Health inspection·January 12, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed a Brief Interview for Mental Status score of 02 out of 15 indicating severe cognitive impact. Section G for Functional Status indicated for eating-how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration) that the resident requires Extensive Assistance with One-person physical assist, Total Dependence, Section I for active diagnosis revealed diagnoses include but not limited to Muscle Wasting and Atrophy-Multiple Sites, Alzheimer's Disease, Dysphagia, Oropharyngeal Phase, Dementia with agitation, Schizoaffective Disorder, Other Lack of Coordination. Review of Resident #7's Care Plan with start date 12/14/22 and end date 12/30/22 revealed Preference/Choice: Resident has indicated the following preferences to eat with fingers with the following interventions: Inform resident of positive benefits of following plan of care and/or recommendations. Resident has Activities of Daily Living Self Care Performance Deficit As Evidence By: Need for assistance to Complete Activities of Daily Living tasks and requires individualized interventions to maintain because: Assist for thoroughness, Weakness, Poor Motivation, Impaired Cognition. Provide assistance as needed to perform Activities of Daily Living functions including but not limited to Feeding. Provide assistance required to complete task and document, Eating: Assist of 1. Resident has behaviors in refusal of care-eat with fingers with the following interventions: Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation, Document observed behavior and attempted interventions. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of order dated 5/5/2021 revealed Level of Assist with escort for impaired cognition and physical assistance. During an interview on 01/11/23 at 01:46 PM, Certified Nurse Assistant (CNA), Staff D revealed that at the time they had 5 residents who needed assistance with feeding. Staff D stated I have 2 today, sometimes I have 3, [Resident #7] she can eat sometimes and other time we have to help her. Also, sometimes you can help her but sometimes you cannot because she doesn't want the spoon in her mouth .sometimes she fights too, you can try to feed her with the spoon she says no, no and then she uses her finger. I know she could start eating I didn't try to feed her. I know she likes sugar, and I placed it in front of her but that was it. During an interview on 01/11/23 at 01:55 PM, Certified Nurse Assistant (CNA), Staff E stated: I'm not in charge of feeding [Resident #7], her CNA has three people for assistance so anybody can help the resident. She needs help all the time but sometimes she does eat with her finger. She has her preferences to eat . I don't know when she wants help or not. I thought somebody was helping her when I realized she needed help I came to help her. During an interview on 01/12/23 at 08:51 AM, Certified Nurse Assistant, Staff F stated that for Resident #7, when it comes to eating, she has assistance mostly, sometimes it is limited, and sometimes she wants to eat with her finger .When we try to feed [Resident #7] and she says no, no we let her feed herself with her finger, if she doesn't want to be fed by a spoon we have to let her, but she needs a person to be there with her. Staff F reported that anyone can assist with feeding the residents. Staff F further reported they had 5 residents who needed assistance in the unit and at the time she oversaw three residents. Review of the facility's Policy and Procedure, Topic All Hands Dining Effective January 2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105408 If continuation sheet Page 2 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Isle Care Center 1735 N Treasure Drive North Bay Village, FL 33141 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed the following: Policy- To allow members of the staff to interact with residents and provide assistance with meals to better meet resident individual needs. with Procedure- All Hands Dining: 1. Involve all departments, including, but not limited to: a. Administrator, b. Social Services, c. Registered Dietitian-Home Facility (if shared), d. Food Service Manager, e. Nursing Administration, f. Activities Director, g. Medical Records, h. Admissions Coordinator. 