Signature Healthcare Of Palm Beach

F-F690).

b) Failure to ensure timely and appropriate respiratory care for Residents #78, #51, #31, and #82. (Refer to

F-F695).

c) Failure to ensure palatable and hot food as voiced by Residents #82, #89, #93, and #77. (Refer to

F-F770 for details). An order dated 06/25/24 documented the use of an antifungal and steroid cream to the sacrum.

Review of the latest skin evaluation completed on 06/27/24 documented a rash to the sacrum with orders in place. This assessment lacked any redness to the perineal area.

Review of the current care plans initiated on 04/30/23 confirmed the bowel and bladder incontinence and the resident's need for total assistance with incontinence care.

During an interview on 06/24/24 at 2:50 PM, the son of Resident #66 volunteered, Mom gets lots of UTIs here. She did not get them at home.

An observation of incontinence care for Resident #66 was made on 06/27/24 at 11:24 AM with Staff T, Certified Nursing Assistant (CNA). Upon removal of the resident's adult brief and during personal care to the resident's front side, the skin was noted to be red, and the resident was grimacing as if uncomfortable. The CNA did not notice the resident's grimacing. The CNA provided appropriate care to the resident's front area, then assisted the resident to her side. Staff T then cleaned the resident's back side by wiping from the buttock toward the front with each cleansing swipe and rinse. Resident #66 continued to grimace. When asked by the surveyor if that hurt, the resident stated, Yes, that hurts. The CNA acknowledged and provided care more gently. A diffuse red rash was noted on the resident's upper buttock and lower back.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 During an interview after the provision of care, when asked the appropriate direction for cleansing of the resident during incontinence care, Staff T stated, Front to back. When asked why she cleaned the back side Level of Harm - Minimal harm or of Resident #66 from back to front, the CNA responded, I did? and had no further reasoning. potential for actual harm

During an interview with the Second Floor Unit Manager on 06/27/24 in the afternoon, she was unaware of Residents Affected - Few the resident's redness and grimacing observed during the incontinence care earlier that day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25404 potential for actual harm Based on policy review, record review, observation, and interview, the facility failed to ensure oxygen care Residents Affected - Few and services for 4 of 5 sampled residents (Residents #78, #51, #31, and #82).

The findings included:

Review of the policy Nursing - Oxygen Administration effective 04/01/22 documented, General Guidelines: . 5. All disposable equipment labeled with the resident's name, the date it was opened or provided, and should be changed a minimum of every 7 days.

1) Review of the record revealed Resident #78 was admitted to the facility on [DATE REDACTED] and moved to his current room on 05/14/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented the resident was on continuous oxygen. This MDS documented the resident was totally dependent upon staff for all activities of daily living (ADLs) and had functional limitation in range of motion to all extremities.

During an observation on 06/24/24 at 11:14 AM, Resident #78 was lying in bed with the oxygen concentrator running at 3 liters per minute. The concentrator was visibly dirty with black debris, tan colored splattering of what looked like tube feeding formula, and faded white streaks. The filter on the back of the oxygen concentrator was gray to white in color, appeared dusty instead of clean and black or dark. The nasal cannula was noted just under the resident's right eye.

During a supplemental observation on 06/26/24 at 9:13 AM, the oxygen equipment remained in the same condition.

During an interview on 06/28/24 at 9:58 AM, the Maintenance Director stated his department was not responsible for the oxygen concentrators or oxygen filters.

During an interview on 06/28/24 at 10:11 AM, the Housekeeping Manager stated the housekeepers were responsible for cleaning the resident equipment in the rooms, such as oxygen concentrators, but was unsure who was responsible for the oxygen filters.

During the environmental tour on 06/28/24 at 10:45 AM with managerial staff, the Administrator stated that

the maintenance department was responsible for changing the oxygen filters.

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2) Record review revealed Resident #51 was admitted to the facility on [DATE REDACTED] with diagnoses that included cancer of the larynx. Review of the admission Minimum Data Set (MDS), assessment reference date 05/25/24, recorded a brief interview for mental status (BIMS) score of 15, which indicated Resident #51 was cognitively intact. This MDS recorded no mood or behavior concern. Review of physician order, dated 05/20/24, documented Ambu bag at bedside. (Ambu bag is a device known as a bag valve mask, which is used to provide respiratory support to patients).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0695 On 06/26/24 at 3:23 PM, Resident #51 was noted with tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea from outside the neck). An interview was held with Level of Harm - Minimal harm or Resident #51, and the resident was asked about the ambu bag which was supposed to be at bedside. The potential for actual harm resident signaled I don't know.

Residents Affected - Few With his permission, the surveyor looked for the Ambu bag in the drawers and closet. It was not there. At approximately 3:28 PM, the surveyor called the Director of Nursing (DON) to the room and inquired about the Ambu bag which was supposed to be at bedside, per the physician order. The DON searched for the ambu bag in the same locations that the surveyor had searched, and she was not able to find the ambu bag, either. Subsequently, the DON asked Staff C, the North and South Unit Manager, for the ambu bag. Staff C left and went to the other side of the unit and obtained a bag with trach care items, including an ambu bag. When asked where these items were found, Staff C said she kept them in the trach room.

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3) Resident # 31 was admitted to the facility on [DATE REDACTED] with the diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Chronic Respiratory Failure with Hypoxia (Low Oxygen Tissue Level), Shortness of Breath (SOB) when lying flat.

