Inspection·April 20, 2023

F 0645 The form revealed the resident was not a provisional admission. Level of Harm - Minimal harm or potential for actual harm Record review of admission Minimum Data Set (MDS) Section A dated 02/07/2023 revealed A1500. Preadmission Screening and Resident Review (PASRR) Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No. Residents Affected - Few Record review of Medicare-5 days MDS Section C Cognitive Patterns dated 02/07/2023 revealed, the resident's Brief Interview for Mental Status (BIMS) summary score was 00 of 15. Review of Medicare -5 days MDS Section I Active Diagnosis dated 02/07/2023revealed the resident's diagnoses were Depression and Psychotic Disorder. Review of Medicare-5 days MDS, Section N - Medications dated 03/07/2023 revealed the resident was receiving antipsychotic and antidepressants medications seven days in a week. Record review of the Care Plan initiated on 02/02/2023 and revised on 03/03/2023 revealed, the resident was at risk for drug related side effects due to use of psychotropic medications for the diagnosis of Major Depressive Disorder and Psychosis Disorder. Goal: The resident will remain free of drug related side effects through the next review date. Interventions: Assess for fall risk and precautions needed. Encourage activities as tolerated. License Nurse to follow up behavior monitoring sheet. Medicate as ordered. Psychiatrist consultation/evaluation as needed. Monitor behavior and mood every shift and document. Monitor for adverse side effects of drugs (Lethargy, dizziness, increase in confusion, gait disturbance). Monitor for behavior/mood changes. Notify Social Worker about any changes in behavior pattern. Observe for decline in function. Report changes to physician as needed. Record review of Psychiatrist Consultation dated 04/03/2023 revealed, the resident had no negative behaviors and sleeping issues. The treatment plan was to continue with the same medications and follow up as needed. Interview with Staff N Licensed Practical Nurse (LPN) on 04/20/23 at 10:57 AM, she stated the resident was doing well, she was not aggressive toward staff. She stated the resident was easy to redirect. She stated the resident tolerated the medication very well. She stated she observed her mood and behavior before administrating the medication. Interview with Social Services Director on 04/20/23 at 02:50 PM, she stated the department in charge of the PASRR Level I is the nursing staff, when the resident will be admitted to the facility. The hospital sent the form before the resident was admitted . Interview with Assistant Director of Nursing on 04/20/23 at 03:37 PM, she stated her department oversees and reviewed the form coming from the hospital before the resident will be admitted . She stated if the resident had no diagnosis in the records, when they are admitted we reviewed the records at time of admission. She stated there were no excuses not to complete these forms. She stated the importance of completing the form to see if the facility will be appropriate for the residents and if the facility had the specialized services for the residents' needs. 2. Observation of resident # 153 on 04/19/23 at 08:33 AM, the resident was sleeping. No distress or anxiety was noted. It was observed the call light within easy reach. Observation of resident # 153 on 04/20/23 08:03 AM, the resident was lying on his bed, awake. No distress or anxiety was noted. The resident did not answer the questions asked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 2 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 0645 Level of Harm - Minimal harm or potential for actual harm Record review of the clinical records for Resident # 153 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included, but were not limited to, Bilateral Primary Osteoarthritis of Knee; Unspecified Psychosis not due to a Substance or Known Physiological Condition; Major Depressive Disorder, Recurrent, Moderate; Unspecified Dementia, Unspecified Severity, with Psychotic Disturbance; Major Depressive Disorder, Recurrent, Unspecified. Residents Affected - Few Record review of Orders for Resident # 153 dated 02/02/2023 revealed, the resident was receiving Zoloft Oral tablet twenty-five milligrams (Sertraline HCL). Give one tablet by mouth once a day related to Major Depressive Disorder, Recurrent, Moderate. Record review of Orders for Resident # 153 dated 04/03/2023 revealed, the resident was receiving Quetiapine Fumarate Oral tablet twenty-five milligrams. Give 0.5 milligrams tablet by mouth at bedtime related to Unspecified Psychosis not Due to a Substance or Known Physiological Condition. Record review of Medication Administration Record for the month of April 2023 revealed, the resident # 153 was receiving Zoloft Oral tablet twenty-five milligrams as ordered. Record review of Medication Administration Record for the month of April 2023 revealed, the resident # 153 was receiving Quetiapine Fumarate Oral tablet twenty-five milligrams as ordered. Record review of Level I Preadmission Screening of Resident Review (PASRR) dated 12/29/2022 Section I Screen Decision Making Section IA was not marked as the resident had diagnosis of serious mental illness. Section IV PASRR Screen Completion stated the resident had no mental illness or suspicion. The form revealed the resident was not a provisional admission. Record review of admission Minimum Data Set (MDS) Section A dated 02/07/2023 revealed A1500. Preadmission Screening and Resident Review (PASRR) Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No. Record review of Medicare-5 days Minimum Data Set (MDS) Section C Cognitive Patterns dated 02/06/2023 revealed, the resident's Brief Interview for Mental Status summary score was 03 of 15. Review of Medicare 5- days MDS Section I Active Diagnosis dated 02/06/2023 revealed, the resident's diagnoses were Depression and Psychosis Disorder. Review of Medicare -5 days MDS, Section N - Medications dated 02/06/2023 revealed, the resident was receiving antipsychotics and antidepressants medications