practical Nurse (LPN), stated that any controlled substance medication removed from the controlled box had to be documented on the residents' MAR. 2. On 07/26/22 at 3:24 PM, a side by side review of the facility's unit one medication cart and its controlled substance record for Resident #82 was conducted with Staff M, RN. The resident's controlled substance record for Alprazolam (Xanax) 0.25 mg one tablet once daily as needed for Anxiety, documented that one tablet was removed on 07/08/22 at 1115 hours (11:15 AM). Review of Resident #82's MAR for July 2022 revealed that Alprazolam (Xanax) 0.25 mg one tablet was not documented as administered on 07/08/22 at 1115 hours. On 07/28/22 at 12:34 PM, during an interview, the DON stated that controlled substance medications are documented on the residents' controlled substance record and the MAR. The DON was apprised of Resident #82's and #93's MAR lack documentation of controlled substance administration /reconciliation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 17 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 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** Based on observation and interviews, the facility failed to ensure that residents' personal medications were properly supervised / stored as evidenced by over the counter medications observed on the residents' bedside table for 1 of 1 sampled resident (Resident #101); failed to ensure that residents' medications were labeled as evidenced by unlabeled medications noted in the medication cart in the facility's Unit Two; and failed to ensure the facility's treatment carts were secured on Unit One and Unit Two. The findings included: 1. Review of Resident #101's clinical record lack evidence of documentation that the resident can self-administer the medications observed on her table. The clinical record documented an initial admission to the facility on [DATE] with no readmissions. Review of the resident's Minimum Data Set (MDS) assessment, dated 07/07/22, documented a Brief Interview of Mental Status (BIMS) score of 14 of 15 indicating no cognitive impairment. On 07/25/22 at 9:45 AM, during tour to the facility's unit one, observation revealed Resident #101 in bed. Further observation revealed a bottle of Melatonin 3 milligrams (mg), Tylenol Extra Strength 500 mg, Artificial Tears-eye Drops, a bottle of Regular Strength Calcium Carbonate (Antacid) 500 mg and a box of Metamucil Fiber-Thins, was on the resident's bedside table. An interview was conducted with the resident who was alert and oriented, and an inquiry was made regarding the unsecured medications on her table. The resident stated that she was taking Melatonin throughout the day, artificial tears for her dry eyes, Tylenol for her right knee pain and the Antacid. The resident added that she can't wait for the nurses because they take a longtime to bring her medications. The resident was asked if the nurses were aware of the medications on her table and stated that she did not know. Photographic Evidence Obtained. On 07/25/22 at 1:22 PM, observation revealed Resident #101's Melatonin 3 milligrams (mg), Tylenol Extra Strength 500 mg, Artificial Tears-eye Drops, a bottle of Regular Strength Calcium Carbonate (Antacid) 500 mg and a box of Metamucil Fiber-Thins continue to be unsecured on her bedside table. On 07/26/22 at 10:59 AM, an interview was conducted with Resident #101 who stated she will be moved to another room after lunch. The resident was asked for the medications she had on the table on yesterday (07/25/22). The resident stated she put them in a bag because she was told if she left them out, they would confiscate them. On 07/26/22 at 11:06 AM, an interview was conducted with Staff P, Registered Nurse (RN), who stated that the residents were not supposed to have medications left at the bedside. On 07/28/22 at 9:39 AM, an interview was conducted was conducted Staff K, Licensed Practical Nurse (LPN), who stated she informed Resident #101 that she could not have the medications at her bedside, took them from her and placed them in the medication cart. Staff K was asked if she obtained physician orders for those medications that the resident had on her table. Staff K replied that she passed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 18 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the information to the incoming nurse to get a physician order. Staff K was asked to show the medications in the medication cart and stated that Resident #101 was moved to another room and the medications were moved to the other medication cart. On 07/28/22 at 9:45 AM, a side by side review of Resident #101 new room location medication cart was conducted with Staff O, RN. The review revealed that Resident #101 personal medications were not stored in the medication. On 07/28/22 at 12:15 PM, during an interview, the Director of Nursing (DON) was apprised regarding Resident #101 medications at the bedside. The DON was asked to submit the facility policy related to the storage of medications and it was not provided. 2. On 07/26/22 at 2:07 PM, a side by side review of the facility's Unit Two's medication cart was conducted with Staff I, RN. The review revealed six (6) loose, unlabeled (no resident name) medications to include: Levetiracetam (anticonvulsant) tablets and one (1) loose, unlabeled Verapamil SR tablet inside the 9th drawer of the medication cart. During the review, Staff I was asked regarding the loose tablets and stated she did not know why the tablets were there. 