Inspection·November 9, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to place it in the book. The maintenance department can fix it. We also can make adaptations like a full rest to the wheelchair for rehabilitation. I'm going to fix the wheelchair now for Resident #88. On 11/09/23 at 12:27 PM, in an interview with Staff E, LPN (Licensed Practical Nurse). When asked, How is Resident's #88s mobility in the wheelchair and were you aware or told of the arm tray being broken? Staff E stated, Resident #88 is non-ambulatory, uses a wheelchair, and receives assistance in/out of the wheelchair. Resident #88 has left-sided weakness and receives assistance to propel in a wheelchair. The wheelchair has a left armrest tray to assist with left-sided weakness. I am not aware that the armrest tray is broken. No one has informed me the appliance was broken. When there is a broken appliance. I notify the supervisor and maintenance using radio or work hub, which is a computer system where maintenance orders are placed. On 11/09/23 at 12:34 PM, in an interview with Staff C, CNA, When asked, How is Resident's #88 mobility in the wheelchair and were you aware or told about the armrest tray being broken? Staff C stated, Resident #88 needs assistance into the wheelchair. The staff or resident propels the wheelchair. I became aware of the armrest tray being broken three weeks ago. Resident #88 told me that the armrest tray was broken again, and I did not inform any other staff due to maintenance not working that day. Record review of Resident #88 revealed, a medical diagnosis of Hemiplegia (paralysis of one side of the body) and Hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affecting the left arm non-dominant side. Record review of physician orders revealed, occupational therapy evaluation and treatment for wheelchair and positioning dated 03/21/2023. Record review of the minimum data set date(MDS) dated [DATE] revealed, in Section C (cognitive patterns), a brief interview of the mental status score was a 15 on a scale of 0-15 indicating the resident was cognitively intact. In Section GG (Functional Abilities and Goals), the resident needed some help from staff for indoor mobility and transfer, uses a manual wheelchair, requires moderate assistance to wheel 50 feet, and is non-ambulatory. In Section I (Diagnosis), the residents medical diagnoses of Cerebrovascular Accident (stroke), Transient Ischemic Attack (Stroke), Hemiplegia or Hemiparesis. Record review of the care plan dated 2/24/2023 revealed, Resident #88 had a mobility deficit as evidenced by decreased balance endurance safety awareness strength and requires maximum assistance with bed mobility, maximum assistance with transfers, and total assistance with wheelchair mobility. Interventions were to assist in transfers to and from bed, toilet, and chair observing safety measures. Maintain safety precautions. Encourage the resident to participate in bed mobility and praise efforts. Review of the facility's policy titled, Patient equipment/ bed repairs. Effective 4/1/2019. Last reviewed 8/14/23. The policy states the engineering department intends to place all patient-related equipment back in service as soon as possible. If the equipment is classified as clinical equipment, proper documentation will be provided to the biomedical department for their equipment history. In the section titled Procedure, 1. Upon either being notified or discovering that a patient's bed is inoperative, the bed, if there is no patient involved, will be transported to a maintenance shop for needed repairs or if possible fixed in the room. A. a repairs/service request describing the repairs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 2 of 5 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 105560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Annes Nursing Center, St Annes Residence Inc 11855 Quail Roost Drive Miami, FL 33177 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 0584 to be done will be generated. Documentation of corrective repairs and equipment repair history will be maintained in the engineering department. 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: 105560 If continuation sheet Page 3 of 5 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 105560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Annes Nursing Center, St Annes Residence Inc 11855 Quail Roost Drive Miami, FL 33177 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement infection control procedures for one (Resident #430) out of 35 sampled residents. As evidenced by Respiratory equipment (Nebulizer and tubing) stored uncovered on bedside table next to a live plant. There were 191 residents residing in the facility at the time of the survey. Residents Affected - Few The Findings Included: During Observation on 11/06/23 at 09:45 AM, Resident #430 was sitting on the side of the bed in the residents room, the Oxygen (02) running at 2 Liters per minute (LPM) via Nasal canula (NC), Resident #430 stated he is waiting on his extra food. The nebulizer mask was stored on the residents bedside table uncovered next to a live plant (Photo Obtained). The 02-tubing with water dated 10/30/23 was stored in bag hanging from the wall. (Photo Obtained) During Observation on 11/07/23 at 09:24 AMm Resident #430 was in the wheelchair in the residents room eating breakfast. The 02 was running at 3lpm via NC, the nebulizer mask was on bedside table uncovered next to a live plant. (Photo Obtained). On 11/08/23 08:17 AM Resident#430 observed in bed awake, 02 running at 3 LPM via NC, nebulizer mask stored on bedside table uncovered next to live plant (photo). Review of the medical records for Resident #430 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but werenot limited to: Cough, Unspecified. Review of the Physician's Orders Sheet for November 2023 revealed, Resident #430 had orders that included but were not limited to: Oxygen (O2) at 2-4 liters /minute (LPM) via NC continuously for shortness of breath, Albuterol Sulfate 0.083% nebulization solution dose. (2.5mg/3ml) inhalation via nebulizer every 4 hours as needed for coughing and wheezing and Atrovent 0.02% solution-give 2.5ml via nebulizer every 4 hours as needed for cough and wheezing. Record review of Resident #430's Electronic Medication Administration Record (EMAR) revealed, the resident did not receive nebulizer treatments for the last 7 days (11/2/23-11/9/23). Record review of Resident #430 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score of 15, on a 0-15 scale indicating the resident is cognitively intact. Section GG for Functional Abilities and Goals documented supervision for oral hygiene and eating, Partial assistance for personal hygiene and upper body dressing, Dependent for lower body dressing. Section J for Health Conditions documented shortness of breath or trouble breathing with exertion and when sitting at rest and Section O for special Treatments and Procedures documented resident received oxygen therapy and hospice care in the last 14 days while a resident. Record Review of Resident # 430's Care Plans Reference Date 08/31/23 revealed, the resident has the potential for Shortness of breath, alteration in respiratory status due to impaired mobility, end stage heart failure, and wheezing. Interventions include-Administer oxygen and nebulizer treatments as ordered. Document as needed use and effectiveness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 4 of 5 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 105560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Annes Nursing Center, St Annes Residence Inc 11855 Quail Roost Drive Miami, FL 33177 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/08/23 at 08:22 AM, Registered Nurse, D/E wing (Staff A) stated, I have been working here for 6 years, when I do my rounds, I check every room and resident assigned, make sure anything the resident has/needs are in place. The nurses do the respiratory treatment for the residents assigned, we change the mask once a week and if needed or if the mask is soiled. When the mask is not is used, the mask is stored in the dated bag on the wall for tubing supplies. If the mask is found on the floor or exposed, we will replace the mask. Interview on 11/08/23 at 08:39 AM, Registered Nurse, G wing (Staff B) stated, I have been working here for almost 1 year, I work all over the facility, I really do not have a specific assignment. During rounds and constantly during the shift we check on the residents to make sure the safety precautions are in place. The nurses do the respiratory treatments for the residents, once a week or as needed we change the respiratory supplies, after we do the nebulizer treatments, we clean the mask and store the nebulizer mask and tubing in the plastic bag on the wall that is dated until next use. Interview on 11/09/23 at 09:15 AM, the Assistant Director of Nursing (ADON) stated, I have been the ADON since last December 2022, the nurses have been educated to change the oxygen tubing once a week and as needed, the nebulizer mask and tubing are to be stored in the clear bag provided that is dated, when not in use. During rounds and throughout their shift the nurses are educated to check on the residents and make sure all fall, and safety precautions are in place, all respiratory equipment is stored correctly and to make sure that the residents are in no discomfort. Review of the facility's policy titled, Infection Control-Nursing revision date 8/22/2022 states-Nursing Staff are responsible for functions essential to the prevention, recognition, and management of infections. Prevention of infection is the main goal of the staff. This is accomplished by practicing good aseptic techniques, observing infection control policies and procedures, and recognizing the potential risks associated with invasive procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 5 of 5