Inspection·June 8, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stays, the drainage specifically. I just come once a month and we have a nurse on site that monitors the techs. If the patient is sharing the room with a person that is mobile then the connection should be taken out, the drainage specifically. During an interview with the Housekeeping Manager on 06/08/23 at 03:41 PM, he stated, the bathrooms are cleaned on a schedule. When asked about the dialysis machine stored in the bathrooms, he stated, when the dialysis machine is in the bathrooms, they clean around the area, but they do not touch the equipment. 2. On 06/08/23 at 10:08 AM, observed Resident #62 in Geri chair, alert, hands fanning out, the call light cord in the bed was missing the pressing button. When the surveyor asked about how he asks for assistance he stated, I scream, I am not able to use the call light at all. Photo evidence. Record Review of Resident #62's Minimum Data Set (MDS) Annual dated 3/24/2023, admission date: 03/22/2022, Section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating that the resident is cognitively intact. During an interview with Staff A-Licensed Practical Nurse on 06/08/23 at 10:11 AM she stated, I come two days a week, in regard to Resident #62, is paraplegic, he cannot move his legs, and he moves his hands but not a lot, when he needs assistance, he verbalizes it. When asked if he is able to press the call light she stated, he is able to press the call light and at times he yells for the nurse. During an interview with Staff B-Certified Nurse Assistant on 06/08/23 at 10:17 AM she stated, when the resident needs something, he presses the call light, he is able to press the light, when laying on bed you give him the call light and he presses the call light. When asked about the broken call light, she stated, I talked to the maintenance staff about the call button being off the cord, yesterday I talked to maintenance and he said, we will be back this morning to fix it, I just put it in the bed like that today. During an interview with the Director of Maintenance on 06/08/23 at 10:43 AM he stated, every week we come and check the call light in the nurse stations plus the rooms. The Surveyor pointed out that the call light was missing the pressing button then he stated, it broke, when we came to the rooms, we press the button and we change the call light if it's broken, and if we come to the room and see things like these, we change them. Then he stated, last time I came to the room was Monday or Friday one of these days, I did not know it was broken. Review of document titled, Policy, Procedures and Information, Policy: Preventive Maintenance Program revealed: Purpose: To develop and implement a preventive maintenance program that promotes a safe, functional, and comfortable environment for all residents. Procedure: 1. The facility's maintenance program is based on regular and routine maintenance designed to maintain a safe, comfortable, operating environment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 2 of 20 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 06/08/2023 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 0558 2. Level of Harm - Minimal harm or potential for actual harm The Maintenance Director shall assess all aspects of the physical plant to determine if Preventive Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, significant event reviews, life safety requirements, and/or experience. Residents Affected - Few 3. This should include but is not limited to: a. Essential mechanical, electrical, life safety and patient care equipment. b. Maintain nurse call system 4. The Maintenance Director should maintain a system for routine audits of each of the areas above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 3 of 20 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 06/08/2023 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 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 observations, interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for three residents (Resident # 12, the resident's diagnosis was coded wrong, Resident # 75, the MDS was coded wrong for wander guard not in use, Resident # 29, the discharge status was coded wrong), out of 30 sampled resident's at the time of survey. This deficiency has the potential to affect 109 residents residing in the facility at the time of survey. Residents Affected - Few The Findings included: 1. Record review of the clinical records for Resident # 12 revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included, but were not limited to, Other sequelae of Cerebral Infarction Affecting Unspecified Side, Type 2 Diabetes Mellitus with Unspecified Complications; Unspecified Dementia, Unspecified Severity, Without Behavior Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. Record review of Orders dated 05/24/2022 revealed, the resident was receiving Trazodone HCL 25 milligrams. Give 25 milligrams by mouth at bedtime for depression. Record review of the Medication Administration Record for the month of April 2023 revealed, the resident was receiving Trazodone HCL tablet 25 milligram tablet by mouth at bedtime for depression. Start date 05/25/2022 as ordered. Record review of the Medication