Health inspection·June 15, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Nursing (DON), Surveyor asked about any interaction between him and Resident #11's family members, the NHA stated, let me refresh my memory. When asked if a resident has a BIMS score of 15 would they still notify the family about any change in condition, the NHA and DON stated, we still notify the family members when anything happens, unless the patient would not desire for them to by notified as they are alert and oriented x4. During record review there was no documentation found about notifying the family member of the transfer of Resident #11 to the [local hospital] on 8/23/2022 and the surgery she underwent. Review of the document titled, Change in a Resident's Condition or Status, Revised February 2021 revealed: Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. Accident or incident involving the resident. b. Discovery of injuries of an unknown source. c. Significant change in the resident's physical/emotional/mental condition. d. Need to transfer the resident to a hospital/treatment center. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105217 If continuation sheet Page 2 of 10 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 105217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Beach Healthcare and Rehabilitation Center 2201 NE 170th Street North Miami Beach, FL 33160 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 0580 disease-related clinical interventions (is not self-limiting) Level of Harm - Minimal harm or potential for actual harm b. Impacts more than one area of the resident's health status; Residents Affected - Few c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. There is a significant change in the resident's physical mental, or psychosocial status; b. It is necessary to transfer the resident to a hospital/treatment center FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105217 If continuation sheet Page 3 of 10 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 105217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Beach Healthcare and Rehabilitation Center 2201 NE 170th Street North Miami Beach, FL 33160 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to file a report per federal requirements for one resident (Resident #11) out three residents who were investigated for falls, most specifically in regard to major bodily injury of a known source. This deficient practice has the potential to affect all 95 residents residing at the facility at the time of the complaint investigation. The findings included: Record Review of Resident #11's Minimum Data Set (MDS)- Significant Change in Status dated 10/13/2022 and admit date : [DATE] revealed: Section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 15 meaning the resident was cognitively intact. Section G-Functional Status revealed: Bed mobility-Extensive assistance with two+ person physical assist, Transfer-Total dependence with two+ person physical assist, Locomotion on and off unit-Supervision with one person physical assist. Functional Limitation in Range of Motion revealed: Upper extremity-No impairment, Lower extremity-Impairment on both sides. Mobility Devices: Wheelchair. Review of the MDS Section J-Health Conditions revealed: Fall History on Admission/Entry or Reentry revealed: Has the resident had any falls since admission/entry or reentry or the prior assessment whichever is more recent? No Other orthopedic surgery- J2510. Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot)-No selection, blank A. Did the resident have a fall any time in the last month prior to admission/entry or reentry? No B. Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? No C. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry? No Record Review of Resident #11's diagnoses revealed that the resident has diagnoses to include but were not limited to: Generalized Edema, Difficulty in Walking, Unsteadiness on Feet, Pain in Right Hip dated 9/27/22, Fall from Non-Moving Wheelchair Initial Encounter dated 8/26/2022, Displaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing dated 8/26/2022, Other Specified Disorders of Bone Density and Structure, Unspecified site dated 8/19/2022, Unilateral Primary Osteoarthritis, Right Hip dated 8/19/2022. Record Review of Resident #11's Care Plan with Date Initiated: 07/22/2022 and Revision on: 08/19/2022 revealed: Resident status-post FALL 8/13/22, Resident noted sitting on the floor in her bathroom. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105217 If continuation sheet Page 4 of 10 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 105217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Beach Healthcare and Rehabilitation Center 2201 NE 170th Street North Miami Beach, FL 33160 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8/19/22- resident noted lying on ground in the patio. With complaint of pain to the right leg. Goals and Interventions included but were not limited to: Assist to wheel to destinations with date initiated: 07/22/2022, Educate/remind resident to request assistance prior to ambulation/transfers as needed with date initiated: 07/22/2022. Record Review of Resident #11's Progress Notes revealed that on an Alert Note dated 8/19/2022 Staff member was called to patio to assess. Upon entrance observed resident lying on ground in right lateral position, complaining of pain to the right leg. Call placed to Medical Doctor (MD) response pending. Call placed to daughter [ .] made aware of fall. On an Alert Note dated 8/19/2022 Staff was called to patio to assess. Upon entrance observed resident lying on ground in right lateral position. complaining of pain to the right leg. No bruising, swelling, shortening or lateral rotation of extremity noted. Resident assisted up by 4 attendants and placed back in her wheelchair as she insisted. On a Narrative Nurses Note dated 8/19/2022 revealed X-RAY right hip done result pending. On a Narrative Nurses Note dated 8/23/2022 revealed that resident has increased pain to right leg. Requesting pain medication that is not available for the patient. Called MD and received order to transfer patient to [local hospital]. On a Narrative Nurse Note dated 8/26/2022 revealed patient was readmitted from [local hospital], alert and oriented x3, spoke with daughter [ . ] and informed her that patient arrived and refusing treatment, daughter states she understands no distress noted. Record Review of Resident #11's Progress Notes revealed a Skin Wound Note dated 8/27/2022 with the following information: Right Proximal Hip, Right Proximal Hip: surgical incision with 11 staple 8.7 X 1.0 Light serous drainage 100% dermis, Will be seen by wound specialist upon next visit. Record Review of Resident #11's Progress Notes revealed a Narrative Nurses Note dated 8/27/2022 with the following information: Patient readmit to room [ROOM NUMBER]-A, skin warm to touch. Wound care nurse assess skin from Head to Toes, Noted wounds to Right Heel, Left Heel, Right med Foot, Right Proximal Hip, Right Med Hip, Right distal Hip, Left First Toe. Left Lateral Foot. Left arm shunt for Dialysis and bruises to bilateral arms and Left Hip. Place call to MD, Advanced Registered Nurse Practitioner covering for the doctor, treatment order given and carried out. Record Review of Physician Progress Note dated 8/31/2022 in regard to Resident #11's status revealed that the resident had a Chief Complaint of right hip and lower extremities pain. She presented to the hospital with right hip pain status post (s/p) fall out of wheelchair resulting in a right sided 3 part intertrochanteric femur fracture. Patient underwent trochanteric intramedullary nail. Then, she was transferred to North Beach Rehab Center for continuity of care and rehabilitation. Patient complained of significant pain on the right hip and lower extremities, not alleviated with current medications. The pain is described as aching with associated burning sensation. The pain interferes with activities of daily living, and it is ranked as an 8/10 on Visual Analogue Scale (VAS). Chart was reviewed and case discussed with nursing staff. No family member at bedside at the time of my visit. Record Review of document titled, Radiology: Hip Unilateral with or without pelvis 2-3 view dated 10/11/2022, interpretation/diagnosis Pain in Right Hip with comparison to Xray done on August 19, 2022, with findings as follows: There is a new right compression hip screw placed since the prior study. This appears to be in satisfactory position. There is deformity of the proximal right femur. Bony structures are osteopenic. There are degenerative changes present. No destructive process. There is vascular calcification within the soft tissues. Conclusion: Right compression hip screw stabilizing nondisplaced fracture of the proximal right femur. Follow up recommended as indicated clinically. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105217 If continuation sheet Page 5 of 10 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 105217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Beach Healthcare and Rehabilitation Center 2201 NE 170th Street North Miami Beach, FL 33160 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 0609 Level of Harm - Minimal harm or potential for actual harm Record Review of documents titled, Fall With Major Injury List with 8/1/22-6/13/23 Resident #11 was not listed. There were only 4 other residents listed but Resident #11's name was not one of those names. Record Review of Incidents By Incident Type revealed: Fall Incidents- Resident #11 was listed with the following dates and times: 8/19/22 11:33 AM and 8/13/22 1:55 PM. Residents Affected - Few Record Review of [local hospital] documentation for Resident #11 with admit date [DATE], Reason for consult was code hip and History of Present Illness Resident #11's, [AGE] year-old woman who presented after having fallen from her wheelchair. She sustained a right femur intertrochanteric fracture for which she is scheduled for urgent surgery today. She received