Inspection·October 13, 2022

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a second observational tour conducted on 10/10/22 at 12:27 PM, Resident #22 was still observed with long, dirty, sharp, unkempt fingernails on both hands: with some unidentified black matter located under three (3) of the five (5) fingernails on Resident #22's left hand. During a third observational tour conducted on 10/11/22 at 10:12 AM, Resident #22 was still observed with long, dirty, sharp, unkempt fingernails on both hands: with some unidentified black matter located under three (3) of the five (5) fingernails on Resident #22's left hand. During a fourth observational tour conducted on 10/11/22 at 1:30 PM, Resident #22 was still observed with long, dirty, sharp, unkempt fingernails on both hands: with some unidentified black matter located under three (3) of the five (5) fingernails on Resident #22's left hand. During a fifth observational tour conducted on 10/12/22 at 10:11 AM, Resident #22 was still observed with long, dirty, sharp, unkempt fingernails on both hands: with some unidentified black matter located under three (3) of the five (5) fingernails on Resident #22's left hand. Record review of the Resident #22's Monthly CNA (Certified Nursing Assistant) ADL Flowsheet Record dated 09/29/22 thru 10/12/22 revealed that resident's (ADL)s for Personal Hygiene indicated that Resident #22 required limited to extensive assistance from facility staff. Record review of Resident #22's Care plan initiated 09/01/22 and revised 10/05/22 indicated Focus: Activities of Daily Living (ADL): Resident #22 with diagnosis of: status post Fall, left Femur fracture Open Reduction Internal Fixation (ORIF), Dementia, Leucytosis, Pain and Weakness. She is at risk for ADL/self-care performance deficit Interventions: She requires assistance of staff x1 with personal hygiene Goal: Resident #22 will improve current level of function through the review date. Further record review of the Minimum Data Set (MDS) sections A and G dated 09/05/22 for Resident #22 indicated that Resident #22 requires extensive assistance with personal hygiene, and she also requires one person physical assistance. An interview was conducted with Staff C, a CNA on 10/12/22 at 10:33 AM, which she revealed that they had not provided fingernail care to Resident #22 and she said that it is the responsibility of the CNAs to clean and trim the residents fingernails. She further acknowledged that the resident's fingernails were long, sharp, untrimmed, and unkempt. An interview was conducted with Staff D, a Licensed Practical Nurse (LPN) on 10/12/22 at 10:37 AM, regarding Resident #22's long, unkempt nails and she also agreed that Resident #22's fingernails were long, sharp, untrimmed and unkempt. An interview was conducted with the Activities Director on 10/12/22 at 10:50 AM in which she stated that her department has been doing fingernail polishing and filing for the residents, as requested or needed by the resident by either one (1) of her three (3) activities assistants. However, she added that her department is not allowed to cut any of the resident's fingernails. There is also a Beauty Salon located on the third floor and open on Mondays which can also only polish and file resident fingernails; no cutting. She added that if her staff were to see a resident with long, dirty fingernails that she would alert the nurse of the floor, wing or unit involved and to let them know to follow-up with the resident. The Activities Director said that her department had not provided any nail care service to Resident #22. The Director also acknowledged that Resident #22's fingernails were all long, untrimmed and unkempt. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106111 If continuation sheet Page 2 of 9 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 106111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Health Center at Sinai Residences 21044 95th Avenue South 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/12/22 at 11:17 AM, an interview was conducted with Staff E, a Registered Nurse (RN), daytime Supervisor, regarding Resident #22's fingernails being long, sharp and untrimmed. She agreed that it is the responsibility of the CNAs to clean and trim the residents nails and she further acknowledged that the resident's fingernails were long and that they should have been cleaned/trimmed/cut. On 10/12/22 at 11:48 AM, an interview was conducted with the DON regarding Resident #22's fingernails being long, sharp and untrimmed and she also acknowledged that it is the responsibility of the CNAs to clean and trim the resident's nails and she further acknowledged that the resident's fingernails were long and that they should have been cleaned/trimmed/cut; this was not done. On 10/13/22 at 9:30 AM, a follow up observation was conducted of Resident #22, it was noted that her fingernails were now cut, neat and trimmed. She expressed to the surveyor that she was happy and pleased with her clean fingernails. Resident #22's fingernails were not cleaned and trimmed from 10/10/22 - 10/12/22, until after surveyor inquisition/intervention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106111 If continuation sheet Page 3 of 9 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 106111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Health Center at Sinai Residences 21044 95th Avenue South 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an accurate nutritional assessment