Inspection·October 19, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER] - On 10/16/23 at 08:41 AM, the sink had cracked lines around the water stopper. The counter had chipped paint. room [ROOM NUMBER] - On 10/16/23 at 09:20 AM, The sink was painted white. The sink had cracked lines into the white paint around the water stopper. Residents Affected - Few On 10/19/23 at 10:02 AM, in an interview with the Maintenance Director. the Maintenance Director reported, The sinks in multiple rooms have cracks in them. What are the facility's plans to repair them?' The Maintenance Director stated, It's part of what we do every day. We paint and fix things every day. We worked on the west area of the facility two years ago. The administration changed since then. We replaced the sinks two years ago. I don't know how the sink was damaged. The plan is to work on the east side step by step. We cannot order but 2 sinks at a time due to space. In the review of the facility's policies and policies titled, Maintenance Service. Revised December 2009. The Policy Statement states Maintenance service shall be provided to all areas of the building, grounds, and equipment. In the section titled, Policy Interpretation and Implementation. 2. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. B. Maintaining the building in good repair and free from hazards. F. Establishing priorities in providing repair service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 records review, the facility failed to ensure one resident (Resident # 59) was free from the use of physical restraints, as evidenced by the facility's staff inhibiting the resident's ability to get out of his bed by placing four wheelchairs on each side of his bed, out of one resident investigated for restraints. This facility practice had the potential to have a negative impact on the health and safety of all 90 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: During an observation of resident # 59 on 10/16/2023 at 09:25 AM, the resident was observed to be sleeping and four wheelchairs were observed around the bed. There were two wheelchairs by the right side and two wheelchairs by the left side of the bed. (Photographic evidence). On 10/16/2023 at 09:45 AM, Resident 59 was lying on his bed, awake. It was observed that the resident was dressed. Resident #59 was observed with four wheelchairs around the bed, there were two wheelchairs by the right side and two wheelchairs by the left side of the bed. Record review of the clinical records for Resident # 59 revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE] and transferred to the hospital on [DATE] due to malfunction of tube feeding. Clinical diagnoses included, but were not limited to, Unspecified Atrial Fibrillation; Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity; Aneurysm of the Ascending Aorta, without Rupture; Unspecified Dementia, Unspecified Severity, Without Behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Unspecified Mood (Affective) Disorder; Encounter for Attention to Gastronomy; Unspecified Severe Protein-Calorie Malnutrition; Noninfective Gastroenteritis and colitis, Unspecified. Record review of the physican orders dated 10/09/2023 revealed, Fall/Aspiration/Decubitus precautions, every shift. Record review of admission Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns revealed the resident's Brief Interview for Mental Status (BIMS) summary score was 00 out of 15, indicating severe cognitive impairment. Review of Section E, Behavior revealed the resident had no potential indicators for Psychosis, physical behavioral symptoms were not exhibited. Review of Section P, Restraints and Alarms revealed the resident had no restraints. Record review of Falls Care Plan initiated on 08/31/2023 and the next review date 01/14/2024 revealed the resident was at risk for falls related to Osteoarthritis, Muscle weakness. Goal: The resident will be free of falls through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light was within reach and encouraged the resident to use it for assistance as needed. The resident needs a prompt response to all requests for assistance. Follow facility fall protocol. Interview with Staff A, Licensed Practical Nurse (LPN) on 10/16/23 at 09:45 AM revealed, she stated that she doesn't know why the chairs were by the resident bed. She stated that maybe staff want to know which one is good for the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0604 Level of Harm - Minimal harm or potential for actual harm Interview with Staff B, Certified Nursing Assistant (CNA) on 10/16/23 at 09:48 AM revealed, she stated the resident is at risk of falling, so the wheelchairs would protect him from getting out of the bed. She stated, when she got here in the morning the wheelchairs were there. She stated, she provided care for the resident and dressed him to get out of the bed. She stated, she is waiting for another CNA to help her to transfer the resident to the wheelchair. Residents Affected - Few Interview with Director of Nursing/Risk Manager on 10/19/23 10:08 AM revealed, she stated resident # 59 is ambulatory with his wheelchair. She stated, the resident as alert and oriented to person and very confused. She stated, the resident was admitted in August 2023, he came without tube feeding and he lost weight, and the physician decided to place a tube feeding. She stated, she had no words to explain the incident with the wheelchairs because we trained all nursing staff not to use any restraints on residents. She stated, there were many interventions to prevent a resident from falls such as floor mats, bed in the lowest position. She stated, the nursing staff will have in-service education for abuse/neglect/restraints immediately. The CNA and the nurse had a teachable moment. Review of the facility's Policy and Procedures for Use of Restraints revised in April 2017 revealed, Policy: Restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Policy Interpretation and Implementation. 