Inspection·January 24, 2025

F 0580 in this case, Ondansetron (Zofran) injection would be administered. Level of Harm - Minimal harm or potential for actual harm On 01/22/2025 at 02:30 PM, Staff B, RN Supervisor entered the room performed hand hygiene put on gloves, checked the resident's mouth and exited the room without checking the residents vital signs and did not assess the bowel sounds and auscultate the lung sounds. Residents Affected - Few Record review of Resident #3's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include Cerebral Infarction, Chronic Obstructive Pulmonary Disease (COPD), Dysphagia following Cerebral Infarction and seizures. Review of Resident # 3's Care Plans with start date of 1/14/2025 and target completion date of 1/28/2025 include: Focus- [Resident] is at risk for ASPIRATION related to PEG tube, Goal: The resident will safely tolerate a least restrictive diet without signs and symptoms (s/s) of aspiration daily thru next review date (NRD). Interventions/Task: Monitor for any coughing/choking and refer, monitor labs as available. Position/sit resident upright at all meals. Focus: [Resident] is at risk for complications related to tube feeding such as aspiration, infection, intolerance to feeding, fluid overload/deficits, etc. Goal: [Resident] will tolerate tube feeding without signs/symptoms of complications . Monitor for signs of intolerance such as nausea, vomiting, diarrhea. If vomiting, hold feeding and notify MD (Medical Doctor). Monitor for signs/symptoms of aspiration every shift such as congestion, coughing, changes in respiratory rate and rhythm and notify MD as needed. Interview on 01/23/2025 at 3:03 PM, Staff C, CNA revealed she has been working in the facility for 10 years and the conditions displayed the day prior with Resident #3 was unusual, also today Resident #3 did not have any other episodes of vomiting. Interview on 01/23/2025 at 3:25 PM, Staff A, RN was asked if he was concerned about Resident # 3's condition on 01/23/2025. He stated, I always see her like that, I opened her mouth to check if anything was in her mouth. Staff A, RN, was asked what basic interventions should have been implemented to address the respiratory concerns for a resident who has PEG feeding and at high risk for aspiration, he stated: Yesterday I did not check the lungs and held the feeding. Staff A, RN, reported he notified the family and the doctor, and no new orders were received, and he had also documented all this information in the residents records and told the supervisor. On 01/23/2025 At 3:41 PM the surveyor reviewed the electronic health records (EHR) with Staff A, RN to confirm documentation regarding notification of change in condition to the doctor and family. Side by side review of Resident #3's Electronic Health Records (EHR) with Staff A, RN revealed no documentation indicating the resident's family and doctor were notified. On 01/23/2025 at 4:05 PM Staff B, RN Supervisor revealed he was not informed of a change in condition related to Resident #3 on 01/22/2025; and the policy for changes in condition; the doctor must be called, notify the family, document in the computer and the 24-hour log. On 01/23/2025 at 4:10 PM, review of the 24-hour log for 01/22/2024 revealed no documentation related to Resident # 3's change in condition. Review of the facility's policy and procedure titled: Change in Condition; issued: 3/2020 and revised 3/22/2024 indicates: The purpose of this policy is to ensure the facility promptly informs the resident, consult the resident's physician; and notify, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 2 of 13 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 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 0580 resident, consult with the resident's physician, and /or notify the resident's family member or legal representative when there is a change requiring such notification. 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: 105513 If continuation sheet Page 3 of 13 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to implement measures to prevent aspiration for one (Resident #3) out of three residents with percutaneous endoscopic gastrostomy (PEG) tube at risk for aspiration as evidenced by Resident # 3 was observed with vomit draining from her mouth and the Registered Nurses failed to implement interventions in a timely manner; and failed to implement interventions to prevent PEG tube dislodgement for two (Resident #6 and Resident # 7) out of three residents sampled as evidenced by Resident #6 was noted with his unsecured PEG tube line resting above his hand and Resident #7's tube feeding line was observed wrapped around the privacy curtain that was wrapped around the metal pole that had the feeding infusing and hanging loosely on the inner section of the wheelchair's wheel (Photo evidence). Both residents clinical diagnoses include Seizures. These