Inspection·June 3, 2022

F 0584 The privacy curtain was noted to have numerous tears and holes. Level of Harm - Minimal harm or potential for actual harm The ceiling light over the bathing table was not working. The ceiling vent and surrounding ceiling area were covered in a black mold type substance. Residents Affected - Some * Photographic Evidence Obtained 3) Classroom: The threshold and exteriors of the entry/exit doors (4) were noted to be heavily soiled * Photographic Evidence Obtained 4) Patio Area: The floor base of the patio was noted to be extremely hot and numerous large holes throughout the 12 by 16 area. * Photographic Evidence Obtained 5) Hallways: The ceiling air-condition vent located in the main hallway near the shower room was noted to have a heavy build-up of black mold type matter. * Photographic Evidence Obtained 6) Nursery: The interior of the commercial medication refrigerator was noted to be heavily soiled and large area of brown dried matter. The door gasket had an approximate 12 inch tear which could potential effect the refrigerator's temperature. The clips that hold the individual resident privacy curtains (17) were noted to be heavily rust laden. Nine ceiling tiles located throughout the nursery were heavily soiled and stained. The walls of the nursery were noted to be in disrepair and numerous holes. *Photographic Evidence Obtained 7) Resident Rooms: room [ROOM NUMBER] - Room wall soiled and areas of dried matter. room [ROOM NUMBER] - Electrical outlet cover was not secured to the wall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 2 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 room [ROOM NUMBER] - Ceiling vent soiled, and ceiling area noted to be soiled and spotted areas of dried brown matter. room [ROOM NUMBER] - Ceiling damage and heavily stained throughout, and ceiling air-conditioning vent mold laden. Residents Affected - Some *Photographic Evidence Obtained 8) Respiratory Storage Room: The floor area was heavily soiled and littered with trash. 9) Clean Linen Storage Room: Ceiling air-conditioning vent noted to have yellow mold type matter with visible spores. * Photographic Evidence Obtained Following the 06/02/22 Environment Tour the findings were confirmed with the Administrator and Director of Maintenance. The Director of Maintenance stated that the facility has a computer program for staff to document and alert housekeeping and maintenance of issues. He further stated that the program is part of staff orientation however, staff are not utilizing the computer program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 3 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews it was determined that the facility had failed to follow a physician's order to apply bilateral hand splints on 1 of 3 sampled residents (Resident #25) at a designated time, from 9:00 AM to 3:00 PM. The findings included: Resident #25 was admitted to the facility on [DATE] with the following diagnoses: Diffuse Traumatic Brain Injury; Fracture of Vault of Skull, Initial Encounter For Closed Fracture; Dependence on Respirator [Ventilator] Status. Review of the physician's order dated December 11, 2021 showed that Resident #25 needed to wear bilateral ankle foot orthosis (AFO) daily, for a minimum of 8 hours while in bed or wheelchair (WC). The AFOs were to be worn at all times when Resident #25 is in the WC. He also needed to wear a bilateral [NAME] hand splints daily from 9am-3pm, effective 12/11/2021. The following observations were made: On 06/01/22 at 10:17 AM Resident #25 had no hand splints. He was in bed laying down. 06/02/22 at 2:25 PM Resident #25 was observed without hand splint while laying down in bed. On 06/03/22 at 1:25 PM, Resident #25 had no hand splint on, he was also in bed laying down. Review of the Care plan dated 1/18/2022 revealed that Resident #25 had potential for fracture related to osteopenia. o Resident #25 will be free of fractures through next review date. o Staff will adhere to physical management by placing boots at bedside for proper positioning and use of orthotics. o observe for swollen extremities o Reinforce safety measures, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 4 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 o Level of Harm - Minimal harm or potential for actual harm Report and document any change in resident condition. o Residents Affected - Few Transfer resident from chair to bed and vice versa with care. The minimum data set (MDS) section G dated 4/17/2022 revealed that Resident #25 was totally dependent on staff for all activities of daily living. Section C1000 of the MDS noted that Resident #25 had severe cognitive impairment. In an interview conducted on 06/03/22 at 3:38 PM,with one of the resident's assigned nurses Staff B who is a licensed practical nurse, Staff B reported that she did not know the time Resident #25 was supposed to wear the bilateral splints. Staff B informed that it was the responsibility of the Activity Director to put the splint on the resident. Staff B said that she has been working at the facility for over a year. During the exit meeting held on 6/3/2022, the information was shared with the Administrator and staff present. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 5 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, it was determined that the facility failed to maintain acceptable parameters of nutrition status that include following of physician orders for 2 (Resident #26 and #30) of 2 sampled residents. Residents Affected - Few The findings included: 1) During the review of the clinical record of Resident #30 on 05/31/22 it was noted a current physician order to administer Glucerna 1.2, 240 ml if the resident consumes 50% or less of meals. Observation of the breakfast and lunch meals on 05/31/22, 06/01/22, 06/02/22 noted that the resident refused the breakfast on the 3 dates and ate less than 50% lunch meals on these dates. A review of the Medication Administration Record of Resident #30 noted that there was no documentation of the resident's meal intake for these meals and no administration of the 240 ml of Glucerna 1.2. The issues was brought to the attention of of the facility's Quality Improvement (QI) Nurse for review. Following the review by the QI the surveyor was informed that the Glucerna was not administered for the dates of 05/31/22 (2), 06/01/22 (2), and 06/02/22 (2) . The QI also stated that the physician order was not clear to the medication nurse and that the order would be clarified to ensure that the Glucerna would be administered as ordered 2) During the review of the clinical record of Resident #30 on 05/31/22, it was noted that physician orders dated 08/02/21 to add 1 tsp of Easy Peasie Vegetable Blend (dietary vitamin & mineral supplement) to all meals and mix well into foods three times (TID) per day. Interview conducted with the facility cook (Staff A) on 05/31/22 and 06/01/22 noted to state that she was unaware of the physician order and that the Easie Peasie Vegetable Blend was not available in supply in the dietary department. Staff A also stated that she has been employed at the facility for over 6 months and has never been aware of the physician order and never given the product for use. Interview with the Interim Director of Nursing (DON)on 06/01/22 to review the issue revealed that the Easy Peasie Vegetable Blend was to be purchased by the facility's corporate purchasing on a regular basis. The DON also stated that she went into the dietary department and confirmed that the Easy Peasie Vegetable Blend was not in supply and that Staff A had no knowledge of the dietary supplement and was not using the supplement according to physician orders for over 6 months. The DON further stated that the attending physician would be notified of the error in the administration of the supplement. 