Inspection·April 28, 2022

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #63's Progress Notes dated 04/11/2022 revealed, Late Entry: Note Text: On last visit nursing reported that resident has been complaining of increased voices''. I assessed resident and found that she was extremely anxious and stating that the voices had increased and was troubling for her. Today she was smiling and more engaging post administration of medications. She is sleeping better. Appetite has returned and nursing staff was reminded to give her more H20 via peg. Will follow up in 14 days with client. Again, benefits of meds outweigh risks. Record review of Resident #63's Progress Notes dated 1/18/2022 at 12:30pm revealed, ARNP/NP/PA (Advanced Registered Nurse Practitioner/Nurse Practitioner/Physician Assistant) Late Entry: Note Text: Psych Note January 18th, 2022 Resident was previously seen and is known to writer. She remains pleasant, is alert and interacts well with staff and peers. Appears stated age. Information is obtained mostly from chart or staff. Stable with no new problems. No recent mental health changes. Loss of energy noted. No evidence of suicidal gestures. Mood is appropriate to situation. No negative reports received from staff. No behavioral issues noted or reported. Assessment remains unchanged since last visit. Discussed treatment plan with nursing staff. No new meds ordered, if need be, will review for GDR [Gradual Dose Reduction] of meds. Record review of Resident #63's Psych consults dated 06/07/2021, 07/12/2021, 08/08/2021, 08/30/2021, 09/24/2021, 11/09/2021, 02/15/2021 and 03/08/2021 revealed Resident #63 received an evaluation on the resident's mental condition and diagnoses. The consults revealed Resident #63 did not receive antidepressant medication. Record review of the undated Policy on Resident Assessments revealed: Policy Statement: A comprehensive assessment of every resident's needs is made at interval designed by Omnibus Budget Reconciliation Act (OBRA) and Prospective Payment System (PPS) requirements. Policy Interpretation and Implementation 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements: 2. A comprehensive assessment includes: a. Completion of Minimum Data Set (MDS); b. Completion of the Care Area Assessment (CAA) Process; c. Development of the comprehensive care plan. Interview with Staff A, the MDS Assistant on 04/28/2022 at 05:59 pm revealed she completed the last MDS (Annual) for Resident #63. Staff A stated she coded Resident #63 for receiving antipsychotic and antidepressant medications and did not code it for the anti-anxiety medication. Staff A stated she did the assessment based on the physician orders, and administration records. After stating that, Staff A reviewed the assessment completed on the medication and stated, It was wrong. I only put antipsychotic that was 7 days and should be 4 days and the antidepressant was coded by mistake. Staff A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 2 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 stated, the resident was taking anti-anxiety medication (Lorazepam for 3 days in the lookback period and Buspirone for 7 days) but it was not coded. 2. Record review of the admission Record revealed the resident was admitted to the facility on [DATE] and discharged home on [DATE]. Residents Affected - Few Record review of the Medical Diagnoses revealed the resident's diagnosis included, but were not limited to, Cerebral Infarction, Unspecified; Disorder of Muscle, Unspecified. Record review of the Care Plan initiated on 01/18/2022 and completed on 01/25/2022 revealed, the resident wishes to be discharged to home. Goal: The resident's discharge goals were to regain strength. Interventions: Evaluate the resident's motivation to return to the community. Record review of Social Services Notes dated 03/28/2022 revealed a referral made for Durable Medical Equipment to a medical supply company. Record review of the Nursing Notes dated 03/28/2022 revealed the Resident left in stable condition with son. Medications were reviewed with the resident. No pain or discomfort noted. Record review of the Discharge Return not Anticipated Minimum Data Set (MDS) Section A dated 03/28/2022 revealed the resident was discharged to an acute care hospital. Record review of the Discharge Return Not Anticipated MDS Section C dated 03/28/2022 revealed the Brief Interview for Mental Status Summary Score was left blank. Record review of the Discharge Return Not Anticipated MDS Section G dated 03/28/2022 revealed the resident needed extensive assistance for bed mobility, dressing and personal hygiene. Interview with the Social Services Director on 04/28/22 at 03:24 PM revealed, she stated the resident was discharged to his house in North Carolina, that's why we did not send a Nursing Home Transfer and Discharge to the Ombudsman Council. Interview with Staff A, a Licensed Practical Nurse/MDS Assistant on 4/28/22 at 05:39 PM revealed she stated the resident was discharged before the new company took over and she had not accessed the old system. Record review of Policies and Procedures not dated revealed Policy: A comprehensive assessment of every resident's needs is made at intervals designated by the Omnibus Budget Reconciliation Act (OBRA) and Prospective Payment System (PPS) requirements. Policy Interpretation and Implementation: The resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessment and reviews according to the following requirements: 5-Discharge Assessment-Conducted when a resident is discharged from the facility. 3. On 04/25/22 at 11:33 AM Resident #66 stated I have pain in my feet that is getting worse, my Clonazepam medications were not available for 4 days earlier this month, this is not good I need to have that medication, please check into this. On 04/26/22 at 01:55 PM Resident #66 was in the hallway walking with a walker and asked if the surveyor found out about his medication situation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 3 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 Review of resident #66's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Pain Unspecified Joint and Anxiety Disorder. Record review of the physician order sheet revealed Resident #66 had orders for Clonazepam 0.5Milligrams (MG) 1 Tablet-Give 0.5 mg by mouth at bedtime related to anxiety disorder. Residents Affected - Few Record review of the Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C-Brief interview of Mental Status score (BIMS) is 15 on a 0-10 scale, indicating the resident is cognitively intact. Section N-0410 B-was not coded for antianxiety medications in the last 7 days. Record review of the Quarterly MDS dated [DATE] revealed: Section N-0410 B-was not coded for antianxiety medications in the last 7 days. Record review of Resident #66 care plan revealed- Focus: The resident uses anti-anxiety medications r/t [related to] anxiety disorder. