Inspection·November 30, 2023

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few send Resident #189's unused funds to that family member. Then, after reading the financial records, the BOM said that the funds or the remaining balance of the Resident #189's account was sent to the resident's family member. However, after reviewing the checkbooks, the BOM rescinded her statement and stated that the facility did not yet send the remaining balance to the Resident's family member. Review of the balance sheet provided for review showed that on [DATE] $ 600.00 dollars were transferred to Resident #189's new account with this facility. On [DATE], the facility received an additional $200.00 dollars for Resident #189. On [DATE], the former facility closed Resident #189's account. The record showed that the account had a balance of $800.00 dollars as of [DATE]. However, there was no further evidence that new deposits were made in the account for [DATE] and [DATE]. Finally, it was noted that on [DATE], a debit in the amount of $800.00 dollars was processed and the payment was issued to Resident #189 on [DATE]. Meanwhile, the records showed that Resident #189 passed away on [DATE] at the facility. This information raised a question which the BOM could not immediately explain. In fact, the BOM said on [DATE] at about 1:00 PM, after reviewing her check book, that the funds were supposed to be sent to the family member, but there was no records showing that payments were made or that a debit was processed from the Resident's account. The payment was not sent or disbursed to anyone. She said that the Regional Business Office Manager (RBOM) would be the one who could answer any further questions related to this account. The BOM said that she did not know why the payment was not sent to the family member. As evidence, the BOM showed an email dated [DATE] which reflected conversation undertaken between the facility and the family member (POA), requesting that all additional funds and or checks be mailed to POA. An inscription on the email revealed that two checks were mailed to POA. When questioned, the BOM could not provide copies of the checks that were sent to the family member nor how they were sent. Additionally, neither the facility nor the family member could provide evidence of a power of attorney (POA) documents, upon request. During a follow-up interview with the RBOM on [DATE] at about 2:30 PM, she stated that she was not aware of any requests made to send money to Resident #189's family member. She explained that the reason why it was documented that payment was sent to Resident #189, was because the resident had expired. She ensued that once the account was closed, the system automatically generated all credits due to the account owner. The RBOM said that they would not send a check to the family member because she did not have power of attorney. Further review of Resident #189's account revealed that there was no one listed as power of attorney. Resident #189 was personally liable and responsible for her account. Furthermore, the funds were state funds issued to Resident #189 which were supposed to be refunded to the State within 30 days after the Resident #189 had died. Yet, there was documentation noting that the funds would be returned to the family member. There was a clear desire from the facility to send set funds to the family, although there was no legal support for this inclination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 2 of 29 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 11/30/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain sanitary, orderly interiors for resident rooms (Unit 1 and Unit 2), resident lounge areas, main dining room, and laundry area. The findings included: 1. During observation of the lunch meal in the main dining room on 11/27/23 at 12:30 PM, it was noted that the exteriors of 10 of 19 dining room chairs were heavily worn and had large amounts of a white substance dripped over the entire wood chair frame. Photographic evidence Obtained. 2. During resident screening conducted by surveyors on 11/27/23 and the Environment Tour conducted on 11/29/23 at 2:00 PM, accompanied with the Director of Maintenance and Director of Housekeeping, the following were noted: Unit 1: West Community Shower Room: Two of two shower stall lights were not working. South Community Shower Room: One of three shower stall lights was not working. room [ROOM NUMBER]: Room window glass was covered with a white stain. room [ROOM NUMBER]: Room window glass was covered with a white stain. room [ROOM NUMBER]: Room wall mounted clock was not working, and overbed light pull cord was missing (B bed) . room [ROOM NUMBER]: Overbed light cord was missing (B bed) , and room walls were in disrepair and in need of repainting, and the room window glass was covered with a white stain. room [ROOM NUMBER]: Room window glass was covered with a white stain. room [ROOM NUMBER]: Room window glass was covered with a white stain. room [ROOM NUMBER]: Room window glass was covered with a white stain. Unit 2: room [ROOM NUMBER]: Bathroom floor was noted to have numerous areas of black stains, and the room window glass covered with a white stain. room [ROOM NUMBER]: Numerous areas of room wallpaper was peeling, and exterior of nightstands (2) were heavily worn. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 3 of 29 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 11/30/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER]: Numerous areas of room wallpaper was peeling, and room walls were in disrepair and in need of repainting. room [ROOM NUMBER]: Bathroom nurse call light cord was wrapped around handrail and could not be activated, bathroom floor was noted to have large areas of black stains, large areas of room wallpaper were peeling off of walls, toilet required re-caulking to the floor, and the room windows glass were noted to have areas of white stains. room [ROOM NUMBER]: Overbed light pull cord was missing from B bed, exterior of room chair was heavily worn, room walls were damaged and in need of repair and repainting, room wallpaper behind resident's beds was peeling off form walls. room [ROOM NUMBER]: Bathroom lights were constantly flickering off and on, and large areas of room wallpaper were peeling off from the walls. room [ROOM NUMBER]: Room walls were in disrepair and in need of repainting, and wallpaper behind residents' beds (2) was peeling off from the walls. room [ROOM NUMBER]: Room walls were in disrepair and in need of painting, and toilet seat was not properly secured. room [ROOM NUMBER]: Room ceiling smoke detector was not properly secured and in danger of falling off from the ceiling. room [ROOM NUMBER]: Room window glass was covered with a white stain. room [ROOM NUMBER]: Room window glass was covered with a white stain. Following the 11/28/23 Environment Tour, the findings were reviewed and discussed with the facility's Administrator. 3. During the observation conducted on 11/28/23 at 2:49 PM of the Medbridge Lounge room, it was noted the the room was open / unlocked, mold-like substance was on 4 of 4 walls and covering the opening of the old light fixture. Seven (7) old, dirty lidded garbage cans were in room, with no trash inside, but all were foul smelling. 4. During a follow up environment tour on 11/29/23 at 1:04 PM accompanied with the Environmental Services Director, it was noted in the 100 Unit that the hallway ceiling vents were dust laden and in need of cleaning. In the soiled utility room near the Medbridge hallway, there was a ceiling tile which had a large greenish-yellow stain directly above the doorway. In the hallway leading to the kitchen and laundry room, the surveyors observed a bath blanket lying on the floor. When asked why this was on the floor, the Environmental Service Director stated the wall had started leaking at that spot earlier in the day. The surveyor looked in the kitchen on the other side of this wall and observed that the kitchen's 3-compartment sink is on the kitchen-side of this wall. The surveyor further observed that the drain and floor under the 3-compartment sink appeared to be in disrepair. Also observed in the hallway were ceiling vents which were dust laden and covered in a black, mold-like substance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 4 of 29 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 11/30/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Upon entering the laundry room, the surveyor noted the inside surface of the utility sink appeared to be covered in a dark substance. The Environmental Services Supervisor stated this sink is used to pre-clean dirty laundry and that this dark substance was not mold but that the sink could be cleaned with a bleach cleaner. Upon entering the washing machine room, the surveyor observed 3 washing machines. It was stated that all 3 washing machines were working. The 3rd washing machine had a filter which was dust/lint laden and appeared to be falling apart. The ceiling vents were also dust/lint laden. Throughout the laundry room, there were numerous light bulbs which were not working. In the