3) During the review of the clinical record of Resident #26 on 05/31/22, it was noted that physician orders dated 06/28/21 to add 1 tsp of Easy Peasie Vegetable Blend (dietary vitamin & mineral supplement) to all meals and mix well into foods three times (TID) per day. Interview conducted with the facility cook (Staff A) on 05/31/22 and 06/01/22 noted to state that she was unaware of of the physician order and that the Easie Peasie Vegetable Blend was not available in supply in the dietary department. Staff A also stated that she has been employed at the facility for over 6 months and has never been aware of the physician order and never given the product for use. Interview with the Interim Director of Nursing (DON)on 06/01/22 to review the issue revealed that the Easy Peasie Vegetable Blend was to be purchased by the facility's corporate purchasing on a regular basis. The DON also stated that she went into the dietary department and confirmed that the Easy Peasie Vegetable Blend was not in supply and that Staff A had no knowledge of the dietary supplement and was not using the supplement according to physician orders for over 6 months. The DON further stated that the attending physician would be notified of the error in the administration of the supplement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 6 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to ensure staffing information was posted in a prominent place accessible to residents and visitors from 05/31/22 to 06/03/22. Residents Affected - Few The findings included: On 05/31/22 at 7:05 AM, observation revealed no posting of the nursing staffing data in a prominent place accessible to visitors and residents. On 06/01/22 at 8:03 AM, observation revealed no posting of the nursing staffing data in a prominent place accessible to visitors and residents. On 06/02/22 at 11:45 AM, observation revealed no posting of the nursing staffing data in a prominent place accessible to visitors and residents. On 06/03/22 at 10:11 AM, observation revealed no posting of the nursing staffing data in a prominent place accessible to visitors and residents. On 06/03/22 at 10:59 AM, an interview was conducted with the facility's Nurse Manager. An inquiry was made regarding nursing staffing hours posting. The Manager stated she did not know that they have to post the nursing staffing hours. She confirmed that the facility had not been posting the nursing staffing hours for the public. On 06/03/22 at 1:40 PM, a side-by-side review of the facility's staffing record was conducted with the Staffing Coordinator (SC). The SC stated she had been in the position since March 2022. The SC stated she completes the form titled Direct Care Nursing Staffing the next day and then files it in a drawer. She stated she was not told that the staffing hours form needed to be posted. Observation revealed the SC pulled the facility's Direct Care Nursing Staffing forms for 06/03/22 from the top of her desk. The review revealed the form did not document the staffing actual hours of direct care as per regulation. Review of the Direct Care Nursing Staffing forms from 05/24/22 to 06/02/22 did not document the staffing actual hours of direct care as per regulation. On 06/03/22 at 3:01 PM, during an interview, the administrator was asked to show where did the facility post the nursing staffing hours for the visitors/public to see. The administrator stated the posting was by the nurses station. She added that the visitors were not allowed to pass the double door to go to the nurses station or residents area. She was apprised that nursing staffing hours were not posted as per regulation in a place where visitors could see. The administrator asked the Staffing Coordinator for the posting hours and the Coordinator pulled the incomplete staffing posting sheets from a bottom drawer at her desk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 7 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to review and to act on 2 of 5 residents (Resident #18 and #30) sampled for Unnecessary Medications review. The findings included: Review of the facility's provided policy titled Consultant Pharmacists Monthly Drug Regimen Review with no effective or revision date docuemnted .Physicians/prescribers are to act on recommendations by or before their NEXT visit date to the facility. If they do not act on recommendations by their next visit, the D.O.N. will promptly forward those recommendations to the Medical Director for follow up. The D.O.N. will notify the administrator and document non-compliance to the CQI committee for follow up actions.The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. The D.O.N. is responsible for ensuring non-physician type recommendations are acted on in a timely manner. Timeframe: The D.O.N. will be responsible to ensure that documentation is completed to verify the Consultant Pharmacist Recommendations are acted on with a target completion timeframe of TWO weeks from the report date. 1). Review of Resident #18's clinical record documented an initial admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Major Depressive Disorder, Seizures and Dependence on a Ventilator. Review of the physician orders dated 07/01/21 documented Escitalopram (Lexapro) 10 mg (milligrams) daily for Depression. Review of the resident's Medication Administration Record (MAR) for May and June 2022 documented Escitalopram 10 mg administered daily. On 06/03/22 at 1:27 PM, a side by side review of Resident #18's Medication Regimen Review (MRR) dated 04/11/22 was conducted with the facility's Acting Director of Nursing (A-DON) and the Nurse Manager. The MRR documented recommendations as to .consider a Gradual Dose Reduction (GDR) for Lexapro 10 mg (milligrams) daily since 07/14/18. If unable to reduce or discontinue please provide a brief explanation why reductions cannot be attempted at this time. During the review, the Nurse Manager stated that Resident #18's insurance was switched and his psychiatrist did not accept the new insurance and the resident had not been seen by a psychiatrist. The Nurse Manager stated the residents April 2022 MRR had not been reviewed by the attending physician or the Medical Director. The A-DON stated she will be taking care of the review of the resident's MRR. 2). Review of Resident #30's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure and Quadriplegia. Review of the resident's physician orders documented the following active medications: -Rexulti Tablet 3 MG (Brexpiprazole) Give 3 mg via G-Tube in the morning for Depression dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 8 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0756 10/16/2021. Level of Harm - Minimal harm or potential for actual harm -Amitriptyline HCl Tablet 100 MG Give 100 mg by mouth at bedtime for Depression 100 mg dated 5/15/2022. Residents Affected - Few -Zoloft Tablet 100 MG (Sertraline HCl) Give 100 mg by mouth in the morning related to Major Depressive Disorder dated 5/19/2022. -Hydroxyzine Pamoate Capsule 25 MG Give 25 mg via G-Tube every 12 hours as needed for Anxiety Take one capsule by mouth every morning as needed for anxiety dated 5/17/2022. -Hydroxyzine Pamoate Capsule 25 MG Give 50 mg by mouth as needed for insomnia Take 2 capsules every night at bedtime as needed 50 mg=2 capsules dated 3/7/2022. -Zyrtec Allergy Tablet 10 MG (Cetirizine HCl) Give 1 tablet via G-Tube at bedtime for Allergies dated 9/26/2017. Review of Resident #30's Medication Regimen Review (MRR) documented the following recommendations: 02/07/22- recommend review of the following medications and consider for GDR: Zoloft 100 mg daily since 11/24/18. Elavil (Amitriptyline) 75 mg at bedtime since 09/26/17. Rexulti 3 mg daily since 10/16/21. Vistaril (Hydroxyzine Pamoate) 25 mg daily and 50 mg at bedtime since 10/15/21. Also recommend risk benefit documentation concerning the use of 2 (two) antidepressants. If unable to reduce or discontinue, recommend a brief explanation why reductions cannot be attempted at this time. Please address each medication individually. 03/14/22- documented resident receiving Zyrtec 10 mg daily for greater than 14 days .should only be used for a limited duration (less than 14 days) unless there is documented evidence of enduring symptoms that cannot otherwise be alleviated and for which a cause cannot be identified and corrected, Yearly note. Please provide a stop date. If indefinite please provide note below explaining continued use. 04/11/22- documented .ordered Vistaril (hydroxyzine Pamoate) 25 mg and 50 mg as needed (prn) without a stop date. CMS phase 2 regulations require a 14 day limit on all new orders for prn psychotropic meds. If the medication should be continued past 14 days, please have the MD document rationale of continuing the order and provide a stop date. 05/09/22- documented .ordered Vistaril (hydroxyzine Pamoate) 25 mg daily for anxiety and 50 mg at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 9 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bedtime prn for insomnia without a stop date. CMS phase 2 regulations require a 14 day limit on all new orders for prn psychotropic meds. If the medication should be continued past 14 days, please document rationale of continuing the order, and provide a stop date. Review of Residents #30's MAR for February, March, April, May, and June 2022 was conducted. Resident #30 Zoloft was discontinued on 05/04/22 and reordered in 05/19/22, lack of documentation noted related to the pharmacist recommendations for GDR on 02/07/22. Resident's Elavil was increased on 05/15/22, lack of documentation noted related to the pharmacist recommendations for GDR on 02/07/22. Review of the clinical record lack documentation of the rationale of continuing Vistaril as needed, Zyrtec Rexulti and Elavil daily. On 06/03/22 at 1:18 PM, a side by side review of Resident #30's MRR dated 02/07/22, 03/14/22, 04/11/22 and 05/09/22 was conducted with the facility's A-DON and the Nurse Manager. The Nurse Manager stated the resident was seen by an outside Primary Care Physician (PCP) who was not coming to the facility. She stated they faxed the resident's MRR to her PCP and called them and did not get a response. The Nurse Manager added that the resident goes out to a