Inspection·April 27, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Maintenance Director. He is now working with another facility from the same company, and he is familiar with the process of reporting anything that needs to be fixed. The acting Maintenance Director stated this facility keeps a workbook in the nursing stations where everyone (staff) will document any need for maintenance or repair in the rooms or the common areas. When asked if Resident #218 reported a problem with the bed mattress and how is the process to change a mattress, he stated it will be the same process. The acting Maintenance Director stated any staff who knows about the problem will log it in the book, and the maintenance person that is working full time here will check the book daily, and they will take care of any report. The acting Maintenance Director stated sometimes they change the mattress and residents keep asking them for the mattress to be changed because they do not realize they did it already. When asked if he was aware of Resident #218's request to change the mattress, he said he did not know anything about it. He stated sometimes residents told the staff (Certified Nursing Assistants -CNAs) and they forget to tell Maintenance or to put it in the book. Observation on 04/27/2023 at 10:40 am revealed Resident #218 was not in her room and was said to be in therapy. Observation conducted with the acting Maintenance Director revealed the bed was changed. There was a bed with a headboard in good condition and observed no concerns. Observation revealed the new mattress looks in good condition. Interview with the Social Services Assistant on 04/27/2023 at 10:42 am revealed she did not receive any grievance or request from Resident #218 to have her mattress changed. Interview with Staff B, Registered Nurse (RN) on 04/27/2023 at 10:45 am revealed she did not see the headboard of Resident #218's bed was in disrepair. When asked if she entered the resident's room to take care of resident, Staff B stated she does but she did not notice anything out of the ordinary in the room. Staff B stated Resident #218 did not tell her she was uncomfortable with this mattress. Interview with Staff C, RN, and Unit Manager on 04/27/23 at 10:50 am revealed she and Resident #218's CNA changed her bed about 10 minutes ago. When asked why she changed Resident #218's bed, Staff C stated they did it because Resident #218 told her CNA she did not like the mattress, she told the CNA it was in bad condition like sinking in the middle. Staff C stated Resident #218 complained about the mattress but not the bed. When asked Staff C what she observed on Resident #218's bed, she stated the bed was working properly there was no problem with the bed, and stated they changed the bed from the room across from Resident #218's room that was empty. When surveyor asked Staff C's opinion about the Resident #218 original bed, she stated she observed there was something on the headboard on the right side, something cracked on the wood. When the surveyor asked if she believes it was ok for a resident to have that bed in the bedroom, Staff C stated, no that is not ok. Staff C acknowledged she did not report to Maintenance after seeing Resident #218's bed headboard condition. Staff C stated any staff going inside the room is supposed to observe and report any situation where residents' rooms and furniture needs to be repaired and they will put in the book for maintenance to do it, but so far nobody has reported. Staff C stated she is aware it is not good to have this furniture in the room, they should have been reported and replaced. Interview with Staff D, Maintenance on 04/27/2023 at 01:55 am stated he went to Resident #218's room to check when the acting Maintenance Director told him about the problem with the bed's headboard, and they had just changed it. Staff D stated there was no work order in the book, he went to take care of the bed's headboard after the acting Maintenance Director told him, but the bed was changed already. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105709 If continuation sheet Page 2 of 10 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 105709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Miami Lakes 5725 NW 186 Street Hialeah, FL 33015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the acting Maintenance Director on 04/27/2023 at 11:00 am revealed the staff from nursing who is entering in the rooms all the time are supposed to report about any repairs or replacements that need to be done in the residents' rooms, but nobody reported or wrote in the book. Interview with the Nursing Home Administrator (NHA) on 04/27/2023 at 11:35 am revealed she did not have any grievance on behalf of Resident #218. Today they filed a grievance on behalf of this resident because another CNA who is not assigned to the resident overheard when Resident #218 was telling the surveyor about the mattress, and she was informed, and they filed a grievance. The NHA stated they took care of that, they filed a grievance, and they changed the bed from another room, which was done by the Unit Manager (Staff C) and another staff, and it was resolved. The NHA stated they tried to resolve the concerns right away to