Inspection·April 15, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm 2. Observation on 4/12/22 at 10:55 AM revealed Resident #29 in his room in bed. Observation revealed an enteral feeding pump at the bedside. The pump was not infusing formula at the time of this observation. There was a closed system bag of Isosource 1.5 hanging. The label on the bag indicated the bag was hung on 4/11/22 at 6:15 am. There was approximately 100 ml remaining in the 1000 ml bag. The label indicated the rate of infusion was 70 ml/hour. Residents Affected - Few Record review of the demographic face sheet revealed Resident #29 was admitted to the facility on [DATE] with multiple diagnoses including Cerebrovascular Accident, Emphysema, Diabetes Mellitus, Hypertension, Dysphasia, Anemia, Depression, Anxiety, and Chronic Obstructive Pulmonary Disease. Review of the minimum data set (MDS) dated [DATE] revealed Resident #29 BIMS (brief interview for mental status) score was 3 indicating a severe cognitive deficit. Section K Swallowing/Nutrition status was coded to indicate Resident #29 received nutrition/hydration through a feeding tube. Review of Resident #29's care plan dated 12/14/21 revealed: Feeding tube present. Resident at risk for unintended weight loss /decline in parameters of nutrition. Interventions included PEG (percutaneous endoscopic gastrostomy) feeding and flushes as ordered. Review Resident #29's April 2022 physician order sheet (POS) revealed an order for Isosource 1.5 @ 70/ml/hour for 20 hours (off at 10 am and on at 2 PM), change bag every day, change irrigation set every day, may hold tube feeding during resident care every shift, NPO (nothing by mouth). Based on the observation 4/12/22 at 10:55 am and review of the physician order, if the formula was hung on 4/11/22 at 6:15 am, turned off from 10 am to 2 PM, then resumed from 2 PM 4/11/22 through 10 AM 4/12/22 the total infusion for 23.75 hours at a rate of 70 ml/hour would have been 1662 ml. The observation revealed approximately 900 ml had been administered during this time period. Interview with the Director of Nursing (DON) on 4/15/22 at 11:32 AM revealed all enteral feeding bags are changed at least every 24 hours or more frequently if they are going to be empty based on prescription. Some residents get more than 1000 ml per day. After 24 hours the bags are changed even if formula remains in the bag. We use a closed system for all residents. When the nurse hangs the formula they put the residents name, date and hang time on the label. The rate is also placed on the label. The staff does not initial the bag. The nurses are responsible for the tube feedings. If a C N A (Certified Nursing Assistant) needs to provide care they call the nurse to turn off the pump. Resident # 4 feeding order is to run @75 ml/hour for 20 hours per day. Our protocol allows the feeding to be turned off during care, maybe 15 minutes or so to change the patient, maybe longer if a resident needs to be showered. Related to the observation you made on 4/12/22 with Resident # 4 's feeding bag dated 4/11/22, because of the higher rate of feeding he would need more than 1000 ml in a 24 hours period so there should not have been anything left in the formula bag. The calculations do not compute if the bag was hung on 4/11/22. This also applies to Resident #29. Due to the high rate of infusion, he would need more than 1000 ml in a 24 hour period. The discrepancy may be partially related to the feeding being turned off for the provision of care. The nurse clears the bag each time the bag is cleared but the nurses do not document the total amount infused. There is no record of intake over a 24 hour period per our policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105331 If continuation sheet Page 2 of 7 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 105331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura Rehab and Nursing Center 1800 N E 168th Street North Miami Beach, FL 33162 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure enteral feedings were administered as ordered for two (Resident #4 and #29) of two residents reviewed for tube feeding of eights residents receiving nutrition and hydration via a tube feeding of eighty one residents residing in the facility at the time of the survey. The findings included: 1. Observation on 04/12/22 at 11:35 AM revealed Resident #4 in his room in bed. Observation revealed an enteral feeding pump at the bedside. The pump was not infusing formula at the time of this observation. There was a closed system bag of Glucerna 1.5 hanging. The label on the bag indicated the bag was hung on 4/11/22 at 6:30 AM. There was approximately 400 ml remaining in the 1000 ml (milliliter) bag. The label indicated the rate of infusion was 65/ml per