dryer room, it was noted the linen cart covers were torn and in disrepair. Event ID: Facility ID: 106005 If continuation sheet Page 5 of 29 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 11/30/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on records review and interviews, the facility failed to ensure Minimum Data Set (MDS) assessments, related to significant change and discharge with a non-anticipated return, were completed accurately for 1 of 1 sampled resident, Resident #33. Residents Affected - Few The findings included: On 08/14/23, the facility completed a Significant change assessment update related to Resident #33's health decline. The clinical records showed that Resident #33 refused to be weighed for 4 consecutive months and had a history of weight decline. When the significant change assessment was completed, Resident #33 was a hospice care recipient, so a significant change was not warranted since health decline was expected due to Resident #33's terminal diagnosis. On 08/14/23, the facility initiated a MDS discharge assessment. The Nursing progress notes documented Resident #33 was transferred out of the facility to a Hospice Unit at a local Hospital, on crisis. The MDS Coordinator who completed the assessment indicated that the resident was discharged and the resident's return was anticipated. Further record review revealed that Resident #33 was admitted to hospice on 06/29/23, and a significant change was then completed. On 11/30/23 at 1:23 PM, the MDS Coordinator stated when she initiated the second assessment for a significant change on 08/14/23, she was not aware that Resident #33 was a hospice resident. After realizing the error, she wanted to correct the records but could not do so. She left it and forgot to update the MDS since that time. The MDS Coordinator said that Resident #33 was observed to have new wounds to the right Trochanter, blister to the left heel, deep tissue injury (DTI) to her right heel, and also had a stage III wound to the sacrum. Resident #3 received Prosource ZAC 30ml by mouth daily to promote healing; and received nutritional juice 3x/day. It was also noted that Resident #33 was non-compliant with her dietary regimen. The MDS Coordinator said that she had forgotten to complete the assessment she initiated which indicated that the resident was discharged from the facility and was expected to return to the facility. On 11/30/23 at 1:23 PM, the Regional MDS Coordinator stated that the two incomplete MDS assessments were incorrect and that they would be corrected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 6 of 29 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 11/30/2023 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, interviews and record review, the facility failed to provide fingernail grooming for 2 of 2 sampled residents, Residents #72 and #86. Residents Affected - Few The findings included: Review of the facility's policy, titled, Nail Care, revised on 04/03/22 documented, The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health .routine cleaning and inspection of nails will be providing during ADL (activities of daily living) care on an ongoing basis to trimming and filing .principles of nail care: nails should be kept smooth to avoid skin injury . 1. Review of Resident #72's clinical record documented an admission on [DATE] with no readmissions, with diagnoses that included Cerebral Infarction, Cognitive Communication Deficit, Urinary Tract Infection, Heart Failure, Wedge Compression Fracture Of Fifth Lumbar Vertebra, Fracture Of Sacrum, Subsequent Encounter For Muscle Weakness, Personal History Of Transient Ischemic Attack (TIA), and Scoliosis. Review of Resident #72's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 0, indicating the resident had severe cognition impairment. The assessment documented under Functional Status that the resident was dependent on the staff to complete the activities of daily living (ADLs). Review of Resident #72's care plan, titled, ADL Self-care deficit related to physical limitations, initiated and revised on 09/29/23 documented an intervention that read assist with daily hygiene, grooming, dressing, oral care and eating as needed . Review of Resident #72's care plan review revealed no care plan was initiated related to the resident refusing fingernail care. Review of Resident #72's Certified Nursing Assistant (CNA) tasks record documented the resident was dependent on the staff for ADLs including the washing of her hands. On 11/27/23 at 12:00 PM, observation revealed Resident #72 lying down in bed, fiddling with her pants, pulling the bottom of the left pant leg down from her knee. Observation revealed the resident had one scabbed lesion below her left knee and a dry dressing on her on her right knee and mid lower right leg. Further observation revealed Resident #72 had long fingernails and some fingernails had black matter under the nail bed. On 11/28/23 at 9:22 AM, observation revealed Resident #72 in bed being fed by Staff M, CNA. Observation revealed Resident #72's fingernails continued to be long with black matter underneath of some of the nail beds. On 11/28/23 at 2:21 PM, during a medication room review with Staff L, Licensed Practical Nurse (LPN), it was noted that the facility had multiple nail clippers in the room. During an interview, Staff L stated that the staff monitor the resident's nails and the CNAs will clip them as necessary. Staff L added that some residents were getting their nails done by the Beauty Salon staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 7 of 29 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 11/30/2023 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 On 11/28/23 at 2:33 PM, observation revealed Staff P (CNA) and Staff M (CNA) providing care to Resident #72. During the observation, Staff M was asked about the resident's long fingernails. Staff M stated the CNAs were responsible to do the residents' nails and did not know why it has not been done. Staff M stated that Resident #72's fingernails needed to be clipped and trimmed. Staff M stated the resident was able to move in the bed and will remove her dressings. Residents Affected - Few On 11/28/23 at 2:59 PM, observation revealed Resident #72 lying sideways in the bed with her legs hanging down the rail. Further observation revealed the resident right leg dressing was on the floor. On 11/29/23 at 12:18 PM, during an interview, the Director of Nursing (DON) was apprised of Resident #72's long fingernails and that the resident was able to remove her right leg bloody wound dressing presenting a risk for a wound infection. On 11/29/23 at 12:45 PM, an interview was conducted with Staff N, CNA, who stated that she checks the resident's nails while doing care and will clip and trim as necessary. Staff N stated that Resident #72 refuses to have her fingernails done and the nurse was notified. Staff N was apprised that the resident was not care plan as refusing to have her fingernails done. On 11/29/23 at 12:46 PM, interview was conducted with Staff P, CNA, who stated he does residents' nails as needed, and would clip and trim them as necessary. Staff P stated he never had Resident #72 assigned to him. On 11/29/23 at 12:58 PM, an interview was conducted with Staff O, Registered Nurse (RN) who stated she was aware of Resident #72 refusing to have her fingernails done but had not documented it. Staff O was apprised the resident was not care plan as refusing her fingernails done. A side by side review of the resident's fingernails was conducted with Staff O who confirmed the fingernails needed to be clipped and trimmed. On 11/30/23 at 8:58 AM, a joint interview was conducted with the facility's Regional Nurse. The Regional Nurse stated a nail sweep audit was done and found that some residents needed nail care. The Regional Nurse was apprised that Resident #72 was not care plan for refusal of care and no documentation was noted on the CNAs tasks or [NAME]. The Regional Nurse stated the CNA task/[NAME] for the refusal of nail had been added. 