Health inspection·May 26, 2022

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the Physician Orders dated 03/21/2022 revealed the resident is receiving Citalopram tablet 20 mg once a day for Depression, and Olanzapine 5m by mouth once a day for Psychosis. Record review of the admission MDS Section A-Identification dated 03/27/2022, A1500 revealed, the resident is not considered for a Level II PASARR. A1510 is coded for the resident's diagnosis of serious mental illness, intellectual disability and other related conditions. Record review of the admission MDS Section I-Active Diagnoses dated 03/27/2022 revealed, the resident had depression and a psychotic disorder. Record review of the admission MDS Section N-Medications dated 03/27/2022 revealed the resident had antipsychotic and antidepressant medications six (6) times in a week. Record review of the admission MDS Section O-Special Treatment, Procedures and Programs dated 03/27/2022 revealed the resident is not receiving psychological therapy. During interview with the Director of Nursing on 05/26/22 at 12:05 PM, he stated for PASARR requirements they follow the policies and procedures and the regulations. He stated the residents admission is based on the Level I PASARR. The Level II PASARR is triggered if the resident had a mental illness or intellectual disability and the questions in Section II are answered yes. The level II PASRR had to be requested. Residents who don't exhibit any behaviors or the Psychiatrist certified they had no issues, then we don't requested a Level II PASARR after the 30 days admission. 3. Record review of Face Sheet revealed resident #82 was admitted to the facility on [DATE] Record review of Medical Diagnosis revealed the resident's diagnoses included but are not limited to, End stage renal disease; Dependence on renal dialysis; Psychotic disorder with delusions due to known physiological condition. There was no Level I PASARR found resident # 82's medical record. 4. Record review of Face Sheet revealed resident #92 was admitted to the facility on [DATE] and readmitted on [DATE]. Observation of resident # 92 on 05/25/22 at 11:30 AM revealed the resident was laying on her bed, awake. No distress or anxiety was noted. Record review of the residents Medical Diagnoses revealed the resident's diagnoses included, but are not limited to, Unspecified; Cachexia; Dysphagia following cerebral infarction. Record review of the Physician Orders dated 11/19/2021 revealed the resident is currently receiving Quetiapine (Seroquel) tablet 25 mg at bedtime via Percutaneous Endoscopic Gastrostomy (PEG) tube daily at bedtime for Psychosis. Record review of the admission MDS Section A-Identification dated 04/19/2021, A1510 Level II PASARR revealed the resident had a serious mental illness, intellectual disability, other related conditions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105172 If continuation sheet Page 2 of 11 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 105172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Manor Health & Rehabilitation Center 390 NE 135th St 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 the Annual MDS Section C-Cognitive Patterns dated 04/20/2022 revealed the resident Brief Interview for Mental Status (BIMS) Summary score was 99, meaning unable to complete the interview. Record review of the Annual MDS Section E-Behavior dated 04/20/2022 revealed the resident had no potential indicators of Psychosis. Record review of the Annual MDS Section G-Functional Status dated 04/20/2022 revealed the resident needed extensive assistance with one-person physical assistance for bed mobility, dressing. The resident needed total dependence with two-person physical assistance for transfer, locomotion, eating, toilet use, personal hygiene and bathing. Record review of the Annual MDS Section I-Active Diagnosis dated 04/20/2022 revealed the resident had a psychotic disorder. Record review of the Annual MDS Section N-Medications dated 04/20/2022 revealed the resident was receiving antipsychotics, seven (7) times in a week. Record review of the Annual MDS Section O-Special Treatments, Procedures and Programs dated 04/20/2022 revealed the resident was not receiving psychological therapy. Record review of the Psychiatrist Consultation dated 05/16/2021 revealed the resident was seen for a complete evaluation. The Doctor recommended the resident continues with the treatment. She continues to exhibit symptoms of an emotional disorder, that interfere with day to day functioning and she is unable to alleviate these symptoms on her own and is in need of medication management and requires continued medications. Decrease Seroquel 50 mg(milligrams) by mouth to 25 mg by mouth at bedtime. There was no Level II in the residents medical record. 