Administration Record for the month of May 2023 revealed, the resident was receiving Trazodone HCL tablet 25 milligram tablet by mouth at bedtime for depression. Start date 05/25/2022 as ordered. Record review of Medication Administration Record for the month of June 2023 revealed, the resident was receiving Trazodone HCL tablet 25 milligram tablet by mouth at bedtime for depression. Start date 05/25/2022 as ordered. Record review of the Medicare 5 day Minimum Data Set (MDS) Section C Cognitive Patterns dated 04/18/2023 revealed, the resident's Brief Interview for Mental Status (BIMS) summary score was 06 of 15, indicating severe cognitive impairment, Section I Active Diagnosis dated 04/18/2023 revealed, the resident's diagnoses were Stroke, Anemia, Hypertension, Diabetes Mellitus, Cerebrovascular Accident, Non-Alzheimer's Dementia and Hemiplegia and Section N Medications dated 04/18/2023 revealed the resident was receiving antidepressants seven days in a week. Record review of Care Plan initiated on 02/07/2019 and with the next review date 09/04/2023 revealed, the resident uses antidepressant medication related to Depression. Goal: The resident will be free from discomfort or adverse reactions to antidepressant therapy through the review date. Interventions include: Administer Antidepressants medications as ordered by the physician. Monitor/document side effects and effectiveness every shift. Educate the resident /resident representative about risks, benefits, and the side effects and/or toxic symptoms of antidepressant medication. Monitor/document/report as needed adverse reactions to Antidepressant therapy. Interview with Director of Nursing on 06/08/2023 at 11:33 AM. She stated, the person in charge is no longer working with the company. She stated she is in the MDS Coordinator right now. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 4 of 20 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 06/08/2023 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 Residents Affected - Few there are two part-timers working, they are working on Monday, Tuesday, and Thursday. She stated, resident # 12's MDS was coded wrong for resident's diagnosis. She stated, there was no other explanation. 2. Observation of resident # 75 on 06/05/2023 at 1:11 PM. The resident was observed seated in his wheelchair wandering in the hallway. The nurse redirects him to his room. It was observed that the resident had a wander guard on his right ankle. Record review of the clinical records for Resident # 75 revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included, but were not limited to, Other Seizures; Diffuse Traumatic Brain Injury with Loss of consciousness of Unspecified Duration, Sequelae; Major Depressive disorder, Recurrent, Unspecified; and Unspecified Injury of head, Initial Encounter. Record review of physician orders dated 01/31/2023 revealed, the order for a Wander guard to right lower extremity. Monitor for function, placement, and expiration of wander guard. Wander guard on right leg always every shift for exit seeking behavior. Elopement risk. Record review of Quarterly Minimum Data Set (MDS) Section C Cognitive Patterns dated 04/28/2023 revealed, the residents BIMS summary score was 03 of 15, indicating severe cognitive impairment, Section E Behavior-Wandering revealed, the resident did not exhibit the behavior, Section P Restraint and Alarms revealed, the resident's wander/elopement alarm was not used. Record review of the Care Plan initiated on 06/29/2022 with the next review date 07/27/2023 Elopement Risk revealed, the resident was an elopement risk/wanderer related to impaired safety awareness, resident wanders aimlessly 09/18/2022 Resident went outside to get some air without assistance. The resident was an elopement risk/wanderer related to Dementia, Disoriented to place, history of wandering, impaired safety awareness. At times difficult to redirect. 09/19/2022 Wander guard device to right lower extremity. Goal: The resident will not leave facility unattended through the review date. The resident's safety will be maintained through the review date. The resident will demonstrate happiness with daily routine through the review date. Interventions: Assess for elopement risk. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversations, television, books Resident prefers. Electronic monitoring device: wander guard to right ankle. Identify pattern of wandering: Is wandering purposeful, aimless or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor skin around wander guard every shift. Monitor right lower leg skin integrity around wander guard every shift. Provide structured activities: toileting, walking inside and outside, reorientation, strategies including signs, pictures and memory boxes. Interview with Director of Nursing on 06/08/2023 at 11:38 AM. She stated, the resident has an active wander guard. She stated she realized it is not coded in the MDS that the resident had a wander guard. The MDS staff made an error. No other explanation for this. Record review of policy titled, Policies, Procedures and Information for Resident Assessments effective date 04/01/2022 revealed: Policy: Resident Assessments Purpose: To ensure a comprehensive assessment of every resident's needs is made at