2. Review of Resident #86's clinical record documented an admission on [DATE] with no readmissions and diagnoses that included Urinary Tract Infection, Anemia, Depression, Gastrointestinal Hemorrhage, Dementia, Cellulitis of Abdominal Wall and Dysphagia. Review of Resident #86's MDS admission assessment dated [DATE] documented a BIMS score of 0 indicating the resident has severe cognition impairment. The assessment documented under Functional Status the resident was dependent for assistance from the staff to complete the ADLs. Review of Resident #86's care plan, titled, ADL Self-care deficit related to physical limitations, Dementia, initiated on 10/24/23 documented interventions that read: assist with daily hygiene, grooming, dressing, oral care and eating as needed . Review of Resident #86's care plan, titled, At risk for alteration in skin integrity related to: limited physical functioning, incontinence, recent cellulitis of abdominal wall initiated on 10/24/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 8 of 29 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 11/30/2023 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 documented interventions that read: Body audit . Level of Harm - Minimal harm or potential for actual harm Review of Resident #86's care plan review revealed no care plan was initiated related to the resident refusing fingernail care. Residents Affected - Few Review of Resident #86's CNAs tasks record documented the resident was dependent on the staff for her personal needs including washing of her hands. On 11/27/23 at 12:09 PM, observation revealed Resident #86 in bed and Resident #86's right hand fingernails were long with black matter under the nail beds and some of the findgernails were jagged. The resident was not interviewable. On 11/28/23 at 9:32 AM, observation revealed Resident #86 in bed and awake and the resident continued to have jagged fingernails and was scratching her left cheek. On 11/28/23 at 2:39 PM, a side by side observation of Resident #86's fingernails was conducted with Staff L, LPN. Staff L stated the resident moves a lot. Observation revealed the resident was able to put her index finger unto her ear. Staff L acknowledged that Resident #86 fingernails needed to be clipped. On 11/28/23 at 2:44 PM, a side by side review of Resident #86's fingernails was conducted with Staff M, CNA. During the review, observation revealed the resident was scratching her eye lid. Staff M stated the resident was able to move her hands and scratch herself. Staff M acknowledged that Resident #86 needed her fingernails clipped. Staff M added she would clip the residents nails now. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 9 of 29 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 11/30/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to prevent the development and worsening of pressure ulcers for 2 of 6 sampled residents reviewed for pressure ulcers, Residents #289 and #339. Residents Affected - Few The findings included: 1. Record review for Resident #289 revealed that he was initially admitted to the facility on [DATE]. He was last readmitted from the hospital on [DATE] and was discharged to the hospital on [DATE]. He did not return from the hospital. Resident #289 had a medical history significant for Dementia, Stroke, Trouble Swallowing, Confusion, Liver Cirrhosis, Diabetes, Altered Mental Status, End Stage Renal Disease (on Dialysis), Depression and Anxiety. A Significant Change Minimum Data Set (MDS) was documented on 10/17/23. This MDS documented Resident #289 had a Brief Interview of Mental Status (BIMS) score of 6, indicating he was severely cognitively impaired. Review of Section M, for Skin, revealed Resident #289 had no wounds on his skin. The resident required a low air loss mattress, assistance with ADL'S, incontinence care, a wheelchair cushion, and turning/repositioning. Review of Resident #289's Care Plans revealed there were no care plans in place regarding actual skin breakdown or pressure ulcer development. A General Progress Note written on 10/25/23 at 7:42 PM documented the following: Body audit done: found patient having an open area to sacrum treatment initiated per facility protocol, family member notified, MD [physician] aware. An Encounter Note written on 10/31/23 at 1:00 AM documented the initial wound evaluation and care order written by the physician: Initial wound Evaluation. Patient is seen today for wound rounds at nursing request. Acute sacrum unstageable pressure injury with slough tissue to wound bed. wound care is Dakin's soaked gauze to wound bed. Acute left lower leg unstageable pressure injury with eschar tissue, wound care is betadine pads. This note did not document that the wounds were unavoidable. A second Encounter Note written on 11/03/23 at 1:00 AM documented the physician's wound follow up and additional wounds that were also discovered: Patient is seen today for wound follow up. Acute Bilateral heels & Thoracic Spine unstageable pressure injury, Chronic sacrum unstageable pressure injury with slough tissue to wound bed & Left lower leg unstageable pressure injury with necrosis, wound care is Betadine soaked gauze to wounds bed. This note also did not document that the wounds were unavoidable. Resident #289's initial Skin and Wound Evaluation was done on 11/03/23 at 11:59 AM. This evaluation documented an in-house acquired middle thoracic unstageable pressure wound. On 11/07/23, additional Skin and Wound Evaluations were done which documented an in-house acquired front left lateral lower leg unstageable pressure wound, an in-house acquired left lateral heel unstageable pressure wound, an in-house acquired right lateral heel unstageable pressure wound, and an in-house acquired middle sacrum unstageable pressure wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 10 of 29 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 11/30/2023 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 0686 A Pressure Ulcer Assessment was done on 11/03/23 which documented the left heel, right heel, and sacrum wounds as unstageable. Level of Harm - Actual harm Residents Affected - Few Review of the wound measurements documented on the Skin and Wound Evaluations revealed the following for the sacral wound: On 11/03/23, the documented unstageable sacral wound measurements were 2.0cm long x 0.6cm wide. On 11/07/23, the documented unstageable sacral wound measurements were 7.1cm long x 4.0cm wide. There were 3 additional wounds also documented that included the acquired front left lateral lower leg unstageable pressure wound, left lateral heel unstageable pressure wound, and right lateral heel unstageable pressure wound. The initial wound care order was written on 10/31/23 for Resident #289's sacral wound which was found on 10/25/23. The facility provided the AHCA Immediate Report and the 5-day report which documented the facility was notified of neglect allegations by another State agency related to the state of the pressure wounds found when Resident #289 entered the hospital on [DATE]. An interview was conducted with Staff D, Nurse Practitioner, on 11/30/23 at 2:20 PM. In reviewing the chart, Staff D recalled Resident #289 was out to the hospital a lot. She said on 11/07/23, Resident #289 was lethargic and clammy and that he had labored breathing and a low grade fever of 99.8 degrees along with low blood pressure of 97/50. She stated his oxygen level was also low and he had to be placed on oxygen. She read a Progress Note written on 11/08/23 which documented Resident #289 was placed in hospice upon being admitted to the hospital. She confirmed that he was not in hospice while he was at the nursing home. When asked if she was familiar with Resident #289's pressure ulcers, she stated the Wound Care Nurse Practitioner was responsible for assessing and writing orders for all wound care at the facility. A telephone interview was attempted with the facility's Wound Care Nurse Practitioner, but she was unavailable for interview as she was out of the country. An interview was conducted with Staff E, Licensed Practical Nurse (LPN) and Staff F, Registered Nurse (RN) on 11/30/23 at 3:09 PM. They confirmed that they were familiar with Resident #289 and worked with him regularly when he was at the facility. Staff F stated she found his sacral pressure ulcer on 10/25/23. They stated they did not recall when the wound care orders were written but that they did perform the wound care for him. 2. Record review revealed Resident #339 was admitted to the facility on [DATE], with a medical history of Traumatic Subdural Hemorrhage with loss of consciousness, Stage 4 Decubitus Pressure Ulcer of Sacral Region, Dysphagia, Altered Mental Status, Epilepsy, and Dementia. An admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #339 had a Brief Interview of Mental Status (BIMs) score of 99, indicating she was never or rarely understood and was severely cognitive impaired. She required extensive assistance for all her Activities of Daily Living (ADLs). Review of the Care Plan dated 05/05/23 revealed Resident #339 had a pressure injury to the sacrum. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 11 of 29 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 11/30/2023 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 0686 The care plan goals included: free from sign and symptoms of infection (such as increased drainage/pain/peri wound erythema). Level of Harm - Actual harm Residents Affected - Few Review of the Physician's orders revealed an order dated 04/19/23 regarding Resident #339's stage 4 pressure ulcer of the sacral region for negative pressure wound therapy (NPWT) or wound VAC at 125mmHg continuous every shift. Further review revealed an order for the wound VAC dressing is to be changed every Monday, Wednesday, and Friday until 06/05/23. On 06/01/23, Resident #339 was hospitalized due to a worsening decubitus ulcer with an infection and went through wound debridement at the hospital. On 06/16/23, she returned to the facility. Review of two Skin and Wound Evaluations revealed the following: On 05/19/23, the wound measurements were Length (L)=3.8 cm, Width (W)=4.7 cm, Area=12.8 cm2. On 07/07/23, the wound measurements were L=5.9 cm, W=5.0 cm, Area=21.0 cm2. Review of the Nurses Notes revealed Resident #339 had a follow-up appointment with her neurologist on 06/01/23. During the appointment, the physician recommended she be sent to the hospital. The hospital's admission History and Physical (H&P) report, dated 06/02/23, stated that Resident #339 was sent to the Emergency Department due to a sacral decubitus with concern for infection due to a foul-smelling odor coming from it. In the History & Physical (H&P) report, the hospital physician documented Resident #339's son had said the sacral ulcer was previously treated with a wound VAC, but the facility had run out of wound VAC supplies. Because of this, Resident #339 had been without her wound VAC for several days; that the facility's Wound Care Nurse Practitioner had said the pressure ulcer was stable, but another physician had looked at the pressure ulcer and determined that it appeared infected due to the new foul-smelling odor and Resident #339 was sent to the hospital. Review of the Progress Note from the facility's Wound Care Nurse Practitioner dated 05/26/23 documented that Resident #339 received wound care, the wound VAC was applied, and the wound was stable. Review of Physician's Notes dated 05/26/23 and 05/29/23 revealed that the wound VAC had foul-smelling drainage and requested for the wound care team to check the wound dressing. Review of Nurse Note written on 05/30/23 revealed Negative pressure machine therapy supplies did not arrive yet. Once supplies arrive, the NPWT will continue. Responsible party was informed. Review of the Progress Notes from Staff D, the facility's Nurse Practitioner dated 05/31/23 revealed that Resident #339's family reported that she appeared with increased fatigue and less engagement in care over the past few weeks. An interview was conducted with Staff D, the facility's Nurse Practitioner on 11/30/23 at 12:43 PM. Staff D stated Resident #339 had a history of wounds and debridement. Staff D stated she briefly reviews skin care notes but that she does not do a full assessment of resident's skin. The surveyor asked Staff D to review the hospital History and Physical (H&P) report. Staff D stated that she was not aware of the 06/02/23 H&P report or that Resident #339 was out of wound VAC supplies. She stated that she saw Resident #339 on 05/31/23 and she looked fine and had the wound Vac in place. The facility's Wound Care Nurse Practitioner was not available for interview on 11/30/23 but Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 12 of 29 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 11/30/2023 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 0686 D had texted her, she had called Staff D stating that Everything is in her notes, which could be reviewed. Level of Harm - Actual harm Review of the progress notes for 07/24/23 revealed Resident #339 was sent to the hospital again on 07/24/23 for right side facial drooping. Resident #339 did not return to the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 13 of 29 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 11/30/2023 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** Based on observations, interviews and record review, the facility failed to ensure that a resident who enters the facility with an indwelling catheter was assessed for the removal of the catheter, failed to ensure the involvement of the resident's representative in the discussion of the use of the catheter, and failed to submit documented evidence of the medical justification for the catheter as evidenced by the lack of written documentation in the resident's clinical record of attempts to remove the catheter (voiding trials), a consultation with a specialist (Urologist) and lack of written discussion with the resident's representative. The findings included: Review of the facility's policy, titled, Indwelling Catheter Use and Removal, revised on 05/08/23 documented, It is the policy of this facility to ensure that indwelling catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice .residents that admit with an indwelling catheter or subsequently receives one will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that the catheter is necessary .if an indwelling catheter is in use, the facility will provide care in accordance with current professional standards of practice and resident care policies and procedures that include .documentation of the involvement of the resident representative in the discussion of the risks and benefits of the use of the catheter .the right to decline the use of the catheter .attempts to remove the catheter as soon as possible . Review of Resident #43's clinical record documented an admission on [DATE] with no readmissions, and diagnoses that included Chronic Kidney Disease Stage 3, Neuromuscular Dysfunction of Bladder Unspecified, Vascular Dementia, Cerebral Infarction, Muscle Weakness, Anxiety Disorder, Need for Assistance with Personal Care, Ataxic Gait, and Cognitive Communication Deficit. Review of Resident #43's physician order dated 04/21/23 documented admission to hospice services with a diagnosis of Cerebral Atherosclerosis. Review of Resident #43 Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 6 indicating the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed partial to moderate assistance with toilet transfers from the staff; and was coded for an indwelling catheter. Review of Resident #43's care plan, titled, Use of indwelling urinary catheter needed due to neurogenic bladder, initiated on 03/17/23 had interventions that documented evaluate as needed for possible removal of catheter and bladder retraining or toileting . Review of Resident #43's clinical record revealed no written documentation related to a consultation with a specialist (Urologist) or written progress notes of any attempts to remove (voiding trials) the resident's indwelling catheter. Review of Resident #43's Primary Care Physician's Nurse Practitioner's note dated 03/17/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 14 of 29 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 11/30/2023 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 documented .no bladder distention or tenderness .Foley draining yellow urine .Diagnosis - Chronic Kidney Disease stable .Plan - nephrology consult. Review of the resident's record lack evidence of a written nephrology consultation record. Review of Resident #43's Infectious Disease Evaluation note documented, .Bacteriuria (bacteria in urine) Pyuria (pus in the urine) secondary to chronic foley catheter . Review of Resident #43's nursing note dated 04/08/23 at 6:00 AM documented .Patient pull off her catheter. Patient catheter balloon was still inflated, and no sign of bleeding noted. Patient is stable. MD [physician] notified and new order giving to reinsert the catheter if patient is not void. Patient will continue to monitor for voiding . Review of Resident #43's nursing note dated 04/08/23-7:30 AM documented, No urine noted during patient AM care and a new catheter 16 FR was inserted with 10 cc balloon, and 400 cc of yellow urine noted in patient urinary bag. Review of Resident #43's nursing note dated 04/09/23 documented, Around 0550 [5:50 AM] this morning Pt [Patient] foley catheter dislodged. Dr. [name] notified, new foley (16 French, 10 ml) was reinserted. Clear, yellow urine noted in bag. We will continue to monitor pt and provide foley care . Review of Resident #43's nursing note dated 05/28/23 documented, This writer was notified by the 3-11 (3PM-11PM] nurse that the resident had pulled the foley catheter out and a new order for a new foley catheter was ordered and was inserted. At 0140 [1:40 AM] this writer noticed that the resident had pulled out the foley catheter for a second time. Writer did an assessment on the resident and found no injuries. The NP [Nurse Practitioner] was notified and gave orders not to reinsert the foley catheter in and to monitor the resident for urine retention and if there is any output . Review of Resident #43's nursing note dated 05/28/23 documented, Catheter had pulled by the PT [patient]. NP was notified stated to monitor PT by the nurse 11-7 [11PM-7AM]. Pt monitored, bladder scan done, no urine retaining. Review of Resident #43's nursing note dated 05/29/23 documented, Patient voided without difficulty during shift no c/o [complained of] of pain voiced will continue to monitor. Review of Resident #43's nursing note dated 05/30/23 documented Indwelling Catheter 16Fr with 10 cc balloon reinserted per MD order. Inserted without difficulty, resident denies pain and discomfort, good draining. Review of Resident #43's care plan progress notes from 03/2023 to 11/2023 lacked documentation of discussion of the resident's Foley (indwelling catheter) with the resident's representative. On 11/29/23 at 9:12 AM, an interview was conducted with Resident #43 who stated that she had a Foley catheter and did not know why. The resident added that her daughter told her that because she had an infection. The resident stated she would like to have it out. The resident denied having any pressure sores in her back. The resident added that