Inspection·February 15, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bathroom and turned the hot water knob on for the sink. After waiting one minute (timed), the hot water in the sink was cold to the touch. The Surveyor proceeded to turn the hot water knob in the shower and waited one minute. After one minute, the hot water in the shower remained cold to the touch. A record review of the Certified Nursing Assistants (CNAs) documentation under the task section titled PRN (as needed) ADL-bathing (prefers to specify) revealed the following: question one regarding the bathing task completed showed yes. Section 2, regarding how the resident takes full body, baths/showers, and sponge baths, revealed the type of assistance that was provided but did not show what type of bath was given. The 3rd section asked if Resident #219 needed one-person assistance or two-person assistance with bathing, which showed the resident needed one-person assistance with baths. Interview with Staff A, Certified Nursing Assistant (CNA), on 02/14/24 at 3:52 PM, she stated that the residents are scheduled for baths on specific days noted in a shower book on the unit. She said that most residents get a bath three times a week, and some want their baths every day. When asked where she documents in the electronic system after she gives residents their baths, she said it is in the PRN (as needed) ADL-bathing (prefers to specify) and proceeded to show the Surveyor. Staff A was not able to show the Surveyor what type of bath was given under this documentation section of the electronic system. Further review of the shower book that was provided by Staff A did not show any documentation regarding showers for residents. In an interview conducted on 02/14/24 at 4:08 PM, Staff B, Certified Nursing Assistant, she stated that the PRN ADL-bathing (prefers to specify) section under the task is where she documents when a shower is given to any residents. According to Staff B, this section in the electronic system does not have a section where one can write what type of bath is given. In an interview conducted on 02/14/24 at 4:18 PM with Staff C, Certified Nursing Assistant, she stated that Resident #219 likes sponge baths and that this is his preference for bathing. Staff C reported that she uses the sink water to give Resident #219 his bath using a soaked towel. She then proceeded to walk into Resident #219 room and turn the hot water on in the sink. She waited about 30 seconds and said, I think it is getting warm. The Surveyor touched the hot sink water, which was Lukewarm to the touch. The Surveyor then asked Staff C if she thought this was warm enough; she then said, I guess it can be warmer. The Surveyor waited another minute and touched the hot sink water again, which felt the same. In an interview conducted on 02/14/24 at 4:50 PM with Resident #219, he stated that the Maintenance Director did not come into the room to look at the hot water temperature in his bathroom. When asked if another staff came to check the situation, he said no. In an observation conducted on 02/14/24 at 5:01 PM, accompanied by the facility ' s Administrator, Resident #219 's sink hot water was checked using the facility's thermometer. The temperature of the hot water took 5 minutes to get from 86.9 degrees Fahrenheit to 100.2 degrees Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106111 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 106111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 observations, interviews, and record reviews, the facility failed to provide nutritional intervention in a timely manner for 1 of 3 sampled residents reviewed for nutrition (Resident #48). Residents Affected - Few The findings included: A review of the facility's policy titled, Weight Recording, revised on 09/11/23, revealed the following: the nurse at each station is responsible for maintaining weights in the electronic medical record, verifying, and reporting any weight discrepancies of 3 pounds in a day and 5 pounds in a week or 5% in a month. The Registered Dietitian is responsible for any diet modifications necessary to stop any undesired weight changes. In an observation conducted on 02/13/24 at 8:40 AM, Resident #48 was noted in his room eating the breakfast meal. In this observation, Resident #48 was asked if he lost weight; he said yes and that it was not intentional. He further said that he had asked for nutritional supplements in the past to help with his weight loss and was given a few times. He stated he really likes the Ensure complete (nutritional supplement) chocolate flavor and would drink the supplements if provided. Record review revealed that Resident #48 was readmitted to the facility on [DATE] with diagnoses of Cancer, Depression, and Chronic Kidney Disease. The Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #48 had a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. A review of the Physician's orders showed an order for a regular diet, which was dated 01/14/24, but no nutritional supplements were ordered. The weight log showed the following weights recorded for Resident #48: 175 pounds noted on 01/15/24, 166 pounds noted on 01/24/24, and 155.2 pounds on 01/31/24. This showed that Resident #48 lost 5.1% severe weight loss in 9 days from 01/15/24 to 01/24/24. Resident #48 lost 11.3% severe weight loss in two weeks from 01/15/24 to 01/31/24. A review of the nutrition admission assessment dated [DATE] revealed the following: Resident #48 is at nutritional risk due to weight change, varying PO intake, refusal of nutritional supplements, and needs cues and encouragement for increased intake. Weight remains within the high end of the healthy weight range and noted with 10-13 pounds of weight loss in the last six months. The next nutrition progress note was not until 02/01/24, not addressing the severe weight loss noted on 01/24/24. The nutritional progress note dated 02/01/24 revealed the following: Resident #48 was noted with a further weight decline of 11.3% (19.8 pounds) from readmission on [DATE] to 01/30/24. It further showed that Resident #48 was eating between 50% to 75% of his meals. Resident #48 agreed to receive Ensure Complete (chocolate) twice a day to prevent further weight loss. A review of the Physician's orders did not show that an order was written for Ensure supplements two times a day, as noted in the nutrition progress note on 02/01/24. The nutrition care plan showed the following: The dietitian will evaluate and make diet changes and recommendations as needed, Resident #48 will be weighed at the same time of the day, and the weights will be recorded as per the facility's policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106111 