risk factors increases the risk for dislodgement of the PEG tubes and affect the residents' nutritional status. The findings included: On 01/22/2025 at 8:44 AM Resident #3 was observed in bed with her eyes closed; loud gurgling sounds were noted, the head of the bed was slightly elevated and dark beige thick liquid resembling vomit was drooling from Resident # 3's mouth, a large white towel was tucked under the chin and draped across the resident's chest absorbing the thick liquid. Oxygen via nasal cannula was flowing at 2 Liters Per Minute (LPM), tube feeding was infusing at 65 milliliters per hour (ml/hr.). Respiratory supplies for breathing treatments were dated 01/10/2025 and the oxygen humidifier was dated 01/08/2025. The nurse was called to the room and asked what interventions were in place related to the concerns observed. Staff A, Registered Nurse (RN) entered the room and looked at the resident, Staff A revealed the resident is always like that resident does not need suctioning or anything and exited the room. On 01/22/2025 at 8:46 AM Staff C, Certified Nursing Assistant (CNA) walked into Resident # 3's room and cleaned the vomit draining from the resident's mouth and placed a clean towel under the resident's chin and across the chest. Observation on 01/22/2025 at 02:09 PM, Resident #3 was in bed with eyes closed and still had the gurgling sounds and vomit draining from her mouth. The PEG feeding infusing formula at 65 ml/hr. Closer observation revealed a Scopolamine patch (usually used for motion sickness and for drying secretions) was noted behind the resident's right ear. On 01/22/2025 at 2:13 PM Staff C, CNA entered Resident #3's room, cleaned the vomit draining from Resident #3's mouth and revealed the nurse knew and she was going to inform him again. Observation on 01/22/2025 at 02:09 PM; Resident #3 was in bed with eyes closed and still had the gurgling sounds and drainage from the mouth. The tube feeding was infusing at 65 ml/hr. Closer observation of the resident revealed a Scopolamine patch (usually used for motion sickness and for drying secretions) was observed behind the residents right ear On 01/22/2025 at 2:13 PM Staff C walked into the room wiped the cleaned the resident's mouth and reported she was going to inform the nurse. She also revealed the nurse knew and she was going to inform him again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 4 of 13 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/22/2025 at 02:24 PM, Staff A, RN entered the room, looked at the resident and mentioned this happens sometimes and Ondansetron (Zofran) injection would be administered in this case. The nurse did not check the residents vitals, did not check bowel sounds, did not auscultate lung sounds and did not hold the PEG feeding. On 01/22/2025 at 02:30 PM Staff B, RN Supervisor entered the room performed hand hygiene put on gloves, checked the resident's mouth and exited the room. Record review revealed Resident # 3 was admitted to the facility on [DATE]. Clinical diagnoses include Chronic Obstructive Pulmonary Disease (COPD), Dysphagia following Cerebral Infarction and seizures. Review of the Physician Orders for January 2025 included but not limited to: Scopolamine Transdermal Patch 72 Hour 1 MG (milligram) every 3 days at 9:00AM- Start Date: 12/17/2024. Check Scopolamine Transdermal Patch every shift Enteral Feeding two times a day 65 ml/hr. for 20 hrs, start at 2:00 PM, end at 10:00 AM, (or until 1300 ml total formula volume)-revision date 9/21/2024. Water flush two times a day Auto flush water 50 ml/hr. for 20 hrs via Peg (percutaneous endoscopic gastrostomy), off:10:00AM, on :1400-Revision date 9/19/2024. Oxygen at 2 LPM via nasal cannula every shift for COPD, ipratropium-Albuterol inhalation Solution 3 ml inhale orally via nebulizer every 6 hours related to COPD; Ondansetron HCI Injection Solution 4 MG/2 ML -Inject 2 ml intramuscularly every 6 hours as needed for Nausea and vomiting. Enhanced Barrier Precautions related to presence of Peg tube. On 01/23/2025 at 08:03 AM, during a PEG tube medication administration for Resident #6, it was noted that the PEG tube was above the resident's right hand; the resident guarded the site and Staff B, RN had to hold the resident's hands while Staff A, RN administered the medications. The PEG tube site was not secured. Review of Resident #6's clinical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with clinical diagnoses that include Gastronomy status, Seizures, Tracheostomy status and Dysphagia, Review of a Health Status Notes dated 1/15/2025 time stamped 02:15:00 and note dated 1/16/2025 time stamped 07:13:08 created By: Staff L, Licensed Practical Nurse (LPN) indicate: Resident fights and guards abdomen area when trying to provide PEG care, PEG site noted leaking fluids with odor and brown drainage, Review of Health Status Note dated 1/16/2025 time stamped 11:30 