and failed to order an additional nutritional supplement to aid with wound healing for 1 of 3 sampled residents reviewed for nutrition (Resident #5). Resident #5 had a pressure ulcer, which would indicate a need for increased nutrition. Residents Affected - Few The findings included: A chart review showed that Resident #5 was discharged to an acute care hospital on [DATE] and readmitted to the facility on [DATE]., with diagnoses of dysphagia, muscle weakness, and seizures. Diet order noted for Regular diet, Mechanical Soft (Chopped) - Soft and Bite-Sized texture, Mildly Thick (Nectar) consistency, for nutrition support needs assistance with feeding at all meals, which was dated 08/05/22. The Minimum Data Set, dated [DATE] showed that Resident #5 had a stage 4 pressure ulcer under section M for the skin. Section C showed that Resident #5 was severely cognitively impaired. In an observation conducted on 10/11/22 at 8:35 AM, Resident #5 was noted in bed. Staff B, Certified Nursing Assistant, was in the room assisting the Resident with her breakfast tray. Closer observation showed a tray with thickened liquids for the coffee and the juice. Weighted forks and knives were also noted on the plate with a scoop plate. Staff B encouraged the Resident to eat her meal and assisted her in grabbing the food with the weighted utensils. The care plan initiated on 07/09/20 for pressure ulcers showed that Resident #5 has a stage-4 pressure ulcer to her Sacro-coccyx. Alteration in nutritional status as evidence By potential for weight change and aspiration-related therapeutic and mechanically altered diet. It further showed that Resident #5 would consume adequate kcal/protein and fluids to meet estimated needs and prevent significant weight loss. A wound care note dated 07/11/22, which was three days after readmission, showed that Resident #5 was with a stage 4 sacrum wound. It further showed to maintain adequate nutrition and supplement to promote wound healing. A wound care note dated 07/18/22 showed that Resident #5 was with a stage 4 sacrum wound. It further showed to maintain adequate nutrition and supplement to promote wound healing. A wound care note dated 08/01/22 showed that Resident #5 was with a stage 4 sacrum wound. It further showed to maintain adequate nutrition and supplement to promote wound healing. A Dietary follow-up note written a day after readmission showed that Resident #5 was with a sacral wound and that she was going to be followed up by the Wound Care Team. Protein and vitamin intake appear to be adequate to meet needs for nutrition and wound healing. It was further documented that the Resident was also receiving Prostat (a protein supplement for wound healing). The Initial readmission Assessment conducted on 07/11/22, which was four days after readmission, showed that the facility's Clinical Dietitian documented that Resident #5 had edema on the skin but did not document any staged four wounds. In this note, she further stated that Resident #5 is receiving Prostat (protein supplement for wound healing) and the that the protein and vitamins appear to be adequate to meet needs for nutrition and wound healing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106111 If continuation sheet Page 4 of 9 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 106111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Health Center at Sinai Residences 21044 95th Avenue South 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A follow-up note dated 07/20/22 showed that Resident #5's appetite and intake are good to excellent, and there is no documentation regarding the stage four sacral wound. A Dietary follow-up note dated 07/29/22 showed that Resident #5 was receiving a Magic cup daily (a small container of an ice cream-like dessert with additional nutrients), to aid in protein intake and help with wound healing with an open area to the sacrum. A review of the Medication Administration Record (MAR) showed that the order for the magic cup twice a day was discontinued on 07/01/22 and never restarted after Resident #5 was readmitted on [DATE]. Further review showed that the order for Prostat twice a day was stopped on 07/01/22 and restarted on 07/09/22 but with only one scoop a day and not twice a day. A review of Resident #5's intake of meals documented by the CNAs (Certified Nursing Assistants) from 09/28/22 to 10/10/22 showed the following: Resident #5 ate two meals at 0 intakes, three meals between 26% to 50% intake, 12 meals between 76% to 100% intake, and 47 meals between 51 to 75% intake. In an interview, conducted on 10/12/22 at 1:27 PM with the facility's Clinical Dietitian, it was stated that residents who are admitted with stage 4 pressure ulcer wounds are considered high-risk residents. The protein needs will be assessed at higher needs, and she recommends Prostat for wound healing twice a day as well as a nutritional supplement. When asked why she did not document in her assessment that Resident #5 had a stage four pressure ulcer after she was readmitted . She said that she did not know that Resident #5 had a pressure ulcer wound. According to the Clinical Dietitian, after admission or readmission, the Wound Care Team will assess the residents. They will then send an email to the clinical staff to let them know if any residents have pressure ulcers and the stage. She further noted that she cannot see any of the wound care assessments in the current electronic system and must wait for the emails