pain medication and is somewhat somnolent. She denies a history of angina or cardiac conditions, but the patient has multiple comorbid conditions and also presents with elevated Blood Pressures. History is mostly from ALF paperwork sent with patient, some history from patient. Trauma consulted for admission for hip fracture; patient made hip alert, orthopedics already consulted. Record Review of the document titled, Resident Abuse Investigation Report Form for Resident #11's Fall Incident revealed Location of Incident was Outside Patio, date Incident occurred and Reported 8-19-22, Name of Individual Reporting Incident: Dialysis Nurse, Resident injured: No visible injuries. Resident stated she has pain in her leg. Summary of interview with person(s) reporting the incident: Staff stated that he was assisting resident to get over the threshold. He stated the chair went forward suddenly and Resident #11 fell forward landing on her right side. Resident interview: Resident refused to answer questions. She just wanted to be allowed to be smoking. Summary of interview with staff members having contact with the resident during the period of the incident: Dialysis nurse was asked to call for assistance. Nurse sated he was concerned because resident refused the morning session of dialysis stating she will do it later. He attempted several times throughout the morning when he met her in the hallway wheeling herself. Summary interview with resident's family members/visitors: Family made aware of fall and plan Xray. Summary of investigator's findings: Resident refused to go to dialysis and dialysis nurse was attempting to convince resident to go as she was insisting on smoking. She asked for assistance to get over the door threshold and he returned and push the button at the same time assisting her as she was wheeling over the door threshold. Wheelchair rolled forward quickly causing resident to fall forward suddenly. Results of findings and corrective action taken reported to: Administrator, Date 8-19-22 by Former Director of Nursing. Additional Comments: On 8-23-22 resident transferred to [local hospital] for increased complaining of leg pain. Interview and Record Review with the Nursing Home Administrator (NHA) and Director Of Nursing (DON) on 06/15/2023 at 8:36 AM. The Nursing Home Administrator stated I am the Risk Manager in conjunction with the Director of Nursing. The DON stated that she was hired earlier this year. When NHA and DON were asked about Resident #11 status the NHA stated she was discharged , let me check where she was discharged . He proceeded to check Resident #11's records. The DON stated, the Resident went to an appointment and was hospitalized , it was an appointment with a vascular surgeon, and they did not specify why, the reason of transfer was low heart rate. When asked about Resident #11's falls with or without injuries the DON reviewed the Resident's records and stated, the Resident was awake and alert, sitting in room in bathroom she said she was trying to go to the bathroom by herself and fell from wheelchair. At that time the Medical Doctor (MD) was notified, Xray of bilateral hips was ordered, they educated the patient on call light use and they verbalize that she understood to use call light, this was on 8/13/22. When prompted about a second (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105217 If continuation sheet Page 6 of 10 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 105217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Beach Healthcare and Rehabilitation Center 2201 NE 170th Street North Miami Beach, FL 33160 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fall the DON reviewed the Resident's records and stated, the next fall was on 8/19/2022, the nurse says she was called to the patio and the nurse went to the patio to assess the patient that had a fall, the patient was found on right lateral position, she was complaining of pain in right leg, she had swollen and shortening or lateral rotation of extremity, they assess her and assisted her to her wheelchair. They ordered Xray-STAT (term used as directive to medical personnel during in an emergency situation, means instantly), family and MD were notified. When asked about if the resident sustained any injuries she stated, I will have to check if she sustained any injuries at this time, I do not see any fractures for that last one. When prompted to an Xray in October 2022. She reviewed Resident #11's Xray results then she stated, in October there was another result, it was compression in hip, screw in hip and deformity of proximal right femur, osteopenic of bone, they describe as deformity not fracture, she had a screw and the osteopenia, and the screw caused the deformity, apparently it was not due to a fall as there is vascular calcification. I see on the notes that she had a follow up with vascular and this was not due to fracture. The resident went to see a vascular surgeon and an angioplasty was done in December; this was not a fracture. Surveyor prompted