Health inspection·September 18, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interventions to reduce fall risk. Monitor clinical concerns that may contribute to poor safety awareness such as: UTI (Urinary Tract Infections), hydration, medications, acute anemia, physical limitation and coping methods. Evaluate the effectiveness and continual need for safety equipment on a quarterly basis and/or as condition changes. Staff to anticipate and prioritize needs: reduce time in room alone, encourage activities, one of the last residents put to bed, reduce naps in daytime hours, personal items within reach, call light within reach, report poor sleeping patterns, etc. Follow code star protocol, keep floor clean, dry and free of debris: encourage use of non-skid soles and use of appropriate device with assistance for ambulation and transfers. Keep call light within reach and remind resident not to get up unassisted. Resident #4Observation on 09/18/2025 at 9:25 AM of Resident #4's morning care provided by Certified Nursing Assistants Staff C and D and revealed the resident was confused at times and communicated in English and Spanish at the same time.Record review of Resident #4's clinical records revealed the resident was initially admitted on [DATE] and readmitted [DATE]; clinical diagnoses included but not limited to: Alzheimer's disease, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, Review of Resident # 4 Care Plans indicated:PROBLEM:- Review dated 05/25/2022 [Resident #4] has the potential for falls related to decreased safety awareness, use of psychotropic medications, impaired mobility. Dx (diagnoses)includes anxiety, Alzheimer's, and dementia.Resident # 4's Care Plan Problems remained the same from 08/18/2022 to 01/31/2023.On 03/02/2023 Update: late entry for 2/21/2023- Resident observed on floor in room. See nurses' notes. No apparent injuries noted at the time. Neuro checks started. She continues to be monitored.Record review revealed no changes on Resident #4's Care Plans' section for Problem from 03/2023 until the Quarterly Review dated 09/04/2025 noting: Resident is not on psychotropic meds at this time. GOAL:-Injuries related to falls will be minimizedwith daily intervention, re-directing andthe use of assistive devices during thenext 90 days.Estimated Date: 12/05/2025 INTERVENTIONS:- Evaluate as needed by rehab and nursing for safety equipmentand interventions to reduce fall risk.-Monitor clinical concerns that may contribute to poor safetyawareness such as: UTI, hydration, medications, acute anemia, physical limitationand coping methods.-Evaluate the effectiveness and continual need for safetyequipment on a quarterly basis and/or as condition changes-Staff to anticipate and prioritize needs: reduce time in room alone,encourage activities, one of the last residents put to bed, reduce naps in daytimehours, personal items within reach, call light within reach, report poor sleepingpatterns, etc.-Follow code star protocol.-Keep floor clean, dry and free of debris: encourage use of non-skid soles and use of appropriate device with assistance for ambulation and transfers*Keep call light within reach and remind resident not to get up unassisted.-1/4 side rails up as needed to assist with positioning and personal care tasks.-Monitor at least q2-3 (every 2 to 3) hours and PRN (as needed) when in room for safety andcomfort.-Maintain low bedMonitor psychotropic drug use for side effects related to falls such as over sedation, hypotension, increased restlessness and notify MD of abnormalFalling Star Program per facility protocolINTERVENTION: 5/8/2023-Bilateral floor mats when in bed as ordered Interview on 09/18/2025 at 3:02 PM, the Care Plan Coordinator was asked what interventions were implemented for Resident # 1 after the fall on 02/14/2024 and 3/14/2025 she stated: I don't know what interventions were implemented and I need to check with [Risk Manager]; the Care Plan Coordinator left the room and returned at 3:34 PM. The Care Plan Coordinator stated that the goals and interventions in care plans for residents at risk of falls are centered around the residents. Although the goals and interventions may be similar and include regular evaluations and monitoring .On 09/19/2025 at 3:36 PM, the Care Plan Coordinator, Director of Nursing, and Risk Manager informed staff about the identified concerns related to the lack of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 2 of 6 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 09/18/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm individualized care plans. Interview on 09/18/2025 at 4:54 PM Resident # 1's Physician was asked what interventions were expected after Resident #1's fall that occurred on 2/14/2024 with no interventions implemented until the fall that occurred on 08/25/2025; he stated: After the first fall she should have had fall precaution such as the floor mats and low bed in place to prevent fall with injuries even though she was bedbound. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 3 of 6 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 09/18/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations records reviewed and interviews, the facility failed to provide adequate supervision and safety measures for two (Resident #1 and Resident #4) out of four sampled residents as evidence by Resident #1 has severe cognitive impairment experienced a fall out of bed due to lack of supervision during personal care, resulting in a head injury. 