her roommate was using the bathroom a lot, maybe that was why they put the catheter on her. The resident was asked if she had seen a specialist related to her Foley catheter and replied she had not been anywhere. On 11/29/23 at 10:07 AM, observation of Resident #43's indwelling catheter care performed by Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 15 of 29 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 11/30/2023 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 N, Certified Nursing Assistant (CNA), was conducted. Staff N stated she had done the resident's catheter care before. During the care, Resident #43 was asking multiple times if she had an infection. On 11/29/23 at 10:38 AM, an interview was conducted with Staff L, Licensed Practical Nurse (LPN), who stated that Resident #43 did not have an infection at the time of the survey. Consequently, a side-by-side review of Resident #43's clinical record was conducted with staff L. The review revealed a physician order dated 05/18/23 that read Maintain indwelling foley catheter with 16 FR 10 cc balloon with a diagnosis of Neurogenic bladder, every shift. Staff L was asked if Resident #43 had been seen by a urologist and replied, we have to check the chart, you can ask the resident, she is alert. Staff L was apprised that the resident told the surveyor that she had not been out of the facility to see a specialist. On 11/29/23 at 11:50 AM, a telephone interview was conducted with Resident #43's hospice Registered Nurse (RN). The hospice RN stated she had the resident under her care for almost a year. The hospice RN stated the resident's Foley catheter was discussed with the daughter on 11/24/23 for the first time and the daughter will let her know. The hospice RN stated Resident #43 wanted the Foley catheter out, and cannot tolerate the catheter anymore. The hospice RN stated the resident had the catheter before hospice services were started. The hospice RN was asked if the resident had a urologist consult who replied she never had a consult for her. She added that hospice could do a urologist consult. The hospice RN stated that the resident did not have trouble voiding before per her daughter. The hospice RN was asked what the hospice policy was related to having a Foley in place. She stated that she would discuss it with the hospice doctor on Thursday during their team meeting. The hospice RN was asked for Resident #43's hospice diagnosis. She replied the resident was admitted to hospice with a diagnosis of Cerebral Atherosclerosis and did not have a diagnosis to support the resident's Foley catheter, and would go to the chart. On 11/29/23 at 12:03 PM, an interview was conducted with the Director of Nursing (DON) who stated that hospice gave Resident #43 a diagnosis for the Foley catheter. The DON was apprised that the resident had the Foley prior to hospice services. The DON stated the resident was admitted on [DATE] and came in with a Foley catheter from a local nursing home. The DON was asked about the facility's process / policy related to a resident coming into the facility with a Foley catheter. The DON stated that the facility process was to have voiding trails and a bladder scan. The DON was asked to submit written evidence related to Resident #43 been assessed by a Urologist and/or written documentation of voiding trails. On 11/30/23 at 8:58 AM, during an interview, the Regional Nurse inquired why the surveyor asked for the Catheter care policy. The Regional Nurse was informed that we would like to review the policy. The Regional Nurse was apprised that on 11/29/23, the DON was asked to submit a physician progress note to validate Resident #43's medical justification for the Foley catheter, and voiding trials documentation. On 11/30/23 at 10:00 AM, the DON submitted Resident #43's general nursing progress note dated 04/08/23 that documented, No urine noted during patient AM care and a new catheter 16 FR was inserted with 100 cc balloon, and 400 cc of yellow urine noted in patient urinary bag. During an interview, the DON stated the staff did the voiding trials but did not do a bladder scan as per the facility process. The DON was asked to submit the nurses notes related to the voiding trials, discontinuation of the foley and the facility process/policy. On 11/30/23 at 11:13 AM, telephone call was made to Resident #43's representative who stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 16 of 29 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 11/30/2023 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 comes to the facility twice a week. The representative stated that the resident's Foley catheter was placed prior to coming to the facility at a hospital. The representative stated she suspected the reason for the Foley was because the resident was very delirious and added obviously she needed a lot of assistance going to the bathroom. The representative stated the hospital staff made that determination to put a Foley and neither facility had attempted to remove it. The representative was asked if she knew the reason the resident had a Foley who stated she have not been told but assumed, wrongly that the resident was not able to get off the wheelchair into the toilet, was wearing diapers, and developed a pretty bad rash. The representative was asked if anyone from the facility had talked to her about removing the Foley, who replied that no one had talked to her about the removal of the Foley catheter. The representative added the resident had been asking her the same question. The representative stated she asked the hospice nurse about the Foley and she was waiting on someone to get a response. The representative was asked if she would like the resident's Foley removed and replied she would like the Foley remove. The representative stated the resident had a history of UTI's (urinary tract infections) and had one recently in the last two weeks. The representative stated the resident had a UTI with sepsis two years ago. The representative stated that two weeks ago, the resident told her that she was burning down there and told one of the nurses during shift change. The representative added that by the evening no one had contacted her, she had called the evening nurse and no had told her of the resident's having burning sensation. The representative stated she called the hospice nurse and finally, three days later, they took a urine specimen and she had an UTI. On 11/30/23 at 1:46 PM, an interview was conducted with the facility's Adult Registered Nurse Practitioner (ARNP) who stated she was contracted and was physically in the facility Monday through Friday. The ARNP stated Resident #43 came into the facility with a Foley and had a diagnosis of neurogenic bladder. The ARNP was asked who diagnosed the resident with a neurogenic bladder and the ARNP was not able to provide where she got the diagnosis from. The ARNP added the resident had a history of a stroke. The ARNP stated she saw a bladder scan results and was asked to provide a copy of the results. The ARNP was not able to provide a copy of Resident #43's bladder scan. The ARNP was apprised the resident's Primary Care Physicians' Nurse Practitioner wrote an order for a nephrology consult. The ARNP stated she was not aware of a nephrology consult and replied that the resident was on hospice care. The ARNP stated Resident #43 pulled the foley out in 03/27/23 and was re-inserted. The ARNP added that on 04/08/23, the resident pulled out the catheter at 6:00 AM, no urine noted during AM care, and the Foley was re-inserted at 7:30 AM with 400 ml of urine. The ARNP stated she documented on 04/11/23 voiding trial failed. The ARNP stated the reason for her to document voiding trial failed was because the resident had 400 ml of urine after re-insertion. The ARNP read a nursing note dated 05/28/23 that the resident pulled the Foley catheter for a second time. The ARNP read a nursing note dated 05/29/23 that documented that the resident voided without difficulty. The ARNP was apprised of the nursing note documentation that the Foley was reinserted on 05/30/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 17 of 29 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 11/30/2023 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain Intravenous (IV) lines and dressings for 2 of 3 sampled residents reviewed for IV lines, Resident #52 and #12. Residents Affected - Few The findings included: 1. Record review for Resident #52 revealed that an initial admission to the facility on [DATE] and was the last readmission on [DATE]. Upon returning from the hospital, Resident #52 had a PICC (peripherally inserted central catheterline), a midline intravenous line used for long term medications such as antibiotics, in her left upper arm. Resident #52 had a medical history significant for a Left Heel Wound Infection for which she was receiving intravenous (IV) antibiotics. During the initial tour of the facility conducted on 11/27/23, the surveyor observed Resident #52's PICC line dressing was dated 11/14/23. Review of the physician orders revealed an order was written on 11/15/23 for PICC to upper left change dressing every Wednesday night. Review of the Treatment Administration Record (TAR) revealed the PICC line dressing task was not signed off on 11/22/23, indicating it was not done on that day by the nurse. Interviews were attempted with Resident #52 during the survey week regarding her PICC line but due to her mental status, she was unable to answer questions. An observation was made on 11/30/23 at 8:24 AM of Resident #52's PICC line dressing and it was dated 11/29/23. An interview was conducted with Staff G, Licensed Practical Nurse (LPN), on 11/30/23 at 3:00 PM. She stated she used the PICC line to infuse Resident #52's antibiotic and that it worked well but that she did not notice the date on the dressing She said it is the night shift nurse's responsibility to change the dressing on Wednesday nights. She stated Resident #52 is typically in a good mood and rarely refuses cares from her during her shift. 