Inspection·March 15, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few storage.I will do frequent rounds to ensure staff are implementing this strategy and an in-service for all staff regarding dignity bags. On 03/12/2024 at 9:42 AM Staff F, LPN stated residents with indwelling urinary drainage catheter should have a dignity bag covering the drainage bag to provide dignity for the resident. I normally check residents before they leave the unit to make sure the urinary collection bag is covered inside a dignity bag, but I was unable to with Resident #175 because I did not check this time because I was administering medications down the hallway. 03/12/2024 at 10:05 AM, Staff C, CNA stated the protocol for transporting a resident with an indwelling urinary catheter is to ensure the collection bag is inside a dignity bag to provide privacy for that resident.I did not ensure the collection bag was fully covered because I saw a dignity bag but didn't realize it didn't fully cover the drainage bag and forgot to check before transporting the resident out of room. I will make sure to cover the drainage bag for any resident who I transport to therapy who has an indwelling urinary catheter before I leave that room with that resident. On 03/13/2024 at 9:46 AM Staff E, LPN stated indwelling urinary catheter drainage bags must be covered with a dignity bag to provide dignity. Stated dignity bags are available in the storage room.I will make more frequent rounds to ensure staff are implementing this strategy and I will do an in-service for all staff everyone regarding dignity bags. On 03/14/2024 at 4:22 PM, The DON stated for residents with an indwelling catheter the drainage bag should be always covered with the dignity bag. I will re-educate staff about the indwelling catheter and dignity and require a return demonstration. On 03/15/2024 at 10:54 AM Staff D, CNA stated: I transport the residents from their room to rehab. I have been doing this since 1984. When transporting residents with indwelling catheters before I leave the room with the resident, I make sure the drainage bag is not touching the floor, not full and properly hanging on the wheelchair. On 03/15/2024 at 11:43 AM Staff G, CNA stated: For residents who have indwelling urinary catheters bags I make sure the bag is always covered. Record review of The facility's Policy and Procedure effective date 5/1/2002 and review date 2/14/2024, Subject: Resident Privacy/ Dignity, Policy: The facility ensures that all resident care procedures are performed in consideration of their privacy. Procedure: During any procedure, the resident will be provided with privacy to the maximum degree possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 2 of 15 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 03/15/2024 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to electronically transmit the Discharge- Return Anticipated Minimum Data Set (MDS) to Centers of Medicare and Medicaid (CMS) within 14 days for one (Resident # 159) out of four residents who were discharged to a short-term general hospital. Residents Affected - Few The findings included: Record review of the clinical records for Resident # 159 revealed the resident was admitted to the facility on [DATE] and discharged to a short-term general hospital on [DATE]. Discharge Return Anticipated MDS Section A Identification Information dated 12/04/2023 revealed the resident was discharged to a short-term general hospital. Discharge Return Anticipated MDS dated [DATE] was not electronically transmitted within 14 days of completion. Discharge Return Anticipated MDS dated [DATE] was transmitted on 03/14/2024. Interview with Regional MDS Coordinator on 03/15/2024 at 01:23 PM. She stated the assessment was completed but not transmitted after completion. She stated the MDS coordinator forgot to transmit on time after completion. She stated the facility MDS Coordinator validated and transmitted on 03/14/2024. Review of Policy and Procedures for Resident Assessment Instrument (RAI) and the Interdisciplinary Care Planning Process Effective 05/28/2008 revised 11/28/2016 reviewed on 02/22/2024 revealed Purpose: The Resident Assessment Instrument (RAI) is a regulatory framework mandated by Centers of Medicare and Medicaid (CMS). The facility will make a comprehensive assessment of the resident's needs, strengths, goals, life history and preferences using the RAI. It will be used as an interdisciplinary comprehensive assessment tool to coordinate the overall care of each patient/resident in the nursing center. The goals of care are to maximize and prevent decline of level of independence, functional capacity, and quality of life, and prevent complications. Guidelines/Procedure: E-The completed RAI data will be transmitted to the state as per regulatory time frames. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 3 of 15 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 03/15/2024 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 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** Based on Interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for three residents (Residents # 86, # 29 and #166 ) out of three resident's whose MDS assessments were reviewed at the time of survey. Residents Affected - Few The findings included: 1) Review of admission records revealed Resident # 86 was admitted to the facility on [DATE]. Record review of the Care Plan dated 12/05/2023 with annual review 12/13/2023 revealed, Focus: Resident is at nutrition and or hydration risk as evidenced by consuming less than 75% of food and/or fluids at most meals missing/broken teeth. Record review of Quarterly Minimum Data Set (MDS) Section A dated 02/14/2024 revealed in section L for Oral/Dental - None. On 03/14/2024 at 10:40 AM the Social Service Director stated that the resident received her partial dentures on 01/25/2024. Resident has not complaint about not fitting them properly. If a complaint arises, I will expedite it and have again a dentist appointment to check and review it but, as far as I know the resident has not complaint about her denture. The dentist is coming tomorrow, and I will make sure that he will see her. On 03/14/24 at 11:24 AM Resident # 86 stated she has not told anybody about the issues with her denture. They should know that I have issues with my denture, The dentist came last month but my dentures were not bothering me, now they are. On 03/14/2024 at 11:50 AM the MDS Coordinator stated that she did not mark denture on the quarterly MDS because it did not ask for dentures. 'The resident did not tell me that she was wearing denture. 2) Record Review of admission records revealed Resident # 29 was admitted to the facility on [DATE]. Record review of Medical Diagnosis revealed the resident's diagnosis included, but were not limited to, Pneumonia due to Coronavirus disease. Benign Prostatic Hyperplasia without lower urinary tract symptoms; Bipolar disorder, Schizophrenia, Unspecified. Record review of the Care Plan, dated 12/05/2023 with annual review 12/13/2023 revealed the resident is able to go to a designated area to smoke without injury to self or others. Goal: The resident will comply with facility smoking policy as evidenced by observation of policy adherence without injury to self or others over the next 90 days. Interventions: Determine the need for safety devices such as smoker's apron personal alarm and instruct on use as needed. Maintain cigarettes and lighters in a safe location. Redirect resident if noted to be smoking in a non-designated area. Provide supervision while smoking cessation strategy explaining risks and consequences of continued tobacco use. Ongoing observation of resident's ability and willingness to be compliant with policy. Notify family, social services with any concerns. Educate resident and family on the facility's smoking policy. Explain and demonstrate to resident and family where the facility's designated smoking areas are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 4 of 15 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 03/15/2024 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 located. Level of Harm - Minimal harm or potential for actual harm Record review of Annual MDS Section J dated 11/08/2023 revealed the resident did not use tobacco. Residents Affected - Few Review of the smokers list revealed the Resident # 29-time preferences to smoke are after breakfast (9-9:30 AM) after lunch (1:00 PM-1:30 PM) Dinner (Occasionally). Comments: The resident doesn't require assistance; self-propels himself on/off units and outside to patio safely, aware of all smoking policy and procedures. If the resident is non-complaint with location of smoking. Review of the smoking assessment date 01/26/2024 revealed the resident summary evaluation: Resident may smoke independently. The resident must request smoking materials from staff. Resident/resident representative/family have been informed of smoking procedures. Resident is aware of all smoking protocol; however, he does not want to be bothered at times and has the tendency to be non-complaint. He stated that I don't need any apron to smoke. Resident smokes safely: Yes Resident utilizes ashtrays safely and properly: Yes. Resident is able to extinguish cigarettes safely and completely when finished smoking: Yes. Interview with MDS Coordinator on 03/14/2024 at 11:50 AM. She stated her assistant was the one in charge. She will ask the assistant what reason for the correction. The MDS coordinator acknowledged that the MDS for Residents #166, #86 and # 29 were not coded accurately. 3) On 03/12/2024 at 10:23 AM Resident#166 was observed in bed with oxygen in progress at a rate of three Liters per minute via nasal cannula from a concentrator. Record review of Resident # 166's demographic sheet revealed admission dates of 5/19/2023, 6/21/2023, and 7/3/2023. Diagnosis included Emphysema. Record review of Quarterly Minimum Data Set (MDS) dated [DATE] Section C for cognitive status revealed a Brief Mental Status Score of 15 on a scale of 0-15 indicating no cognitive impairment. Section GG revealed Resident #166 was dependent for all Activities of Daily Living (ADL). Section J for Health Conditions revealed Resident #166 had shortness of breath/trouble breathing with exertion and Section O for Special treatments revealed Oxygen therapy not coded. Record review of physician's orders revealed order date 11/4/2023 apply oxygen via nasal cannula at a rate of two Liters per minute continuous. Further record revealed order date 1/27/2024 apply oxygen via nasal cannula at three Liters per minute continuous. Record review of Care Plan 5/30/2023 for shortness of breath, alteration in respiratory status revealed interventions included: administer oxygen, respiratory treatments as ordered. Monitor for episodes of shortness of breath. Monitor frequency, duration, activity level and interventions that are successful. Monitor for signs and symptoms of respiratory distress. 