2. Participation by all staff is necessary and is accountable by the Administrator-1. Modifications to number of hosts may be made according to facility size. Review of the facility's Policy & Procedure effective February 2021, Topic Resident Rights revealed the following: Policy- The facility strives to assure that each resident has a dignified existences, self-determination, and communication with, and access to, persons and services inside and outside the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105408 If continuation sheet Page 3 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Isle Care Center 1735 N Treasure Drive North Bay Village, FL 33141 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 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. During meeting and interview with the Resident's Council on 01/10/23 at 11:01 AM, it was reported that there is not enough staff on all shifts. Residents Affected - Some During an interview with resident #30 on 01/10/2023 at 11:20 AM, the resident stated there is not enough staff in all shifts. He reported that when he used the call light for assistance he has to wait one hour or more for someone to assist. Review of the facility's Policy and Procedure Effective April 2015 Topic Staffing revealed the following: Policy- Each nursing center has sufficient nursing staff to pride nursing and related services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident, as required by the federal law, and sufficient staff to meet applicable state law requirements (including minimum staffing ratios). The projected staffing plans are re-evaluated on an on-going basis in response to changes in the facility, resident population, or other circumstances. Staffing is monitored on an ongoing basis through a combination of offside and onsite facility reviews conducted by Facility, Consulting and Compliance staff. The facility Administrator and/or Director of Nursing should evaluate staffing on a daily basis with Procedure: Establish Facility Projected Staffing Levels 1. Monitor the census and resident special care needs daily, 2. 11-7 is the first shift of the day, 3. Adjust staffing throughout the day based on census and resident special care needs changes, 4. Develop daily staffing patterns that allocate positions per unit per shift, 5. The daily staffing patterns should be focused on permanent consistent assignments, 6. Monitor to ensure minimum State staffing levels are always maintained. Daily Staffing Sheets: 1. Prepare one week in advance, 2. Review at the beginning of the week with the Supervisor, 3. Post sheets daily, 4. Scheduler and Supervisor meet weekly to discuss open positions and shifts. Other: 1. Post the daily staffing hours. Ongoing Monitoring 2. Evaluate the adequacy and appropriateness of facility-specific projected staffing plans throughout the day, 3. Monitor the adequacy and appropriateness of staff on an ongoing basis through the QAPI program. Based on observation, interview, and record review the facility failed to provide sufficient staffing for 2 ( unit 2 and unit 3) out of 5 units. This had the potential to affect the 89 residents who resided in those units out of the 169 residents residing in the facility during this survey. The finding included: Upon entering the facility on 01/09/2023 at 6:00 AM, while the surveyors were in the lobby area the kitchen manager asked the team to wait in the lobby before entering the facility. After waiting in the lobby area for ten minutes, the team entered the facility towards the residents' rooms and no staff was observed leaving or entering the facility through the main door. At the time, there was a male staff from kitchen observed by surveyors who was also waiting in the lobby area. Observation on Unit 3 on 01/09/23 at 6:11 AM revealed the staffing information board did not have information for current staff working, the board only had the unit manager's name from day shift, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105408 If continuation sheet Page 4 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Isle Care Center 1735 N Treasure Drive North Bay Village, FL 33141 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some census, and break times. At the time of this observation there was only one (1) nurse (Staff G, a Registered Nurse). It was revealed that there is another nurse who was on her break, and a third Certified Nurse Assistant is out of the facility at this time. The nurse reported the missing Certified Nurse Assistant had to leave because she had an emergency, however she left without informing anyone in the facility. The nurse then proceeded to contact Registered Nurse, Staff N. The nurse reported that stated that Staff N went out on a break and had left the facility at around 6:00 AM or a few minutes later. Staff N was observed to arrive in the facility at approximately 6:45 AM. Interview and observation with the Registered Nurse (Staff G) on 01/09/23 at 6:15 AM revealed, he worked from 11:00 PM to 7:00 AM on Unit 2. He stated that there is no charge nurse, right now I am but we do not have one, if anything were to happen, we call the Director of Nursing. He continued and stated, there is not a supervisor today, but you can say it's me. Observation of the staffing board with Staff