2. Review of Resident #12's clinical record documented an admission on [DATE] with no readmissions, and diagnoses that included Cognitive Communication Deficit, Dementia, and Anxiety Disorder. Review of Resident #12's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 7, indicating the resident had severe cognition impairment. Review of Resident #12's physician order dated 11/25/23 documented, Midline insertion one time only for MRSA [Methicillin-resistant Staphylococcus aureus] in Urine for 1 Day. Review of Resident #12's physician order dated 11/27/23 documented, Monitor midline to left upper for signs of infection. Flush IV line with 5 ml NS (normal saline) before and after medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 18 of 29 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 11/30/2023 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 0694 administration every shift. Level of Harm - Minimal harm or potential for actual harm Review of Resident #12's clinical record revealed a physician order dated 11/25/23, as, Vancomycin Intravenous solution 750 mg/150 ml (milligrams/millimeters) every 12 hours for MRSA in the urine for 7 days. Residents Affected - Few Review of Resident #12's November Medication Administration Record (MAR) documented Vancomycin Intravenous (IV) solution 750 mg/150 ml (milligrams/millimeters) every 12 hours for MRSA in the urine for 7 days hours (scheduled) for 9:00 AM and 9:00 PM. On 11/27/23 at 10:21 AM, observation revealed Staff L, Licensed Practical Nurse (LPN), outside of Resident #12's room. An interview was conducted with Staff L who stated she was going to do Resident #12's IV Vanco antibiotic, scheduled for twice a day every 12 hours. Staff L was informed that we would like to do observation of the IV medication administration for Resident #12. At 10:29 AM, Staff L entered Resident #12's room, observation revealed an IV pump attached to an IV pole; and a bag labeled Vancomycin 750 mg/150 ml hanging at the pole. At 10:33 AM, Staff L started to prime the IV line and set up the IV pump. Observation revealed a 10 cc normal saline syringe on top of the resident's night stand. An inquiry was made about the syringe and Staff L stated it was an extra syringe. At 10:39 AM, continued observation revealed Staff L retrieved the normal saline syringe from the night stand, attempted to flush the line and was not able to do it. Observation revealed Resident #12 had a Midline catheter on her upper left arm, the line tubing was taped, and the tape was covering the port that did not have a cap on it. Continued observation revealed Staff L with her gloves on, reached into her uniform pocket and retrieved a pair of scissors and cut off the piece of tape that was impeding her to flush the Midline catheter. Staff L then placed the pair of scissors back in her pocket without disinfecting the scissors. Observation revealed Staff L then proceeded to connect the normal saline syringe to the Midline port without disinfecting the port and flushed the line with 5 cc of saline. Staff L then connected the IV Vancomycin line to the port and did not disinfect the port prior to the connection. On 11/29/23 at 12:33 PM, a joint interview was conducted with Staff L and the Director of Nursing (DON). Staff L was apprised that she did not disinfect Resident #12's Midline port before connecting to the flush syringe or the IV Vancomycin line. Staff L stated she did not remember if the resident had a cap or not on the IV line. Staff L was asked to show a sample of the cap that should be in place. Staff L showed an orange color cap (swab cap). The DON stated that if the resident line did not have a cap, the nurses needed to disinfect the line with an alcohol swab prior to connecting to the IV line or the syringe. The DON and Staff L were apprised that Resident #12 did not have a cab on her Midline port prior to Staff L flushing the line with normal saline syringe. On 11/29/23 at 12:45 PM, a side-by-side review of the facility's policy, titled, Intravenous Therapy, revised on 04/01/23, was conducted with the Director Of Nursing. The policy documented .disinfect needleless connector with appropriate antiseptic agent. Attach 10 ml syringe normal saline .disinfect needleless connector again . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 19 of 29 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 11/30/2023 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 0759 Ensure medication error rates are not 5 percent or greater. 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 medication error rate was 6.45 percent (%). Two (2) medication errors were identified while observing a total of 31 opportunities, affecting Resident #12. Residents Affected - Few The findings included: Review of the facility's policy, titled, Medication Administration, revised on 04/14/23 documented, .compare medication source (bubble pack, vial etc.) with MAR [medication administration record] . administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician .sign MAR after administered . Review of Resident #12's clinical record documented an admission on [DATE] with no readmissions, and diagnoses that included Cognitive Communication Deficit, Dementia, and Anxiety Disorder. Review of Resident #12's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 7, indicating the resident had severe cognition impairment. Review of Resident #12's clinical record revealed a physician order dated 11/25/23 as, Vancomycin Intravenous solution 750 mg/150 ml (milligrams/millimeters) every 12 hours for MRSA [Methicillin-resistant Staphylococcus aureus] in the urine for 7 days. Review of Resident #12's November Medication Administration Record (MAR) documented, Vancomycin [Vanco] Intravenous (IV) solution 750 mg/150 ml (milligrams/millimeters) every 12 hours for MRSA in the urine for 7 days hours (scheduled) for 9:00 AM and 9:00 PM. On 11/27/23 at 10:21 AM, observation revealed Staff L, Licensed Practical Nurse (LPN) outside of Resident #12's room. An interview was conducted with Staff L who stated she was going to do Resident #12's IV Vanco antibiotic scheduled for twice a day every 12 hours. Staff L was informed that we would like to do observation of the IV medication administration for Resident #12. At 10:25 AM, observation revealed Staff L retrieved a bottle of Clear-lax powder and poured 17 grams into a medication cup. At 10:29 AM, Staff L entered Resident #12's room, and poured the Clear-lax powder into a cup with a colored liquid and left it on top of the table. Observation in this room revealed an IV pump attached to an IV pole, and a bag labeled Vancomycin 750 mg/150 ml hanging at the pole. At 10:33 AM, Staff L started to prime the IV line and set up the IV pump. At 10:41 AM, continued observation revealed Staff L connected Resident #12's Vancomycin IV antibiotic, that was scheduled for 9:00 AM, at 60 ml per hour. During the observation, Resident #12 asked Staff L how long would the IV run for it and Staff L replied for one (1) hour. An interview was conducted with Staff L who stated that she was moving the resident's personal belongings that the resident had requested and that she was only 15 minutes behind administering the antibiotic. Staff L was apprised that she was 41 minutes behind scheduled time. On 11/28/23 at 10:25 AM, the facility's Consultant Pharmacist was apprised of Resident #12's Vancomycin antibiotic given after scheduled time and at a wrong rate. On 11/28/23 at 10:41 AM, observation revealed Resident #12 in her room sitting in a recliner chair. Observation revealed Staff O, Registered Nurse (RN), was in the resident's bathroom. Staff O was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 20 of 29 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 11/30/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few asked if she administered Resident #12's Vancomycin IV antibiotic scheduled for 9:00 AM. Staff O stated that Staff L, LPN, will do the resident's IV. Staff O stated she did not know that Resident #12 had an IV antibiotic scheduled for 9:00 AM. Staff O stated she was busy with another surveyor passing meds. On 11/28/23 at 10:46 AM, a side-by-side review of Resident #12's IV Vancomycin physician order was reviewed with Staff