Health inspection·August 11, 2022

F 0584 room [ROOM NUMBER] - Room floor was heavily soiled and numerous areas of black stains. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER] - Room floor was heavily soiled and numerous areas of black stains, broken drawers in room dresser, and room chair exterior was heavily worn. Residents Affected - Some room [ROOM NUMBER] - Room floor was heavily soiled and numerous areas of black stains. room [ROOM NUMBER] - Room floor was heavily soiled and numerous areas of black stains. room [ROOM NUMBER] - Room floor was heavily soiled and numerous areas of black stains. room [ROOM NUMBER] - Bathroom entry door in disrepair and in need of re-painting, and room floor was heavily soiled and numerous black stain areas. Medication Storage Room - repairs to room walls had not been completed (3 weeks) and no hand soap in sink dispenser. 4) Galilee (200 Unit) : Soiled Utility Room - Observation of the Specimen Refrigerator noted that there was a urine sample that was not properly labeled and documented. It was also noted that the resident was discharged from the facility 20 days ago. Electrical Room - Observation noted that the entry door was unlocked and was a potential for residents to enter the room unattended. The Manager stated that the room is to be locked at all times. Hydration Cart - The exterior of the cart was soiled, cracked, and rust laden. room [ROOM NUMBER] - Room floor was noted to be heavily soiled and numerous areas of black stains. room [ROOM NUMBER] - The room base boards and room walls were noted to have numerous areas of peeling paint, large hole in bathroom wall, and the exteriors of room and bathroom entry doors were in disrepair was areas of sharp edges. room [ROOM NUMBER] - Over-bed table exterior was soiled, room window shade was nonoperational, and dresser drawers were broken and would not close. Following the tour the findings were again confirmed with the Director of Operation. Further interview with the Director noted that a Maintenance/Housekeeping Log is located at each of the 2 nurses station. Facility staff are to report issues on the log for the issues to be addressed by the facility's maintenance and housekeeping departments, however following the tour the director stated that staff are not properly documenting specific maintenance and housekeeping issues. 5) During a tour of laundry room on 08/11/22 at 12:00 PM with Director of Operations and Director of Housekeeping, the Director of Housekeeping stated that nursing staff bring bagged dirty laundry to the soiled utility room, then laundry staff bring soiled laundry to the laundry room. Laundry is open from 6:30 AM to 5:30 AM. One of 2 washing machines is not working for about a week, 1 of 3 dryers is not working for about a month. Dryers had loose lint in the lint traps. There was debris and rotten wood behind the washing machines. There was a rusty vent in the washing machine room. The floor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105685 If continuation sheet Page 2 of 13 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 105685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menorah House 9945 Central Park Blvd N Boca Raton, FL 33428 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 in the clean laundry room was dirty with debris along baseboards and in corners. Level of Harm - Minimal harm or potential for actual harm During a tour of the central supply room on 08/11/22 at 12:20 PM with the Director of Operations and the Central Supply Clerk, there were several boxes stacked on bare wooden pallets and bare wooden platforms. The floor was dirty with debris. Residents Affected - Some Photographic evidence obtained. During an interview conducted on 08/11/22 at 12:35 PM with the Director of Operations he stated he will get working on correcting these issues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105685 If continuation sheet Page 3 of 13 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 105685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menorah House 9945 Central Park Blvd N Boca Raton, FL 33428 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to follow physician orders for daily wound care and failed to provide wound care with appropriate technique for 1 of 1 resident (Resident #85). Residents Affected - Few The findings included: Review of the facility policy titled Wound Care with a revision date of October 2010, included in the steps in the procedure is wash and dry your hands thoroughly, use a no-touch technique, wear exam gloves for holding gauze. Record review for Resident #85 revealed the resident was admitted on [DATE]. His Diagnoses included Acute Kidney Failure, Pressure Ulcer of Sacral Region, Pressure Ulcer of Right Heel, Type 2 Diabetes Mellitus, Absence of Left Leg Below Knee, Colostomy. The minimum data set (MDS) dated [DATE] revealed in Section C a brief interview for minimum status (BIMS) score of 15 which indicates intact cognitive response. Section G revealed bed mobility, transfer, toilet use all have self-performance of extensive assistance with support of one-person physical assist. Physician Order for Resident #85 dated 07/07/22 to cleanse sacral wound with Dakin's 0.25% solution, apply Collagen powder and pack with Dakin's 0.25% moisten gauzes and cover with dry dressing daily and as needed, every day shift for Sacral stage IV pressure injury. Record review for Resident #85 revealed the resident did not receive wound care on 07/18/22, 07/28/22, 07/29/22, and 08/02/22. Care plan for Resident #85 dated 6/28/22 with