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ant-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Educate the resident about risks, benefits, and the side effects and/or toxic symptoms of the medications. Monitor the resident for safety-The resident is taking anti-anxiety medications which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Monitor/record occurrence for target behavior symptoms and document per facility protocol. On 04/28/22 at 10:19 AM when asked about resident #66's MDS section coding protocols, Staff A, Licensed Practical Nurse (LPN) MDS assistant coordinator, Staff A stated we have an Registered Nurse (RN) that comes in three times a week, I have no idea why the resident was not coded for antianxiety medications, it should have been, I work the floor, I do restorative, care plans and MDS, I have a lot on my plate, the new company took over about three weeks ago and we are still working things out. Review of the undated facility's Policy and procedure titled, Resident Assessment, states: The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements. A comprehensive assessment includes Completion of the Minimum Data Set (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 4 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I for mental disorder (MD) or intellectual disability (ID) was completed correctly at the time of admission for three (Resident #27, Resident #63, and Resident #16) out of three residents investigated and failed to ensure the completion of a level II PASARR for those three residents. This deficiency had the potential to affect 83 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: 1. Record review of the Resident #63's Face sheet revealed a date of admission of 08/10/2021. The original admission date was 05/03/2010. The diagnoses included but were not limited to: Essential (primary) Hypertension, Chronic Obstructive Pulmonary Disease, unspecified, Schizoaffective Disorder, unspecified, Anxiety Disorder, unspecified, Major Depressive Disorder, single episode, unspecified, etc. Record review of Resident #63's PASARR Level I completed on 05/03/2010 revealed no identification of any psychiatric diagnosis under 1A. In Section 1B it was not checked for Severe Mental Illness (SMI). In Section 2,3, and 4 (No) was checked. In Section IV: PASARR Screen Completion revealed the Master in Social Work (MSW) from the facility checked, No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. The Level II PASARR evaluation was not required. Record review of Resident #63's PASARR Level I completed on 07/08/2021 revealed no identification of any psychiatric diagnosis under section 1A. In Section 1B it was not checked for SMI. Section 2, 3, 4 (No) was checked all cases. In Section IV: PASARR Screen Completion revealed the Master in Social Work (MSW) from the facility checked, No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. The Level II PASARR evaluation not required. Record review of Resident #63's Minimum Data Set (MDS) Annual dated 01/09/2022 revealed, in Section C, the Brief Interview for Mental Status (BIMS) for Resident #63 was a score of 9, indicating moderate cognitive impairment, Section A -Identification Information-A 1500 was coded as (No) on the Preadmission Screening and Resident Review (PASARR) Level 2 consideration. In the Section I-Active Diagnoses included Anxiety, Depression and Schizophrenia. In Section N - Medications the resident was coded for the use of Antipsychotics and Antidepressant, however Resident #63 was not receiving an antidepressant medication as per the April 2022 physician orders reviewed. Resident #63 was receiving an Anti-anxiety medication (Lorazepam) which was not coded. Record review of Resident #63's Consent for use of psychoactive medication therapy dated 08/12/2021 revealed the resident's consent for use of Risperidone and Quetiapine was completed. Record review of Resident #63's Physician orders (POs) dated 02/11/2022 and changed on 04/06/2022 revealed Risperdal 2 mg, 1 tablet at bedtime for a diagnoses of Schizoaffective Affective Disorder. On 02/11/2022, Buspirone HCI (Hydrochloride) tablet 5 mg, 1 tablet by mouth twice for a diagnosis of anxiety; on 04/06/2022 Quetiapine Fumarate Tablet 100 MG, Give 1 tablet by mouth two times a day for a diagnosis of psychosis, on 04/07/2022 Lorazepam Tablet 0.5 MG twice a day for psychosis. There was no order for antidepressant medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 5 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 Record review of the Care Plan dated 12/30/2018 revealed Resident #63 was cared planned for use of Psychotropic medications daily, Classification: Antipsychotic/Antianxiety. On 12/30/2018 a care plan was done for Resident #63 for at risk for adverse effects from the use of Antidepressant. But there was no antidepressant medication ordered currently as a physician orders). Record review of Resident #63's Progress Notes dated 04/11/2022 revealed, Late Entry: Note Text: On last visit nursing reported that resident has been complaining of increased voices''. I assessed resident and found that she was extremely anxious and stating that the voices had increased and was troubling for her. Today she was smiling and more engaging post administration of medications. She is sleeping better. Appetite has returned and nursing staff was reminded to give her more H20 via peg. Will follow up in 14 days with client. Again, benefits of meds outweigh risks. Record review of Resident #63's Progress Notes dated 1/18/2022 at 12:30pm revealed, ARNP/NP/PA (Advanced Registered Nurse Practitioner/Nurse Practitioner/Physician Assistant) Late Entry: Note Text: Psych Note January 18th, 2022 Resident was previously seen and is known to writer. She remains pleasant, is alert and interacts well with staff and peers. Appears stated age. Information is obtained mostly from chart or staff. Stable with no new problems. No recent mental health changes. Loss of energy noted. No evidence of suicidal gestures. Mood is appropriate to situation. No negative reports received from staff. No behavioral issues noted or reported. Assessment remains unchanged since last visit. Discussed treatment plan with nursing staff. No new meds ordered, if need be, will review for GDR [Gradual Dose Reduction] of meds. Record review of Resident #63's Psych consults dated 06/07/2021, 07/12/2021, 08/08/2021, 08/30/2021, 09/24/2021, 11/09/2021, 02/15/2021 and 03/08/2021 revealed