O. The review revealed a pharmacy label of Vancomycin 750 mg per 150 ml dated 11/25/24. Staff O was informed that we would like to do IV medication administration observation for Resident #12. On 11/28/23 at 10:53 AM, IV Vancomycin medication administration observation, performed by Staff O, was started. Observation revealed Staff O, RN entered Resident #12's room and proceeded to discard the previous emptied IV Vancomycin bag left on the IV pole. Staff O performed hand hygiene, donned gloves, removed the resident's Midline port's cap and flushed the line with normal saline syringe. Staff O primed the IV line and connected Resident #12's IV Vancomycin antibiotic, set up the pump at 100 cc per hour at 11:02 AM. Staff O stated the IV was running at 100 cc an hour for 1.5 hours. Staff O was asked when she would document the medication was administered, who stated after it is given. Staff O was apprised that she hung the IV Vancomycin at 11:02 AM. On 11/28/23 at 2:10 PM, during an interview, Staff L, LPN was apprised that Resident #12's IV Vancomycin rate was 100 cc per hour to be infused in 90 minutes and that she set it up at 60 cc per hour on 11/27/23. Staff L stated that she did not know if the order was changed. A side-by-side review of Resident #12's IV Vancomycin supply sent from the pharmacy was conducted with Staff L. The review revealed that 14 bags were sent from the pharmacy on 11/25/23 and the rate had not been changed. Staff L read the physician order as 750 mg/150 ml IV one time only 11/25/23. Staff L stated she did not see any other orders with the rate to be infused. On 11/29/23 at 12:45 PM, during an interview, the Director Of Nursing (DON) was apprised of Resident #12's IV Vancomycin scheduled for 9:00 AM given after 10:00 AM on 11/27/23 and 11/28/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 21 of 29 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 11/30/2023 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 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 observation, interview, and record review, the facility failed to provide physician ordered pureed diets that were prepared in a smooth form and texture and free from whole, minced or ground pieces to meet the needs of 6 facility residents on a specialized diet, that included Resident #3. The census at the time of survey was 95 residents. The findings included: Review of the facility's Purred Diet (References: American Dietetic Association, National Dysphagia Diet Task Force) noted the following: Description: Pureed diet is used for patients with swallowing and chewing difficulties. All foods are smooth in texture and free from whole, minced or ground pieces. 1. During the observation of the Tray Assembly Line in the Main Kitchen on 11/28/23 at 7:30 AM, it was noted that the Approved menu documented Purred Diet to receive 4-oz serving of Pureed Hashbrown Potatoes. Observation of the Pureed hashbrown potatoes on the steam table noted large pieces of potatoes with the pureed mixture. At the request of the surveyor, the pureed hashbrown potatoes were taste tested by the Corporate Food Service Director (CFSD) and and Food Service Director (FSD). The test revealed that the mixture was not pureed to smooth consistency and was not acceptable for residents with physician ordered Pureed Diet. The surveyor also tasted the mixture and confirmed that the mixture was not prepared to the proper smooth consistency. Mashed Potatoes were substituted in place of the pureed hashbrowns by the FSD . Interview with the [NAME] (Staff A) at the time of the observation reviewed that he was not aware of proper food pureed consistency and had no training in preparation pureed diets. A review of the employee file of Staff A noted a hire date of 02/09/22 for the job position of cook. A review of the [NAME] - Job Description noted documentation of food Preparation / Production Responsibilities that included: * Reviews menus, patient census information , and determines type and quantities of food to be prepared. * Prepares meal items according to planned menus and standardized recipes. * Tests and observes food by tasting for palpability. * Attends and participates in scheduled in-service training and meeting. Further review of employee file of Staff A did not locate any documentation concerning food preparation techniques and requirements for pureed diet. 2. During the observation of the lunch meal in the main kitchen on 11/30/23 at 11:30 AM, the consistency of the pureed menu items (beef stroganoff, noodles, carrots, and bread) were tasted for proper pureed consistency by the Corporate Food Service Director (CFSD) and the surveyor. The testing noted that the both the pureed pasta and pureed carrots contained large pieces and were not smooth in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 22 of 29 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 11/30/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few consistency. The CFSD stated to the cook (Staff B) that the pureed pasta and carrots were required to be remade. Interview conducted with Staff B at the time of the meal observation noted to state that Staff B had not been trained for proper preparation of pureed foods and dysphagia, and does not taste-test for proper smooth pureed consistency. A review of the employee file of Staff B noted a hire date of 02/09/22 for the job position of cook. A review of the [NAME] - Job Description noted documentation of food Preparation / Production Responsibilities that included: * Reviews menus, patient census information , and determines type and quantities of food to be prepared. * Prepares meal items according to planned menus and standardized recipes. * Tests and observes food by tasting for palpability. * Attends and participates in scheduled in-service training and meeting. Further review of employee file of Staff B did not locate any documentation concerning food preparation techniques and requirements for pureed diet. 3. During the review of the diet census for 11/27/23, it was noted that there were currently 6 facility residents with physician ordered Pureed diet. It was further noted that Resident #3 had a current physician order for Pureed (PU4) / CHO Controlled / Moderately Thick Liquids. 4. Review of Standardized recipes on 11/30/23 noted the following: * Pureed Hashbrown Potatoes: Combine thickener and milk to make a slurry, process until smooth adding 1 ounce of slurry per 1/2 cup portion, check product consistency periodically. * Pureed Baby Carrots: Process until smooth, check product consistency periodically. * Pureed Buttered Noodles: Process pasta until smooth adding 1 ounce water per portion 5: Review of clinical record of Resident #3 noted the following: Date of admission: re-admission [DATE] Diagnoses included: Dysphagia, Dementia, Type 2 Diabetes Current Physician Orders: 10/14/22 - Pureed Texture/Moderate Thick Liquids/Carbohydrate Controlled. MDS (Minimum Data Set Assessment) of 10/06/23 - Quarterly included: Section C: BIMS (Brief Interview for Mental Status) = 00 (Cognitive Impairment) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 23 of 29 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 11/30/2023 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 0805 Sec G: Eating = Extensive Assistance Level of Harm - Minimal harm or potential for actual harm Sec K: Mechanically Altered Diet/ Therapeutic Diet Sec I : Active Diagnoses - Dysphagia. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 24 of 29 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 11/30/2023 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, interview, and record review, 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. Review of facility policy, titled, Date Marking for Food Safety, date implemented: 04/07/23 included: Policy: Facility adheres to a date marking system to ensure the safety of ready-to-eat, time / temperature control for food safety. Policy Explanation: #2: The individual opening or preparing a food shall be responsible for date marking the food at the time the food is open or prepared. #3: The marking system shall consist of a label , the day/date of opening. #4: The discard day or date may not exceed the manufacturer's use-by-date. #5: The cook , or designee shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. #6: The Dietary Manager , or designee shall spot check refrigerators for compliance, and document accordingly. During the initial Kitchen / Food Service observation tour conducted on 11/27/23 at 9:00 AM and accompanied with the Food Service Director (FSD) and Corporate Food Service Director (CFSD), the following were noted : (a) The exterior of the ceiling mounted air conditioning vents (4) located in the food preparation, food serving, dry food / canned food storage room, and dish machine areas were noted to be soiled, rusted, areas of peeling paint, and black mold type substance. Further observation noted that the exteriors also had large areas of dripping condensation. It was discussed that contaminated condensation, paint chips, and rust could fall directly into foods, food preparation and serving surfaces, fall onto clean