intervals designated by OBRA [Omnibus Budget Reconciliation Act] and PPS [Propective Pay System] requirements. General Guidelines: 1. The Resident Assessment Coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessment and reviews according to the requirements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 5 of 20 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 06/08/2023 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 Residents Affected - Few 3. Resident #29's last submitted Minimum Data Set (MDS) was a Quarterly Prospective Payment System (PPS) dated 3/24/2023. The Discharge-Assessment Reference Date (ARD) of 4/24/2023 was 30 days overdue. During an interview with the Director of Nursing (DON) on 06/07/23 at 03:24 PM, she stated, the Minimum Data Set (MDS) coordinator resigned, we have two part-timers here on Monday, Tuesday and Thursday and we just added them to come on Friday, they will be here tomorrow. When asked about Resident's 29 discharge status she stated, she was discharged on 4/24/23. When asked about the last submitted MDS, she stated, the last MDS submitted was the quarterly on 3/24/23. When asked about the MDS for the Resident's discharge, she stated, the MDS is right here in front of me. When surveyor then looked at her screen, the MDS for discharge was highlighted in red and not submitted, then the DON stated, It was not submitted. When asked about the submission timeline, she stated, the MDS is open the following day after the discharge, we have 14 days to complete, and it is supposed to be submitted before day 31. Record review of submitted Minimum Data Set for Resident #29 revealed: MDS-Discharge Return Not Anticipated dated 4/24/2023 with Status: In progress. Record review of the MDS-Discharge Return Not Anticipated dated 4/24/2023, admit date : [DATE], signed and dated Wed., June 7, 2023, at 04:22:46 PM revealed: Section A- Identification Information: Entry/discharge reporting-10. Discharge-return not anticipated, G. Type of Discharge-2. Unplanned, A2000. discharge date : [DATE], A2100. Discharge Status: 01. Community, A2300. Assessment Reference Date: 04/24/2023. During an interview on 06/08/23 at 11:32 AM with the Director of Nursing. When asked about Resident's #29 MDS for her discharge, she stated, I called the person to come to complete it, and she did, then I submitted it. I did an audit for the past 6 months to see if there were any discharges left out by mistake and there was none. When asked, where the resident was discharge to, she stated, she went next door to [ Hospital]. When asked to check the MDS discharge date d 4/24/2023, Section A-Identification Information and subsection Discharge Status, she stated. I am going to have correct the MDS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 6 of 20 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 06/08/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician's order for changing the midline (intravenous(IV) catheter) dressing for one (Resident #77) out of one resident's who was receiving intravenous therapy as evidenced by the midline dressing date being over 7 days old. Residents Affected - Few The findings include: Observation on 6/5/23 at 7:32 AM, Resident #77 was receiving intravenous antibiotics. On 6/6/23 at 8:43 AM, it was observed that Resident #77 midline dressing to right arm appeared to be dated 5/11/23 or 5/17/23 (See photo evidence). It was noted that Resident #77 readmission to the facility was on 5/19/23. It was observed on 6/6/23 at 12:32 PM, 6/7/23 at 3:00PM (see photo evidence) and 6/8/23 at 9:20 AM the midline dressing was observed with dates that appeared to be 5/11/23 or 5/17/23. On 6/8/23 at 9:20 AM, an interview with Staff H, Licensed Practical Nurse (LPN) revealed, when asked What date is on Resident #77's midline dressing and how frequently are they changed? Staff H, L.P.N stated, The order states to change every 7 days or as needed. On 06/08/23 at 11:22 AM, in an interview/observation with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP), the ADON/ I.P R.N was made aware of the midline dressing date by pictures taken and it was observed that the midline was removed from the right arm. On 06/08/23 at 02:30 PM, in an interview with the Director of Nursing about Resident #77's midline dressing the Director of Nursing stated, I spoke to the nurse, and she stated that she has changed the dressing. It is noted that on Medication Administration Record that it is charted on 6/8/23 next to the Physician order to change the dressing to right arm midline every 7 days on the 11-7 shift and as needed. Review of the Physician Orders for May 2023, start date of 5/21/23 for Sodium Chloride Solution 0.9 %, use 10 milliliters intravenously one time a day for flush until 06/03/2023 before and after antibiotic administration. Start date was 5/21/23. Start date of 5/19/23 for Daptomycin 940 milligrams intravenous every 48 hours for Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia until 6/3/23. Start date of 5/23/23 for order change dressing to right arm midline every 7 days on 11-7 shift and as needed every night shift every 7 days for intravenous maintenance. Record review of Resident #77 revealed, diagnoses of cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Minimum