Record review of Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident # 31 scored 14 under Section C of the Brief Interview for Mental Status (BIMS) indicating good cognitive function.

Review of Physician Order written on 06/03/24 and activated on 06/09/24 showed to Change nebulizer tubing/mouthpiece every Sunday during night shift. Another order for oxygen equipment showed to change tubing every Sunday night, and to provide oxygen inhalation (via nasal cannula at 3 Liters per minute {@3 L}.

Review of Care Plan showed this resident has altered respiratory status/difficulty breathing related to Chronic Obstructive Pulmonary Disease (COPD), emphysema, chronic respiratory failure, Shortness of Breath (SOB) when lying flat. The goal of this care plan is for staff to make sure resident have minimal risk of complications related to Shortness of Breath (SOB) though the review date. The interventions include monitoring for the effectiveness and side effects of oxygen therapy with changing and dating nebulizer mask and tubing as ordered, monitoring for signs and symptoms (s/sx ) of respiratory distress, and reporting to Medical Doctor (MD) PRN (pro re nata or as needed) these respiratory distress signs and symptoms.

During observation and interview on 06/24/24 at 10:33 AM, this resident was observed with oxygen tubing and nasal cannula wrapped around the left wrist. Resident # 31 stated, I am uncomfortable. The humidifying solution canister and the oxygen tubing had a written date of 06/09.

During observation and interview on 06/25/24 at 10 :20 AM, Resident #31 was sitting on his bed with nasal cannula and tubing wrapped around his left wrist. He stated, I can control when to put them inside my nose.

He added the insides of his nose were getting dried. Upon closer observation, the oxygen level was between 3 and 4 Liters per minute and the humidifier was on. The green top of humidifying canister had the date of 06/09 written in black ink.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0695 In another observation on 06/25/2024 at 11:00 AM, Staff M saw the resident without nasal cannula on both nares indicating he was not receiving the oxygen therapy, This Staff did not say anything to the resident or Level of Harm - Minimal harm or inform a Nurse that this resident was not receiving oxygen therapy. She left the room without a word. potential for actual harm

During observation on 06/26/2024 at 12:55 PM, this resident's oxygen canister (humidifier) and tubing still Residents Affected - Few have the same date of 06/09. Resident made a productive cough, and his nasal cannulas and tubing were wrapped around wrist. Suddenly Staff L, a RN, came in (she did not knock on the door). She looked at the resident but did not say anything to him (or reminded resident to put the nasal cannula back on the nares).

She went in and then out. This Surveyor waited to make sure she had informed a Nurse regarding this resident not wearing nasal cannula on both nares. After 5 minutes, no Staff came back inside the room.

During observation and interview on 06/26/24 2:18 PM with Staff L, an RN, when asked if she had noticed resident was not receiving oxygen therapy because the nasal cannula and tubing were wrapped on his left arm, she stated she just made a quick glance if resident was eating lunch. She stated she did not check anything else. After this conversation, this Staff did not go back to the resident's room to check the oxygen therapy but continued sitting at the front desk.

Review of progress notes dated on 06/27/2024 at 00:15 revealed Resident # 31 was restless in bed and had

a chief complaint of Shortness of breath presenting an O2 sat (oxygen saturation {the amount of hemoglobin bound to oxygen in your blood}) of 93% (Normal oxygen saturation is 95 % to 100%) on room air. He called 911 and was re- hospitalized .

4) Resident #82 was admitted on [DATE REDACTED] with the diagnoses of Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), and Chronic Respiratory Failure with Hypoxia and Heart Failure. He was hospitalized on [DATE REDACTED] with a complaint of Left Flank Pain and a diagnosis of Major Sepsis. He was readmitted to the facility on [DATE REDACTED] with the diagnoses of Sepsis unspecified Organism, non -ST Elevation Myocardial Infarction, Acute Posthemorrhagic Anemia, Acute Respiratory Failure with Hypoxia.

The resident's quarterly Minimum Data Set (MDS) performed on 06/05/2024 revealed a score of 15 on Brief

Interview for Mental Status (BIMS) located on Section C indicating good cognitive function. Section O assessment on 06/13/2024 revealed Continuous Oxygen therapy.

Further review of plan showed to monitor oxygen saturation and respiratory status, to use oxygen pro re nata (prn or as needed) to maintain oxygen saturation greater than 92 percent (O2 sat >92%), to continue Nebulized treatment, to continue medications, and to get out of bed (OOB) with assistance.

The following orders activated on 05/10/24 included to change oxygen tubing and humidifier every Sunday night shift.; to provide oxygen at 3 Liters per Nasal Cannula (L per NC) every shift; to change Nebulizer Tubing and Mask every Sunday during night shift and to date, initial, and place in dated bag; to encourage

this resident to use Incentive Spirometry for 3 sets of 10 breathes for 15 minutes; to record volume with best effort and good technique two times a day related to chronic obstructive pulmonary disease, unspecified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0695 Record review of Care Plans based on the diagnoses of COPD, Chronic Respiratory Failure with Hypoxia, Shortness of Breath (SOB) when lying flat and the resident's oxygen usage, this resident will display optimal Level of Harm - Minimal harm or breathing patterns daily through review date. The facility Staff must do the following: Change oxygen tubing potential for actual harm and humidifier as ordered and PRN (pro re nata or as needed); Give aerosol or bronchodilators as ordered.

