Inspection·July 28, 2022

F 0604 get up. Level of Harm - Minimal harm or potential for actual harm Record review of the demographic face sheet revealed Resident #11 was admitted to the facility on [DATE] with multiple diagnosis including Fractured Femur, Dysphagia, Anxiety Disorder, Protein Calorie Malnutrition, Seizures, history of Falls, Insomnia, Schizoaffective Disorder, and Major Depressive Disorder Residents Affected - Few Review of Resident #11's annual minimum data set (MDS) dated [DATE] revealed: Section C for cognitive pattern indicated the resident rarely/never understood, impaired memory, severely impaired decision making. Section D for mood indicators included feeling down, depressed, moving slowly, or being so fidgety or restless or that she has been moving a lot more than usual. Section E Behaviors included physical behaviors, verbal behaviors, and other behaviors not directed towards others. Section G for functional status indicated need for limited to extensive ADL (activities of daily living) assistance. Section for health status indicated J no falls. Section N for mediations included antipsychotic, antidepressant, antianxiety, and hypnotic use. Section O indicated no special treatments and Section P indicated Restraints - not used (not coded for use of trunk restraint in bed or out of bed. No bed alarms, no floor mats, no motion sensor alarms. Review of Resident #11's care plan revealed: Implemented 5/18/21, revised 6/17/22 Resident has limited physical mobility related to poor balance and coordination, unsteady gait, dementia progression, continuously bending forward when in wheelchairs. Intervention included: Velcro ® safety belt when in wheelchair to promote independent wheelchair mobility and to maintain upright seating position when in wheelchair (6/17/22) Implemented 5/18/20, revised 5/19/22. Resident has an ADL self-care performance deficit related to disease process, need assistance for all ADLs. Interventions included: Monitor for any signs or symptoms of decline in function due to use of Velcro safety belt. Implemented 5/18/20, revised 5/19/22. Risk for further falls related to gait /balance problems, history of falls, confusion, poor communication/comprehension, psychoactive drug use. Unaware of safety needs. Interventions included: soft Velcro ® safety belt when in wheelchair to maintain posture and independent wheelchair mobility to prevent falling forward out of chair. Scoop mattress on bed. Review of an initial restraint assessment dated [DATE] revealed the reason for use of the physical restraint was unsteady gait, agitated behavior, frequent falls, sliding out of chair/ wheelchair, attempts to self-transfer. Others: leans forward. Resident continuously leans forward while in wheelchair. She had falls out of chair due to leaning over too far forward. Alternative attempts to reduce risk of harm to resident or others prior to application of restraint: recliner, activities, alternate seating, regular toileting, wedge cushion, therapy. Alternatives did not work; resident continues to lean/bend over when in wheelchair due to cognitive impairment. IDT (interdisciplinary team), doctor and family agreed that a soft Velcro belt will be implemented to allow her to maintain independent wheelchair mobility, to maintain her seating posture in wheelchair to minimize risk of her falling forward in the chair. Review of a quarterly restraint assessment dated [DATE] revealed: Reason for use of physical restraint: agitated behavior, frequent falls, attempts to self-transfer, climbs out of bed. Resident continuously leans forward when in wheelchair. Resident is severely cognitively impaired, unable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 2 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 0604 Level of Harm - Minimal harm or potential for actual harm ambulate or transfer, she has poor safety awareness, poor decision-making skills, and a longstanding history of falls from bed/chair. Alternatives in past quarter: increased restraint free episodes through day, family companion, 1:1 activities, high-low bed, regular toileting, anticipated hunger/pain, med review, blood work/labs, physical and occupational therapy, and Psych consult, None of the interventions were successful. Team recommends Velcro safety belt while in wheelchair. Family agreed with safety belt use. Residents Affected - Few Review of the physician order sheet revealed Resident #11 had an order 8/3/21, discontinued on 2/3/22 and reordered 6/16/22 for a soft Velcro safety belt when in wheelchair to maintain posture and independent wheelchair mobility to prevent falling forward out of char. Review of the informed consent for use of physical restraint dated 8/3/21 revealed: I give my consent that Soft Velcro ® Belt restraint be used for the purpose of maintaining seating posture, maintaining independent wheelchair mobility, minimize risk of falls for (Resident #11). The consent was received via telephone from the responsible party on 8/3/21. Review of the informed consent for use of physical restraint dated 6/16/22 revealed: I give my consent that (blank) restraint be used for the purpose of maintaining seating posture, maintaining independent wheelchair mobility, minimize risk of falling forward out of wheelchair for (Resident # 11). Signed by responsible party 6/16/22. During an interview the Nursing Home Administrator (NHA) on 7/28/22 at 8:07 AM, revealed [Resident # 11] is my cousin. She has no family, and I am her responsible party. She is a handful. She has a lot of energy. She was initially admitted to the assisted living unit from home. She did not last long in assisted living as she started to have a cognitive decline. She was always wandering, and she wanted to go home. She was placed in the skilled unit. For two years to now the declines have been cognitive. She does not recognize me anymore. She grabs at everything; she is very flexible, and you will see her moving her legs up and all over the place. About a year and half ago she fell and fractured her hip. I wanted her to have a belt on because she is always grabbing onto to someone or something and without the belt she is at risk for falls. She has like an abdominal binder on that keeps her seated in the wheelchair. She is unable to release it so that is why it is considered a restraint. She is on medication for that fidgeting and the nervousness. She is good in bed, and she sleeps throughout the night. She does not try to get out of bed. She likes to sleep until around 9 or 10 am. All the incidents are when she is out of bed when she is constantly grabbing at everything. We do keep the bed in the lowest position, and I believe she has the scoop mattress to keep her safe. The bed could be up against the wall to help her not to fall but I do not believe they do this. If so, the other side of the bed is free. She has not had a fall from bed. I am aware that this belt is considered a restraint, but it is only used when she is up to the wheelchair. Interview with a Certified Nursing Assistant (Staff G, translated by Spanish speaking Licensed Practical Nurse (Staff F) on 7/28/22 at 10:11 AM revealed, Resident # 11 has a restraint. We try to speak to her in a way that she can understand but she is very confused. Emotionally she does not repeat anything, but physically she is always moving around and grabbing at everything. One minute she will be here and the next minute she will be grabbing on to the railings. The restraint we put on her is a belt. I do not know the name of the belt, but we put it over her the belly, insert it through slits in the wheelchair and then secure it in the back with the Velcro. She tries to remove pretty much everything, clothing items such as shoes and socks, but she cannot remove the belt. The reason they told me she needs the restraint is she is a fall risk, and she will try to get up. I work the 7-3 shift. [Resident # 11] usually gets up after breakfast, sometimes around 9 or so. Today she is still (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 