mental health clinic as well. The Nurse Manager stated they tried to contact the mental health clinic and it was very difficult to talk to them. She added she had called the PCP office and the mental health clinic and hardly ever get a response from them. The A-DON and the Nurse Manager were asked to submit documentation related to faxing or communicating with Resident #30's PCP and the psychiatrist. The Nurse Manager stated she did not have written evidence. During the review, the Nurse Manager stated that Resident #30's MRR had not been reviewed by the attending physician or the Medical Director since previous DON departure in March 2022. The A-DON stated she will be taking care of the review of the resident's MRR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 10 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to: 1) ensure that expired medications were removed from the facility's Over the counter storage room, the medication cart in the nursery wing, the treatment cart in the north and south wing and from the respiratory treatment cart in the south wing. 2) ensure that only authorized staff had access to medication cart in the nursery wing as evidenced by unauthorized staff accessing the medication cart. 3) ensure that residents medications were properly supervised/stored/secured as evidenced by controlled substance medication refrigerator being left unlocked; unattended medication left on the resident's bedside table during a Medication Administration Observation for 1 of 10 sampled residents (Resident #26). 4) ensure that it secured the resident medications in 1 of 4 Medication carts (Medication Cart of the south wing). The findings included: Review of the facility's provided policy titled Medication Administration, Documentation and Storage revised on 07/01/20 documented .each resident's medication .stored in a locked medication cart .medications requiring refrigeration will be stored in a locked medication refrigerator. Medication cabinets and refrigerators are kept locked at all times. For expired, unused, or discontinued medications will be disposed of appropriately by the nursing supervisor and another witness 1) On 06/01/22 at 8:56 AM, medication administration observation for Resident #10 in the nursery performed by Staff E, a Registered Nurse (RN) was conducted. Staff E stated he had to get the medications from another cart and poured Polyvisol (a multivitamin) 1 ml (millimeter) and administered to Resident #10. A side-by-side review of the bottle of Polyvisol was conducted with Staff E and revealed an expiration date of 05/01/22 with an opening date of 05/02/22. During an interview with Staff E, he stated that he pulled the bottle from the medication storage room. He confirmed that Polyvisol was expired. 2) On 06/01/22 at 10:06 AM, a side-by-side review of the facility's Over the Counter medication storage room was conducted with the administrator. The review revealed 3 (three) unopened bottles of Iron 100 tablets each bottle with a Best by date of 05/2022 and 9 (nine) unopened bottles of Vitamin C 250 mg (milligrams) 100 tablets bottle with a Best by date of 12/2021. The administrator was asked to contact the pharmaceutical to check on the best by date. The administrator stated she goggled and stated that Best by date is not expiration date. She was asked to submit written documentation from the pharmaceutical. On 06/02/22 at 11:27 AM, an interview was conducted with the facility's Consultant Pharmacist. He stated Best by date is an expiration date. He stated those Vitamin C bottle were expired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 11 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3) On 06/01/22 at 10:12 AM, a side-by-side review of south hallway medication room was conducted with Staff F, RN. The review revealed 6 (six) blood culture vials with an expiration date of 04/30/22. Staff F stated that the nurses uses the vial to draw residents blood culture and confirmed the vials were expired. 4) On 06/01/22 at 12:16 PM, side by side review of the north hallway treatment cart was conducted with Staff G, RN. The review revealed the following drugs and biologicals expired: 1 (one) zinc oxide ointment tubes with expiration date 06/21 and 1(one) with expiration date on 06/20. 2 (two) Triple antibiotic tubes with expiration date on 08/21. 6 (six) Povidone-Iodine swab stick with expiration date on 02/21. 1 (one) Povidone prep pad with expiration date on 02/18. 1 (one) Hydrocortisone cream tube with expiration date on 03/21. 2 (two) Hydrocortisone cream tube with expiration date on 03/20. 7 (seven) Skin-prep protectives wipe with expiration date on 07/21 1(one) Hydrogen peroxide opened bottle with an opening date on 09/01/19 and expiration date 05/20. 1 (one) Vaseline gauze with expiration date on 09/18. 1 (one) Mepilex AG (alginate) dressing opened package with expiration date on 12/28/21. 1 (one) AG silver dressing with expiration date on 01/22. 5 (five) Midline swab cap with expiration date on 01/08/21. 4 (four) lubricating Jelly with expiration date on 12/18/20. 2 (two) dressing change tray CVC (central venous catheter) with expiration date on 03/31/21. 3 (three) French self-catheter with expiration date on 05/04/21. 1 (one) IV (intravenous) tubing extension with expiration date on 06/30/21. 1 (one) Tubing extension set with expiration date on 12/18. 1 (one) IV catheter with expiration date on 10/18. 3 (three) 25-gauge hypodermic needle with expiration date on 09/20. 4 (four) 18-gauge needle with expiration date on 02/28/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 12 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 1 (one) [NAME] lock tip with expiration date on 08/28/20. Level of Harm - Minimal harm or potential for actual harm 1 (one) [NAME] lock tip with expiration date on 03/20. 1(one) [NAME] lock tip with expiration date on 09/20. Residents Affected - Some 1 (one) 7 x 4 x 2 plastic box labeled Wound Care Box noted full of expired skin protectant ointment packages. 3 (three) IV administration sets with expiration date on 01/24/21. 3 (three) IV administration sets with expiration date on 03/04/22. 1 (one) Gastrostomy feeding tube with expiration date on 07/01/21. On 06/01/22 at 12:59 PM, a joint interview was conducted with Staff G, RN, and the Nurse Manager (NM). The NM stated it was nursing responsibilities to check the treatment cart for expired items. 5) On 06/01/22 at 1:01 PM, a side-by-side review of the facility's south wing respiratory cart and interview was conducted with Staff H, a Respiratory Therapist (RT). The review revealed the following expired medical items: 6 (six) 22-gauge hypodermic needle with expiration date on 09/18. She stated she uses to give resident medication through nebulizer. 2 (two) culture swab with expiration date on 01/31/22. She stated they usually do the cultures themselves. 6) On 06/01/22 at 1:12 PM, a side-by-side review of the south hallway treatment cart and interview was conducted with Staff F, RN. The review revealed the following: 3 (three) IV catheter 24-gauge with expiration date on 06/30/19. 1(one) IV catheter 24-gauge with expiration date on 04/30/20. 3 (three) suction toothbrushes with expiration date on 03/14/22. 1(one) IV start kit with expiration date on 02/15/22. 1(one) Infusion set with expiration date on 10/18. 3(three) 25-gauge hypodermic needle with expiration date on 09/20. 2 (two) 23-gauge hypodermic needle with expiration date on 05/21. 2 (two) 19-gauge filler needle with expiration date on 10/20. 2 (two) suction toothbrushes with expiration date on 05/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 13 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7) On 06/01/22 at 8:06 AM, observation revealed an unlocked medication storage refrigerator located in the nursery wing, main hallway. Further observations revealed a key lock noted in the bottom shelf of the unlocked refrigerator. Furthermore, observation revealed Staff D, RN opened the unlocked fridge and retrieved a plastic bin with 4 (four) medications bottles and walked away without locking the refrigerator. On 06/01/22 at 9:14 AM, observation revealed Staff E, RN walked with a basket of medications to an unlocked refrigerator located in the facility's nursery wing and placed Resident #5's medications in the refrigerator. Further observation revealed Staff E walked away from the refrigerator and did not lock the refrigerator. On 06/02/22 at 10:02 AM, observation revealed the facility's administrator and the Maintenance Director and another surveyor conducting a tour on the nursery wing. Continued observation revealed the surveyor was able to open the refrigerator located in the main hallway in the nursery. Consequently, a side-by-side review of the nursery refrigerator was conducted with Staff O, RN. Staff O stated they kept the residents medications that needed refrigeration in the fridge located in the main hallway of the nursery and narcotic that needs refrigeration like Lorazepam. Observation revealed Staff O opened the unlocked refrigerator and revealed a