Health inspection·February 26, 2026

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote dignity and respect for three Residents (Resident #48 and Resident # 4) out of 20 sampled residents. As evidenced by facility staff observed standing while feeding Resident #48 and observation of Resident #4's indwelling urinary catheter drainage bag without a privacy cover. There were 69 residents residing in the facility at the time of the survey. The findings include Resident #48 On 02/23/2026 at 8:51 AM, Staff D, Certified Nursing Assistant (CNA) was observed standing next to the bed feeding Resident #48 from the breakfast tray located on the overbed table in front of the resident. Staff D, CNA and Resident #48 were the only persons in the room at the time of the surveyor's observation. Review of Resident #48's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Traumatic Subarachnoid Hemorrhage without loss of consciousness, subsequent encounter. Interview on 02/23/2026 at 8:51 AM, Staff D, CNA stated: I know I am supposed to be sitting and feeding the resident, the resident's husband was using the chair, that is why I was standing up. Review of the facility policy and procedure titled Meal Services and Dignified feeding assistance dated 07/2025 states: The facility shall provide meal services in a safe, sanitary, dignified, and homelike manner that promotes resident choice, infection prevention, nutritional adequacy, and respect for individuality. All staff assisting with meal service and feeding must: Follow proper food handling and infection control techniques. Promote dignity by sitting at eye level when assisting residents. Provide meals in a manner that enhances resident choice and self-determination. Resident #4 Observation on 02/25/2026 at 09:23 AM revealed Resident #4's indwelling catheter drainage bag was visible from the hallway without a privacy bag in place and was anchored to the left side of the bed Record review of Resident #4's clinical records revealed the resident was admitted on [DATE] with a re-entry on 10/15/2025 with a diagnosis of obstructive and reflux uropathy. Physician orders dated 2/18/2026 through 2/24/2026 indicated the resident has an indwelling urinary catheter for urinary retention. Page 1 of 5 105508 105508 02/26/2026 East Ridge Rehabilitation and Nursing Center 19225 SW 87th Ave Cutler Bay, FL 33157

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #4's admission Minimum Data Set, dated [DATE] indicated the resident had moderate cognitive impairment, uses a wheelchair and requires partial to moderate assistance activities of daily living. Review of the care plan dated 1/29/2026 identified the resident as having an indwelling catheter related to obstructive uropathy and included interventions to monitor intake and output, assess tubing for kinks each shift, monitor for signs and symptoms of urinary tract infection and catheter-related complications Interview on 02/25/26 at 11:25AM, Staff F, Certified Nursing Assistant revealed indwelling urinary catheter drainage bag should be inside a privacy bag and then attached to the side of the bed, it is not ok to see the bag when you walk into the room and the visible urine. Interview on 02/25/2026 at 11:32AM, Staff E revealed urinary drainage bag should not be touching the floor and it should be covered with a privacy bag. 105508 Page 2 of 5 105508 02/26/2026 East Ridge Rehabilitation and Nursing Center 19225 SW 87th Ave Cutler Bay, FL 33157

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 observations, record review and interviews, the facility failed to provide safe and secure storage of biologicals for two Residents (#20 and #83) out of 20 residents sampled. There were 69 residents residing in the facility at the time of the survey. The findings include.Resident #20During the initial observational tour of the facility on 02/23/2026 at 8:46 AM Resident #20 was in bed awake, there was one ointment on the bedside table and one cream on top of the dresser.On 02/24/2026 at 8:00 AM Resident #20 was in bed asleep, an ointment remained on bedside table (Photographic evidence) Resident # 83On 02/23/2026 at 8:59 AM Resident #83 was observed in bed awake, bed in the lowest position, a bottle of eyedrops on the overbed table (Photographic evidence available)On 02/24/2026 at 8:04 AM three (3) tubes of biologicals observed on the bedside table (Photographic evidence available)On 02/25/2026 at 8:17 AM Resident #83 was in bed asleep, wheelchair next to the bed, a bottle of eyedrops on the overbed table. Interview on 02/25/2026 8:21 AM Registered Nurse (Staff C) assigned to the 2300 and 2400 unit stated: During my rounds if medications are found in the residents' rooms-if the resident is alert and oriented, I ask the resident about the medication and educate the resident about all medications needing to be stored on the nursing cart, any narcotics found are reported to the nursing supervisor for further investigation. Interview on 02/25/2026 at 8:24 AM Certified Nursing Assistant (Staff B) stated: If I find any medications in the residents' rooms, I notify the nurse of my findings. Interview on 02/25/2026 at 9:13 AM Certified Nursing Assistant (Staff A) stated: During rounds or at any time on my shift, if I find medications in the residents' room, I notify the nurse and follow up to make sure the medications are removed from the room. Review of the facility policy and procedure titled Medication Labeling and Storage revision date 02/2023 states: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.Policy Interpretation and ImplementationMedication Storage4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 105508 Page 3 of 5 105508 02/26/2026 East Ridge Rehabilitation and Nursing Center 19225 SW 87th Ave Cutler Bay, FL 33157

