Health inspection·November 4, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Environmental Services dated 03/01/10, included the following: The resident has a right to a safe, clean, comfortable, and homelike environment. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Facility will provide adequate and comfortable lighting levels in all areas. Residents Affected - Few A tour of the facility was conducted on 11/04/22 at 9:20 AM with the Administrator and Staff F, Maintenance Assistant, the Administrator took notes of the items of concern and translated for Staff F, Maintenance Assistant (whose first language is Spanish). Staff F, Maintenance Assistant showed surveyor the Maintenance Log located at each nursing station, he explained that areas of concern by staff/residents are entered onto a repair requisition sheet that is kept in the Maintenance Log. Staff F, Maintenance Assistant said he reviews the Maintenance Logs daily on weekdays. He stated that the only staff that enter items of concern onto a repair requisition sheet are staff that work on the 11:00 PM -7:00 AM shift and weekend staff. For all other times a concern is identified by staff, they verbally inform the maintenance staff directly. During an interview conducted on 11/04/22 at 9:40 AM with the Administrator, he stated that they were and are using a Gang Tackling System for identifying and completing maintenance concerns. He stated they have not had a Director of Maintenance for about 4-6 weeks, and it is possible that all concerns may not have been documented since the Director of Maintenance left. They have plans to implement an electronic system (TELS) in the next year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 2 of 13 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist during dining for 1 of 1 resident reviewed for Activities of Daily Living (ADLs), Resident #22. Residents Affected - Few The findings included: In an observation conducted on 11/01/22 at 1:00 PM, the lunch tray was brought into Resident #22's room. Closer observation showed a tray with NAS (No Added Salt) diet mechanical soft consistency. The lunch plate was noted with meat lasagna, collard greens, and tropical fruits. Staff brought the tray into the room and walked out. Continued observation at 1:25 PM showed that Resident #22 only ate 10% of her lunch tray. In an observation conducted on 11/01/22 at 5:15 PM, the dinner tray was brought into Resident #22's room by Staff A, Certified Nursing Assistance (CNA). She set up the tray by the bedside and walked out of the room. Continued observation showed a dinner plate with an egg salad sandwich, potato salad, vegetable soup, and milk. At 5:32 PM, Resident #22 ate only 10% of her dinner meal. In an observation conducted on 11/02/22 at 7:34 AM, the breakfast tray was brought into Resident #22's room, and Staff walked out. Continued observation showed a breakfast tray with the following: Super cereal, pancakes, eggs, milk, coffee, juice, and fruits. At 7:55 AM, Resident #22 ate only 10% of her breakfast meal. No staff was observed in the room during this entire observation. A chart review showed that Resident #22 was admitted to the facility on [DATE] with diagnoses of Dementia, Hypertension, and Arthritis. The order noted for a Mechanical Soft Diet. The Minimum Data Set (MDS) dated [DATE] showed that Resident #22 had a Brief Interview of Mental Status (BIMS) score of 01 out of 15 meaning the resident has severe cognitive impairment. Section G for eating showed that Resident #22 needs total assistance with one person assist for eating. A progress note dated 09/22/22 by the facility's clinical dietitian showed that Resident #22 weight was noted at 160 pounds on 09/19/22. It further showed that Resident #22 needs maximum assistance and encouragement with her meals. Another progress note dated 10/15/22 showed that Resident #22 lost 2 pounds and is now at 158 pounds. It further revealed that Resident #22 requires some assistance with her meals and needs to be encouraged at times. In an interview conducted on 11/02/22 at 2:53 PM with Staff C, Minimum Data Set (MDS) Coordinator stated that she based Section G on eating after speaking to the nursing staff, CNAs, Social Worker, and any staff members who interact with Resident #22. She also stated that the state of the residents might change, and she is only assessing their status for a specific time frame. In an interview conducted on 11/03/22 at 10:40 AM, Staff D, Certified Nursing Assistant (CNA), stated that Resident #22 needs assistance with her meals. She further stated that she needs encouragement with her meals and did that today for the morning meal. In an observation conducted on 11/03/22 at 11:10 AM with Staff E, a Certified Nursing