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 106111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 FORM CMS-2567 (02/99) Previous Versions Obsolete In an interview conducted on 02/13/24 at 3:18 PM with Staff, H, the Registered Dietitian, she stated that she prints out a weekly report on all residents and reviews any weight changes of 3% plus or minus. The weight report usually runs on Wednesdays, and any weight changes will be identified on time. She often evaluates the accuracy of some of the weight changes and asks Staff to reweigh the residents again. They also conduct weekly weight meetings to discuss any significant weight losses that are noted. Staff H stated that she would provide nutritional supplements if needed to help with any weight loss that is identified. The Ensure Complete will give an extra 360 calories and 30 grams of protein per can. When asked what percent weight loss Resident #48 had from 01/15/24 to 01/24/24, she said 5.7% and acknowledged that it was a significant weight loss. According to Staff H, she only identified the significant weight loss on 02/01/24, which was about one week later. When asked why she did not order the nutritional supplements (Ensure) she recommended in her nutrition progress note on 02/01/24, she said, I do not know how it was missed. Event ID: Facility ID: 106111 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 106111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for 2 of 2 kitchen observations. It also failed to practice hand hygiene during meal observation for 4 of 4 residents observed during dining (Resident #35, Resident #48, Resident #15, and Resident #115). The findings included: In an observation conducted on 02/12/24 at 9:50 AM in the Main Kitchen, the reach-in Freezer was noted with an internal temperature of 20 degrees Fahrenheit and not at the recommended 0 degrees and below Fahrenheit. Closer observation revealed that some of the food items (breads) were soft to the touch. In this observation, Staff G (Cook) stated that the temperature of the reach-in Freezer is not within guidelines because it's been opened and closed all morning by staff members. A chart review revealed that Resident #35 was readmitted to the facility on [DATE]. The Modification Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #35 had a Brief Interview of Mental Status (BIMS) score of 14, which was cognitively intact. In an observation conducted on 02/13/24 at 8:17 AM, Staff E (Certified Nursing Assistant) brought the meal tray into Resident #35 ' s room. A closer observation did not show that Staff E encouraged or asked Resident #35 to clean his hands before touching his breakfast meal. A chart review revealed that Resident #48 was readmitted to the facility on [DATE]. The admission MDS assessment dated [DATE] showed that Resident #48 had a Brief Interview of Mental Status (BIMS) score of 15, which was cognitively intact. In an observation conducted on 02/13/24 at 8:40 AM, Resident #48 was noted in his room eating the breakfast meal. In this observation, Resident #48 said that they never ask him or remind him to wash his hands or clean his hands before eating. A chart review revealed that Resident #15 was admitted to the facility on [DATE]. The admission MDS assessment dated [DATE] showed that Resident #15 had a Brief Interview of Mental Status (BIMS) score of 15, which was cognitively intact. In an observation conducted on 02/13/24 at 8:41 AM, Resident #115 was noted in his room with the breakfast tray, which did not have hand sanitizer or sanitizing wipes to clean his hands. In this observation, Resident #115 stated that the Staff never told him to clean his hands before eating or encouraged/reminded him to wash his hands. A chart review showed that Resident #41 was admitted to the facility on [DATE]. The Quarterly MDS assessment dated [DATE] showed no BIMS score for Resident #41. In an observation conducted on 02/13/24 at 8:45 AM, Staff D, a Certified Nursing Assistant, brought the breakfast tray into Resident #41's room. Staff D set up the tray for Resident #41 and left the room. In this observation, Staff D did not help Resident #41 clean her hands before she started eating. A second visit to the central kitchen conducted on 02/14/24 at 11:30 AM revealed that the reach-in Freezer had an internal temperature of 20 degrees Fahrenheit and not the recommended 0 degrees and below Fahrenheit. In this observation, Staff J, the Registered Dietitian, acknowledged that some of the food items (bread) in the reach Freezer were still soft to the touch, as observed on 02/12/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106111 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 106111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further observation revealed a metal container that had nine corn beef and cheese sandwiches cut in halves. Staff G was observed placing the metal container with the nine sandwiches on top of another metal container filled with ice. Staff G said that these are the sandwiches that are for the lunch meal today. Staff G took the temperature of one corn beef and cheese sandwich using the facility-calibrated thermometer. The temperature was noted at 53.9 degrees Fahrenheit and not the recommended 41 degrees Fahrenheit and below. Two other corn beef and cheese sandwiches were noted with a temperature of 50.7 degrees Fahrenheit and 53.2 degrees Fahrenheit and not the recommended 41 degrees Fahrenheit and below. In an observation conducted on 02/14/24 at 11:44 AM on the second-floor satellite Kitchen, Staff I, Culinary Laison, was observed taking a metal container that was noted with nine corn beef and cheese sandwiches cut in halves that were sent earlier from the central kitchen. Staff, I proceeded to take the temperature using a facility-calibrated thermometer of two corn beef and cheese sandwiches. One sandwich was noted at 51.0 degrees Fahrenheit, and the second sandwich was noted at 54.9 degrees Fahrenheit. Continued observation revealed Staff I plated the two corn beef sandwiches on a lunch plate and placed them on the meal cart that was getting ready to leave the kitchen to the floor. In an interview conducted on 02/15/24 at 10:30 AM with Staff D, the Certified Nursing Assistant stated that during mealtimes, she needs to place disposable hand sanitizer wipes on each meal tray so the residents can clean their hands. When asked about residents who cannot do it themselves, she said she does it for them. In an interview conducted on 02/15/24 at 11:00 AM with the facility's Administrator, he was told of the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106111 If continuation sheet Page 6 of 6