DON to go to a progress note dated 8/31/22 in regard to a mentioned fracture she stated, I can tell you that everything was related to the screw previously mentioned, everything was related to the deformity, and everything was followed up with vascular. There is an MD note on 8/31/22, the fall was on 8/19 and 8/13. She started reading the note and stated, she presented to the hospital with right hip pain, apparently that femur fracture was before she was admitted here, she has a history of hip fracture and was placed for rehabilitation, they do not say when the fall was, when they did the Xray, she already had a screw. It describes a history of not an acute fracture. My understanding from what I am reading on that doctor's note is that she had the screw in place already as we did an Xray, and she already had the screw. When prompted to Narrative Nurse Note dated 8/26/2022 with context pt re admitted from [local hospital], alert and oriented x3. spoke with daughter [] and informed her that pt. arrived and refusing treatment. daughter states she understands no distress noted, the DON stated, this was due to pain in right leg this was the reason for this hospitalization. Upon all this complaining of pain she was referred to vascular, they found the calcification of veins then she was referred to vascular. On that Xray that was mentioned before, there is no fracture and a few days later she kept complaining of pain and she was sent out on the 23rd and she returned on the 26th, which is this note. During a Phone Interview with the Registered Nurse/Physician Dialysis and in the presence of NHA and DON on 06/15/2023 at 9:40 AM. When asked about the Resident #11, he stated yes, I remembered Resident #11. Surveyor stated yesterday when you were interviewed what was your answer when I asked if there were any incidents with the resident, what did you state? He said, No. Then surveyor proceeded and asked one more time, were there any incidents that you know of that involve Resident #11? He stated, yes, there was one day that she fell down and she had a hip fracture, she was sent to the hospital after. I remembered that she had a fall. When asked about transferring patients from their rooms to the dialysis room he stated, we do not transfer the patient from the dialysis room to their room or from their room to the dialysis room. It is our policy not to. I remember that before the patient starts the treatment, we go to see if they are ready, we go to their room to remind them to get the dialysis. The reason I remember that day, the dialysis was ready, and she took a little long, so I went to check again and at that time she was wheeling herself down the hallway, she was going to get a smoke and she was trying to get over the hump, and I saw her fall down. I got the DON, and with other staff we helped her get into the chair. When asked if he was assisting the resident or touching (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105217 If continuation sheet Page 7 of 10 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 105217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Beach Healthcare and Rehabilitation Center 2201 NE 170th Street North Miami Beach, FL 33160 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the wheelchair at the time of the fall he stated, I was not touching the chair I was walking up to her and then she tried to get over the hump with her wheelchair and she fell forward. When asked about Resident #11 reason for hospitalizations, the Nursing Home Administrator stated, I just do not recall right now, I remembered why she was hospitalized , I just don't recall right now, I am trying to recall I apologize. After speaking with Social Services Director, the Nursing Home Administrator rejoined the interview and he stated, I do remember, I'm pretty sure this is the resident, the fall she had on the patio, the dialysis person was trying to get her over the hump, the threshold as she was having trouble, the dialysis gentleman was trying to help. Everybody afterwards met and we discussed this. She alleged a fall. I remember I spoke with the dialysis person, the dialysis company, with the internal team and the resident. We did have a discussion all around with everyone and we realized that the intention was for him to assist her there was not issue in him assisting her. Surveyor asked about documentation, and he stated that the former DON had everything, and he was going to provided it as soon as he found it. He stated, for the dates, I need to verify the dates, we should have some notation indicating that. I remember discussing with the former DON, she was obtaining statements from everyone. I remember telling her to let the corporate nurse know. When the family called concerning what happened, there was no allegation of an injury. If there is an injury related to a fall it all depends on the circumstances we file a report, I need to get the investigation papers to find out. The DON in charge and Corporate Nurse are not here anymore. When asked about