Health inspection·July 14, 2022

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #84's Primary Physician consult dated 11/13/2021 revealed a psychiatric consult evaluation and revision of comorbid Schizophrenia. Record review of Resident #84's Psychiatric consult dated 02/07/2022 revealed a referral for psych evaluation and diagnosis of psychosis and depression. Evaluation completed and treatment ordered included Seroquel 100 mg in the morning and 300 mg at bedtime. Record review of Resident # 84's Psychiatric consult dated 04/27/2022 revealed Schizophrenia among other diagnosis and ordered to continue Seroquel 100 mg daily and 300 mg at bedtime. Interview with the MDS Coordinator on 07/14/2022 at 03:02 PM revealed that after reviewing Resident #84's chart (diagnosis, medication, and psychiatric consult) the diagnosis of Schizophrenia should have been coded in the MDS. The MDS Coordinator stated that she did not complete the Quarterly assessment on 06/22/2022. Record review of Resident # 84's MDS Quarterly (2) Modifying existing record dated 06/22/2022 and Center for Medicare Services (CMS) Submission Report MDS 3.0 NH (Nursing Home) Final Validation report revealed a corrected and coded diagnosis of Schizophrenia and corrected by not coding Psychotic disorder (submitted to CMS). Record review of Policy and Procedures on MDS revised on 09/2021 revealed: Policy Statement The Assessment Coordinator and/or the Interdisciplinary Assessment Team will follow the established process for completing, submitting, and making corrections to the MDS. Policy Interpretation and Implementation Completion of MDS. 1. Interdisciplinary Team will complete sections of MDS for a resident in the facility. Correction of Error 5. If an error is discovered after the encoding period and the record in error is an OBRA Assessment, determine if the error is major or minor. MDS Coordinator may modify assessment within 2 years of ARD and modification can be completed 14 days after error is discovered. a. A minor error is one related to the coding of the MDS. For minor errors, correct the record and submit to the QIES ASAP system. During an interview on 07/14/2022 at 06:30 PM the Director of Nursing (DON) revealed when asked about Resident # 84's Quarterly MDS in which the facility did not code the resident for diagnosis of Schizophrenia, the DON stated it was done by mistake and it should have been coded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 2 of 14 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 105008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Biscayne Health and Rehabilitation Center 12505 NE 16th Ave North Miami, FL 33161 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations,record review and interview, the facility failed to ensure two residents (Resident # 84 and Resident #2) out of three residents sampled for Preadmission Screening and Resident Review (PASRR) were referred for evaluation to ensure and complete Level II PASRR. There were 92 residents residing in the facility at the time of the survey. the findings included: On 07/11/22 at 10:20 AM, Resident # 84 was observed lying in bed, he was alert times one (person) but not interviewable. Record review of Resident # 84's medical records revealed the resident was originally admitted to the facility on [DATE]. According to the face sheet, the resident had diagnoses to include but not limited to Unspecified Psychosis not due to substance or known physiological condition, Major Depressive disorder, Schizophrenia, and Disorganized Schizophrenia. Record review of Resident # 84's Quarterly Minimum Date Set (MDS) with Assessment Reference Date (ARD) of 06/22/2022 revealed in Section A Identification Information documented PASRR Level II coded as No. In Section C for Cognitive Patterns coded a score of 04 out of 15 in the Brief Interview for Mental Status (BIMS) meaning severely impaired cognition. Section I for Active Diagnoses coded under Psychiatric/ Mood disorders diagnosis of Depression and Psychotic disorder (other than Schizophrenia) and additional diagnosis of Insomnia and did not have Schizophrenia coded. Section N for medications coded antipsychotic and antidepressant medication. Record review of Resident # 84's Quarterly MDS (2) Modifying existing record dated 06/22/2022 and Center for Medicare Services (CMS) Submission Report MDS 3.0 NH Final Validation report revealed it was corrected and coded diagnosis of Schizophrenia and corrected by not coding Psychotic disorder (submitted to CMS). Record review of Resident #84's PASRR Level I completed at the hospital and dated on 10/27/2021 revealed the hospital's nurse did not check any mental illness in Section I on the PASRR Screen Decision-Making, in Section II Other Indications for PASRR Screen-Decision Making checked all boxes indicating No when answering all questions on the form, in Section IV PASRR Screen Completion checked option No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Record review of Resident #84's care plan dated 11/11/2021 and last revised on 06/22/2022 revealed use of psychotropic medications related to diagnosis of Schizophrenia and is at risk for negative effects from the use of the medication, and the use of antidepressant medication related to diagnosis of depression. Record review of Resident #84's Physician Orders (PO) revealed Seroquel Tablet (Quetiapine Fumarate) 100 mg (milligram) ordered to give 1 tablet by mouth two times a day and 300 mg at bedtime related to Disorganized Schizophrenia, and Trazodone HCL 100 mg tablet ordered to be given 100 mg by mouth at bedtime for Depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 3 of 14 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 105008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Biscayne Health and Rehabilitation Center 12505 NE 16th Ave North Miami, FL 33161 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 0644 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #84's current Medication Administration Record (MAR) revealed he was receiving Seroquel and Trazodone as ordered. Record review of Resident #84's Primary Physician consult dated 11/13/2021 revealed a psychiatry consult evaluation and revision of comorbid Schizophrenia. Residents Affected - Few Record review of Resident #84's Psychiatry Intake Note dated 02/07/2022 revealed referral for psych evaluation and diagnosis of psychosis and depression. Evaluation completed and treatment ordered included Seroquel 100 mg in the morning and 300 mg at bedtime, and Trazodone 100 mg at bedtime. Record review of Resident #84's Psychiatry Intake Note dated 04/27/2022 revealed Schizophrenia, Insomnia Disorder, and Probable Major Neurocognitive Disorder due to Alzheimer's Disease, with behavioral disturbance, and ordered to continue Seroquel 100 mg daily and 300 mg at bedtime, and Trazodone 100 mg at bedtime. Resident #2 On 07/13/2022 at 10:15 AM, Resident # 2 was observed lying in bed and watching television. the resident was not no alert and oriented. Record review of Resident # 2's medical record revealed the resident was admitted to the facility on [DATE]. According to the face sheet, clinical diagnoses include but not limited to Schizophrenia, unspecified, Primary Insomnia, Depression Unspecified, Unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, unspecified, other specified depressive episodes, major depressive disorder, recurrent, moderate. Record review of Resident # 2's admission Minimum Date Set (MDS) with Assessment Reference Date (ARD) of 04/05/2022 in Section A for Identification Information indicated PASRR Level II coded as No. In Section C Cognitive Patterns coded a score of 01 out of 15 in the Brief Interview for Mental Status (BIMS). In Section I Active Disease Diagnosis indicated Psychiatric/Mood disorder Diagnosis coded Schizophrenia, Anxiety, Depression, Psychotic disorder. In Section N for Medications was coded for use of antipsychotic and antidepressant medications. Record review of Resident # 2's PASRR Level I, completed on 08/03/2021 by a Registered Nurse (RN) at the previous facility where resident lived revealed no mental illness checked in Section I: PASRR Screen-Decision Making, In Section II Other Indications for PASRR Screen-Decision Making checked all boxes indicating No when answering all questions on the form, in Section IV PASRR Screen Completion checked option No diagnosis or Suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Record review of Resident # 2's Care plan dated 04/11/2022 documented the use of psychotropic medications related to diagnosis of Schizophrenia, for sedative/hypnotic therapy related to insomnia, and for the use of antidepressant medication related to diagnosis of depression. Record review of Resident # 2's physician orders (PO) revealed Mirtazapine 7.5 mg at bedtime for Depression, Depakene 250 mg twice a day for mood stabilization, Risperidone 0.5 mg at bedtime for psychosis, and Melatonin 5 mg at bedtime, Temazepam 15 mg at bedtime for Insomnia, Zyprexa 5 mg at bedtime, and Lorazepam 0.5 mg twice a day for anxiety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 4 of 14 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 105008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Biscayne Health and Rehabilitation Center 12505 NE 16th Ave North Miami, FL 33161 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #2's current Medication Administration Record (MAR) revealed he was receiving medications as ordered. Record review of Resident #2's Psychiatry Intake Note dated 03/31/2022 revealed diagnosis of Major Depressive Disorder, Recurrent episode, Moderate, Unspecified Schizophrenia Spectrum and other psychotic disorder, Unspecified Anxiety Disorder, Insomnia Disorder, and Probable Major Neurocognitive Disorder due to Alzheimer's disease, with behavioral disturbance. Plan: 1. Discontinue Zoloft, start Mirtazapine 7.5 mg at bedtime, start Depakote 125 mg twice a day for mood stabilization, Depakote level in one week, and Continue Risperidone 0.5 mg at bedtime for psychosis. Record review of Resident # 2's Psychiatry Intake Note dated 06/28/2022 revealed diagnosis of Major Depressive Disorder, recurrent episode, moderate, Unspecified Schizophrenia Spectrum and other psychotic disorder, Unspecified Anxiety Disorder, Insomnia Disorder, and Probable Major Neurocognitive Disorder due to Alzheimer's disease, with behavioral disturbance. Plan case and plan discussed with doctor . with the following ordered Medications: - Continue Depakene 250 mg 3 times a day. - Continue Zyprexa 5 mg at bedtime - Continue Mirtazapine 7.5 mg at bedtime - Continue Melatonin 5 mg at bedtime - Continue Temazepam 