Assistance, she was asked by Surveyor to take the weight on Resident #22. Staff E used the mechanical lift to take the weight of Resident #22, which showed a weight of 153.1 pounds. This showed a weight loss from 158 pounds from 10/13/22 to 11/03/22 at 153.1 pounds in about two and ½ weeks which is a 3.1% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 3 of 13 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150 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 0677 weight loss. Level of Harm - Minimal harm or potential for actual harm In an interview conducted on 11/03/22 at 4:00 PM, the facility's Administrator was informed of the findings. Residents Affected - Few Review of the facility's policy Activities of Daily Living (ADLs) dated 2005 showed that ADLs are both essential and routine aspects of self-care. This facility's policy encourages residents to maintain their highest practical level of functioning and prevent a decline in ADLs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 4 of 13 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150 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 record reviews, observations and interviews the facility failed to follow tube feeding orders for 2 out of 5 sampled residents reviewed for tube feeding (Resident #72 and Resident #288). The findings included: Review of the facility's policy titled Tube (Enteral) Fed Residents with a revision date of 2019 included the following: The Dietitian/Diet Technician assesses the adequacy of the tube feeding and recommends changes as indicated. Nursing Services is responsible for the administration of the tube feeding. 1)Record review of Resident #72's clinical records revealed the resident was admitted to the facility on [DATE] with the most recent readmission date of 05/07/21. The diagnoses included Type 2 Diabetes and Encounter for Attention to Gastrostomy. Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #72 had a Brief Interview for Mental Status of 0, which indicated that she had severe cognitive impact. Review of Section G of the MDS dated [DATE] documented that Resident #72 had a bed mobility self-performance of total dependence with support of one person, transfer self-support of total dependence with support of two persons, dressing self-performance of total dependence with support of one person, eating self-performance of total dependence with support of one person, toilet use self-performance of total dependence with support of one person, personal hygiene with self-performance of total dependence with support of one person. Review of the Physician's orders for Resident #72 revealed a Physician's order dated 02/23/22 for Isosource 1.5 (formulary type) at 60 milliliters (ml) per hour for 20 hours via peg tube, hold from 5:00 AM to 9:00 AM daily for nourishment. Review of Resident #72's Care Plan dated 04/21/22 with a focus on problem of resident is at risk for complications of tube feeding i.e., aspiration, infection intolerance to feeding, and fluid overload/deficit. Goal was for resident to tolerate tube feeding without signs/symptoms (s/s) of complications and have stable weights thru next review date (NRD). Interventions included: Keep height of bed (HOB) on moderate high back rest. Tube feeding formula per Medical Doctor (MD) order. May hold feeding during shower care. Review of handwritten documentation in Nurse's Notes did not reveal any issues with the tube feeding for Resident #72. On 11/02/22 at 8:25 AM an observation was made of Resident # 72 resting in bed. Upon closer observation the resident had an unopened, bag of Isosource 1.5 (formulary type) that was at the 1,500 milliliter (ml) mark out of a 1,500 ml capacity bag. The tube feeding was not infusing. On 11/02/22 at 10:10 AM an observation was made of Resident #72 lying in bed and singing. A closer observation revealed a tube feeding bag with Isosource 1.5 (formulary type) that was started on 11/02/22 (no time was indicated). Closer observation revealed the tube feeding was at the 1,500 milliliter (ml) mark out of a 1,500 ml capacity bag. The tube feeding was at 60 milliliters per hour via an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 5 of 13 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150 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 electric pump. Level of Harm - Minimal harm or potential for actual harm On 11/02/22 at 11:05 AM an observation was made of Resident #72 resting in bed and watching television. A closer observation revealed the tube feeding was at the 1,450-milliliter mark out of a 1,500 milliliter capacity bag. The tube feeding was infusing via pump at 60 milliliters per hour via an electric pump. Residents Affected - Few On 11/02/22 at 2:00 PM an observation