locked box that contained one opened bottle of Lorazepam (a controlled substance medication) 2 mg/ml with 32.5 ml (millimeters) left in the bottle for a resident. During the review, Staff O was asked regarding the refrigerator lock and stated they will lock the fridge after morning medication pass (administration). She added the fridge is unlocked throughout the morning during medication pass then it is supposed to be locked. At 10:22 AM, Staff O was asked if she was done with the residents morning medication pass (administration) and stated she was done/finished. She was asked if the refrigerator was supposed to be unlocked at the time and stated it was supposed to be locked. Staff O confirmed that maintenance staff and other non-nursing staff walked up and down the main hallway where the unlocked fridge was located and stated again it should be locked. On 06/02/22 at 10:23 AM, an interview was conducted with Staff E, RN and stated the nursery refrigerator should be locked at all times. They both were apprised that the refrigerator had been unlocked on 06/01/22 and 06/02/22. On 06/03/22 at 7:55 AM, observation revealed the facility's nursery wing which refrigerator contained controlled substance was unlocked. On 06/03/22 at 8:19 AM, observation revealed the facility's housekeeping staff walked by the unlocked refrigerator. On 06/03/22 08:20 AM, observation revealed the facility's school teacher walked by the unlocked refrigerator to the residents nursery wing. On 06/03/22 at 9:21 AM, an interview was conducted with Staff D, RN and stated she was not sure if the nursery refrigerator needed to be locked. Staff D opened the unlocked fridge and stated there is a lock box. She was asked how many locks was supposed to have and stated there is one lock, and she added they did not have a locked door and the controlled substance was supposed to have a double lock. Staff D stated the fridge cannot be locked. Staff D was apprised of the fridge lock and was able to see that she had a key to lock the fridge. She stated she was not aware of that. On 06/03/22 at 2:30 PM, an interview was conducted with the Nurse Manager and she was apprised of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 14 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some observations of the nursery refrigerator unlocked throughout the survey, medication and treatment cart unlocked and unattended medications. She stated that refrigerator and the carts were to be locked at all times. 8) On 06/01/22 at 9:17 AM, during medication administration observation performed by Staff E, RN, it was observed that Staff E gave/passed his medication cart key ring to Staff N, a Maintenance Staff. Staff E was 6 (six) feet away from the medication cart administering medication to Resident #10 and unable to face the medication cart. Observation revealed Staff E telling Staff N that the green key opened the medication cart, and continued administering Resident #10's medications. Further observation revealed Staff N opened the medication cart and pulled two of the drawers and placed them to the side. Continue observation revealed Staff E returned to the medication cart at 9:29 AM and removed the key ring from the lock. On 06/03/22 at 1:00 PM, an interview was conducted with the facility's Nurse Manager (NM) and was apprised regarding Staff E giving/passing the medication cart keys to Staff N, Maintenance Staff. The NM stated Staff E should not do that he had to keep sight of the cart and hold on to the keys. 9) On 06/01/22 at 9:40 AM, a side by side review of the nursery medication cart was conducted with Staff E, RN. The review revealed a bottle of Lasix (a diuretic medication) liquid for a random resident. The bottle had large amount of crusted material around the bottle. Observation revealed Staff E placed the bottle on top of the medication cart and walked away leaving the medication unsecured and unattended. 10) On 06/01/22 at 1:11 PM, observation revealed the facility's south wing treatment cart was unlocked and unattended. At 1:12 PM, observation revealed Staff F, RN came out of a resident's room and locked the cart. 11) On 06/02/22 at 11:49 AM, during a medication administration observation for Resident #9 performed by Staff P, RN was conducted. Observation revealed Staff P left the medication cart unlocked and walked to the resident's room. Observation revealed Staff P returned to the unlocked cart at 11:58 AM and locked the cart. On 06/03/22 at 10:11 AM, an interview was conducted with Staff P and she confirmed she left the cart unlocked on 06/02/22 during medication administration observation for Resident #9. 12) On 06/02/22 at 11:58 AM, during medication administration observation for Resident #26 performed by Staff P, RN. Staff P poured Calcium Carbonate 1.4 ml (millimeters). Staff P entered the resident's room at 12:02 PM and stated she had to go to get a syringe. Observation revealed Staff P placed Resident #26's medication cup on top of his table, unsecured and unattended. Staff P returned to the room at 12:04 PM. On 06/03/22 at 10:11 AM, an interview was conducted with Staff P and she stated that she thought it was okay to leave the medication with the surveyor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 15 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview, and record review, it was determined that the facility failed to provide a nourishing, palatable, well balanced diet to meet the daily nutritional and special dietary needs of 4 (Resident's #18, #26, #28, and #30) of 4 sampled residents. The findings included: During the Long Term Care Survey conducted on 05/31/22 through 06/03/22, the following were noted: 1) Observations of breakfast and lunch meals on 05/31/22 through 06/03/22,and review of the approved menu for the dates of 05/31/22 through 06/03/22 noted that the menu was not being followed and menu foods deleted with prepartion of a substitute. 2) Menu foods were not prepared by the use of standardized recipes to ensure nutritive value, palability, and attractivness. Interviews with Residents #18, #26, #28 and #30, were noted to state disapproval with quality, attractivenss, and variety of menu items. Further interview noted that Residents #18, #28, and #30 have foods delivered from area restaurants 3-4 times per week. Further interview with Residents #26 and #30, they eat only microwave Macaroni & Cheese on a daily basis for lunch and dinner meals. 3) Review of consistency altered diets noted that physician ordered diet of Minced & Moist 5 (MM5) needed for diagnoses of dysphagia and chewing were not preprared. Further investigation revealed that kitchen staff were not trained on the preparation of the diet and were not provided documented information to follow the MM5 diet. 4) Review of clinicl records of Resident #26 and #30 noted that physician ordered vitamin and mineral supplments were not administredred as ordered three times per day. Interview with kitchen staff noted there was no Easy Peasie Vegetable Blend powder in supply and kitchen staff were not trained on how to use the supplment. It was estimated that the supplment was not in supply for over 6 - 8 months. 5) Review of the clinical record of Redsident #30 noted a current physician order to administer 240 ml of Glucerna 1.2 via tube if resident consumes less than 50 percent of meal. Observations conducted on 05/31/22, 06/01/22, 06/02/22 noted the resident refused lunch and dinner meals and was not administered the physician's ordered supplement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 16 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review, and interview, it was determined that the approved menu was not being followed for 4 Residents (#18, #26, #28, and #30) of 4 sampled residents who eat by mouth. Residents Affected - Some The findings included: During the observations of the breakfast, lunch, and dinner meals from 05/31/22 through 06/03/22, review of approved menu for 05/31/22 through 06/03/22, and interview with the facility cook (Staff A) on 05/31/22 through 06/03/22, the following were noted: 1) Observation and review of approved menu (Cycle #1) for Breakfast meal on 5/31/22 (Tuesday) noted: 1 oz Low Fat cheese - not served. 1 Scrambled Egg - /Margarine - not served, 2 fried eggs served. 1/2 Fresh Fruit - not available -no substitute provided. 8 ounces milk - available but not not served. 2) Observation and review of approved menu (Cycle #1) for Lunch meal on 5/31/22 (Tuesday) noted: Kidney Bean Salad - Canned 3 Bean Salad served in place, however canned Red Kidney Beans available in store room. 1/2 Mandarin Oranges - not served, and applesauce served. 1 sliced WG Bread /Margarine - not served. 8 ounces of Milk - available but not served. 3) Review approved menu (Cycle #1) for Dinner meal and interview with Staff A on 5/31/22 (Tuesday) noted: 1 slice of WW Garlic Bread - not served. 1/2 cup Fresh Fruit - not served, not available. 1 Cookie - not served, graham crackers served. 8 ounces Milk available but not served. 