Resident #63 received an evaluation on the resident's mental condition and diagnoses. The consults revealed Resident #63 did not receive antidepressant medication. Interview with the Social Services Director on 04/28/2022 at 04:15 pm revealed, upon admission and based on documentation sent from the hospital the PASARR Level I should have the mental diagnosis checked. The Social Services Director stated that if the PASARR Level I is not completed properly they will send it back to the hospital for correction, or the Director of Nursing (DON) will have to redo it. The Social Services Director stated Resident #63's psychiatric diagnoses were missed on the original PASARR completed on admission and the one completed last year on 07/08/2021. The Social Services Director stated the facility did not request a PASARR Level II screening for Resident #63. The Social Services Director stated she started working in this position recently, but if she would have seen mental illnesses as diagnosis, she would have requested the screening for a Level II after reviewing it and corrections would've been done. The Social Services Director agreed that a Level II PASARR should have been requested when the last Level I was completed. Record review of undated policy on admission Criteria revealed for the PASARR: Statement: Our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation: 9.- All new admission and readmission are screened for a mental disorder (MD), intellectual disabilities (ID) or related disorder (RD) per the Medicaid Pre-admission Screening and Resident Review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 6 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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) process. Level of Harm - Minimal harm or potential for actual harm a. Residents Affected - Few The facility conducts Level I PASARR screen for all potential admission, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for Level II (evaluation and determination) screening process. 1) The admitting nurse notifies the social services department when a resident is identified as a possible (or evident) MD, ID, or RD. 2) The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. The State PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the State PASARR representative, the potential resident and his or her representative are notified. 2. Observation of resident #27 on 04/27/2022 at 12:05 PM, the Resident was seated in her wheelchair in the hallways. No distress or anxiety was noted. Record review of the admission Record revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 7 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 Record review of the Medical Diagnosis revealed the resident's diagnoses included, but were not limited to, Parkinson's Disease; Unspecified Dementia without Behavioral Disturbance; Schizoaffective Disorder, Unspecified. Record review of the PASARR Level I not dated revealed no identification of any mental health diagnosis under 1A. Section 1B was not checked for Serious Mental Illness (SMI). Section 2, 3 (A/B) and 4 (A/B) were checked (No). Section II Part A & B were checked (No). Section IV, V and VI were not completed. Record review of the Annual Minimum Data Set (MDS) Section A dated 08/10/2021 revealed the resident was not currently considered by the state Level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. Record review of the Physician Orders dated 01/28/2022 revealed the resident was currently receiving Zoloft Tablet 25 mg (Sertraline HCL) Given 1 tablet by mouth one time a day for depression. Record review of the Care Plan initiated on 02/08/2022 and completed on 02/15/2022 revealed the resident was at risk for adverse effects from the use of antipsychotic medication for schizoaffective disorder. Goal: The resident will be/remain free of antipsychotic drug related complications. Interventions: Administer Antipsychotic medications as ordered by physician. Monitor behavioral symptoms and side effects. Complete Abnormal Involuntary Movement Scale (AIMS) quarterly. Dose reduction attempts per evaluation if clinically indicated. Evaluate medication use and resident's response quarterly. Provide non-pharmaceutical intervention as needed. Psychiatrist consultation as needed. Record review of the Quarterly MDS Section C dated 02/10/2022 revealed the residents Brief Interview for Mental Status (BIMS) Summary Score was 03, indicating severe cognitive impairment. Record review of the Quarterly MDS Section I dated 02/10/2022 revealed one of the resident's diagnoses was Schizophrenia. Record review of the Medication Administration Record for the month of April 2022 revealed the resident was receiving Zoloft Tablet 25 MG (Sertraline HCL) Give 1 tablet by mouth one time a day for depression. -Start Date 01/29/2022. Record review of Advanced Registered Nurse Practitioner (ARNP) notes dated 02/10/2022 revealed Psychiatric follow up note: Resident seen and assessed at bedside. As it relates to psychiatric disorder, resident condition was chronic. Appetite and sleep were fair. Appears stable and staff states that there were no management issues. No reports of audio/visual hallucinations or paranoia. Some level of mild depression and anxiety on occasion as reported by nursing staff at times, however it does not interfere with treatment plan. No evidence of behavioral issues reported or noted. Nurses' states that resident was stable and complaint with milieu. No documentation of suicidal thoughts or gestures reported. Benefits of medications outweighs risks. Will follow up in 7-30 days as needed. Record review of the Psychiatrist Notes dated 04/07/2022 revealed a Psychiatrist Visit 4/7/22 HX[History]: Mood Disorder. Resident seen at bedside, alert and oriented to name and place. Appears stable at this time. No acute psychosis noted. Mood and affect appropriate. No audio/visual hallucinations. Complaint with medication Zoloft. No side effects voiced. Benefits of medications outweighs risks at this time. Nursing maintaining COVID protocols. Treatment Plan: continue with supportive and medication management. Monitor mood behavior, sleep and appetite. Encourage resident to participate in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 8 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 Activities to improve cognitive function. Follow up discussed with nursing. Level of Harm - Minimal harm or potential for actual harm Interview with Staff C, a Licensed Practical Nurse (LPN) on 04/28/22 at 11:18 AM. She stated the resident was not aggressive but confused. The Resident was alert but not oriented. She stated the resident is very quiet and pleasant with the staff and other residents. She can request assistance. The Family is very involved in the resident's care; resident assisted the Certified Nursing Assistant with some tasks that she can do by herself. Her appetite is good, and the resident tolerated medications with no problem. Residents Affected - Few Interview with the Social Services Director on 04/28/22 at 02:26 PM. She stated the resident was admitted in 2014. The resident was admitted from a local hospital on [DATE] and the Level I PASARR was received. She stated, Now I noted the form was incomplete I will send the form back to the hospital where the resident was admitted from. Record review of the Policies and Procedures not dated revealed Policy: Our facility admits only residents who's medical and nursing care needs can be met. Policy Interpretation and Implementation: 1-The objectives of our admission criteria policy are to: assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission. 