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observations, interviews, and record review, the facility failed to demonstrate that effective action plans were implemented and sustained to correct identified quality deficiencies related to repeated deficient practice for F761 Label/Store Drugs and Biologicals. There were 69 residents residing in the facility at the time of the survey. The findings include. Review of the facility's survey history revealed that during a recertification survey with an exit date of 02/19/2025, the facility was cited under F761 - Label/Store Drugs and Biologicals after failing to ensure appropriate storage of medications on the medication cart for one of three medication carts observed. Observation revealed loose pills in different compartments of the medication drawer and the narcotics lock box was left unlocked in one of two medication rooms. During the current survey with an exit date of 02/26/2026, repeated deficient practice was identified under F761 Label/Store Drugs and Biologicals. Related medications and biologicals at two residents' bedsides. Interview on 02/26/2026 at 2:03 PM, the Director of Nursing (DON) revealed the facility has a Quality Assessment and Assurance (QAA) Committee that meets at least quarterly; however, meetings are held monthly on the first Thursday of each month, with the last meeting conducted on 02/19/2026. The QAA committee includes the required members such as the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Admissions, Social Services, MDS, Activities, Dietary, Wound Care, Restorative Nurse, Infection Preventionist, Therapy, Central Supply, Housekeeping, Maintenance, Committee Physician, Pharmacy, and other department representatives. The purpose of the QAA committee is to identify potential risks and benefits, determine when a process or intervention is not working effectively. Issues within departments are identified through routine communication and meetings; when concerns arise, meetings are called as needed, and periodic QAPI meetings review quality measures to support ongoing performance improvement. The Administrator, DON, and Medical Director meet frequently to address quality concerns, and a daily morning clinical meeting is held to discuss residents' clinical The DON stated the QAA committee determines issues to focus on based on safety risks, infection control concerns, and staff education needs identified during routine monitoring. Review of policy and procedure titled QAPI Program Systematic Analysis and Systemic Action issued on 11/28/2019, revised on 10/23/2025 revealed that the facility will take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. 105508 Page 4 of 5 105508 02/26/2026 East Ridge Rehabilitation and Nursing Center 19225 SW 87th Ave Cutler Bay, FL 33157

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 interviews, the facility failed to follow infection prevention and control procedures for the environment and three Residents (Resident #17, Resident #20 and Resident, #83). As evidenced by Two Urinals, one Spirometer, and one Adult Brief were not stored in compliance with infection control standards. There were 69 residents residing in the facility at the time of the survey. The findings include.During the observational tour on 02/24/2026 at 7:42 AM an Adult Brief was observed stored between the wall and the handrail in the 2300 hallway next to room [ROOM NUMBER] (photographic evidence). On 02/24/2026 at 7:56 AM Resident #17 was in bed with eyes closed and the Spirometer stored on the overbed table was uncovered.On 02/25/2026 8:19 AM Resident #17 was in bed with eyes closed and the Spirometer remained stored on the overbed table uncovered. Observation on 02/24/2026 at 8:00 AM revealed Resident #20 in bed awake there was an uncapped Urinal on the bedside table.On 02/25/2026 at 8:10 AM Resident #20 was in bed with eyes closed and an uncapped Urinal was observed on the bedside table. On 02/23/2026 at 8:59 AM Resident #83 was in bed awake, an uncapped Urinal was on the bedside table.On 02/24/2026 at 8:04 AM Resident #83 was in bed asleep, there was an uncapped Urinal on the bedside table partially filled with a yellow-colored liquid.On 02/25/2026 at 8:17 AM Resident #83 was in bed asleep, there was an uncapped Urinal on the bedside table partially filled with a yellow-colored liquid. Interview on 02/25/2026 at 8:21 AM Registered Nurse (Staff C) assigned to the 2300 and 2400 units stated: Oxygen equipment to include mask, tubing, and Spirometers when not in use are stored in clear plastic bags. The oxygen equipment is changed every Friday night and placed in clear plastic bags labeled with the date. Urinals are stored in a clear plastic bag covered in the bathroom. At bedtime the urinals are stored on the bedrails with a cover on top for use. Soiled briefs are disposed of in a closed plastic bag in the soiled utility room bin. This is to prevent cross contamination between residents and risk of infection for staff and residents.' Interview on 02/25/2026 at 8:24 AM Certified Nursing Assistant (Staff B) revealed oxygen equipment when not in use is stored in a clear plastic bag in the resident's drawer; urinals are stored in the bathroom in clear plastic bags when not in use, dirty adult briefs are placed in the soiled utility room for pick up by housekeeping to prevent infection control issues. Interview on 02/25/2026 at 9:13 AM Certified Nursing Assistant (Staff A) stated urinals are stored in a clear plastic bag in the bathroom. Soiled diapers are disposed of in a closed plastic bag in the soiled utility room bin. Oxygen equipment when not in use is stored in a clear plastic bag in the resident's drawer. This is done to avoid contamination or infection issues. Review of the facility policy and procedure titled Infection Control Prevention and Control Program dated 02/21/23 states: The facility shall establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Residents Affected - Few 105508 Page 5 of 5