15 mg at bedtime - Continue Lorazepam 0.5 mg 2 times a day. On 07/14/2022 at 12:29 PM the Director of Social Services (DSS) revealed she is not in charge of the PASRRs and that it is done by the admissions department. On 07/14/2022 at 12:52 PM, the Admissions Coordinator revealed that during admissions she makes sure that the residents came with the PASRR Level I and residents with PASRR Level II are not admitted to the facility on ce they know resident needs Level II PASRR. The Admissions Coordinator explained she only checks the Level I PASRR the name, date of birth , and date signed are correct, makes sure the 5 pages are in the package and signed by the RN (Registered Nurse) in the hospital. If a resident is being admitted from home, the facility will complete a Level I and the Director of Nursing (DON) or a designated RN will sign it. The Admissions Coordinator stated that after she reviews the package for Level I PASRR, it is checked by the medical records staff. The medical records staff will take the PASRR Level I; if it is completed and upload it in the electronic record. The Admissions Coordinator stated that the facility never admitted a resident with a PASRR Level II; and added that Level II is for example is if a person has multiple psych issues, conditions like Down Syndrome, etc. and noted that for those cases they would do a Level II PASRR. The Admissions Coordinator stated that all residents should be screened for PASRR Level I because without it the facility does not get paid and that will tell if the resident meets the criteria to receive rehabilitation. In case a resident has schizophrenia or behavior and if the form said yes and if she finds it in the documents, she will go to DON. Before going to the DON, she will contact the Case Manager from the hospital to verify that the information for diagnosis or behavior is correct. The Admissions Coordinator stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 5 of 14 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 105008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Biscayne Health and Rehabilitation Center 12505 NE 16th Ave North Miami, FL 33161 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she has been working in the facility for three years and never had a resident admitted that had a PASRR Level I completed with answer to Yes to any questions in Section II, and never had to go to the DON to ask her about it. The Admissions Coordinator explained that in the past she admitted residents with diagnosis in the Section I of the PASRR Level I with Schizophrenia, Bipolar disorder, Anxiety, Depression, etc. but the answer to all questions in Section II were No. and she never had a resident who required a Level II PASRR. When asked why Resident # 84 did not have a Level II PASRR, the Admissions Coordinator stated it was not done because the hospital stated that the patient did not require a Level II PASRR. The admission Coordinator stated that she was not aware Resident # 84 and Resident #2 had a mental condition such as Schizophrenia when they were admitted in the facility. The Admissions Coordinator stated when she checked the residents' PASRR Level I she only checked the name, dates, and number of pages, but not the diagnosis on the hospital records On 07/14/2022 at 1:50 PM, the medical records staff was asked about her involvement with the newly admitted residents' PASRR Level I, the medical records staff stated that she only uploaded the PASRR Level I in the electronic system when the residents came from hospital, and reports to Admissions Coordinator if they do not have PASRR Level I. The medical records staff stated that she only looked at the name and date on the last page to make sure it is signed and completed but she does not check for diagnosis or anything else. The medical records staff stated if there is something missing from the documents, she will bring it to the Admissions Coordinator's attention. When asked what she would do if she does not see a checked mark in Section I for diagnosis, the medical records staff stated that she is not too familiar with what she should be looking for in the PASRR because the facility did not train her on PASRR. The medical records staff re-stated that she only looked for names, signature, and dates. The medical record staff added that she will report anything missing on the Level I PASRR during the morning meetings but sometimes the Level I PASRRs are already uploaded by the Admissions Coordinator, so therefore she does not check those documents because they are already uploaded. Interview with the DON on 07/14/2022 at 06:15 PM revealed, when the hospital sends referrals for new admissions, the facility makes sure the Level I PASRR is completed in the documentation they receive. The DON stated that it is usually the Admissions Coordinator who receives all the paperwork, and she emails it to her or print out the documents and they will look at it. The DON stated she looks at the diagnosis on the PASRR, the patient information and other documentation such as where the resident is coming from, medication, etc. The DON stated in cases where there is no mental diagnosis listed on the Level I PASRR, but the patient is taking psych meds she will check the history and check if the patient has an actual mental diagnosis. The DON stated if