The Staff must also monitor/document any side effects and effectiveness of treatment, ensure the head of Residents Affected - Few bed is elevated or resident is out of bed upright in a chair during episodes of difficulty breathing, monitor for difficulty breathing (Dyspnea) on exertion, remind resident not to push beyond endurance, monitor for signs and symptoms ( s/sx) of acute respiratory insufficiency such as Anxiety, Confusion, Restlessness, Shortness of Breath (SOB) at rest, Cyanosis, Somnolence.

During initial observation and interview on 06/24/24 11:22 AM, this Resident's oxygen tubing had a paper tag dated 6/12/24. In an interview, resident said Staff did not change his Oxygen tubing yesterday since he requires longer tubing to go to the bathroom. The Staff said the facility did not have a longer oxygen tubing for him.

During observation and interview on 06/24/2024 at 1:22 PM, this resident said he is always on 3 Liters of oxygen per minute. This surveyor observed the oxygen humidifying canister (humidifier is usually a container of a distilled water given concurrently with oxygen therapy to provide moisture to the inhaled air thus preventing nasal mucosa dryness) dated 06/16/2024. The long oxygen clear tubing was dated 06/12/24 (tag wrapped around the tubing).

During observation on 06/25/24 at 12:30 PM, Resident # 82 was sitting in bed with the same clear oxygen tubing (dated 06/12/24). He added that Staff did not change his oxygen tubing. It was supposed to be changed last Sunday (06/23/2024). The same canister (humidifier) was dated 06/16/2024.

On 06/27/24 at 12:27 PM, during observation this Surveyor noticed the oxygen tubing is connected directly to

the oxygen concentrator (the canister of humidifier was missing; observed during the first days of survey), delivering 3 Liters per minute (L/min). There was a new green colored tubing connected to a clear nasal cannula tubing with tape tag dated 06/23/24. Resident # 82 stated they just changed the tubing but did not provide a new humidifier (green top plastic cannister was gone). (The order states to change humidifier every Sunday night).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25404

Residents Affected - Some Based on observations, interviews, and staffing calculations, the facility failed to ensure sufficient staffing as evidenced by identified care issues during this survey, voiced concerns from Residents #73, #31, #74, #63, #45, #221, and #104, documented low-weekend staffing, and concerns voiced in Resident Council.

The findings included:

1) During this recertification survey, the following issues, potentially related to the lack of staff, were identified and noted:

a) Failure to ensure timely and proper incontinence care for Residents #47 and #66, failed to ensure shower and shampooing hair for Resident #74, and failed to ensure nail care for Resident #8. (Refer to

F-F804).

d) On 06/24/24 at 11:57 AM it was noted the Second Floor Unit Manager was working as the direct care nurse for the 2N unit. When asked why she was working the floor as a direct care nurse, the Unit Manager stated, We had a call out. You know it happens.

e) Upon arrival to the 2N unit on 06/27/24 at 9:33 AM, the staffing was posted on the white board and documented Staff U, Licensed Practical Nurse (LPN) was the assigned direct care nurse. Upon arrival to the 2N medication cart, the First Floor Unit Manager was at the cart, appeared rushed preparing medications for

the residents, with the Second Floor Unit Manager at her side. When asked about the lack of the assigned direct care LPN, the Second Floor Unit Manager stated they had a call-off a little earlier.

2) During this recertificaiton survey, the following voiced concerns related to staffing were noted:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0725 a) During an interview on 06/25/24 at 11:32 AM, when asked if staff were responsive to his needs, Resident #73 stated, The evening and night CNAs (Certified Nursing Assistants) don't respond. They are sleeping. Level of Harm - Minimal harm or Resident #73 stated his call light is on the floor more often than within his reach, even though he asks them potential for actual harm to tie it onto his bed rail. The resident explained he often has to yell out for help or get his roommate to push

the call light. The resident stated he was so aggravated at times he, Feels like throwing things (to get Residents Affected - Some attention, but he doesn't). When asked why he usually calls for help, the resident stated it was to get changed (referring to incontinent care). Resident #73 stated the average wait time for care on the evening and night shift is an hour, and if it's close to shift change it is a longer wait. When asked how the staff respond, the resident stated staff come in and turn the call light off at times, but most of the time they don't even show up. The resident voiced the staffing was worse on the weekends. When asked if he had voiced his concerns to anyone, Resident #73 stated he spoke with management a while ago. Review of the record revealed the resident's Brief Interview for Mental Status (BIMS) score was 13, on a scale of 0 to 15, indicating the resident was cognitively intact.

b) During an interview on 06/24/24 at 10:33 AM, Resident #31 stated he often has to wait an hour for staff to assist him with repositioning. The resident's BIMS score was 14, indicating he was cognitively intact.

c) During an interview on 06/25/24 at 11:43 AM, Resident #74 stated he has been left in his chair for up to five hours because there is not enough staff. The resident also stated sometimes incontinent care is provided at 1 PM, and then he is not provided incontinent care again until 9 PM. Resident #74 stated there is not enough staff to help reposition him either. Resident #74 had a BIMS score of 13, indicating he is cognitively intact.

