Health inspection·July 27, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Room#101- The exterior of the nightstand had sharp edges (X2), a very strong urine odor coming out from the bathroom, and wires on the floor around Bed A. Room#102- The exterior of the resident room chair was noted to be heavily worn, and the bathroom floor was heavily stained throughout. Residents Affected - Some Room#103- There was a small hole on the floor between the closet doors, the exterior of the nightstand had exposed sharp edges (X2), and the bathroom ceiling appeared to have water damage. Room#104- The exterior of the nightstand had exposed sharp edges (X2). Room#105 -The exterior of the nightstand had exposed sharp edges (X2), the window blinds did not work and there were 3 slats missing. The exterior of the overbed tables were is disrepair and had exposed sharp edges. Room#106- The exteriors of the nightstand had sharp edges (X2), and tiles at the entrance of the room were broken and were a trip hazard. Room#107 -The exterior of the nightstand had sharp edges (X2), the light cover located over the room sink was missing, and the doorstop needed to be removed due to it being a trip hazard. Room#109 -The exterior of the nightstand had exposed sharp edges (X2). Room#110 -The exterior of the nightstands had exposed sharp edges (X2), and bathroom light was missing one light bulb out of two. Room#111- The exterior of the nightstand had sharp edges (X2), the bathroom door handle was loose, and the bathroom ceiling appeared to have water damage. Room#115 -The exterior of the nightstands had exposed sharp edges (X2), and the bathroom floor was heavily soiled and stained. Room#116 -The exterior of the nightstands had exposed sharp edges (X2), the bathroom entry/exterior door had areas of peeling paint, and bathroom floor was in disrepair with heavy areas of peeling paint. Room#118 The floor in the room was dirty, the sink had stains, the exterior of the nightstand had sharp edges (X2), and the paint on the walls was peeling. Room#120 -The exterior of the nightstands had exposed sharp edges (X2), the toilet seat was falling off the commode, the blinds were missing from the window, the bathroom floor was in disrepair and there were numerous areas of peeling paint. Room#121- The exterior of the nightstands had exposed sharp edges (X2), the bathroom floor was in disrepair with numerous areas of peeling paint , and the ceiling air conditioner vent was in need of re-painting. The First Floor Nurses Station had numerous hazardous chemicals stored without being secured that included: 1070-ml sterile water, Floor Care/maintenance of finished floor, Chemtron-Hand cleanser and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 2 of 17 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 07/27/2023 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 0584 sanitizer, Glass cleaner, Cleaner and Disinfectant, Glove-Free no boil-Fryer cleaner. Level of Harm - Minimal harm or potential for actual harm The First Floor Nursing Storage Closet- The room was noted to be unlocked and not secured with supplies that included: Vitamin A&D Ointment, disposable razor packs, Nebulizer mask and kit, hair brushes, tooth paste, and oral care swabs. Residents Affected - Some 2) Second Floor: Room#201- The bathroom floor was in disrepair with numerous areas of peeling paint. Room#202- The bathroom walls were heavily soiled, there was peeling paint, the bathroom toilet required re-caulking to the floor, and the exterior of the room chair was heavily worn. Room#203- The room base boards required re-painting, and te shower room floor was in disrepair with numerous areas of peeling paint. Room#205- The bathroom floor was in disrepair with numerous areas of peeling paint, the room base boards required re-painting, and the room floor was noted to have large black stains. Room#206- The bathroom floor had areas of peeling paint, the shower room floor was heavily soiled and stained, and exteriors of overbed table had exposed sharp edges (X2). Room#207- The night stands (X2) had exposed sharp edges, the bathroom walls and floor was in disrepair and soiled, and the bathroom ceiling had a stain and was black in color. Room#208- The exterior room chair was heavily worn, and the bathroom floor was heavily soiled and stained. Room#209- The bathroom floor was heavily soiled and in disrepair, and the exterior of the nightstand had exposed sharp edges (Bed A). Room#210 - The exterior of the room chair was heavily worn, and bathroom floor heavily soiled, stained and in disrepair. Room#211- The bathroom floor was heavily soiled and in disrepair with numerous large areas of peeling paint, and room walls were in disrepair and required repainting. Room#212- The exterior of the room chair was heavily worn, and the bathroom floor was heavily soiled, in disrepair with numerous areas of peeling paint. Room#213- The exterior of the nightstands (X2) had exposed sharp edges. The bathroom floor was in disrepair with numerous