there is no mental diagnosis checked and patient is taking psych medication, she cannot admit the resident until the document is corrected. The DON explained the PASRR document is done on preadmission, so it is supposed to be corrected before admission. The DON reported that she cannot state for sure that she is checking 100% of all admissions, but the new admissions are discussed in the morning meetings and added that the facility does not do PASRR Level I if the document was not completed correctly and unless the resident has a new condition, a change, or a new mental diagnosis. The DON stated, I know when they have certain diagnosis such as Schizophrenia or changes on condition, they meet criteria to be screened for Level II. The DON stated she started as a DON here in September and she does not remember to have reviewed any Level I PASRR that required a Level II evaluation. The DON stated she is the one in charge of reviewing the PASRR Level I because the facility does not have any staff with a master's degree in social work; and is aware that another RN can also do the review, but she is the one doing it. The DON was showed Resident #84 and Resident#2's PASRR Level I which did not have any checked diagnosis, the DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 6 of 14 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 105008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Biscayne Health and Rehabilitation Center 12505 NE 16th Ave North Miami, FL 33161 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few acknowledged it was not completed properly because both residents have a diagnosis of Schizophrenia. The DON stated she knew the Level I PASRR is completed to let the facility know if a resident can be admitted in the facility. The DON was asked what she would have done if noticed both residents' PASRR Level I were not completed properly, the DON stated that she would have the doctor evaluate Resident # 84 and Resident # 2 to decide if the residents were able to stay in the facility. The DON was asked if she knew about the state mental health designated authority that can do the screening and decide if PASRR Level II is required, and DON stated she did not know. Record review of Policy and Procedures on PASRR effective 04/2015 and revised on 10/2021 revealed: I. PURPOSE: Pre-admission Screening and Resident Review (PASRR) is a federal requirement mandated by the Social Security Act. It is intended to ensure that Medicaid-certified nursing facility applicants and residents with diagnosis of or suspicion of serious mental illness or intellectual disabilities, or related conditions are identified and admitted or allowed to remain in the nursing facility only if there is a verified need for such services. IV. POLICY: The facility ensures that all residents admitted to the facility has PASRR Level I done prior to admission to facility or Level II as indicated by resident's condition and behavior. The facility ensures that PASRR Level I must reflect current condition and diagnosis of resident. Facility will follow form mandated by AHCA at any given time. V. PROCEDURE: 1. Prior to admission, the admission department including nursing navigator must ensure that hospital or another nursing home facility has completed PASRR Level I for new residents prior to admittance to facility 2. Upon receipt of PASRR I from hospital or another nursing home, facility will review PASRR Level I by DON or designee. If PASRR Level I indicated that resident exhibited actions or behaviors that may make resident a danger to self or others, facility must request from hospital or nursing home a Level II PASRR. If PASRR Level I indicates that a resident has serious mental illness and PASRR Level I indicates that a PASRR Level II is needed, facility must request from hospital or another nursing home, a PASRR Level II priors to admission to facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 7 of 14 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 105008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Biscayne Health and Rehabilitation Center 12505 NE 16th Ave North Miami, FL 33161 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 the Preadmission Screening and Resident Review (PASRR) Level I for Severe Mental Disorder (SMI) or intellectual disability (ID) was completed correctly at the time of admission for two residents (Resident #84 and Resident #2) out of three residents investigated for PASRR by admitting both residents with diagnosis of severe mental illnesses without the mental conditions being identified in the documents. This deficiency has the potential to affect 92 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Resident #84 On 07/11/22 at 10:20 AM, Resident # 84 was observed lying in bed, he was alert times one (person) but not interviewable. Record review of Resident #84's medical record revealed the resident was originally admitted on [DATE]. According to the face sheet, the resident had diagnoses to include but not limited to Unspecified Psychosis not due to substance or known physiological condition, Major Depressive disorder, Schizophrenia, and Disorganized Schizophrenia. Record review of Resident # 84's Quarterly Minimum Date Set (MDS) with Assessment Reference Date (ARD) of 06/22/2022 revealed in Section A Identification Information