1-Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 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 the daily nurse staffing schedule posted prior to the beginning of shifts on two out of two nurses' stations. This practice had the potential to affect all 90 residents residing in those units and the public who visited the facility at the time of the survey. Residents Affected - Few The findings included: During observation on the East nursing station on 10/16/2023 at 08:17 AM, it was noted that the staffing information posting board had no assignment written down on the board. On 10/16/2023 at 08:17 AM, Staff F, Licensed Practical Nurse (LPN), stated We don't have a schedule here. We keep the schedule at the other nursing station. During observation on the [NAME] nursing station on 10/16/2023 at 08:18 AM, it was noted that the staffing information posting board had no assignments written down on the board. On 10/16/23 at 08:19 AM, Staff E, Registered Nurse(RN), stated, The secretary called off today. I'm going to write the assignment down right now. On 10/16/23 at 08:21 AM, Staff F stated, Oh, I didn't know we had the schedule here. During an interview with the Staffing Coordinator on 10/19/23 at 11:02 AM regarding the staffing schedule, the Staffing Coordinator stated, I make the schedule in the afternoon before I leave and give it to the charge nurse for the next day schedule. They have to write it down on the board. On 10/19/2023 at 01:20 PM, the Assistant Director of Nursing (ADON) stated, the secretary is responsible for writing the schedule on the board in the morning at the start of the shift. The schedule is written by the staffing coordinator on the paper, then the secretary is supposed transfer the information to the board. The ADON then stated, What happened Monday is that the secretary called off because she has a death in the family. Review of the facility's policy and procedures titled, Posting Direct Care Daily Staffing Numbers that was revised in July 2016 revealed: Policy Statement: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy interpretation and implementation: 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and Licensed Vocational Nurse (LVNs) and the number of unlicensed nursing personnel Certified Nursing Assistant (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 2. Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including, but not limited to, assisting with activities of daily living (ADLs), performing gastrointestinal feeds, giving medications, supervising care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0732 Level of Harm - Minimal harm or potential for actual harm given by CNAs, and performing nursing assessments to admit residents or notify physicians of changes of conditions. 3. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: Residents Affected - Few a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement infection control procedures for three (Residents #89, #347, #348) out of 28 sampled residents. As evidenced by Transmission Based Precaution (TBP) signage was not posted on Resident #347's door and oxygen therapy equipment not stored sanitarily for Resident's #89 and #348. This had the potential to affect 90 residents residing in the facility at the time of the survey. Residents Affected - Few The Findings Included: 1. On 10/16/23 at 08:22 AM, observed Resident #89 in bed asleep, bed was in the lowest position, bilateral floor mats present, high back wheelchair in room, Continuous Positive Airway Pressure (CPAP) machine tubing and mask on the floor besides the resident's bed (Photo available). On 10/17/23 at 10:26 AM, Resident #89 observed in bed asleep, bed in lowest position, bilateral floor mats present, Continuous Positive Airway Pressure (CPAP) machine with tubing and mask exposed on bedside table (Photo available). On 10/18/23 at 08:50 AM, Resident #89 observed in bed asleep, bilateral floor mats present, bed in the lowest position, bedside table clean and clear. Review of the medical records for Resident #89 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Cerebral Infarction, Unspecified. Review of the Physician's Orders Sheet for October 2023 revealed, Resident #89 had orders that included but were not limited to: Oxygen (O2) at 2 liters /minute (LPM) as needed for shortness of breath or 02 saturation below 92%. Record review of Resident #89 's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score was unable to be determined. Section GG for Functional Status documented extensive assistance for bed mobility and transfer, total dependence for toilet use and limited assistance for eating. Interview on 10/17/23 at 09:42 AM, Licensed Practical Nurse (Staff C) from east wing stated, Resident #89 has a Continuous Positive Airway Pressure (CPAP) machine, It is his personal machine that he came with on admission, the family is supposed to be picking up the machine. I am not sure if he has used the machine, CPAP machines are usually used on the 3-11 PM shift, and I work on the 7-3 PM shift. On 10/19/23 at 08:21 AM during interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed, Resident #89 is on hospice, on admission his daughter brought the Continuous Positive Airway Pressure (CPAP) machine, she stated he was not really using it at home, we spoke to the hospice Doctor (MD) about the resident probably needing the CPAP machine. The MD stated to monitor the resident and he did not give any orders for the CPAP machine, we spoke to the resident's daughter and she stated that she will be in the facility to pick up the machine, the resident has never used the CPAP machine. Any resident's medical equipment if used it needs to be cleaned and disinfected and stored properly when not in use. The CPAP machine if used would be stored in a Ziploc bag with a date, and if not being used would be stored in its packaging and kept in a safe place (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0880 for the resident. Level of Harm - Minimal harm or potential for actual harm 2. On 10/16/23 at 08:34 AM, observed Resident #347's room door with Personal Protective Equipment (PPE) available hanging on the door, there was no signage observed on the use of PPE and what type of Transmission Based Precaution (TBP) the resident was on. (Photo available). Residents Affected - Few On 10/16/23 at 8:40AM, Certified Nursing Assistant (Staff D) was present in hallway, when asked why the resident was on precautions, Staff D stated I believe the resident has a wound infection. On 10/17/23 at 8:48PM, Resident #347 was not in the room, the medical records revealed resident was discharged