4) Observation and review approved menu (Cycle #1) for Breakfast meal on 6/01/22 (Wed) noted: Low Sodium Sausages - not available, regular sausage patties served (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 17 of 34 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 106110 B. Wing (X3) DATE SURVEY COMPLETED A. Building 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 1 WG English Muffin - not available, not purchased, toast served Level of Harm - Minimal harm or potential for actual harm Half Banana - not served, not purchased, no substitute served 8 Ounces Milk - available but not served Residents Affected - Some 5) Observation and review of approved menu (Cycle #1) for Lunch meal on 06/01/22 (Wed) noted: 1/4 cup Chopped Cucumbers - not served, not purchased, no substitute served. 1/4 Cup Chopped Tomato - not served, not purchased, no substitute served. 8 ounces Milk - available but not served. 6) Observation and review of approved menu (Cycle #1) for Dinner on 06/01/22 (Wed), and interview with Staff A noted: 1/2 Cup Lettuce & Tomato - not served, not purchased, no substitute served. 1/2 Baked Sweet Potato - not served, not purchased, no substitute served. 1/2 Mandarin Oranges - not served, not purchased, apple sauce substituted. 8 ounces Milk - available but not served. 7) Observation and review of approved menu (Cycle #1) for Breakfast meal on 06/02/22 (Thursday) noted: 1.5 Ounces Low Sodium Sausage - not served, not purchased, regular sausage patties served. 1/2 Fresh Fruit - not served, not purchased, no substitute served. 8 ounces Milk - available but not served. 8) Observation and review of approved menu (Cycle #1) for Lunch meal on 06/02 (Thursday) noted: BBQ Chicken - no BBQ sauce available, not purchased, chicken in gravy served. Cornbread - not served, not purchased, no substitute served. 1/2 Cup Roasted Sweet Potato - not served, not purchased, Instant Mashed Potatoes served. 1/2 Cup Cream Corn - not served, not purchased, kernel corn served. 8 ounces Milk - available but not served. 9) Observation and review of approved menu (Cycle #1) for Dinner meal on 06/02/22 (Thursday) and interview with Staff A noted: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 18 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 1/2 Cup Garlic Mashed Potatoes - not served, not purchased, instant Mashed Potato served. Level of Harm - Minimal harm or potential for actual harm 1/2 Cup Sweet Corn - served repeat vegetable from lunch meal. 1/2 Cup Peaches - served repeat fruit from lunch meal. Residents Affected - Some 8 ounces Milk - available but not served. 10) Observation and review of approved menu (Cycle #1) for Breakfast meal on 06/03/22 (Friday) noted: Scrambles Eggs - fried prepared (2) Orange Wedges - not purchased, served applesauce No milk served. 11) Observation and review approved menu (Cycle #1) for Lunch meal on 06/03/22 (Friday) noted: 1 ounce Low Fat Cheese - not served, not purchased, regular cheese substituted. 1/2 Mango - not served, not purchased, no substitute served. 1/2 Cup Fresh Fruit - not served, not purchased, no substitute served. 8 ounces Milk - available but not served. 12) Review approved menu (Cycle #1) for Dinner meal on 06/03/22 (Friday) and interview with Staff A noted: 8 ounce Chicken Quesadilla - not served, not purchased, chicken and gravy substituted (same entree lunch 06/02/22). 2 WW Tortillas - not served, not purchased, no substitute served. 1/4 Cup Salsa - not served, not purchased, no substitute served. 1/2 Cup Fresh Fruit - not served, not purchased, no substitute served. 1 Pkt Sour Cream - not served, not purchased. 8 ounces Milk - available but not served. On 05/31/22, 06/01/22, 06/02/22, and 06/03/22 interviews were conducted with Staff A who stated that she has been employed at the facility for over six months. Staff A also stated she was aware that menu items were not being purchased to ensure that the approved menu would be followed. The issue was brought to the attention of the facility Administrator, however there was no resolution to ensure that food menu items would be purchased. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 19 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 it was determined that the facility failed to prepare food that is palatable, attractive,and appetizing for 4 of 4 sampled residents (Residents #18, #26, #28, and #30). Residents Affected - Few The findings included: 1) During the review of facility records on 05/31/22 it was noted that only 4 of the 30 residents residing at the facility receive PO nutrition. They were identified as Resident #18, #26, #28, and #30. Interviews conducted with these residents on 05/31/22, 06/01/22, and 06/02/22 revealed the following. Interview with Resident #26 on 06/01/22 and 06/02/22 noted resident to state I refuse all meals as the food here is terrible. I drink only the juice for breakfast and eat microwave [NAME] Macaroni & Cheese and Ramen Noodle for all lunch and dinner meals. My mother purchases these foods by the case and delivers them to the facility. I tell the staff that the food here is bad and I don't like it . I wish they would assist me with this issue. The menu is not kid friendly and more variety of foods need to be added to the menu. The menu needs to include more foods like; hot dog, hamburgers, breakfast breads, and kid foods. Review of clinical record of Resident #26 noted the current MDS BIMS score of 15. Observation of resident meals for the breakfast meal on 05/31/22, 06/01/22, 06/02/22 and 06/03/22 noted the resident refused the meal and only drank the juice. Continued observation of the lunch meals for the same dates noted the resident to refuse the meal and request microwave [NAME] Macaroni & Cheese. Interview with Resident #30 on 05/31/22, 06/01/22, and 06/02/22 noted she does not like the facility food due to poor taste, quality, and poor variety. The desserts are poor and I hate the canned fruit daily. The facility need to change the menu to include: pizza, burgers, hot dogs, fresh fruit, and Mexican and Chinese foods. I often order out for my meals and have them delivered. Observation of breakfast and lunch meals on 05/31/22, 06/01/22, 06/02/22 noted the resident to refuse the meals. The resident was noted to requested [NAME] macaroni & Cheese for the lunch meals . Review of clinical record of Resident #30 noted current MDS BIMS score of 15. Interview conducted with Resident #28 on 06/02/22 and 06/03/22 noted the resident stated he does not eat the food here. I only eat the fried eggs and toast for the breakfast meals. The food has been lousy for years with poor appearance and taste. I am not served foods that I like and they always send me foods that I don't like. The resident further stated he orders take out foods from local restaurants at least 4 to 5 times per week. Review of clinical record of R #28 noted current MDS BIMS score of 15. Interview with Resident #18 on 05/31/22 and 06/01/22 noted he stated he does not eat the breakfast meals. Further stated he does not like the lunch and dinner meals. The resident stated the menu has no variety and would like to see the menu changed to include more foods for younger people. Would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 20 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0804 Level of Harm - Minimal harm or potential for actual harm like to see more pizza, burgers, appetizers, Mexican, Chinese, Italian. He stated the food here is for old people. The resident further stated he orders out foods for deliver almost every day from local restaurants, and will save left overs for the next day. Review of clinical record of Resident #18 noted current MDS BIMS score of 15. Residents Affected - Few Observations of breakfast and lunch meals conducted in the Main Kitchen on 05/31/22, 06/01/22, 06/02/22, 06/03/22 noted that menu foods are not prepared due to foods not being purchased (See F 803) and no substitutions for menu items that are not available (See F 803). Interview with the facility cook (Staff A) during the meal observations noted that she has not received any food preparation training and does not follow menu recipes. A review of the the facility standardized recipe book noted that there was no standardized recipes for menu foods that included; Kidney Bean Salad, Turkey Pasta Salad, Beef Lasagna, BBQ Chicken, Chicken with Gravy, Baked Pork Chop, Beef Pasta Casserole, and Chicken Quesadilla, and various vegetable and starch menu food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 21 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, it was determined that the facility failed to prepare food in a required form (MM5 - Moist & Minced - Level 5 ) for 2 of 2 sampled residents (Residents #26 and #30). Residents Affected - Few The findings included: 1) During the observation of the breakfast meal on 05/31/22 at 7:30 AM, it was noted that tray label on the food tray of Resident's #26 and #30 documented to serve a MM5 diet (Minced & Moist - Level 5. Interview with the cook (Staff A) at the time of the observation revealed that she was unaware of