03/15/2024 at 11:19 AM, MDS coordinator stated the process for coding special treatments code in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 5 of 15 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 03/15/2024 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Section O once it is signed in the Medication Administration Records (MAR) and a visual assessment is done, Oxygen is not coded in Section O for Special Treatments for Resident #166. There is an order for oxygen, and I see that the nurses have signed off in the MAR for oxygen. I do not know why it was missed. I will make the correction now. Review of the facility's Policy and Procedures for Resident Assessment. effective 04/06/2005 reviewed 02/14/2024 revealed the policy: It is the policy of this facility that each resident admitted to the institution shall receive a complete head-to toe admission observation/assessment by a qualified individual so that a plan of care can be developed to best meet the needs of the resident. The observation/assessment of the care or treatment required to meet the needs of the resident will be ongoing throughout the resident's facility stay, with the observation/assessment process individualized to meet the needs of the resident population. Event ID: Facility ID: 105232 If continuation sheet Page 6 of 15 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 03/15/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide a safe environment by following physician orders to place floor mats for four residents ( #36, #71, #23 and #171) out of four residents reviewed for fall precautions. As evidenced by the Residents had a physician's order for bilateral floor mats while in bed and they were not in place. The findings include: Observation of Resident # 36 on 03/11/2024 at 10:57 AM. The resident was in bed sleeping. It was observed that the floor mats were folded and leaning against the wall. (Photographic evidence). Observation of Resident # 36 on 03/13/2024 at 09:19 AM. The resident was lying on her bed, awake. The floor mat was placed on one side of the bed, and the other mat was folded leaning against the wall. (Photographic evidence). Record review of the clinical records for Resident # 36 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include, but not limited to, Type 2 Diabetes, Age-related Osteoporosis without Current Pathologic Fracture and Hemiplegia. Record review of the Physician Orders revealed an order dated 11/02/2016 for Fall Precautions and Safety Precautions. Order dated 12/17/2019 Hourly rounds for safety measure and fall prevention. Order dated 11/09/2016 Bilateral floor mats when in bed. Record review of the Quarterly Minimum Date Set (MDS) Section C Cognitive Patterns revealed the Brief Interview of Mental Status (BIMS) summary score was 03 out of 15 that suggests the resident has severe cognitive impairment. Review of the Quarterly MDS Section GG Functional Abilities and Goals revealed the resident needed partial/moderate assistance for oral hygiene, upper body dressing, The resident was dependent for toileting hygiene, shower/bathe, lower body dressing. Record review of Task for the month of March 2024 revealed the bilateral floor mats were documented as place while resident was in bed. Review of Fall Care Plan 12/11/2017 revised on 01/25/2024 The resident had the potential for falls related to history of falls for impaired gait and balance. Goal: Injuries related to falls will be minimized with daily intervention, re-directing and the use of assistive devices during the next 90 days. Interventions: Evaluate as needed by rehabilitation and nursing for safety equipment and interventions to reduce fall risk. Monitor clinical concerns that may contribute to poor safety awareness such as: Maintain bed in the lowest position bilateral floor mats. Interview with the Risk Manager on 03/15/2024 at 09:42 AM. She stated that floor mats are interventions to prevent the resident's fall. She stated that if the order was bilateral floor mats, it should be placed on both sides of bed, and she does not know why the floor mats were folded and leaning by the wall for this resident. Interview with Staff P Certified Nursing Assistant (CNA) on 03/15/2024 at 11:37 AM. She stated the floor mats should be on both sides of the bed, but she took one up to serve the lunch to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 7 of 15 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 03/15/2024 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 0689 resident and after lunch the floor mats leaned by the wall should be placed on the floor. Level of Harm - Minimal harm or potential for actual harm Interview with Staff O Licensed Practical Nurse (LPN) on 03/15/2024 at 11:40 AM. She stated that the floor mat was folded, waiting to serve lunch to the resident. She stated after lunch the floor mat will be in place by the bed. Residents Affected - Few Record review of Policies and Procedures Fall Program Effective 04/06/2005 revised on 12/21/2017 and last reviewed date 02/14/2024. Policy: The Fall Program is a facility wide, multi-disciplinary program whose purpose is to properly identify residents who are at risk for falls and potential environmental risks which may facilitate accidents resulting in resident injury. Procedure: 2-a Resident fall screening will include but may not be limited to: History of falling, secondary diagnosis, ambulatory aid, gait, and mental status. 