was made of Resident #72 resting in bed and watching television. A closer observation revealed the tube feeding was at the 1,300 milliliter mark out of a 1,500 milliliter bag. The tube feeding was infusing at 60 milliliters per hour via an electric pump. The tube feeding according to the Physician's orders for Resident #72 should have infused from 9:00 AM to 2:00 PM (5 hours) at 60 milliliters per hour which should have provided a total volume of 300 milliliters. The bag should have had the remaining tube feeding at the 1200 mark out of a 1500 ml capacity bag. 2)Record review for Resident #288 revealed that the resident was admitted to the facility on [DATE] with the most recent readmission date of 09/22/22. Diagnoses included Acute Hypoxia Respiratory Failure and Encephalopathy. Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #288 had a Brief Interview for Mental Status of 0, which indicated that she had severe cognitive impairment. Review of Section G of the MDS dated [DATE] documented that Resident #288 had a bed mobility, transfer, dressing, eating, toilet use, and personal hygiene all had a self-performance of total dependence with support of one person. Review of the Physician's orders for Resident #288 revealed an order dated 10/02/22 for Isosource 1.5 (formulary type) at 65 milliliters per hour for 22 hours via Percutaneous Endoscopic Gastrostomy (PEG) tube off at 11:00 AM, on at 1:00 PM for Nutrition. Review of Resident #288's Care Plan dated 09/23/22 with a focus on problem of resident is at risk for complications of tube feeding i.e., aspiration, infection intolerance to feeding, and fluid overload/deficit. Goal was for resident to tolerate tube feeding without signs/symptoms (s/s) of complications and have stable weights thru next review date (NRD). Interventions included: Keep height of bed (HOB) on moderate high back rest. Tube feeding formula per Medical Doctor (MD) order. May hold feeding during shower care. Review of handwritten documentation in Nurse's Notes did not reveal any issues with the tube feeding for Resident #288. On 11/02/22 at 8:30 AM an observation was made of Resident #288 lying in bed with eyes closed. Upon closer observation revealed the resident had Isosource 1.5 (type of tube feeding) that was started on 11/02/22 at 6:30 AM, it was infusing at 65 milliliters (ml) per hour via a feeding pump, with a volume of 1500 milliliters (mls) in a 1,500 milliliter (ml) bag. On 11/02/22 at 10:00 AM an observation was made of Resident #288 lying in bed with eyes closed. A closer observation revealed the resident had a tube feeding bag that was started on 11/02/22 at 6:30 AM. The tube feeding was at the 1,400 milliliter (ml) mark out of a 1,500-milliliter capacity bag. The tube feeding was infusing at 65 milliliters (ml) per hour via an electric pump. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 6 of 13 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150 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 On 11/02/22 at 11:15 AM an observation was made of Resident #288 lying in bed with eyes closed. A closer observation revealed the resident had tube feeding that was started on 11/02/22 at 6:30 AM and was at the 1,350 milliliter (ml) mark out of a 1,500-milliliter capacity bag. The tube feeding was infusing at 65 milliliters (ml) per hour via an electric pump On 11/02/22 at 2:05 PM an observation was made of Resident #288 lying in bed with eyes closed. A closer observation revealed the resident had tube feeding that was started on 11/02/22 at 6:30 AM and was at the 1,300 milliliter (ml) mark out of a 1,500-milliliter capacity bag. The tube feeding was infusing at 65 milliliters (ml) per hour via an electric pump The tube feeding according to the Physician's orders for Resident #288 should have infused from 6:30 AM to 11:00 AM and restarted at 1:00 PM (5.5 hours) at 65 milliliters per hour which at 2:00 PM should have provided a total volume of 357.5 milliliters. The bag should have had the remaining tube feeding at the 1,142.5 mark out of a 1,500 ml capacity bag. During an interview conducted on 11/03/22 at 9:05 AM with Staff H, Licensed Practical Nurse (LPN)when asked about tube feedings, she stated that the nurse is responsible for the tube feeding administration. Most times the tube feedings are hung and started at 6:00 AM and many of the resident's tube feedings are turned off from 10:00 AM to 2:00 PM for activities of daily care (ADLs) to be performed. During an interview conducted on 11/04/22 at 8:30 AM with the DON she stated that the nurse is responsible to monitor and document the tube feeding for residents. Any exceptions for the tube feeding from the physician's orders should be documented in the progress notes. The documentation in the