hour. Record review of the demographic face sheet revealed Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's Disease, Diabetes Mellitus, Protein Calorie Malnutrition, Dysphasia, Gastro Esophageal Reflux Disease, Dementia, and Gastrostomy. Review of the minimum data set (MDS) dated [DATE] revealed Resident #4 BIMS (brief interview for mental status) score was 1 indicating a severe cognitive deficit. Section K Swallowing/Nutrition status was coded to indicate Resident #4 had swallowing difficulty and received nutrition/hydration through a feeding tube. Review of Resident #4's care plan dated 12/14/21 revealed: Feeding tube present. Resident at risk for unintended weight loss /decline in parameters of nutrition. Interventions included provide tube feeding and water flushes as ordered: Glucerna 1.5 @75 ml/hour x 20 hours, auto flush of 45 ml/hour x 20 hours . Extra flushes as ordered. Review Resident #4's April 2022 physician order sheet (POS) revealed an order for Glucerna 1.5 @75 ml/hour x 20 hours (on at 2 PM, off at 10 am). Check for residual every shift. If residual is 100 ml or more hold feeding for one hour, then recheck. If still 100 ml or more, call MD. G (Give) with 30 ml water before and after each med pass and 5 ml between each med. Based on the observation 4/12/22 at 11:35 AM and review of the physician order, if the formula was hung on 4/11/22 at 6:30 am, turned off from 10 am to 2 PM, then resumed from 2 PM 4/11/22 through 10 AM 4/12/22 the total infusion for 23.5 hours at a rate of 75 ml/hour would have been 1762 ml. The observation revealed approximately 600 ml had been administered during this time period. 2. Observation on 4/12/22 at 10:55 AM revealed Resident #29 in his room in bed. Observation revealed an enteral feeding pump at the bedside. The pump was not infusing formula at the time of this observation. There was a closed system bag of Isosource 1.5 hanging. The label on the bag indicated the bag was hung on 4/11/22 at 6:15 am. There was approximately 100 ml remaining in the 1000 ml bag. The label indicated the rate of infusion was 70 ml/hour. Record review of the demographic face sheet revealed Resident #29 was admitted to the facility on [DATE] with multiple diagnoses including Cerebrovascular Accident, Emphysema, Diabetes Mellitus, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105331 If continuation sheet Page 3 of 7 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 105331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura Rehab and Nursing Center 1800 N E 168th Street North Miami Beach, FL 33162 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 0693 Hypertension, Dysphasia, Anemia, Depression, Anxiety, and Chronic Obstructive Pulmonary Disease. Level of Harm - Minimal harm or potential for actual harm Review of the minimum data set (MDS) dated [DATE] revealed Resident #29 BIMS (brief interview for mental status) score was 3 indicating a severe cognitive deficit. Section K Swallowing/Nutrition status was coded to indicate Resident #29 received nutrition/hydration through a feeding tube. Residents Affected - Few Review of Resident #29's care plan dated 12/14/21 revealed: Feeding tube present. Resident at risk for unintended weight loss /decline in parameters of nutrition. Interventions included PEG (percutaneous endoscopic gastrostomy) feeding and flushes as ordered. Review Resident #29's April 2022 physician order sheet (POS) revealed an order for Isosource 1.5 @ 70/ml/hour for 20 hours (off at 10 am and on at 2 PM), change bag every day, change irrigation set every day, may hold tube feeding during resident care every shift, NPO (nothing by mouth). Based on the observation 4/12/22 at 10:55 am and review of the physician order, if the formula was hung on 4/11/22 at 6:15 am, turned off from 10 am to 2 PM, then resumed from 2 PM 4/11/22 through 10 AM 4/12/22 the total infusion for 23.75 hours at a rate of 70 ml/hour would have been 1662 ml. The observation revealed approximately 900 ml had been administered during this time period. Interview with the Registered Dietitian (staff A) on 4/14/22 at 3:12 PM revealed all of the enteral feeding formula bags are changed daily on the 11-7 shift. The nurse clears the pump when the formula bag is changed. I make rounds and check to see if the feeding/flushes are at the correct rate and infusing as ordered. I check weekly to ensure the orders are being followed and the pump is functional. I report any identified concerns to the nurse and the DON (Director of Nursing). I have not identified any concerns. Interview with a Licensed Practical Nurse (staff B) on 4/14/22 at 3:18 PM revealed all of the enteral feeding formula bags are changed every 24 hours, typically on the 11-7 shift, but they can be changed on any shift. This will