Health inspection·April 25, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide advance directives documentation for seven out of seven sampled residents (Resident #102, Resident # 137, Resident # 305, Resident # 307, Resident # 65, Resident # 76 and Resident # 77). The findings included: Record review of Resident #102's demographic face sheet noted an admission date of 03/20/2024. Review of Resident # 102's clinical records showed no written documentation related to advance directives. Record review of Resident #137's demographic face sheet noted an admission date of 03/05/2024. Review of Resident # 137 clinical records showed no written documentation related to advance directives. Record review of Resident # 305's demographic face sheet noted an admission date of 04/12/2024. Review of Resident # 305's clinical records showed no written documentation related to advance directives. Record review of Resident # 307's demographic face sheet noted an admission date of 03/29/2024. Review of Resident # 307's clinical records showed no written documentation related to advance directives. During an interview on 04/24/2024 at 8:10 AM. The Administrator reported; Resident # 102, Resident # 137, Resident # 305, Resident # 307 do not have Advance Directives on file. Interview with Social Services Director on 04/24/24 at 10:01 AM. She reported, the Advance Directives was part of the admission Package. as soon as a resident is admitted . The admission Director oversees offering the Advance Directives to residents at time of Admission. Interview with admission Director on 04/24/24 at 10:46 AM. She reported that when a resident is admitted , she explain to the resident or resident's representatives about the Advance Directives. The resident or the resident's representative then decides whether to execute or not; the resident or the resident's representative is informed that if they already have any form of Advance Directives at home such as Living Will, Power of Attorney, Health Care Surrogate, etc. They must bring these documents to the facility as soon as possible. The facility does not have any document signed by the residents or the residents' representative informing them they are being offered the Advance Directives by the facility and decided not to execute. Record review of Policies and Procedures for Advance Directives dated November 2017 revealed the Policy: A resident's choice about Advance directives will be respected. Policy Interpretation and Implementation: 1-Prior to, or upon admission the Care Plan Team will ask residents/their family members, about the existence of Any Advance Directives. 2-Should the resident indicate that he or she has issued Advance Directives about his or her care and treatment, the Center will require that a copy of such directives be included in the medical record. Review of Resident #76's medical records, revealed the resident was admitted to the facility on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 2 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [DATE]. The records reviewed for the resident or family's receipt of advance directive information was not found in the resident's records. On 04/24/24 at 07:15 AM the Administrator stated: For some residents we do not have documentation. On 04/24/24 at 10:00 AM Social Services reported that upon admission the advance directive is offered together with the admission package, if the residents do not want executed, the facility does not keep any record. Record review of Resident #65's demographic face sheet noted admission date was 4/10/2023. Review of Resident #65's clinical record showed no written documentation related to advance directives. On 4/25/2024 at 12:27 PM, interview with the Social Services Director revealed, she does not have an Advance Directives on file. Record review of Resident #77's demographic sheet noted admission date was 10/30/2023. Review of Resident #77's clinical record showed no written documentation related to advance directives. On 4/25/2024 at 1:08 PM, during an interview the Social Services Director reported she does not have an Advance Directives on file. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 3 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident #149) out of five residents reviewed for discharges. As evidenced Resident #149 was discharged to home; but the MDS indicated the resident was discharged to hospital. Residents Affected - Few The finding included: Record review of Resident #149's admission record revealed the resident was admitted to the facility on [DATE] and discharged home on [DATE]. Record review of Medical Diagnosis revealed the resident's diagnosis included, but were not limited to, Malnutrition and chronic obstructive pulmonary disease with (acute) exacerbation, Record review of Resident #149's Care Plan initiated on 04/12/2024 revealed Focus: The resident wishes to return/be discharged to home with sister-in-law. Record review of progress notes dated 4/4/2024 at 18:33 revealed Discharge Summary Resident is going home discharge in stable condition . discharge instructions signed by patient. Record review of Discharge Return Not Anticipated Minimum Data Set (MDS) Section C dated 04/24/2024 revealed the Brief Interview for Mental Status Summary score was 09 out of 15. Review of section A2105 for Discharge Status documentation