areas of peeling paint. Room#216 - The toilet seat was not secured and was heavily worn, and shower floor was heavily soiled and stained. Room#218- The bathroom floor was heavily soiled and in disrepair with numerous areas of peeling paint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 3 of 17 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 07/27/2023 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 0584 Room#219 -The bathroom floor was heavily soiled and stained. Level of Harm - Minimal harm or potential for actual harm Room#220- The bathroom floor and walls were in disrepair with numerous areas of peeling paint, and the shower room floor was soiled, stained and in disrepair. Residents Affected - Some Room#221- The resident's privacy curtain was soiled, the bathroom floor was heavily soiled and in disrepair. Room#222- The bathroom floor was soiled, stained and in disrepair with areas of peeling paint, and wall rail molding was coming off the wall (B Bed). Room#223- The bathroom floor was heavily soiled, stained and in disrepair with numerous areas of peeling paint, and the exterior of over-bed tables (X2) had exposed sharp edges. Room#224- The bathroom and shower room were heavily soiled, stained and in disrepair with numerous areas of peeling paint. Room#225- The bathroom floor was in disrepair with numerous areas of peeling paint, and the exterior over bed tables (X2) had exposed sharp edges. Room#226 -The bathroom floor was in disrepair with numerous areas of peeling paint. Room#227-The exterior of the room chairs were heavily worn (2X). The bathroom and shower room floor were heavily soiled, stained and in disrepair with numerous areas of peeling paint. Room#228- The bathroom and shower floor were in disrepair with numerous areas of peeling paint, the room walls required re-painting and the room base boards required re-painting. Room#229- The bathroom and shower floors were in disrepair with numerous areas of peeling paint, and the window blinds were missing and not working. The second floor nursing storage closet was unlocked and there were disposable razor packs, Nebulizer mask and kit, tooth paste, tooth brushes, Oral Care Swabs and other items in the room. The second floor Dining/Activities Room - Windows were dirty inside and out and a green algae build-up was observed, the floor had large stains, and the therapy equipment was stored in a corner and was rusty. Observation of the Dialysis Treatment Room on 07/26/2023 at 10:17AM: (a) The 2 garbage containers were noted to be without a lid and was overflowing with garbage, food wrappers, dirty gloves and Personal Protective Equipment (PPE). (b) A Red Bag for Biohazardous Waste was noted to be stored on the room floor near the dialysis machines. The dialysis nurse, a Licensed Practical Nurse (LPN) (Staff D) reported, it is the policy that red bags should be stored in a Biohazardous Box. (c) The wall around the room handwash sink was noted to have areas of peeling paint and there was a black mold like substance around and under the sink. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 4 of 17 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 07/27/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (d) The door to the dialysis treatment chemicals room did not have a lock and there was open staff food observed and food lunches stored directly on the chemical shelves. Staff D reported, the the lunch bag was brought from his home and is stored in the room on a daily basis. (e) The 4 walls and room floor were heavily soiled and stained. There were large areas of peeling paint. Interview conducted with Staff D during the tour revealed, dialysis staff did not know who or how often the room was cleaned and sanitized. (f) There was soiled cleaning equipment, a (a broom and dustpan stored in the clean dialysis chemical room. Interview with Staff C, a Registered Nurse & Staff D revealed, this is where the soiled equipment is stored and they were not aware of the location were the soiled equipment was to be stored when not in use. (g) The room blinds were observed to be broken and slats were noted to be missing and was not providing resident privacy during the dialysis treatment. (h) The room window (inside and outside) was heavily soiled with dirt, dust, rust, and dead insects. Following the tours the environment issues were again confirmed with the administrative staff. * Photographic evidence obtained for all issues with the environment tours. 