seven days in a week. Review of Care Plan initiated on 01/31/2023 and the next review date 07/10/2023. The resident was at risk for drug related side effects due to the use of psychotropics medications. For the diagnosis of Depression and Psychosis Disorder. Goal: The resident will remain free of drug related side effects through the next review date. Interventions: Assess for fall risk and precautions needed. Encourage activities as tolerated. License Nurse to follow up behavior monitoring sheet. Medicate as ordered. Psychiatrist consultation/evaluation as needed. Monitor behavior and mood every shift and document. Monitor for adverse side effects of drugs (Lethargy, dizziness, increase in confusion, gait disturbance). Monitor for behavior/mood changes. Notify Social Worker about any changes in behavior pattern. Observe for decline in function. Report changes to physician as needed. Record review of Psychiatrist Consultation dated 04/03/2023 revealed, the resident was seen by the psychiatrist. The treatment Plan was educate resident, discussed risk and benefits of the treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 3 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 0645 Continue with the same medications. Follow up as needed. Level of Harm - Minimal harm or potential for actual harm Interview with Staff N, Licensed Practical Nurse (LPN) on 04/20/23 at 10:57 AM, she stated the resident was doing well, she was not aggressive toward staff. She stated the resident was easy to redirect. She stated the resident tolerated the medication very well. She stated she observed her mood and behavior before administrating the medication. Residents Affected - Few Interview with the Social Services Director on 04/20/23 at 02:50 PM, she stated the department in charge of the PASRR Level I is the nursing staff, when the resident will be admitted to the facility. The hospital sent the form before the resident was admitted . Interview with Assistant Director of Nursing on 04/20/23 at 03:37 PM, she stated her department oversees and reviewed the form coming from the hospital before the resident will be admitted . She stated if the resident had no diagnosis in the records, when they were admitted we reviewed the records at time of admission. She stated there were no excuses not to complete these forms. She stated the importance of completing the form to see if the facility will be appropriate for the residents and if the facility had specialized services for the resident's needs. Review of Policies and Procedures for PASRR dated 03/2023 revealed the Policy: It is the policy of the facility to assure that all residents admitted to the facility receive a Preadmission Screening and Resident Review, in accordance with State and Federal Regulations. Procedure: 3-Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. The facility will not admit, on or after January 1989, any residents with a. Mental disorder, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 4 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Record Review and Interview, the facility failed to implement a comprehensive care plan for falls for one (Resident #101) out of 44 residents sampled. There were 213 residents residing in the facility at the time of this survey. The Findings Included: During Observation on 04/17/23 at 09:23 AM, Resident #101 was in bed awake, a floor mat was on one side of the bed, the other floor mat was at the foot of bed against the wall (photo available). On 04/18/23 at 09:26 AM, Resident #101 was out of the facility at a medical appointment. On 04/19/23 at 08:59 Resident #101 was in bed awake, bilateral floor mats were resting on the wall at the foot of the bed (photo available). On 04/20/23 at 08:25 AM Resident #101 was observed in bed awake, bilateral floor mats were against the wall at the foot of the bed, a black stool was by the right side of the bed. Review of the medical records for Resident #101 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: End stage renal disease, Unspecified Glaucoma, Essential (primary) Hypertension and Legal blindness, as defined in the United States. Review of the Physician's Orders Sheet for April 2023 revealed, Resident #101 had orders that included but were not limited to: Adaptive Equipment: Floor mats on each side of bed, when in bed to reduce risk of injury every shift. Low bed with siderails x two (2) secondary to contour of air mattress with high risk for falls per manufacturer's guidelines every shift. Medications include: Dorzolamide HCl-Timolol Mal Solution 22.3-6.8 MG/ML (milligram/milliliters)-Instill one (1) drop in both eyes two times a day related to Primary open-angle glaucoma, bilateral, moderate stage. Record review of Resident #101 's Significant Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented, the Brief Interview for Mental Status Score 6, on a 0-15 scale indicating resident is cognitively impaired. Section E for Behaviors documented resident exhibit no behaviors. Section G for functional status documented resident requires extensive assistance with bed mobility, total dependence for transfer and eating with one person assistance. Section H for Bladder and Bowel documented resident is always incontinent of bowel and bladder. Section J for Health Conditions documented resident received scheduled pain medication regimen in the last five (5) days, no falls, does not use tobacco. Section M for Skin Condition documented resident have one stage three (3) pressure ulcer, present on admission. Section O for Special Treatment and Procedures documented resident received Passive Range of Motion exercises three (3) times in the last seven (7) days. Section P for Restraints documented no restraints or alarms used on resident. Record review of Resident #101 's Care Plans Dated 03/06/2023 revealed: Resident is at risk for falls related to: impaired mobility, has diagnosis of End Stage Renal Disease on Hemodialysis 3x/week, Hypertension, Anemia, had history of fall, has impaired vision related to Glaucoma- as per resident she is legally blind due to her