depend on the physician ordered rate. Even if a resident has a lower rate and the entire 1000 ml of formula has not infused in 24 hours, we discard any remaining formula, clear the pump and hang a new bag. We compare the amount infused against what the physician orders to ensure the order is followed. We check the rate and amount, but we do not document the total intake when we clear the pump and hang the new bag. Interview with the Consultant Dietitian (staff C) on 4/15/22 at 12:45 PM revealed the dietitian's role is to assess the residents nutritional needs and make recommendation for the enteral feeding order including the formula, rate and flush. In addition we monitor weights, labs, feeding tolerance and make recommendations for changes as indicated. We monitor nutritional outcomes. We also make rounds and check to ensure the feeding is delivered as ordered and the pump is functional. Interview with the Director of Nursing (DON) on 4/15/22 at 11:32 AM revealed all enteral feeding bags are changed at least every 24 hours or more frequently if they are going to be empty based on prescription. Some residents get more than 1000 ml per day. After 24 hours the bags are changed even if formula remains in the bag. We use a closed system for all residents. When the nurse hangs the formula they put the residents name, date and hang time on the label. The rate is also placed on the label. The staff does not initial the bag. The nurses are responsible for the tube feedings. If a C N A (Certified Nursing Assistant) needs to provide care they call the nurse to turn off the pump. Resident # 4 feeding order is to run @75 ml/hour for 20 hours per day. Our protocol allows the feeding to be turned off during care, maybe 15 minutes or so to change the patient, maybe longer if a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105331 If continuation sheet Page 4 of 7 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 105331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura Rehab and Nursing Center 1800 N E 168th Street North Miami Beach, FL 33162 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needs to be showered. Related to the observation you made on 4/12/22 with Resident # 4 's feeding bag dated 4/11/22, because of the higher rate of feeding he would need more than 1000 ml in a 24 hours period so there should not have been anything left in the formula bag. The calculations do not compute if the bag was hung on 4/11/22. This also applies to Resident #29. Due to the high rate of infusion, he would need more than 1000 ml in a 24 hour period. The discrepancy may be partially related to the feeding being turned off for provision of care. The nurse clears the bag each time the bag is cleared but the nurses do not document the total amount infused. There is no record of intake over a 24 hour period per our policy. Review of the facility policy titled Enteral Nutrition revised November 2018 revealed the policy does not address monitoring intake over a 23 hour period and does not address the frequency the formula is changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105331 If continuation sheet Page 5 of 7 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 105331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura Rehab and Nursing Center 1800 N E 168th Street North Miami Beach, FL 33162 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility 1.) failed to ensure the medical record was complete and accurate for one (Resident #4) related to advance directives and 2.) failed to ensure the medical record was readily assessable for review by the state agency for one (Resident #430) of twenty five residents whose medical records were reviewed. There were eighty one residents residing in the facility at the time of the survey. The findings included: 1.) Record review revealed Resident #4 was admitted to the facility on [DATE]. Review of the electronic health record for Resident #4 revealed a Health Care Proxy Designation and Acceptance Letter dated 10/14/21 indicated his wife was his health care proxy. Review of the Advanced Directives Acknowledgement form signed by the resident representative on 10/14/21 section Check the advance Directive Executed or Wish to Execute items checked included living will, DNR (do not resuscitate), Health Care Surrogate/Proxy (medical and financial), guardian (medical and financial). Review of the physician orders indicated Resident # 4 's code status was full code. Interview with the Director of Social Services on 4/14/22 at 12:32 PM revealed the advance directive forms are provided by admissions in the admission packet. My responsibility is to check to make sure we have all the documents from the hospital or family. I would also contact the health care surrogate or medical