a focus on resident has pressure ulcers to: Sacrum stage IV and Right heel stage III and remains at high risk for further skin breakdown related to: mobility impairment, Diabetes, Renal Failure. Goal included Current skin condition will not show sign and symptoms of deterioration by the next review date. Current wound will show evidence of improvement by decreasing in size by next review date. Interventions included Ask resident to express pain or/and observe for nonverbal pain signs during treatment. Assess wound weekly to include size, tissue type, drainage, and document accordingly. On 08/10/22 at 8:30 AM an observation was conducted of wound care for Resident # 85 with Staff L, LPN. He began pulling supplies out of the treatment cart without washing his hands or using alcohol-based hand sanitizer and not wearing gloves. He then ripped open approximately 8 gauze packets and pulled the gauze out of their package with his unwashed/non-sanitized gloveless hands. This gauze was wet with the Dakin's solution and was intended to be used to clean and pack the resident's wound. When asked about what technique he was using for the wound care, he stated clean. Surveyor informed him that he did not wash/sanitize hands first, was not wearing gloves and touching the gauze with his bare hands. He then threw away the gauze, washed and gloved his hands and proceeded to gather supplies. Staff L LPN then performed the dressing change as ordered and washing his hands between glove changes. Also noted the LPN was perspiring excessively and drops of sweat were dripping into the treatment cart that was open. During an interview conducted on 08/08/22 at 10:35 AM with Resident # 85 he stated his sacral wound is a stage 4 and there is an order for the wound care to be done daily, the problem is that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105685 If continuation sheet Page 4 of 13 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 105685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menorah House 9945 Central Park Blvd N Boca Raton, FL 33428 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 wound care is not done daily. He just wants to have his wound heal so he can go back home. Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 08/10/22 at 1:55 PM with Staff L, LPN, he stated he has been a nurse since 2011 and has been with the facility since May 2022. He stated he works Monday to Friday every week doing wound care and on average he has 13 residents that receive wound care. When asked about the wound care he performed earlier in the day for Resident #85 he stated he should not have touched the gauze with his bare hands, and he should have washed his hands and put on gloves before gathering his supplies and He acknowledged that he has an issue with perspiration that can come in contact with wound care supplies. When asked about the daily sacral wound care not being performed for 4 days, he replied, I don't know, I was out 1 day. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105685 If continuation sheet Page 5 of 13 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 105685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menorah House 9945 Central Park Blvd N Boca Raton, FL 33428 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3). On 08/08/22 at 12:23 PM, initial tour to the facility's Masada's unit revealed Resident #77 in her room. An interview was conducted with Resident #77 and she stated she had a wound vac and was getting therapy. An observation revealed a bottle of Multivitamins on top of the resident's table in plain view and two bottles of undated normal saline solution half empty on top of the night stand next to her bed (Photographic evidence taken). During the interview, the resident stated that her friend brought in the Multivitamins bottle. An inquiry was made regarding the normal saline bottles on top of her night stand and the resident stated that the normal saline bottles were left in her room by the nurse who changed her wound vac dressing. The resident stated that the wound vac dressing was changed on Mondays, Wednesday and Friday's. On 08/09/22 at 10:07 AM, a second observation revealed Resident #77 in her room sitting up in a wheelchair. Further observation revealed the Multivitamins bottle continues to be on top of the resident's table and the two normal saline bottles continues to be on top of the resident's night stand. On 08/09/22 at 1:04 PM, a third observation revealed Resident #77 in her room. Further observation revealed the Multivitamins bottle continues to be on top of the resident's table and the two normal saline bottles continues to be on top of the resident's night stand. On 08/09/22 at 1:05 PM, an interview was conducted with Staff N, a Certified Nursing Assistant (CNA) and was asked if she noticed that Resident #77 had a medication bottle on top of her table. Staff N stated she did not notice that the resident had a bottle of medication on her table. On 08/09/22 at 1:09 PM, an interview was conducted with Staff M, CNA. Staff M was asked if she noticed that Resident #77 had a bottle of Multivitamins on top of her table. Staff M stated she did not know the resident had a bottle of Vitamins on her table. Staff M stated if she see it, she will let the nurse know. Staff M confirmed that Resident #77 had a bottle of a medication on her table. Staff M was apprised that the bottle of vitamins had been on her table since Monday. On 08/09/22 at 1:32 PM, an interview was conducted with Staff H, a Registered Nurse (RN) and stated that she administered Resident #77 morning medications and did not see a bottle of Multivitamins on her table. Staff H stated the resident was not supposed to have medications in her room. Staff H stated she removed the bottle from the residents room today after Staff N, CNA told her. Staff H was apprised that Resident #77 bottle of Multivitamins was on top of her table since the survey started on 08/08/22. On 08/09/22 at 1:43 PM, an interview was conducted with the Unit Manager and stated the residents are not supposed to have medications in their room. The Unit Manager added that the resident would be assessed if they want to self-administer any medication. The Unit Manager stated that did not have any resident doing self-administration of medications at the time of the survey. Review of Resident #77 clinical record documented an admission to the facility on [DATE]. The resident diagnoses included Hypertension, Atrial Fibrillation, Deep Incisional Surgical Site and Muscle Weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105685 If continuation sheet Page 6 of 13 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 105685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menorah House 9945 Central Park Blvd N Boca Raton, FL 33428 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #77 Minimum Data Set (MDS) 5 days assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 of 15 indicating that the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance with her Activities of Daily Living (ADL's) and supervision with eating. Review of Residents #77's care plans lack evidence of a care plan created related to self-administration of medications. Further review revealed lack of evidence of an assessment completion related to self-administration of medications. Review of Resident #77's Medication Administration Record (MAR) for August 2022 documented that the resident was receiving Multivitamin with Minerals tablets daily since 05/26/22. 4). On 08/09/22 at 10:16 AM, an interview was conducted with Resident #98 and she stated that she was stressed out because of being in the facility. The resident added that she might be getting something (medication) to help her relax. The resident was moving her hands from side to side and looking from side to side, appeared to be anxious. Observation revealed a bottle of lubricant eye drops on top of the resident's night stand and a bottle of Vitamin D-3 gummies on top of a dresser in front of her and her roommate's bed. During an interview, Resident #98 stated that she put the lubricant eye drops, one on each eye, twice or once a day for itching eyes and that she was taking the Vitamin D-3 gummies every day. On 08/09/22 at 10:30 AM, observation revealed Staff E, LPN in front of Resident #98's room with the medication cart. An interview was conducted with Staff E, LPN and was informed of Resident #98 feeling stressed with an anxious appearance. Staff E stated she was ready to administer the resident's medications. Staff E added the resident was getting something to relax her. On 08/09/22 at 1:48 PM, an interview was conducted with Staff E, LPN. Staff E stated she did not know Resident #98 had medications at the bedside. Consequently, a side by side review of the resident bedside was conducted with Staff E. Staff E stated she administered eyes lubricant to the resident in the morning and did not notice the bottle of lubricant eye drops on top of her night stand. Staff E stated the resident was not supposed to have medications in the room. On 08/09/22 at 2:01 PM, during an interview with the Unit Manager, it was pointed out, the location of Resident #98's bottle of Vitamin D-3 gummies. The Unit Manager was apprised that the resident also had a bottle of lubricant eye drops on top of her night stand. The Unit Manager stated the resident had not been assessed to do self-administration of medications, therefore she should not have any medications in her room. Review of Resident #98's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident diagnoses included Cognitive Communication Deficit, Anxiety Disorder, and Dementia. Review of Resident #98's MDS quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 6 of 15 indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed limited assistance with her ADL's and supervision with eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105685 If continuation sheet Page 7 of 13 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 105685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menorah House 9945 Central Park Blvd N Boca Raton, FL 33428 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #98's care plans lack evidence of a care plan created related to self-administration of medications. Further review revealed lack of evidence of an assessment completion related to self-administration of medications. Review of Resident #98's Medication Administration Record (MAR) for August 2022 documented that the resident was receiving Systane Ultra (a lubricant eye drops) solution one drop in both eyes twice a day for Dry Eye Syndrome since 03/08/22. Based on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to 1) ensure that it secured over-the-counter (OTC) medications for 3 of 4 residents (Residents #253, #77, and #98). The findings included: 1) Review of facility policy and procedure on 08/09/22 at 3:15 PM for Medication Storage provided by the Director of Nursing (DON) revised date 05/05/22 indicated Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes and needles 3. General Storage Procedures: .3.2 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is not accessible by residents and visitors 13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. 