PASRR Level II coded as No. In Section C for Cognitive Patterns coded score 04 out of 15 for the Brief Interview for Mental Status (BIMS). In Section I Active Diagnoses coded Psychiatric/ Mood disorders, Depression and Psychotic disorder (other than Schizophrenia) and additional diagnosis of Insomnia. There was no documented coding for Schizophrenia. In Section N Medications coded antipsychotic and antidepressant medication. Review of Resident #84's PASRR Level I completed at the hospital and dated on 10/27/2021 revealed the hospital did not check any mental illness in Section I PASARR Screen Decision-Making, in Section II Other Indications for PASRR Screen-Decision Making checked all boxes indicating No when answering all questions on the form, in Section IV PASRR Screen Completion checked option No diagnosis or Suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Review of Resident #84's care plan dated 11/11/2021 and last revised on 06/22/2022 revealed use of psychotropic medications related to diagnosis of Schizophrenia and is at risk for negative effects from the use of the medication, and the use of antidepressant medication related to diagnosis of depression. Record review of Resident #84's physician orders (PO) revealed Seroquel (Quetiapine Fumarate) tablet 100 mg (milligram) ordered 1 tablet by mouth two times a day and 300 mg at bedtime related to Disorganized Schizophrenia, and Trazodone HCL 100 mg tablet ordered to be given 100 mg by mouth at bedtime for Depression. Record review of Resident #84's primary physician consult dated 11/13/2021 revealed a psychiatry consult evaluation and revision for comorbid Schizophrenia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 8 of 14 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 105008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Biscayne Health and Rehabilitation Center 12505 NE 16th Ave North Miami, FL 33161 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident # 84's Psychiatry Intake Note dated 02/07/2022 revealed a referral for psych evaluation and diagnosis of psychosis and depression. Evaluation completed and treatment ordered included Seroquel 100 mg in the morning and 300 mg at bedtime, and Trazodone 100 mg at bedtime. Record review of Resident # 84's Psychiatry Intake Note dated 04/27/2022 revealed Schizophrenia, Insomnia Disorder and Probable Major Neurocognitive Disorder due to Alzheimer's Disease, with behavioral disturbance, orders to continue Seroquel 100 mg daily and 300 mg at bedtime, and Trazodone 100 mg at bedtime. Resident #2 On 07/13/2022 at 10:15 AM, Resident # 2 was observed lying in bed and watching television. the resident was not no alert and oriented. Record review of Resident # 2's medical record revealed the resident was admitted on [DATE]. According to the face sheet, the resident diagnoses include but not limited to Schizophrenia, unspecified, Primary Insomnia, Depression unspecified, unspecified Psychosis not due to a substance or known physiological condition, Anxiety Disorder, unspecified, other specified depressive episodes, Major Depressive Disorder, recurrent, moderate. Record review of Resident # 2's admission Minimum Date Set (MDS) with Assessment Reference Date (ARD) of 04/05/2022 in Section A for Identification Information indicated PASRR Level II coded as No. In Section C Cognitive Patterns coded a score of 01 out of 15 in the Brief Interview for Mental Status (BIMS). In Section I Active Disease Diagnosis indicated Psychiatric/Mood disorder Diagnosis coded Schizophrenia, Anxiety, Depression, Psychotic disorder. In Section N for Medications was coded for use of antipsychotic and antidepressant medications. Record review of Resident # 2's PASRR Level I, completed on 08/03/2021 by a Registered Nurse (RN) at the previous facility where resident lived revealed no mental illness checked in Section I: PASRR Screen-Decision Making, In Section II Other Indications for PASRR Screen-Decision Making checked all boxes indicating No when answering all questions on the form, in Section IV PASRR Screen Completion checked option No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Record review of Resident #2's Care plan dated 04/11/2022 revealed use of psychotropic medications related to diagnosis of Schizophrenia, for sedative/hypnotic therapy related to Insomnia, and for the use of antidepressant medication related to diagnosis of Depression. Record review of Resident # 2's Physician Orders (PO) revealed Mirtazapine 7.5 mg at bedtime for Depression, Depakene 250 mg twice a day for mood stabilization, Risperidone 0.5 mg at bedtime for psychosis, and Melatonin 5 mg at bedtime, Temazepam 15 mg at bedtime for Insomnia, Zyprexa 5 mg at bedtime, and Lorazepam 0.5 mg twice a day for anxiety. Record review of Resident #2's current Medication Administration Record (MAR) revealed he was receiving medication as ordered. Record review of Resident #2's Psychiatry Intake Note dated 03/31/2022 revealed diagnosis of Major Depressive Disorder, Recurrent episode, Moderate, Unspecified Schizophrenia Spectrum and Other Psychotic disorder, Unspecified Anxiety Disorder, Insomnia Disorder, and Probable Major Neurocognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 9 of 14 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 105008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Biscayne