3) Observation completed on 07/24/23 at 11:15 AM revealed Resident #141 lying in his bed, the resident was alert and oriented. Resident #141 stated he lives with his daughter, and he came here temporarily and was admitted recently. The resident reported, he had a stroke in 2019 and is not able to move his left arm, and he needs assistance. Resident #141 stated the bed makes his body painful, but he can't be sit in his wheelchair for long periods because it hurts too. Resident #141 stated he talked to the Maintenance staff who said he is looking for another mattress for him and will also see if the bed needs to be replaced. Observation on 07/26/23 at 09:40 AM revealed, Resident #141 was lying in his bed, he was sleeping but woke up and stated he was willing to be interviewed. Resident #141 stated he was not good because they had not changed his mattress. The resident reported he had already spoke to Maintenance Staff (Staff G). The resident reported, they were going to change his mattress, but they never did it and he is leaving the facility tomorrow. Resident #141 was asked did Staff G provide an explanation why they did not change his mattress, he reported, they did not. Observation on 07/26/2023 at 12:40pm revealed, Resident #141 was in his room, sitting in his chair, and he reported he wanted to go to in the dining room for lunch. Resident #141 reported, he was told they will change his mattress today and he was very thankful to the surveyor and reported, at least today I will sleep good in the bed. While completing observations and interview, the Maintenance Director and Staff G were observed bringing a new mattress in a box into Resident #141's room. They removed the old mattress and replaced it with the new one. Observation on 07/27/23 at 11:45 AM revealed, Resident #141 was lying in his bed, he was very happy with the new mattress and he was able to sleep the night before. Resident #141 reported, he is leaving today and was waiting to bef picked up to go home. The resident had no concerns with anything else. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 5 of 17 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 07/27/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Staff G, a Maintenance Staff member on 07/26/23 10:41 AM revealed, when a resident told him he/she is not comfortable with the bed or mattress he will check and report it immediately to the head of the Maintenance Department. Staff G added, if they have mattresses in storage, they will replace the mattress, but if there is none, they will replace the mattress with another mattress they would take from an empty bed. Staff G stated, this facility does not have a system to report work orders, or to report problems and the need for repairs, instead they work with what they need to do every day. Staff G reported, the facility had 2 staff members. One person covered the first floor, and he was assigned the second floor, but now he covers both floors. Staff G stated, there is only one maintenance staff member beside the head of the Department. Staff G reported, the facility is looking to hire for the maintenance position. Staff G stated, At this moment the facility does not have any bed mattress (regular or air mattress) in storage. They received about 10 units, and they had pending request and they replaced the ones who needed the mattresses to be replaced. Staff G stated, he was aware Resident #141 had been uncomfortable with the mattress he had in his bed; he checked the bed, and he found no problems. The problem is the mattress pad in the middle is gone. Staff G added, the mattress assigned to Resident #141is thinner than others, the regular ones. Staff G reported, Resident #141 told him about his mattress a couple of days ago. Staff G stated, Resident #141 is very pleasant person and very alert. Staff G stated, he told his boss, the head of his department and he said that he was going to change it, but he did not say anything else. Staff G stated, on those cases he usually does change the mattress himself, but it is a process because he has to talk to the nurse, to tell Certified Nursing Assistant(CNA) to take resident out of the bed. Staff G reported, he will bring another mattress from an empty bed and will replace the bad one, but Staff G reported, he has been overwhelmed too and he did not do it yet. Staff G stated, that mattress that is in the resident's bed is not good at all, it should be thrown in the garbage. Interview with the Maintenance Director on 07/26/23 at 11:10 AM revealed, when residents have problems with their mattress, they put on a new mattress or swap them from an empty bed and sanitize them. The Maintenance Director stated, the facility does not have any mattresses in storage now, but they ordered 10 a while ago. The Maintenance Director stated the last time the facility received new mattress was about two months ago, but when they do not have new mattress in storage, they replace the one the resident is complaining about with one taken from an empty room. The Maintenance Director stated his department has a system in place to make sure the residents' request for a new mattress or bed or any situation that is being handled by his department is resolved. The Maintenance Director stated, they have books on both floors in the nurse stations. The Maintenance Director explained he and his staff will look at the book daily, and he assigns work to his staff or himself to be resolved. When asked about Resident #141, the Maintenance Director stated he fixed his TV in the room the