revealed Resident # 6's PEG tube was noted out of place and the Nurse Practitioner was notified. Review of dietary note created by the Dietitian on 1/17/2025 time stamped 12:45:00 noted: WEIGHT WARNING, Weekly weight completed: resident's weight continues to decline. Weight 121 lbs, down 4 lbs this week . Currently, Feeding is on hold D/T (due to) PEG-Tube is out of place. Review of Health Status note dated 1/17/2025 timestamped 23:29:00 revealed Resident #3's PEG tube was reinserted, On 01/23/2025 at 9:30 AM and at 09:43 AM, Resident #7 was observed in her room seated in a wheelchair asleep. The tube feeding line was wrapped around the metal pole that had the feeding pump, the privacy curtain and the wheelchair. The feeding was running at 60 ml/hr. (milliliters per hour). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 5 of 13 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 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 0693 (Photo evidence) increasing the risk for dislodgement. Level of Harm - Minimal harm or potential for actual harm On 01/23/2025 at 9:45 AM Staff I, RN was asked why Resident #7 was in the room seated in wheelchair; staff I, RN explained Resident #7 had been waiting to be transported to therapy. Staff I was told to check the resident tubing. Residents Affected - Few Review of Resident #7's clinical records revealed an initial admission date of 1/22/2024 and a readmission dated 11/19/2024. Clinical Diagnoses include Gastronomy Status, Dysphagia, and other Seizures. Interview on 01/23/2025 at 03:16 PM. Staff A revealed they do not secure the Residents' PEG tubes and there is no need to. 01/23/2025 at 03:16 PM Staff B, RN supervisor revealed peg tubes does not need to be secured. On 01/23/2025 at 4:47 PM, the Director of Nursing (DON) was asked what interventions the facility has in place to secure and prevent a percutaneous endoscopic gastrostomy (PEG) tube from dislodging. The DON revealed, no special anchoring or adhesive is used to secure the PEG tubes. On 01/24/ 2025 Staff J, CNA revealed the tube feeding line should not be wrapped around anything because it increases the risk of dislodgment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 6 of 13 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 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** Based on observations records reviewed and interviews, the facility's staff failed to address respiratory emergencies in a timely manner for two (Resident # 5 and Resident #6) out of three residents sampled residents; as evidenced by Resident #5 and Resident # 6 were noted in respiratory distress and the nurses failed to implement interventions in a timely manner. Residents Affected - Some The findings included: On 01/23/2025 at 08:03 AM, Resident #6 was observed slumped in bed in distress; loud gurgling sounds noted, coughing and drooling; the resident shaking his head from side to side with facial grimacing indicating he is not feeling well, when asked if he had pain he nodded his head indicating yes. The oxygen was at 4 Liters Per Minute (LPM), tube feeding was infusing at infusing at 75 ml/hr. The nurse was called to the room. Staff A, RN entered the room to assist the resident and left the room to get Tylenol for the resident. came to the room put on gloves, was not wearing a gown and was not wearing a mask and speaking very close to the resident in a loud tone. Staff B, RN Supervisor checked the bowel sounds and did not osculate the lung sounds and did not check the vital signs. On 01/23/2025 at 8:09 AM Staff A, RN administered the medication and still did The nurse was asked what he was going to do about the residents crackles. Staff A, RN gathered the suctioning supplies; Staff A, RN did not osculate the lung sounds and did not take the vital signs before administering the medication and before suctioning the resident. On 01/23/2025 at 09:19 AM, Resident #6 was in respiratory distress again with gurgling sounds, the drainage collection bag for secretions was missing from the resident' tracheostomy Y-Adaptor. Staff B, RN was called to the room, he took the collection bag that was on the side table and attached it. Staff B, RN proceeded with suctioning the resident without checking the oxygen level, did not auscultate the lung sounds, did not clean/prime the suction machine with normal saline before using it on the resident. Review of Resident #6's clinical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with clinical diagnoses that include Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, Chronic Obstructive Pulmonary Disease (COPD), Tracheostomy status, Dysphagia, oropharyngeal phase. Record review of Resident #6's Physician Orders for January 2025 included but not limited to: Acetaminophen (Tylenol) Tablet 325 MG.