4Residents identified as medium risk based on the Morse Fall Scale screening parameters should be considered for placement on the Falling Star program; residents identified as being high risk should be placed on the falling star program. In section: Moderate Interventions: Place on Ambulation Program and Floor Mats. 2) On 03/11/2024 at 11:33 AM, during observation and interview Resident #71 was sitting in a wheelchair and had a fall alert bracelet. Resident #71 stated, I can't open my right hand and move my arm. It's difficult. I fell and broke my arm in three places. Review of the clinical records revealed an order for bilateral floor mats and a recent fall with a shoulder fracture. On 03/12/2024 at 10:05 AM. Resident #71 was in the room. It was observed that there were no bilateral floor mats on the floor. The mats were up against the wall. On 03/12/2024 at 11:58 AM. It was observed that Resident #71 was resting in bed with eyes closed with no bilateral floor mats in place or room. (See photo evidence) On 03/13/2024 at 11:19 AM. It was observed that Resident #71 had no bilateral floor mats in place or the room, and the resident was not present. On 03/14/2024 at 09:10 AM. It was observed that Resident #71 was in a wheelchair and receiving medication from a nurse. On 03/14/2024 at 02:57 PM. It was observed that Resident #71 was in bed with eyes closed with no bilateral floor mats in place or in the room. Review of the Physician's orders revealed an order on 2/8/24 for bilateral floor mats when in bed and an order on 2/27/2024 for safety device: bilateral floor mats when in bed every shift. Review of the treatment administration record for Resident #71 revealed Nursing staff had signed off on the order for bilateral floor mats when in bed order every shift from March 1 to March 14, 2024. On 03/14/2024 at 03:02 PM. In an interview with Staff A LPN (Licensed Practical Nurse) was asked if Resident #71 had any fall in the past and interventions in place. Staff A revealed the resident has orders for bilateral floor mats. Staff A was asked where the mats were. Staff A stated: She hasn't had a fall since she been here. Her arm was dislocated from the right shoulder joint. She had this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 8 of 15 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 03/15/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few before coming here. She is to have floor mats. I can get them from therapy, the Director of Nursing, Housekeeping. The CNAs (Certified Nursing Assistants) put them in a bag and put them away. I don't know where the Aids put them. On 03/14/2024 at 03:12 PM, in an interview with Staff B, CNA was asked about if Resident #71 was on fall precautions. Staff B stated: The bed is to be low; she doesn't try to get out of bed. I place the tray table on her left side. She can't use her right arm. We don't have any fall mats. She hasn't had a fall since being here. I would have to get them by restorative nursing. On 03/14/2024 at 03:19 PM. In an interview the Assistant Director of Nursing (ADON) was asked about Resident #71's medical history, and if the resident has fall precautions and has orders for floor mats. The ADON stated, [Resident #71] has a dislocation of the right shoulder. We have everyone on fall precautions. What is important is floor mats and placing the bed in a low position. There is an order for bilateral floor mats while in bed. She used to have floor mats. I saw it the other day. They may have removed them to clean them. On 03/15/2024 at 11:16 AM. In an interview with the Director of Nursing. When asked about residents that are on fall precautions and orders for the bilateral floor mats, and the expectations for nurses and CNAs. The Director of Nursing stated: Safety if they had a fall and side rails for the resident to be able to be mobile in bed. The floor mats are to avoid a hard fall and a cushion on the floor. Staff are to be taught when providing care to remove the floor mats and place them back. Housekeeping move and put it back. They have to clean under the mat. We are going to provide in-services and educate. We are going to have each nurse a sheet, which tells the nurse which residents are to have floor mats. It's updated, where there's a change in the floor mats to communicate who needs a mat on their assignment, Housekeeping will be in-service. Review of the medical diagnosis revealed Parkinson's disease, muscle weakness, abnormalities of gait and mobility, and dislocation of the right shoulder joint. Review of admission Minimum Data Set, dated [DATE]. In section C: Cognitive Patterns, the brief interview of mental status was a 13 suggesting the resident is cognitively intact. In section E: Behavior, no behaviors were noted. In section GG: functional abilities and goals, the upper extremity was checked for impairment on one side, and the lower extremities were impaired on both sides. In section J: Health, for fall history it was checked yes that the resident had a fall anytime in the last month before the last month before admission or reentry. It was checked yes that the resident had a fracture related to a fall in the last six months before admission or reentry. Review of the care plan dated 2/19/2024 revealed Resident #71 has the potential for falls related to a history of falls, impaired gait and balance, use of psychotropic medications, and Parkinson's disease. Resident #71 is status post-recent fall with a right shoulder fracture. The goal was injuries related to falls will be minimized with