Glaucoma on Ophthalmic medication for Glaucoma. Interventions include but were not limited to: Check at frequent intervals to monitor for unsafe actions and intervene (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 5 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few promptly, floor mats as ordered, Hoyer lift transfer of 2 assist, keep bed in lowest position, Make sure resident's bed is secure/properly locked when they need to move or Transfer, Observe for safety, Staff to evaluate/record/address fall risk factors. Interview on 04/18/23 at 03:52 PM, the Director of Nursing (DON) stated I will complete re-in-services with all the staff with help from the restorative team about maintaining floor mats at the sides of the bed when the resident is in bed at all times, explained again to all staff in detail of the purpose of the floor mats. Interview on 04/19/23 at 04:25 PM, the Licensed Practical Nurse (Staff H) assigned to Resident #101 stated for residents with floor mats, the nurses, and the Certified Nursing Assistant (CNAs) are responsible for making sure the orders are followed for the resident, when the floor mats are not use, they are placed against the wall in the resident's room. Interview on 04/20/23 at 08:29 AM, Certified Nursing Assistant (Staff M) assigned to Resident #101 when asked why the floor mats are against the wall and the resident is currently in bed stated I moved the floor mats to sit and feed the resident, then I will put it back. (Staff M) was in the hallway carrying mechanical lift to another room at the time of the interview. Review of the facility's Policy and Procedures titled, Falls Prevention revised date 07/08/2021 states: Residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls. Each resident will be evaluated for safety risks including falls and accidents. Care plans will be created and implemented based on the individual's risk factors to aid in the prevention of falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 6 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide a safe environment free of accident hazards for one (Resident #101) out of 44 residents sampled, as evidenced by bilateral floor mats not on the floor beside the resident's bed while the resident was in bed. There were 213 residents residing in the facility at the time of this survey. The Findings Included: During Observation on 04/17/23 at 09:23 AM, Resident #101 was in bed awake, a floor mat was on one side of the bed, the other floor mat was at the foot of bed against the wall (photo available). On 04/18/23 at 09:26 AM, Resident #101 was out of the facility at a medical appointment. On 04/19/23 at 08:59 Resident #101 was in bed awake, bilateral floor mats were resting on the wall at the foot of the bed (photo available). On 04/20/23 at 08:25 AM Resident #101 was observed in bed awake, bilateral floor mats were against the wall at the foot of the bed, a black stool was by the right side of the bed. Review of the medical records for Resident #101 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: End stage renal disease, Unspecified Glaucoma, Essential (primary) Hypertension and Legal blindness, as defined in the United States. Review of the Physician's Orders Sheet for April 2023 revealed, Resident #101 had orders that included but were not limited to: Adaptive Equipment: Floor mats on each side of bed, when in bed to reduce risk of injury every shift. Low bed with siderails x two (2) secondary to contour of air mattress with high risk for falls per manufacturer's guidelines every shift. Medications include: Dorzolamide HCl-Timolol Mal Solution 22.3-6.8 MG/ML (milligram/milliliters)-Instill one (1) drop in both eyes two times a day related to Primary open-angle glaucoma, bilateral, moderate stage. Record review of Resident #101 's Significant Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented, the Brief Interview for Mental Status Score 6, on a 0-15 scale indicating resident is cognitively impaired. Section E for Behaviors documented resident exhibit no behaviors. Section G for functional status documented resident requires extensive assistance with bed mobility, total dependence for transfer and eating with one person assistance. Section H for Bladder and Bowel documented resident is always incontinent of bowel and bladder. Section J for Health Conditions documented resident received scheduled pain medication regimen in the last five (5) days, no falls, does not use tobacco. Section M for Skin Condition documented resident have one stage three (3) pressure ulcer, present on admission. Section O for Special Treatment and Procedures documented resident received Passive Range of Motion exercises three (3) times in the last seven (7) days. Section P for Restraints documented no restraints or alarms used on resident. Record review of Resident #101 's Care Plans Dated 03/06/2023 revealed: Resident is at risk for falls related to: impaired mobility, has diagnosis of End Stage Renal Disease on Hemodialysis 3x/week, Hypertension, Anemia, had history of fall, has impaired vision related to Glaucoma- as per resident she is legally blind due to her Glaucoma on Ophthalmic medication for Glaucoma. Interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 7 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few include but were not limited to: Check at frequent intervals to monitor for unsafe actions and intervene promptly, floor mats as ordered, Hoyer lift transfer of 2 assist, keep bed in lowest position, Make sure resident's bed is secure/properly locked when they need to move or Transfer, Observe for safety, Staff to evaluate/record/address fall risk factors. Interview on 04/18/23 at 03:52 PM, the Director of Nursing (DON) stated I will complete re-in-services with all the staff with help from the restorative team about maintaining floor mats at the sides of the bed when the resident is in bed at all times, explained again to all staff in detail of the purpose of the floor mats. Interview on 04/19/23 at 04:25 PM, the Licensed Practical Nurse (Staff H) assigned to Resident #101 stated for residents with floor mats, the nurses, and the Certified Nursing Assistant (CNAs) are responsible for making sure the orders are followed for the resident, when the floor mats are not use, they are placed against the wall in the resident's room. Interview on 04/20/23 at 08:29 AM, Certified Nursing Assistant (Staff M) assigned to Resident #101 when asked why the floor mats are against the wall and the resident is currently in bed stated I moved the floor mats to sit and feed the resident, then I will put it back. (Staff M) was in the hallway carrying mechanical lift to another room at the time of the interview. Review of the facility's Policy and Procedures titled, Falls Prevention revised date 07/08/2021 states: Residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls. Each resident will be evaluated for safety risks including falls and accidents. Care plans will be created and implemented based on the individual's risk factors to aid in the prevention of falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 8 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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** 4. Observation of Resident # 145 on [DATE] at 10:32 AM. Resident was observed on her bed, awake. Resident was non-verbal. No distress or anxiety was noted. The oxygen concentrator gauge was set up at 1.5 Liters Per Minute (LPM). (Photographic evidence). Residents Affected - Few Observation of resident # 145 on [DATE] at 7:58 AM. The resident was sleeping. The oxygen concentrator gauge was set up at 1.5 LPM. Observation of resident # 145 on [DATE] at 07:55 AM. The resident was observed sleeping. The oxygen concentrator gauge was set up at 2 LPM. Record review of the clinical records for Resident # 145 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included, but were not limited to, Nontraumatic Intracerebral Hemorrhage, Unspecified; Type 2 Diabetes Mellitus Without Complications; Respiratory Failure, Unspecified, Unspecified whether with hypoxia or Hypercapnia; Pneumonia Due to Other Specified Infectious Organisms. Record review of Orders dated [DATE] revealed Oxygen at 2 LPM via nasal cannula. May titrate up to 5 Liters as needed to maintain a saturation level above 92 % every shift related to Chronic Obstructive Pulmonary Disease, Unspecified. Record review of Orders dated [DATE] revealed Oxygen at 2 LPM via nasal cannula Diagnosis Chronic Obstructive Pulmonary Disease. Every shift. Record review of Treatment Administration Record for the month of [DATE] revealed, the resident received the oxygen treatment as ordered. Record review of Medicare 5-days Minimum Data Set (MDS) Section C - Cognitive Patterns dated [DATE] revealed, the Brief Interview for Mental Status (BIMS) summary score was 00 of 15. Review of Medicare 5-days MDS, Section G Functions Status dated [DATE] revealed, the resident needed total dependence with one-person physical assistance for bed mobility, locomotion, dressing, eating, toilet use and personal hygiene. The resident needed total dependence with two-persons physical assistance for transfer. Review of Medicare 5-days Section O Special Treatments, Procedures and Programs dated [DATE] revealed the resident was coded for oxygen. Record review of Care Plan initiated on [DATE] and next review date [DATE]. The resident was at risk for ineffective breathing pattern related to Chronic Obstructive Pulmonary Disease. Goal: the resident will demonstrate an effective respiratory rate depth and pattern, increase activity tolerance and no stated discomfort through the next review date. Interventions: Adjust head of bed and body positioning to assist ease of breathing. Administer medication /oxygen as ordered. Arrange activities to allow adequate rest and increase activities as tolerated. Instruct the resident in relaxation techniques. Keep Head of Bed elevated to facilitate easy respiration. Monitor laboratory reports and refer to physician. Monitor lung sounds, pallor, cough, and character of sputum. Monitor resident's anxiety and give support/assistance as needed. Monitor respiratory rate, depth, and effort. Interview with Staff N, Licensed Practical Nurse (LPN) on [DATE] at 10:57 AM. She stated she checked the oxygen concentrator gauge was set up following doctor's orders when the shift started. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 9 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 Residents Affected - Few stated that she entered today to work since last week. She stated the resident's order for oxygen was 2 LPM. Interview with Staff O, Registered Nurse/Nurse Supervisor (RN) on [DATE] at 12:08 PM. He stated the nurses checked the oxygen concentrator every shift. He stated the oxygen concentrator gauge was extremely sensitive to the touch and sometimes, it moved when the staff was cleaning, changing the residents. He stated it should be checked more frequently. 5. Observation of Resident # 187 on [DATE] at 01:15 PM. Resident was observed sleeping. The oxygen concentrator gauge was observed set up at 1.5 Liters per Minute (LPM). (Photographic Evidence) Observation of Resident # 187 on [DATE] at 07:56 AM. Resident was observed sleeping. The oxygen concentrator gauge was set up at 1.5 LPM. (Photographic Evidence) Observation of resident # 187 on [DATE] at 07:58 AM. The resident was observed sleeping. The oxygen concentrator gauge was set up to 1.5 LPM. (Photographic Evidence) Record review of the clinical records for Resident # 187 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident expired on [DATE]. Clinical diagnoses include, but not limited to, Encounter for Palliative Care; Alzheimer's Disease, Unspecified; Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Unspecified Psychosis not Due to a Substance or known Physiological Condition. Record review of Orders dated [DATE] revealed Continuous Oxygen at 2 liters nasal cannula every shift. Record review of Orders dated [DATE] revealed Oxygen at 2 LPM via nasal cannula every shift. Record review of Treatment Administration Record for the month of [DATE] revealed, the