Data Set (MDS) dated [DATE] on admission - None PPS. Brief interview of mental status is not assessed. Bed mobility is total dependence and two-person physical assist. In the last days, Resident #77 was on antibiotics for 3 days. Record review of the care plan initiated on 6/2/23. It is noted that the resident is on intravenous medications. The focus is the resident will not have any complications related to intravenous therapy through the next review date. Interventions included was observe dressing, change dressing and record observations of site. Monitor/document/ report as needed signs and symptoms of infection at the site: drainage, inflammation, swelling, redness, and warmth.mr (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 7 of 20 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 06/08/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Review of facility's policies and procedures titled, Midline dressing changes. Last reviewed date 1/17/2019. It stated that midline catheter dressings will be changed at specified intervals or when needed to prevent catheter related infections associated with contaminated, loosened, or soiled catheter-site dressings. General guidelines. 1. Change midline catheter dressing 23 hours after catheter insertion, every 5-7 days or if it is wet, dirty, not intact, or compromised in any way. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 8 of 20 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 06/08/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow prescribed doctor's orders for enteral feedings for three out of 22 residents receiving enteral feedings (Residents #67, #310 and #311) as evidenced by the enteral feeding rates were incorrect. This practice has the potential to affect 22 residents who receive tube feeding at the facility. The findings include: 1. On 6/6/23 at 8:48 AM and on 6/6/23 at 12:33 PM observations of Resident #67 revealed, the enteral feeding rate was set at 40 milliliters(ml) an hour. On 6/7/23 at 11:11 AM, the Enteral feeding rate was set at 70 milliliters an hour. Record review of Resident #67 revealed, Medical diagnoses were respiratory failure, tracheostomy, gastrostomy status, cerebral infarction (stroke) and dependence on respirator (ventilator) status. Review of the Physician orders of Resident #67 revealed, a start date of 5/30/23 for Enteral formula to run at 70 milliliters an hour for 22 hours or until 1540 ml is infused within 24 hours. Record review of minimum data set (MDS) dated [DATE], entry discharge return anticipated. In Section C: Cognitive patterns, brief interview of mental status (BIMS) was not assessed. In Section G: functional status, eating is total dependence. In Section K: Swallowing/Nutritional Status it stated No to percutaneous endoscopic gastrostomy (PEG). In the review of the care plan, date initiated on 2/17/22, it was noted that Resident #67 has a nutritional problem or potential nutritional problem. The goal is Resident #67 will maintain adequate nutritional status as evidenced by absence of unplanned significant weight changes, no signs/symptoms of malnutrition, and tolerating tube feeding/ water flushes through review date. Intervention included was provide tube feeding/water flushes as ordered. 2. On 6/5/23 at 6:44 AM, in an observation of Resident #310's enteral feeding rate it was set at 60 milliliters an hour. On 6/6/23 at 7:42 AM and 6/7/23 at 7:38 AM the Enteral feeding rate was set at 50 milliliters an hour. Review of Resident #310's electronic health care record revealed medical diagnoses included cerebral infarction (stroke), tracheostomy, gastrostomy (feeding tube), and dysphagia (difficulty swallowing). Review of the Physician orders revealed, it was started on 5/18/23 for the enteral formula to run at 60 milliliters an hour for 20 hours or until 1200 ml are infused within 24 hours. Review of minimum data set, in Section C: Cognitive patterns, a brief interview of mental status was not assessed. In section G: Bed mobility was total dependence and two-persons physical assist. Eating was total dependent with two personal physical assists. In section K: Swallowing/Nutritional status has a feeding tube while as a resident. In Section I: Active diagnosis of a stroke. Record review of the care plan, date initiated 5/18/23. Resident #310 has a nutritional problem or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 9 of 20 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 06/08/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few potential nutritional problem. The goal was, the resident will maintain adequate nutritional status as evidenced by absence of unplanned significant weight changes, no signs/ symptoms of malnutrition, and tolerating tube feeding/water flushes through review date. Interventions included administering medications as ordered. 