Inspection·December 1, 2022

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical records for Resident #59 revealed the resident was admitted on [DATE] with the diagnoses including insomnia, COVID-19, other chest pain, Orthostatic hypotension, Vitamin D deficiency, constipation, atherosclerotic heart disease of native coronary artery without angina pectoris, mild cognitive impairment of uncertain of unknown etiology, anxiety disorder, hyperlipidemia, hypothyroidism, essential (primary) hypertension, cognitive communication deficit, muscle weakness (generalized), weakness, spinal stenosis, lumbar region without neurogenic claudication, presence of right artificial hip joint, cervical disc disorder at C4-C5 level with radiculopathy, multiple myeloma not having achieved remission. Residents Affected - Few Review of quarterly MDS dated [DATE] under Section L- Oral/Dental Status showed the option B. No natural teeth or tooth fragment(s) (edentulous), was blank. Review of quarterly MDS dated [DATE] under Section L- Oral/Dental Status showed the option B. No natural teeth or tooth fragment(s) (edentulous), was blank. Review of Patient Progress Report dated 10/7/2022 reads, Notes: Patient presents for follow up on existing P/dentures. Patient states that has not wear existing partials because was not aware she has them. Patient seems confused. U/L Partials were found in the drawer. L/P fit well on the edentulous spaces however U/P was not fitting well due migration of remaining teeth. On edentulous area of tooth #7, the space has been reduced, adjustments were done to make partial fit. Patient was wearing partial while doing adjustments but requested to remove them soon after finish alleging they are very hard and bother. Explained to the patient that partials should be wear in daily basis to avoid migration of remaining teeth to the edentulous areas which will interfere with the fitting of U/L partials in the future. No follow up needed. Review of the progress note dated 7/22/2022, reads, Assessments/Plans: Partially edentulous maxillary and mandibular arches Patient presents for 2nd visit in U/L partial dentures fabrication. Bite registration was taken, shade selected. Review of the progress note dated 7/5/2022, reads, Assessments/Plans: Partially edentulous maxillary and mandibular arches Patient presents for first visit in U/L partial dentures fabrication. Review of the progress note dated 8/5/2022 reads, Assessments/Plans: Partially edentulous maxillary and mandibular arches Patient presents for 3rd visit in U/L partial dentures fabrication. Wax try was done; CR confirmed. Review of the progress note dated 9/6/2022 reads, Assessments/Plans: Partially edentulous maxillary and mandibular arches Patient presents for last visit in U/L partial dentures fabrication . During an interview on 12/1/2022 at 9:30 AM, the MDS Coordinator checked the MDS dated [DATE] and confirmed that option B. No natural teeth or tooth fragment(s) (edentulous) was blank. A policy on accurate completion of Minimum Data Set Assessments was requested and Staff A replied, We follow the Resident Assessment Instrument (RAI). Based on record review and interview the facility failed to accurately document the dental status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 2 of 9 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of one resident (Resident #59) out of two sampled for dental the discharge status for one (Resident #199) out of four residents sampled for discharge status review. Findings include: 1. Record review showed Resident #199 was admitted to the facility on [DATE] with diagnoses including: aftercare following joint replacement surgery, muscle weakness, cognitive communication deficit, and hypertensive heart disease without heart failure. Resident #199 was discharged on 10/20/22. Review of Resident #199's Minimum Data Set (MDS) Discharge Return Not Anticipated assessment dated [DATE] showed Section A denotes resident as discharged to acute hospital on [DATE]. Review of Resident #199's nursing notes showed a note dated 10/20/22 at 8:14 PM which read, Patient discharge from Villa [NAME] Nursing Center in stable condition with no respiration distress noted. and a note on 10/20/22 at 7:54 PM which read, Resident discharged to private home/ apartment with no home health services. During an interview with Staff A, Minimum Data Set (MDS) Coordinator on 11/29/22 at 02:02 PM, she confirmed Resident #199 discharged home and the MDS dated [DATE] was inaccurate. During an interview conducted on 11/30/22 at 10:45 AM with the facility's Social Services Director, she verified resident is denoted as going to acute hospital and the denotation is an error. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 3 of 9 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide care and services for central venous access devices in accordance with professional standards of practice for 2 out of 2 residents with midline catheters ( Resident #167 and #458) out of a a total sample of 54 residents. Residents Affected - Some Findings include: Review of the medical record documented Resident #167 was readmitted to the facility on [DATE] with the following diagnoses: Right ankle osteomyelitis ( an infection of the bone), hypertension ( high blood pressure), hyperlipidemia ( high cholesterol), atherosclerotic heart disease ( thickening and narrowing of the arteries of the heart), a history of a left below the knee amputation, peripheral artery disease ( a condition which narrows blood vessels and causes less blood flow to the legs), and diabetes mellitus. During an observation on 11/28/2022 at 10:36 AM Resident #167 was observed resting in bed with a right arm midline catheter ( a special type of intravenous catheter that is placed in a major vein for administering medications) that was dated 11/16/2022 and had a 2 x 2 gauze under a transparent dressing. During an observation on 11/28/2022 at 2:35 PM, Resident #167 was observed resting in bed with a transparent dressing with a 2 x 2 gauze dressing under the transparent dressing dated 11/16/2022. Review of the physician orders dated 11/16/2022 reads, Insert midline for IV ( intravenous) AB ( antibiotics) every 8 hours x 6 weeks, every shift. Review of the physician orders dated 11/22/2022 reads, Change dressing to midline weekly 1 x/wk( week) Tuesday first date 11/22/2022. Review of the IV Access insertion form for Resident # 167 documented that a right cephalic vein midline catheter was inserted on 11/16/2022 at 4:36 PM. Review of the Treatment administration record does not document any midline catheter dressing change completed on 11/22/2022. During an interview on 11/28/2022 at 2:35 PM Staff B, Registered Nurse stated, The date on the dressing looks like 11/16/2022, it should have been changed already. I don't think there is anything wrong with the dressing. I guess there should not be gauze under the dressing. I will get the dressing changed. There is an order for the dressing to be changed. During an interview on 11/30/2022 at 1: 40 PM the Director of Nursing stated, I did not know that the dressings have had gauze under the transparent dressings. They should be changed more frequently if they are like that. We should be able to see the insertion site for the line and evaluate that when we give the antibiotics. 2. Review of the medical record documented Resident # 458 was admitted to the facility on [DATE] with a readmission on [DATE] with the following diagnoses: post operative infection, and intra-abdominal abscess. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 4 of 9 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 11/28/22 at 1:30 PM Resident #458 was observed resting in bed with a right upper arm midline line catheter with a 2 x 2 gauze under a transparent dressing that was dated 11/26/2022. During an observation on 11/29/22 at 9:00 AM Resident #458 was observed resting in bed with a right upper arm midline catheter with transparent dressing with a 2 x 2 gauze under the dressing dated 11/26/2022. Review of the physician orders there were no dressing change orders for the midline dressing. Review of the Treatment administration record (TAR) does not document any midline catheter dressing changes. Review of progress notes, TAR and medication administration record indicate there are no measurements of the external catheter length. During an observation of medication administration conducted on 11/30/2022 at 11:55 AM, Staff C, Licensed Practical Nurse ( LPN) assembled all supplies to administer midline Intravenous antibiotic, staff administered 5 milliliters of normal saline flush and did not verify line placement by checking for blood return prior to administering the normal saline or antibiotic. During an interview conducted on 11/30/2022 at 12:15 PM Staff C, LPN stated, I should have checked for blood return before I gave the flush or the antibiotic. I don't know why I didn't. During an interview conducted on 11/29/2022 at 1:32 PM the Assistant Director of Nursing ( DON) stated, There should not be gauze under the transparent dressing. It should be changed. I don't see that there are any orders for the dressing to get changed. I don't see that there are any measurements of the catheter length. During an interview conducted on 11/30/2022 at 1:45 PM the Director of Nursing ( DON) stated, All mid line catheters should have dressing changes ordered and there shouldn't be any gauze under the transparent dressings. and documented in the medical record. It is our policy to