resident received oxygen treatment as ordered. Record review of Quarterly Minimum Data Set (MDS) Section C Cognitive Patterns dated [DATE] revealed, the resident's Brief Interview for Mental Status (BIMS) summary score was 06 of 15. Review of Quarterly MDS Section G Functional Status dated [DATE] revealed the resident needed extensive assistance with one-person physical assistance for bed mobility and personal hygiene. The resident needed total dependence with one-person physical assistance for locomotion, dressing, eating and toilet use. Review of Quarterly MDS Section O Special Treatments, Procedures and Programs dated [DATE] revealed the resident was receiving oxygen treatment. Record review of Care Plan initiated on [DATE] and the next review date [DATE] revealed, the resident required the use of oxygen therapy. Goal: The resident will have no signs or symptoms of poor oxygen absorption through the review date. Interventions: Administer oxygen 2 Liters per Minute via nasal cannula. Change resident's position every two hours to facilitate lung secretion movement and drainage. Encourage or assist with ambulation as indicated. For residents who are ambulatory provide extension tubing or portable oxygen apparatus. Give medications as ordered by physician. Monitor document side effects and effectiveness. If the resident was allowed to eat, oxygen must still be delivered but the delivery method may need to be adjusted. Return to normal delivery method when done eating. Monitor for signs or symptoms of respiratory distress and report to physician as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 10 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 Residents Affected - Few Interview with Staff O Registered Nurse/Nurse Supervisor (RN) on [DATE] at 12:08 PM. He stated the nurses checked the oxygen concentrator every shift. He stated the oxygen concentrator gauge is extremely sensitive to touch and sometimes, it moves when the staff is cleaning, changing the residents. He stated it should be checked more frequently. Record review of Policies and Procedures for Respiratory Care and Oxygen Administration issued on 03/2020 revised on 10/2022 revealed, Standard: It is the standard of this facility to provide guidelines for respiratory care and safe oxygen administration. Guidelines: 1-Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's orders for oxygen administration, nebulizer treatments, inhalers, trach care, chest tube/Pleura care, BIPAP, CPAP or medication administration. Based on observations, interviews, and record review, the facility failed to change the oxygen tubing weekly as required for three (3) Residents (#23, #70, #462) and follow the physician's order for oxygen therapy as prescribed for two (2) Residents (#145, #187) out of four (4) sampled residents. This had the potential to affect the 38 residents receiving respiratory therapy in the facility at the time of the survey. The Findings Included: 1. During observation on [DATE] at 09:17 AM, Resident #23 was observed in bed oxygen (02) running at 2.0 liters per minute (LPM) via nasal canula (NC), no dates observed on 02 tubing, Intravenous pole at bedside, nebulizer at bed side in a bag dated [DATE] (photo available). On [DATE] at 09:32 AM, Resident #23 was in bed watching television, 02 running at 2LPM via NC, stated she needs the door to be left opened, Staff explained to resident they close the door while giving care to the resident's roommate. On [DATE] at 08:55 AM, Resident #23 was observed in bed asleep, 02 running at correct rate, bed in lowest position, no distress noted. Review of the medical records for Resident #23 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Chronic Obstructive Pulmonary Disease (COPD), Unspecified, shortness of breath. Review of the Physician's Orders Sheet for [DATE] revealed, Resident #23 had orders that included but were not limited to: Oxygen at two (2) liters per minute (LPM) via nasal cannula May titrate to keep Saturation 95% every shift. Ipratropium Bromide Inhalation Solution 0.02 % (Ipratropium Bromide) One (1) vial inhale orally every six (6) hours as needed for COPD related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED. Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% -(1) vial inhale orally via nebulizer every (6) hours as needed for COPD. Record review of Resident #23 's Quarterly 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 G for Functional Status documented the resident requires extensive assistance for bed mobility, total dependence for transfer and eating with one person assistance. Section J for Health Conditions documented resident experiences shortness of breath or trouble breathing when sitting at rest. Section O for Special Treatments and Programs documented resident received oxygen therapy in the last 14 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 11 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 Record review of Resident #23 's Care Plans Reference Date [DATE] revealed: Resident is at risk for chest pain related to CHF (Congestive Heart Failure), COPD, and ASHD (Atherosclerotic Heart Disease). Interventions include but not limited to: Administer oxygen at 2LPM upon complaining of chest pain. Monitor for complaints of chest pain. Assess location, intensity, description of pain (ex. dull, sharp, stabbing, radiating) and time of onset (ex. during activities or at rest). Residents Affected - Few 2. During observation on [DATE] at 09:53 AM, Resident #70 in bed, nebulizer at bedside, mask and tubing in plastic bag dated [DATE] (Photo available). On [DATE] at 08:32 AM Resident #70 observed in bed asleep, does not want to be disturbed, mask and tubing in plastic bag dated [DATE]. On [DATE] at 08:56 AM Resident #70 observed in bed asleep, covered with a blanket from head to toe. Review of the medical records for Resident #70 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Chronic obstructive pulmonary (COPD), and Shortness of Breath (SOB). Review of the Physician's Orders Sheet for [DATE] revealed Resident #70 had orders