5. Record review of the PASARR Level I revealed resident #95 had a mental illness diagnosis and there was no Level II PASARR. Observation of resident # 95 on 05/25/22 at 11:41 AM revealed, resident #95 was laying on his bed, awake. The resident was looking at the surveyor, but was not talking. No distress or anxiety was noted. Record review of the Face Sheet revealed the resident was admitted to the facility on [DATE]. Record review of the Medical Diagnoses revealed the resident's diagnoses included, but are not limited to, Encephalopathy, Unspecified; Altered Mental Status, Unspecified; Anxiety disorder; Unspecified psychosis not due to a substance or known physiological condition. Record review of the Level I PASARR dated 04/16/2022 revealed Section IV: PASARR Screen Completion Individual may not be admitted to a Nursing Facility. Required a Level II PASRR. Resident had Serious Mental Illness. Record review of the Physician Orders dated 04/20/2022 revealed the resident is currently receiving Seroquel (Quetiapine) tablet 25 mg by mouth at bedtime for Psychosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105172 If continuation sheet Page 3 of 11 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 105172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Manor Health & Rehabilitation Center 390 NE 135th St 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 Record review of the admission MDS Section A-Identification dated 04/24/2022, A1500 revealed the resident is not considered for a Level II PASARR. Record review of the admission MDS Section C-Cognitive Patterns dated 04/24/2022 revealed the resident BIMS summary Score was 03, meaning severe cognitive impairment. Residents Affected - Few Record review of the admission MDS Section E-Behavior dated 04/24/2022 revealed the resident had no potential indicators for Psychosis and no behavioral symptoms. Record review of the admission MDS Section I-Active Diagnoses dated 04/24/2022 revealed the resident had a Psychotic Disorder. Record review of the admission MDS Section N-Medications dated 04/24/2022 revealed the resident was receiving antipsychotic medications, seven (7) times in a week. Record review of the admission MDS Section O-Special Treatment, Procedures and Programs dated 04/24/2022 revealed the resident had no Psychological Therapy. 6. Record review of the Face Sheet revealed resident #109 was admitted to the facility on [DATE]. Record review of the Medical Diagnoses revealed the resident's diagnoses include, but are not limited to, Major depressive disorder, recurrent, moderate; Generalized anxiety disorder (History of). Record review of Physician Orders dated 05/29/2019 revealed the resident is receiving Mirtazapine tablets 30 mg at bedtime for Major Depressive disorder, recurrent, moderate. Record review of Physician Orders dated 04/14/2022 revealed the resident is receiving Seroquel (Quetiapine) tablet 50 mg at bedtime for Paranoid Schizophrenia. Record review of the Psychiatrist Consultation dated 04/13/2022 revealed the resident was seen by the MD. The plan was to decrease some medications. Reviewed and Discussed the risk and benefits of medication. Patient voiced understanding. Monitor for changes and side effects. Follow with psychiatrist as needed. Record review of the Annual MDS Section A-Identification dated 05/04/2022, A1500 revealed the resident is not considered for Level II PASARR. A1510 revealed the resident had serious mental illness, intellectual disability and other related conditions. Record review of the Annual MDS Section I-Active Diagnoses dated 05/04/2022 revealed the resident had Depression and Schizophrenia. Record review of the Annual MDS Section N dated 05/04/2022 revealed the resident was receiving an antipsychotic and antianxiety seven (7) times in a week. Record review of the Annual MDS Section O-Special Treatments, Procedures and Programs dated 05/04/2022 revealed the resident is not receiving psychological therapy. Interview with Director of Nursing on 05/26/22 at 12:05 PM, he stated for PASARR requirements they follow the policies and procedures and the regulations. He stated the residents admission is based (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105172 If continuation sheet Page 4 of 11 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 105172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Manor Health & Rehabilitation Center 390 NE 135th St 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 on a Level I PASARR. The Level II PASARR is triggered if the resident had a mental illness or intellectual disability and the questions in Section II are answered, yes. The level II PASARR had to be requested. Residents who don't exhibit any behaviors or the Psychiatrist certified that had no issues, then we don't request a Level II PASARR after the 30 days admission. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105172 If continuation sheet Page 5 of 11 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 105172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Manor Health & Rehabilitation Center 390 NE 135th St 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have a care plan to address one out of 28 sampled residents (Resident #76) range of motion. The facility had 37 residents with contractures at the time of the survey. The facility's census was 131 at the time of the survey. The findings included: On 05/26/22 at 11:15 AM, resident #76 was observed in bed asleep, music was playing in the room and a radio on was on the bedsiden table. The residents legs appeared to be contracted bilaterally. The residents legs were bent at the knee and were bent against her buttocks. The residents siderails were padded bilaterally. During the review of the medical record it noted the resident was admitted to the facility on [DATE]. The residents diagnosis included, but were not limited to, Cerebral Palsy, Intellectual Disability, Type 2 Diabetes Mellitus (DM) and Legally Blind. During the review of the Minimum Data Set (MDS) Annual MDS dated [DATE] and Quarterly assessment dated [DATE] it was noted in Section G-Functional Status, the following was coded: Bed Mobility - 4/2(Total Dependence/One person physical assist), Transfer-4/3(Total Dependence/Two person physical Assist), Range of Motion (ROM)-A-No upper extremity impairment, B- lower extremity Impairment on both sides. Section O-Special Treatments, Procedures and Programs documented: O400D-Occupational Therapy (OT)-0, O400C-Physical Therapy (PT)-0, Restorative Nursing Programs - O500- A to J-0. During the review of Resident #76 care plans was noted the residents care plans included: At risk for falls d/t (due to) impaired balance and mobility, poor safety awareness, impaired cognition, Self Care Deficit d/t impaired balance and mobility, poor safety awareness, incontinence B & B (Bowel & Bladder), functions dx (diagnosis) cerebral palsy, CAD (Coronary Artery Disease), vitamin deficiency, anemia, DM, peg. (Percutaneous Endoscopic Gastrostomy) Category- ADL (Activity of Daily Living) Function and Rehab Potential. During the review of the care plans it was noted the care plans did not include approaches for ROM for the residents lower extremities. During an interview on 05/26/22 at 03:05 PM with Staff D, Registered Nurse, she reports she only does a care plan if they're on restorative. She reports, the resident straightens her legs, she reports, she would be on maintenance with Certified Nursing Assistants (C N As). Interview on 05/26/22 at 03:20 PM with the Director of Nurses (DON) revealed, no care plan is completed for maintenance of ROM. During the review of the facility's policy on Resident Mobility and Range of Motion dated July 2017, revealed the Policy Statement - 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services and/or prevent a futher decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105172 If continuation sheet Page 6 of 11 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 105172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Manor Health & Rehabilitation Center 390 NE 135th St 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 0656 unavoidable. Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation: 4. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105172 If continuation sheet Page 7 of 11 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 105172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Manor Health & Rehabilitation Center 390 NE 135th St 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 05/25/22 at 09:55 AM, a narcotic count was completed with Staff C, on Cart 2, Station 2. While counting the Ativan 1 mg tablets, the form documented there were 2 remaining Ativan, but there were 3 tablets remaining. Staff C corrected the count to document there were 3 tablets remaining. During the review of the facility's policy and procedure for Controlled Substances dated revised April 2019. The Policy Statement revealed, The facility complies with all laws, regulations and other requirements related to handling, sotrage, disposal and documentation of controlled medications. Policy Interpretation and Implementation: 7. Controlled substances are reconciled upon receipt, administration, disposition and at the end of each shift. Based on observation, record review and interview, the facility failed to ensure pharmaceutical procedures were followed during medication administration for 1) One (Resident # 63) out of three (3) residents sampled as evidenced by the Licensed Practical Nurse (Staff C) signing off on the medications