3. Observation on 06/05/23 at 07:04 AM revealed, Resident #311's enteral formula was set at 50 milliliters an hour. On 06/06/23 at 08:32 AM and 06/06/23 at 11:39 AM, the Enteral formula was set at 50 milliliters an hour. Record review of Resident #311's electronic health record revealed medical diagnoses included chronic respiratory failure, gastrostomy and dysphagia. Record review of the physician orders was start date of 5/23/23 for enteral formula to run at 80 millimeters an hour or when 1600 milliliters was infused. Record review of the Minimum Data Set, dated [DATE] on entry Discharge Return Anticipated. In Section C: Cognitive patterns, a brief interview of mental status was not assessed. In section G: Functional status eating was total dependent. In Section K: Swallowing/Nutritional status, was on a feeding tube while a resident. Record review of the care plan, date initiated 3/6/2023 revealed, Resident #311 has a nutritional problem or potential nutritional problem. The goal was Resident #311 will maintain adequate nutritional status as evidenced by absence of unplanned significant weight changes, no signs or symptoms of malnutrition and tolerating tube feeding/water flushes through review date. Interventions included, provide tube feeding/ water flushes as ordered and monitor tolerance. On 6/8/23 at 12:00 PM, in an interview with Staff G and Staff H Registered Dietitian's(RD) revealed, when asked, were the three enteral feedings running at the incorrect rate on 6/6/23. How do you follow the resident's enteral nutrition status? Staff G, R.D stated, We check enteral feeding rates and total volumes. The purpose of total volume is to receive the nutrition for the day. Staff G, R.D stated, If there is a weight change, it alerts us. We assess the resident's health and check in with the nurses. In review of facility's policies and procedures titled, Enteral feedings via continuous pump. The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. General guidelines: 3. Check the enteral nutrition label against the order before administration. Check the following information. G: Rate of administration (milliliters an hour). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 10 of 20 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 06/08/2023 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** Based on observation, record review and interview, the facility failed to ensure one (Resident # 209) out of 23 residents receiving oxygen treatments, had a doctor's order for oxygen therapy before administration. The facility failed to follow doctor's orders as evidenced by one resident (Resident # 209) out of 23 residents receiving oxygen therapy, the doctor's prescribed 2 Liters per Minute (LPM) and resident #209 was observed to be receiving 1.5 LPM of oxygen. Residents Affected - Few The findings included: Observation of Resident # 209 on 06/05/2023 at 10:09 AM, the resident was sleeping. The resident was observed with a nasal cannula and the oxygen concentrator gauge was set up at 1.5 LPM. (Photographic evidence). Review of the residents physician orders revealed, there was no order for oxygen found. Observation of Resident # 209 on 06/06/2023 at 10:29 AM, the Resident was sleeping. The resident did not have the nasal cannula in place in nose. The oxygen concentrator gauge was set up at 1.5 LPM. (Photographic evidence). Review if the residents physician orders revealed there was a new order for oxygen at 2 LPM and dated 06/06/2023. Observation of resident # 209 on 06/07/2023 at 8:40 AM revealed, the resident was observed sleeping. The resident did not have the nasal cannula in place. The oxygen concentrator gauge was set at 1.5 LPM. Record review of the clinical records for Resident # 209 revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included, but were not limited to, Encounter for Orthopedic Aftercare Following Surgical Amputation; Complete Traumatic Amputation of right Great Toe, subsequent Encounter; Type 2 Diabetes Mellitus Without Complications. Record review of physician orders dated 06/06/2023 revealed an order for Oxygen at 2 LPM as needed for shortness of breathing, every 8 hours as needed. Record review of the Nurses Notes dated 06/04/2023 revealed the resident was readmitted to facility for service under her primary care physician, with diagnoses of Gangrene right foot infection Acquired absence of right leg above knee (S/P Right AKA-above the knee amputation), the resident had diagnosis of Diabetes Mellitus, Hypertension, Peripheral Arterial Disease, full code and no known allergies. Residents remain awake and alert and in no acute distress. Skin inspection done resident is noted on continuous oxygen, ecchymosis to both upper extremities, edema to both arms, sacrum with open area, left thigh with yellow necrotic tissue, inside left thigh is bruised, left bunion serum diiodotyrosine (Deep Tissue Injury-DTI), left lower leg lateral aspect DTI Left 5th digit lateral area with DTI, treatment were initiated, right AKA with 35 staples and intact. Interview with Staff D, Licensed Practical Nurse (LPN) on 06/08/23 at 01:15 PM revealed, she stated the resident was readmitted to the facility recently. She stated, the doctor's order for oxygen was ordered on 06/07/2023. The order was oxygen at 2 LPM as needed. She stated, she checked the oxygen in the morning when the shift starts. She stated, she doesn't know what the resident had the oxygen on for Monday because the order was written on Tuesday. She stated, sometimes the concentrator gauge moved with any movement, it could happened when the care was provided to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 11 of 20 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 06/08/2023 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of Policy, Procedures, and Information dated 04/01/2022 revealed, Policy: Nursing Oxygen Administration. 