13.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room . 2) During an observational room tour on 08/08/22 at 10:39 AM, Resident #253's room was observed with a used container of ultra-strength OTC Muscle Rub with an expiration date 05/2024, located near the resident's bed, on top of his air conditioner's rim; it was unlocked, unsecured, visible and easily accessible to other residents, employees and visitors. Resident #253 was originally admitted to the facility on [DATE] with diagnoses which included Joint Replacement surgery of the right shoulder, Bipolar Disorder, Polyneuropathy, Primary Osteoarthritis of right ankle and foot, Hypertension, and Gastroesophageal Reflux Disease (GERD). He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). Photographic evidence was obtained of the tube of OTC Muscle Rub. During an interview conducted on 08/09/22 at 2:16 PM with Staff J, a Licensed Practical Nurse (LPN) and with Staff K, an (LPN)/Unit Manager (LPN/UM), for the Galilee Unit, they both indicated this resident does not self-administer any of his own medications and neither was he assessed to be able to do so. Side-by-side record review was conducted with Staff K, neither Resident #253's hard copy chart nor his computerized Point-Click-Care (PCC) medical record indicated that the resident had any self-assessment completed in order for him to be able to administer his own medications. There was no order on the Resident #253's Medication Administration Record (MAR) for this OTC medication to be administered to this resident. On 08/09/22 at 2:42 PM the Director of Nursing (DON) further acknowledged and recognized that the OTC Muscle Rub medication should not have been left at the resident's bedside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105685 If continuation sheet Page 8 of 13 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 105685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menorah House 9945 Central Park Blvd N Boca Raton, FL 33428 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, it was determined that the facility failed to ensure that physician ordered No Concentrated sweet Diets and No Concentrated Sweet/No Added Salt diets were followed for 36 residents that included Resident #6 and Resident #64. The findings included: During the review of the approved menu for the lunch meal of 8/10/22 , it was noted that the No Concentrated Sweets Diet (NCS) and No Concentrated Sweets/No Added Salt (NCS/NAS) were to be served a #8 scoop (4 ounces) of Fruit Mix Packed in Juice. During the observation of the lunch meal in the main kitchen on 8/10/22 at 12 PM it was noted that a fruit mix was being served to NCS and NCS/NAS diets, however the surveyor requested to see the #10 cans of fruit utilized for NCS and NCA/NAS diets. The surveyor review the #10 can ingredients and it was noted that the label indicated that the fruit had been packed in Light Syrup . Following the review the surveyor informed the Food Service Director the fruit mix being utilized was incorrect for the NCS and NCS/NAS diets. The surveyor review the approved lunch menu and reviewed that the diet indicated fruit that was packed in juice. Following the observation and review, the surveyor requested a 8/10/22 diet census to indicated how many residents had physician orders for a NCS or NCS/NAS diet. The finding of the review indicated that there were 8 residents (including Resident #64) with current physician diet order of No Concentrated sweets and 29 residents (including Resident #6) with current physician order of No Concentrated Sweets/No Added Salt diet . Further investigation noted all 36 residents including Residents 6 and #64 had a current diagnoses of Diabetes Mellitus. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105685 If continuation sheet Page 9 of 13 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 105685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menorah House 9945 Central Park Blvd N Boca Raton, FL 33428 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. Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, that included ensure the dish machine and 3-compartment sink maintain required levels of sanitizing chemical as per regulation, proper food holding temperatures as per regulation, maintenance of food refrigeration units, and maintenance of air-conditioning ventilation system. The findings included: 1) During the initial kitchen/food service observation tour conducted on 8/8/22 at 9 AM and accompanied with the Food Service Director (FSD), the following were noted: (a) Upon entering the kitchen, it was noted that the breakfast meal was being served from the Dairy Kitchen (Kosher Kitchen). Observations noted that there were 4 ceiling air-condition vents (3 located above the tray line and 1 located in the 3-compartment sink area) the were soiled and had a heavy build-up of condensation which were steadily dripping. It was noted that the contaminated condensation was dripping down onto prepared foods located in the steam table, food preparation surfaces, food preparation equipment, clean dishware, and staff working in the areas. It was discussed with the FSD that the contaminated dripping condensation could potentially result in food borne illness and food contamination. The surveyor informed the FSD that the Dairy Kitchen should be shut down and not reopened until the air-conditioning ventilation issues was assessed and repaired. (b) Observation of the Meat Kitchen