- Give 2 tablet via PEG-Tube two times a day related to pain. Oxygen titrate 2-6 LPM via trach to maintain saturation above 92%. Oxygen titrate 2-5 LPM via trachea to maintain saturation above 94% - every shift. Suction every 2 Hours and PRN every 2 hours and as needed. Pre and Post Treatment (Tx) Lung Sounds; Pre and Post Tx - Pulse, Respirations and Oxygen Saturation (O2 Sat) results. Aspiration precautions every shift. Review of Resident # 6's Annual Minimum Data Set (MDS)MDS dated [DATE] indicated the residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 7 of 13 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 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 cognitive status was unable to be determined. The residents functional abilities indicate the resident is dependent on staff for Activities of daily living (ADLs). Health conditions documented the resident does not have schedule pain medication; Receives PRN (as needed) pain medication and has shortness of breath or trouble breathing when lying flat. Residents Affected - Some Review of Resident #6's Care Plan with start date 1/17/2025: documented Focus: [Resident #6] is at risk for aspiration r/t (related to) peg tube. Goal: [Resident] will safely tolerate a least restrictive diet without s/s of aspiration daily thru NRD (Next Review Date). Interventions included: Monitor for any coughing/choking . During an interview on 01/23/2025 Staff A, RN acknowledged he did not auscultate the Resident #6's lungs, did not turn the feeding of before repositioning the resident, did not check the vital signs before administering the medications and before and after suctioning the resident. On 01/23/25 at 03:52 PM Staff B, RN Nurse supervisor acknowledged he should have checked the residents' vitals before and after suctioning the resident. Resident #5 On 01/23/2025 at 8:40 AM Staff F, Licensed Practical Nurse (LPN) was observed leaving Resident #5's room, when asked if she had completed Trach care and medication administration for Resident #5. Staff F, LPN revealed she had just administered the medication and left the room. Upon entering the room Resident #5 was observed with facial grimacing and loud gurgling sounds were noted. The feeding was infusing via PEG at 60 ml per hour (ml/hr.). The surveyor immediately informed Staff F, LPN to return to the room based on the identified concerns. Staff F, LPN briefly entered the room and revealed she would be back to suction the resident. Staff F, LPN did not display any immediacy to address the residents respiratory distress. At 8:53 AM (twelve minutes later) Staff F, LPN returned to the resident's room with Staff E, Registered Nurse (RN). Both nurses donned PPE. Staff E, RN revealed 2 persons usually work together for suctioning residents. Staff E, RN positioned herself on the side that the suction machine was located and Staff F, LPN on the side that the feeding tube pump was located; Staff F, LPN did not stop the feeding. The nurses lowered the head of the bed. Staff F, LPN left the room to get a vital signs machine. Upon noting the feeding was still infusing, Staff E, RN immediately stopped the feeding. Staff F, RN returned to the room eleven minutes later with a vital signs machine, changed gloves and stood at the opposite side of the bed. After Staff E, RN completed suctioning the resident and checked vital signs etc. Staff E, RN revealed Resident # 5 has orders for suctioning to be done every two hours and as needed. Staff F, LPN had already left the room and was not available for an interview. On 01/24/2025 several attempts were made to conduct interviews via telephone with Staff F, LPN were unsuccessful. Review of Resident #5's clinical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include Encounter for attention to tracheostomy 11/29/2018, Chronic respiratory failure. Review of Resident #5's Physician Orders included: Suction every 2 hours and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 8 of 13 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 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 Oxygen titrate 2-5 LPM via trachea to maintain saturation above 94% - every shift for Oxygen related to chronic respiratory failure. Head of bed to be elevated 30-45 degrees. Aspiration precautions. every shift. Level of Harm - Minimal harm or potential for actual harm Pre and Post treatment Lung Sounds-Pulse, Respirations, and Oxygen Saturation. Residents Affected - Some Trach care every shift and as needed related to encounter for attention to tracheostomy. Review of Resident # 5's Care Plan with a review start date of 02/17/2025 and Target Completion Date 03/07/2025 indicate: Focus: [Resident] is at risk for aspiration related to: PEG tube, Tracheal intubation. Goal: [Resident] will safely tolerate a least restrictive diet without signs/symptoms of aspiration daily thru next review date. Interventions: Monitor for any coughing/choking and refer. Focus: [Resident] is at risk for complication related to use of Tracheostomy tube