9- All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. 3. Review of the Demographic Face Sheet for Resident #16 documented the resident was admitted to the facility on [DATE] with diagnoses to include substance abuse, dementia, and major depression. Observation of Resident #16 on 4/25/22 at 11:46 AM revealed the resident sitting in a chair with her eyes full of tears, started crying and saying, I want my mother. She had a wander guard on her right ankle for elopement. Review of the Minimum Data Set (MDS) Comprehensive Assessment for Resident #16 dated 7/20/21 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 4 out of 15. The MDS Quarterly Assessment for Resident #16 dated 4/21/22 had a BIMS Summary score of 5 out of 15 indicating that the resident is very cognitively impaired and in need of supervision and reorientation. Review of the Physician's Orders (POS) dated 7/13/2021 for Resident #16 documented the resident received Trazodone HCl (Hydrochloride) tablet 50mg for Depression, give 1 tablet by mouth at bedtime. Also, the resident had an order dated on 7/28/2021 for Depakene Solution 250mg/5ml (Valproate Sodium), give 250mg by mouth two times a day for mood swings. The resident had an order for the staff to monitor the resident's behavior when on Trazodone as well as monitoring the outcome interventions. The physician placed the order on 9/05/2021 for monitoring: Outcome of intervention. I-Improved, U-unchanged, W-worsened (call MD) to all staff. Review of the EMAR (electronic medical administration record) dated July 2021 for Resident #16 documented that the staff had been documenting the resident's behavior throughout the shifts. Review of Resident's #16's care plan dated 7/14/2021 documented that the resident had a diagnosis of dementia, has impaired cognitive function/dementia or impaired thought processes related to long term memory loss. The interventions include the following: Will maintain current level of cognitive function through the review date, Ask yes/no questions in order to determine the resident's needs and Cue, reorient and supervise as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 9 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of Resident's #16 PASARR Level I dated 7/13/2021 documented it was completed by the staff at a local hospital. The level 1 included the question, if the individual had a primary diagnosis of dementia, the answer was checked, (no) on the form. Interview and record review with the Social Worker Manager/Director on 4/28/22 at 3:30 PM revealed that she agreed that resident #16 should have a PASARR Level II done. She also stated that Resident #16 had not gone out to the hospital. The Social Worker Manager/Director agreed the PASSAR is incomplete. Event ID: Facility ID: 105903 If continuation sheet Page 10 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement one (Resident #40) out of 40 sampled residents comprehensive care plan for administering tube feedings as ordered by the physician. This had the potential to affect 14 residents receiving tube feeding at the time of the survey. The findings included: During observation on 04/25/22 at 12:12 PM, resident #40 was observed in bed, his eyes were open, the resident's eyes were looking around but they did not focus and the resident did not respond verbally when his name was called. Resident #40 was observed to have a tube feeding of Jevity 1.5 at 55ml (milliliters)/hr (hour) infusing via a PEG (Percutaneous Endoscopic Gastrostomy) tube. The resident's lips were observed to be very dry. The resident appeared to have contractures in his fingers and legs. The resident was in a low bed with 2 siderails up. Two surveyors observed the residents at this time. Observation on 04/25/22 at 03:47 PM, the resident was in bed awake, the Jevity 1.5 tube feeding was infusing at 55ml/hr. Two surveyors observed the residents at this time. Observation on 04/26/22 at 10:01 AM, resident #40 was in bed with his eyes open, but he appeared to be sleeping. The Jevity tube feeding was infusing at 55ml/hr, the Jevity 1.5 bag was dated for 4/26/22, and the tube feeding pump showed 76ml had infused. There was a syringe attached on the tube feeding pole and it was dated 4/26/22. Two surveyors observed the residents at this time. Observation on 04/27/22 at 12:41 PM, Resident #40 was observed in bed awake, the Jevity 1.5 tube feeding had been increased to 65 ml/hr and 258ml had infused. The Jevity bag and syringe were dated 4/27/22. Two surveyors observed the residents at this time. During observation on 04/28/22 at 11:42 AM, resident #40 was in bed awake the tube feeding was in progress with Jevity 1.5 at 65 cc/hr infusing via the PEG. During record review it was noted resident #40 was admitted to the facility on [DATE], the current readmission was on 02/11/2022, the resident's diagnoses, included Cerebral Infarction, Dysphagia, Type 2 Diabetes, Chronic Obstructive Pulmonary Disease (COPD), Malnutrition, Hemiplegia, muscle weakness, abnormal posture, Gastrostomy, Heart Failure, Dementia, and Acute Kidney Failure. The residents Brief Interview for Mental Status (BIMS) couldn't be calculated because the resident was rarely understood. The resident's weights were documented as: On 01/19/2022, 130lbs (pounds) On 02/22/2022, 127.3lbs On 03/28/2022, 130lbs On 04/25/2022,122.9lbs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 11 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During the review of the physicians orders it was noted the resident's orders included: Level of Harm - Minimal harm or potential for actual harm Nothing by Mouth diet, (NPO) texture, the order was active since 2/14/2022. Residents Affected - Few Jevity 1.5 @ 65 ml/hr via PEG X 22hrs (OFF 6am ON 8am) or until 1,430 volume is infused every shift this order was active since 3/2/2022. Flush Q (every) shift with 350 ccs (cubic centimeter) of water every shift effective 2/14/2022. Record review of resident #40's care plans included the following care plans that interventions were not implemented for the administration of the tube feeding orders: 1. The resident requires tube feeding r/t [related to] Dysphagia. Goal: The resident will maintain adequate nutritional and hydration status . weight stable, no s/sx {signs and symptoms] of malnutrition or dehydration through the review date. The approaches included: The resident is dependent with tube feeding and water flushes. See MD [Medical Doctor] orders for current feeding orders. [LPN, RN] [Licensed Practical Nurse, Registered Nurse]. Shows on [NAME]. 