Health inspection·February 16, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of Resident #36's Care Plans Reference Date 1/11/2023 revealed: The resident requires use of device: Sling right upper extremity NWB. Interventions Include: Monitor sight for device application daily and take off to clean extremity, monitor for pain, moaning, removal of device and report to nurse, notify Medical Doctor (MD) of any adverse sign and symptoms related to device usage, notify to MD resident device use preference, and educate resident on consequences of not following assistive device use. Residents Affected - Few Review of February 2023 Treatment Administration Record (TAR), revealed from 2/1/2023 to 2/14/2023 -every shift (7 AM-30PM, 30PM-11 PM, 11 PM-7 AM) nurses signed off that the resident is always wearing right upper extremity NWB sling. Review of progress notes dated 2/15/2023, timestamped 09:50 AM written by the Assistant Director of Nursing (ADON) documented: Nurse on shift reported that patient not wearing the sling device. When patient interviewed, he reported that he was told by our psychiatrist that he doesn't need anymore . called resident's MD and confirmed about comment from the patient. Physician will submit his progress notes. Phone order obtain to discontinue device. Physical therapy and restorative nurse informed. During an interview on 02/15/2023 at 08:59 AM Registered Nurse (Staff A) when asked about the resident's right shoulder sling, Staff A stated that she will have to ask the Certified Nursing Assistant (CNA) assigned to the resident about the sling. Staff A stated; this resident used the sling before, but I need to know what is going on with the resident's sling now. The surveyor told Staff A to check the TAR which revealed that the nurses have been signing off on the right sling being used every shift. Staff A confirmed that nurses on all shifts have been signing off on resident having the right shoulder sling on. The surveyor and Staff A went to Resident #36's room, Staff A questioned Resident #36 about the upper extremity sling. The resident stated; the sling is in my drawer, and I do not need it, therapy told me I do not need it. Staff A located the right extremity sling in resident's bedside drawer. Staff A stated she will speak to therapy, her supervisor and the resident's doctor and get back with the surveyor afterwards. During an interview on 02/15/2023 at 01:07 PM, the Director of Nursing stated (DON) reported that the resident has an order from the MD to discontinue the upper extremity device. The surveyor requested a copy of the physician note, progress note, care plan, Treatment Administration Record (TAR) for February 2022, face sheet, current and discontinued orders, facility policy and procedure on positioning devices. On 02/15/2023 at 03:16 PM, the Administrator (NHA) brought documentation for the resident's discontinued order related to the right upper extremity sling dated 2/15/2023 at 10:48 AM and a consultation note dated 1/23/2023 from the MD that documented-Findings/Diagnosis: Right proximal humerus fracture, right shoulder pendulum exercise and passive range of motion 0-90 degrees. Patient may feed self if able. Otherwise non weight bearing (NWB) to right upper extremity., 2/15/2023 progress note, February 2023 TAR, care plans, and orders. During an interview on 2/16/2023 at 9:49 AM the Director of Nursing (DON) stated he will be educating the nurses on documentation, which they have done in the past and will continue to do. He stated, we have a nursing dashboard on the units for nurses to use as a quick guide to know which residents have devices, oxygen, peg tube, wounds etc. and the dashboard is updated every Monday. On 02/16/2023 at 03:54 PM the DON brought surveyor a Physiatrist follow up note, the date of service noted was 02/09/2023, follow up care-documented continue with NWB of right upper extremity pending (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106007 If continuation sheet Page 2 of 5 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 106007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Floridean Health & Rehabilitation Center 47 NW 32nd Place Miami, FL 33125 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 FORM CMS-2567 (02/99) Previous Versions Obsolete ortho follow up for weight bearing status changes. May remove sling according to orthopedics' recommendations. Review of the facility's policy and procedures titled, Contractures Prevention revision date 8/22/2017 states: Each resident must be evaluated for need of contracture prevention procedure on admission, readmission and as needed. Positioning: Some residents may have braces or splints to prevent or help release contractures-be sure to follow the physicians order regarding the schedule of when to put these on and when to remove them. Event ID: Facility ID: 106007 If continuation sheet Page 3 of 5 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 