foods included or not included on the diet and further stated she was not trained on the preparation and serving of the diet. Staff A stated that she has been employed as a cook for over 6 months. Also stated that there was no posted documentation in the kitchen to follow the diet. It was noted that facility standardized recipes did not include documentation of preparation of MM5 diet. 2) Observation of the breakfast and lunch meals of 05/31/22 and 06/01/22 noted the following foods were served to Resident's #26 and #30: Breakfast: (05/31/22) Fried Eggs (2) Lunch (05/31/22): Three Bean Salad Whole Chicken Nuggets (cut into large pieces 1/2 inch) Whole French Fries * Photographic Evidence Obtained. Breakfast (06/01/22): Whole Sausage Patties Fried Eggs (2) Lunch (06/01/22) Whole Grain Turkey Pasta Salad (cut into large pieces 1/2 inch) Breakfast (06/02/22) Chicken & Gravy (large pieces of chicken -1/4 inch diameter Pureed Corn (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 22 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 Pureed Bread Level of Harm - Minimal harm or potential for actual harm * Photographic Evidence Obtained. Residents Affected - Few 3) Because the facility failed to have specific documentation of specific individual directions to follow a MM5, the diet was reviewed on the Internet. The Internet findings for the MM5 diet noted that only foods 4 mm wide X 8 mm long. The 4 mm is approximately the space between the prongs of a fork . Foods that do not fit between the prongs are not in compliance with the IDDSI - MM5 diet requirements. All foods, should not be sticky, soft and moist throughout, require minimum chewing, and mashed with small amount of pressure from a fork. 4) On 06/01/22 the surveyor contacted the facility Speech Language Pathologist (SLP) to review that the facility staff are not trained to follow the MM5 diet for Resident's #26 and #30. The SLP stated the she would immediately provide training and documentation to kitchen staff concerning the MM5 diet. On 06/02/22 the surveyor met with the facility's newly hired Consultant Dietitian to also review that the facility staff has not been properly trained to follow the MM5 diet for Residents #26 and #30. The Dietitian stated that proper training would be provided to kitchen staff on 06/03/22. 5) Review of the clinical records of Resident #26 on 06/01/22 noted diagnoses of Dyspahgia, Trach Status, Gastronomy Status, and GERD with Esophagitis. Further review noted a physician's order dated 06/28/21 for MM5-minced moist foods for Dyspahgia. 6) Review of the clinical record of Resident #30 on 06/01/22 noted diagnoses of Diabetes, GERD, Pneumonia, Gastgrostomy Status, and Muscular Dystrophy. Further review noted a physician's order dated 8/02/21 for MM5-Minced and Moist, and Diabetic Diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 23 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to provide food preferences and food alternatives and different choices for 4 (Resident #18, #26, #28, and #30) of 4 sampled residents residing in the facility that eat by mouth. During the observation of the breakfast and lunch meals on 05/31/22, 06/01/22, 06/02/22, and 06/03/22, the following were noted: 1) A review of the approved menu for 05/31/22 through 06/05/22 noted that there was no documentation of any planned alternative food choices to the menu. A Food Substitute was posted in the dining and documented the following are available at all meals: Chicken Breast Chicken Tenders Hamburger Yogurt Stuffed Baked Potato Hot Dog Ham or Turkey Sandwich on Whole grain Bread Interview conducted with the cook (Staff A) on 06/01/22 revealed the following: Chicken Breast - not available, not purchased by facility Chicken Tenders - frozen, not readily available for meals Hamburger - frozen, not readily available for meals Yogurt - available Stuffed Baked Potato - not available, not purchased Hot Dog - not available, not purchased by facility Ham or Turkey Sandwich - the dates of the thawed ham was 04/29/22 and turkey was 04/28/22. The surveyor requested that the outdated spoiled meats be discarded. Further interview with Staff A on 06/01/22 noted that a thorough list of resident preferences have not been obtained for Residents #18, #26, #28, and #30. Staff A also stated that she was aware that the food substitutes were not available and no attempt to purchase the foods was being made. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 24 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2) During individual interviews conducted with Resident's #18, #26, #28, and #30 on 06/01/22 and 06/02/22 noted that there are not food substitute available. The interviews also noted that Resident's #18, 328, and #30 call out for food orders and have their food delivered from local restaurants because there are no menu alternates. 3) During the observation of the lunch meal on 05/31/22 at 12:30 noted that Resident #28 was served Chicken Nuggets and French Fries. A review of the CCCC Oral Diet Resident List dated 08/09/21 documented Resident #30 dislikes Chicken Nuggets and French Fries. The list also documented the resident is lactose intolerant and likes Potatoes and Chicken Breast which are listed on the Food Substitute List but are not available. It was also revealed that the dietary department does not have Lactose free Milk available. 4) During the observation of the lunch meals on 05/31/22, 06/01/22, and 06/02/22 it was noted that that Residents #26 and #30 refused the meal. It was further noted that staff heated up a microwave [NAME] Macaroni & Cheese portion for the meals that was being provided by the family for the these residents. 5) During the observation of the breakfast and lunch meals for 05/31/22, 06/01/22, and 06/02/22, it was noted that facility staff were aware that there are no food substitutes available and that microwave [NAME] Macaroni & Cheese and Ramen Noodles are the only alternatives available for Resident's #26 and #30. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 25 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to store prepare, distribute, and serve food in accordance with professional standards for food service safety. The findings included: 1) During the initial observation tour of the dining room on 05/31/22, the following were noted: (a) The exterior of the garbage container was heavily soiled with large areas of dried food matter. (b) The dining room tables (2) were noted to be soiled and numerous particles of food matter. (c) The exterior of the entry/exit door was noted to be soiled and rust laden. (d) The exterior of the large commercial cooler located with in the room was heavily soiled. * Photographic Evidence Obtained. 2) During the initial tour of the main kitchen on 05/31/22 at 7 AM, the following were noted: (e) Open resident trays from prior evening meal were noted to have open trash and garbage. The trays were noted to be located near the food preparation table. (f) Six soiled cleaning rags were located laying inside of the sink area. (g) The exterior of the tray service door between the kitchen and dining room was heavily soiled and areas of dried food matter. (h) The covers of the overhead light fixtures (4) were heavily soiled and had dead bugs. (i) The food preparation skillets (3) were noted to have particles of dried food and large areas of build-up of carbon. (j) The large green commercial cutting board had areas that appeared to be black mold. (k) The kitchen utility cart was soiled. (l) Three portions of milk located within the walk-in refrigerator was not documented with a date. (m) The door gaskets (3) of the cooks refrigerator were soiled and build-up of dried foods and black mold type matter. (n) The exteriors of the ceiling mounted air-conditioning vents (2) were black mold ladens. (o) The temperature of the reach-in refrigerator was not being maintained the minimum regulatory temperature of 41 degrees F or below. The temperature of the thermometer located within the unit was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 26 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 50 degrees F. Level of Harm - Minimal harm or potential for actual harm * Photographic Evidence Obtained. Residents Affected - Many 3) Holding food temperatures were not being kept at the regulatory temperature of 41 degrees or below, and 135 degrees F or above, as evidenced by the following: (p) Three Bean Salad = 63 degrees F (lunch meal of 05/31/22 at 12:30 PM) (q) Turkey Pasta Salad = 84 F degrees F. (Lunch meal of 06/01/22 at 12:30 PM). * Photographic Evidence Obtained. 