to the hospital on [DATE] at 8 PM. Review of the medical records for Resident #347 revealed, the resident was admitted to the facility on [DATE], last readmission was on 10/06/23. Clinical diagnoses included but were not limited to: Extended Spectrum Beta Lactamase (ESBL) resistance, Pressure Ulcer of unspecified heel, unstageable and Cellulitis of left lower limb. Resident #347 was discharged on 10/16/23. Review of the Physician's Orders Sheet for October 2023 revealed Resident #347 had orders that included but not limited to: 10/9/23- Meropenem Intravenous Solution Reconstituted one (1) Gram (GM) Use 1 gram intravenously three times a day related to Extended Spectrum Beta Lactamase (ESBL) Resistance for 10 Days. Record review of Resident #347 's Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented the Brief Interview for Mental Status Score was unable to be determined. Interview on 10/17/23 at 9:53 AM Licensed Practical Nurse, Staff C, East Wing stated Resident #347 was transferred to the hospital on [DATE], the resident was on TBP for Extended Spectrum Beta Lactamase (ESBL) resistance. Staff C stated when a resident is placed on Transmission Based Precautions (TBP), the nursing supervisor and the Infection Control person make sure the resident has all the PPE and signage needed. The information about residents on TBP is communicated to the floor staff from the 24 hours report, verbally and the shift report. If a resident upon admission is on TBP, the assigned nurse, certified nursing assistants and housekeeping is informed by admissions and the supervisors. On 10/19/23 at 08:27 AM, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) stated Resident #347 was on contact precautions for an infection to the left heel ESBL positive, he came back from the hospital on readmission with the infection, when a resident is admitted on TBP, we call housekeeping to supply the PPE equipment box, get all the needed supplies from central supplies, get the signage, the ADON makes sure that all the equipment and signage is in the location where they are supposed to be. The nursing supervisor informs the nurse about the residents TBP status, the nurse informs the Certified Nursing Assistants (CNAs), also housekeeping and dietary staff are informed of the resident's TBP status. The central supply clerk checks the PPE supplies during the morning rounds daily and replenish what is running low, the nursing supervisor does daily rounds in the afternoon to make sure all PPE supplies are in place. Moving forward we are going to conduct an in-service with all the nursing staff about doing daily rounds and reporting any missing signage or PPE equipment/supplies for residents on TBP. There is an order in the system for this resident that states: Contact Isolation precautions, left heel wound ESBL positive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. On 10/16/23 at 08:29 AM, Resident #348 was observed in bed asleep, Oxygen (02) not running, the Nasal cannula (N/C) was hanging from the lower bed rail (Photo available), and the N/C tubing bag dated 10/16/23 was attached to the 02 concentrator. On 10/16/23 at 11:18 AM, Resident #348 was observed in bed awake. The surveyor attempted to interview the resident, but resident refused. On 10/17/23 at 10:23 AM, Resident #348 was observed in bed awake, he stated he is doing okay today, there was no oxygen concentrator or tubing observed in the resident's room. On 10/18/23 at 08:57 AM, Resident #348 was observed in bed receiving AM care, no distress was noted, and the oxygen concentrator was not in the room. Review of the medical records for Resident #348 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Chronic Obstructive Pulmonary Disease (COPD). Review of the Physician's Orders Sheet for October 2023 revealed, Resident #348 had orders that included but were not limited to: Oxygen (O2) at 2 liters /minute (LPM)via nasal cannula (N/C) as needed (PRN) for (oxygen saturation) sp02 <92%. Record review of Resident # 348's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score 15, on a 0-15 scale indicating the resident is cognitively intact. Section GG for Functional Ability and Goals documented supervision for eating, maximal assistance for all other Activities of Daily Living (ADLS). Interview on 10/17/23 at 09:55 AM with Licensed Practical Nurse, Staff C, from the East Wing stated when we make our rounds, we check to make sure the residents call lights are in reach, if a resident is receiving oxygen (02), an 02 sign needs to be on the door, if a resident is receiving breathing treatments we check how often, precautions and protocols, when 02 is not in use in the resident's rooms we store the 02 tubing in a Ziploc bag that is dated, the 02 tubing and supplies are changed weekly. On 10/19/23 at 08:14 AM during an interview with the Director of Nursing (DON) it was reported, when the 02 tubing is in use we put the date on the tubing, the tubing is changed weekly and when the 02 concentrator is not in used, it is placed in storage. We will be reeducating our nursing staff to pay attention during their rounds on the oxygen tube storage when the oxygen is not in use and making sure infection control standards are being followed regarding the 02-tubing storage. Review of the facility's policy and procedures titled, Infection Control/Cleaning and Disinfection dated January 2020 states: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations, and national guidelines. Review of the undated facility's policy and procedures titled, Standard and Transmission Based Precautions states: Step #7-To designate a room for Transmission Based Precautions, a sign will be placed (Facility note where it will be, what it looks like, if color coded, etc.) Staff will be notified of the type of transmission-based precautions a resident is placed on and the reason. Staff are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 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 105449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 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 0880 notified (Note how and when staff are notified, describe if staff are notified at staff huddle, shift change, or regular meeting). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105449 If continuation sheet Page 10 of 10