the Wound Care Team sends. When asked about the magic cup supplements, she stated that Resident #5 refused the supplements but was not able to provide any documentation regarding Resident #5 refusing the supplements. In an interview conducted on 10/12/22 at 1:35 PM, with the facility's Corporate Dietitian, she was told of the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106111 If continuation sheet Page 5 of 9 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 106111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Health Center at Sinai Residences 21044 95th Avenue South 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to ensure daily nurse staffing was updated properly. Residents Affected - Few The findings included: Multiple observations were made on 10/10/22 (9:40 AM, 10:20 AM, 12:05 PM, 2:08 PM) on the 3rd floor of the facility in between the East and [NAME] wings of the posted nurse staffing being dated 10/08/22. Photographic evidence obtained. An additional observation was made on 10/11/22 at 8:50 AM of this posted nurse staffing still dated 10/08/22. On 10/11/22 at 1:15 PM, the surveyor observed the facility Administrator changing this posted nurse staffing. Upon closer observation, the date on the new posted nurse staffing was 09/11/22. Photographic evidence obtained. An additional observation was made on 10/12/22 at 8:20 AM of this posted nurse staffing still dated 09/11/22. A tour of the facility was conducted on 10/12/22 at 11:20 AM with the facility Administrator. During this tour, the surveyor made the facility Administrator aware of this issue. He stated he would talk to the staffing office as they are responsible for updating these posted nurse staffing. An interview was conducted with the facility Director of Nursing on 10/13/22 at 11:22 AM. She stated she had talked to the staffing office, and they are aware of the issue and they will be more mindful of updating the posted nurse staffing daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106111 If continuation sheet Page 6 of 9 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 106111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Health Center at Sinai Residences 21044 95th Avenue South 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) Resident #10 was admitted to the facility on [DATE] with diagnoses which included Age Related Cognitive Decline, Hypothyroidism, Hypertension, Major Depressive Disorder and Gastroesophageal Reflux Disease. She had a Brief Interview Mental Status (BIM) score of 12 (moderately impaired). During an initial observational screening tour conducted on 10/10/22 at 10:07 AM, it was observed that there was a used container of OTC Zinc Oxide 20% cream medication in Resident #10's bathroom with an expiration date of 03/2025 observed in plain sight, visible, unattended, accessible to other residents, employees and visitors. Photographic evidence was obtained. 4) During a continued initial observational screening tour on 10/10/22 at 10:10 AM, it was also observed that there was a used tube of prescription Clotrimazole and Betamethasone Diproprionate 1%/0.5% with an expiration date of 07/24 observed in plain sight in Resident #10's open bedside dresser drawer, visible, unattended, accessible to other residents, employees and visitors. Photographic evidence was obtained. During a second observational tour conducted on 10/10/22 at 12:42 PM, it was observed again that there was a used container of OTC Zinc Oxide 20% cream medication still at the bedside of Resident #10's bedroom with an expiration date of 03/2025 observed in plain sight, visible, unattended, accessible to other residents, employees and visitors. And, it was also observed that there was a used tube of prescription Clotrimazole and Betamethasone Diproprionate 1%/0.5% with an expiration date of 07/24 still observed in plain sight in Resident #10's open bedside dresser drawer, visible, unattended, accessible to other residents, employees and visitors. During a third observational tour conducted on 10/11/22 at 9:49 AM, it was observed again that there was a used container of OTC Zinc Oxide 20% cream medication still at the bedside of Resident #10's bedroom with an expiration date of 03/2025 observed in plain sight, visible, unattended, accessible to other residents, employees and visitors. And, it was also observed that there was a used tube of prescription Clotrimazole and Betamethasone Diproprionate 1%/0.5% with an expiration date of 07/24 still observed in plain sight in Resident #10's open bedside dresser drawer, visible, unattended, accessible to other residents, employees and visitors. During a fourth subsequent tour conducted on 10/11/22 at 1:30 PM, it was observed again that there was a used container of OTC Zinc Oxide 20% cream medication still at the bedside of Resident #10's bedroom with an expiration date of 03/2025 observed in plain sight, visible, unattended, accessible to other residents, employees and visitors. And, it was also observed that there was a used tube of prescription Clotrimazole and Betamethasone Diproprionate 1%/0.5% with an expiration date of 07/24 still observed in plain sight in Resident #10's open bedside dresser drawer, visible, unattended, accessible to other residents, employees and visitors. During a fifth observational tour conducted on 10/12/22 at 10:11 AM, it was observed again that there was a used container of OTC Zinc Oxide 20% cream medication still at the bedside of Resident #10's