2. The resident has a potential nutritional problem d/t [due to] PMH [past medical history] of cerebral infarct, DM [Diabetes Mellitus], Kidney Failure (acute), malnutrition, anxiety, HTN (Hypertension], quadriplegia, dementia, dependent on enteral feeds, hx [history] of sig wt changes, impaired skin to BIL [bilateral] feet on reentry. Goal: The resident will maintain adequate nutritional status as evidenced by absence of unplanned sig wt [weight] changes, no s/sx of malnutrition, and tolerance to TF [tube feeding]/water flushes through review date. The interventions included: Provide TF [tube feeding] and water flushes as ordered [CNA, LPN, RN] [Certified Nursing Assistant, Licensed Practical Nurse, Registered Nurse]. During interview with Staff C, Licensed Practical Nurse, on 4/28/22 at 2:45pm Staff C was asked whether there was any change in resident #40s tube feeding order recently? Staff C reported, no, its 65 cc/hr. Staff C was informed two surveyors observed the tube feeding at 55cc/hr on 04/25/2022 and 04/26/2022. Staff C reported, she checked the tube feeding and it was 65cc/hr. Staff C reported, at one time the tube feeding was 55cc/hr, but it was a while back. Interview on 4/28/22 at 2:55pm with the Director of Nurses (DON), the DON was informed about the tube feeding being observed at 55ml/hr, and the facility's tube feeding policy was requested. During the review of the facility's Enteral Nutrition policy, the policy was not dated, the policy statement documented: Adequate nutritional support through enteral feeding will be provided to residents. The Policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 12 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Interpretation and Implementation included: 4. Enteral nutrition will be ordered by the Physician based on the recommendations of the Dietitian. 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: 105903 If continuation sheet Page 13 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation of resident #68 on 04/25/22 at 11:41 AM, revealed the resident was in bed, eyes closed, and she opened her eyes, when her name was called. The resident had on a nasal cannula (NC) and the oxygen (O2) was on at 3L (liters)/minute (min). The oxygen concentrator was observed on the left side of the resident's bed. The resident was able to speak, but her tone of voice was low. Residents Affected - Few Observation on 04/25/22 at 01:06 PM revealed, resident #68 was in bed asleep, her lunch tray was on the bedside table in front of her. The resident had eaten approximately 10% of her food. Observation on 04/25/22 at 03:37 PM, resident #68 was observed in bed asleep, the O2 was on at 3L/min via NC. During record review it noted resident #68 was admitted to the facility on [DATE] with diagnoses to include Diabetes Mellitus, Cerebrovascular Disease and Shortness of Breath. On 04/26/22 at 09:32 AM, resident #68 was observed in bed awake, the residents breakfast tray was on the bedside table. The residents NC was on and the O2 was observed to be set at 2 1/2L/min. A picture was obtained. On 04/27/22 at 04:29 PM, resident #68 was observed in bed asleep with her NC on and her O2 was on at 2 1/2 L/min. The resident's son was at her bedside. On 04/28/22 at 11:36 AM, observed resident #68 in bed asleep with her NC on and her O2 was set at 2 1/2 liters. On 4/28/22 at 2:45pm Staff C, a Licensed Practical Nurse, was interviewed about resident #68's O2 setting. Staff C reported the residents O2 setting is 2L/ per min. Staff C was informed resident #68's O2 has been observed at 2 1/2 liters to 3 liters. Staff C and I went to resident #68's room to check the O2 setting. The resident's son was sitting in the room, and the resident was awake, and no distress was observed. Staff C was observed to adjust the O2 to 2L/min. During record review it was noted the resident had an MD (Medical Doctor) order for Continuous Oxygen at 2L/min via NC every day for SOB (Shortness of Breath) dated 12/15/2021. During the review of resident #68s Minimum Data Set, dated [DATE], Section O, O100 - documented the resident was receiving Oxygen. During the review of the resident's care plans, the resident was noted to have a care plan for: The resident has oxygen therapy r/t (related to) Short of Breath. The goal was - The resident will have no s/sx (signs and symptoms) of poor oxygen absorption through the review date. The care plan approaches included - OXYGEN SETTINGS: O2 via (nasal cannula @ (2)L (continuously). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 14 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 0695 Level of Harm - Minimal harm or potential for actual harm Based on observations, interview and record review, the facility failed to follow physician's orders for the administration of oxygen for 2 (Resident #67 and #68) out of 11 residents receiving respiratory treatments at the time of the survey. As evidenced by the physician prescribed 2L/min (Liters per Minute) of oxygen for resident #67 and the resident was observed receiving 4L/min and 3L/min of oxygen. Resident #68 was observed receiving 3L/minute instead of the ordered 2L/min of oxygen. Residents Affected - Few The findings included: 1. Observation of resident # 67 on 04/25/22 at 10:27 AM, the Resident was observed lying on his bed, awake. The Resident was receiving oxygen therapy. It was observed the oxygen concentrator level was set at 4L/min. (Photographic evidence obtained). There was no distress or anxiety observed. A sign for Oxygen in use was observed at the room door. Observation of resident # 67 on 04/27/22 at 12:53 PM, the Resident was observed seated on his bed eating lunch. There was no distress noted. The oxygen concentrator level was set at 3L/min (Photographic evidence obtained). Observation of resident # 67 on 04/28/22 at 10:38 AM, the Resident was sleeping. There was no distress observed. The oxygen concentrator level was