3 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sleeping. I have never seen any type of bed restraints. We have to constantly keep going into the room. She is okay when sleeping but if she is awake, we have to get her up right away. She can get out of bed, but she is at risk for falls. She can walk but not without assistance. When I come in, I did not notice that the bed is up against the wall. She uses a special mattress and a regular wheelchair. Interview with a Licensed Practical Nurse (Staff H) on 7/28/22 at 1:42 PM revealed Resident # 11 at times becomes a little restless and she will hold on to objects really tight. She is not really aggressive, but she is always moving. She is very confused, and she came ambulate in the wheelchair about the unit. She also disrobes at times. She will try to go into other resident rooms, but she does not try to get out of the exits. She wears a belt due to previous falls; she is constantly trying to reach and tries to bend down. The belt helps assure she does not fall over. She has good flexibility. Sometimes she will cry but mostly she is just restless. The medications help. She takes both Seroquel and Ativan, and we monitor her behaviors and side effects. The only type of restraint device they use is the soft Velcro ® belt. This is the device the staff is supposed to use, and it is ordered by the doctor. The staff are not supposed to be using any other type of restraint. She should not have the vest type with the click belt. I work the 7 am - 3 PM shift. She is in bed when I make my rounds. We have to make sure her bed is low, so she does not get out of bed. We are not supposed to put the bed up against the wall and there should not be furniture against the bed. We cannot block her from getting up. She is able to get out of bed, but she would fall. We get her up to the chair as soon as she wakes up. She sleeps late at times but other days she wakes early so we have to monitor her closely. We all look after her. She is calm today but at times she will pull hard on the arms of the wheelchair and grip the handrails. To calm her down, we will place her near the station, and we will talk to her and hold her hand. Review of the facility policy and procedure titled Physical Restraints revised 8/22/17 revealed: Policy: Residents always have the right to considerate and respectful care and under all circumstances, with recognition of their personal dignity and safety in the least restrictive manner. As needed, the interdisciplinary team will evaluate the resident for the potential need for physical restraint. This restraint must be the least restrictive means available .Monitoring and release of restraints will be done according to any state specific regulation. Procedure: A restraint evaluation will be performed by nursing to assess physical, mental and other contributing factors which indicate the need for a restraint/enabler. The responsible party will sign the consent for the use of a safety device after review of risks/benefits .The nurse will obtain the physician's order for the restraint. This order will include the medical reason for the restraint. Photo evidence submitted FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 4 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 transmit a Minimum Data Set (MDS) assessment timely for one (Resident #1) out of one resident reviewed for timely submissions of resident assessments. Residents Affected - Few The findings included: Record review of the facility's policy titled, MDS (effective date 11/30/2014, revision date 09/25/2017) documented: Policy: The center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and/or state required RAI (Resident Assessment Instrument). Closed record review of the demographic face sheet for Resident #1 documented the resident was admitted on [DATE] with a diagnosis of bilateral osteoarthritis, presence of left artificial knee joint, insomnia and hypertension. The resident was discharged from the facility on 3/25/2022. Review of the Minimum Data Set (MDS) admission Assessment for Resident #1 dated 3/22/22 documented the assessment was completed but not submitted. The MDS record was over 120 days old. Interview with Staff D, Registered Nurse (RN) Corporate MDS on 7/28/22 at 9:45 AM. She stated, There was a batch discharge, it was not transmitted. It is a late transmission. It should have been transmitted in April. It will be transmitted today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 5 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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** 2.) Record review of the list of residents who smoke provided by the facility revealed there are two resident currently residing in the facility who smoke including Resident #13. Residents Affected - Few Interview with Resident #13 on 7/24/22 at 1:41 PM revealed he does smoke, but I only smoke a few cigarettes a day. I mostly go outside for fresh air. Observation on 7/28/22 at 1:08 PM revealed Resident #13 stopping at the reception desk and then proceed outside to the front of the building. Observation at 1:15 PM revealed Resident # 13 in the smoking area smoking a cigarette. Review of the demographic face sheet for Resident #13 revealed he was admitted to the facility on [DATE]. with multiple diagnosis including Hypertension, Rhabdomyolysis, history of falls, Anemia, and hearing loss. Review of the annual MDS dated [DATE] revealed Resident #13's BIMS score was 15 indicating intact cognitive function. Section G for functional status was coded to indicate Resident #13 required only supervision for ADLs (activities of daily living), Section J tobacco use was coded no. Review of Resident #13's care plan dated 8/19/19 and lasted reviewed 5/19/22 revealed: Resident is a smoker. Interview with the MDS Coordinator (Staff C) on 7/27/22 at 4:34 PM revealed review of the MDS indicated Resident # 13 does not use tobacco. His care plan indicates Resident # 13 is a smoker. There is an open smoking screen in his electronic health record (EHR) for May 2022. Maybe he took a break from smoking at the time the MDS was completed. If he was smoking the MDS should have been coded yes for tobacco use. Review of the EHR on 7/28/22 revealed a modification of the annual MDS from 5/10/22 that was completed on 7/27/22 at 5:29 PM. The modified MDS indicated Resident # 13 uses tobacco. Interview with the MDS Coordinator (Staff C) on 7/28/22 at 2:16 PM revealed, based on the conversation we had yesterday I went into the system and modified the MDS and coded it to indicate Resident #13 uses tobacco. Based on observation, record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for two (Resident #19 and Resident #13) out of two residents reviewed for resident assessments. 1.) Resident #19 was not coded for hearing impaired. This has the potential to affect two hearing impaired residents residing in the facility at the time of this survey. The resident was not included on the list for residents identified to have hearing impairment. 2.) Resident #13's MDS was not coded for tobacco use. This has the potential to affect two residents in the facility who were included on the smoking list. There were 99 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's policy titled, MDS (effective date 11/30/2014, revision date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 6 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 09/25/2017) documented: Policy: The center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and/or state required RAI (Resident Assessment Instrument). 