that included but were not limited to: Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams/milliliters (MG/ML)- 3 ML inhale orally via nebulizer every 6 hours as needed for Shortness of breath related to shortness of breath, and Pulmicort Suspension 0.5 MG/2ML (Budesonide) 2 ml inhale orally every 12 hours related to shortness of breath. Record review of Resident #70 's Quarterly 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 G for Functional Status documented the resident requires supervision with Activities of daily living. Section J for Health Conditions documented resident experience no shortness of breath in the last 5 days. Section O for Special Treatments and Programs documented resident received no oxygen therapy in the last 14 days. Record review of Resident #70 's Care Plans Reference Date [DATE] revealed: Resident is at risk for shortness of breath or chest pain related to COPD, right upper lung mass, and recent history of smoking and COVID-19. Interventions include but limited to: Resident will have no shortness of breath, chest pain, edema, or elevated Blood pressure (BP). Monitor for episodes of SOB. Implement interventions for same and notify physician (MD) promptly. Notify MD if edema, chest pains, elevated BP, or SOB occurs. 3. During observation on [DATE] at 09:54 AM Resident #462 in bed asleep, nebulizer at bedside, mask and tubing in plastic bag dated [DATE] (photo available), 02 tubing no date. On [DATE] at 08:31 AM Resident #462 observed in bed awake, eating breakfast, 02 running at 2LPM via NC, mask and tubing in plastic bag dated [DATE], 02 tubing no date. On [DATE] at 08:48 AM Resident#462 in bed asleep, 02 running at correct rate, no distress noted. Review of the medical records for Resident #462 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Malignant neoplasm of unspecified part of unspecified bronchus or lung and Chronic embolism and thrombosis of unspecified deep veins of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 12 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 right lower extremity. Level of Harm - Minimal harm or potential for actual harm Review of the Physician's Orders Sheet for [DATE] revealed, Resident #462 had orders that included but not limited to: Ipratropium Bromide Inhalation Solution 0.02 % (Ipratropium Bromide) 1 vial inhale orally via nebulizer every 6 hours for SOB and Oxygen at 2 LPM via nasal canula every shift related to Chronic embolism and thrombosis of unspecified deep veins of right lower extremity. Residents Affected - Few Record review of Resident #462 '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 G for Functional Status documented the resident requires extensive assistance for Activities of Daily Living (ADLs) with one person assistance, except eating which requires supervision. Section J for Health Conditions documented no shortness of breath. Section O for Special Treatments and Programs documented resident received oxygen therapy in the last 14 days. Record review of Resident # 462's Care Plans Reference Date [DATE] revealed: Resident is at risk for ineffective breathing pattern related to: Lung Cancer. Interventions include but were not limited to: Adjust head of bed and body positioning to assist ease of breathing. Administer medication/oxygen as ordered. Arrange activities to allow adequate rest and increase activities as tolerated. Monitor lung sounds, pallor, cough and character of sputum. Monitor placement of facial mask. Interview on [DATE] at 02:13 PM Licensed Practical Nurse (Staff H) one (1) south station, stated we change the tubing and mask as needed for residents on oxygen therapy and for those who use nebulizers. Interview on [DATE] at 2:54PM Licensed Practical Nurse (Staff J) one (1) north station when asked about how often resident's 02 tubing and nebulizer mask get changed, stated once a week we change them, usually every Thursday on 7-3AM shift. This is something that all nurses were told by the Director of Nursing (DON), there is no paper work that we sign off on stating that the tubing and the masks were changed. Interview on [DATE] at 3:07 PM Licensed Practical Nurse (Staff K) one (1) north station stated I change my 02 tubing every Thursday on my shift, we put the date, time, shift, room number and resident name on the bag. We had a meeting after we no longer had respiratory therapist on site in the facility and were told by the DON that changing the 02-therapy tubing will be the nurses' responsibility. Interview on [DATE] at 08:08 AM Director of Nursing (DON) stated the Nebulizer and 02 tubing are changed weekly, the nurses had an in-service and they know that they must change this equipment weekly, they do not have to document that they change the tubing, just make sure that it is done. DON stated they will be checking all residents on respiratory treatment and making sure their respiratory equipment has been changed as required. Review of the facility's policy and procedure titled, Respiratory Care and Oxygen Administration revised date 10/2022 states: Guideline #10-Oxygen, Trach and nebulizer tubing is changed weekly and dated as verification that the tubing was changed. Tubing order may be recorded in the clinical record but is not required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 13 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure pharmaceutical procedures were followed during and after medication administration for two (Resident #54, #89) out of six (6) residents sampled. There were 213 residents residing in the facility at the time of the survey. The Findings Included: 1. During medication observation on 4/18/2023 at 8:40AM with Licensed Practical Nurse (Staff G) poured 10 milliliters (ML) of Vitamin C Liquid in a medication cup and placed it on a foam tray for medication administration. Before leaving the cart to administer liquid vitamin C to Resident #54, surveyor requested Staff G to take a look at the order, Staff G stated the order is for 5ML of vitamin C, when asked how much medication is in the medication cup, Staff G stated 10ML, Staff G then proceeded to pour some of the liquid vitamin C into the drug buster on the medication cart and then rechecked the medication at eye level on the flat surface of the cart. The amount left in the medication cup was 5ML. Staff G then proceeded to Resident #54's room to administer the morning medications. Review of the medical records for Resident #54 revealed, 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 April 2023 revealed, Resident #54 had orders that included but were not limited to: Medications included: Vitamin C Liquid 500 MG/5ML (Ascorbic Acid)-Give 5 ML via PEG-Tube two times a day related to deficiency of nutrient element, unspecified. Record review of Resident #54 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented brief Interview for Mental Status Score is unable to be determined. 