progress notes should show how much tube feeding has been infused in their shift. The nurses also sign on the medication administration record MAR) as well. If the nurse just documented on the MAR, that would indicate that the feeding was infusing as ordered. During an interview conducted on 11/04/22 at 11:10 AM with Registered Dietician, when asked how does she know that the residents receiving tube feeding are they getting the full amount daily, she replied that she makes daily rounds and verifies that the tube feeding pump is running at correct rate and verifies that the hang time on the tube feeding bag and the amount left in the bag match the amount that should have been infused. She also stated that based on the residents' weights she will adjust the tube feeding accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 7 of 13 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to change the oxygen tubing weekly and document changing the oxygen tubing weekly as per facility's policy for 2 out of 3 sampled residents (Resident #288 and Resident #67). Residents Affected - Few The findings included: Review of the facility's policy titled Oxygen Concentrator with an issued date of 03/2020 and no revised date. The policy included the following: Care of the Concentrator - Document in the resident's clinical record. Change tubing weekly. 1)Record review of clinical records for Resident #67 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission date of 09/28/22. Diagnoses included Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Pneumonia. The Minimum Data Set (MDS) for Resident #67, dated 10/03/22 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognitive response. In Section O revealed that Resident #67 was receiving oxygen therapy while not a resident and while she was a resident. Review of the Physician's orders for Resident #67 revealed the following: Physician's order dated 10/06/22 for oxygen 2 liters/minute via nasal cannula (n/c) as needed (prn) for shortness of breath (sob), O2 sat <92% (oxygen saturation less than 92 percent) Physician's order dated 09/29/22 to monitor oxygen saturation every shift. Record review of Resident #67's Medication Administration Record and Treatment Administration Record from 09/01/22 to 10/31/22 revealed no documentation of oxygen being administered, and no documentation of oxygen tubing being changed. Record review of Resident #67's handwritten documentation under Daily Skilled Notes from 10/01/22 to 11/03/22 included the following: On 10/02/22 documentation of oxygen at 2 liters. On 10/03/22 documentation of oxygen (O2) at 2 liters via cannula. On 10/13/22 (Thursday) documentation of O2 nasal cannula changed every Sunday on 11-7 (11:00 PM-7:00 AM) as per facility protocol. On 10/13/22 documentation of O2 in progress at 2 Liters per minute via nasal cannula. On 10/28/22 documentation of O2 96% nasal cannula (n/c) 2 liters, all car provided. On 11/01/22 documentation of O2 at 2 liters per minute. On 11/02/22 documentation of O2 at 2 liters via n/c ongoing. Care Plan for Resident #67 dated 09/28/22 with a problem of oxygen therapy related to diagnosis of Chronic Obstructive Pulmonary Disease (COPD) as needed, resident has a diagnosis of COPD and Acute Respiratory Failure and requires the use of oxygen and respiratory treatments as per Medical Doctor (MD) orders. Goals included: will have no complications from oxygen therapy, resident will retain proper oxygenation by next review date (NRD). Interventions included: Administer oxygen per MD orders. Change tubing as needed. Observe for shortness of breath, cyanosis, anxiety, and report abnormal findings to MD with follow up as indicated. On 11/01/22 at 11:00 AM an observation was made of Resident #67 lying in bed. Upon a closer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 8 of 13 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150 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 0695 Level of Harm - Minimal harm or potential for actual harm observation the resident had humidified oxygen infusing via nasal cannula, the oxygen tubing had a date of 10/03/22 (Photographic Evidence Obtained). On 11/02/22 at 3:00 PM an observation was made of Resident #67 lying in bed. Upon a closer observation the resident had humidified oxygen infusing via nasal cannula, the oxygen tubing had a date of 10/03/22. Residents Affected - Few On 11/02/22 at 8:26 AM an observation was made of Resident #67 sitting up on the side of her bed eating breakfast bed. Upon a closer observation the resident had humidified oxygen infusing via nasal cannula, the oxygen tubing continued to have a date of 10/03/22. Record review for Resident #288 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE]. Diagnosis included Acute Hypoxia Respiratory Failure. The Minimum Data Set (MDS) for Resident #288, dated 09/01/22 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impact. Review of the Physician's orders for Resident #288 revealed the following: A Physician's order dated 09/22/22 for Oxygen at 2 Liters/minute via nasal cannula (NC) as needed for shortness of breath. A Physician's order dated 09/22/22 to monitor oxygen saturation every shift call MD if less than 92%. 