3a. On 07/27/22 at 1:35 PM, during an environmental tour, the Housekeeping Director unlocked the facility's Unit Two's clean utility room using the door key pad. Inside the room, it was noted that the treatment cart was unlocked. Observation revealed the treatment cart had many prescriptions cream, ointments and powders. An interview was conducted with Staff F, RN at this time, who stated the treatment cart is supposed to be locked. A joint interview was conducted with the DON and Staff F. The DON stated that they did not keep the treatment cart locked. The DON was asked who had access to the clean utility room and stated the nurses and the Certified Nursing Assistants (CNAs). A side by side review of the medications in the treatment cart was conducted with the DON and Staff F. The review revealed many prescription medications bags inside the unlocked cart to include Premarin vaginal cream, Nystatin 100,000 units/gram powder, Diclofenac Sodium 1% gel, Mupirocin 2% ointment, Permethrin 5% cream, Lotrisone cream 1-0.05%, Ketoconazole 2% cream, Ammonium Lactate 12% lotion, Dakin's 0.25% solution, Triamcinolone Acetonide ointment 0.5%, Ketoconazole Shampoo 2%, Metronidazole cream 0.75%, and Betamethasone Dipropionate cream 0.05%. During the review, the DON was informed that residents' prescribed medications are to be locked up. b. On 07/27/22 01:49 PM, observation revealed the DON accessed the facility's Unit One's clean utility room by entering a code on the door key pad. Observation revealed the unit treatment cart in the clean utility room was unlocked. A side by side review of the treatment cart was conducted with the DON. The review revealed many prescription medications bags inside the unlocked cart to include Ketoconazole Shampoo 2%, Metronidazole cream 0.75%, and Betamethasone Dipropionate cream 0.05%, Triamcinolone Acetonide ointment 0.5%, Lotrisone cream 1-0.05%, Ketoconazole 2% cream, Permethrin 5% cream, Ammonium Lactate 12% lotion, Nystatin 100,000 units/gram powder and Diclofenac Sodium 1% gel. On 07/27/22 at 1:52 PM, an interview was conducted with the Director of Rehabilitation (DOR) and stated she had access to the clean utility room. Observation revealed the DOR entered a code on the clean utility room door key pad and entered the room. While inside the room, the DOR was asked the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 19 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reason for her to access the room. The DOR stated she enters the clean utility room to obtain oxygen equipment or any other supplies for the residents. On 07/27/22 at 1:55 PM, an interview was conducted with Staff N, Housekeeping / Floor Tech. Staff N was asked if he had access to the clean utility room and stated he did. Staff N entered the code on the door key pad and opened the door for the surveyor. While in the room, Staff N was asked the reason for him to access the room and stated he cleans the room's floor. On 07/27/22 at 2:06 PM, an interview was conducted with Staff Q, Housekeeping Aide who stated that she cleans the clean utility room sometimes. Staff Q was asked to open the clean utility room door. Observation revealed Staff Q entered the code on the door key pad and was able to open the door where the facility kept the unlocked treatment cart with residents' medications inside the cart. On 07/27/22 at 2:29 PM, an interview was conducted with Staff O, RN in Unit One who stated that the treatment cart has a locked but it does not have to be locked. On 07/27/22 at 2:40 PM, an interview was conducted with Staff I, RN in Unit One who stated that treatment cart is locked and it had a code to open it. Staff I was asked to open the treatment cart in the clean utility room and stated she did not remember the code. Staff I open the clean utility room and the treatment cart was unlocked. On 07/28/22 at 10:34 AM, the facility's DON provided information regarding many medications inside the two treatment carts. There was a total of 17 prescribed medications kept in the unlocked treatment carts in the facility's units. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 20 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the approved residents' menu was not being followed for physician ordered purred diets, mechanical soft diets, cardiac diets, and regular diets. The failure to follow the approved menu potentially affected 40 of the facility residents. The census at the time of the survey was 95. The findings included: During the observation of the breakfast meal in the main kitchen on 07/26/22 at 7:30 AM and review of the approved menu for the breakfast meal of 07/26/22, the following were noted: (a) Review of the approved menu noted 4 ounce serving of Chilled Fruit Cocktail for residents with physician ordered Cardiac Therapeutic Diet. Observation of the breakfast meal noted that portions of the fruit cocktail were not prepared or served to these residents. Interview with the facility's Breakfast [NAME] at the time of the observation noted to state that the canned fruit cocktail was not delivered. Interview with the Dietary Manager (DM) also at the time of observation revealed that he failed to substitute another canned fruit in place of the fruit cocktail. A review of the resident Diet Census of 07/27/22 noted that there were 20 residents with physician ordered Cardiac Diet (low Sodium). (b) Review of the approved menu noted that a 4-ounce portion (#8 scoop) of pureed Oatmeal was to be served to physician ordered Pureed 4 Mechanically Altered Diet. Observation of the meal noted that pureed oatmeal was not prepared as per the approved menu and regular Oatmeal was being served to the Pureed 4 diet. Interview with the breakfast cook at the time of the observation revealed that the cook was unaware the approved Purred 4 diet documented pureed Oatmeal. A review of the resident Diet Census for 07/26/22 noted that there were 10 facility residents with physician ordered Pureed Diet. (c) Review of the approved menu noted that a 4-ounce (#8 scoop) portion of Pureed Scrambled Egg was to be served to Pureed 4 Mechanically Altered Diet. Observation of the meal noted that a 2 ounce (#12 scoop) was being utilized as a standard serving of the pureed eggs. Interview with the breakfast cook at the time of the observation noted to state that the DM failed to have a copy of the approved menu on the tray line for dietary preparation staff for their review to ensure that portions are followed as per the approved menu. A review of the facility's resident Diet Census for 07/27/22 noted that there were 10 residents with physician ordered Pureed Diet. (d) Review of the approved