set at 3L/min. (Photographic evidence obtained). Record review of the admission Record revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the residents Medical Diagnosis revealed the resident's diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD), Unspecified; Unilateral Inguinal Hernia with Obstruction, Without Gangrene, Not specified as recurrent; Major Depressive Disorder, Recurrent, Unspecified; Major Depressive Disorder, Recurrent, Unspecified. Record review of the physician orders dated 08/31/2021 revealed, the resident had an order for Oxygen Therapy at 2L/min via nasal cannula. Every shift related to Chronic Obstructive Pulmonary Disease, Unspecified. Record review of the Quarterly Minimum Data Set (MDS) Section C dated 03/23/2022 revealed, the resident Brief Interview for Mental Status (BIMS) Summary Score was 07, indicating severe cognitive impairment. Record review of the Quarterly MDS Section G dated 03/23/2022 revealed, the resident needed extensive assistance with one-person physical assistance for dressing and personal hygiene. The resident needed supervision with one-person physical assistance for bed mobility and walking in the corridor. The resident is independent with set up only for transfer, walking in the room and eating. Record review of Quarterly MDS Section O dated 03/23/2022 revealed, the resident was receiving oxygen therapy. Record review of Care Plan initiated on 03/17/2022 and completed on 03/24/2022 revealed, the resident had oxygen therapy related to Respiratory Illness (COPD). Goal: The resident will have no sign and symptoms of poor oxygen absorption through the review date. Interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor for signs and symptoms of respiratory distress and report to physician as needed. Oxygen setting: Oxygen at 2L/min via nasal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 15 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 0695 Level of Harm - Minimal harm or potential for actual harm cannula. Every shift related to Chronic Obstructive Pulmonary Disease. Oxygen Saturation every shift, if less than 92 % call physician. Suction as needed. Interview with Staff C, Licensed Practical Nurse (LPN) on 04/28/22 at 11:03 AM. She stated, the oxygen level for this resident must be 2L/min. Residents Affected - Few Interview with Staff A, LPN on 04/28/22 at 11:09 AM. She stated that she was not the regular nurse for this resident. She stated, that was her mistake not to check the oxygen for this resident when she started the shift. Record review of the Policies and Procedure, not dated, revealed the Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1- Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Record review of the Policies and Procedures effective date 05/21/20, last reviewed on 05/20/20 revealed: Title: Physician's Orders. Policy: It is the policy of [E .] Care Group to write physician's orders to establish a plan of care to follow for the care of the patient. Purpose: To ensure that the plan of care is followed in accordance with the orders established by the physician and/or nurse practitioner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 16 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 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 observations, interviews and record reviews, the facility failed to ensure the availability Residents Affected - Few of prescribed medication to be administered daily for 1 out 4 residents sampled (Resident #66), as evidenced by Clonazepam 0.5 milligrams (MG) 1 Tablet not being available to administer to Resident #66 on two consecutive days. The findings included: On 04/25/22 at 11:33 AM Resident #66 stated I have pain in my feet that is getting worse, my Clonazepam medications were not available for 4 days earlier this month, this is not good I need to have that medication, please check into this. On 04/26/22 at 01:55 PM Resident #66 was in the hallway walking with a walker, the resident asked if surveyor found out about his medication situation. Review of resident #66's medical records revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Pain Unspecified Joint and Anxiety Disorder. Record review of the physician order sheet revealed Resident #66 had orders for Clonazepam 0.5Milligrams (MG) 1 Tablet-Give 0.5 mg by mouth at bedtime related to anxiety disorder. Record review of the Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C-Brief interview of Mental Status score (BIMS) is 15 on a 0-10 scale, indicating the resident is cognitively intact. Section N-0410 B-was not coded for antianxiety medications in the last 7 days. Record review of the Quarterly MDS dated [DATE] revealed: Section N-0410 B-was not coded for antianxiety medications in the last 7 days. Record review of Resident #66 care plan revealed- Focus: The resident uses anti-anxiety medications r/t [related to] anxiety disorder. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ant-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Educate the resident about risks, benefits, and the side effects and/or toxic symptoms of the medications. Monitor the resident for safety-The resident is taking anti-anxiety medications which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Monitor/record occurrence for target behavior symptoms and document per facility protocol Record review of Resident #66 Electronic Medication Administration Record (EMAR) revealed on 3/31/22 and 4/1/22 at 9PM-Clonazepam 0.5MG (1) tablet was not given to the resident as prescribed. Interview on 04/28/22 at 09:44 AM, when asked about resident #66's Clonazepam 0.5 MG 1 tab not being available for two consecutive days. The Director of Nursing (DON) stated on 4/1/22 we transitioned to the new company and new pharmacy. We gave the new pharmacy the resident's Psychiatrist number so the pharmacy could collaborate with the psychiatrist to get the medications ordered and apparently (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 17 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 there was a delay in the order. As far as if the medication was available in the Emergency Supply Kit (Ekit), l cannot say for sure, we were in transition with the new company. No behavioral issues were reported about this resident to me during the time he did not have his medication. I have a very good rapport with this resident, and he never told me anything about his medications. This resident always reports all his problems/issues. Residents Affected - Few Review of the undated facility's Policy and procedure titled, Administering Medications, states: Medications are administered in a safe and timely manner, and as prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 