dishware, and onto staff resulting in food contamination and food borne illness. The surveyor requested that the air-conditioning ventilation system be be reported immediately to the administration for evaluation and repair. (b) During the observation of the walk-in refrigerator, it was noted that the cooling unit had a large area of ice build up and was thawing. Further observation noted that the drip from the thawing was not contained and was dripping directly onto 3 cases of commercially prepared desserts. The surveyor requested that the desserts be discarded, and all foods moved away from the dripping area. The surveyor also requested that the unit be reported to administration for evaluation and repair immediately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 25 of 29 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 11/30/2023 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 Residents Affected - Many (c) During the observation of the walk-in refrigerator, it was noted that there were 3 cases of Jello (18 -4 ounce portions per case) with a manufacturer's expiration date of 11/03/23. The CFSD stated that the refrigerator are to be checked daily as per policy to remove and discard the outdated commercially prepared foods. (d) During the observation of Reach-in Refrigerator #1, it was noted individual portions of pureed fruit (5) and Yogurt (2) . Further observation noted that none of the portioned foods were labeled with a preparation date. Interview with the CFSD noted to state that the faculty's policy for labeling and dating prepared foods was not followed. (e) During the observation of the walk-in freezer, it was noted that a 20 pound box of broccoli was opened. Further observation noted that the broccoli contents were not properly closed and wrapped with the internal plastic bag. It was further noted that the broccoli was freezer burned and not acceptable for preparation and serving. The surveyor requested to the CFSD that the broccoli be discarded. (f) Observation of the steam table noted to have 2- 4 foot attached sections of cutting boards. Further observation noted that the exterior of the boards were heavily worn with deep cut grooves and the boards were covered with a black mold-type substance. The surveyor discussed with the CFSD that there was a potential for food contamination and food borne illness and further requested that the boards be discarded and new boards purchased. (g) Observation of the commercial meat sliced noted to have small pieces of dried food matter around the blade slicing surface. The CFSD stated that the slicing machine had not been properly cleaned and sanitized after the last use. The CFSD further stated that the slicer would not be utilized until staff properly cleaned and sanitized. (h) Observation of the coffee station area noted noted that approximately 4-5 large ceiling tiles that were located directly over the area were having soiled and mold-like laden. The CFSD stated that the tile would be replaced immediately and did not know why a work order for replacement was not issues to maintenance. (i) Observation of the dish machine area noted that a 6-foot section of the wall tiles and base board tiles were in disrepair. The CFSD stated that a maintenance repair order would be issues. Photographic Evidence Obtained. 2. During a follow-up food service / kitchen observation tour on 11/28/23 at 7:00 AM and accompanied with the Corporate Food Service Director, the following were noted: (a) The exterior of the ceiling vent located in the dry / canned food storage room was noted to be covered in a black mold-type substance. It was discussed with the Corporate Director that the substance could result in food borne illness and contamination. (b) The exterior of the ceiling vent and ceiling tiles located above the cooks preparation sink was noted to have large area of peeling paint. It was discussed with the Corporate Director that the paint substance could fall into foods and could result in food borne illness and contamination. (c) Observation of the dry / canned food storage room noted that there was a soiled jacket that was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 26 of 29 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 11/30/2023 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 Residents Affected - Many utilized by staff for use in the walk-in freezer. Further observation noted that the soiled jacket was hanging on a food storage shelf and was coming into direct contact with foods (thickened water/juice). The surveyor requested that the soiled jacket not be hung or stored within the food storage room. (d) Observation of the dry / canned food storage room noted that a case of plastic fork cutlery and case of plastic knife cutlery were being stored on a shelf. Further observation noted that entire contents of the cases was not covered and was exposed to air. The surveyor requested that the plastic cutlery be disposed. Photographic Evidence Obtained. 3. During a third follow-up to the kitchen / food service department on 11/29/23 at 11:30 AM, the following was noted: (a) Observation of the silverware noted that the silverware was being washed in a overloaded dish rack. Numerous pieces of soiled silverware were noted in the rack. During an interview conducted with the Diet Aide (Staff C) at the time of the observation noted that the soiled silverware was not being rewashed and were being placed directly on resident food trays. Interview with the CFSD at the time of the observation noted to state that the washing, sanitizing, and handling clean silverware was not properly followed. Staff C failed to follow a 4 step program to ensure that residents receive properly washed and sanitized silverware with their meals. Photographic Evidence Obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 27 of 29 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 11/30/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to appropriately consult the responsible party regarding residents' vaccine status for 1 of 5 sampled residents reviewed for vaccines, Resident #62. Residents Affected - Few The findings included: Review of the vaccination status revealed Resident #62 was not properly reviewed by the facility for vaccines. Resident #62 was admitted to the facility on [DATE], with a medical history significant for Dementia, Parkinson's Disease, Depression, and Pneumonia. Review of the quarterly Minimum Data Set (MDS), dated [DATE], documented Resident #62 had a Brief Interview of Mental Status (BIMS) score of 0, indicating he was severely cognitively impaired and unable to make his own healthcare decisions. During Resident #62's admission, the admitting nurse documented Patient Vaccination, in part, as follows: Information Acknowledgment Forms which showed vaccination education was given to the resident, despite him being unable to make his own healthcare decisions. An interview was conducted with the facility's Infection Prevention (IP) Nurse on 11/30/23 at 10:50 AM. She confirmed the admission nurse documented Resident #62's vaccination information was discussed with him and him being his own decision maker. The IP nurse confirmed that Resident #62 had a brother who was his decision maker. She stated she had talked to Resident #62's brother previously to confirm whether he wanted Resident #62 to receive the vaccinations, but that the brother had stated he did not want Resident #62 to receive the vaccinations. When asked if she had documented the conversation in a note, she stated she had not. She said she would call him again to confirm the vaccinations. Review of Resident #62's hospital records from 02/17/23 documented he had been hospitalized with pneumonia prior to being admitted to the facility. Review of the physician orders during his time at the facility revealed Resident #62 had antibiotic orders in August and October 2023 for a diagnosis of pneumonia. A secondary interview was conducted with the facility's IP nurse on 11/30/23 at 2:08 PM, who stated she had spoken to Resident #62's brother and he confirmed that he wanted Resident #62 to receive the pneumococcal and influenza vaccines. She stated she was going to talk with Staff D, Nurse Practitioner, about ordering the vaccines for Resident #62. An interview was conducted with Staff D on 11/30/23 at 2:34 PM, who confirmed Resident #62 is not able to make his own decisions. She confirmed that Resident #62's brother is his decision maker. She stated vaccines are typically ordered by a resident's primary care doctor and that it is not part of her workflow to follow up on vaccinations unless specifically asked to do so. An interview was conducted with Staff E, Licensed Practical Nurse (LPN), on 11/30/23 at 3:04 PM. She confirmed that Resident #62 is not able to make his own decisions. She confirmed Resident #62's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 28 of 29 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 11/30/2023 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 0883 brother is his decision maker. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106005 If continuation sheet Page 29 of 29