as given/completed in the Electronic Medication Administration Record (EMAR) before administering medications to Resident #63 2) The narcotic count being inaccurate during a narcotic count. The Findings Included: 1. During Observation on 05/24/22 at 8:25 AM, the Medication Administration obsevation with (Staff C), Licensed Practical Nurse(LPN). Staff C signed off on all of Resident #63's medication as given and completed in the Electronic Medication Administration Record (EMAR) before the medication was given to Resident #63. Review of the medical records for Resident #63 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Hyperlipidemia, Muscle Wasting and Atrophy, Acute Respiratory Failure with hypoxia and Severe sepsis without Septic Shock. Record Review of the Physician's Orders Sheet for May 2022 revealed, Resident #63 had orders that included but were not limited to: Amlodipine 10MG (milligram) (1) tablet (tab), Vitamin D 500 MG (2) tabs, Citalopram 20MG (1) tab, Fenofibrate tablet 120 mg (1) tab-Not given/found during medication reconciliation. Record review of Resident # 63's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C-Brief Interview for Mental Status Score (BIMS) 7 on a 0-15 scale, indicating the resident is severely impaired cognitively. Interview on 5/24/22 at 8:40 AM with Staff C, When asked by the surveyor why did she sign off the medications as completed before giving them to the residents, Staff C stated, I know this resident and he always takes his medication, so I signed it off beforehand, I know I am supposed to sign off on the medications after I give it. Interview on 05/24/22 at 10:45 AM, the Director of Nursing (DON) reported, Staff C told me she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105172 If continuation sheet Page 8 of 11 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 105172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Manor Health & Rehabilitation Center 390 NE 135th St 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete nervous during the medication administration observation with the surveyor, and she signed off the medications for the resident before giving it. Review of the facility's policies and procedures titled, Administering Medications revision date 4/2019 states: The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Event ID: Facility ID: 105172 If continuation sheet Page 9 of 11 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 105172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Manor Health & Rehabilitation Center 390 NE 135th St 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure standard precautions were implemented for 1out of 2 residents reviewed for pressure ulcers ( Resident #99) during a wound care observation, as evidenced by Registered Nurse (Staff A) not performing hand hygiene and changing gloves when transitioning from contaminated/dirty to clean during wound care. This had the potential to affect 27 residents in the facility receiving wound care treatment at the time of this survey Residents Affected - Few The Findings Included: During observation on 05/25/22 at 10:57 AM, Staff A, Registered Nurse Wound Care Nurse, Staff B, Certified Nursing Assistant assisting with wound care, during the observation Resident #99 was in bed, Staff A identified the resident, exited the room, completed hand hygiene, prepared supplies, brought the overbed table to to the room door, completed hand hygiene, Donned gloves, used a Sani-Cloth to wipe down the overbed table, discarded the gloves, completed hand hygiene, set up multiple trays, set up the red biohazard bag, gloves were on a tray, Alginate was on tray, the dry dressing tape was dated 5/25/22 and initialed, Staff A had tongue depressors with supplies, completed hand hygiene, Donned gloves, opened a new tube of Santyl, dated the tube 5/25/22, a dry 4x4 gauze, the 4x4 gauze was soaked in a wound cleaner. Staff A entered resident #99s' room, washed hands, Donned gloves. Staff B washed hands, Donned gloves, talked with the resident, repositioned the resident for wound care. Staff A removed the old dressing dated 5/24/22, slight light yellow drainage was observed, the wound was deep, pink and dark colored. Staff A washed her hands, Donned gloves, cleaned the wound with the gauze soaked in wound cleaner x2, dried the wound with gauze x 2, applied Santyl, applied Alginate, applied 4x4 gauze, covered with the dry dressing tape dated 5/25/22 and initialed, disposed of supplies in the red biohazard bag, completed hand hygiene, Donned gloves, closed the red biohazard bag. Staff B changed Resident #99's brief. Staff A took the red biohazard bag to the soiled utility room, disposed of the red biohazard bag in red bin, washed hands, exited the soiled utility room, and signed off on