which was to be utilized for the lunch meal on 8/8/22 was observed and it was also noted that the 4 air-conditioning vents (3 vents over the tray line and 1 over the 3-compartment sink area) was also full of contaminated condensation and were continuously dripping. The surveyor requested the Director of Maintenance to view the issues and confirmed the surveyor's findings. The Maintenance Director was informed by the surveyor that the issue must be repaired prior to the lunch meal due to threat of food borne illness and food contamination. The director informed the surveyor that a air-conditioning vendor would be contacted for immediate service to assess and repair the ventilation system. (c) Observation of the dish machine room noted that the area was thick with steam from the machine. It was noted that the exhaust system located over the machine was pulling the steam out of the room. Observation of the ceiling air-conditioning vent located over the middle of the room was black mold laden and full of condensation that was steadily dripping down onto clean dishes being stored with the room. The surveyor informed the FSD that the dishes were being contaminated and could not be used until they were re-washed. During the observation it was noted that staff were washing dishes and silverware to be used for the breakfast and lunch meal. At the surveyor's request the low-temperature dish-machine was tested to ensure that the chemical sanitizing agent was present in the final rinse. Following 4 tests conducted with chemical strips provided by the facility it was determined that the dish-machine was not sanitizing dishware and silverware according to chlorine regulations. The surveyor informed the FSD that the machine could not be utilized for washing until the issues was resolved. The surveyor also informed the FSD that dishes and silverware washed on 8/8/22 could not be utilized for resident use on 8/8/22. The FSD informed the surveyor the chemical company servicing the dish-machine would be called for immediate servicing. It was also noted during the observation that there was no documentation of a log that the dish-machine was tested for sanitizing chemical levels for all meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105685 If continuation sheet Page 10 of 13 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 105685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menorah House 9945 Central Park Blvd N Boca Raton, FL 33428 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) Observation of walk-in refrigerator #1 noted that the temperature was recorded internally at 50 degrees F. The surveyor informed the FSD that the minimum required temperature of 41 degrees F or below must be maintained as per regulation requirement. The surveyor informed the FSD that the unit should not be utilized until the temperature issue was resolved. During the observation of walk-in refrigerator #1 it was also noted that the floor area was heavily stained and soiled, and that all the interior walls had large areas of peeling paint and pitting. (e) During the observation of walk-in refrigerator #2 it was noted that the interior floor was heavily soiled and the interior room walls had areas of peeling paint and heavy pitting. (f) Observation of the commercial ice machine noted that the interior walls (3) had a build-up of yellow matter which could be a potential hazardous mold. The surveyor requested that ice not be used from the machine and that the ice should be emptied and properly cleaned and sanitized prior to use. (g) Observation of the dry/canned storage room noted that the entire floor was heavily soiled and stained. (h) During the testing of the cleaning cloth buckets it was noted that 2 of the 4 buckets did not contain the required chemical sanitizing agent level as per regulation. (i) During the observation of the breakfast tray line in the Dairy Kitchen on 8/8/22 at 9 AM, the temperatures of the hot and cold foods were taken utilizing the facility calibrated bayonet thermometer. The temperature testing revealed that hot foods were not being maintained at the regulatory temperature of 135 degrees F and cold foods were not being held at the regulatory temperature of 41 degrees F or below. The temperatures were noted as follows; Milk (35 -8 ounce cartons = 60 degrees F Honey Thick Juice (20 portions) = 55 degrees F Cottage Cheese Portions = 46 degrees F Boiled Eggs (30 individual) = 48 degrees F 2) During the observation of the lunch meal being prepared in the meat kitchen located within the main kitchen on 8/8/22 at 11:30 AM, the following were noted: (a) Clean silverware was not being handled in a sanitary manner, specifically the clean silverware was located in a open dish rack and Staff B was handling each piece of silverware by the eating section with their bare hands prior to bagging. The surveyor informed the FSD that Staff B was contaminating the silverware and to cease immediately and re-wash all silverware. It was noted 15 minutes latter that Staff B was wiping each piece of silverware with a soiled rag prior to bagging. Once again, the surveyor informed the FSD that the silverware was contaminated and required re-washing and sanitizing. (b) Observation noted that a 5 pound package of commercial wrapped sliced ham was being thawed in a container of room temperature water. The surveyor informed the FSD that this thawing method is not allowed per regulation and that the ham could only be thawed in running cold water. The surveyor requested that the FSD discard the package of sliced ham. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105685 If continuation sheet Page 11 of 13 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 105685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menorah House 9945 Central Park Blvd N Boca Raton, FL 33428 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many (c) During the lunch observation it was noted that staff A was bagging individual slices of bread with bare hands. Staff A had been noted to be working in the garbage/refuse area prior to the meal observation and hand washing was not observed by the surveyor. The surveyor informed the FSD to discard all bagged bread and to ensure proper hand washing and to wear gloved hands during this task. (d) During the lunch observation it was noted that the 4 soiled ceiling vents were full of condensation and continued to drip constantly onto foods located in the steam table, food preparation surfaces, food preparation equipment, clean dishware, and staff working within the area. The surveyor informed the FSD that there was a high potential of food borne illness and food contamination . 3) During a subsequent observation conducted on 8/11/22 at 11 AM , observed Housekeeping Aide enter the kitchen with housekeeping cart (open trash, broom, mops, dustpan, no hair net) pushed cart through food preparation and serving area. Surveyor asked what she doing and she stated she was cleaning in the dietary department specifically the rest rooms . FSD stated the housekeeping department are required to enter the dietary department though the back door of the department where the rest rooms are located. 4) During a subsequent observation of the main kitchen on 08/10/22 at 12 PM, it was noted that the lunch meal was being served from the Meat Section of the kitchen. Further observation noted that 1 of the ceiling mounted air-conditioning vents located directly over the food tray assembly line and was still noted to be full of condensation and was dripping down onto foods located on the steam table. The surveyor again stated to the FSD that the issue is a potential food borne illness and potentially food contamination issues and requires correction immediately. Also during the 08/10/22 observation the 3-compartment sinks in both the Dairy and Meat sections of the kitchen were being utilized to wash food preparation equipment. At the surveyor's request both 3-compartment sinks were tested for the chemical level in the sanitizing sink. Following multiple (3) testing by the FSD it was noted that both the Dairy and Meat 3-compartment sinks failed the chemical testing as per regulation. The surveyor requested that the use of the 3-compartment sinks cease, and correct the issue prior to continue use. The surveyor also stated that food preparation equipment must be rewashed and sanitized prior to use. Also during the 08/10/22 observation it was noted that the bench mounted commercial can opener was rust laden and the opening blade was dull causing a layer of metal shavings on the blade surface. The surveyor requested the commercial can open be properly cleaned to eliminate rust and that a new opening blade be installed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105685 If continuation sheet Page 12 of 13 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 105685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menorah House 9945 Central Park Blvd N Boca Raton, FL 33428 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 potential for actual harm During observation, interview, and record review the facility failed to implement infection control policies to prevent the development and transmission of communicable diseases and infections for 7 out of 7 residents sampled (Residents #302, #303, #74, #304, #19, #305, #306). Residents Affected - Some The findings included: Review of the facility policy titled Isolation Trays dated 2020 revealed any resident with a suspected or known communicable disease or infection will receive an isolation meal tray as per community guidelines. The isolation tray will consist of all disposable dishes and flatware. This includes paper plates, napkins, silverware, and condiments. No item that come in contact with the resident or resident's room will be returned to the Dining Services Department. During an observation made on 08/08/22 at 10:00 AM Residents #74, 303, 304, 305, 302, 19 and 306 were all in isolation (droplet precautions) and they all had regular dishes, regular cups, and regular silverware instead of the disposable ware. During an interview conducted on 08/08/22 at 10:30 AM with the Infection Preventionist she stated the residents that are in isolation should be receiving all meals with disposable plates, cups and plasticware. During an interview conducted on 08/08/22 at 11:00 AM with the Licensed Dietician who stated nursing is supposed to notify Dining Services Department when a resident is put on isolation or taken off isolation. She stated that on Monday morning the dish machine had 4 chemical tests conducted to ensure the machine was sanitizing properly. The 4 chlorine test strips conducted indicated no chemical level present in final rinse. Surveyor ordered to cease use of dish machine, until it was repaired. Ecolab came in on 08/08/22 at 10:52 AM machine diagnosed and found the sanitizer pump was bad. The sanitizer pump was replaced, and the lines primed with appropriate sanitizing chemicals. Now testing at 100 ppm for chlorine sanitizer. The machine is now functioning properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105685 If continuation sheet Page 13 of 13