bedroom with an expiration date of 03/2025 observed in plain sight, visible, unattended, accessible to other residents, employees and visitors. An interview was conducted with Resident #10's Staff F, a private duty aide, on 10/11/22 at 1 PM in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106111 If continuation sheet Page 7 of 9 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 106111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Health Center at Sinai Residences 21044 95th Avenue South 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 which she was asked about the OTC cream medication located in Resident #10's bathroom, and she acknowledged that the cream medication was there, and she added that it is applied Resident #10's buttock area. On 08/05/22 the Treatment Administration Record (TAR) documented Skin barrier cream to buttocks during toileting or adjusting in bed to prevent skin breakdown. Every day and night shift for skin integrity. And, on 10/03/22 the TAR also documented Lotrisone Cream 1-0.05% (Clotrimazole-Betamethsone) Apply to groin topically two times a day for rash for fourteen (14) days, as being initialed and administered by facility nursing staff. However, both the prescription and OTC cream medications remained unattended and accessible at Resident #10's bedside. An interview was conducted on 10/12/22 at 11:06 AM with Resident #10's nurse, Staff D, a Licensed Practical Nurse (LPN) regarding the prescription and OTC cream medications observed in Resident #10's bathroom and she acknowledged that the prescription and OTC cream medications should not have been there. During an interview conducted on 10/12/22 at 11:13 AM with Staff E, a Registered Nurse (RN), daytime Supervisor, she indicated this resident does not self-administer any of her own medications and neither was she assessed to be able to do so. Side-by-side record review was conducted with Staff E, in which it was noted that neither Resident #10's hard copy chart nor her computerized Point-Click-Care (PCC) medical record indicated that the resident had any self-assessment completed in order for her to be to administer her own medications. In fact, the tube of prescription medication and the container of OTC cream medication was not removed from this resident's bedside along with an order for this medication to be now administered to Resident #10 as needed, until after surveyor inquisition. On 10/12/22 at 11:50 AM the DON further acknowledged and recognized that the prescription and OTC cream medications should not have been left at the resident's bedside. Based on observations, interviews, and record review, the facility failed to ensure proper storage of medications. The findings included: Review of the facility policy titled Storage of Medications, revised April 2007 revealed the following: The Policy Statement states, The facility shall store all drugs and biologicals in a safe, secure and orderly manner. The Policy Interpretation and Implementation states, The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe and sanitary manner and Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. 1) During a tour of the facility conducted on 10/11/22 at 1:11 PM, the surveyor observed three medications which were left unattended in Resident #301's room. The three medications were observed to be an inhaler, an antibiotic to be infused through an intravenous line, and an unidentified white capsule in a medication cup. Photographic evidence obtained. Staff A was interviewed about these unattended medications. She stated she planned to administer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106111 If continuation sheet Page 8 of 9 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 106111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Health Center at Sinai Residences 21044 95th Avenue South 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 these medications to Resident #301, but the therapy staff had taken Resident #301 to complete her therapy treatment for the day before Staff A was able to administer the medications. Staff A stated she would put the medications in the medication cart until Resident #301 was returned to her room. When the surveyor asked Staff A how much longer Resident #301 would be at therapy, she stated Resident #301 would return to her room in approximately 30 minutes from therapy. The surveyor stated she would return in 30 minutes to observe the medication administration. The surveyor then observed Staff A place the inhaler and intravenous antibiotic back into the medication cart. Review of Resident #301's Medication Administration Record revealed she was due to receive the following medications at the following times: Atrovent HFA (inhaler) at 1:00 PM, Zosyn solution (antibiotic) at 2:00 PM, and Gabapentin (pain medication) at 1:00 PM. 2) During a tour of the facility conducted on 10/11/22 at 1:45 PM, the surveyor observed a white capsule on the floor in the main hallway in front of the medication cart on the 3-East wing near the nurse's station. Closer observation revealed this white capsule appeared to be the same Gabapentin that had been taken out of Resident #301's room earlier. When Staff A was interviewed on 10/11/22 at 1:48 PM about this white capsule, she picked it up from the floor, took it to the medication room, and placed it in the bottle of Pill Buster in front of the surveyor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106111 If continuation sheet Page 9 of 9