4) During the observation of the Nourishment Room on 06/03/22 at 11 AM, the following were noted: (r) Five 13 ounce containers of Similac Neosource were located on the shelves. Further investigation noted that all five containers were opened and failed to be documented with an opening date. It was also noted that the measuring scoop was left inside each container and was in contact with the container powder contents. (s) One -13 ounce container of Neocate Infant DHA/[NAME] were located on the shelves. Further investigation noted that the container were opened and failed to be documented with an opening date. It was also noted that the measuring scoop was left inside the container and was in contact with the container powdered contents. (t) Observation of the reach-in refrigerator noted a container of Pedialyte (1 quart liquid) . Further observation noted that the Pedialyte was not labeled with an opening date. (u) The temperature of the thermometer located in the reach-in refrigerator was 50 degrees F. Review of log noted no documentation for 06/03/22. (v) Findings discussed with Medication LPN (Staff B), stated all must be dated and temp of fridge was supposed to be taken by the 06/02/22 night shift. * Photographic Evidence Obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 27 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation it was determined that the facility failed to dispose of garbage and refuse properly. The findings included: Residents Affected - Some During the initial kitchen/food service observation tour conducted on 05/31/22 at 7:15 AM, the following were noted: 1) One of the two dumpster covers was broken and was left in the wide open position exposing the interior of the of the dumpster unit. Observation of the unit noted numerous broken bags of garbage/trash resulting in exposed garbage/trash. It was noted that there were numerous flying insects inside and offensive odor coming from the unit. 2) The ground area around the base of the dumpster was noted to be littered with trash/garbage and disposed nursing care supplies. * Photographic Evidence Obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 28 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interviews and record review, the facility failed to ensure that the individual responsible for the facility's Infection Prevention and Control Program (IPCP) had completed specialized training in infection prevention and control. The findings included: On 05/31/22 at 9:05 AM, an interview was conducted with the facility's Administrator and he stated the Quality Assurance (QA) Staff was the Infection Preventionist. On 05/31/22, an interview was conducted with the QA staff and she stated Infection Control was been done together with the Acting Director for Nursing (A-DON) and the Nurse Manager. On 05/31/22 at 9:40 AM, during an interview, the facility's Nurse Manager stated she was doing Infection Control together with the QA staff. On 05/31/22 at 9:45 AM, during a joint interview with the administrator, the Nurse Manager and the QA staff, they were asked to submit a copy of the Infection Preventionist certificate for the completed specialized training . On 06/02/22 at 1:22 PM, during the review of the Infection Control task conducted with the QA staff and the Nurse Manager, they were asked again to submit a copy of the Infection Preventionist certificate. They both stated they did not have it. The QA staff stated she believed the A-DON did not have it neither. On 06/03/22 at 10:28 AM, a joint interview was conducted with the facility's A-DON, QA staff and the Nurse Manager. They all stated the former DON was the only one who was Infection Preventionist certified. They all stated they did not have the Infection Control training certificate. They were apprised that one has to have the certificate as per regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 29 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed: 1-to screen surveyors for COVID-19 prior to residents contact. Residents Affected - Some 2- to provide documentation of staff COVID-19 screening prior to residents contact 3-to provide documentation of COVID-19 testing results of each staff test for the month of May 2022. 4-to provide documentation of COVID-19 testing results of each staff test for the facility last COVID-19 outbreak in January 2022 and 5- to Conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests. The findings included: Review of the facility's policy provided titled COVID-19 (Florida) Guidance and Initiatives revised on 03/17/22 documented .facilities will make every effort to minimize exposures to SARS-COVID-19 .will make every effort to follow the federal guidelines .will perform active health screening and surveillance on staff .through strict monitoring of any of the following: signs and symptoms consistent with COVID-19 .active health screening will be performed upon reporting to duty at the beginning of their shift .an employee screening tool (paper or electronic) will be used for data collection .actively take the temperature of the employees and document the results .facility shall comply with state and federal directives concerning staff and residents testing .routine testing of unvaccinated staff is based on the extent of the virus in the community .when a new case of COVID-19 among residents or staff is identified, facilities will immediately begin outbreak testing in accordance with CDC guidelines . Review of the Centers for Medicare and Medicaid Services (CMS) memo QSO-20-38-NH Revised on 03/10/2022 documented .the facility must document testing results in a secure manner consistent with requirements specified in 483.80(h)(3) .Conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests .for each instance of testing: Document that testing was completed and the results of each staff test . 1). On 05/31/22 at 6:56 AM, three surveyor entered the facility through the main door opened by Staff C, Therapist. Staff C did not direct the surveyors to do any type of COVID-19 screening and did not check the surveyors temperature. Staff C was asked who was in charge and stated she will find out. Staff C returned and stated that the staff did not know who was in charge. Staff C was told that surveyors needed to get in the facility and stated it was okay for us to go in. Staff C opened the double doors connecting to the residents room hallway. The surveyors walked through the residents north hallway without been screened for COVID-19. On 05/31/22 at 7:45 AM, an interview was conducted with Staff K, RN. Staff K was stated she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 30 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0886 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some supposed to do the surveyors COVID-19 testing before entering the facility. She was asked why she did not do it and replied she was with a residents. She stated she was supposed to send someone to do the test or to have someone to take care of the residents that was going out to an appointment. On 05/31/22 at 08:20 AM, during an interview, the Administrator was informed that we (the Surveyors) were not screened for COVID-19. On 05/31/122 at 9:07 AM, surveyor was COVID-19 rapid test by the Quality Assurance (QA) staff. She directed the surveyor to go back to the lunch room located by the residents area and wait for results. On 05/31/22 at 9:19 AM, an interview was conducted with QA staff. She stated that they did COVID-19 testing to all visitors, anyone that will be making contact with the residents. She added that she was doing COVID-19 testing twice a week for staff, not sure what was the frequency today. 2). On 05/31/22 at 7:06 AM, observation revealed Staff Q, a Certified Nursing Assistant (CNA) came through the facility's south entrance. Consequently, an interview was conducted with Staff Q and she stated she comes through the south door every time she comes to work. Observation revealed Staff Q continue to walk towards the residents area without checking her temperature and completing a COVID-19 screening. On 05/31/22 at 7:07 AM, an interview was conducted with Staff I, a Registered Nurse (RN). She stated she worked from 7:00 PM to 7:30 AM since 03/2022. Staff I stated she did not COVID-19 screening and added that she only checked her temperature at the temperature scanner. She stated Staff K, RN was in charge. On 05/31/22 at 7:12 AM an interview was conducted with Staff J, a Respiratory Therapist (RT). She stated she worked 7:00 PM to 7:30 AM. She stated Staff K was in charge. Staff J was asked regarding COVID-19 screening and stated she had not seen or done the screening form and did check her temperature on the little thing referring to the temperature scanner. On 05/31/22 at 7:45 AM, an interview was conducted with Staff K, RN and she stated she was in charge for the night shift. She stated the facility protocol when an employee comes in to the facility, the employee sign in- electronically. She added that they used to do COVID-19 test, but not anymore. She stated that she did not monitor staff COVID-19 screening. She added that the administration may had a way to check the screening record. Staff K stated she expected the staff to check their own temperature and answer the questions asked in the screening form and that she did not oversee the process. Staff K was asked to submit her COVID-19 screening for 05/30/22 and stated she did not do it because she was running late and rushing in the residents area to get report. Staff