Health inspection·December 14, 2023

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 12/12/23 at 12 PM, it was noted that the Chicken Noodle Soup was located on the steam table. Observation of the soup noted that the soup contained only chicken broth and tiny particles of chicken. No noodles were located with the soup. Interview with the Dietary Manager (DM) stated that it is usual serving practice that there is a separate container of pasta and chicken pieces. The pasta and chicken are combined with the chicken broth when a resident orders a serving of Chicken Noodle Soup. The DM stated that the pasta is held separately because if it is put into the soup mixture prior to serving it results in large portions of blown-up pasta pieces. Further observation noted that DM called the main kitchen to have pasta and chicken sent to the satellite kitchen. It was noted that the main kitchen had to prepare the pasta and chicken and it took over 30 - 45 minutes for the pasta and chicken to be sent to the satellite kitchen. The 20 residents seated in the dining room were noted to sit and wait the 30-45 minutes for the soup and were noted to become agitated with the lunch meal service. At 12:45 PM, the pasta and noodles arrived from the main kitchen for the soup service. The surveyor tasted the pasta and noted it to be well undercooked and semi hard. The soup ingredients were combined for each soup portion and served to the residents. The CDM (Certified DM) stated to the surveyor that the serving of the soup for the third-floor residents is the same procedure. On 12/13/23 at 9:00 AM, an interview was conducted with the Main Kitchen Culinary Director (CD) it was stated that the soup ingredients of chicken broth, cooked pasta, and chicken pieces are kept separately because of Kosher request from the residents. The surveyor said to the Culinary Director (CD) that there are no resident requests who reside in the nursing home for Kosher or Kosher style foods. The CD then corrected himself and stated that the Kosher requests are from the Independent Living residents and not the facility residents. The CD further stated that the soup for the facility residents should have been prepared according to the standardized recipe with all ingredients combined during the preparation of the soup. At the request of the surveyor, the CD submitted the standardized recipe for the preparation of the Chicken Noodle Soup. Following the review with the CD, it was noted that the method of preparation and serving of the soup was not followed. A review of the facility's diet census for 12/11/23 noted that the issues could potentially affect 18 out of 19 residents on the 3rd floor, certified section who may make a request for Chicken Noodle soup during meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105489 If continuation sheet Page 2 of 6 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 105489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court Skilled Care Center - Edgewater 23305 Blue Water Circle Boca Raton, FL 33433 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, record review and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety potentially for 18 out of 19 residents residing on the 3rd floor, certified section. The findings included: Review of the facility's Culinary Services Manual - Policies and Procedures: Cleaning and Sanitation Issued: 11/13, Revised: 11/13, documented, in part, the following: Procedure: (b) The Culinary and Nutrition Services management team is responsible for developing written daily cleaning schedules. (c) The manager initiates the cleaning schedule and supervises employee comp, to the schedule. (d) All cleaning tasks will be checked nightly to ensure the meet ACTS standards. (f) Heavy duty monthly and semi-annual cleaning projects must also be scheduled and documented by the management staff. During the kitchen observation tour conducted on 12/11/23, it was noted that Cleaning and Sanitation Policies and Procedures were not followed as evidenced by the following: 1. During the initial kitchen / food service observation tour conducted on the main kitchen accompanied with the Culinary Director (CD) and Certified Dietary Manager (CDM) on 12/11/23 at 8:50 AM, the following was noted: (a) Walk-in Freezer #1 was noted to have food that was not properly dated and covered. Further observation noted that a 5-gallon container of ice cream was not covered and the contents of the container were open to air; 1 case of cookie dough contents was open to the air; and 1 case of croissants was open to the air. The CD stated that the products were not properly covered, and would discard all 3 food products. (b) Walk-in Freezer #1 was noted to have large areas of frozen water like droplets on the refrigeration unit and the ceiling area. The surveyor discussed with the CD that the freezer unit is not operating properly and requested the unit be evaluated. (c) Walk-in Freezer #2 was noted to have unlabeled and non-dated foods that were exposed to the air resulting in freezer burn. Further observation noted 3, third sized steam table pans of cooked / leftover meats, that were not labeled with a preparation date and were freezer burned. The CD stated that the frozen meats were not properly dated and covered. The CD further stated that the food products would be discarded. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105489 If continuation sheet Page 3 of 6 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 105489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court Skilled Care Center - Edgewater 23305 Blue Water Circle Boca Raton, FL 33433 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 (d) Walk-in Refrigerator #1 was noted to have a green/black mold type substance growing around the entire unit and ceiling area. It was also noted that the tubing exterior leading to the unit was full of condensation and dripping down onto a case of fresh eggs. The surveyor discussed with the CD that there was the potential for food contamination and food borne illness. It was requested by the surveyor that all foods located beneath the refrigeration unit be moved and a refrigeration specialist be contacted to evaluate the unit. (e) Walk-in Refrigerator #1 was noted to have 2 small steam table pans that contained a mixture of Herbs (1) and a mixture of parsley spices. Further observation noted that the foods were labeled with dates that documented the expiration. The Herb mixture was dated with a facility expiration date of 12/07/23 and the Parsley mixture was dated with a facility expiration date of 12/10/23. The CD stated to the surveyor that the foods were expired and should have been discarded by the expiration date. (f) Walk-in Refrigerator #2 was noted to have a large pan of [NAME] Slaw with a labeled expiration date of 12/10/23. The CM stated to the surveyor that the coleslaw should have been discarded by