other day, and Resident #141 told him a few days ago, he does not speak English, but he made signs indicating a problem in his back. The Maintenance Director stated, he was assisted with translation by Staff G who speaks the same language of Resident #141 and told him they must change his mattress. The Maintenance Director acknowledged he did not change the mattress. The Maintenance Director stated, Staff G is working right now on changing Resident #141's mattress, after he was interviewed. When asked why it was not changed before, the Maintenance Director stated, I was waiting for the new mattresses they ordered. Asked why he did not replace with a mattress from an empty bed, he stated I wanted to give him a new mattress. Asked if he observed the condition of Resident#141's mattress, the Maintenance Director stated he did not see it because the resident was in bed most of the time. The Maintenance Director stated, Resident #141's work order was not in the book, and when asked why his request was not logged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 6 of 17 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 07/27/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in the book for work orders, the Maintenance Director stated, I don't know, but I know he needs a mattress and I was waiting for the new mattresses to come. The Maintenance Director provided the surveyor with the work order book from the second floor, and he verified there was no order to change the mattress for Resident #141. A ftew minutes later he provided a copy of the purchase order created on 07/26/2023 at 11:09 am, minutes after this surveyor interviewed Staff G and the facility was made aware about the Resident #141's concern. It was noted, the purchase order was created after the first interview with Staff G. The Maintenance Director admitted they completed the order a few minutes ago to purchase new mattresses. During a further interview with the Maintenance Director on 07/26/2023 at 12:45 pm, while he was taking the new mattress out of the box and replacing Resident #141's old mattress revealed, he did not have any new mattress in storage, but his boss bought this one and gave to him to replace the old one. Record review of Resident #141's Face sheet revealed Resident #141's date of admission was on 07/18/2023. Diagnoses included but were not limited to Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side, Other specified arthritis, unspecified side, Depression, and Hypertensive heart disease with heart failure. Record review of the Work Order Book for the month of the month of July revealed, no work order listed under resident #141's name. Record review of the Purchase Order dated 07/26/2023 created at 11:09am revealed, the order was placed for Mattress Pressure relief 80 (10 units). Record review of the Minimum Data Set (MDS) revealed it was in progress to be completed. Record review of Resident #141's Care Plan dated 07/19/2023 revealed: Resident has an Activity of Daily Living (ADL) self-care deficit related to (r/t) chronic medical condition. Goal: Resident will not have a decline in ADL functioning through the next review date. Interventions included but were not limited to: Assistive devices as ordered/indicated, Encourage and assist with all Activities for Daily Living (ADLs) tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. The resident is Independent for meeting emotional, intellectual, physical, and social needs. Prefers a balance of social and independent leisure activities. Physical Limitations Resident prefers to spend some time in his room, states he enjoys watching television (tv), updated with the cable line up. Interventions: The resident will be encouraged to (3) groups of choice weekly for social and cognitive stimuli by next review date, Assist/escort to activity functions of potential interest as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 7 of 17 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 07/27/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Social Services (DSS) on 07/26/23 at 12:25 PM revealed, she did not receive any complaint or concern voiced by Resident #141. The DSS provided the grievance log for this month and only three grievances had been filed. None of them belonged to resident #141. Record review of Grievance Log revealed no grievances filed on behalf of resident #141. Residents Affected - Some Record review of the Policy and Procedures on Maintenance Services revised 2009, reviewed January 2023 revealed: Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner always. 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. f. Establishing priorities in providing repair service. i. Providing routinely scheduled maintenance service to all areas. j. Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 8. The Maintenance Director is responsible for maintaining the following records/reports. k. Inspection of buildings; l. Work order requests; m. Maintenance schedules; 10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 8 of 17 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 07/27/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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, it was determined that foods were not prepared by methods that conserve nutritive value, flavor, and appearance for 4 (#53, #56, #64, and #391) out of 19 residents with physician ordered Pureed diets. Residents Affected - Some The findings included: 1) During the initial kitchen/food service observational tour on 7/24/2023 at 9:00AM, a 1/3 pan of pureed vegetables dated 07/23/23 was located in the walk-in refrigerator. During the initial tour the breakfast/lunch cook, (Staff A) was interviewed and it was reported, the pan was puréed green beans that had been fully cooked and pureed on 07/23/23 and were intended to be served for the lunch meal of 07/24/23. Observation of the green beans revealed them to be thoroughly cooked, pureed and lacked a bright green color. Staff A further stated, all pureed vegetables are regularly cooked and pureed over 24 hours ahead of the intended meal. The surveyor discussed with Staff and the Food Service Director (FSD) that the vegetables were fully cooked and would be heated and held at high temperature prior to serving on 07/24/23. It was also discussed that prolonged cooking and heating results in a loss of nutrient content as well as appearance and palpability. It was also discussed that resident's with physician ordered Pureed diet are often at nutritional risk. Staff A reported, she is a recent hire and has not been trained and didn't have knowledge of the preparation of pureed foods. Review of the facility's Diet Census for 07/24/23 revealed, there were currently 19 resident's with a physician ordered Pureed Diet. Resident's #53, #56, #64, and #391 were included in the sample of the 19 residents. 2) During the review of the approved menu for the breakfast meal of 07/25/23 , it was noted that 4 ounces (#8 Scoop) of Pureed Pancakes was to be served to residents with a physician ordered Pureed Diet. Observation of the breakfast meal in the main kitchen on 07/25/23 at 7:15 AM revealed, that a 3 ounce (#10) scoop was being utilized as a standard serving of the pureed pancake. The FSD confirmed the surveyors observation and stated that the cook (Staff A ) was using the incorrect serving utensil. Review of the facility's Diet Census for 07/24/23 noted that there were currently 19 resident's with physician ordered Pureed Diet. Resident's #53, #56, #64, and #391 were included in the sample of the 19 residents. 3) A review of the clinical rerecords of sampled Resident's #53, 56, #64, and #391 revealed, all resident were at nutritional risk , underweight, or malnourished as evidenced by the following: Resident #53 Date Of admission: [DATE] Diagnoses: Protein/Calorie Malnutrition Physician's Orders: Pureed Diet with Nectar Thick Liquids (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 9 of 17 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 07/27/2023 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 0804 Weight History: Level of Harm - Minimal harm or potential for actual harm 7/25/23 = 57 # 7/14/23 = 60# Residents Affected - Some 7/1/23 = 64 # Body Mass Index (BMI) = 9.2 (Severely Malnurished) Ht = 66 Resident #56 Date Of admission: [DATE] Diagnoses: Protein/Calorie Malnutrition/ Diabetes Type 2 Physicians Order: Pureed /NAS/CCHO (No added Salt/Consistent Controlled Carbohydrate Diet) Weight History: 7/20/23 = 145 # (Risk For Malnutrition) BMI= 26.5 Resident #64 Date Of admission: [DATE] Diagnoses: Protein/Calorie Malnutrition Physician's Orders: Pureed Diet Weight History: 7/25/23 = 108# 6/9/23 = 109 3/23/23 = 110 BMI = 18 (Underweight/Malnutrition) Ht = 65 Resident #391 Date Of admission: [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 10 of 17 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 07/27/2023 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 0804 Diagnoses: Protein/Calorie Malnutrition, Diabetes Type 2 Level of Harm - Minimal harm or potential for actual harm Physician's Orders Pureed Diet with Nectar Thick Liquids Weight History: Residents Affected - Some 7/24/23 = 137 6/9/23 = 153 3/1/23 = 156 1/20/23 = 172 BMI = 21.5 - Risk For Malnutrition Ht = 67 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 11 of 17 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 07/27/2023 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, it was determined that the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety that include; ensure the department is free of pest, ensure that hot and cold foods are held at regulatory temperatures, ensure that equipment is cleaned and maintained on a regular basis, and ensure that dietary staff facial hair is properly covered as per regulation. The findings included: 1) During the initial kitchen/food service observation tour conducted on 07/24/23 at 9:00 AM and accompanied with the facility's Food Service (FSD), the following were noted: (a) Flying