1) An initial observation and interview with Resident #19 was conducted on 7/24/22 at 11:05 AM. The resident was sitting in a wheelchair in her room, clean and well groomed. She revealed, I am very hard of hearing. I need to get a hearing aid. I missed an appointment when I was in the hospital but they have not said anything about rescheduling. The resident was having difficulty hearing questions during the interview. Second observation of Resident #19 was conducted on 7/26/22 at 11:45 AM. The resident was sitting in a wheelchair in her room, close in front of the television with the volume turned up loud, wearing eyeglasses. No hearing aid was noted. Record review of the demographic face sheet for Resident #19 documented the resident was admitted on [DATE] with a diagnosis of end stage renal disease, dependence on renal dialysis, diabetes mellitus, chronic congestive heart failure and hypertension. The resident was discharged to the hospital on 2/23/22. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #19 dated 5/12/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 15 out of 15 indicating no cognitive impairment and the resident was able to make her needs known. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and hearing was coded as adequate and no hearing aid was noted. Review of the local hospital final report dated 2/23/22 for Resident #19 noted the hospital course documented the resident was hearing impaired. Interview with Staff C, a Licensed Practical Nurse (LPN) MDS on 7/28/22 at 9:50 AM. She stated, At the time of the interview for MDS, there was no problem with her hearing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 7 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 1.) failed to submit a request to the state mental health authority for a Level II Pre-admission Screening and Resident Review (PASRR) for one (Resident #11) whose diagnosis included Schizophrenia and Psychosis when the resident remained in the facility past the 30 day provisional admission period, 2.) failed to ensure a Level I PASRR was on file in the hybrid clinical record for one (Resident #51) and 3.) failed to ensure the Level I PASRR was accurate; therefore, not requesting a Level II screening for one (Resident #53) of three residents reviewed for PASRR. This has the potential to affect 99 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: 1.) On 7/24/22 at 12:37 PM, Resident # 11 was observed in the hallway sitting in a wheelchair wandering aimlessly on the hallway. On 7/24/22 at 2:01 PM she was observed attempting to bend down to touch the floor. She had removed her shoes and socks. She was moving constantly, bending up and down from an upright position to touching the floor. Resident # 11 appeared very agitated. Record review of the demographic face sheet revealed Resident #11 was admitted to the facility on [DATE] with multiple diagnosis including Anxiety Disorder, Insomnia, Schizoaffective Disorder and Major Depressive Disorder. Review of Resident #11's annual minimum data set (MDS) dated [DATE] Section A 1500 PASRR Is resident currently considered by the state level II PASRR process to have serious mental illness and or ID or related condition: No. Section C for cognitive status indicated the resident rarely/never understood, impaired memory, severely impaired decision making. Section D mood indicators included feeling down, depressed, moving slowly, or being so fidgety or restless or that she has been moving a lot more than usual. Section E Behaviors included physical behaviors, verbal behaviors, and other behaviors not directed towards others. Section I Active diagnosis included Anxiety Disorder, Schizophrenia, and Insomnia. Section N medications included antipsychotic, antidepressant, antianxiety, and hypnotic use. Review of Resident #11's care plans revealed: Resident has been observed with behavioral distress as evidenced by disrobing possibly related to impaired cognition, resident is verbally and physically aggressive toward staff and showing her fist to staff related to ineffective coping skills, poor impulse controls and low frustration tolerance, continuously disrobing in public, resident has impaired cognitive function , short / long term memory loss and poor decision making skills, resident has periods of anxiety, restlessness, screaming spells, evidenced by poor impulse control and low frustration tolerance, resident is on sedative/hypnotic therapy related to insomnia, resident uses anti-anxiety medications related to anxiety disorder, and resident uses antidepressant medication related to depression. Review of the physician's order sheet (POS) reveals Resident #11's medication include Ativan 2 mg (milligrams) daily at bedtime for Anxiety and 1 mg twice daily for Anxiety, Sertraline 100 mg daily for Depression, Seroquel 50 mg twice daily for Psychosis, and Restoril 15 mg capsule at bedtime for Insomnia. Review of Resident #11 Level I PASRR dated 5/14/20 Section I MI (Mental Illness) or suspected MI: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 8 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 Level of Harm - Minimal harm or potential for actual harm Other: Psychosis. Currently receiving services for MI. Findings based on documented history, medications. Section II other indicators checked Yes for Psychiatric treatment more intensive than outpatient. Section III Exemption included provisional admission. Resident may be admitted to a nursing facility as provisional admission. PASRR level II not requested. Reason checked: provisional admission. Residents Affected - Few Resident # 11 remains in the facility - no PASRR level 2 on file. Review of psychiatric consults dated 3/10/21 revealed Resident #11 is alert and oriented x 1, communicative, cognitive impairment evident, delusion present. History of mental illness. Behaviors: impulse behaviors continue. Diagnosis: Generalized Anxiety Disorder, Alzheimer's Disease with late onset, Schizophrenia, unspecified. Review of a Psychiatric progress note dated 12/21/21 revealed Patient seen today for follow up treatment. I spoke to the nursing staff and reviewed medical charts. She has been very anxious; she has been from one side to another one in her wheelchair. As per nurses she has been like that all the time. She has been working on talking interrupting other's activity. Patient alert but disoriented to person, time, place and situation. Affect is flat and her mood is anxious. Unable to assess through process and though content due to patient will be given impairment. Unable to assess suicidal or homicidal ideation due to impaired mental status. Patient's insight and judgment are poor. Review of a psychiatric progress note dated 4/13/22 revealed Patient seen today for follow up treatment. I spoke to the nursing staff and reviewed medical charts. As per nursing, she has been agitated, anxious, trying to take out her growth. She does have a severe cognitive impairment. Patient looks anxious, in her wheelchair going from one side to another constantly. Patient alert but disoriented to person, time, place and situation. Speech is clear her voice is normal rate volume; Affect is flat, and her mood is indifferent. Unable to assess through process and though content due to patient will be given impairment. Unable to assess suicidal or homicidal ideation due to impaired mental status. Patient's insight and judgment are poor. Review of a psychiatric progress note dated 5/23/22 revealed Patient seen for follow up treatment. Spoke to nursing staff and reviewed medical charts. She has been stable on medications. No signs and symptoms/ of anxiety or depression or agitation was seen on her part reported by nurses. Patient is alert but disoriented to person, place time and situation. Her speech is clear her voice is normal in volume and rate. Affect is congruent with her euthymic mood. Thought process and thought content unable to assess due to cognitive judgment. Insight and judgement are poor. Interview with the Director of Social Services (DSS) on 7/28/22 at 12:02 PM revealed, we require that all residents come with a PASRR on admission. When I do my assessment, I check to make sure the PASRR is in the record, and I check to make sure all the diagnosis are listed. If I find that the PASRR is not correct, I will give it to nursing to complete a new PASRR. The nurses have access to (state mental health authority) website and they will correct the PASRR. If a resident needs a Level II, I fax documentation required for