indicated a coding of 01 meaning the resident was discharged to Home/Community. Interview on 04/24/2024 at 10:34 AM, the MDS Coordinator stated: I believe it was an oversite while coding it and I will correct it immediately. Review of the facility's Policy and Procedure; Subject: Resident Assess Instrument (RAI), dated 1/12/2024. Intent: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frame stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for each care plan development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 4 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, record review and interview, the facility failed to ensure that a splint device was in place/worn to prevent worsening of left hand and left elbow contractures for one (Resident #12) out of one resident reviewed for positioning and mobility out of twelve residents with contractures. The findings included: An initial observation of Resident #12 was conducted on 4/22/2024 at 8:47 AM. The resident was sitting up in bed, watching television, the resident had contractures on the right elbow, right hand, left elbow and left hand. No hand rolls were noted on the right or left hand and no splints were noted on the right or left elbows. Second observation of Resident #12 was conducted on 4/23/2024 at 8:40 AM. The resident was sitting up in bed eating breakfast, television. No hand rolls were noted on the right or left hand and no splints were noted on the right or left elbows. Third observation of Resident #12 was conducted on 4/24/2024 at 10:03 AM. The resident was sitting up in bed asleep, television was o. No hand rolls were noted on the right- or left-hand contractures and no splints were noted on the contractures for the right or left elbows. Fourth observation of Resident #12 was conducted on 4/24/2024 at 12:56 PM. The resident was sitting up in bed asleep, television on. No hand rolls were noted on the right or left hand and no splints were noted on the right or left elbows. Record review of the Demographic Face Sheet for Resident #12 documented the resident was admitted on initially 4/19/2016. The resident was discharged to the hospital on 3/29/2024 and returned the same day (3/29/2024) to the facility, with diagnoses that include but not limited to multiple sclerosis, diabetes mellitus, functional quadriplegia, anxiety disorder, contractures on right elbow and right hand, left elbow and left hand. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #12 dated 2/20/2024 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 09 out of 15 indicating mild cognitive impairment and required total dependence assistance for ADLs (Activities of Daily Living) and had impairment on both sides for the upper and lower extremities. Review of Resident #12 Physician's Order Sheet (POS) for April 2024 documented the resident was to wear left grip hand splint and left elbow contracture management splint to be worn daily on in AM and off in PM as tolerated during therapy one time only for contracture management of the left hand and elbow for 30 days. The start date was 4/23/2024 and the end date 5/23/2024. The order was written on 4/23/2024. Review of Resident #12's Contracture care plan written 9/12/2023 and revised 2/27/2024 documented the resident has an alteration in musculoskeletal status related to contracture, right elbow, functional quadriplegia, contracture left elbow, contracture right hand, muscle spasm, contracture left hand; Goals: 1) Resident will remain free of injuries or complications related to review date, 2) Resident will remain free from pain or at a level of discomfort acceptable to the resident through the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 5 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few review date; Interventions: Anticipate and meet needs, Resident needs to change position; No interventions noted with splints. On 4/25/2024 at 10:07 AM, interview with Staff B, Registered Nurse. She stated, She is total care, but eats by herself. She started wearing splint on left arm on Tuesday, 4/23/2024. She wears it for 3-4 hours. Therapy comes into her room to give her therapy. On 4/25/2024 at 11:26 AM, interview with the Director of Rehab. She stated: She was just evaluated. She has left hand and left elbow contractures. She has a splint on the left hand. The order was written on 4/23/2024 by the therapist and signed off by the doctor. She only tolerates it a couple of hours per day. She receives OT (occupational therapy) and SLP (speech therapy). She had OT on 10/19/2023 and was discharged from OT on 11/22/23. She was tolerating it for two hours. She was again evaluated for OT on 4/23/2024 and determined to wear the grip left hand splint and left elbow contracture management splint. Fifth observation of Resident #12 was conducted on 4/25/2024 at 11:31 AM. The resident was sitting up in bed watching television and had contractures on the right elbow, right hand, left elbow and left hand. No hand rolls were noted on the right or left hand and no splints were noted on the right or left elbows. Interview with the resident she revealed that before this week she did not wear a splint on her left hand or arm. The facility only put on the left hand splint this week. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment for Resident #12 documented the resident was certified to received OT services for 4/23/2024 to 5/22/2024; Diagnoses: Contracture left elbow; Contracture left hand with a frequency of 16 times for 30 days. Short term Goals: Patient will tolerate left hand orthosis (brace) for 4 hours daily or as tolerated; PT (patient)will tolerate left elbow flexion contracture orthosis for 4 hours daily; Reason for therapy: Referred to skilled OT services by nursing for left UE (upper extremities) contracture management and to assess appropriateness of the previously recommended orthotic devices for contracture management. Patient was found with increased left elbow flexion rigidity; however, patient was receptive to work on wearing the orthosis to try preventing further joint contracture of the left elbow and hand. Left slim grip hand orthosis was applied and appeared to fit well however the left elbow contracture management orthosis was not able to fit at this time due to increased rigidity. On 4/25/2024 at 1:56 PM, the Director of Nursing (DON) stated: When the resident went to the hospital, the splint was discontinued. She went to the hospital on 3/29/24. The doctor wrote the order on 4/23/24 for her to wear the splint. Record review of the Assistive Devices and Equipment Policy and Procedure (Revised 12/12/2023) documented: Policy-All resident who are observed to need rehabilitation equipment (such as splint/brace/prosthetic devices) will be screened and/or evaluated by a licensed therapist to determine medical necessity and the most appropriate device for that situation; Procedure: 1) Upon admission, transfer or return, all residents will be screened/evaluated for appropriate rehab equipment; 2) Whenever indicated, nursing will send a consultation request form to the Rehab department identifying a perceived need for Rehab equipment; 3) A licensed therapist will screen/evaluate the resident to determine medical necessity and the most appropriate type of device and 4) The therapist will provide off the shelf, customize equipment or contact a vendor to order an appropriate device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 6 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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. Based on observation, record review and interview facility failed to keep drug records in an order that an account of all controlled drugs is maintained and periodically reconciled for one resident (Resident #74) out of seven residents sampled as evidenced by total number of pills in bingo card labeled Clonazepam Tab 0.5 mg (milligrams), less than the amount recorded on Controlled Drug Receipt/Proof of use/Disposition form. There were 142 residents residing in the facility at the time of the survey. The findings included: On 04/24/24 at 3:37 PM a narcotic count was completed with Staff C, a Licensed Practical Nurse (LPN) for South cart in nursing section 300. Resident #74's Clonazepam 0.5 mg (milligrams) tablet blister pack count was 33 tablets and the Controlled Drug Receipt/Proof of use/Disposition form for Resident #74's Clonazepam 0.5 mg tablet was 34, last signed on 4/23/2024. (photo evidence) Record review of electronic medication administration record revealed Staff C, LPN signed that Clonazepam 0.5 mg tablet was administered to Resident #74 on 4/24/2024 at 1:16 PM. Staff C, LPN stated she forgot to sign after administration of medication. Staff C stated: I am supposed to sign after administering to the resident, but I got distracted. On 4/25/2024 at 12:22 PM The Director of Nursing DON stated that nurses are to sign out the controlled medications on The Controlled Drug Receipt/Proof of use/Disposition form at the time it is removed from the from the bingo card. Record review of the facility's policy and procedure entitled, Control Drugs dated 10/2017 revealed Policy Drugs listed in Schedule II, III, IV, shall be subject to special handling, storage, disposal, and record keeping. Policy Interpretation and Implementation. 3. If the count is correct, a control sheet must be made for each substance. Do not enter more than one (1) prescription per page. This record must contain d. Number on hand. i. Time of administration. K. Signature of nurse administering drug. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 7 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 observation, interview, and record review the facility failed to properly store medications for one resident (Resident#122) out of seven residents sampled as evidenced by an observation of medication in the room Resident#122's room without staff present. There were 142 residents residing in the facility at the time of the survey. On 4/23/2024 at 9:09 AM. An observation was made of two small, white, circular tablets inside a transparent medicine cup, on top of side table next to Resident#122's. (photo evidence). Resident #122 stated the medication was given to her by the overnight nurse and kept due to not wanting to take it on an empty stomach. On 4/23/2024 at 9:14 AM, Staff C, Licensed Practical Nurse (LPN) was asked about the medications observed in Resident #122's room. Staff C, LPN stated: I did not administer any medication to Resident#122. Staff C stated: I did rounds at 7:15 AM this morning and visually assessed [Resident #122] and I did not see any medication. I am not aware of [Resident#122] approved to independently medicate herself. If medications are