insects were noted to be observed in the food preparation/tray line serving area, the food storage room, and the main dining room. Flying insects were noted to be landing directly on clean food preparation surfaces, and containers of prepared foods. Dietary staff were observed to be swatting at the flying insects. Four flying insects were observed in the food preparation/serving area. The FSD stated, that there has been fly issues lately in the kitchen, but the issue had not been reported to administration. The FSD reported, she did not know were the flies were entering, but possibly from the kitchen delivery entrance. An observation of the delivery entrance was completed and there was an installed air-curtain to stop the entrance of insects however, the unit was noted to be old and a very small air stream was being forced from the unit and did not cover the entire entrance for the prevention of insect entrance. (b) Observation of the Convection Ovens (#1 and #2) revealed, both to be heavily soiled and with a heavy build-up of black carbon matter. The FSD confirmed, the surveyors observation and stated that the ovens were not being cleaned weekly according to the equipment cleaning schedule. It was also discussed that potential carbon ingestion by resident's could result in a food borne illness. (c) Observation conducted of the Reach -in Refrigerator #1 noted that the exteriors of the 8 food storage shelves located within the unit were peeling plastic and paint. The FSD confirmed, the surveyors findings and stated that new shelves would be ordered. It was discussed with the FSD that small pieces of plastic and rust could potentially fall into foods being stored within the unit and result in a resident food borne illness. 2) During a second kitchen/food service tour conducted on 07/25/23 at 7:20 AM the following was observed: (d) Flying insects (3) were again noted to be observed in the food production/serving area. The insects were noted to be landing on the clean food preparation and serving surfaces and prepared foods. The FSD reported, the pest control company was contacted concerning the kitchen pest issues on 07/24/23. (e) Temperatures of the hot and cold foods located on the tray line with the use of the facility's calibrated food bayonet thermometer. The temperatures test noted that hot foods were not being held at a minimum of 135 degrees Fahreinheit (F) and cold foods were not being held at the regulatory requirement of a minimum 41 degrees F. The food temperatures were recorded as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 12 of 17 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 07/27/2023 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 Individual Sausage Patties = 120 degrees F Level of Harm - Minimal harm or potential for actual harm Pancakes = 90 degrees F Whole Milk (8 once cartons) = 59 degrees F Residents Affected - Many Fruit Juice (4 ounce portions) = 51 degrees F (f) During the observation it was noted that a dietary porter with facial hair was without a proper covering. The [NAME] was observed to be working in the food preparation/serving areas and dish machine areas without a covering. The FSD stated, that the kitchen did not have beard coverings in supply. It was discussed that Staff B, the Diet Aide, that facial hair could potentially fall into foods while working in the food preparation/serving areas. 3) During the observation of the first and second floor pantry rooms conducted on 07/26/24 at 1:30 PM, and accompanied with the Director of Nursing the following was observed: (g) First Floor Pantry Room: The refrigerator gaskets were noted to have a heavy build-up of black mold type matter, the rooms floor was heavily soiled and stained and appeared it was not cleaned on a regular basis, and the cupboard drawers (2) were heavily soiled and full of soiled disposable plates, cups, and lids. (h) Second Floor Pantry Room: The refrigerator gaskets were soiled and there was a buildup of black mold type matter, and the rooms floor was heavily soiled and stained. * Photographic evidence obtained FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 13 of 17 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 07/27/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F812 Food Procurement, Store/Prepare/Serve-Sanitary. This practice has the potential to increase the risk of negative resident outcomes and to affect all 91 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with the exit date 08/14/2022 Food Procurement, Store/Prepare/Serve-Sanitary was cited related to the facility failed to ensure foods were prepared and distributed at safe temperatures, as evidenced by a failure to provide food holding temperatures were consistently monitored and recorded for all menu items. During an interview on 07/27/2023 at 01:34 PM, the Nursing Home Administrator and Director of Nursing (DON) revealed, the Quality Assessment and Assurance Committee (QAA) meets the second Thursday of every month. The administrator