2)During Resident #4's personal care, staff failed to use fall prevention devices properly, leaving the resident at risk of falling. There were 186 residents residing in the facility at the time of the survey. The findings include:Review of the facility's organization's policy titled, Accident Hazards/Supervision/Devices revised February 2025 documented: Policy Statement: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1) Identifying hazards and risks, 2) Evaluating and analyzing hazards and risks, 3) Implementing interventions to reduce hazards and risks and 4) Monitoring effectiveness and modifying interventions. Resident #1On 09/18/2025 at 9:19 AM and 11:15 AM Resident #1 was observed in bed with eyes closed. Bed in lowest position and bilateral safety mats on floor.Review of resident #1's clinical records revealed an initial admission dated 6/26/2023 and readmitted on [DATE] (resident was hospitalized from [DATE] to 8/30/2025). Clinical diagnoses include but not limited to Dementia, Pressure-induced deep tissue damage of right heel and Constipation, unspecified.Review of Resident #1's Physician Order (POS) for August to September 2025 included but not limited to Eliquis 2.5 mg (milligrams) 1 tablet BID (twice daily) ASA (aspirin) 81 mg QD (daily) and Lactulose 10gm/15 ml (10 milligrams per 15 milliliters) -20gm/30ml QD for constipation.Review of nurse's notes dated 8/27/2025 timestamped 01:02:04 incident dated 08/25/2025time of incident: 03:50 incident type-Fall: CNA reported while providing morning care, patient rolled over the bed and fell, striking the back of the head large hematoma to the occipital area noted. Large amount of blood noted. CNA remain at the bedside throughout the event. Patient remained alert able to speak to staff and 911 no s/s of distress noted or loss of consciousness observed patient was transferred to [NAME] south via 911Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] cognitive Section's Brief Interview for Mental Status (BIMS) documented a score of 00 on a scale of 0 to 15, which indicates severe cognitive impairment.Review of Resident #1's Care Plan dated 08/03/2025 Quarterly Review updated 08/26/2025 documented: On 8/25/2025-Resident noted with fall from bed, hematoma noted to occipital area. Neuro checks initiated. Transferred to hospital for further evaluation. Interventions added on 9/12/2025 indicated: Bilateral bed wedges when in bed as ordered and an intervention added on 9/16/2025 indicated Bilateral floor mats when in bed as ordered. Review of Resident #1's hospital records documented: pt (patient) brought by [local rescue] for fall or rollover from St [NAME] Nsg. (Nursing) Home today about 30 minutes ago, pt has hx. (history) of dementia. It was noticed on arrival that pt was on blood thinners Eliquis once she was in the ED (Emergency Department) room. Code resuscitation called on arrival after pt was bedded. (Emergency Services) asked St [NAME]'s staff multiple times if she was on anticoagulants. Staff at St [NAME]'s told them no but once she arrived at ED it was on her med rec. Pt arrived with scalp laceration and bleeding. General: .Scalp: puncture woundCT (Computerized Tomography) Brain:1. No acute intracranial hemorrhage, midline shift, or mass effect.2. There is a right posterior parietal laceration, contusion and hematoma.Discharge Patient, 08/30/2025 06:27:00 EDT (Eastern Daylight Time), Fall I Syncope I Atrial fibrillation I GIB (gastrointestinal bleeding).Interview on 09/08/2025 at 2:41PM The Risk Manager revealed Resident #1's first fall in the facility happened in 2024 and no staff was involved. The second fall occurred on 08/25/2025, the resident rolled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 4 of 6 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 09/18/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from the bed when the CNA (Certified Nursing Assistant) went to change gloves, the resident fell from the bed, the fall was just a normal hematoma. The CNA was working alone, it depends on the patient, then they work in pairs. At that time the resident did not have wedges on the side of the bed and the CNA said she had her in the middle of the bed. On average each CNA is assigned 10-12 patients at night (11:00PM to 7:00AM shift) and they work in pairs. The resident was in the hospital for a little over a week. When asked if the fall could have been prevented; the Risk Manager stated: She (Resident #1) is not a very active maybe the fall could not have been prevented. The Risk Manager revealed the incident was reported as an adverse incident and not negligence.Interview on 09/08/2025 at 2:29 PM the Assistant Director of Nursing (ADON) revealed: As far as I know the CNA was providing care and turned around to change gloves and the resident fell of the bed. The staff had the bed at required level. I was not here so I only went by what the staff said and from the reports.Telephone Interview on 09/08/2025 at 4:01 PM, Staff B, Licensed Practical Nurse (LPN) stated: Around 3:00 in the morning on a Monday morning I was charting at the nursing station and around 4:00 AM the CNA was giving care and she ran to the nursing station the CNA was shaking she said she was giving care the patient had a large BM (Bowel Movement) when I went to the room the sheet everything was full of BM; the patient was on the floor and I called my supervisor. I tried to reach the family.and