the protocol to follow when there is a fall with injury, he stated, when there is a fall with injury the protocol is, we do an investigation, we obtain statements, and we notify family, doctors, place interventions for that, and we do a root cause analysis. He also sated, we did recognize this issue and we got cited for Quality Assurance and Performance Improvement (QAPI) last survey, we got a Performance Improvement Plan (PIP) going for falls, and we have seen a dramatic improvement in regard of falls, also for falls we file all the right avenues, we make sure it is done in a timely manner and we notify everybody. At 10:10 AM on 06/15/2023 the Nursing Home Administrator stated, we did find the investigation report for Resident #11. He reviewed the investigation report binder and he stated, We did obtain the statements of all involve parties including the Registered Nurse/Physician Dialysis. There is a written investigation, we did an initial Xray, and this came back negative. When asked about State or Federal reporting, he stated, We did know of the fractured hip; however, this was completely out of our control and there is nothing we could have done to prevent this further and that is what the investigation determined. The adverse event, again the investigation determined that it was beyond our control, and it did not require the subsequent adverse reporting, we do a very thorough investigation determination, and this did not require as we could have not done anything further to prevent this. Record Review of of the policy and procedure, Standards and Guidelines: SG Adverse Event Reporting FL, Policy Number: 12.08.010, Section: Risk Management, Issued: 10/1/2004, Revised 3/27/2021 documents, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105217 If continuation sheet Page 8 of 10 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 105217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Beach Healthcare and Rehabilitation Center 2201 NE 170th Street North Miami Beach, FL 33160 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 0609 Level of Harm - Minimal harm or potential for actual harm Standard: It will be the standard of this facility to ensure that events determined to be adverse are timely identified, investigated, and reported to the facility risk manager as defined by the Florida statutes. In the event of a potential adverse event, the facility administrator will be notified as soon as possible, but no later than 3 days after the occurrence of the event. Residents Affected - Few An adverse event is defined as an event over which the facility could exercise control, and which is associated in whole or in part the facility's interventions, rather than the condition for which such interventions occurred which results in the following: Fracture/dislocation of a bone or joint Transfer to a higher level of care Guidelines: 1. Once an event occurs within the facility, the staff has 3 days to make the facility risk manager (nursing home administrator or designee) aware. 2. The facility risk manager completes a preliminary investigation within 1 day to determine whether the event should be reported. 3. If the event is determined to be adverse, the event is reported online within 15 days of the occurrence of the event. 4. The risk manager will conduct a complete investigation into the event by interviewing residents, staff, and witnesses of the event, and reviewing 24-hour reports, medical records, and care plans. 5. To complete the adverse report: a. Describe the facts of the occurrence clearly and concisely. b. The report should be reviewed and approved by the facility risk manager, Director of Nursing or Executive Director. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105217 If continuation sheet Page 9 of 10 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 105217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Beach Healthcare and Rehabilitation Center 2201 NE 170th Street North Miami Beach, FL 33160 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 0609 c. Level of Harm - Minimal harm or potential for actual harm Must include the who, what, when, and why of the event. d. Residents Affected - Few Report must include the corrective or proactive actions that have been put into place to prevent it from happening again. e. Adverse events reported to the agency are discussed at the monthly risk management/quality assurance meeting for trends and recommendations by the committee to prevent further events. f. All adverse event reports and supplemental investigational reports will be kept in the facility for 7 years. g. Adverse event reports are not discoverable. Adverse events are not to be copied or reviewed by others outside the facility without the express consent of the Executive Director. h. Staff will be in-serviced on hire and annually on the need for immediate reporting within the require time frame for any potential adverse event. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105217 If continuation sheet Page 10 of 10