the wound care treatment. Review of the medical records for Resident #99 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Adult Failure to Thrive, Anemia, Anorexia, Hemiplegia and Hemiparesis and Type II Diabetes Mellitus with Diabetic Neuropathy. Review of the Physician's Orders Sheet for May 2022 revealed, Resident #99 had orders that included but were not limited to: Tramadol 50MG 1 tablet daily prior to wound care, Clean sacral wound with wound cleaner apply Santyl and cover with Alginate then cover with dry dressing daily, Apply barrier cream to perineal area and sacrum every shift and as needed and Low Air loss mattress. Record review of Resident #99's Discharge Minimum Data Set (MDS) dated [DATE] revealed: Section C-Cognitive Patterns-Brief Interview for Mental Status Score (BIMS)-unable to determine. Section G-Functional Status-Total dependence for Activities of Daily Living. Section H-Bowel and Bladder-Always incontinent of bowel and bladder. Section J-Health Conditions-Resident received scheduled pain medications in the last 5 days. Section K-Nutritional Status-Resident has weight loss and is not on a physician prescribed weight loss regimen. Section M-Skin Conditions-Stage 4 pressure ulcer not present on admission. Record review of Resident #99's Care Plans Dated 05/04/22 revealed: Problem: Resident has pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105172 If continuation sheet Page 10 of 11 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 105172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Manor Health & Rehabilitation Center 390 NE 135th St 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 ulcer to the sacrum at risk for developing further skin breakdown. Goal: Resident will have affected area show evidence of healthy healing tissue and reduce in size and will minimize the risk of infection by the next review date. Interventions: Low air loss mattress, Monitor for signs and symptoms of infection, wound care nurse to observe and document weekly, pressure relieving device for bed/chair, use aseptic technique during dressing change, proper hand washing before and after dressing change, dietary consult as ordered to asses nutritional needs, encourage 100 percent dietary intake daily, assist resident to turn and reposition frequently, treatment to affected area as ordered, observe for improvement or decline in condition of wound and for possible need to change treatment and Evaluate wound size, characteristic, presence of drainage, color and document weekly. Record review of Resident #99's [V ] Wound Care notes for five weeks revealed: 5/17/22-sacral wound deteriorated, 5/10/22-sacral wound improved, 5/3/22-sacral wound improved, 4/26/22-sacral wound improved, and 4/19/22-sacral wound improved. Interview on 05/25/22 at 11:47 with Staff A, she reported she has been doing wound care for six months in the facility. Staff A stated this resident has been in this facility for years, she has a sacral wound, stage 4 that has reopened, treatment is to clean the sacral wound with wound cleaner, apply Santyl and cover with Alginate and dry dressing. This resident wound is getting better, but it is taking time to heal because she cannot sit for long periods of time because of the pressure on the wounds. We make sure she is being turned often, not less than every 2 hours, I check to make sure the resident is facing a different direction after 2 hours to ensure the Certified Nursing Assistants (CNAs) and direct care staff are turning this resident. [V ] wound care comes to the facility once a week, every Tuesday, I do rounds with the [V ] team, the Wound Care Physician (MD) measures all wounds, assess the wounds, and gives recommendations as needed. We access the [V ] notes to see what new orders or treatment the wound care MD orders, there are two wound care nurses and one of us is always working, and we have two other nurses that have experience with wound care that can cover if needed. Staff A explained the steps to the wound care procedure she performed on Resident # 99, it was shared with Staff A the step between cleaning Resident #99's wound and applying the clean dressing, she did not change her gloves and wash her hands. Staff A stated yes, I did not change my gloves after I cleaned the resident's wound, I put the clean dressing on right away, I was so nervous. Review of the facility's policy and procedures titled, Infection Prevention and Control Program revision date 10/2018 states: Policy Interpretation and Implementation Step 11-Prevention of Infection-Step 3-educating staff and ensuring that they adhere to proper techniques and procedures. Step 4-Communicating the importance of standard precautions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105172 If continuation sheet Page 11 of 11