2)Record review of Resident #288's Medication Administration Record and Treatment Administration Record from 09/01/22 to 10/31/22 revealed no documentation of oxygen being administered, and no documentation of oxygen tubing being changed. Record review of Resident #288's handwritten documentation under Nurse's Notes and the Daily Skilled Nurse's Notes from 10/01/22 to 11/03/22 included the following: On 10/02/22 O2 2 liters per minute continuous. On 10/03/22 documentation included O2 in use via n/c. On 10/08/22 documentation included O2 in use via n/c. Care Plan for Resident #288 dated 09/22/22 with a problem of oxygen therapy as needed related to diagnosis of Acute Hypoxia Respiratory Failure. Goals included: will have no complications from oxygen therapy, resident will have decreased episodes of shortness of breath (SOB) by next review date (NRD). Interventions included Administer oxygen per MD order, change tubing as needed, observe for shortness of breath, cyanosis, anxiety, and report abnormal findings to MD with follow up as indicated. On 11/01/22 at 10:20 AM an observation was made of Resident #288 lying in bed with humidified oxygen on via nasal cannula, upon closer observation the oxygen tubing was not dated Photographic Evidence Obtained). On 11/01/22 at 3:15 PM an observation was made of Resident #288 lying in bed with humidified oxygen on via nasal cannula, upon closer observation the oxygen tubing was not dated. On 11/02/22 at 8:30 AM an observation was made of Resident #288 lying in bed with her eyes closed and with humidified oxygen via nasal cannula, upon closer observation the oxygen tubing nor the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 9 of 13 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150 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 0695 humidification bottle were dated. Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 11/04/22 at 8:30 AM with the Assistant Director of Nursing when asked if oxygen tubing needs to be changed/documented, she stated the oxygen tubing needs to be changed as per policy and it gets labeled with date when changed. This should be done weekly, usually on Sundays. The tubing change should be documented in the progress notes. For resident who have oxygen ordered there should be an order in the record to change the tubing (indicating when and how often). She stated for any resident who is ordered oxygen there should be standing orders to change tube tubing, but she has not seen any such standing orders. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 10 of 13 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to monitor post-dialysis treatments. As evidenced by failure to administer medication for dialysis per the physician ' s orders for 1 of 1 resident reviewed for dialysis (Resident #84). Residents Affected - Few The findings included: A chart review showed that Resident #84 was admitted on [DATE] with diagnoses of Anxiety, Anemia and is dependent on dialysis. A review of orders showed an order for dialysis three times a week on Mondays, Wednesdays, and Fridays dated 10/03/22. It further showed an order for Sevelamer (medication used to treat too much phosphate in the blood), 800 milligrams (mg), take 2 tablets 1600 mg by mouth with a meal for End Stage Renal Disease dated 10/03/22. Resident #84 was hospitalized due to Colitis and syncope/ dehydration. In an observation conducted on 11/01/22 at 1:00 PM, the meal cart arrived at the Unit and was brought into Resident #84's room at 1:10 PM. The continued observation did not show that Sevelamer was given to Resident #84. In an observation conducted on 11/1/22 from 5:00 PM to 5:30 PM, the dinner tray was brought into Resident #84's room and placed at the side table. Resident #84 was noted asleep, with the tray untouched at the bedside. No staff was observed in the room to provide the medication (Sevelamer) with the meal. The tray was noted with two egg sandwiches, a slice of pound cake, and 8 ounces of coffee. The continued observation did not show any staff going into Resident #84's room to administer the above medication. In an observation conducted on 11/02/22 at 7:50 AM, the breakfast tray was brought into Resident #84 ' s room and placed at the side table. Resident #84 was getting ready to eat