daily intervention, redirecting, and the use of assistive devices during the next 90 days. Estimated 5/19/2024. The intervention was bilateral floor mats when in bed as ordered. Falling star program as indicated per facility protocol. Review of the facility's policies titled Falls program. Last reviewed date 2/14/2024. The policy statement was the fall program is a facility-wide, multi-disciplinary program whose purpose is to properly identify residents who are at risk for falls and potential environmental risks that may facilitate accidents resulting in resident injury. In the section titled Procedure 2. A Resident fall screening will include, but may not be limited to a. history of falling, secondary diagnosis, ambulatory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 9 of 15 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 03/15/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aid, gait, and mental status. 4. Resident's identified as medium risk based on the Morse Fall Scale screening parameters should be considered for placement on the Falling Star program; residents identified as being high risk should be placed on the falling star program. In section, moderate interventions, place on ambulation program and floor mats. 3) On 03/12/2024 at 11:51 AM Resident#23 was observed in bed, the floor mat folded up and leaned against the wall. (see photo evidence) Record review of demographic face sheet revealed an admission date of 8/30/2023 with diagnosis that included Diabetes Mellitus. Record review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C for cognitive status revealed a Brief Mental Status (BIMS) score of 0 on a scale of 0-15 indicated severe cognitive impairment. Section E for behaviors revealed no indicators of psychosis, no rejection of care and no wandering. Section GG for Functional status revealed dependent for all Activities of Daily Living (ADL). Section J revealed no falls since last assessment. Record review of physician orders revealed an order dated 9/5/2022 for one floor mat when in bed every shift. Record review of Care Plan dated 11/9/21 for status post fall on 11/7/2021, interventions included: keep floor mat in place, bed in lowest position. On 03/12/2024 at 9:40 AM Staff M, Licensed Practical Nurse (LPN) Stated there is an order for the floor mat for [Resident #23]. Stated : The floor mat is supposed to be always on the floor while the resident is in bed unless the staff is giving care. It was folded up against the wall because a staff member checked the resident's vitals and removed them. When I made rounds in the morning the floor mat was in place. I will continue to make rounds to ensure floor mat is in place. On 03/12/2024 at 9:50 AM Staff N, Certified Nursing Assistant (CNA) stated: I am aware of an order for [Resident #23] to have a floor mat in place for safety to prevent injury in case she falls. I removed the floor mat to get closer to the resident to take her vitals. I forgot to put the floor mat back in place. I have now placed the floor mat in place. On 03/13/2024 at 9:33 AM Staff E, LPN stated: The floor mats are for residents who are trying to get out of bed but cannot walk. The floor mats can be removed during hygiene care or when staff are assisting residents eat but must be placed back on floor if resident remains in bed. I do frequent rounds to make sure the floor mats are in place. I will educate staff to make sure they are rounding. We have a huddle at the end of the shift to discuss with current and oncoming shift pertinent interventions needed for residents. On 03/15/2024 at 9:15 AM, Staff J LPN stated: When a resident falls I get an order for floor mats. The floor mats should always be in place when residents are in the bed. The floor mats can be folded and placed in a plastic bag when the resident is out of bed and during ADL care. The housekeeping staff take floor mats out of room to clean, and I replace the floor mats at that time. On 03/11/2024 at 3:57 PM Resident#171 was observed seated on the side of bed, one floor mat was on left side of bed in place, no floor mat on right side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 10 of 15 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 03/15/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/12/2024 at 3:25 PM, Resident #171 was observed in bed with one floor mat folded and leaned against the wall and the other floor mat partially folded on the floor on the right side of the resident's bed. (see photo evidence) Record review of demographic face sheet revealed an admission date of 9/15/2023 with diagnosis that included Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. Record review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C for cognitive status revealed a Brief Mental Status (BIMS) score of 5 on a scale of 0-15 indicating severe cognitive impairment. Section GG for functional status revealed substantial/maximal assist for dressing and dependent for shower/bathe, toileting, personal hygiene. Section H for bowel and bladder revealed always incontinent of bowel and bladder. Section J revealed fall without injury. Record review of physician orders revealed an order dated 11/6/2023 for bilateral floor mats when in bed. Record review of nursing note dated 10/28/2023 revealed Resident #171 was found on floor at his bedside laying on his right side. Record review of Incident log revealed on 10/28/23 at 12:10 PM Resident #171 was found on floor mattress without any injury. Record review of care plan dated 11/17/2023 for status post fall. Interventions bed to low position with floor mats in place, staff should make frequent rounds to check resident, call bell near and monitor every two to three hours and as needed when in room for safety and comfort. On 03/12/2024 at 4:29 PM, Staff K, Registered Nurse (RN) stated: I started my shift today at 3:00PM. When I started my shift, I made rounds and visualized each resident. There is an order for bilateral floor mats for [Resident#171] while in bed. I don't know why it was not in place. I will do frequent rounds to ensure the floor mats are in place. I will communicate with CNAs to reinforce need for floor mats to be in place. 