d) During an interview on 06/24/24 at 1:05 PM, Resident #63 stated his only complaint is that the 11 PM to 7 AM staff are not attentive. The resident stated he has to yell and scream, they just won't come, and he feels

the staff are sleeping at night. When asked what assistance he required during the night, Resident #63 explained that he has a sacral pressure ulcer and although he can't lie on his sides for a long period of time,

he would like to get off of his back at times. He further stated if staff do put him on his side, they won't come back to put him back on his back when he calls. Resident #63 had a BIMS score of 15, indicating he was cognitively intact.

e) During an interview on 06/24/24 at 10:58 AM, Resident #45 stated when she does number 2 (defecate) in

the morning, sometimes she doesn't get changed until the afternoon. Resident #45 was admitted to the facility on [DATE REDACTED] and stated that had happened three times. The resident voiced there's not enough staff. Although the resident's BIMS score was an 08, indicating she had some cognitive issues, she was able to be interviewed.

f) During an interview on 06/24/24 at 11:30 AM, Resident #221 stated, I don't think there is enough staff.

During the night I have to wait a long time to get someone to answer my call for help. Sometimes they don't come. Resident #221 was a new admission, was alert and oriented, and able to be interviewed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0725 g) During an interview on 06/24/24 at 10:46 AM, Resident #104 voiced concern about a lack of staff. The resident explained she has waited two hours for staff to answer her call light and change her (provide Level of Harm - Minimal harm or incontinence care). Resident #104 had a BIMS score of 14, indicating she was cognitively intact. During this potential for actual harm interview, her roommate stated the night CNAs do not answer the call light timely. The roommate stated they were short staffed on Saturday 06/22/24, and Resident #104 had to wait two hours for incontinence care. Residents Affected - Some 3) Review of the staffing calculations for the second quarter of 2024 (starting on 03/31/24) to present, revealed the facility consistently utilized 10 CNAs over a 24-hour period on the weekends, with only 9 CNAs noted on Saturday 05/18/24. The number of CNAs during the week for this same time frame was 11 to 13 CNAs in a 24-hour period.

During an interview on 06/28/24 at 4:31 PM, when asked if they had enough staff, the Staffing Coordinator stated they are pretty well staffed except for Sundays. When asked about the weekends in general, the Staffing Coordinator agreed they should staff the same on the weekends as they do during the week. When told their staffing numbers are consistently lower on the weekends, the Staffing Coordinator agreed.

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4) On 06/27/24 at 3:00 PM, a special Resident Council meeting was held to discuss concerns voiced by many of the residents during the initial interview process. The following 4 residents in attendance for this meeting were all alert and oriented and regularly attended the monthly resident council meetings:

Resident #88, who has a BIMS (Brief Interview of Mental Status) of 13 out of 15 (cognitively intact);

Resident #84, who has a BIMS of 14 out of 15;

Resident #14; who has a BIMS of 15 out of 15; and

Resident #15, who has a BIMS of 13 out of 15.

Resident #54, who has a BIMS of 15 and had never attended a Resident Council meeting before, attended for approximately 5 minutes in the beginning.

Each of these 5 residents confirmed that staff response to call lights is very bad at night and on weekends.

Resident #15 stated, Staff will come in and tell you they are coming back, but they never do.

Residents #88, #84, #54, and #14 all stated that during the nights and on weekends, it often takes a couple hours to get help, and sometimes staff will never come at all.

The 4 regular Resident Council attendees confirmed that incontinent care is not done in a timely manner, especially at night.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0725 Resident #14 stated: I have had to stay in wet briefs all night because I couldn't get staff to answer the call light. I would hear them laughing and talking outside my room, but as soon as I turn on my call light, they all Level of Harm - Minimal harm or seem to disappear. potential for actual harm

These 4 Resident Council Attendees also stated that the food is consistently served cold. They each stated Residents Affected - Some they have complained to the Dietary Department about the food being served cold. Resident #14 stated, Even though there has been a small improvement lately, it hasn't been a consistent improvement. The 4 resident Council attendees ( Residents #88, #84, #15, and #14) confirmed that food trays will often sit in the carts for a long time before staff pass them out to the residents.

Also, each of the Residents Council attendees stated there are many times the food is not served according to the resident's preferences.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 25404 potential for actual harm Based on observation, interview and record review, the medication error rate was 7.69 percent. Two Residents Affected - Few medication errors were identified while observing a total of 27 opportunities, affecting 2 of 6 residents observed (Residents #64, and #57).

The findings included:

1) A medication administration observation for Resident #64 was made on 06/27/24 beginning at 5:33 PM with Staff U, Licensed Practical Nurse (LPN). The LPN poured two Tylenol 325 milligram (mg) tablets into the medication cup followed by one 500 mg Methocarbamol (a muscle relaxant) tablet. The LPN poured a cup of water and locked the medication cart. When asked if that was all that was due at that time, the LPN's response was yes. When asked how many pills the nurse had poured into the medication cup for administration, the LPN stated three.

The LPN provided the three pills to Resident #64 and continued on with her medication pass.

During the reconciliation of medications, the record revealed the current order for the Methocarbamol 500 mg was to give two tablets.

During an interview on 06/27/24 at 6:19 PM, when asked to verify the order for the Methocarbamol administered to Resident #64, Staff U, LPN agreed she should have provided two tablets.