prevent further complaints. Asked her opinion about the condition of the broken headboard of Resident #18's bed, the NHA stated she believes it is just the headboard not the bed, the bed was working well, but the headboard should have been reported and replaced. The NHA stated this facility was inherited from another company recently, and they are trying to fix anything they find, they are doing good with costumer service, and they are trying to fix everything they need. The NHA stated she believes they do the best for residents in the facility, but when there is a mistake, she will accept and fix the problem. The NHA stated they do have a Performance Improvement Plan (PIP) open for Maintenance, but it is for bathroom and rooms' remodeling. The CNA only reported she overheard the surveyor and resident talking about the mattress, but she did not report anything about the bed condition. The NHA disagreed with the fact of considering Resident #218's bed headboard condition not meeting the home environment condition as they are required. The NHA stated she believes a home environment is together with everything around, she believes its not just the bed or furniture condition but the care, the staff who provide the care and about the satisfaction with what they receive. But the NHA stated she considers it should have been reported to maintenance, they have spare headboards in the facility, and it would have been taken care of by Maintenance staff as they did it. The NHA stated the facility only has one person doing work in the Maintenance Department. They are looking for the right candidates, but they have not found the right person with experience to do the job. They are hiring a Maintenance Director. Record review of the Workbook dated 04/2023 revealed no work order related to changing Resident #218's mattress. There is no work order to replace or repair the resident's bed headboard. Record review of Policy and Procedures on Maintenance dated 11/30/2014 revealed: Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/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 of hazards and in proper physical condition. All employees will report physical plant areas or equipment in need of repair or service to their supervisor. All items needing maintenance assistance will be reported to maintenance using the Maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105709 If continuation sheet Page 3 of 10 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 105709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Miami Lakes 5725 NW 186 Street Hialeah, FL 33015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 using the Maintenance Repair Request form (attachment A). Level of Harm - Minimal harm or potential for actual harm The form will be completed and placed in a designated area on the nursing unit or in the maintenance office. Residents Affected - Few Environmental Services personnel will check for completed forms through the day. Record review of the Complaint/ Grievance report dated 04/27/2023 revealed grievance a filed on behalf of resident #218 with concerns stated mattress. Assistant Director of Nurses (ADON) went and interviewed the resident and she said she was not comfortable with the mattress. The bed and mattress were changed immediately. Interview with Staff E, CNA on 04/27/2023 at 01:55 pm revealed she did not see the headboard on the bed was broken, she stated she is aware she must report anything that needs repair to maintenance staff, but she did not see it. When asked if she provides assistance to this resident daily, she said she does but she did not see it. Staff E stated it was today after Resident #218 stated she wanted her mattress to be changed, she and Staff C, the Unit Manager changed her bed to another room that was empty. Staff E stated, the original bed assigned to Resident #218 was working well, and she did not see anything bad on the headboard. A further interview with the NHA on 04/27/2023 at 02:30 pm revealed the request to change the mattress is something that should not be managed as a grievance. The NHA stated they did it today because the CNA overheard the resident complaining about it to surveyor, but that request should have been addressed as a work order for Maintenance. The NHA stated if staff did not put it in the book, it means they should re-train staff to identify the need of a work order. Grievance is for complaints voiced out by residents that have not been resolved immediately. Policies and Procedures on Grievances dated 11/30/2014 revealed no concerns. Policy: Prior to or upon admission, the resident's designated person will be informed of the right to file and the procedure for filing a complaint. Procedure: Reporting: If the resident or residents designated person, feel or believe that the residents rights have been or are being violated by staff or another resident or in any other way, the resident and/or residents designated person shall make his/her complaint known to the Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105709 If continuation sheet Page 4 of 10 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 105709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Miami Lakes 5725 NW 186 Street Hialeah, FL 