the expiration date of 12/10/23. (g) The exterior of the commercial VCM mixer/blender was noted to have large areas of dried food matter and areas of rust. The CD stated to the surveyor that the unit was not being properly cleaned and maintained. (h) Ceiling light fixture located directly above the main cooking line were noted to be not properly maintained. Specifically, 2 light fixture covers were cracked / broken. It was discussed with the CD that there was the potential for small plastic pieces of the cracked / broken fixtures to fall into food resulting in food contamination. (i) Two of two bench mounted tilt kettles were noted to have approximately 2 inches of stagnant fluid inside of each unit. The surveyor discussed with the CD that the 2 units must be dry of fluid after each cleaning to ensure food contamination does not occur. (j) The internal cavity of the commercial convection oven was noted to be heavily soiled and had a thick layer of build-up carbon. The CD stated that the unit was not properly cleaned on a regular basis. (k) The commercial grill was noted to have a thick black layer of matter on the entire bottom of the unit and on the surrounding gas fixtures. The surveyor discussed with the CD that the unit was not being properly cleaned and maintained on a regular basis. It was also discussed that the unit could potentially cause food borne illness and food contamination. (l) The exteriors of the fire extinguisher units (2) were noted to be heavily soiled and had a thick coating of black mold type matter. It was also noted the units were located on the main cooking line and were a potential source of foodborne illness and food contamination. The CD stated to the surveyor that dietary staff do not clean the units and that the maintenance department had not maintained and cleaned the units on a regular basis. (m) The exterior of the commercial floor mixture located in the cold food preparation area was noted to have large areas of dried food matter and areas of rust that were located directly above the mixing bowl. The surveyor discussed with the CD that the dried food matter and rust fall into foods (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105489 If continuation sheet Page 4 of 6 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 105489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court Skilled Care Center - Edgewater 23305 Blue Water Circle Boca Raton, FL 33433 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 being mixed each time the unit is utilized resulting in potential food borne illness and food contamination, the surveyor requested that the unit not be utilized until proper cleaning and sanitizing. (n) The exterior of the commercial bench mounted mixture located in the cold food preparation area was noted to have large areas of dried food matter and areas of rust that were located directly above the mixing bowl. The surveyor discussed with the CD that the dried food matter and rust fall into foods being mixed each time the unit is utilized resulting in potential food borne illness and food contamination, the surveyor requested that the unit not be utilized until proper cleaning and sanitizing. (o) Observation of the dish machine room area noted that the exterior of the dish machine was covered in numerous dried food particles. The surveyor discussed with the CD that the interior and exterior of the dish machine require proper cleaning and sanitizing after each use. (p) Observation of the dish machine room area noted that the resident silverware was not being washed / sanitized and held in a sanitary manner. Specifically, noted that a large container of resident silverware was being stored with the eating portion in an upright position after washing and sanitizing. The surveyor discussed with the CD that the resident silverware requires a separate wash / sanitizing with the silver eating portion on a downward position to ensure that staff handle the silverware in a sanitary manner prior to resident use. (q) Observation of the dish machine room noted that the ceiling mounted light cover and ceiling tiles (2) surrounding the light were broken and had large areas of peeling paint. Further observation noted that the light fixture and tiles surrounding the light were located directly above the 3-compartment sink. The surveyor discussed with the CD that small pieces of the plastic light cover and peeling paint were dropping directly into the 3-compartment sinks. The surveyor requested that the 3-compartment sinks not be utilized until the issues were corrected. (r) Observation of the dish machine room noted clean dish and food preparation equipment were being stored on soiled and paint peeling shelving. Specifically, 12 storage shelves were noted to have a large area of dried food matter and peeling paint. The surveyor requested of the CD to clean or purchase new shelving. (s) Observation of the dish machine room noted the walls surrounding the dish machine and 3-compartment sink were heavily soiled and had a build-up of black mold type matter. The surveyor requested of the CD to clean and sanitize the area walls immediately. Photographic Evidence Obtained for 1. (a) through (s). 2. During the observation of the lunch meal on 12/11/23 at 12:15 PM, food temperatures were taken by the facility's Consultant Registered Dietitian (CRD) with the use of the facility's calibrated thermometer in the satellite kitchen. The temperature testing noted that cold foods were not being held with the regulatory temperature of 41 degrees F (Fahrenheit) or below. The temperatures were recorded as follows: Chicken Caesar Salad (8 individual portions) = 46 degrees F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105489 If continuation sheet Page 5 of 6 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 105489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court Skilled Care Center - Edgewater 23305 Blue Water Circle Boca Raton, FL 33433 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 Sliced Turkey Sandwich ( 9 individual portions) = 46 degrees F. Level of Harm - Minimal harm or potential for actual harm 3) During the observation of the breakfast meal conducted on 12/12/23 at 7:30 AM in the Third Floor Satellite Kitchen, accompanied with the facility's Consultant Registered Dietitian, the following were noted: Residents Affected - Many (a) The wall area located above the wall-mounted storage cabinets were heavily soiled and dust laden. (b) The wall area located above the commercial microwave oven was noted to covered in a black oil type matter and was leaking down onto the oven. (c) The floor area and base board located under the steam table and serving counter was noted to be soiled, stained, and numerous areas of dried food matter. Photographic Evidence Obtained for 3. (a), (b), (c). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105489 If continuation sheet Page 6 of 6