03/15/2024 at 9:30 AM, Staff I, CNA stated: I am working on the third floor. Floor mats are to prevent injury for residents who try to get out of bed but cannot walk. We remove the floor mats when we are giving care to residents or when the resident is out of bed. However, as soon as resident is in bed, we have to make sure floor mats in place. I have residents with one or two floor mats depending on the order. The nurse tells me what the order is. On 03/15/24 at 9:54 AM, Environment Service Director stated: Housekeeping deliver the floor mats, clean, and replace them as needed. When housekeeping removes the floor mats for cleaning, we immediately replace the dirty one with a clean one if the resident is in bed. The purpose of the floor mats is for safety. On 03/15/2024 at 11:45 AM Staff H, CNA stated: The floor mats are in place to prevent injury for residents who tend to fall and should be in place whenever residents are in bed. When I am giving care or feeding residents, I fold the floor mats and place them in a plastic bag until I am finished and then I replace the floor mats if the residents stay in bed. On 03/15/2024 at 10:36 AM Staff L, CNA stated: When the resident is at risk for falls, they have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 11 of 15 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 03/15/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete floor mats. The floor mats should always be in place. When I am giving care to the resident I remove the floor mats and fold them and place them in a plastic bag and once I am done giving care I put the floor mat back in place. On 03/14/2024 at 04:15 PM the Director of Nursing stated: All admissions are evaluated by restorative nursing for the need for floor mat. If the resident had a fall and cannot walk independently, we get an order for low bed and floor mats to prevent an injury after a fall. The floor mats should be in place while the resident is in bed. Floor mats can be removed, folded, and placed in a plastic bag when staff are providing care or if a resident refuses the floor mat. Once the resident is back in bed or the staff is finished with care, the floor mats must be placed back on floor. Staff assigned to the resident are responsible for making sure the floor mats are in place as ordered. The charge nurse also monitors to make sure the floor mats are in place. I will educate staff about floor mats and the purpose. Event ID: Facility ID: 105232 If continuation sheet Page 12 of 15 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 03/15/2024 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. This deficiency had the potential to affect 197 residents residing in the facility, staff, and visitors at the time of survey. Residents Affected - Many Cross Reference Event ID # PFKY21 The findings included: Interview with Maintenance Supervisor on 03/15/2024 at 12:33 PM. He stated that the fire alarm was undergoing routine inspections and at one point the fire alarm was not working properly. He stated it followed the normal procedures to submit all documents to the company who oversees repairs. It was repaired but the work was not completed. He stated it happened again and the company came but we realized the work was not completed. He stated the facility administration is trying to get estimates and bids to assess the fire alarm panel replacement or repairs. Interview with Nursing Home Administrator on 03/15/2024 at 12: 45 PM. He stated the building is old and they had an addition. He stated the maintenance inspections were done weekly, monthly, and quarterly. The alarm company in charge came and tried to fix the motherboard (panel) which is too old, it couldn't be fixed. He stated the company tried to integrate a new panel, but it couldn't be integrated. He stated the panel does not send signals to the door to work properly. The facility is in the process to replace the fire panel. He stated that the facility is asking for an estimate and bids for the fire alarm. He stated the new system will be wireless. Review of Policies and Procedures for Utilities Management Plan Effective date: 04/01/2009 revised on 11/19/2018 reviewed on 01/26/2024 revealed Scope: Utilities and the operating systems provide support to all areas and aspects of the healthcare environment. Therefore, the provision of a safe and comfortable environment for the patients, staff and visitors of Catholic Health Services facilities and the consistent and reliable performance of the critical operating systems is the goal of the Utilities Management Plan. Objectives: The objectives for the Utility Systems Program are developed from information gathered during routine and special risk assessment activities, annual evaluation for the previous years' program activities, performance