proxy if the resident is not able to make decisions. Resident # 4's health care proxy is his wife. She signed the Health Care Proxy Designation Form on 12/12/21. She also signed the Advanced Directive Acknowledgement Form provided at admission. The IDT (interdisciplinary team) including myself spoke to Resident #4 wife and she never expressed that she wanted him to have a DNR order. Usually the admission packet is reviewed with the resident / representative but often they want to take it home and fill out the forms. Maybe his wife checked the DNR box by mistake but, I am sure based on IDT discussions that she wants a full code status. Interview with the Nursing Home Administrator (NHA) on 4/14/2022 at 12:45 PM revealed the advance directive acknowledge form is part of the admission packet. If a resident or representative wishes to execute advance directive including a DNR, the facility will follow up to assist in formulating the desired advance directive. If a resident / representative requests to have a DNR order, we would contact the physician. In the case of Resident # 4, his wife is the health care proxy and she is very involved in his care. The team meets with her frequently and she does not want her husband to have a DNR. Sometimes the family member takes the admission packet forms home and she must have checked the DNR section by mistake. The facility does check these forms for accuracy to assist with formulating advance directive. This form is not accurate and we will contact her to correct the document. The NHA provided a corrected Advance Directive Acknowledgement form 4/14/22 at approximately 1:30 PM. The NHA stated the resident's wife was in the facility visiting and she competed a new acknowledgment form which indicates she does not want a DNR order executed for Resident # 4 . Review of the Advanced Directives Acknowledgement form signed by the resident representative (wife) on 4/14/22 section Check the advance Directive Executed or Wish to Execute items checked included Heath care Surrogate/Proxy only. The DNR, Guardian and living will boxes were not selected on the revised form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105331 If continuation sheet Page 6 of 7 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 105331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura Rehab and Nursing Center 1800 N E 168th Street North Miami Beach, FL 33162 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 0842 Level of Harm - Minimal harm or potential for actual harm 2.) Record review revealed Resident #430 was admitted to the facility on [DATE], transferred to the hospital on 2/20/20, readmitted [DATE] and discharged [DATE]. Review of the electronic health record (E H R) system revealed Resident #430's medical record was not accessible. Residents Affected - Few Interview with the Director of Nursing (DON) on 4/14/22 at 3:36 PM revealed the facility transitioned from one E H R system to another and this may have been when Resident #430 resided in the facility. There was a period of time during the transition that the medicals records were on paper. Interview with the Nursing Home Administrator (NHA) on 4/14/22 at 3:50 PM revealed the paper medical record for this resident is no longer stored in the facility, it has been sent to a storage unit. It usually takes at least two days to get the record once requested. I can submit a request today but I do not think we can obtain the record by the end of the survey. Interview with the Regional RAI (Resident Assessment Instrument) Consultant on 4/15/22 at 12:45 PM revealed the facility previously used a different system for maintaining clinical records. The facility switched to a new system May of 2020. The old system was in use through September 2019. During the transition we had access to the previous system for two months. The transition to the new system was not until May of 2020 so from September 2019 to May 2020 the clinical records were paper. We maintain medical records in the facility for the current year and the year prior so we would have 2020 and 2021 on site. The records prior to this date are sent out for storage. The NHA contacted the storage company to request the closed record for Resident # 430 yesterday but it takes 48 hours to obtain the record. Review of the policy and procedure titled Retention of Medical Records revised 2020 revealed: Medical records of discharged resident will be retained in the facility for a period of one year in the facility. Medical records of discharged resident past the one year will be stored in a designated storage company. The facility will keep records in the designated storage company for a total of seven years. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105331 If continuation sheet Page 7 of 7