get external catheter lengths , they should be documented. Review of the policy and procedure titled Insertion of PICC and Mid-line catheters policy # 2119 review date of 8/22/2022 reads, Policy: The facility will insert PICC ( peripherally inserted central catheter) lines and midlines only if there is a physician order; insertion will be performed by a registered nurse ( RN) who is certified and qualified in the procedure. Monitoring and maintenance of PICC or Mid-Line catheter: At the time of insertion, the catheter length will be measured and documented in the medical record. If the patient is admitted with a PICC or Mid-line, the nurse shall obtain this information from the transferring facility. The licensed nurse will monitor external catheter length when administering medications and at the time of dressing changes; if there is a question of possible migration of the catheter he/she will notify the attending physician for further orders. Transparent dressings will be used at site of insertion. The dressing shall be changed upon admission or at 24 hours post insertion, weekly and as needed. Dressings shall be labeled with date and time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 5 of 9 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Residents Affected - Some Findings include: During the initial tour of the kitchen conducted on 11/28/22 beginning at 9:00 AM, the drip pans located below the gas range were observed to be lined with aluminum foil and contain a buildup of food sediment on them. The sealant around the hood vent above the gas range was observed to be peeling and hanging from the hood vent. In the walk-in freezer, a single unwrapped and unlabeled ground beef patty was observed on a metal wire shelf. Also observed on the shelf was a pan of lasagna with a date tag on it which had been ripped partially off, making the date frozen unreadable. An open box containing an unsealed bag of ground beef patties was observed on a second shelf below the single patty. Ice buildup was observed on a box on a wire shelf below the coolant equipment. During the tray line observation conducted on 11/29/22 beginning at 7:35 AM, one cart of resident trays was being plated and placed on the cart to be taken to the floor. The Kitchen Manager tested the temperature of a carton of whole milk and a single serve yogurt both which were selected from stock being used for tray filling and both temperatures were found to be 46 degrees Fahrenheit. Review of facility policy, titled food safety labeling guidance and procedure for our teams, dated 12/4/17 and reviewed on 1/28/22, showed it read, procedure C. Date mark ready to eat foods that have been prepared on site or commercially prepared and opened being held for more than 24 hours with date to be consumed. D. Purchased ready to eat foods removed from original container and not served during the next meal must be labeled and date. During an interview conducted on 11/28/22 at 9:10 AM, with the facilities kitchen manager, she verified the unlabeled on packaged food in the freezer, the icicles on the box in the freezer and the torn label on the lasagna in the freezer. she confirmed that all foods should be labeled and dated correctly and the ice buildup in the freezer was not supposed to be on the box. She further confirmed the trees under the range should have been cleaned out and the sealant it around the hood vent needs to be repaired. Review of facility policy titled work order process: Maintenance responsibility dated 8/21/22 showed it read, Procedure: The Engineering Department through inspections of the building and through PM checks made on equipment will attempt to locate and repair any defect found. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 6 of 9 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Potential for minimal harm Based on record review and interview the facility failed to ensure the arbitration agreements presented to 3 residents, Resident #55, Resident #124 and Resident #201, of 3 residents reviewed explicitly granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement. Residents Affected - Many Findings include: Review of the facility Voluntary Binding Arbitration Agreements presented to Resident #55 on 11/2/2022, presented to Resident #124 on 11/11/2022 and presented to Resident #201 on 11/18/2022 failed to explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement. During an interview on 11/29/2022 at 2:28 PM, the Administrator confirmed the facility arbitration agreement had not yet been revised to include explicitly granting the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement. During interview on 11/30/2022 at or about 8:36 AM, the Administrator reported the facility had revised the arbitration form to