related to Chronic Respiratory Failure. Goal: [Resident] will have clear and equal breath sounds bilaterally through the review date. [Resident] will have no abnormal drainage around trach site through the review date. Interventions: Suction as necessary. TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB to 45 degrees and stay with resident. Obtain medical help IMMEDIATELY. Review of the Quarterly MDS dated [DATE] revealed the residents cognitive status is unable to determine. Functional abilities indicate the resident is dependent for all Activities of Daily Living (ADLs). Interview on 1/23/2025 at 2:28 PM, Staff C, CNA revealed if she heard gurgling sounds coming from a resident with a tracheostomy, she does not touch the resident until the nurse suction the resident. Residents with tracheostomy and tube feedings should not be flat while in bed. If the oxygen humidifier container is empty the nurse must be notified immediately. During an interview on 01/23/2025 at 4:34 PM; the Director Of Nursing (DON) was informed of the concerns identified. The DON revealed the nurses should complete an assessment; even if the Resident has been here for a long time. Residents with feeding tubes are at risk for aspiration and if observed with emesis and simple vomiting staff should elevate the head of the bed assess the vital signs hold the feeding and notify the doctor. The DON revealed the LPNs are trained to suction residents with trachs. When a resident is in respiratory distress the nurse should act immediately, It only takes 1 minute to do so, and 15 minutes will be a long time pending on what is needed. The expectation is the safety of the patient and maintaining an open airway Interview on 01/24/2025 at 11:50 AM with Staff I, RN, revealed all nurses can perform suctioning and usually suctioning is completed by two nurses. For a resident in respiratory difficulty immediate assistance is required more than five minutes is too long to provide suctioning for a resident in respiratory distress. For a resident in respiratory difficulty immediate assistance is required. On 01/24/2025 several attempts were made to conduct interviews via telephone with Staff F, LPN were unsuccessful. Review of document provided by the facility indicate: Manual: Nursing Manual: Nursing Section: Respiratory Standards and Guidelines: Issued 3/2020. Documented: Respiratory Care and Oxygen Administration Standard: It is the standard of this facility to provide guidelines for respiratory care and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 9 of 13 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 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 safe oxygen administration. Level of Harm - Minimal harm or potential for actual harm Review of the facility's document titled: Tracheostomy Care. Date Implemented: 3/2020 Reviewed/Revised 06/2023, 08/2024 indicates: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Residents Affected - Some Compliance Guidelines: Item 2. The facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and/or suctioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 10 of 13 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed and interviews, the facility failed to secure medications and ensure the resident (Resident #6) received all of the crushed medications mixed with water during medication administration observation for one out of one resident (Resident #6) as evidenced by, Staff A, Registered Nurse (RN) left Resident #6's medications unattended and failed to ensure the resident received the full amount of each medication via PEG (Percutaneous Endoscopic Gastrostomy/also known as G-tube). There were 27 Residents residing in the facility with PEG tubes. Medication observation on 01/23/2025 at 08:09 AM, Staff A, RN was observed administering medications to Resident # 6 via PEG. Staff A, RN entered the resident's room with crushed medications Tylenol 325 milligrams (mg.) 2 tablets and Eliquis Oral Tablet 2.5 mg 1 tablet separately mixed with water in cups and. room to get the medications for the resident. Staff A, RN returned to the room with the medications (Tylenol 325 milligrams(mg) 1 tablet, Levetiracetam solution 100 5mL (milliliters) and Eliquis oral tablet 2.5 mg), placed the medications on the resident's overbed table and walked out of the room leaving the medications on the table (photographic evidence). Staff A, RN returned to the room, administered the medication via PEG and was about to discard the medication cups and extra water, the surveyor intervened and showed Staff A, RN, that approximately 75 percent (%) of the Tylenol and Eliquis were still in the cups (Photographic evidence). Staff A, RN left the room to get more water, left the cups with the left-over medications on the overbed table then returned and mixed and administered the mixtures via PEG. Review of Resident #6's clinical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with clinical diagnoses that include Tracheostomy status. Record review of Resident #6's Physician Orders for January 2025 included Levetiracetam 100 mg/ml-Give 5 ml via G-Tube two times a day related to unspecified convulsions. Eliquis oral tablet 2.5 MG (Apixaban)-Give 1 tablet via PEG-Tube two times a day for DVT (Deep Vein Thrombosis) Prophylactic, Acetaminophen (Tylenol) Tablet 325 MG.