2. During Observation on 04/18/2023 at 11:41 AM in Resident # 89's room (156 Window) Intravenous (IV) medication vial and tubing hanging on IV pole, medication (Ceftriaxone) observed in vial attached to IV tubing on pole (photo available). Resident #89 was not in the room. On 04/19/23 at 09:37 Licensed Practical Nurse (Staff H) stated the resident is out of the facility on an appointment. Asked Staff H what time does Resident #89 gets his intravenous medication. Staff H stated mid-morning. 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: Encounter for orthopedic aftercare following surgical amputation and local infection of the skin and subcutaneous tissue, unspecified. Review of the Physician's Orders Sheet for April 2023 revealed, Resident #89 had orders that included but were not limited to: Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush) Use 10 ML intravenously every shift related to cellulitis of left lower limb. Check IV site every shift for signs and symptoms of infection, infiltration, or pain. Document presence or absence using codes provided. Medications included: Ceftriaxone Sodium Solution Reconstituted 2 grams (GM) Use 2 GM intravenously one time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 14 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 0755 a day for infection related to cellulitis of left lower limb. Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 89's admission Five Day 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 G for Functional status documented resident require supervision for eating and bed mobility, limited assistance with one person for transfer. Section I for Active Diagnosis documented resident has a wound infection. Section M for Skin Conditions documented resident has a surgical wound. Residents Affected - Few Interview on 04/18/2023 at 8:45AM Licensed Practical Nurse, Staff G poured vitamin C in medication cap and placed on foam tray to be administered to resident, when asked how much medication was in the cup nurse stated 5 ml, surveyor and nurse checked the medication on the medication cart on a flat surface at eye level and the amount in the cup was 10ml, Staff G discarded the excess medication in the drug buster on the medication cart. When asked how you check for the accuracy of the liquid medications before you administer to the residents, the nurse stated I check the amount in the medication cup at eye level. Interview on 04/18/23 at 2:20 PM with Licensed Practical Nurse, Staff A, one south station, when asked about the care of a resident on intravenous (IV)therapy stated, we have to make sure the IV tubing is capped when not in use both on the resident and the actual tubing. When asked what should be done if after medication administration there is left over medication in the IV bag or vial. Staff H stated, I go by what the IV machine says. when it says medication is complete, I turn off the pump. Interview on 04/18/23 at 03:50 PM with the Director of Nursing (DON) when told about the issue of how one of the nurses was dispensing liquid medication for a resident during medication administration observation, Director of Nursing (DON) stated I will be doing in-services with all the nurses about the correct medication administration for liquid medications and all other medications. Interview on 04/18/23 at 03:56 PM with the DON when asked what the guidance to the nursing staff is if a resident does not receive their full dose of a medication via IV therapy, DON stated I will go ahead and call the infectious disease doctor (MD) about the resident's medication to see if this qualifies as a miss dose situation and see what the MD wants to do, maybe draw labs etc. My guidance if there is left over medication in the tubing to ask for guidance from the supervisory team and make the resident's MD aware of the situation to see what their direction will be. Interview on 04/19/23 at 04:10 PM, the DON stated I called the MD about the resident IV medication, no new recommendations were given, we will continue to monitor the resident. Review of the facility's policy titled, Medication Administration Guidelines effective date July 2016 states: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Five Rights-Right resident, right drug, right dose, right route, and right time are applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration (1) when the medication is selected, (2) when the dose is removed from the container and finally (3) just after the dose is prepared and the medication put away. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 15 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure proper temperatures of the foods stored in the 1 North Unit Floor Pantry Refrigerator. The refrigerator did not contain a thermometer in the refrigerator and the freezer. This has the potential to affect forty six residents out of fifty six residents who eat orally residing on 1 North wing. The findings included: Record review of the Refrigerator Temperature Monitoring Policy and Procedure (written 09/1998, revised 06/2021) documented the following: Policy: Pantry refrigerator temperature will be checked by the 11-7 Licensed Nurse and recorded daily on the Pantry refrigerator temperature log located in the pantry. Temperature will be maintained between 36 to 46 degrees at all times; Purpose: Regulatory compliance for the storage of perishable food items; Procedure: Licensed nurse records on the temperature log daily, Licensed nurse ensure that defective thermometer are replaced as needed. Observation of the 1 North Unit Floor Pantry Refrigerator with Staff S, Licensed Practical Nurse (LPN) 11-7 shift on 4/19/23 at 7:03 AM revealed, the refrigerator and the freezer did not contain a thermometer. The refrigerator contained resident's food items with the resident's name, resident's room number and dates that the food items were placed in the refrigerator. Interview with Staff S, LPN 11-7 shift on 4/19/23 at 7:04 AM. She revealed that there should be a thermometer in the refrigerator and freezer. She confirmed there were no thermometers in the refrigerator and freezer. Observation of the 1 North Unit Floor Pantry Refrigerator with Staff T, Registered Nurse (RN) Supervisor on 4/19/23 at 7:19 AM revealed, the refrigerator and the freezer did not contain a thermometer. Interview with Staff T, RN Supervisor on 4/19/23 at 7:19 AM. She confirmed there were no thermometers in the refrigerator and freezer. She stated, A thermometer should be in the refrigerator. Record review of the 1 North Unit Pantry Refrigerator/Freezer Temperature Log dated 4/19/23 documented the refrigerator temperature was 38 degrees F (Fahrenheit) and the freezer temperature was 0 degrees F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 16 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure the arbitration agreements presented to three residents (Resident number 165, Resident number 120 and Resident number 210) out of three residents reviewed provided for the selection of a venue convenient to both parties. Residents Affected - Few The findings included: Record review for Arbitration agreements on facility letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents to enter into an arbitration agreement and provides new admissions with the arbitration agreement during the admission process and 3) The NHA (Nursing Home Administrator) is responsible for the binding arbitration agreements. Review of the facility's Voluntary Binding Arbitration Agreements presented to Resident number 165 on 1/18/2023, presented to Resident number 120 on 4/05/2022 and presented to Resident number 210 on 2/22/2023 failed to show the arbitration agreement provided for the selection of a venue convenient to both parties. Interview and record review with the Admissions Director on 4/20/23 at 8:53 AM revealed, the arbitration form failed to show the arbitration agreement provided for the selection of a venue convenient to both parties. She stated, The form we have does not have the wording concerning a venue convenient to both parties. Interview with the Administrator on 4/20/23 at 10:12 AM revealed, the Administrator confirmed the facility arbitration agreement had not yet been revised to provide for the selection of a venue convenient to both parties but the facility is working on it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 17 of 18 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 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North Miami, FL 33161 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 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, interview and record review, the facility failed to demonstrate an effective plans of action were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F602 Free from Misappropriation/Exploitation related to the facility failed to prevent misappropriation of funds for Resident #611, 316, 62, 315, 314, 313, and F755 Pharmacy Service/Procedures/Pharmacist/Records related to the facility failed to follow pharmacy procedures for Resident # 54, #89. These deficiencies have the potential to affect 213 residents residing in the facility at the time of survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with an exit dated 09/22/2016, F602 Free from Misappropriation/Exploitation related to the facility failed to prevent misappropriation of funds and F755 with an exit date of 01/27/2022 Pharmacy Service/Procedures/Pharmacist/Records related to the facility failed to follow pharmacy procedures. Review of the Policy and procedures revealed, It is the policy of the facility to develop, Implement, and maintain an effective, comprehensive, data driven QAPI (Quality Assurance and Performance Improvement) program that focuses on indicators of the outcomes of care and quality of life. The facility will take action aimed at performance improvement as documented in QAA (Quality Assurance and Assessment) committee meeting minutes and action plan. Performance/success of action will be monitored in subsequent QAA Committee or sub-committee meeting. Corrective action plans should include, but not limited to, the following: A definition of the problem Measurable goals and targets Step by step interventions to correct the problem and achieve established goals. A description of how the QAA committee will monitor to ensure changes yield the expected results. The facility will utilize Root Cause Analysis and the Plan, Do, Study, Act (PDSA) cycle of improvement to improve existing processes. Chosen actions for change will be linked to the root causes and will be designed to effect change at the systems level. To ensure improvements are sustained, the effectiveness of performance improvement activities will be monitored in QAA Committee meetings in accordance with QAPIU plan, but no less than annually. On 04/20/2023 at 02:25 PM during an interview with the Risk Manager, Director of Nursing (DON), and Assistant of Director of Nursing (ADON) it was stated that they meet monthly with all departments, Administrator, DON, infection control, Housekeeping, some staff from MDS, Rehab, Restorative and the Medical Director. They review the binder with all the Performance Improvement Project (PIP's) to make sure that they are on track and getting the goals met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 18 of 18