33015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (Resident # 114) out of 24 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS section A, subsection A2100 for Discharge Status for Resident #114. There were 107 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Review of the medical records for Resident #114 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Unspecified Atrial Fibrillation and Problems related to Care Provider Dependency. Resident #114 was discharged on 04/06/2023. Review of the Physician's Orders Sheet for April 2023 revealed Resident #114 had orders that included but were not limited to: 4/6/2023-Discharge home per family request, home health services-Registered Nurse, Physical therapy, Occupational therapy, Home Health Aide evaluation and treatment. Transportation provided by insurance. Record review of Resident #114's Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section A for Identification Information in subsection A 2100 for Discharge Status documented that the resident was discharged to an Acute Hospital. Record review of Resident #114 's Care Plans dated 03/24/2023 revealed: Resident wishes to return to home. Interventions included: Encourage the resident to discuss feelings and concerns with impending discharge, establish a pre-discharge plan with the resident/family/caregivers, evaluate progress and revise the plan as needed. Review of the Social service's progress notes for Resident #114 documented on 04/06/2023 at 16:19 Members transportation just arrived for resident to return to home. Review of the Discharge planning progress notes for Resident #114 on 04/04/2023 at 18:21 documented family requested that the resident be discharged from the facility on 04/06/2023. Patient will be discharged home, address provided, family notified, transportation will be provided by insurance. Interview on 04/27/23 at 08:10 AM Director of Nursing (DON) stated this resident was discharged home on 4/6/2023, requested the DON review the Discharge MDS section A, subsection- A2100, the DON acknowledged Section A2100 documented discharge to acute hospital. Interview on 04/27/23 at 09:34 AM Minimum Data set (MDS) Coordinator (Staff A) when asked about the coding error in section A, subsection A2100 of the resident's MDS, stated the error was corrected and retransmitted to Center for Medicare and Medicaid Services (CMS) today. We are currently randomly picking 10 resident's MDS weekly and checking for accuracy, we have a Performance Improvement plan (PIP) in place, the Performance improvement plan was started last year December (12/2022) when the facility was hacked. Reviewed MDS PIP with MDS coordinator and explained to the MDS coordinator the PIP presented states: area being reviewed -Timeliness of MDS assessments, the PIP does not address MDS inaccurate coding/errors. Copy of PIP received. Review of the facility policy and procedures titled, Minimum Data Set effective date 11/30/2014 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105709 If continuation sheet Page 5 of 10 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 105709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Miami Lakes 5725 NW 186 Street Hialeah, FL 33015 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 states: 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 Resident Assessment Instrument (RAI). Procedures step 3-Each person completing a section or portion of a section of the MDS signs the attestation statement indicating its accuracy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105709 If continuation sheet Page 6 of 10 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 105709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Miami Lakes 5725 NW 186 Street Hialeah, FL 33015 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 failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F584 Safe/Clean/Comfortable/Homelike Environment and F641 Accuracy of Assessment. This practice has the potential to increase the risk of negative outcomes for all residents in the facility. There was a census of 107 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit 02/20/2022, Safe/Clean/Comfortable/Homelike Environment was cited related to the facility failed to maintain room temperatures within an acceptable range of 71 to 81-degrees Fahrenheit for three residents' rooms and facility failed to accurately code the Minimum Data Set(MDS) for one out of twenty three sampled residents, as evidenced by not documenting active diagnosis of Diabetes Mellitus and medication on the admission MDS. During an interview on 04/27/2023 at 02:43 PM, the Nursing Home Administrator revealed that the Quality Assessment and Assurance Committee (QAA) meets the last Thursday of every month. The administrator stated that the QAA Committee is comprised of the following members: Director of Nursing Services, Administrator, Business Office Manager, Registered Dietitian, Environmental Director, Maintenance Director, Social Services Director, Discharge Coordinator, Director of Rehab, Minimum Data Set (MDS) Coordinator, Unit Manager, and Medical Director. Nursing Home Administrator stated, we are working on 4 Performance Improvement Plans (PIP) on Nutrition, Return to hospital, Remodeling, and