2) A medication administration observation for Resident #57 was made on 06/27/24 at 5:59 PM with Staff U, Licensed Practical Nurse (LPN). The LPN explained the resident had a blood pressure medication due, so

she obtained a blood pressure reading. Upon return to the medication cart, the LPN obtained three medications to include a probiotic, an anti-seizure medication, and Losartan 50 milligrams (the anti-hypertensive/blood pressure medication). When asked if that was all that was due at that time, the LPN's response was yes. When asked how many pills the nurse had poured into the medication cup for administration, the LPN stated three. Staff U administered the three medications to Resident #57.

During the reconciliation of medications, record review revealed the resident was only due to receive the probiotic and anti-seizure medication, and that the Losartan was not due to be administered until 10 PM.

During a side-by-side review of the record and continued interview on 06/27/24 at 6:19 PM, Staff U, LPN confirmed the order documented the Losartan was to be given at 10 AM and 10 PM. The LPN stated the medication came up on the electronic MAR to administer. The LPN could not figure out why.

During an interview on 06/27/24 at 6:35 PM, when explained to the Assistant Director of Nursing (ADON) and upon review of the MAR, she determined the medication had either not been provided that morning, or not been signed off as administered by the First Floor Unit Manager, who had taken the assignment late due to a call off. That failure by the morning nurse caused the Losartan to remain on the electronic MAR to be administered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25404 potential for actual harm Based on record review and interview, the facility failed to ensure laboratory services for 2 of 5 sampled Residents Affected - Few residents as evidenced by the failure to obtain a urine sample from Resident #66 three times as per physician order, and failure to obtain the most recent blood work for Resident #73.

The findings included:

1) Review of the record revealed Resident #66 was admitted to the facility on [DATE REDACTED]. Review of the current Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #66 was cognitively impaired and always incontinent of urine.

Review of the orders, lab results, Treatment Administration Record (TAR), and corresponding progress notes revealed the following:

a) An order dated 12/24/23 documented staff were to obtain urine for a urinalysis. A corresponding nursing progress note dated 12/24/23 at 8:23 PM documented the family reported the resident was complaining of pain when urination. This note further documented upon assessment by the nurse, Resident #66 said it was very painful and with a burning sensation. The record lacked any results of the urinalysis and any further documentation.

b) An order dated 05/26/24 documented staff were to obtain urine for a urinalysis. A corresponding nursing progress note dated 05/27/24 at 11:28 PM documented unable to obtain, incontinent. The record lacked any results or additional information regarding the ordered urinalysis, although the TAR documented a checkmark indicating it was completed.

c) An order dated 06/16/24 documented staff were to obtain urine for a urinalysis. The record lacked any results, the laboratory requisition documented not collected, and the TAR indicated it was completed. The progress notes lacked any further information related to the urinalysis.

During a side-by-side review of the record and interview on 06/27/24 at 10:24 AM, the Assistant Director of Nursing (ADON) explained the process for a urinalysis was after obtaining the order, the request is put directly into the laboratory website and a requisition is printed out and put into their laboratory binder. The ADON stated if staff were unable to collect the urine, they should notify the physician and obtain order to either attempt another collection or do a straight catheterization to obtain the urine. The ADON searched the laboratory website and was unable to locate results for the above three ordered urinalysis. The ADON also was unable to provide any progress notes or reason for the failure to obtain and or follow through with their process.

2) Review of the record revealed Resident #73 was admitted to the facility on [DATE REDACTED]. Review of the record revealed an order dated 03/14/24 to obtain a CMP (comprehensive metabolic panel) and a CBC (complete blood count) on 03/15/24. Review of the corresponding Treatment Administration Record (TAR) documented

the blood work was completed as evidenced by a checkmark. Further review of the record lacked any results or documentation about the ordered laboratory services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0770 During an interview on 06/28/24 at 12:13 PM, the Second Floor Unit Manager was told of the concern and stated she would look into the missing blood work. As of the exit conference on 06/28/24 at 6:45 PM no Level of Harm - Minimal harm or further information had been provided. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50895 potential for actual harm Based on interviews, record reviews, and a review of the grievance logs, the facility failed to ensure that Residents Affected - Few residents were served food at a palatable temperature for 3 of 15 sampled residents with voiced food concerns (Residents #82, #89, and #77), and 4 residents from Resident Council who voiced food concerns also (Residents #88, #84, #14, and #15).

The findings included:

1) During an interview on 06/27/24 at 5:48 PM. Resident #82 was asked how the temperature of his dinner was. The resident responded, It's a little warm today. Sometimes it's cold, not every day. When asked how often the food was cold the resident answered, half and half. Review of the Minimum Data Set assessment dated [DATE REDACTED] showed that Resident #82's Brief Interview for Mental Status (BIMS) score was 15. This indicated that the resident was cognitively intact.

2) An interview with Resident #89 on 06/27/24 at 6:02 PM revealed that when she was asked how the temperature of her dinner was, she responded: Most times it's warm, sometimes it's cold.

3) Review of the grievance log for the past six months revealed resident complaints of cold food on 12/12/23 and 02/07/24 with resolutions to reheat meals in the microwave and to provide a staff in-service to deliver the trays upon arrival to the units. In addition, on 5/21/24, there were 4 Food/customer service grievances filed.

The resolutions all specified In service with staff.

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4) Review of the record revealed Resident #77 was admitted to the facility on [DATE REDACTED]. Review of the current Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating he was cognitively intact.

During an interview on 06/24/24 at 11:39 AM, Resident #77 stated the food was always cold. The resident stated he eats in his room and the cart sits out in the hall.

