Inspection·April 3, 2025

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to assist in obtaining oral surgery dental services for one (Resident #26) out of one Medicare pay resident reviewed for dental services. There were 105 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Record review of the Dental Services Policy and Procedure revised 03/2025 documented: Policy-It is the policy of this facility to assist residents in obtaining routine and emergency dental care; Policy Explanation and Compliance Guidelines-1) The dental needs of each resident are identified through the physical assessment and MDS (Minimum Data Service) assessment processes and are addressed in each resident's plan of care and 4) The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location. Observation and interview with Resident number 26 on 3/31/25 at 9:45 AM revealed the resident sitting up in bed, watching television with missing top and bottom teeth. The resident revealed she couldn't remember the last time she saw a dentist and wanted to see a dentist. Review of the Demographic Face Sheet for Resident number 26 documented the resident was initially admitted on [DATE] with a diagnosis of diabetes mellitus, hypertensive heart disease, chronic kidney disease, hypertension and chronic obstructive pulmonary disease. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident number 26 documented the resident's Mental Status (BIMS) Summary Score was 13, indicating no cognitive impairment and able to make her needs known and she required substantial/maximal to dependent assistance for ADLs (activities daily living) and setup assistance for eating. Review of the Physician's Order Sheets (POS) dated March 2025 and April 2025 for Resident number 26 documented the resident was on a Consistent Carbohydrate, No Added Salt, Regular diet and dental care consultation as needed. Review of the care plans for Resident number 26 revealed no dental care plan was available. Review of the dental consults for Resident number 26 documented the following: Dated 5/28/24-Periodontal Exam; No extractions have been completed recently #20 tooth fx (fracture) at gum line. Refer to [ ] nurse for referral to community oral surgeon to extract #20 tooth; dated 6/04/24-Periodontal Exam; Refer patient to oral surgeon for offending teeth lower left & lower right and dated 7/17/24-Periodontal Exam. Review of the Nurses' Progress Notes for Resident number 26 documented the following: Dated 06/05/2024 at 02:48 pm-Receive final dental report dated June 4th from [ ] dentist impression: Resident to follow up with removal of left lower right tooth via oral surgeon. Spoke with nurse practitioner. Practitioner verbalized she will follow up with listed surgeons. Dated 06/10/2024 at 06:59 pm-Residential dental coverage providers. Was able to reserve an appointment with [ ] dental provider office date July 11 at 11 AM. Resident is agreeable with plan of care. Dated 07/05/2024 at 05:21 pm-Call placed to [ ] non-emergency medical transportation and informed [ ] representative that resident has new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105715 If continuation sheet Page 2 of 3 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 105715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Court Nursing and Rehabilitation Center 16100 NW 2nd Avenue North Miami Beach, FL 33169 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appointment scheduled 7/11/2024 at 11AM with oral surgeon. [ ] representative stated she is unable to schedule transportation with wheelchair for the resident at this time, but she will call 7/8/2024 in the morning to set up transportation services for resident. Dated 07/08/2024 at 04:59 pm-Call placed to [ ] non-emergency medical transportation and spoke with [ ] representative. [ ] representative informed nurse that their company is unable to provide transportation for resident appointment on 7/11/2024 due to [ ] insurance provider not reimbursing their company for services. Nurse to reschedule transportation with another provider. -Dated 07/11/2024 at 02:28 pm-Received call from medical doctor's office spoke from office manager. I was informed that the resident approval for initial consultation with oral surgeon has not been provided by dental insurance at this time. Office manager and myself agree to continue to reach out to provider and reschedule consultation appointment. All identifying resident information has been reviewed with office manager. [ ] Resident number 26 made aware of the same and is agreeable with plan. She denies any complaint of tooth pain. Resident did verbalize she would like the crack tooth fixed. All transmissions were faxed to oral surgeons office. Will keep resident informed. Dated on 07/11/2024 at 07:01 pm-Reached out to [ ] health care insurance. Spoke with advocate [ ]. List of oral surgeons available under resident dental plan under [ ] health care insurance made available to writer. Will follow-up next business day. On 4/03/25 at 10:01 AM, interview and record review with Staff A, Registered Nurse. She confirmed that the progress notes concerning the oral surgery dental written on 6/05/24, 6/10/24 and 7/11/24 were written by her. She stated, I vaguely remember this situation. I will have to discuss with the case manager about the situation. Subsequent interview on 4/03/25 at 11:21 AM she confirmed that no further arrangements were made for Resident number 26 to have oral surgery as recommended by the dentist. On 4/03/25 at 10:17 AM with the Director of Social Services. She stated, I started working here on 3/17/25. The Social Worker will make appointments for dental for in-house. If the resident is going out, someone else makes the arrangements. Subsequent interview on 4/03/25 at 11:02 AM. She stated, We reviewed the notes and I asked what happened with the oral surgery dental appointment. I asked the nurse was there an appointment made for the extraction and the answer was no. I am going to arrange an appointment for extraction. On 4/03/25 at 12:17 PM with Staff B, MDS (Minimum Data Service) Coordinator. She stated, There is no dental care plan for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105715 If continuation sheet Page 3 of 3