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 orders or facility protocol for oxygen administration. Record review of Policy, Procedures and Information dated 04/01/2022 revealed, Policy: Nursing, Physician's Orders. Purpose: To ensure that the plan of care is followed in accordance with the order's established by the physician and/or nurse practitioner. Procedure: 1- Physician's orders can be written by the doctor or nurse practitioner. Event ID: Facility ID: 105903 If continuation sheet Page 12 of 20 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 06/08/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, Interview, and record review, the facility failed to ensure that a Registered Nurse (RN) was providing services at least 8 consecutives hours a day, 7 days a week. This had the potential to affect the 109 residents who resided in the facility at the time of this survey. The findings included: During an observation at First floor Nurse's station, on 06/06/2023 at 7:32 AM, it was noted that the staffing information was posted. It was observed that 3 Licensed Practical Nurses (LPN) were providing nursing care to the residents. (Photographic evidence). During an observation at Second floor Nurse's station, on 06/06/2023 at 7:35 AM, it was noted that the staffing information was posted. It was observed that 2 Licensed Practical Nurse (LPN) were providing nursing care to the residents. (Photographic evidence) During an observation at First floor Nurse's station, on 06/07/2023 at 8:12 AM, it was noted that the staffing information was posted. It was observed that 3 Licensed Practical Nurses (LPN) were providing nursing care to the residents. (Photographic evidence). During an observation at Second floor Nurse's station, on 06/07/2023 at 8:15 AM, it was noted that the staffing information was posted. It was observed that 2 Licensed Practical Nurses (LPN) were providing nursing care to the residents. (Photographic evidence). During an observation at First floor Nurse's station, on 06/08/2023 at 8:29 AM, it was noted that the staffing information was posted. It was observed that 3 Licensed Practical Nurses (LPN) were providing nursing care to the residents. (Photographic evidence). During an observation at Second floor Nurse's station, on 06/08/2023 at 8:38 AM, it was noted that the staffing information was posted. It was observed that 2 Licensed Practical Nurses (LPN) were providing nursing care to the residents. (Photographic evidence). Record review of Calculating State Minimum Nursing Staff for Long -Term Care Facilities for the week of 10/09/2022 through 10/15/2022. On 10/13/2022 the Registered Nurses (RN) Hours were only 16 hours in a day. Record review of Calculating State Minimum Nursing Staff for Long-Term Care Facilities for the week of 10/16/2022 through 10/22/2022. On 10/17/2022 RN hours was 16 hours in a day. On 10/18/2022 and 10/19/2022 RN hours were 8 hours in a day. Record review of Calculating State Minimum Nursing Staff for Long-Term Care Facilities for the week of 10/23/through 10/29/2022. On 10/26/2022 through 10/29/2022 RN hours were 8 hours each day. Record review of Calculating State Minimum Nursing Staff for Long-Term Care Facilities for the week of 10/31/2022 through 11/04/2022. The entire week RN hours were 8 hours in each day. Record review of Calculating State Minimum Nursing Staff for Long-Term Care Facilities for the week of 11/06/2022 through 11/12/2022. On Sunday 11/06/2022 RN hours were 12 hours. On Saturday (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 13 of 20 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 06/08/2023 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 0727 11/12/2022 RN hours were 8 hours in a day. Level of Harm - Minimal harm or potential for actual harm Record review of Calculating State Minimum Nursing Staff for Long-Term Care Facilities for the week of 11/27/2022 through 12/03/2022. On Sunday 11/27/2022 RN hours were 8 hours in a day. Residents Affected - Few Monday 11/28/2022 RN hours were 8 hours in a day. Saturday 12 /03/2022 RN hours were 8 hours in a day. Record review of Calculating State Minimum Nursing Staff for Long-Term Care Facilities for the week of 12/18/2022 through 12/24/2022 Sunday 12/18/2022 RN hours were 8.70 hours in a day. Review of Timecards for Director of Nursing and Assistant Director of Nursing did not reflect the weekends were covered for the shifts in the period of October 1022 and December 2022. Interview with Staff E, the Staff Coordinator on 06/08/2023 at 9:10 AM. She stated, the schedule is based on the facility census. She stated, she had a master schedule, and she made the schedule a month in advance. She stated there a deficit with registered nurses, The facility administration was doing a job fairs to attract registered nurses. She stated, the nurses shift are 8 or 16 hours shifts. (Example a nurse started at 7:00 am and finished at 11:00 PM). She stated registered nurses worked overtime until 16 hours. She stated the facility used the agency only for emergencies. She stated when there were not enough