On 06/26/24 at 12:30 PM, Resident #77 was eating his lunch. When asked if the food was hot, Resident #77 stated, It's warm, shrugged his shoulders, stated he would like it warmer, but was going to eat it.

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5) On 06/27/24 at 3:00 PM, a special Resident Council meeting was held to discuss concerns voiced by many of the residents during the initial interview process. The following 4 residents in attendance for this meeting were all alert and oriented and regularly attended the monthly resident council meetings:

Resident #88, who has a BIMS (Brief Interview of Mental Status) of 13 out of 15 (cognitively intact);

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 Resident #84, who has a BIMS of 14 out of 15;

Level of Harm - Minimal harm or Resident #14; who has a BIMS of 15 out of 15; and potential for actual harm Resident #15, who has a BIMS of 13 out of 15. Residents Affected - Few

These 4 Resident Council Attendees also stated that the food is consistently served cold. They each stated

they have complained to the Dietary Department about the food being served cold. Resident #14 stated, Even though there has been a small improvement lately, it hasn't been a consistent improvement. The 4 resident Council attendees ( Residents #88, #84, #15, and #14) confirmed that food trays will often sit in the carts for a long time before staff pass them out to the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50895

Residents Affected - Few Based on interviews and record reviews the facility failed to provide foods per preferences for 5 of 15 sampled residents with voiced food concerns (Residents #104, #63, #77, #73, and #107).

The findings included:

Review of the policy Dining and Food Preferences, revised 9/2017, documented that food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system. The individual tray assembly ticket will identify all food items appropriate for

the resident/patient based on diet order, allergies & intolerances, and preferences. Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value.

1) In an interview on 06/27/24 at 10:24 AM Resident #104 was asked if she likes the food here. She said she was served foods that she doesn't like, and orange juice every morning that she will never drink because of her diabetes. She added that she could not stand the smell of the eggs. When Resident #104 was asked if

the facility offered other food options she answered: They haven't offered me any. Per resident, I don't eat green beans, snap peas, carrots. A lot of times I get carrots and green beans. This resident's Brief Interview for Mental Status (BIMS) score, per Minimum Data Set (MDS) assessment dated [DATE REDACTED] was 14. This score indicates that this resident was cognitively intact.

2) On 06/26/24 at 1:03 PM, Resident #63 was observed at lunch. His meal ticket listed double potion [sig] Country Fried Steak and double potion [sig] Mashed Potatoes, and double potion [sig] Whole Kernel Corn.

The resident was served a single portion of each. (Photographic Evidence Obtained). Resident #63 did not eat the lunch. He said, I'm not eating this stuff, and he left the dining room. Per the Minimum Data Set assessment dated [DATE REDACTED], this resident's BIMS score equaled 15, which indicated this Resident was cognitively intact. Staff failed to offer the resident another food option. Per resident's care plan, revised 5/15/24, this resident had a potential nutritional problem related to increased needs for nutrition.

3) On 06/27/24 at 11:50 AM there were two dietary aides, and one cook on the tray line plating the lunch meals. The Dietary Manager was present for the entire duration of the tray line and was stationed at the end of the line. He checked all the trays before he placed them on the meal carts (also called trucks) for delivery.

He requested a turkey sandwich for a resident whose meal ticket communicated no lasagna and no egg salad.

4) On 06/28/24 at 4:35 PM an interview with the Dietary Manager revealed that usually two people prepare

the trays after the cook gives them the plate with the entree. Per the Dietary Manager, A third person, either myself or a person who also prepares sandwiches, fruits, or desserts, will help on the line. The third person will also help to bring the food trays on the trucks to the units. When the Dietary Manager was asked about

the process for obtaining food preferences the DM said he receives a communication form from nursing and within the first 24 hours he meets with the resident and he gives them a menu and asks them about their food preferences. He added that he lets them know about the other food options available.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 39167

Level of Harm - Minimal harm or 5) Record review revealed Resident #107 was admitted to the facility on [DATE REDACTED] with diagnoses including: potential for actual harm hypertension, and diabetes. The admission Minimum Data Set (MDS) assessment, reference date 06/03/24, recorded a brief interview for mental status (BIMS) of score 15, indicated Resident #107 was cognitively Residents Affected - Few intact. This MDS recorded no mood or behavior issue. Review of Physician order dated 05/28/24 revealed RESIDENT IS VEGETARIAN, NO MEAT, NO FISH, NO MILK. Review of nutrition assessment completed on 05/29/24 evidenced we are honoring preferences as feasible vegetarian noted. admitted with ccd diet stated being vegetarian. Review of care plan dated 06/12/24 recorded Resident #107 had nutrition problems related to Diabetes, Hyponatremia (low sodium) Hyperlipidemia (high cholesterol), hydronephrosis (excess fluid in kidney), HTN (hypertension) and on a therapeutic diet. Interventions included: Provide and serve diet as ordered.

On 06/27/24 at 12:13 PM, while speaking to Resident #107's roommate, Resident #107 came towards the surveyor and said, Excuse me, can you help me? He stated that his meal ticket specifically states, No meat, and the facility gave him salad with turkey. He expressed being frustrated with the kitchen. He continued to state, Every day the facility gives me the same food, and I am tired of it! Now they gave me a salad with meat on it. It was revealed that Resident #107 was served a chef salad with eggs and turkey on it. The surveyor called Staff A, a CNA who was in the hallway, to assist Resident #107.