his breakfast with a tray containing the following foods: eggs, bacon, two slices of toast, and 8 ounces of tea. The Nurse did not give Resident #84 his medication with the breakfast meal. Resident #84 started eating his breakfast at 7:55 AM, which was almost an hour after he was scheduled to get his morning medication. Review of the Care Plan dated 07/09/22 showed that Resident #84 is on dialysis and is at risk for unintended weight loss and a decline in nutrition parameters. It further showed to observe the access site for signs of infections and complications and to give all medications on dialysis days prior to dialysis as ordered. A review of the Medication Administration Record (MAR) for October 2022 showed that Sevelamer was given at 7:00 AM, 11:30 AM, and 5:00 PM from 10/03/22 to 10/31/22. A review of the Dialysis Communications Sheets showed the following: the note on 10/31/22 did not have the facility's nurse fill out the post-follow-up section after Resident #84 came back from dialysis, the note dated 10/26/22 did not have the facility's nurse fill out the post follow up section after Resident #84 came back from dialysis. The notes dated 10/21/22 and 10/12/22 did not have the facility's nurse fill out the post-follow-up area after Resident #84 came back from dialysis. In an interview conducted on 11/02/22 at 9:20 AM with Staff B, a Registered Nurse stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 11 of 13 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #84 receives Sevelamer 3 times daily. She further reported that he goes to dialysis on Mondays, Wednesdays, and Fridays around noon. When asked if she had given him his first-morning dosage of the Sevelamer, she said not yet. An interview with the Facility's Clinical Pharmacist on 11/02/22 at 2:09 PM stated that the medication Sevelamer is used for Renal residents to help lower their phosphate levels. When asked for the best practice for providing the drug, she said it is essential to give it meals to help with the absorption. In an interview with the Facility's Director of Nursing (DON) on 11/04/22 at 8:20 AM, she stated the nurses assigned to the four dialysis residents they have in-house are the liaison between the dialysis center and the facility. The communication forms should be filled out before they go to treatment and after they come back from treatment. When asked about the Sevelamer medications that are given with meals, the DON revealed that she expects her staff to provide them during mealtimes and not at specific scheduled times that were documented in the MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 12 of 13 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on record review, observations and interviews, the facility failed to secure medications for 1 out of 4 medication carts, and the facility failed to secure medications located in 1 of 2 nursing stations. The findings included: Review of the facility's policy titled Medication Storage in the Facility with a revision date of 03/2021 included the following: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medications supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. On 11/01/22 at 11:15 AM an observation was made of an unlocked and unattended mediation cart located at the East Nursing Station (Photographic Evidence Obtained). Five staff members passed by the unlocked and unattended medication cart. At 11:20 AM Staff G, a Licensed Practical Nurse (LPN) returned to the unlocked medication cart and locked it. On 11/01/22 at 1:15 PM an observation was made of 14 blister packs with medications in them that were on an open shelf inside the unsecured nursing station (Photographic Evidence Obtained). During an interview conducted on 11/01/22 at 11:21 AM with Staff G, Licensed Practical Nurse (LPN) when asked about the unlocked and unattended medication cart, she replied I just stepped away for a minute. During an interview conducted on 11/01/22 at 1:20 PM with the Registered Nurse Consultant, when asked why the mediations are stored unlocked and unsecured on a shelf in an unsecured nursing station, she replied I am not sure, but I will take them out of here. During an interview conducted on 11/04/22 at 10:35 AM with the Director of Nursing, when asked if medications and medication carts should be locked when unattended, she replied yes. She stated medications should never be stored at the nursing station. If a resident is discharged , they bag the remaining medications for the resident and label the bag to be returned to pharmacy for credit. The bags with medications to be returned to the pharmacy should be stored in the locked medication room until picked up by the pharmacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 13 of 13