registered nurses in the shift, for example on Saturdays and Sundays, the Director of Nursing or Assistant Director of Nursing came to work to cover the shift. She stated that from 11:00 PM to 7:00 AM, there are no registered nurses covering the shift. Interview with the Administrator on 06/08/23 at 11:26 AM. She stated the facility did not have policies and procedures for staffing. She stated the facility followed the State regulations for staffing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 14 of 20 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 06/08/2023 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and policy review, the facility failed to assure the garbage and refuse area was clean and discarded furniture were properly disposed and contained on the facility grounds. Residents Affected - Few The findings included: Record review of the Pest Control Policy and Procedure dated 4/02/2022 documented: Purpose-Facility wide pest-control strategies are developed emphasizing kitchens, cafeterias, laundries, central supply areas. Loading docks, construction activities and other regions prone to pest infestations. Procedure- 6) Maintain garbage storage area(s) in a sanitary condition to prevent the harborage and feeding of pests. Observation of the garbage and refuse area with Staff I, Dietary Aide on 6/05/23 at 6:37 am. The area had three trash bins for trash and one trash bin for recycle. The garbage and refuse area had garbage on the ground in piles. Discarded furniture chairs, dressers, air conditioner vent covers, wood planks and empty boxes of exam gloves were scattered on the ground and not contained in the garbage bins. Photographic evidence submitted. Interview with Staff I, Dietary Aide on 6/05/23 at 6:38 am. He confirmed that the garbage should not be on the ground and should be in the dumpsters Interview with the Food Service Director on 6/07/23 at 8:49 am. He confirmed that the garbage should be placed in the dumpsters and not in piles on the ground next to the dumpsters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 15 of 20 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 06/08/2023 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 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 correctly identify quality deficiencies in the problem area related to repeated deficient practices for F641 Accuracy of Assessments, F695 Respiratory/Tracheostomy Care and Suctioning, and

F908 Essential Equipment, Safe Operating Condition. This practice has the potential to increase the risk of negative resident outcomes and to affect all 109 residents residing in the facility at the time of this survey. The finding included: Record review of the facility's survey history revealed, during a recertification survey with exit 04/28/2022, Accuracy of Assessments was cited related to the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for three out 40 sampled residents whose MDS were reviewed, Respiratory/Tracheostomy Care and Suctioning was cited related to the facility failed to follow physician's orders for the administration of oxygen for 2 out of 11 residents receiving respiratory treatments at the time of last survey, and Essential Equipment, Safe Operating Condition was cited related to the facility failed to ensure the essential patient care equipment was in safe operating condition for one resident, the Mechanical lift used to transfer residents who were severely obese from the bed to the chair was not working. During an interview on 06/08/2023 at 03:08 PM, the Nursing Home Administrator and Director of Nursing (DON) revealed that the Quality Assessment and Assurance Committee (QAA) meets the third Wednesday of the moth unless problems arise, then they will meet immediately. The Administrator and Director of Nursing stated that the QAA Committee is comprised of the following members: the Administrator, DON, Social Services Director, Medical Director, Housekeeping Manager, and all department heads, they don't have to be there, but we like them to be there to report any findings on their departments. When asked about which deficiencies they found before the annual survey, the Director of Nursing stated, we identified deficiencies with weights, falls, we are also working on oxygen, and we are carrying this for 12 months as last year we got deemed for the oxygen. We have Performance Improvement Plans (PIP) open for oxygen, weights, notification of physician, and changes in resident conditions. Review of Policy, Procedures and Information with Policy Quality Assurance and Performance Improvement and Revision Date 03/10/23 revealed, Purpose: The facility should ensure an effective Quality Assurance and Performance Improvement program including comprehensive data-driven activities that focus on indicators of the outcomes of care and quality of life and addressed all the acre and unique services the facility provides are implemented in the facility. Definitions: Performance Improvement (PI) is the continuous study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. Quality Assurance (QA) is the specification of standards for quality of service and outcomes, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 16 of 20 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 