At 12:20 PM Staff A returned and informed the surveyor that the resident said he doesn't eat meat, and the facility gave him meat on the salad.

On 06/27/24 at 1:08 PM, the nursing home administrator (NHA) and the food service manager encountered

the surveyor in the hallway, and they revealed they were made aware that the resident had received a chef salad with meat.

25404

6) Review of the record revealed Resident #73 was admitted to the facility on [DATE REDACTED]. Review of the current Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact.

During an interview on 06/25/24 at 11:32 AM, Resident #73 stated he does not get a menu or any of his choices. When asked if he was provided a menu to circle his choice, the resident stated he did not, but the food just arrived. When asked if there was an alternate menu or if he could ask for something different when

the meal arrived, Resident #73 stated, If I ask for something I get the dirty eye. The resident confirmed that meant the staff were not happy when he requested something different.

During an interview on 06/26/24 at 9:21 AM, Resident #73 was told the lunch for that day was hamburger steak with brown gravy and mashed potatoes. The resident stated, I like the hamburger steak, but watch, it will have gravy on it. I don't like gravy, my meal ticket says no gravy, but I'll get the gravy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 On 06/26/24 at 12:30 PM, the lunch tray was provided to Resident #73 and the hamburger steak and mashed potatoes were covered in gravy (Photographic Evidence Obtained). The staff had left the room. Level of Harm - Minimal harm or Resident #73 stated, See . told you, addressing the surveyor. When asked if he wanted a new lunch with no potential for actual harm gravy, the resident stated in frustration, as noted by his tone of voice, No . forget it . I'll just have a ham and cheese sandwich. Residents Affected - Few 7) Review of the record revealed Resident #77 was admitted to the facility on [DATE REDACTED]. Review of the current MDS assessment dated [DATE REDACTED] documented a BIMS score of 13, on a 0 to 15 scale, indicating he was cognitively intact. Further review of this MDS documented the resident was 6 foot 2 inches tall and weighed 191 pounds.

During an interview on 06/24/24 at 11:39 AM, Resident #77 stated he was supposed to get double portions for his meals, and that it rarely happened. When asked how he had maintained his weight, the resident stated he had a stash of honey buns and Vienna sausages that he gets when he goes out on leave. Although Resident #77 received double portions during the survey week, on 06/26/24 at 12:30 PM, the resident confirmed the issue concerning the double portions was an ongoing problem.

Review of the current orders lacked an order for double portions, indicating it was a preference for the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25404 potential for actual harm Based on policy review, record review, observation, and interview, the facility failed to follow Infection control Residents Affected - Few practices during a blood sugar check for 1 of 2 sampled residents observed as evidenced by the failure to properly disinfection the glucometer (machine used to obtain the blood sugar level from a blood sample) (Resident #4), and failed to properly utilize personal protective equipment (PPE) for 1 of 2 sampled residents observed on Enhanced Barrier Precautions (EBP) (Resident #31).

The findings included:

1) The facility's practice was to disinfect the glucometers after each use as per manufacturer's instructions on

the disinfectant wipes. Review of the manufacturer's instructions for the MicroKill Bleach wipes used by the facility, indicated a three minute wet time to kill all organisms, including blood born pathogens.

An observation of a blood sugar check was made for Resident #4 on 06/27/24 at 5:46 PM with Staff U, Licensed Practical Nurse (LPN). The LPN gathered the needed items, including the glucometer. Upon completion of the process, the LPN returned to the medication cart, obtained a wipe from a package of FitRight Wet Wipes, and wiped off the glucometer and placed it back into it's hard plastic case. Review of the instructions and ingredients on the package of FitRight wipes documented the wipes were used for hand hygiene and lacked any type of disinfecting agent.

During an interview on 06/27/24 at 6:19 PM, Staff U verified she used the FitRight Wet Wipes to clean the glucometer. When asked her usual process to disinfect the glucometer, the LPN stated that sometimes she used the FitRight wipes, and at other times she used the MicroKill Bleach wipes, pulling them out of the side of her cart. The LPN then took a MicroKill Bleach wipe, wiped the glucometer, and immediately put it into the plastic container and back into the medication cart. The LPN was unaware of any needed wet time, as per manufacturer's instructions.

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2) Resident # 31 was admitted to the facility in 08/25/2023 with the diagnoses of Prostate Cancer, Unspecified Neuromuscular Dysfunction of the Bladder, Unspecified Urinary Tract Infection, Methicillin Resistant Staphylococcus Aureus (MRSA).

Record review of Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident # 31 scored 14 under Section C of the Brief Interview for Mental Status (BIMS) indicating good cognitive function. Section H showed this resident has an indwelling urinary catheter related to a neurogenic bladder diagnosis. He scored positive for bowel incontinence under the same section. Section M showed Resident # 31 had multiple unhealed pressure injuries prompting pressure ulcer injury care.