Minimum Data Set, we are working on room and bathroom remodeling, we have already completed a PIP in regard to chairs as during COVID we were wiping them too much and they were damaged, we also completed a PIP in regard to wheelchair. She continued and stated, for homelike environment, we have placed furniture as a concern, I have showed one of the other surveyors that we recently bought 5 beds, the order was placed 4/24/23 and they are already here at the facility, as I mentioned before we had issues with damage done in our physical furniture as we were sanitizing them during COVID, and because of this we bought 60 regular chairs for the resident rooms, 100 wheelchairs, multiple air-conditioning units, and the dryers for the laundry. We try to do things every month based on a budget. Also, we try to monitor the rooms through the Guardian Angel Program and if they find anything they can report it to us. We have also been painting and retouching walls, and this is done every day. Regarding Accuracy of Assessment she stated, there was a computer breach at the end of November 2022, at the time we did not have an email to communicate with the Agency for Healthcare Administration (AHCA), we did not have access to the system not even Point Click Care (PCC). For this issue, we did an action plan, we communicated to AHCA that our system was breached, we did not have a system at all, we had to do the manual orders, if there were new admission, we got the reconciliation from the hospital, all the documentation was done on paper. We had issues with transmission, omission, and miscoding on the MDS. For example, on the Minimum Data Set we will code for falls and check yes but then the system would not accept it, the system was transmitting blank information, we had to get a second random set of people at the corporate office that had a special access as the information was not arriving to Center for Medicare & Medicaid Services (CMS), we had some of our consultants doing the MDS outside of the facility. We (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105709 If continuation sheet Page 7 of 10 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 105709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Miami Lakes 5725 NW 186 Street Hialeah, FL 33015 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 implemented the PIP, and we identified the problems we had, it took about 4 weeks. Corporate did not know who hijacked the system, and they did a PIP explaining what was happening, they were working day, night, and people who hijacked the system did not make it to PCC. Review of Policies and Procedures with Subject Quality Assurance Performance Improvement Program (QAPI) and Effective Date 11/30/2014 revealed, Policy: The Center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. Program Design and Scope 1. The center's QAPI program is an on-going comprehensive review of care and services provided to residents. Including but not limited to: a. Environmental Services b. Medical Records 2. Review of activities may include but not be limited to: a. Environment of care/safety b. Staff orientation, in-service and competence Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but it not limited to: a) Implementation b) Ensure corrective actions are implemented to address identified problems in systems. c) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105709 If continuation sheet Page 8 of 10 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 105709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Miami Lakes 5725 NW 186 Street Hialeah, FL 33015 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 Evaluates the effectiveness of actions. Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Few The program is a coordinated effort among departments and services within the organization that involves leadership working with input from Center staff, residents, and families. Feedback: the center will obtain feedback to assist in identifying problems and areas of opportunity. Feedback may be obtained including but not limited to the following sources: a) Direct care staff b) Other staff members c) Residents d) Resident representatives Data Collection Systems and Monitoring: The center will collect and monitor data from different departments reflecting its performance. 4. The center will identify data sources and timeframe for collection. Data sources may include but are not limited to: a. Direct observation tools b. Audit tools c. Quality measures d. MDS data (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105709 If continuation sheet Page 9 of 10 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 105709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Miami Lakes 5725 NW 186 Street Hialeah, FL 33015 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 Systematic Analysis and Action: The center will ensure systems and actions are in place to improve performance. 5. The center will develop corrective actions based on the information gathered and review effectiveness of the actions. 6. The center will review and develop corrective actions on medical Errors and adverse Events. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105709 If continuation sheet Page 10 of 10