menu noted that a 1-ounce portion of scrambled eggs was to be served to Regular Diets. Observation of the meal noted that a 2-ounce (#12 scoop) was being utilized as a standard serving of the regular scrambled eggs. Interview with the breakfast cook at the time of the observation noted to state that the DM failed to have a copy of the approved menu on the tray line for dietary preparation staff for their review to ensure that portions are followed as per the approved menu. A review of the facility's Diet Census for 07/27/22 noted that there were 10 residents with physician ordered Regular Diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 21 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 store, prepare, distribute and serve food in accordance with professional standards for food service safety. Residents Affected - Many The findings included: 1. During the initial kitchen / food service observation tour conducted on 7/25/22 at 9 AM, the following were noted (The Dietary Manager was not in the facility at the time of the observation tour): (a) Observation of the walk-in freezer noted that the internal temperature was not being maintained at the regulatory zero degrees F (Fahrenheit) or below. Food items located on freezer shelves were not soft and not frozen solid. An observation of the thermometer located within the unit was recorded at 30 degrees F. Further observation noted that there was not a freezer log sheet for review of daily temperatures. (b) Observation of Reach-in refrigerator #1 noted that the internal temperature of the unit was not being maintained at the regulatory temperature of 41 degrees F or below. The internal temperature of the unit was noted to be at 46 degrees F. Temperatures of milk and juice portion were taken with the facility calibrated thermometer and were recorded at 69 degrees F (milk) and 58 degrees F (orange juice). Further observation noted that there was no temperature log available for review of daily temperatures. (c) Observation of Reach-in refrigerator #2 noted that the internal temperature of the unit was not being maintained at the regulatory temperature of 41 degrees F or below. It was also noted that the 5 storage shelves located within the unit were soiled with dried food matter and were rust laden. The internal temperature of the unit was noted to be 52 degrees F. (d) Observation of the tray line noted that resident silverware was not being handled in a sanitary manor. Observation noted that the silverware was not being kept in silverware cylinders and was noted to be held in a open bin and not all pieces stored in one direction. Staff was observed handling not by the handle but were being handled by the eating portion. (e) The commercial table mounted can opener was noted to be rust laden and the blade was dull resulting in small pieces of metal shavings collecting blade surface. (f) The table that holds the commercial mixer was noted to have a accumulation of dust and debris. (g) The convection oven was noted to have a heavy build-up of carbon matter and was not being cleaned on a regular basis. (h) The exteriors of the 2 ceiling mounted air-conditioning vents located within the dish-machine area were noted to have a build-up of black mold type matter. (i) Observation of the dish-machine noted that the internal separation curtains had a build up of food matter and were not being properly cleaned from the last evening meal. (j) Observation of 3 large food preparation skillets noted that internal Teflon coating was wearing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 22 of 23 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 106005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446 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 off and could result in food contamination during use in food preparation. Level of Harm - Minimal harm or potential for actual harm (k) The ceiling perimeter located in the dish-machine room was noted to be rust laden. Residents Affected - Many (l) The wall areas of the dish-machine room and coffee area were noted to be heavily soiled with food spills food and were not being properly cleaned on a regular basis. (m) The internal base area of the ingredient bins with soiled and numerous food stains. The units were not being cleaned on a regular basis. (n) Observation of the dry food storage room noted that there were 2 dented #10 commercial cans located on the can shelf that included Chili Sauce (1) and Carrots (1). All dented food cans should be removed from potential use to prevent potential food borne illness. It was also noted that an open and soiled 5 pound container of peanut butter with no opening date was located on a food storage shelf. (o) Observation of the floor area located in the dry food storage room were noted to be heavily soiled and numerous dried food stains. (p) Observation of the dry food storage room noted that 4 of 8 ceiling mounted lights were not working. (q) The service hallway where the entrance/exit of the main kitchen is located was noted to be heavily soiled, stained, and littered with trash. (r) The floor of the cart wash area located in the service hallways was noted to be littered with trash and food debris. 2. During a subsequent observation of the kitchen/food service department on 07/27/22 at 11:45 AM, accompanied with the Corporate Food Service Manager, it was noted that the exteriors of 4 ceiling mounted air-conditioning vents were full of condensation and were noted to be steadily dripping of the condensation. Specifically, the 4 vents were located at the entrance /exit door (1), tray line assembly area (1), food serving area (1), and food preparation area. It was discussed with the Corporate Manager that the potentially contaminated condensation was dripping onto prepared foods, food preparation surfaces, food preparation equipment, and staff. It was further discussed that this issue could potentially result in food borne illness and contamination. Photographic Evidence Obtained of all examples. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 23 of 23