found in a resident's room, the protocol is to retrieve medicine, educate the resident, dispose of medication, and notify the supervisor. On 4/23/2024 at 9:16 AM Staff C, LPN and the surveyor entered Resident #122's room. Staff C, LPN retrieved two small, white circular tablets inside a transparent medication cup located on top of the side table next to Resident #122's bed. Staff C, LPN educated Resident #122 about facility's protocol of taking medication at the time of administration. On 04/23/2024 at 9:30 AM Staff C, LPN disposed of medication found in Resident #122's room, into a drug disposal carton located in the bottom drawer of medication cart and then notified supervisor. Record review of demographic sheet revealed Resident #122 was admitted on [DATE] with diagnosis that included Systemic Lupus Erythematosus. Record review revealed a Quarterly Minimum Data Set (MDS) dated [DATE] Section C for cognitive status Brief Mental Stats score (BIMS) score of 14 on a scale of 0 to 15, indicated no cognitive impairment. Section I for active diagnosis revealed anxiety disorder and depression. Section J for pain revealed Resident #122 received as needed pain medications or was offered and declined, has pain occasionally, pain rarely or not at all effects sleep or day to day activities and pain intensity 2. Record review revealed a care plan initiated on 10/24/2023 and started on 2/9/2024 for at risk for pain related to Lupus, depression, weakness, decreased mobility. Interventions included anticipating the resident's need for pain relief and responding immediately to any complaint of pain, monitor/document for side effects of pain medication. Record review revealed a physician's order dated 10/24/2023 Acetaminophen Tablet 325 milligram (mg); Give two tablets by mouth every six hours as needed for pain. On 4/25/2024 at 12:06 PM The Director of Nursing (DON) stated: there are no residents in the facility approved to self-medicate. No residents are allowed to have medications in their room without (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 8 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 FORM CMS-2567 (02/99) Previous Versions Obsolete staff present. We educate family and residents to not bring any medications inside facility to prevent overdose or adverse interaction. If a resident is found to have medication in the room, medication is removed immediately, staff is reeducated, and physician notified. Record Review of the facility's Policy and procedure, entitled Storage of Medication dated 10/2017 revealed Policy Drugs and biologicals should be stored in a safe, secure, and orderly manner. Policy Interpretation and Implementation. Drugs are stored in an orderly manner in cabinets, drawers, or carts. Event ID: Facility ID: 105550 If continuation sheet Page 9 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 - Many 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 1) food items in the walk-in refrigerator that were opened were labeled and dated, 2) to store food under sanitary conditions and maintain the food safely using a method to determine the temperatures in the milk box and 3) failure to ensure the proper cleaning and maintenance of exhaust hoods and vents to prevent food contamination. This has the potential to affect one-hundred and thirty-two out of one-hundred and forty-two residents who eat orally residing in the facility. The findings included: 1) Record review of the Food from Home and Outside Sources Policy and Procedure (written date November 2017); Policy Statement-Food and Beverage not procured by the Food and Nutrition Services department shall adhere to the same uniform handling procedures established by the center to ensure that the food or beverage is wholesome and safe to consume; Policy Interpretation and Implementation-2) If the food or beverage items require refrigeration or freezer storage, the item must be stored in an appropriate area and bear the following information: Open date and 4) Any and all stored food and beverages found to be left unattended or without proper labeling, dating and storage requirements will be discarded. Observation of the initial kitchen tour with the Accounts Manager/Food Service Director on 4/22/2024 at 6:33 am revealed opened and undated mozzarella cheese and egg salad. (Photographic evidence submitted) Interview with the Accounts Manager/Food Service Director on 4/22/2024 at 6:34 AM. She stated, The items should be dated when opened. If they are not dated, they should not be in here. 2) Record review of the Food Storage Policy and Procedure (written date November 2017); Policy Statement-Food storage areas shall be maintained in a clean, safe and sanitary manner; Policy Interpretation and Implementation-3) Cold foods shall be maintained at temperatures of 41 degrees or below; 4) There is an accurate thermometer in each refrigerator and freezers used for perishable foods and 8) The Dietary Manager or designee will check refrigerators and freezers daily for proper temperatures. Observation of the milk box with the Accounts Manager/Food Service Director on 4/22/2024 at 6:37 am showed no thermometer on the inside of the milk box. The Milk box contained cartons of milk. Interview with the Accounts Manager/Food Service Director on 4/22/2024 at 6:38 am. She stated, There should be a thermometer in here. I will put another one in here. Record review of the Milk Box Refrigerator Temperature Log for the month of April 2024 documented on April 22, 2024 the temperature was 34 degrees F (Fahrenheit) for the AM (morning). 