monitoring and environmental tours. The objectives for this Plan are: Provision of a safe, controlled, and comfortable environment for patients, staff members, and other individuals in the facility. Review of Policies and Procedures for Safety Management Plan Effective on 04/01/2009 and reviewed on 02/14/2024 revealed Scope: The Safety Management Plan describes the program used to manage a safety program to reduce the risk of injury for patients, staff, and visitors for Catholic Health Services Facilities. Safety risks may arise from the structure of the physical environment, from the performance of everyday tasks, or they are related to situations beyond the organization's control, such as the weather. Safety incidents are most often accidental. Fundamentals: A-Department heads and managers need appropriate information and training to develop an understanding of safe working conditions and safe work practices within their area of responsibility. B-Safe working conditions and practices are established by using knowledge of safety principles to educate staff, design appropriate work environments, purchase appropriate equipment and supplies, and monitor the implementation of the processes and policies. C-Safety is dynamic. Regular evaluation of the environment for work practices (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 13 of 15 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 03/15/2024 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 0835 and hazards is required to maintain a current relevant safety program. The program should change as needed to respond to identified risks, hazards, and regulatory compliance issues. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 14 of 15 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 03/15/2024 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and records reviewed, the facility failed to ensure a safe environment endangering the life of all occupants in the facility. The facility failed to maintain the Fire Alarm system and failed to maintain the faulty fire panel. These deficient practices places all occupants of the facility at risk for smoke inhalation, serious burns, or death in the event of fire. The facility also failed to notify the residents and their representatives of the system failures. These findings resulted in the determination of Immediate Jeopardy that started on January 5th, 2024. Cross reference Event PFKY21 The findings included: On March 12, 2024 it was revealed during the Life Safety Coded surveyor that all of the 15 second magnetic door locks on all of the exit doors fire doors (egress) that would allow individuals to exit the facility during an emergency were not working, and the flashing lights that would alert individuals in event of a fire were not working. The facility started a fire watch on January 5, 2024 and instead of having the requirement of having a designated person assigned to solely to the fire watch the facility documented that the floor supervisors are conducting the fire watch. During an interview with Maintenance Supervisor on March 15, 2024 at 12:33 PM. He stated that the fire alarm was undergoing routine inspections and at one point the fire alarm was not working properly. He stated it followed the normal procedures to submit all documents to the company who oversees repairs. It was repaired but the work was not completed. He stated it happened again and the company came but realized the work was not completed. He stated the facility administration is trying to get estimates and bids to assess the fire alarm panel replacement or repairs. During an interview with Nursing Home Administrator on March 15, 2024 at 12:45 PM. He stated the building is old and they had an addition. He stated the maintenance inspections were done weekly, monthly, and quarterly. The alarm company in charge came and tried to fix the motherboard (panel) which is too old, it could not be fixed. He stated the company tried to integrate a new panel, but it could not be integrated. He stated the panel does not send signals to the door to work properly. The facility is in the process to replace the fire panel. He stated that the facility is asking for an estimate and bids for the fire alarm. He stated the new system will be wireless. The Administrator was asked if the residents, residents family and representatives were notified of the system failures. The Administrator revealed that the residents, family nor their representatives were not notified. Review of the facility's Policies and Procedures for Utilities Management Plan Effective date: 04/01/2009 revised on 11/19/2018 reviewed on 01/26/2024 revealed Scope: Utilities and the operating systems provide support to all areas and aspects of the healthcare environment. Therefore, the provision of a safe and comfortable environment for the patients, staff and visitors of Catholic Health Services facilities and the consistent and reliable performance of the critical operating systems is the goal of the Utilities Management Plan. Objectives: The objectives for the Utility Systems Program are developed from information gathered during routine and special risk assessment activities, annual evaluation for the previous years' program activities, performance monitoring and environmental tours. The objectives for this Plan are Provision of a safe, controlled, and comfortable environment for patients, staff members, and other individuals in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 15 of 15