completion of the level II to (state mental health authority) to include the Level I, MDS, all progress notes, physician orders, basically most of the chart is what they ask for. In order to request a level II. I have to fax the level I as well and it needs to be signed by the resident or family before a level II can be requested. I cannot complete or correct a level I PASRR because I am not an MSW (master's in social work), it has to be done by a nurse. The DSS stated if a resident is admitted as a provisional admission, they do not need to have a level II PASRR. If the resident leaves within the 30 days, then they do not need the level II but if they stay in the facility more than 30 days and they have a diagnosis of mental illness then we have to request the level II. A level 2 will also be requested if there is a change in condition and the resident displays behaviors. Resident # 11 was initially admitted as a provisional admission for short term placement, but she remains in the facility as a long-term resident. Her level I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 9 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PASRR was completed at the hospital on 5/14/20. The level II would not have been requested because she was a provisional admission at that time. Once a resident becomes long term care and we request an ICP (Institutionalized Care Program) level. This is only to qualify them for nursing home placement. This has nothing to do with PASRR. Since Resident # 11 remained in the facility after the 30-day provisional admission she should have had a level II PASRR requested due to her diagnosis. Resident # 11 does display behaviors. Her care plan indicates episodes of disrobing and observed behavior distress. She is also receiving antidepressant and antipsychotic medications. She has periods of screaming smells, anxious, restless, low frustration tolerance. 2.) Observation on 7/27/22 at 5:05 PM revealed Resident # 51 in his room in bed. He was awake and alert, states he was feeling good but offered no other responses to questions. No signs or symptoms of distress were noted. Record review of the demographic face sheet revealed Resident #51 was admitted to the facility on [DATE] with multiple diagnosis including Schizoaffective Disorder, and Major Depressive Disorder. Review of Resident #51's annual MDS dated [DATE] revealed: Section A 1500 Is resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related condition - No. Section C for cognitive status BIMS (brief interview for mental status) score 11 indicating intact cognitive function. Section D Mood indicators included feeling down, depressed. Section E revealed no behavior indicators. Section I Active Diagnosis included Depression and Schizophrenia. Section N medications included antipsychotic and antidepressant use. Review of the most recent quarterly MDS dated [DATE] revealed Section C BIMS score 9 indicating moderately impaired cognition. Sections D and E indicated no mood or behavior indicators. Section I Active Diagnosis included Depression and Schizophrenia. Section N medications included antipsychotic and antidepressant use. Review of Resident #51's care plans revealed: Risk for adverse effects related to use of antidepressant medications, Resident is at risk for changes in mood related to history of depression/anxiety, risk for behavior symptoms related to history of depression and anxiety, and Resident uses psychotropic medications. Review of the POS revealed Resident #51's medications included Risperdal 0.5 mg tablet every other day at bedtimes (ordered 3/25/22) for Psychosis, and Remeron 15 mg tablet daily at bedtime for Depression Interview with the Director of Social Services on 7/28/22 at 11:58 AM revealed Resident #51's Level I PASRR may be in medical records if it is not in the chart or scanned into the electronic record. He has not been in the hospital since 2020 so the PASRR should be in his current chart. He is a long-term resident and if there was no change, we would not need a new PASRR Level I. On 7/28/22 at 4:15 PM, the Nursing Home Administrator presented a Level I PASRR for Resident #51 stating the document was located in the thinned medical record. Review of the Level I PASRR provided revealed the screening was incomplete. The document contained only 2 of 4 pages. Section I indicated SMI (Serious Mentally Illness) or suspected SMI diagnosis including Anxiety Disorder and Depressive Disorder, but the document did not include a Level II PASRR determination. 3.) Observation 7/27/22 at 5:10 PM, revealed Resident # 53 in her room in bed. Staff was present in the room to provide care. Resident # 53 offered no response to questions. No signs or symptoms of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 10 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 distress were noted. Level of Harm - Minimal harm or potential for actual harm Record review of the demographic face sheet revealed Resident #53 was admitted to the facility on [DATE] with multiple diagnosis including Schizoaffective Disorder. Residents Affected - Few Review of Resident #53's significant change MDS dated [DATE] revealed: Section A 1500 Is resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related condition - No. Section C BIMS score 3 indicating severely impaired cognitive function. Section D Mood indicators included moving or speaking that other people could have noticed or the opposite, being so fidgety or restless that you have been moving around a lot more than usual. Section E Behavior indicators included verbal behavior symptoms and other behavioral symptoms not directed towards others. Overall presence of behavioral symptoms coded yes. Section I Active Diagnosis included Schizophrenia. Section N Medications included antipsychotic and hypnotic use. Review of Resident #53''s care plan revealed: Resident has been observed with behavioral distress as evidenced by but not limited to having periods of screaming out incoherently, Resident uses psychotropic medications related to disease process of schizoaffective disease and insomnia, Resident is at risk for changes in mood and behavior due to diagnosis of Schizoaffective, and Resident has periods of anxiety evidence by impulse control and low frustration tolerance. Review of the POS revealed Resident #53's medications included: Seroquel 25 mg twice daily for Psychosis. Review of the Level I PASRR on file in Resident #53's the hybrid medical record revealed the review was completed on 6/1/22 by a Registered Nurse at the hospital. Section 1: PASRR Screen Decision Making did not indicate Resident # 53 has any MI (mental illness) or suspected MI. Findings were based on documented history. Section II Other indicators for PASRR Screen Decision Making were all checked No. The screen indicated Resident # 53 did not have a primary diagnosis of Dementia or related Neurocognitive Disorder and was not a provisional admission. Section IV indicated no diagnosis or suspicion of Serious Mental Illness or Intellectual Disability. A Level II PASRR evaluation not required. Interview with the Director of Social Services on 7/28/22 at 12:15 PM and review Resident #53's Level I PASRR revealed, if she has a diagnosis of Schizophrenia, it should have been coded on the PASRR to determine if a level II is indicated. This level I should have been checked on admission to make sure the correct diagnosis was listed on the form. This level I should have been corrected and a level II should have been requested. If the patient comes for short term and leaves within 30 days, we do not have to do a level II. At the time Resident # 53 s The PASRR level I was completed she was not considered a provisional admission to the Level I screen should have been corrected and a Level II request should have been submitted. Review of the facility policy and procedure titled Preadmission Screening and Resident Review (PASRR) dated 11/8/21 revealed: Policy: The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or ID receive the care and services they need in the most appropriate setting. Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screening, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 11 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 agency to conduct the screening and obtain the results. 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: 105641 If continuation sheet Page 12 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care and treatment including assistive device to improve the hearing for one (Resident #19) out of one resident reviewed. This has the potential to affect two hearing impaired residents residing in the facility at the time of this survey. The resident was not included on the list for residents identified to have hearing impairment. Residents Affected - Few The findings included: An initial observation and interview with Resident #19 was conducted on 7/24/22 at 11:05 AM. The resident was sitting in a wheelchair in her room, clean and well groomed. She revealed, I am very hard of hearing. I need to get a hearing aid. I missed an appointment when I was in the hospital but they have not said anything about rescheduling. The resident was having difficulty hearing questions during the interview. Second observation of Resident #19 was conducted on 7/26/22 at 11:45 AM. The resident was sitting in a wheelchair in her room, close in front of the television with the volume turned up loud, wearing eyeglasses. No hearing aid was noted. Review of the demographic face sheet for Resident #19 documented the resident was admitted on [DATE] with a diagnosis of end stage renal disease, dependence on renal dialysis, diabetes mellitus, chronic congestive heart failure and hypertension. The resident was discharged to the hospital on 2/23/22, readmitted to the facility on [DATE], discharged to the hospital on 3/16/22 and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #19 dated 5/12/22 documented the resident's Brief Interview of Mental Status (BIMS) Summary Score had a BIMS Summary Score of 15 out of 15 indicating no cognitive impairment and the resident was able to make her needs known. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and hearing was coded as adequate and no hearing aid was noted. Review of the Physician's Order Sheet (POS) for February 2022 through July 2022 documented no orders for the resident to be seen for hearing impairment. Review of the Social Services Progress Notes documented the following: Dated 2/01/22 at 11:41-Resident has an appointment on 2/08/22 at 10:45 AM with otolaryngologist and dated 2/10/22 at 11:41-Appointment with otolaryngologist was rescheduled for 3/01/22 at 9:15 AM. The resident was in the hospital on 3/01/22, readmitted on [DATE] and the appointment was never rescheduled. Review of the local hospital final report dated 2/23/22 for Resident #19 noted the hospital course documented the resident was hearing impaired. Interview with Staff A, Licensed Practical Nurse (LPN) on 7/27/22 at 10:53 AM. She stated, Not that I am aware of her being hard of hearing. She is usually a little slow the day before dialysis services but she hears well and is able to answer when spoken to. Interview with Staff B, Certified Nursing Assistant (CNA) on 7/27/22 at 11:18 AM. She stated, She can hear me when I talk to her. I can be a distance from her and she will hear without a problem. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 13 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 0685 Level of Harm - Minimal harm or potential for actual harm Interview with the Social Work Director on 7/27/22 at 11:27 AM. She stated, She hasn't had any hearing problems with us. She can communicate with us. She never told me that she can't hear and needed a hearing aid. She never told the staff about not being able to hear. Her family is very involved in her care and they have never mentioned it either. She does not have an appointment for a hearing consult. I can do a hearing consult for her. Residents Affected - Few Interview with the Administrator on 7/28/22 at 7:56 AM. He revealed, that he knows that we were asking about a hearing consult for this resident. She went to the hospital and the final report dated 2/23/22. The Hospital Course documented the resident was hearing impaired. The resident had an appointment on 3/01/22 at 9:15 AM with the otolaryngologist (ENT) but the resident was in the hospital. She has been rescheduled for 8/30/22 at 9:15 AM with the ENT for cleaning ear wax. Interview with Staff C, Licensed Practical Nurse (LPN) MDS on 7/28/22 at 9:50 AM. She stated, At the time of the interview for MDS, there was no problem with her hearing. Interview with the Social Work Director on 7/28/22 at 9:54 AM. She stated, I made an appointment for her on yesterday for an ENT evaluation for 8/30/22 at 9:15 AM. She had an appointment to see the ENT for ear wax on 3/01/22 at 9:15 AM but she was in the hospital at the time. I don't know why she was never rescheduled after she missed the 3/01/22. Review of the appointment notice (received on 7/28/22 at 7:56 AM from the Administrator) documented the resident has an ENT evaluation for 8/30/22 at 9:15 AM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 14 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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, interviews and record review, the facility failed to ensure residents were free from potential accidents and hazards as evidenced by failure to implement the smoking policy, failure to ensure equipment for disposal of smoking material was in safe operating condition, and failure to ensure residents disposed of cigarette butts in an appropriate manner for one (Resident #13) of one resident reviewed for smoking of two residents who smoke. There were 99 residents residing in the facility at the time of the survey. The findings included: Review of the facility policy titled Smoking Supervised revised 8/25/17 revealed: The Center will provide a safe, designated smoking area for residents. Residents will be supervised during smoking. Smoking is only allowed in designated area and oxygen is not permitted. The Center will have safety equipment available in the designated smoking areas including smoking blankets, smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. Procedure includes: 8. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. Observation on the smoking patio on 7/25/22 at 9:00 am revealed the area was equipped with four self-closing ashtrays. Three of the four ashtrays were broken. Only one side of the ashtrays closed. The fourth ashtray was only partially closed and filled with extinguished cigarette butts. One of the broken ashtrays contained both extinguished cigarette butts and paper trash. There were also extinguished cigarette butts on top of the other open ashtrays and trash and cigarette butt on top of the trash can. There were ash cans, a fire extinguisher and a fire blanket in the designated smoking area. Observation on the smoking patio on 7/28/22 at 9:24 AM revealed three ashtrays all designed to self-close but all three ashtrays had only one side of the self-closing device in place. Two were completely missing one side preventing them from fully closing and the third had both sides attached, but only one side would close, the second side was not attached to the ashtray. The ashtrays also contained trash including foam cups and several small plastic cups. Interview with the Director of Housekeeping on 7/28/22 at 9:34 AM translated by the Business Office Manager (Staff N) and observation of the smoking patio revealed housekeeping is responsible for maintaining the smoking area. They come out to the patio and clean the area, pick up any cigarette butts from the ground and empty the ashtrays. They empty the ashtrays into the plastic trash bags and then throw them away with the regular trash. When asked about a fireproof ash can, she reported that the butts and ashes are not placed into an ash can, they are just placed into a plastic bag for disposal. She stated that the ashtrays are supposed to