G, revealed two nurses' names for the unit on the floor; however, Staff G's name was not on the board. He stated, I came in last night and I am supposed to change the board, those two nurses are not here. The nurses' names listed on the staffing board only reflected the staff members who worked on 1/7/2023. He was aware that none of the licensed and registered nurses listed on the board were present in the facility, and the staffing board did not indicate the specific shifts that staff members worked. He stated there should be two nurses on this unit today, and also on unit 3. He also stated, somebody called out yesterday afternoon. On this unit I have 43 residents, and I know I can have up to 40 residents myself. During an interview with Licensed Practical Nurse,( LPN ), Staff C on 01/10/23 at 01:13 PM, when asked why she was in two different units on this day, she stated: I am in two different units today, unit 2 and 3, this only happens when we are short of nurses, I am not sure but maybe somebody called off, I cover between units when somebody calls off. I'm mostly scheduled in unit 2 when I finished that then I come to unit 3. On unit 2 I have 12 residents and on 3 I have 20 residents. Occasionally I do overtime, some of the weekends that I work I do overtime. I can handle the workload it can be better, but I am happy. During an interview with Unit 2's Manager (Staff I) on 01/12/23 at 09:22 AM, when asked about a nurse covering two units on 01/10/23, she stated double floating does not happen often, on that time I remember the nurse called in sick . that day and we call somebody else to replace her, we did not find a replacement that day, and that is when Staff C had to work in the two units. During an interview, Certified Nurse Assistant (Staff J) on 01/12/23 at 11:32 AM revealed, she has been working at the facility since 1988. She stated today I am in charge of 13 residents myself, before I used to have 8 to 9, I have 1 resident intubated, 9 residents that are total assistance and 2 residents to assist only. When there are 4 people in the unit I have 13, when 5 I have 10, it all depends on whenever somebody calls in sick. Sometimes when somebody calls in sick they replace the staff member but not all the time. Staff J revealed that she does overtime mostly every Sunday when they are short of staff and further stated, I don't have no choice with the workload, I hope things change because it is hard on us regarding how many patients we each have. During an interview with the Staffing Coordinator on 01/12/23 at 02:13 PM, when asked about the State Minimum Nursing Staff Calculations for Long Term Care Facilities, she stated, with the ratio in order to calculate it, we sit with the Director of Nursing, and it depends on the census on the unit, we go from there and that is the end of the assignment. In the past month we have not had a ratio below of what the regulation asks for, we have not had any issues in the past month either, not even in the holidays. When asked about Units 3 and 4 staffing, she stated at night Unit 2 has 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105408 If continuation sheet Page 5 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Isle Care Center 1735 N Treasure Drive North Bay Village, FL 33141 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Registered Nurses (RN) or Licensed Practical Nurse (LPN) and the supervisor. A supervisor does pass medications at night as well, section 3 always remains with 2 Registered Nurses (RN), I have not had any issues with staffing in units 3 and 2. During an emergency they must report directly to the Director of Nursing. The Director of Nursing comes in right away if they cannot find a replacement . she has to come and replace, it can be the Director of Nursing or Assistance Director of Nursing. Certified Nurse Assistants are supervised by floor nurses and the Unit managers then supervisor. During an interview with the Director of Nursing (DON) on 01/12/23 at 02:42 PM, when asked about the protocol to follow when staff has an emergency; the DON stated, if someone calls off, we have to replace whoever it is that calls out, we have the staffing set up for whichever shift it is. The protocol they follow when calling out, they call me or they call the facility and speak to the supervisor or staffing coordinator as well. We advised them to call in a timely manner so that we are notified, and we can replace them for someone else. The time is usually 2 hours before any situation happens, it depends on the situation, they call and let us know. If the manager can stay over or someone who want to stay over wants to stay to cover. We have not had any emergencies in the middle of the shift, I am not recalling. They call me if they have an emergency. If anything like that