3) Observation of the dish machine hood ventilation system with the Accounts Manager/Food Service Director on 4/23/2024 at 9:42 AM was rust laden. (Photographic evidence submitted). Interview with the Accounts Manager/Food Service Director on 4/23/2024 at 9:43 AM. She stated, The vent should be cleaned every day. We were cited last year for this. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 10 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 Observation with the Corporate Regional Nurse Consultant on 4/23/2024 at 10:45 AM of the dish machine hood ventilation system was cleaned but still contained rust. (Photographic evidence submitted). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 11 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and interview, the facility failed to ensure an effective Quality Assessment and Assurance (QAA) committee/ Quality Assurance/Performance Improvement (QAPI) as evidenced by not implementing corrective plans of action for correcting repeated deficiencies related to labelling and storage of drugs and biologicals, sanitary food handling and infection control and sanitary food handling. Cross reference F761 Label/Store Drugs & Biologicals; Cross reference of F880 for Infection Prevention and Control and F812 for Sanitary Food Handling and Cross reference of F880 for Infection Prevention and Control and F867 QAPI/QAA. These repeated deficient practices have the potential to increase the risk of negative resident outcomes. There were 142 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during the last recertification survey with exit dated 12/15/2022, F761 Label/Store Drugs & Biologicals, F812- Food Procurement, store/ prepare/serve-Sanitary, F880-Infection Prevention and Control and F867 QAPI/QAA were cited. During an interview on 04/24/2024 at 1:11 PM, the Administrator reported the committee meets monthly and consist of the Director of nursing (DON), Medical Director, Assistant Director of Nursing (ADON), Infection Preventionist/Staff Developer, Director of Social Services, admission Coordinator, Food Service Manager, MDS coordinator, Medical Records, Human Resources Director, Activities Director, Plant Ops Director, Environmental Supervisor, Central Supply, Staffing and Pharmacy Consultant. The Administrator stated: We have Performance Improvement Plans (PIPs) for Fall. Decreasing the falls, implementing fall decrease. Make sure that there is one-on-one staff for residents who hare on a high-risk fall. This started in March and is on-going. The falls have decreased, but we will be working at least for the next three months. Review of the facility's Policies and Procedures dated March 1, 2024: Policy Statement: our center's written QAPI plan provides needed guidance for our overall quality improvement program which coincides with our vision and mission statements. Our QAPI plan includes the policies and procedures used to: Identify and use date to monitor our performance. Establish goals and thresholds for our performance measurement. Utilize resident, staff, and family input. Identify and prioritize problems and opportunities for improvement. Systematically analyzed underlying causes of systematic problems and adverse events. Develop corrective action of performance improvement activities. Current Quality Assessment and Assurance Activities. The QAA committee will review data from areas the Center believes it needs to monitor on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality. How our center will conduct performance improvement projects (PIPs). Our Center will conduct Performance Improvement Projects that are designed to take a systematic approach to revise and improve care or service in areas that we identify as needing attention. We will conduct PIPs that will lead to changes and guide corrective action in our systems, which cross multiple departments, and have an impact on the quality of life and quality of care for residents living in our community. We will conduct PIPs that will improve care and service delivery, increase efficiency, lead to improve staff and resident outcomes, and lead to greater staff, resident, and family satisfaction. An important aspect of our PIPs is a plan to determine the effectiveness of our performance improvement activities and whenever the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 12 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 improvement is sustained. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 13 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 observation and interview facility failed to properly dispose biohazard material for one resident (Resident#74) out of seven sampled residents as evidenced by an observation of staff placing biohazard bag in bin with white lid, after a wound care observation for R#74. There were 142 residents residing in the facility at the time of the survey. Residents Affected - Some The Findings Included: On 4/24/2024 at 10:57 AM After a wound care observation of R#74, Staff D, Certified Nursing Assistant, (CNA) entered The Soiled Utility room and disposed of the biohazard trash bag into a bin with a white lid. (see photo evidence) On 4/24/2023 at 10:58 AM Staff D, CNA When asked where biohazard bag was placed, stated I placed the biohazard bag into the bin with the white lid bin. Stated I am supposed to put in into the bin labeled biohazard box. Stated I placed into the other bin because I didn't see the biohazard bin because I am nervous. On 4/24/2024 at 11:00 AM Staff D, CNA removed biohazard bag from bin with white lid and plaed into carton labeled Biohazard. On 4/25/2024 at 12:01 PM The Director of Nursing (DON) stated any materials that contain blood or body fluids are to be placed inside a biohazard bag for disposal. Stated the biohazard bag is to be then placed into the box labeled Biohazard, located inside The Soiled Utility room in. Stated I have provided staff with education regarding proper disposal of biohazard materials. Stated the purpose of this practice is to protect staff and residents from infection because if the biohazard bag is placed into the incorrect bin it can potentially cause cross contamination. Policy and Procedure entitled, Waste Disposal dated 10/2019. Policy All infectious and regulated waste shall be handled in a safe and appropiate manner. Policy Interpretation ad Implementation. 1. All infectious and regulated waste awaiting disposal shall be placedd in a closable leak- proof containers or bags that are color-coded or labeled as described. It shall be the responsibility of the Infection Preventionist in conjunction with the environmental services director to ensure that waste is properly disposed of and the following rules are observed: Disposal of all infectious and regulated waste shall be in accordance with applicable federal, state, and local regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 14 of 15 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 105550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Gardens Rehabilitation and Nursing Cente 1990 S Canal Drive Homestead, FL 33035 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to ensure the high temperature dish machine for the wash cycle and the final rinse cycle was working properly. This has the potential to affect one-hundred and thirty-two out of one-hundred and forty-two residents who eat orally residing in the facility at the time of the survey. Residents Affected - Some The findings included: Record review of the Dish Machine Temperatures Policy and Procedure (written date November 2017); Policy Statement-Temperatures will be recorded daily in all Dish machine units that are utilized in the dietary department; Policy Interpretation and Implementation-1) A log will be maintained for all Dish machine equipment daily. Temperatures for wash cycle, rinse cycle will be recorded daily as assigned by the dietary department supervisor; 3) If wash temperatures are noted to be outside the safe zone of 160 degrees Fahrenheit (High Temperature Machine), the dietary supervisor must be immediately notified and 5) Rinse Cycle must reach 180 degrees Fahrenheit for (High Temperature Machine). Notify Dietary Supervisor if temperatures do not meet threshold. Observation of the high temperature dish machine on 4/23/2024 at 9:37 AM with Staff A, Dietary Aide and the Accounts Manager/Food Service Director revealed wash dial was at 150 degrees F and the final rinse dial was at 174 degrees F. Staff A, Dietary Aide placed several more trays with cups and dishes to be washed through the dish machine and the wash dial and the final rinse dial did not move, it stayed at 150 degrees F for the wash and the final rinse dial was at 174 degrees F. Several more cycles were conducted and the wash dial stayed at 150 degrees F and the final rinse dial was at 174 degrees F. (Photographic evidence submitted) Interview with the Accounts Manager/Food Service Director on 04/23/2024 09:38 AM. She stated, The dish machine was ran earlier at 9:00 AM and the dish machine log says for breakfast the wash was 155 and the rinse was 191. She revealed the wash temperature should be at 150 and the final rinse at 180. The Accounts Manager/Food Service Director immediately stopped the dish machine and called the service tech company to come to the facility and service the dish machine. Record review of the Dish Machine Log for the month of April 2024 documented on April 23, 2024 the wash temperature was 155 degrees F and the final rinse was 191 degrees F for breakfast. Interview with Staff A, Dietary Aide on 4/23/2024 at 9:39 AM. He stated, The dish machines final rinse temperature should be 180 and the wash should be 155-160. Observation of the high temperature dish machine on 4/23/2024 at 11:37 AM revealed the dish machine technician servicing the dish machine. Interview with the Regional Maintenance Director on 4/23/2024 at 11:38 AM. He stated, There was a knife stuck in the dish machine drain and now it is working. The dish machine is now at the proper temperature. Review of the Dish machine Repair Company Invoice dated 4/23/2024 documented the following: After troubleshooting, I found fork clogged inside drain pipe causing water to leak and temperature to be low. The fork was removed and a new temperature gauge was installed. New vacuum break has also been installed. At this moment machine is reaching proper temperature and functioning 100% properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105550 If continuation sheet Page 15 of 15