close all the way and agreed that the ashtrays were broken. She stated that this has not been reported to maintenance but can tell them so the ashtrays can be replaced. She stated there should not be any trash in the ashtrays, but they probably had not cleaned up this area yet today. Observation on 7/28/22 at 9:40 AM revealed the Director of Housekeeping in the smoking area. She was observed emptying cigarette butts and ashes directly into a plastic trash bag. She was observed taking the plastic trash bag into the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 15 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 Record review of the list of residents who smoke provided by the facility revealed there are two residents currently residing in the facility who smoke including Resident #13. Interview with Resident #13 on 7/24/22 at 1:41 PM revealed he does smoke, but I only smoke a few cigarettes a day. I mostly go outside for fresh air. He stated he is aware of the location to smoke. I go down to the lobby and the receptionist provides me with my cigarette and lights it. I do not keep any cigarettes or lighters; this is not permitted. There are ashtrays in the smoking area for me to use while smoking. Review of the demographic face sheet for Resident #13 revealed he was admitted to the facility on [DATE]. with multiple diagnosis including Hypertension, Handsomely, history of falls, Anemia, and hearing loss. Review of the annual minimum data set (MDS) dated [DATE] revealed Resident #13's BIMS (brief interview for mental status) score was 15 indicating intact cognitive function. Section G for functional status was coded to indicate Resident #13 required only supervision for ADLs (activities of daily living), Section J for tobacco use was coded no. Review of Resident #13's care plan dated 8/19/19 and lasted reviewed 5/19/22 revealed: Resident is a smoker. Review of the Safety Smoking Screen dated 2/20/22 revealed Resident #13 is a safe to smoke without supervision. He is alert and oriented time 3, able to smoke in the smoking area and maintain safety as per properly dispose of cigarette butts. Observation on 7/28/22 at 1:08 PM revealed Resident #13 stopping at the reception desk and then proceed outside to the front of the building. Observation at 1:15 PM revealed Resident # 13 in the smoking area smoking a cigarette. He started to speak in Spanish and pointed to the cigarette. Interview with Resident #13 on 7/28/22 at 1:25 PM translated by the Business Office Manager (Staff N) revealed he must smoke in this area of the patio. Once Resident #13 finished smoking the cigarette, he leaned down and extinguished the cigarette on the wheel of his wheelchair. He then threw the cigarette butt into the trash can that had a plastic liner. There was no smoke or indication that the cigarette was still lit. Staff N pointed to the gooseneck device and Resident #13 stated this is where I usually throw my cigarette but today, I threw it in the trash. Photos submitted FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 16 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, it was determined the facility failed to post nurse staffing information daily. Residents Affected - Few The findings included: During a tour of the facility on Sunday, 7/24/22 at 8:45 AM on the North Wing, the staffing board was observed, and staffing was posted on the board for 7/22/2022. The previous Friday. The staffing included, the census, the day, afternoon and evening shift, nurses, C N As (Certified Nursing Assistants), the assigned hall and the assigned rooms for 7/22/2022. (Photo obtained) During a tour of the facility on Sunday, 7/24/2022 at 9:02 AM on the South Wing, the staffing board was observed to be blank, and a staff member was observed starting to complete the staffing board. During an interview on 7/26/2022 at 3:39 PM with Staff M, C N A and the Staffing Coordinator, she reported, they schedule the assignments based on the census and residents' needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 17 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility failed to provide pharmacy services to meet the needs of the residents. This practice affected 3 discharged residents (Resident # 42, Resident #145 and Resident #147) and 99 admitted residents residing in the facility at the time of the survey. The findings included: On [DATE] at 11:30 AM, a portion of the Medication Storage and Labeling task was completed with Staff L, a Registered Nurse (RN) and Unit Manager for 2 North. The 2 North Medication room was toured, and the following was observed in one of the bottom cabinets: There were medications found for 3 discharged residents: a. Resident #147 who was discharged on [DATE] had the following medications in the cabinet, Enoxaparin Sodium syringes 120 mg/8 mg(milligrams), 6 syringes. The medication label documented Enoxaparin Sodium Solution 120 mg/.8 ml(milliliters). Inject 1 syringe subcutaneously every 12 hours for anticoagulant D/C if INR (International Normalized Ratio) 2-3** DC (Discharge) home on HHS/HHA/RN (Home Health Registered Nurse) evaluate and treat. b. Resident #146 who was discharged on [DATE] had the following medications in the bottom cabinet. Metoprolol Tartrate 50mg, Quin[DATE]mg, Metformin 50mg, Escitalopram 20 mg, Rosuvastatin 20 mg, and Ezetimibe 10 mg. The pharmacy label documented the medications were delivered [DATE]. c. Resident #42 who was discharged on [DATE] had the following medications in the bottom cabinet. Enoxaparin Sodium 2 boxes of 30 mg/.3 mg, Lactulose 473 ml. The medication label documented the medications were delivered [DATE]. The bottom cabinet also had four (4) V.A.C.® GRANUFOAM (Trademark) Dressings, 1 expired on [DATE] and 3 expired on [DATE]. At 11:55am on [DATE], the Director of Nurses (DON) confirmed the 3 residents had been discharged . Inside the 2 North medication room on [DATE] at 12:00PM, a double locked cabinet with a red bag was observed inside the cabinet, but you could not see through the bag. The DON and Staff L were asked what was in the red bag and they reported it was a Narcotic E-kit. The red bag was observed to be closed. The DON and Staff L were asked, how do they know what is in the E-kit. They looked at the bag to identify the list of medications, but there was no list of medications to determine what medications were inside the red bag. The facility's Consultant Pharmacist was on the 2 North Unit at the time and the DON asked him about the red bag, and he reported this is how the Narcotic E-kit was transported. On [DATE] at 12:02PM, the red bag was opened, and the following medications were observed inside the locked and enclosed E-kit, Hydromorphone, Fentanyl, Methadone, Morphine, Oxycodone, Codeine, Lorazepam, Clonazepam, Temazepam, Tramadol, Alprazolam, and Pregabalin. During observation of the medication cart drawers on [DATE] at 12:09 PM, with Staff N, a Licensed Practical Nurse on the 2200 cart, one loose unidentified pill was found at the bottom of one of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 18 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 drawers. Staff N discarded the pill in the pill buster. Level of Harm - Minimal harm or potential for actual harm On [DATE] at approximately 12:15 PM, observation with Staff P, RN, on the South 2500 cart, five unidentified pills were found in the bottom of the cart. The pills were discarded in the pill buster. Residents Affected - Few Review of the facility's Policy and Procedure for Medication Storage in the Facility dated [DATE], included, Policy - Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. Procedures - Medications storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 19 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 - Some 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 food was stored and prepared under sanitary conditions, and dishes were cleaned and stored under sanitary conditions as evidenced by failure to ensure air conditioner (AC) vents directly above food preparation and