18 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to address the pharmacy recommendations related to drug regimen review for antipsychotic medication for one resident (resident #16) out of 5 sampled residents reviewed for unnecessary medications, Psychotropic Medications and Medication Drug Regimen Review. This has the potential to affect 83 residents residing in the facility at the time of this survey. The findings included: Review of the Demographic Face Sheet for Resident #16 documented the resident was admitted to the facility on [DATE] with diagnoses to include substance abuse, dementia, and major depression. Review of the Physician's Orders (POS) dated 7/28/2021 for Resident #16 documented the resident received Depakene Solution 250 mg/5ml (Valproate Sodium), give 250 mg by mouth two times a day for mood swings. Also, POS dated 7/13/2021 Trazodone HCl Tablet 5mg, give 1 tablet by mouth at bedtime for Depression. Review of the Medication Regimen for Resident #16 documented the Depakene Solution 250 mg/5ml (Valproate Sodium), give 250mg by mouth two times a day for mood swings. Review of the Consultation Report January 1, 2022 through January 31, 2022 for Resident #16 dated on 01/24/2022 documented that the pharmacist consultant made a comment and recommended a GDR (gradual dose reduction) of Valproate Sodium to 125mg (milligrams) QD (everyday) and 250mg q (every) 5pm with the end goal of discontinuation while concurrently monitoring for emergencies. Resident 16# is taking a Vitamin D. Recommendation: Please monitor serum calcium and phosphate every 1 to 3 months, monitor PTH [Parathyroid Hormone) every 3 to 6 months or as clinically indicated. The Director of Nursing (DON) and the MD (medical doctor) did not acknowledge the Pharmacist recommendation. There were no comments documented from the physician and DON. Interview with the DON on 4/28/22 at 1:09 PM. He responded, I was the ADON (Assistant Director of Nursing) at the time of the recommendation. The DON should have acknowledged the form before she left. He became the DON in February 2022. Review of the progress notes for Resident #16, the MD nor the DON at the time did not make any comments or acknowledgments to the recommendations by the Pharmacist regarding the Valproate in January 2022. Review of the labs for Resident #16, revealed the Valproic acid levels were low. The lab results dated 3/02/2022: Valproic Acid 44.8ug/ml (microgram/milliliter). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 19 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME] Residents Affected - Few Based on observations, interviews, and record reviews, the facility failed to ensure its medication error rate was five percent or below, as evidenced by an error rate of 12.9 percent during medication administration observation. Four medication errors were identified while observing a total of 31 opportunities, affecting Resident # 339, # 71 and # 22. These errors were considered to be omission errors. The Findings Included: During the facility's recertification survey which started on April 25, 2022, the facility staff reported the (QD) every day medications are given at 9:00AM. On 4/27/22 at 8:40 AM during the medication administration observation with Licensed Practical Nurse (Staff B). It was observed that Staff B did not have on her medication cart and was unable to administer one prescribed medication (Folic Acid 1 MG(milligram) (1) tablet) for Resident # 339 and for for Resident #71 at 9:00AM two prescribed medications (Folic Acid 1Milligram (MG), 1 tablet, and Famotidine 10MG (1) tablet) were not available for administration during the 9:00AM medication observation. Review of Resident # 339 's clinical record documented an initial admission to the facility on [DATE] with diagnoses including Anemia in Chronic Kidney Disease and Diabetes Mellitus. Review of Resident #339's physician orders for April 2022 revealed medications to include, Folic Acid 1Milligram (MG), 1 tablet. Review of Resident #71 's clinical record documented an initial admission to the facility on [DATE] with diagnoses including Seizures and Heart Failure. Review of Resident #71's physician orders for April 2022 revealed medications to included, Folic Acid 1Milligram (MG), 1 tablet, and Famotidine 10MG (1) tablet. On 04/27/22 at 09:28 AM Interview with Staff B, about the medications that were not given to resident #339, Folic Acid 1 MG (1) Tablet, and resident # 71, Folic acid 1 MG (1) tablet, and Famotidine 10MG (1) tablet, Staff B stated, if it's like a blood pressure pill or something I would check the emergency cart, but for these medications I will call the MD (Medical Doctor) and let him know that the milligrams of the medication he ordered are not available and what does he want us to do regarding the medication. Staff B reported, she would let the surveyor know about the outcome of the conversation with the MD. On 04/27/22 at 02:10 PM, the Director of Nursing (DON) when told about the residents who had missing medications during the medication administration observation stated, he would go find out what is going on with those medications from the nurse. On 04/27/22 at 02:33 PM, the DON presented information on resident # 71 and resident #339 revealing the medications (Folic Acid 1MG (1) tablet and Famotidine 10 (1) tablet for resident #71, and Folic Acid 1MG (1) tablet for resident #339) were received from the facility's pharmacy on 4/27/22 and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 20 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 0759 one-time order was obtained from the residents' MD to give medications at 2PM on 4/27/22. Level of Harm - Minimal harm or potential for actual harm Review of the undated facility Policy and Procedure titled, Administering Medications, states in part: Medications are administered in a safe and timely manner, and as prescribed. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapuetic effect of the medication. Preventing potential medication or food interactions and Honoring resident choices and preferences, consistent with his or her care plan. Residents Affected - Few Medications are administered within one hour of the prescribed time, unless otherwise specified (for example, before and after meals orders). On 04/27/2022 at 8:48AM, during the medication observation with Staff C, Licensed Practical Nurse (LPN), it was observed as the nurse was pouring the medications for Resident #22, the residents Lisinopril 40 mg scheduled to be given at 9:00AM for Hypertension was not available for administration. Staff C reported at 9:00AM, she would go to the first floor nurses station to get the medications from the Cubix, medication dispensary machine. Staff C removed (2) 5 mg tablets from the machine. At 9:10AM on 4/27/2022, staff C returned to the cart to resume the medication observation. Upon restarting to pour the medications, staff C realized she had removed 10mg of Lisinopril instead of the 40 mg ordered for Resident #22. Staff C returned the pill cup into the locked cart and went to the Director of Nurses office to explain about the medication not being available at 9:12AM. At 9:23AM, the DON checked the Cubix to determine what medication had been removed. At 9:25AM, the DON called the physician to change the medication time to 2:00PM since the medication was not available for administration at 9:00AM. At 9:34AM, staff C returned to the medication cart to continue with the medication observation. The Lisinopril 40 mg was not given due to the medication not being available in the facility. A review of the Lisinopril physician order revealed the start date was 02/27/2021, the medication was ordered for 40mg, give 1 tablet by mouth one time a day for HTN (Hypertension). On 04/27/22 at 01:57 PM the DON was interviewed about the policy for medication administration and reordering medications. A copy of the policies were requested. The DON reported the facility had switched pharmacies on 4/1/2022. The DON reported, the medication was ordered on 4/25/22, but it was too soon to receive the medication, and he would research to determine the reason the resident didn't have medication. During the review of the facility's undated policy titled, Reordering, Changing, & Discontiunuing Medication Orders revealed, the policy included, The facility will communicate any medication reorders, changes, or discontinuations to the pharmacy in accordance with pharmacy guidelines and state/federal regulations, thus ensuring a standardized process of communication. The procedure included, In the event a medication is requested too soon, the pharmacy will send a Refill Too Soon Communication Form to the facility. The facility will automatically receive the medication when it is due unless the form is signed by a nurse and faxed to the pharmacy for immediate delivery. On 04/27/22 at 02:35 PM, the DON brought the revised physician ordrer for Lisinopril 40 mg, give 1 tablet by mouth one time a day for HTN and a copy of the bingo card that was sent to the facility from the pharmacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 21 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure the essential patient care equipment was in safe operating condition for Resident #7. The Hoyer lift used to transfer residents who were severely obese from the bed to the chair was not working. This has the potential to affect 3 out of 3 residents who use the Hoyer lift used for morbid obese residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Observation and Interview of Resident #7 on 4/25/22 at 11:51 AM revealed the resident sitting up in a wide bed, wearing glasses, with a foley catheter and on his electronic device. He stated, The Hoyer lift has been broke for over a month. They have not moved me from the bed. I'm stuck. I want to get out of the bed. Record review of the Demographic Face Sheet for Resident #7 documented the resident was originally admitted on [DATE] with a diagnosis of cardiomyopathy, pressure ulcer of the heel, pressure ulcer of the right hip, pressure ulcer of the sacral region, severely morbid obese, diabetes mellitus, hypertension, chronic obstructive pulmonary Disease and peripheral vascular disease. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident #7 documented the resident's Mental Status (BIMS) Summary Score was 15, indicating no cognitive impairment and the resident was able to make his needs known. The required total dependence with two+ persons physical assist for transfer. Review of the ADL (Activities Daily Living) self-care Care Plan for Resident #7, written 9/28/21 documented the following: Focus-Resident has an ADL self-care performance deficit r/t (related to) disease process; Goal-Resident will maintain current level of function and comfort through the review date; Interventions-Transfer: The resident requires Mechanical Lift with (X) staff assistance for transfers. Interview with Staff D, Licensed Practical Nurse (LPN) on 4/27/22 at 1:15 PM. She stated, He gets out of the bed. It takes three people and the Hoyer lift to get him out of bed. The Hoyer lift does not work. Interview with Staff E, Certified Nursing Aide (CNA) on 4/27/22 at 1:49 PM. She stated, It takes three people and Hoyer lift to get him out bed. He request when he want to get out of bed. Observation with Staff E, CNA on 4/27/22 at 1:54 PM revealed the Hoyer lift stored in the shower room, broken and not working. Demonstration of the Hoyer lift by Staff E, CNA revealed the Hoyer lift was not working. She stated, The Hoyer lift used for the resident is broken and has been broken for more than a week. I told the maintenance and they said they would fix it but they haven't. The resident asked me to get him out of bed and I told him that it was broken. I took the Hoyer lift to his room to prove to him that it wasn't working. Interview with the Maintenance Director on 4/28/22 at 8:51 AM. He stated, I don't recall anyone telling me about the Hoyer lift not working and needed to be fixed. As far as I know, the Hoyer lift is working. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 22 of 23 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Staff F, CNA on 4/28/22 at 8:55 AM. She stated, They have three Hoyer lifts. One for restorative and two for other patients, one for each floor. The one used to lift heavier patients is not working. Interview with the Director of Nursing (DON) on 4/28/22 at 12:15 PM. He stated, The resident has wounds. We have two electrical lifts and four manual lifts. It's kept on the second floor. I was not aware of the broken lift. The lift should be in working condition. Requested Essential Equipment Policy and Procedure (P&P) from the DON on 4/28/22 at 12:15 PM. He notified the surveyor on 4/28/22 at 1:26 PM, that the facility does not have a P&P on equipment being in proper working condition. Review of the Maintenance Logbook documentation (Received from the facility on 4/28/22 at 1:01 PM) documented Resident Lifts: Inspect mobile lifts, dated 3/7-12/22. No documentation was provided for the month of April 2022. Review of the Biomedical Services Equipment documentation (Received from the facility on 4/28/22 at 1:01 PM) documented Lift, Patient dated 3/1-31/22; Invacare Equipment Tested Passed. No documentation was provided for the month of April 2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 23 of 23