stated that the QAA Committee is comprised of the following members: the Administrator, Medical Director, DON, Assistant Director of Nursing (ADON)/Infection Preventionist, Social Worker, Environmental Director, Rehabilitation Director, Dietitian, Human Resources Director, Medical Records Activities Director, Admissions Director, Food Service Director. The Nursing Home Administrator (NHA) stated, We have Performance Improvement Plans (PIPs) for, Return to Hospital rates, as we have had a higher percent. The DON stated, we have been monitoring the reason why the residents have been going to the hospital. The NHA continued and stated, we worked on one PIP for Customer Service, we are trying to improve out star rating for customer service, to get our google rating up, the system in the front, whenever you check in, gets your phone number in order to ask for your opinion or feedback, we can use that to figure out what was going on. We also have our Guardian Angel rounds with questions to the residents, the services and for grievance processes, we are working on a program moving forward for the employee of the month. The DON stated, we are not where we want to be, and we are trying to improve, I feel that it has gotten better but not where I want it to be, we do not have A high turnover, it has gotten better, more nurses that stay here, it is more stable and that improves our customer service. The NHA stated, for Environmental, basically we had this maintenance assistance who resigned recently and he has not been replaced yet, we have an open position, we have another employee who is part time and he was asked to work full time for now to help around, we have different projects, we replaced 20 LED (Light Emitting Diode) lightbulbs on hallways, we are re-doing bathroom floors on the second floor, up to now on some of them, we repainted the second floor day room, we repair the kitchen's roof, we are painting rooms including bathroom walls, we are going from room to room and we want to do a room every day, the hallways and the room doors have been painted, we are placing chiller pipes in the ceiling and a new compressor to help with the air conditioning (AC), also two weeks ago we did a water hyperchlorination and disinfection project, we flushed the entire building with clorine, we replaced the call light's chain on the overhead lights, we have done re-caulking of the sinks in every room, we are doing deep cleanings and replacing the room tiles; after the survey, we have plans to replace furniture. Review of Policies and Procedures, document titled 2023 QAPI (Quality Assurance and Performance Improvement) Plan revealed: QAPI Goals (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 14 of 17 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 07/27/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few At Biscayne Health and Rehabilitation, we are committed to focusing on clinical care, quality of life and resident choice. We expect all of our facilities to reflect this in their annual regulatory survey outcomes with deficiencies less than the state average, achieving compliance upon the first revisit and not having substandard quality of care deficiencies. On behalf of those we serve, we are committed to using QAPI to improve our performance and practices and to ensure we meet and exceed regulatory requirements and standards. In conducting a root cause analysis for the center's regulatory outcomes, Biscayne Health and Rehabilitation identified the following goals: Goal #1: Decrease/Eliminate complaint surveys by improving customer service. Goal #2: Ensure that the facility is survey ready 365 days a year by embracing company's policies and following them daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 15 of 17 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 07/27/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to follow infection control standards of practice as evidenced by dialysate (a fluid used during dialysis) jugs on the counter next to a disinfectant spray and sink; personal bags found in storage rooms; a broom/dustpan found in dialysate storage rooms; a biohazard bag on floor; and an overflowing trash bin. These actions have the potential to affect the seven residents who are receiving dialysis including sampled Resident #17. Residents Affected - Few The findings included: On 07/26/23 at 10:17 AM. During an observation of the dialysis treatment room. By the sink area, there were five dialysate jugs and one spray bottle that was labeled disinfection spray, and napkins in a clear bin on the counter. (See photographic evidence) An open trash bin was empty and by the sink. One step-on closable red biohazard bin is at the back of the room. Personal bags were located on the floor shelf of the television stand. (See photographic evidence) In the front storage room, there was a resident scale mechanical lift, there was a chair with rusted legs, and an unknown object underneath a plastic blanket, with plastic bags above it. A broom