06/08/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few systems throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards. Quality Assurance and Performance Improvement (QAPI) is the coordinated application of two mutually reinforcing aspects of a quality management system: (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes, while involving residents and families in practical and creative solving. Procedure: 1. The QAA Committee should meet at a minimum and as needed (Ad Hoc) to coordinate and evaluate activities under the QAPI program. The meetings should include: a. Identifying issues with respect to quality assessment and assurance activities including performance improvement projects b. Developing and implementing appropriate plans of action to correct any identified deficiencies c. Reviewing and analyzing date collected as part of the QAPI program and acting on data as appropriate d. Review of all plans of correction 2. The QAPI Program will address the following elements: a. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. 3. The QAPI program plan should: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 17 of 20 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 06/08/2023 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 0867 a. Level of Harm - Minimal harm or potential for actual harm Ensure processes are in place to prioritize activities that focus on safety, health outcomes, autonomy, and choice, and that will ensure care and delivery of service meets accepted standards of quality. Residents Affected - Few b. Focus on high risk, high volume, or problem prone (repetitive) areas identified in the facility assessment. 4. Key components of the QAPI program process should include, but not limited to the following: a. Identifying and prioritizing quality deficiencies b. Analyzing systemically any underlying causes of repeat deficiencies c. Developing and implementing corrective action or performance improvement activities d. Monitoring and evaluating the effectiveness of corrective actions or performance improvement activities and adjust as needed. 5. The QAPI Program Plan program should be written and include the following documentation: i. Facility assessment ii. Resident and staff surveys iii. Documentation supporting corrective actions and/or performance improvement activities. 6. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 18 of 20 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 06/08/2023 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 0867 At least annually, the facility should conduct a minimum of one performance improvement project (PIP) that focuses on high risk or repetitive issues. Level of Harm - Minimal harm or potential for actual harm a. Residents Affected - Few The PIP should include monitoring of progress and outcome FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 19 of 20 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 06/08/2023 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 Based on observation, interview, and policy review, the facility failed to ensure essential equipment was in proper working condition for two out of six laundry machines. This practice has the potential to affect 109 resident's residents at this facility at the time of survey. Residents Affected - Few Findings include: On 06/07/23 at 03:07 PM In an observation/interview with Manager of Housekeeping in laundry room. It was observed that there were 3 washers, and one had a tag on it. It stated, power disconnected 7/17/21. It was observed that there were three dryers and 1 had a sign which stated, Out of order. When asked How long has the dryer been out of order? The Housekeeping Manager stated, About 2 weeks ago. (See photo evidence). It was asked of the Housekeeping Manager and Regional Director of Maintenance to provide documentation of work order for broken washer and dryer. On 06/08/23 at 12:35 PM. In an interview with Maintenance Director. When asked What is the status of the washer being repaired or replaced? The Maintenance Director stated that We are waiting for a quote for the washer, the clothes were not wringing out the water. We are waiting for an answer for approval for repair or replacement of the washer. On 06/08/23 at 12:40 PM. In an interview with Administrator. When asked about two broken laundry machines and if another machine becomes broken or a transmission-based precautions resident resides in facility. The Administrator stated that We are able to meet the needs of the residents. We have 2 dryers and 2 washers. If one of them is down or we need assistance with laundry. We can send laundry to our sister facilities or buy a temporary washer. There is a company comes in later today to give us a quote on the washer and dryer. On 06/08/23 at 12:45 PM. In an interview with Housekeeping Manager. When asked How is it working with only two washers and two dryers? The housekeeping manager stated I'm working with the two washers. It's nice to have three but I've been working with the two. We haven't had Covid in the facility for a while. Record review of Work orders for washer #1 for a total of $244.95 and dryer #two for a subtotal of $115.00 were placed on 6/5/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 20 of 20