- Give 2 tablet via PEG-Tube two times a day related to pain. During an interview on 01/23/2025 at 3:16 PM, Staff A was asked about the unattended medications noted during medication administration for Resident #6. Staff A, RN. Staff A acknowledged he had left the medications unattended, but the resident is not going anywhere and is not able to get the medications. Staff A, LPN revealed he is aware medications should not be left unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 11 of 13 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 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, interviews and record reviewed during this survey's investigations it has been determined that the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F 761 Label/Store Drugs and Biologicals, F693 Tube Feeding Management and F867 QAPI-QAA Improvement Activities. These repeated deficiencies have the potential to affect all residents residing in the facility. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated 08/22/2024 the facility was cited: F 761 Label/Store Drugs and Biologicals, F693 Tube Feeding Management and F867 QAPI-QAA Improvement Activities and during this complaint survey with exit dated 01/24/2024 the facility was cited again for F761 Label/Store Drugs and Biologicals, F693 Tube Feeding Management and F867 QAPI-QAA Improvement Activities. 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 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 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 QAPI plan, but no less than annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 12 of 13 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations records reviewed and interviews the facility's staff failed to implement infection prevention control precautions as evidenced by staff failed to follow Enhanced Barrier Precautions during Tracheostomy care for one out of two residents with tracheostomy in the facility. Residents Affected - Few The findings included: Observation on 01/22/2025 at 02:09 PM Resident #3 was in bed with eyes closed, gurgling sounds and vomit draining from her the mouth. The tube feeding was infusing at 65 ml/hr. On 01/22/2025 at 02:30 PM Staff B, RN Supervisor entered the room performed hand hygiene put gloves on, did not put a gown, he checked the resident's mouth removed gloves and exited the room. On 01/23/24 at 8:03 AM before entering Resident 6's room an Enhanced Barrier Precautions sign was noted posted, and Personal Protective Equipment (PPE) was observed in a plastic container with drawers at the doorway. Resident #6 was observed in bed in distress with loud gurgling sounds noted coughing and drooling; the resident shaking his head from side to side with facial grimacing indicating he is not feeling well, when asked if he is in pain he nodded his head indicating yes. The oxygen was at 4 Liters Per Minute (LPM) via Tracheostomy, tube feeding was infusing at infusing at 75 ml/hr. The nurse was called to the room. Staff A and RN entered the room to assist the resident, and repositioned the resident. the supervisor was not wearing a mask was noted speaking very close to the resident in a loud tone; The supervisor checked the bowel sounds with his stethoscope exited the room and did not clean his stethoscope both. Both Staff A, and Staff B were not a gown while checking the resident Peg tube. On 01/23/2025 Staff A, RN acknowledged he did not follow infection prevention and control policy and procedures for Enhanced Barrier Precautions (EBP) while providing care to Resident #6. On 01/23/25 at 03:52 PM Staff B, RN acknowledged he did not follow and implement infection prevention and control precautions while caring for Resident #3 and Resident #3 at all times. Review of the facility's Policy and Procedures: for Infection Prevention and Control Program Issued: 6/2020 and Revised:9/29/2021, 6/2023 indicates: It is the policy of the facility to ensure that the Infection Control Program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement; provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with State and Federal Regulations, and national guidelines. Item 16: All shared medical equipment will be cleaned using an EPA-approved disinfectant wipe effective against TB and Hepatitis B. The Policy and Procedures: Titled Enhanced Barrier Precautions; Issued: 8/16/2022 and Revised: 4/1/2024 indicate: It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105513 If continuation sheet Page 13 of 13