Health and Rehabilitation Center 12505 NE 16th Ave North Miami, FL 33161 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Disorder due to Alzheimer's disease, with behavioral disturbance. Plan: 1. Discontinue Zoloft, start Mirtazapine 7.5 mg at bedtime. Start Depakote 125 mg twice a day for mood stabilization, Depakote level in one week. Continue Risperidone 0.5 mg at bedtime for psychosis. Record review of Resident #2's Psychiatry Intake Note dated 06/28/2022 revealed diagnosis of Major Depressive Disorder, Recurrent episode, Moderate, Unspecified Schizophrenia Spectrum and Other Psychotic disorder, Unspecified Anxiety Disorder, Insomnia Disorder, and Probable Major Neurocognitive Disorder due to Alzheimer's disease, with behavioral disturbance. Plan Case and plan discussed with doctor who aggressive with the following orders: - Continue Depakene 250 mg 3 times a day. - Continue Zyprexa 5 mg at bedtime - Continue Mirtazapine 7.5 mg at bedtime - Continue Melatonin 5 mg at bedtime - Continue Temazepam 15 mg at bedtime - Continue Lorazepam 0.5 mg 2 times a day. On 07/14/2022 at 12:29 PM the Director of Social Services (DSS) revealed she is not in charge of the PASRRs and that it is done by the admissions department. During an interview on 07/14/2022 at 12:52 PM, the Admissions Coordinator revealed that for the admissions she makes sure that the residents came with the PASRR Level I and residents with PASRR Level II are not admitted to the facility on ce they know resident needs Level II PASRR. The Admissions Coordinator explained she only checks the Level I PASRR the name, date of birth , and date signed are correct, makes sure the 5 pages are in the package and signed by the RN (Registered Nurse) in the hospital. If a resident is being admitted from home, the facility will complete a Level I and the Director of Nursing (DON) or a designated RN will sign it. The Admissions Coordinator stated that after she reviews the package for Level I PASRR, it is checked by the medical records staff. The medical records staff will take the PASRR Level I; if it is completed and upload it in the electronic record. The Admissions Coordinator stated that the facility never admitted a resident with a PASRR Level II; and added that Level II is for example is if a person has multiple psych issues, conditions like Down Syndrome, etc. and noted that for those cases they would do a Level II PASRR. The Admissions Coordinator stated that all residents should be screened for PASRR Level I because without it the facility does not get paid and that will tell if the resident meets the criteria to receive rehabilitation. In case a resident has schizophrenia or behavior and if the form said yes and if she finds it in the documents, she will go to DON. Before going to the DON, she will contact the Case Manager from the hospital to verify that the information for diagnosis or behavior is correct. The Admissions Coordinator stated that she has been working in the facility for three years and never had a resident admitted that had a PASRR Level I completed with answer to Yes to any questions in Section II, and never had to go to the DON to ask her about it. The Admissions Coordinator explained that in the past she admitted residents with diagnosis in the Section I of the PASRR Level I with Schizophrenia, Bipolar disorder, Anxiety, Depression, etc. but the answer to all questions in Section II were No. and she never had a resident who required a Level II PASRR. When asked why Resident # 84 did not have a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 10 of 14 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 105008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Biscayne Health and Rehabilitation Center 12505 NE 16th Ave North Miami, FL 33161 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 0645 Level of Harm - Minimal harm or potential for actual harm Level II PASRR, the Admissions Coordinator stated it was not done because the hospital stated that the patient did not require a Level II PASRR. The admission Coordinator stated that she was not aware Resident # 84 and Resident #2 had a mental condition such as Schizophrenia when they were admitted in the facility. The Admissions Coordinator stated when she checked the residents' PASRR Level I she only checked the name, dates, and number of pages, but not the diagnosis on the hospital records Residents Affected - Few On 07/14/2022 at 1:50 PM, the medical records staff revealed she only uploaded the PASRR Level I in the electronic system when the residents came from hospital, and reported to the Admissions Coordinator if the resident does not have a PASRR Level I. The medical records staff stated that she only looked at the name and date on the last page to make sure it is signed and completed but she does not check for diagnosis or anything else. The medical records staff stated if there is something missing from the documents, she will bring it to the Admissions Coordinator's attention. When asked what she would do if she does not see a checked mark in Section I for diagnosis, the medical records staff stated that she is not too familiar with what she should be looking for in the PASRR because the facility did not train her on PASRR. The medical records staff re-stated that she only looked for names, signature, and