106007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Floridean Health & Rehabilitation Center 47 NW 32nd Place Miami, FL 33125 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 interviews, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area, as evidenced by repeated deficient practice during consecutive annual surveys. Cross reference F 656 develop/implement Comprehensive Care Plan. There were 75 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during an annual survey with exit dated 10/15/2021, deficient practice was cited related to F 656-Develop Implement Comprehensive Care Plan related to due to the facility's failure to implement the activities care plan for one (Resident #62) out of 20 sampled residents. During this survey with exit date of 02/16/2023 the facility was cited F 656-Develop Implement Comprehensive Care Plan related to the facility's failure to implement a comprehensive care plan for an upper extremity device as ordered by the physician for one (Resident #36) out of 19 residents sampled. Review of the facility's plan of correction for the last annual survey with an exit dated 10/15/2021 related to

F 656- Develop/Implement Comprehensive Care Plan indicated as part of the correction measures revealed: The Activity director and/or designee will conduct an audit of residents' activity care plan to ensure that they are followed and documented, random weekly x 4 weeks, then random monthly, thereafter. Findings will be discussed at the monthly QAA meeting to maintain compliance. During an interview with the Administrator, Director of Nursing (DON), and Admissions Director on 02/16/2023 at 2:37 PM it was revealed that the issues identified and discussed in the in previous meetings were missing items and grievances procedure, dietary issues, pandemic management, staffing issues, and Cyber breach. The administrator stated that they do Quality Assurance meetings daily and that they have not done a general meeting for February. They did not identify any concern with the tag F 656 as they run audits every day. The administrator stated that when it comes to assessments, one thing is for late assessment even though they were completed and submitted on time, they show as not submitted. We have tickets open with IT departments as we have had issues with connectivity, Minimum Data Set (MDS) coordinator and her assistant are on point with everything. The Director of Nursing stated that when it comes to Physician Orders, they hold clinical meetings every morning, and that they do 24-hour orders check. They do audits and he noted; I have never noticed that there is a pattern for not following physician orders. For the subject of this survey in particular, the doctor educated the patient, and he did not put a physician order in the record therefore the nurses kept using the splint, and the resident wanted to keep using the splint. The DON explained that audits are done for everything through a CRO (Conversion Rate Optimization audit also known as a conversion audit). The DON stated, we get audits every morning and especially for the new admission we check anything the nurses documented and whatever it needs to be looked at, we get a full report daily then I personally go one by one and try fixing it, this is consistent, and we also do 24-hour review after new admission. We are on top of everything, and we are going to be auditing physician orders specially for orthopedic patients for adaptive devices. Record review of the facility's Policy and Procedure documented : Subject Quality Assessment & Assurance Committee. POLICY: The QAA Committee shall consist of a minimum of the Director of Nursing, a physician designated by the facility and three (3) other members of the facility staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106007 If continuation sheet Page 4 of 5 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 106007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Floridean Health & Rehabilitation Center 47 NW 32nd Place Miami, FL 33125 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 Procedure: The Committee shall: Level of Harm - Minimal harm or potential for actual harm 1. Review the following items to identify current and ongoing issues for committee action: a. Quality Indicator Report Residents Affected - Few b. Accident/Incident Tracking Log c. Adverse Incident Tracking Log d. Regulatory Agency Reports e. Grievance Log f. Customer satisfaction results g. Consultant Reports h. Staff Meeting minutes. i. Resident Council Meeting minutes 2. The committee shall implement a CQI or quality review to investigate trends, patterns, positive or negative outcomes related to the topic. 3. The committee will determine an action plan needed to address any concerns. 4. The committee will implement and revise appropriate corrective actions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106007 If continuation sheet Page 5 of 5