occurs, someone else will have to take over, someone else will have to take charge. During record review of Treasure [NAME] 24 Hour Staffing Schedule Date: Monday 1/9/23 shift 11:00 PM to 7:30 AM revealed Section's 2 schedule with Nurse: Staff G, RN and 3 CNAs, Section's 3 with Nurse: Staff N, RN and Staff O, RN and 4 CNAs. During record review of the facility's State Minimum Nursing Staff Calculations for Long Term Care Facilities from 12/18/2022 through 12/24/2022 it was revealed that the weekly average for the combined Register Nursing (RN) and Licensed Practical Nurse (LPN) Direct Care Staff Hours fell below the minimum of 1.0 direct care per resident per day on 5 out of 7 days. The following averages were noted: 12/18/22: 0.9588, 12/20/22: 0.9689, 12/22/22: 0.8538, 12/23/22: 0.7647, and 12/24/22: 0.9077. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105408 If continuation sheet Page 6 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Isle Care Center 1735 N Treasure Drive North Bay Village, FL 33141 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have daily nurse staffing posted prior to the beginning of shifts on 5 of 5 nursing stations. This had the potential to affect the 169 residents who resided in the facility at the time of this survey. Residents Affected - Some The findings included: During an observation at unit 1 nurse's station, on 01/09/23 at 6:06 AM, it was noted that the staffing information posted was dated Saturday, 01/08/23 for the 3:00 PM to 11:00 PM shift not for the current 11:00 PM to 7:00 AM shift. (Photo Evidence) During an observation at unit 2 nurse's station, on 01/09/23 at 6:11 AM, it was noted that the staffing information posted was dated Saturday, 01/07/23. (Photo Evidence) During an observation at unit 3 nurse's station, on 01/09/23 at 6:08 AM, it was noted that staffing information was missing. The only information posted was the unit manager for the day shift, break times, and census. (Photo Evidence) During observation at unit 5 nurse's station, on 01/09/23 at 6:10 AM, it was noted that the staffing posted was dated 1/7/23, Census 17, Nurse [nurse name], Certified Nurse Assistants (CNAs)-blank (Photo Evidence) During an observation at unit 4 nurse's station on 01/09/23 at 6:13 AM, it was noted that there was no staffing information posted. (Photo Evidence) Interview with Registered Nurse (Staff G) on 01/09/2023 at 6:15 AM revealed, he worked from 11:00 PM to 7:00 AM on Unit 2. Observation of the staffing board on the floor did not reveal his name. Staff G stated, I came in last night, I am supposed to update the board, the RNs posted in the board are not here. During a second observation at unit 2 nurse's station, on 01/09/23 at 6:23 AM, it was noted that Staff G deleted the previous shift nurse's name and proceeded to change it to his name. Staff G was also observed changing the date to 1/8/23. (Photo Evidence) Record Review of Treasure [NAME] 24 Hour Staffing Schedule Dated Monday 1/9/23 shift 11:00 PM to 7:30 AM revealed the following: Section 2 nurse: Staff G/RN with 3 Certified Nurse Assistants (CNAs). During an follow up observation at unit 1 nurse's station, on 01/09/23 at 6:39 AM, it was noted that the staffing information was deleted and was still dated 01/08/23. (Photo Evidence) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105408 If continuation sheet Page 7 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Isle Care Center 1735 N Treasure Drive North Bay Village, FL 33141 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** 2. During the review of Resident #120's medical record, it was noted the resident was admitted to the facility on [DATE] with diagnoses that included but was not limited to Chronic Obstructive Pulmonary Disease. The resident had an order for hospice care dated 10/06/2020. During the review of the resident's electronic medical record it was noted, under the resident's picture, the resident's code status was listed as Full Resuscitation. During the review of the residents electronic medical records Profile tab/section, the resident's code status was listed at the top as Full Resuscitation. On the same page, in the Custom Section, the residents code status was listed as Do Not Resuscitate. During interview on 1/12/2023 at 11:05 AM, the Regional Director was asked about the conflicting information. The Regional Director reported, she thought the resident was a full code, but she would check on the information. Interview at 01/12/2023 at 11:10 AM the Regional Nurse returned and reported they don't check that area in the chart, she reported, the residents code status is a Full Resuscitation, and the information would be corrected. Based on record review and interviews, the facility failed to ensure complete and accurate documentation of resident's Advanced