dates. The medical record staff added that she will report anything missing on the Level I PASRR during the morning meetings but sometimes the Level I PASRRs are already uploaded by the Admissions Coordinator, so therefore she does not check those documents because they are already uploaded. Interview with the DON on 07/14/2022 at 06:15 PM revealed, when the hospital sends referrals for new admissions, the facility makes sure the Level I PASRR is completed in the documentation they receive. The DON stated that it is usually the Admissions Coordinator who receives all the paperwork, and she emails it to her or print out the documents and they will look at it. The DON stated she looks at the diagnosis on the PASRR, the patient information and other documentation such as where the resident is coming from, medication, etc. The DON stated in cases where there is no mental diagnosis listed on the Level I PASRR, but the patient is taking psych meds she will check the history and check if the patient has an actual mental diagnosis. The DON stated if there is no mental diagnosis checked and patient is taking psych medication, she cannot admit the resident until the document is corrected. The DON explained the PASRR document is done on preadmission, so it is supposed to be corrected before admission. The DON reported that she cannot state for sure that she is checking 100% of all admissions, but the new admissions are discussed in the morning meetings and added that the facility does not do PASRR Level I if the document was not completed correctly and unless the resident has a new condition, a change, or a new mental diagnosis. The DON stated, I know when they have certain diagnosis such as Schizophrenia or changes on condition, they meet criteria to be screened for Level II. The DON stated she started as a DON here in September and she does not remember to have reviewed any Level I PASRR that required a Level II evaluation. The DON stated she is the one in charge of reviewing the PASRR Level I because the facility does not have any staff with a master's degree in social work; and is aware that another RN can also do the review, but she is the one doing it. The DON was showed Resident #84 and Resident#2's PASRR Level I which did not have any checked diagnosis, the DON acknowledged it was not completed properly because both residents have a diagnosis of Schizophrenia. The DON stated she knew the Level I PASRR is completed to let the facility know if a resident can be admitted in the facility. The DON was asked what she would have done if noticed both residents' PASRR Level I were not completed properly, the DON stated that she would have the doctor evaluate Resident # 84 and Resident # 2 to decide if the residents were able to stay in the facility. The DON was asked if she knew about the state mental health designated authority that can do the screening and decide if PASRR Level II is required, and DON stated she did not know. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 11 of 14 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 105008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Biscayne Health and Rehabilitation Center 12505 NE 16th Ave North Miami, FL 33161 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 0645 Record review of Policy and Procedures on PASRR effective 04/2015 and revised on 10/2021 revealed: Level of Harm - Minimal harm or potential for actual harm I. PURPOSE: Residents Affected - Few Pre-admission Screening and Resident Review (PASRR) is a federal requirement mandated by the Social Security Act. It is intended to ensure that Medicaid-certified nursing facility applicants and residents with diagnosis of or suspicion of serious mental illness or intellectual disabilities, or related conditions are identified and admitted or allowed to remain in the nursing facility only if there is a verified need for such services. IV. POLICY: The facility ensures that all residents admitted to the facility has PASRR Level I done prior to admission to facility or Level II as indicated by resident's condition and behavior. The facility ensures that PASRR Level I must reflect current condition and diagnosis of resident. Facility will follow form mandated by AHCA at any given time. V. PROCEDURE: 1. Prior to admission, the admission department including nursing navigator must ensure that hospital or another nursing home facility has completed PASRR Level I for new residents prior to admittance to facility 2. Upon receipt of PASRR I from hospital or another nursing home, facility will review PASRR Level I by DON or designee. If PASRR Level I indicated that resident exhibited actions or behaviors that may make resident a danger to self or others, facility must request from hospital or nursing home a Level II PASRR. If PASRR Level I indicates that a resident has serious mental illness and PASRR Level I indicates that a PASRR Level II is needed, facility must request from hospital or another nursing home, a PASRR Level II priors to admission to facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 12 of 14 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 105008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Biscayne Health and Rehabilitation Center 12505 NE 16th Ave North Miami, FL 33161 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 - Some 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, the facility failed to ensure foods were prepared and distributed at safe temperatures, as evidenced by failure to provide evidence that food holding temperatures were consistently monitored and recorded for all menu items. This deficient practice places residents at risk for potential foodborne illness and has the potential to affect 84 residents in the facility who eat orally out of 92 resident residing in the facility at the time of the survey. The findings included: Observation in the kitchen on 7/12/22 at 11:30 AM, revealed staff placing hot food on to the steam table in preparation for lunch service scheduled to begin at 12:00 PM. The [NAME] (Staff A) was observed using a calibrated dial stem thermometer to check food holding temperature for all hot food items on the steam table. This task was completed under the supervision of the Food Service Director (FSD). All temperatures were taken by 11:54 AM, but the staff was not observed recording the temperature results. The tray line service began at 12:05 PM. Interview with the FSD on 7/12/22 at 12:15 PM revealed he maintains a log which is used to record all of the food holding temperatures. The temperatures of all food items are checked and recorded for each meal. The temperatures are usually recorded by the cook on the menu and then transcribed to the temperature log. Review of the the Food Temperature Record for the weeks 6/19/22 to 6/25/22, 6/26/22 to 7/2/22, and 7/3/22 to 7/9/22 revealed all logs were blank. Review of the food temperature log binder revealed no Food Temperature Record on file for the current week 7/10/22 to 7/16/22. Interview with the [NAME] (Staff A) on 07/12/22 at 12:20 PM revealed she writes the temperatures on the menu which is on the clipboard. Review of the documents on the clipboard for Week 4 of the menu cycle revealed temperatures for regular menu items were recorded on the week at a glance menu for the breakfast, lunch and dinner meals on 7/11/22 and for the breakfast meal on 7/12/22. There were no temperatures recorded for the therapeutic and or texture modified hot or cold menu items. There were no therapeutic diet extension sheets on the clipboard for the current week. Interview with the FSD on 7/12/22 at 12:25 PM revealed he sometimes writes the food holding temperatures on another piece of paper and then transfers the temperatures to the log. The FSD was not able to provided any evidence that the temperatures had been taken or recorded for the past three weeks or the first three day of the current week. The FSD revealed the temperatures are usually recorded on the menu and then transferred to the log. The FSD revealed the paper copies of the menu are not maintained after use because any menu substitutions are recorded electronically and approved by the Dietitian. The FSD was not able to locate copies of the menu with the food holding temperatures. Interview with the FSD 07/12/22 at 12:28 PM revealed he removed the therapeutic diet extension sheets from the clipboard on 7/11/22 to make copies for the survey team and he did not put them back on the clipboard. Review of copies provided revealed no temperatures recorded for 7/1022 or 7/11/22 on the therapeutic extension sheets. The FSD stated he had not transferred the temperature to the log for the last 3 weeks and he was unable to locate the menu and or extension sheets for these weeks. There was no evidence that the temperatures had be checked or recorded. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 13 of 14 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 105008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Biscayne Health and Rehabilitation Center 12505 NE 16th Ave North Miami, FL 33161 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 - Some Interview with the Regional Food Service Consultant on 7/12/22 at 2:45 PM revealed the facility policy and procedure regarding food holding temperatures was revised on 7/12/22 and all dietary staff had been in-serviced on use of the temperature log for recoding the temperatures. Review of the facility policy and procedure titled Monitoring of Holding Temperatures dated July 2017 revealed: The temperatures of foods held in the steam table will be monitored by food service staff. 1. An accurate thermometer is maintained in the food service department. 2. The maximum length of time the food will be held on the steam table is 4 hours total. 3. The food service staff will take temperatures prior to meal service to ensure temperatures are in compliance with regulatory standards 4. Temperatures are recorded on the menu. 5. Any food item that is not in compliance with the above standards: hot items will be reheated to 165 degrees Fé (Fahrenheit) for at least 15 seconds before serving. Cold items will be placed back in refrigeration of 41 degrees F or then and rechecked after 2 hours for compliance Review of the facility policy and procedure titled Daily Temperature Log dated 7/12/22 revealed: The Dietary [NAME] or Supervisor will take all hot and cold food and beverage item temperatures three times per day. The temperature will be monitored for acceptable safe temperature zone for each item. Written records of temperatures are stored in the office. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 14 of 14