storage areas and the dish room were clean and free of condensation and walls and ceiling in the dry storage room and the dish room were intact and free of loose peeling paint. This has the potential to contaminate the food and clean dishes. The has the potential to affect 94 residents who eat orally out of 99 residents residing in the facility at the time of the survey. The findings included: Observation in the kitchen on 07/25/22 at beginning 11:09 AM revealed staff placing hot food into the steam table in preparation to serve lunch. Observation revealed a heavy accumulation of a black colored substance and condensation on the air conditioner (AC) vents above the milk box which was open exposing cold food items, above the serving side of the steam table, and directly above food preparation table observed with clean utensils and an open box of plastic wrap. The wall in the hot food preparation area above the hood had an accumulation of dust. The staff was observed preparing food in this area. The A/C vent in the dry storage room where food was stored was observed with an accumulation of black colored residue. The wall in the dry storage room directly above the ready to eat condiment packages was observed to be cracked and the paint was peeling. Observation in the dish room at 11:56 AM revealed peeling paint on the ceiling directly above the soiled dish handling area. Observation above the area where the clean dishes exit the dish machine revealed the ceiling had some rust-colored spots. The ceiling had rough dry wall substance with areas that appeared loose. The surface was rough and uncleanable. Clean dishes were observed in a rack directly below the ceiling. The sprinkler heads in the dish room area were rust colored. Interview with the Dietary Supervisor (Staff J) on 7/25/22 at 11:55 AM revealed the only maintenance request she has pending is to repaint the wall behind the pot storage rack. I also requested that they paint the wall in the dry storage room. Staff J stated that maintenance is responsible for cleaning the AC vents and repairing the damaged walls. Interview with the Director of Maintenance on 7/27/22 at 11:59 AM revealed, I have a little system in my computer to track maintenance issues. I make rounds daily to check the water temperatures, exit signs, fire alarms, eye washing stations. When I tour the building, I also look for other environmental concerns. Usually, other maintenance concerns are reported to me by staff during my environmental rounds or they report to me by radio and concerns. We also have a maintenance work request form located at each station, but most of the time it is just reported to me verbally. If something is reported to me verbally, I just go and fix the problem. The system I created for myself includes preventative maintenance scheduled or completed. The AC vents are cleaned every two months. This includes the vents in the kitchen as well. We cleaned the AC vents in the kitchen yesterday. We also had to repair a crack in the wall in the dry storeroom. We have been working on the ceiling in the dish room. They had a hole in the ceiling covered by plastic. We continue to repair the ceiling in the dish room. I was not aware of any paint chipping in the dish room. Review of the facility policy and procedure titled Maintenance revealed: Policy: The facility's physical plant and equipment will be maintained through a program of preventative maintenance and prompt action to identify area/items in need of repair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 20 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 Photos submitted 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: 105641 If continuation sheet Page 21 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 record review and interview, the facility's quality assurance and assessment committee failed to identify quality concerns to implement an effective plans of action for correcting deficiencies resulting in repeated deficient practice. The facility was cited for Free of Accident Hazards/Supervision/Devices (F689) in 2018, Pharmacy Services/Procedures/Pharmacist/Records (F 755) in 2018, Food Procurement, Store/Prepare/Serve-Sanitary (F 812) in 2018 and 2020 and Quality Assurance/Quality Improvement (QAPI)/QAA Improvement Activities (F 867) in 2020. These repeated deficient practices has the potential to affect any of the 99 residents residing in the facility at the time of the survey. The findings included: Review of the facility's policy titled, Performance Improvement Quality Assurance/Quality Improvement (QAPI) Policy and Procedure with the revision date of 10/29/2020, the policy documented: The center and organization have an ongoing Performance Improvement Program with a design and scope that is ongoing and comprehensive dealing with a full range of services offered by the center that addresses aspects of care. The design and scope of the program is to systematically monitor and evaluate the quality and appropriateness of resident care, pursue opportunities to improve resident care, resolve identified problems and identify opportunities for improvement. Review of the Quality Assurance and Performance Improvement (QAPI/QAA) Committee Meeting Sign-in Sheets dated March 2022, April 2022 and May 2022: documented the facility had a QAPI/QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads. Interview with the Administrator on 7/28/22 at 1:40 PM. He stated, The QAA committee meets at least quarterly, meets once a month and meets the third Thursday of the month. Committee members consist of: Administrator/QAA, Medical Director, DON and Department Heads. The purpose of QAA is to ensure the care and services provided are of quality. So, we review all areas of patient care such as infection control, incidents and accidents, family complaints and satisfaction, care planning, usage of medication, environment of care, weights, psychotropic drug uses, fall preventions and medication errors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 22 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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, interview and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the transmission of communicable diseases such as Coronavirus Disease 2019 (COVID-19). There were 99 residents residing in the facility at the time of the survey. Residents Affected - Some The findings included: Upon entrance into the facility on Sunday, 7/24/2022 at 8:30 AM, the facility's Receptionist told the survey team that everyone did not need to go through the facility's full screening process and only one person needed to go through the full screening at the kiosk. All team members, temperatures were checked. On 7/24/2022, the survey team was provided a letter from the Nursing Home Administrator (NHA) that the facility had one COVID 19 positive resident. The resident was Resident # 93 and located on 2 North, 2300 wing. On 07/24/22 at 12:18 PM, while observing dining on the 2 North wing, the following was observed: On 7/24/2022 at 12:19 PM, Staff K, a Certified Nursing Assistant (CNA) was observed inside Resident #93's room, who was COVID 19 positive and on Transmission Based Precautions, Staff K had a mask on and did not have on proper Personal Protective Equipment (PPE). Staff K did not have on a gown, gloves and face shield. A PPE cart was observed outside the door of Resident #93's room. Resident #93's room had the proper signage on the door for Transmission Based Precautions. Staff K also left the room door open. On 07/24/22 at 12:27 PM, observed Resident #93's call light on, Staff K was observed to enter the room with a mask and gown. No face shield was observed on Staff K. The room door was left open. On 07/24/22 at 12:31 PM, Staff K, was observed to take Resident #93's lunch tray into the room. Staff K did not put on a gown, gloves or face shield prior to entering the room. Resident #93's lunch was served on a disposable Styrofoam tray and containers. On 7/24/22 at 1:30 PM, the Nursing Home Administrator (NHA) was informed about the staff observed not wearing proper PPE when going into Resident #93's room. The NHA reported that, staff should be wearing proper PPE and he would follow up. On 7/25/22 at 1:00PM, the NHA notified the survey team about an COVID 19 outbreak on the 2200 wing. He reported, this was possibly from a family member that had recently visited the facility and reported they tested positive for COVID 19. There were nine (9) new residents that had tested positive for COVID 19. On 7/26/22 at 7:30 AM, upon entrance to the facility, staff were observed entering the facility without masks on and were not being screened for COVID-19. No staff member was observed sitting at the front desk to ensure staff and visitors were properly screened for COVID-19 precautions. During an interview on 7/28/2022 at 2:15PM with the Director of Nurses (DON)/Infection Preventionist and Staff A, the Acting 2 South Unit Manager/Licensed Practical Nurse, it was reported that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 23 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 multiple infection control in-services had been given to staff to include: Level of Harm - Minimal harm or potential for actual harm An Outbreak in-service for 7/25/22, PPE in-service on 7/1/22, 5/19/2022, Infection Control on 6/16/22, 4/13/22 and General Infection Control Practices on 3/10/22. Residents Affected - Some The DON and Staff A were notified about the observations on 7/24/2022 for screening and on 7/24/2022 where Staff K did not wear proper PPE in Resident #93's room and about staff entering the facility without mask and without screening on 7/26/2022. During the review of the facility's COVID 19 Pandemic Plan dated 3/2/2020 and revised on 5/26/2022, it was determined the facility did not follow this Policy and Procedure. The following was not followed, . Procedure . 1. Employee's including contract employees, should be evaluated and observed at the beginning of each shift for signs and symptoms of COVID 19 (including temperature check) . 4. Healthcare personnel (including but not limited to, physicians, physician extenders, hospice providers, laboratory and radiology staff) will be screened and observed for COVID 19 signs and symptoms (including temperature check) . 14. Residents with suspected COVID-19: .Initiate Transmission based precautions per the CDC [Center for Disease Control] including PPE-N 95 or higher respirator, eye protection, gown and gloves . 2. Visitation - a. All visitors will be screened for signs and symptoms of COVID-19 (including questions about and observations of signs and symptoms and temperature checks) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 24 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary environment for residents, staff, and the public as evidenced by failure to maintain ceiling tiles, air conditioning (AC) vents and ceiling clean and free from a black colored residue in the common area of the South Wing and the Therapy Department. This has the potential to affect 55 residents residing on the South Wing and/or 59 residents receiving skilled therapy services. There were 99 residents residing in the facility at the time of the survey The findings included: Observation of the South Wing on 7/24/22 at 12:33 PM, revealed multiple damaged ceiling tiles to the right side of the nursing station leading into the 2600 hall. The tiles had circular stains like water damage and a having an accumulation of black colored residue. Aa observation of the ceiling tiles on the other side of the fire door in the 2600 hall revealed black colored residue on the ceiling tiles and brackets that held the ceiling tiles in place. Observation of the Nursing Staff bathroom at the entrance to the 2600 hall revealed a large amount of black colored residue on the AC vent and the surrounding ceiling tiles. Observation on 7/25/22 at 9:13 AM revealed the stained ceiling tiles on the South Wing had been replaced and the AC vent in the staff bathroom had been cleaned. Observation on 7/26/22 at 1:30 PM revealed the same ceiling tiles to right side of nursing station on the South Wing had more discolored circular stains than those observed at 9:13 AM. The ceiling tiles appeared wet. The ceiling tiles at the entrance to the 2600 Wing also had brownish colored stains that were not present during the 9:13 AM observation. Observation on 7/26/22 at 1:31 PM in the Therapy Department revealed black colored residue on the ceiling and on the AC vent. Interview with the Occupational Therapy Assistant (Staff M) on 7/26/22 at 1:35 PM revealed she noticed the ceiling is black near the AC vents. They clean them once in a while, but the discoloration keeps coming back. It is very damp in here. I hope it is not mold, I worry about the air quality in here. Maybe they could do an air quality test. Interview with the Director of Environmental Services on 7/27/22 at 11:59 AM revealed, I have a little system in my computer to track maintenance issues. I make rounds daily to check the water temperatures, exit signs, fire alarms, and eye washing stations. When I tour the building, I also look for other environmental concerns. Usually, other maintenance concerns are reported to me by staff during my environmental rounds or they report to me by radio. We also have a maintenance work request form located at each station, but most of the time it is just reported to me verbally. If something is reported during rounds, I just go and fix the problem and I do not complete a maintenance request form. I do log the work that has been completed in my computer. The system I created for myself includes a log of preventative maintenance scheduled or completed including work done by outside vendors. We also use and electronic system. The staff does not have access to this system. I record maintenance concerns and repairs in the electronic system. The AC vents are cleaned every two months. In reference to the ceiling tiles in the South Wing, the company that we use for AC service removed the insulation cover to the AC duct. Until they replace the insulation the condensation will continue to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 25 of 26 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 105641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few drip over the ceiling tiles, and they will continue to be wet. Every few weeks we replace the panels, but until they replace the insulation in the ducts this will continue to be a problem. This has been ongoing for around two months. In reference to the black residue on the ceiling, sometimes this is just dust. I try to paint over the areas but that just covers the spots. I try to use a little bit of chlorine to the areas in case this is mold. We have not done any mold or air quality testing. This is an old building. In addition to myself, we have two additional full time maintenance staff. Review of the facility policy and procedure titled Maintenance revealed: Policy: The facility's physical plant and equipment will be maintained through a program of preventative maintenance and prompt action to identify area/items in need of repair. Procedure: The Director of Environmental Services will follow all policies regarding routine periodic maintenance. The Director of Environmental Services will perform daily rounds of the building to ensure the plant is free from hazards and in proper physical condition. All items needing maintenance assistance will be reported to maintenance using the maintenance repair request form. The form will be completed and paced in a designated area on the nursing unit or in the maintenance office. Environmental Services Personnel will check for completed forms throughout the day. The requests will be prioritized and completed according to need. If unable to complete a request in a reasonable time, the originator will be notified as to the current status and future resolutions. Photos submitted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105641 If continuation sheet Page 26 of 26