K stated she was not up-to-date with the COVID-19 vaccines. She stated the COVID-19 screening is to be done every day regardless of vaccination status. Staff K stated COVID-19 testing was done once a week for vaccinated staff and twice a week for unvaccinated. She stated she had a COVID-19 test done two weeks ago. Staff K was asked regarding prior week testing and stated the facility did not have testing supplies and did not have it done last week. Staff K stated every time someone/visitor came in the facility, they had to be COVID-19 tested. On 05/31/22 at 8:20 AM, an interview was conducted with the Administrator and she stated that they use the honesty system in that everyone is held accountable to report their own health status upon coming, or before coming to the facility. The administrator was asked to submit a copy of the staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 31 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0886 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some COVID-19 screening completed by the Rapid Screener. She stated the employees screened themselves before coming in to work. She added that 99.9 percent of the employees are vaccinated. The administrator admitted that the electronic COVID screener/scanner had not been functioning well. She stated that she contacted the Software Engineer for the electronic screener/scanner and was told that she needed to upgrade the software of the Rapid Screener machine. The Administrator stated she will get it done by 6/2/2022. The administrator was asked to submit a copy of the staff COVID-19 screening completed by the Rapid Screener and she was not able to produce a copy. On 06/01/22 at 12:01 PM, an interview was conducted with Resident #18's Private Duty Nurse. He stated he checked his temperature at the facility's front temperature scanner. He stated the scanner did not ask for COVID-19 screening questions. He added that he had not been completing a COVID-19 screening questions for a while because he was told that CDC (Center for Disease Control) guidelines changed. He added that today he noticed that they put the paper questionnaire binder back (he pointed to a binder on top of the nurses station). He stated that no one told him to do the screening, but he did it. He stated he was up-to date with COVID-19 vaccination. On 06/02/22 at 1:10 PM, attempted to review the facility's COVID-19 screening and testing policy. Wrong facility policy provided. On 06/03/22 at 12:48 PM, a joint interview with the Nurse Manager and the QA staff was conducted. The Nurse Manager stated that once they put up the electronic Rapid Screener the temperature scanner kiosk, they stopped doing the paper form for COVID-19 screening questionnaire. The QA staff stated that previous administrator and the DON told them that the screener would collect all the information and was saving the data. The QA staff added that the current administrator logged on and was not able to get the data. On 06/03/22 at 1:06 PM, during an interview the A-DON stated she believed the Rapid Screener was installed around February 2022. 3). On 06/03/22 at 11:22 AM, a joint review with QA staff, the facility's Nurse Manager and the Acting Director of Nursing (A-DON) was conducted. During the review, the A-DON stated the following 5 sampled not-up-to-date staff worked as follow: 1-Staff G, RN worked on 05/03/22, 04, 11, 14, 15, 18, 23, 25 and 29. 2-Staff I, RN; worked on 05/02/22, 04, 11, 16, 18, 19, 25 and 30. 3-Staff K, RN; worked on 05/01/22, 02, 03, 05, 08, 09, 10, 12, 15, 16, 17, 19, 22, 23, 24, 26 and 31. 4-Staff J, RT; worked on 05/01/22; 05/02, 03, 04, 08, 09, 11, 15, 16, 18, 23, 25, 29 and 30. 5-Staff R, RT worked on 05/02/22; 05/03, 04, 10, 11, 13, 14, 16, 17, 18, 20, 23, 24, 27, 28, 30 and 31. During the review, QA staff, the facility's Nurse Manager and the A-DON were asked to submit the above mentioned sampled staff COVID-19 testing documentation. The QA staff stated she did not see a test result log for the sampled staff for the month of May (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 32 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0886 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2022. The QA staff, the facility's Nurse Manager and the A-DON were not able to submit evidence of the sampled staff and their COVID-19 testing as per CDC guidelines. 4). On 06/03/22 at 11:10 AM, a side by side review of the facility last COVID-19 outbreak education, testing and screening was conducted with the QA staff and the Nurse Manager. They both stated 4 (four) employee tested positive for COVID-19 on 01/07/22 and 01/08/22. The were asked to submit the facility-wide COVID-19 staff testing log during the outbreak. They stated they did not have it. The QA staff and the Nurse Manager stated they could not find the January 2022 staff testing log. On 06/03/22 at 11:45 AM, during an interview, the A-DON stated that the facility policy was that for unvaccinated (not-up-to-date) staff are to be COVID-19 tested twice a week She added those that are vaccinated (up-to-date) were to go up to the kiosk (temperature scanner) to check their temperature and screening. She did not recall when they started to apply the policy. The QA staff stated it was about February 2022. The QA staff stated all staff were required to do the COVID-19 screening and temperature check prior to the shift. On 06/03/22 at 12:25 PM, during an interview, the Nurse Manager stated the facility's Staff vaccinated percentage was 79%. 5). Review of the BinaxNow COVID-19 Ag procedure card provided by the QA staff documented .open the card prior to use and lay it flat .patient sample requires 6 drops of extraction reagent .slowly add 6 drops to the top hole .do not touch the card with the dropper tip while dispensing .insert sample or control swab .rotate swab shaft 3 times clockwise . On 06/01/22 at 6:45 AM, surveyor entered the facility through the south entrance. Staff L, a Licensed Practical Nurse (LPN) stated he needed to do the surveyor COVID-19 test. Staff L provided a COVID-19 Screening questionnaire form and pulled a COVID-19 Ag card (rapid test card). Observation revealed Staff L placed three drops of the test reagent solution into the card. During an interview, Staff L was asked how many reagent drops he was supposed to apply to the card and replied two. On 06/01/22 at 6:50 AM, an interview was conducted with Staff M, a Respiratory Therapist (RT). She stated that each staff were to do their own COVID-19 testing. Observation revealed Staff M placed 3 drops of the test reagent in the top hole and two in the bottom hole. Further observation revealed Staff M did not fill out a COVID-19 screening questionnaire. On 06/01/22 at 7:09 AM, observation revealed Staff G, RN performed her self-COVID-19 testing. During an interview, Staff G stated she worked in a Per-diem basis and worked on 05/31/22. She stated she did not do the self-COVID-19 testing because there was not test available and did not ask anybody for test supplies. On 06/02/22 at 7:13 AM, observation revealed Staff D, RN holding the COVID-19 Ag card on her hand, swabbed her nostrils, placed the swab into the card hole, then placed the reagent drops. On 06/01/22 at 7:19 AM, observation revealed Staff A, [NAME] pulled a COVID-19 AG card and with no gloves, swabbed her nostrils, placed more than 6 reagents drops into the hole, placed the swab into the card hole, and without performing hand sanitation, Staff A left the room, entered the kitchen, pulled a cell phone from her blouse pocket, and entered some keys on her phone. Staff A was asked when was she going to perform hand washing, and she stated now at the kitchen sink. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 33 of 34 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0886 Level of Harm - Minimal harm or potential for actual harm On 06/01/22 at 7:25 AM, a joint interview was conducted with the QA staff and the administrator. The QA staff stated that when the staff came in, they are supposed to test themselves. She added non vaccinated (not-up-to-date) staff were to be tested twice a week. The QA staff stated that the charge nurse oversees the night shift staff testing. She added she believed the charge nurse oversees day shift staff but was not 100% sure. Residents Affected - Some The QA staff was apprised there was not a nurse overseeing staff performing COVID-19 self-testing. She was informed that the Staff was either placing more or less amount of the test reagent to the COVID-19 Ag card. The staff was not following the procedure instructions, there was not a log for the staff to sign in and there was not an instructions card in the room. She was informed that staff was not completing the COVID-19 screening questionnaire during the COVID-19 self-testing. The QA staff stated the staff was supposed to complete the questionnaire, but they sometimes were using the Rapid scanner. She was apprised that the electronic scanner was not working properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 34 of 34