and dustpan were stored between the chair and the wall. (See photographic evidence) When asked, Do you have a clean and dirty sink? Staff C, a RN (Registered Nurse) stated, We only have one sink. When asked How do you use this sink and where can you store your dialysate that you're using? Staff D, an LPN (Licensed Practical Nurse) stated, We wash our hands and use hand sanitizer. We hold our dialysate on the sink. We don't want it on the floor. The disinfecting spray is to clean the dialysis machine and dialysis chair between residents. On 07/26/23 at 12:33 PM, during an interview with the Infection Preventionist, the observations were discussed, and the photographic evidence was shown. The Infection Preventionist stated, Those employees work with our contracted dialysis company, and they are covering for the dialysis nurses that usually come to the facility. Another Surveyor addressed the findings with me, and we did a walkthrough together earlier. We contacted our dialysis company to address the situation in the dialysis room. A representative will come out to visit the facility. We did an in-service with the dialysis technicians. We are having a team of maintenance, housekeeping, administration, nursing, and me to come to address the concerns today. On 07/27/23 at 09:30 AM, during an interview of staff from the dialysis contract company, Staff E, a RN (Registered Nurse) and Staff F, a CCHT (Certified Clinical Hemodialysis Technician). Staff E, RN stated, I am a dialysis nurse for the company. I float between facilities, and we are assigned here today. When asked, Is it allowed to have dialysis jugs next to a disinfectant spray bottle at the sink? Staff E RN stated, At dialysis facilities, we would have two sinks. If one sink is available, it would be shared. No, we are not allowed to have dialysate next to a disinfectant bottle. Staff F, CCHT, agreed to the statement. When the dialysis staff were asked, Can you have an open trash can, a Broom with a dustpan be stored in the dialysate room? Staff F stated, We usually do not have brooms and dustpans in the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 16 of 17 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 07/27/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff E, RN stated, For trash, open trash cans can be used but not overflowing. We have regular trash cans that can close. We ask for housekeeping to come in. The broom and dustpan can harbor germs, microbes, and infections. We can't disinfect it. It shouldn't be in the room. It's not like you can wipe down the surface like trash cans, tables, chairs, and dialysis machines. Staff F, CCHT, agreed to the statement. Review of the in-service and training titled, Dialysis Management: Infection control practices for dialysis facilities. Dated 7/26/23 at 10:00 AM. Instructed by Infection Preventionist and Staff C, RN and Staff D, Licensed Practical Nurse (LPN) signatures are present. (See photographic evidence) Review of facility's policy titled, Infection Prevention and Control Plan for Nursing Homes 2022-2023. It is noted on page 5, under Infection Prevention Control program goals and objectives. 2) To provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection and communicable diseases. Review of contract dialysis company policy titled Infection Control Practices for Dialysis Facilities dated revised 04/02/2020 and 07/11/2022. It is noted under section 2. Policy: The infection control practices recommended for dialysis units will reduce opportunities for patient-to-patient transmission of infectious agents, directly or indirectly via contaminated devices, equipment and supplies, environmental surfaces, or hands of personnel. It is noted, under Section 4: Procedure: A sufficient number of sinks with warm water and soap have been available to facilitate hand washing. (TX: Hands-free washing sinks are required in the treatment room.) In D-2: Not handling or storing contaminated (i.e., used) supplies, equipment, blood samples, or biohazard containers in areas where medication and clean (i.e., unused) equipment and supplies are handled. It is noted, in section 5: Environmental Practices, A. Physical environment: 1) Environmental cleaning of the dialysis unit will be accomplished as outlined by the housekeeping policies and procedures. Housekeeping service will have a written schedule that determines the frequency of cleaning and maintaining the cleanliness of all equipment, structures, areas, and systems within its scope of responsibility. E) Clean supplies stored in the treatment area will be segregated to clean carts or cabinets. Review of facility's policy titled Environmental Services, dated September 1, 2021. It is noted, Intent: It is the policy of the facility to provide Environmental services in accordance with State and Federal regulations. 1) The facility will maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. 3) housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105008 If continuation sheet Page 17 of 17