made several calls. We sent her to the hospital and the son called back and we told him what happened [Resident #1] was talking to everybody. I did not see what happened.the room and in the hallway was smelling bad. The only thing I saw was the patient on the floor.On 09/18/2025 at 4:06 PM, telephone interview with Staff A,CNA assigned to Resident #1 on the night of the incident stated: During patient care I had everything set up with me she had a large stool, it got on the sheet and was all over and it got on my gloves and I turn and took off the gloves and throw it in the garbage to put on new gloves while I was putting on the new gloves she was on her side and she fell off the bed; I go towards her on the other side of the bed and asked if she was ok and she said yes. I immediately went to get the nurse and told her the patient fell, and she pretty much took care of her I did see a little bit of blood on the floor. It was revealed that Staff A started working in the facility in June 2025 and had only been a CNA for a few months and after training for seven (7) days she worked alone. Staff A stated: It is hard to work in pairs because sometimes I have 15 to 20 residents to care for by myself.During telephone interview on 09/18/2025 at 4:54 PM, Resident # 1's Physician was asked about the incident involving Resident # 1's fall with injury and expectation as far as the required interventions for a resident such as Resident # 1 who had fallen before; the doctor stated: They called me, and I sent her to the hospital for CT scan. Normally after the first fall the interventions include the bed to be placed in the lowest position and floor mats, no order is needed, this is the standard protocol; they do not need to call me. After the first fall and patients at risk for fall, including bedbound, should have floor mats including bed in lowest position to prevent another fall that could cause injury. The doctor was asked about Resident #1's fall that occurred on 2/14/2024 that documented: The resident was observed after the fall with skin tear to the right hip; and no interventions were implemented until the fall that occurred on 08/25/2025. He stated: After the first fall she should have fall precaution such as the floor mats and low bed in place to prevent fall with injuries even though she was bedbound.During an interview on 09/18/2025 at 5:09 PM with the Nursing Home Administrator, Director of Nursing and the Risk Manager, the identified concerns were discussed including the staffing schedule on the night Resident # 1 fell and sustained injuries. The DON revealed, from the first fall Resident #1 should have floor mats and a physician's order is needed for floor mats and from a professional standard it would be considered as a gap in communication. Root Cause (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 5 of 6 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 09/18/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Analysis (RCA) has not made recommendations, but we could have a standing order for everyone that falls. The DON revealed the fall was unavoidable. When asked why the incident was not reported as neglect, the DON indicated the incident was not intentional and neglect would be considered as being intentional. The Risk Manager revealed on the night Resident # 1 fell and was injured each CNA had 14 residents to care for. Resident #4Observation on 09/18/2025 at 9:25 AM of Resident #4's morning care provided by Certified Nursing Assistants Staff C and D revealed Staff D left the room to get a pair of socks for the resident while Staff C continued providing care. At 10:22AM Staff C, went to the left side of the bed leaving the right side padding/wedge used for fall prevention down, the resident was noted laying on the bed closer to the edge Staff C, returned to the right side of the bed and provided care; then at 10:28 AM Staff C, went to the right side of the bed leaving the left side padding/wedge down.Record review of Resident #4 clinical records revealed the resident was initially admitted [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Alzheimer's disease, Chronic obstructive pulmonary disease, Unspecified atrial fibrillation and Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene.Review of Resident #4's Physician Orders Sheet for September 2025 documented orders that include: Tradjenta (linagliptin) S mg (milligrams) 1 tablet/ 5mg) by mouth daily for Diabetes; [Eliquis]Apixaban 2.S mg 1 tablet 12.5 mg by mouth twice a day for Atrial Fibrillation.Care Plan Goal indicated Injuries related to falls will be minimized with daily intervention, re-directing and the use of assistive devices during the next 90 days. Estimated Date: 12/05/2025.Interview on 09/18/2025 at 2:12 PM Staff C, Certified Nursing Assistant, revealed she started working in the facility August of 2024. I am supposed to put the side up when I am not at the side, but I forgot, and I was nervous. The resident should be in the middle of the bed when I position the resident. On 09/18/2025 at 2:21 PM RN, Unit Manager, was informed of the identified concerns during Resident #4's morning care the unit manager acknowledged the concern and indicated the staff should not have left the side wedge down while on the opposite side of the bed and for bed mobility the resident should be in the middle of the bed and if help is needed call for help. Event ID: Facility ID: 105560 If continuation sheet Page 6 of 6