include explicitly granting the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement but facility staff had not used the revised form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 7 of 9 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Potential for minimal harm Based on record review and interview the facility failed to ensure the arbitration agreements presented to 3 residents, Resident #55, Resident #124 and Resident #201, of 3 residents reviewed provided for the selection of a venue convenient to both parties. Residents Affected - Many Findings include: Review of the facility Voluntary Binding Arbitration Agreements presented to Resident #55 on 11/2/2022, presented to Resident #124 on 11/11/2022 and presented to Resident #201 on 11/18/2022 failed to show the arbitration agreement provided for the selection of a venue convenient to both parties. During an interview on 11/29/2022 at 2:28 PM, the Administrator confirmed the facility arbitration agreement had not yet been revised to provide for the selection of a venue convenient to both parties. During interview on 11/30/2022 at or about 8:36 AM, the Administrator reported the facility had revised the arbitration form to include the provision for the selection of a venue convenient to both parties but facility staff had not used the revised form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 8 of 9 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street 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 observation, interview and record review the facility failed to follow accepted infection control practice standards for intravenous medication administration in 2 out of 2 observations of intravenous medication administration out of a total of 6 medication administration observations. Residents Affected - Few Findings include: During an observation of medication administration on 11/29/2022 at 1:35 PM Staff B, Registered Nurse (RN) entered Resident #167's room with a Styrofoam tray with the 100 milliliter(ml) bag of Meropenem 500 mg, 4 alcohol wipes, and a 5 ml syringe of Normal saline to administered Meropenem 500 mg IV ( intravenously). There was IV tubing on the IV pump, the tubing was not labeled with the date or time that it was hung, the end of the IV tubing did not have an end cap on it and was connected to a needleless port on the IV tubing. Staff B, RN attached the bag of Meropenem to the IV tubing, then removed the end of the tubing from the needleless port and placed the exposed end of the IV tubing directly on the Styrofoam tray, and removed the air from the tubing. Staff B, RN clean the midline catheter port for less than 1 second with one wipe of the alcohol and connected the IV tubing to the midline catheter port and started the Meropenem. During an interview on 11/28/2022 at 2:55 PM Staff B, RN stated, I should not have used that tubing, I should have gotten new tubing. I should have cleaned the needless connector longer During an observation of Medication administration on 11/30/2022 at 11:55 AM Staff C, Licensed Practical Nurse (LPN) entered Resident # 458's room with all supplies, attached a 100 ml bag of Unasyn 3 grams to the IV tubing and cleared the air from the IV line. Staff C, LPN cleaned the needleless connector for less than 1 second and connected the IV tubing to the midline catheter needleless connector. During an interview on 11/30/2022 at 12:15 PM Staff C, LPN stated, I should have cleaned the connector for longer than I did, I guess I was just very nervous. During an interview conducted on 11/30/2022 the Assistant Director of Nursing ( ADON) stated, Staff should all clean the port for at least 5 seconds. During an interview conducted on 11/30/2022 the Director of Nursing ( DON) stated, I expect all nurses to follow infection control standards for IV infusions, it is important they do this and clean the connectors for longer than 1 second. Review of the policy and procedure titled Administration Set/Tubing Changes last approval date of 1/28/2022 reads, Policy: Administration sets and tubing will be changed at specific intervals in order to prevent infections associated with contaminated IV therapy equipment. General Guidelines: 1. Manage all IV equipment, including administration sets, using aseptic technique and observing standard precautions. 5. Change devices that are added to tubing such as extension sets, filters, stopcocks, end caps, or any other devices when tubing is changed. Use only needleless equipment., 6. Label all tubing with start and change date and time. Change and then label accordingly any tubing that is observed not to have a label., 7. Apply a sterile end cap to the end of primary tubing when it is disconnected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 9 of 9