Physician orders initiated on 06/03/2024 included an order to maintain Enhanced Barrier Precautions (EBP) related to foley (Brand name for urinary catheter) and wound every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0880 Review of a document titled Policy, Procedures, and Information -Enhanced Barrier Precautions with an effective date of 04/01/2024, showed Procedure #1 b stating a clear signage will be posted on the door or Level of Harm - Minimal harm or wall outside of the resident room indicating the type of precaution, required personal protective equipment potential for actual harm (PPE), and the high-contact resident care activities which require the use of gown and gloves; Procedure #2 b stated an order of Enhanced Barrier Precautions will be obtained for residents with wounds and/or Residents Affected - Few indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy, ventilator, etc.) regardless of Multiple Drug Resistant Organisms (MDRO) colonization status; Procedure# 3 a. stated to make gowns and gloves immediately available outside of the resident's room. An additional note here showed face protection may also be needed if performing activity with risk of splash or spray; Procedure # 4 stated EBP must be employed for residents when performing the following high-contact resident care activities like a. dressing, b. bathing, (letter c is not appropriate for this case), d. providing hygiene e. changing linens f. changing briefs or assisting with toileting, g. device care or use of urinary catheter h. Wound care: any skin opening requiring a dressing; Procedure #6. stated to continue EBP while the qualifying condition or indwelling device is still active or in use.

In an observation on 06/24/24 at 3:04 PM, Resident #31 stated he is itching and very uncomfortable. Staff F,

a CNA came in and asked what the resident needed. After the resident stated what he needed, this staff put gloves on both hands, then left the resident's room with both gloves on at 3:06 PM. This surveyor observed

the Enhanced Barrier Precautions (EBP) signs (one red paper and 2 white papers) posted next to 5 compartment plastic shelf) inside the room. Only one of the 5-compartment plastic shelves contained a pack of yellow gowns, the other 4 compartments were empty.

Staff F, a CNA came back in with gloves still on both hands carrying supplies (linen, towel, skin protectant cream, and lotion all inside a clear plastic bag). She then closed the door behind her and drew the curtain around Resident# 31.

She put on gloves on top of the other pair of gloves. She started touching this resident's clean brief, cabinet drawer, and basin which she half- filled with water. She then assembled all clean linen from the top of the cabinet of drawers to the top of resident's wheelchair. This resident was observed to have urinary catheter tubing connected to a urine bag hanging on the right lower side of the bed. This Staff un-velcroed both sides of this resident's diaper, took resident's pillow under resident's left leg, and put it next to the clean linen on top of a wheelchair. Resident # 31 was wearing yellow socks. This Staff then wiped the resident's frontal perineal area with wipes. She squeezed some liquid soap on top of the wipes, wet the wipes with water from

the yellow basin, and wiped perineal area (front, sides, scrotum, and frontal anal area). She rinsed these areas with water and dried them with a towel. She wiped the catheter tubing from the tip of the penis downward with the same set of gloves. She was not wearing a protective gown. (EBP Policy & Procedure # 1states high-contact resident care activities require the use of gown and gloves; and Procedure # 4 states EBP must be employed for residents when performing the following high-contact resident care activities such as d. providing hygiene, e. changing linen, f. changing briefs or assisting with toileting, and g. device care or use: urinary catheter). She turned the resident left side up, wiped the resident's posterior anal area, and lower back. A plastic patch was observed on this resident's back and this Staff removed it with the same set of gloves. She proceeded and touched the resident's gown to move it higher. Using her left hand, she rinsed

the resident's back while her right hand was supporting resident's left hip (same gloves). She towel- dried the back areas using her right hand.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 105466 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105466 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Beach Nursing Center 4405 Lakewood Road Lake Worth, FL 33461

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 0880 She then went to this Resident's cabinet of drawers and on top searched for the plastic bag for lotion and skin protectant (using the same gloves). She pushed soiled linen and brief from under the resident and put Level of Harm - Minimal harm or the clean linen and brief underneath resident's right side. Using the same gloves she opened the plastic skin potential for actual harm protectant pouch. She proceeded to apply on Resident #3's lower back and posterior anal area the creamy white protectant. She touched and adjusted the catheter tubing with her left hand. Then, she removed both Residents Affected - Few gloves. This Staff pressed the bed control and raised resident's head up. She put on a new set of gloves on both hands. This staff velcroed the resident's brief (left side), touched resident's right leg, and removed the soiled linen located on the right bottom edge of Resident # 31's bed. Using both newly changed gloves, she bundled the dirty linens including the drying towel, and put them in a plastic bag inside the resident's bathroom. Using the same set of gloves, she then put the pillow back on the resident's right leg, then on the left. She then emptied the urine from the catheter bag into a urinal. She was not wearing an EBP gown or face protection. Additional note states that protection may also be needed if performing activity with risk of splash or spray).

At 03:27 PM, this Staff removed both gloves, then washed her hands inside this resident's bathroom sink.

In an interview with Staff M, a CNA, on 06/24/2024 at 1:45 PM, she was asked by this Surveyor about Resident # 31 and EBP. She stated hand washing or hand sanitation must be provided every time she completes perineal care, and after the resident ate a meal. She did not mention putting on a gown as Personal Protective Equipment (PPE) when providing perineal care.

In an interview with Staff L, an RN on 06/26/2024 at 11:00 AM, she stated EBP is a precautionary measure because this resident has urinary catheter and wound. She did not mention putting gown as part of PPE for

this resident. She stressed the importance of hand washing and gloving.

In another interview with Staff D, an LPN, on 06/25/2024 at 10:30 AM, she stated using only gloves as PPE for proving care to this Resident. She did not mention anything about using a gown as PPE.

Review of progress note dated 06/27/2024 at 1:00 AM revealed that Resident # 31 was in bed, and restless while asking to be sent out to the hospital. He was complaining of burning on urination with the indwelling urinary catheter in place. He was sent to the hospital the same day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 105466