Directives for 2 (Resident #94 and Resident #120) of 34 sampled residents. This had the potential to affect the 169 residents in the facility receiving care and services at the time of this survey. The findings included: 1. Review of the medical records for Resident #94 revealed the Advance Directive (AD) in the care plan reference date 12/13/22 documented resident/authorized responsible party request Full Code wish to be honored. On 1/10/23 at 2:45 PM physical copies of Resident #94' Advance Directives given to the surveyor by the facility's Social Services Director (SSD) revealed, Advance Directive for Resident #94 dated 11/05/2022 documented Do Not Resuscitate (DNR), signed by MD (Medical Doctor). Further review of the medical records for Resident #94 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Unspecified Sequelae of Cerebral Infarction. Review of the Physician's Orders Sheet for January 2023 revealed Resident #94 had orders that included but not limited to: Do Not Resuscitate (DNR). Record review of Resident #94 's Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns indicated Brief Interview for Mental Status Score (BIMS)-Unable to determine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105408 If continuation sheet Page 8 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Isle Care Center 1735 N Treasure Drive North Bay Village, FL 33141 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 Record review of Resident #94 's Care Plans Dated 12/13/2022 revealed: Resident Advance Directives (AD) is as follows: Resident/authorized responsible party request FULL CODE wish to be honored. Residents Advance Directives will be honored as indicated through next review. Interventions Includes: Allow resident, if able to discuss feelings regarding their Advance Directives. Request resident and/or appointed health care representative to provide copies to the facility of any updated Advance Directives. Residents Affected - Few During an interview on 01/11/23 at 11:42 AM the SSD stated, I am in charge of obtaining the residents' Advance Directives, Minimum Date Set (MDS) Coordinator (Staff A) takes care of the care plan, either myself or MDS personnel will enter the Advanced Directives in the care plans within 24 hours initially and if they are any changes by the resident or resident's representative. SSD checked Resident #94's care plans with surveyor present in her office and observed the AD care plan documented the resident is full code, SSD acknowledged the Advanced Directive document given to surveyor for the resident on 1/10/23 documented 11/5/2022 -Do Not Resuscitate (DNR). Interview on 01/12/23 at 09:10 AM with Registered Nurse (RN) Clinical reimbursement specialist (CRS), Minimum Data Set Coordinator (MDS), (Staff B) and RN, CRS, MDS, (Staff A) stated the Interdisciplinary Team (IDT) is responsible for updating the care plans, Advanced Directives (AD) fall under social services, if there is a change in DNR, full code or anything that has to do with AD social services take care of that. The turnaround time for updating the care plans depends on what is going on with the resident. For example, a change in a resident's condition-nursing will do an update and in the morning meetings all changes in residents are discussed and then we go into the system and update the necessary changes. We make sure that all our residents medical records are up to date to the best of our ability. Review of the facility policy and procedures titled Advanced Medical Directives revision date October 2022 states: Procedure upon admission: 1. Verify that information on Advance Directives (AD) was provided to the resident/patient and family/legal representative at the time of admission 2. Obtain any current AD from the resident/patient and family/legal representative and place in the medical record. 3. Obtain physician's order that reflect the patient/resident and/or legal health care decision makers current wishes place as the first document in the chart 4. Document the current AD in the medical records 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105408 If continuation sheet Page 9 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Isle Care Center 1735 N Treasure Drive North Bay Village, FL 33141 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 Provide further information to the physician regarding AD when requested by the resident/patient, family and/or legal representative. Level of Harm - Minimal harm or potential for actual harm 6. Residents Affected - Few Update the medical record with new or revised AD as indicated 7. Review the medical record at least quarterly and document verification of AD in place in the progress notes FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105408 If continuation sheet Page 10 of 10