Inspection·December 21, 2023

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident # 48's physician's orders revealed Quetiapine Fumarate Tablet 100 MG Give 1 tablet by mouth two times a day related to bipolar disorder, current episode manic severe with psychotic feature dated 9/8/23. Trazodone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime related to major depressive disorder, single episode dated 9/11/23. Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 30 ml by mouth at bedtime related to Bipolar Disorder, Current episode manic sever with psychotic features dated 10/2/23. Olanzapine Oral Tablet 5 MG (Olanzapine) Give 1 tablet by mouth two times a day related to Bipolar Disorder, Current episode manic sever with psychotic dated 11/13/23. ClonazePAM Oral Tablet 1 MG (Clonazepam) Give 1 mg by mouth two times a day related to Anxiety dated 11/16/23. Review of Resident # 48's admission Minimum Data Set (MDS) dated [DATE] revealed Section A for Identification resident is not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section C for cognitive status Brief Interview for mental status score was undetermined. Section I for Active Diagnosis for psychiatric/Mood disorder included Anxiety, Depression, and bipolar disorder. Section N for medications resident received 7 antipsychotics, 7 antianxiety and 6 antidepressants in the last 7 days. Section O for Special Treatments, Procedures and Programs resident received Hospice Care. Review of Resident # 48's Care Plan [NAME] has potential for discomfort and side effects related to the use of psychotropic medications for diagnosis of bipolar disorder, anxiety, depression with interventions Administer medication as ordered. Ask physician to review medication for possible dose reduction every three months. Assess for fall risk. Monitor behavior every shift and document. Observe for possible side effects every shift and report to MD PRN: high fever, muscle rigidity, orthostatic hypotension, sedation, dry mouth, balance problem, unsteady gait, restlessness, tremors, Parkinsonism, akinesia, dystonia, akasthesia, tardive dyskinesia. Report pertinent labs results to physician. On 12/19/23 at 02:30 PM the DON stated he reviews, submits, and updates all PASARRs. The DON reviewed resident # 48 diagnosis and stated the diagnosis of bipolar disorder was omitted by mistake. Stated he will update the PASARR with current diagnosis. Based on record review and interview, the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASARR) was completed accurately prior to admission and failed to revise the screening following admission for four (4) Residents (#13, #48, #49, #81) out of 28 sampled residents. There were 135 residents residing in the facility at the time of the survey. The findings Included: 1. During observation on 12/18/23 at 09:27 AM Resident #13 was in bed, complained of call light not working properly that was resolved by the Maintenance Director immediately. Stated she would like to have an extra soup today, Resident' s request was communicated to the dietary staff by the surveyor. On 12/19/23 at 10:15 AM Resident #13 observed in room states everything is great today, the call light was not really broken, it worked, there was just a blinking red light that was always on and it turns out that was not her call light, that was the resident in the other bed's call light. During observation on 12/20/23 at 08:30 AM Resident #13 was in bed asleep, no distress noted. Record Review of Resident #13's Level I PASARR (Preadmission Screening and Resident Review) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106021 If continuation sheet Page 2 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130 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 documented Section I: PASARR Screen Decision Making: A: Mental Illness (MI) or suspected MI (check all that apply) - no mental Disorders checked off. Findings based on documented history were-Section II Other indicators for PASARR screening Decision-Making: All checked - no. Does individual have validating documentation to support dementia or related neurocognitive disorder - no. Section III Not a provisional admission. Section IV. No diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability (ID) indicated. Level II PASRR evaluation not required. PASRR Level I completed by a Nurse Practitioner and Director of Nursing (DON) at the facility on 8/4/22 Record Review of Resident #13's Psychological Consultation dated 11/22/23 revealed, Mental status examination performed, complexity-moderate, follow up in one month. Medications-Seroquel, Ativan, Zoloft, and Mirtazapine, Treatment Plan-Educated patient on characteristics of illness, discussed risks and benefits of treatment options as well as potential side effects, patient verbalized understanding and agree with the plan. lifestyle modification education provided. Supportive therapy provided. Review of the medical records for Resident #13 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Major depressive Disorder, Anxiety Disorder, Insomnia and Psychosis. Review of the Physician's Orders Sheet for December 2023 revealed, Resident #13 had orders that included but not limited to: Seroquel oral tablet 25 milligram (mg) (quetiapine fumarate)-give 1 tablet by mouth in the afternoon related to unspecified psychosis not due to a substance or known physiological condition. Ativan tablet 1 mg (lorazepam)-give 1 tablet by mouth two times a day related to anxiety disorder, unspecified. Zoloft tablet 25 mg (sertraline)-give 1 tablet by mouth one time a day related to major depressive disorder, recurrent, moderate and Mirtazapine tablet 7.5 mg-give 1 tablet by mouth at bedtime related to major depressive disorder, recurrent, moderate. Record review of Resident # 13's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section A 1500 resident is currently considered by the state level II PASRR process to have a SMI or ID or a related condition-Not available. Section C for Cognitive Patterns documented Brief interview for mental status score (BIMS), 10 on a 0-15 scale indicating the resident is moderately impaired cognitively. Section I for Active diagnosis documented Anxiety disorder, Depression Disorder and Psychotic Disorder. Section N for Medications documented resident is taking antipsychotic, antidepressant, anticoagulant, opioids, diuretics, and antianxiety medications. Section O for Special Treatments documented resident received oxygen therapy and hospice care while a resident. Record review of Resident #13 's Care Plans Reference Date 10/20/23 revealed: Resident has a Potential for discomfort and side effects related to the use of psychotropic medications: Resident is on antidepressant, antipsychotic, and anxiolytic medications related to major depressive disorder, Anxiety and Psychosis. Interventions include-Administer medication as ordered. Ask the physician to review medication for possible dose reduction every three months. Assess for fall risk. Monitor behavior every shift and document. Observe for possible side effects every shift and report to MD PRN: high fever, muscle rigidity, orthostatic hypotension, sedation, dry mouth, balance problem, unsteady gait, restlessness, tremors, Parkinsonism, akinesia, dystonia, akathisia, tardive dyskinesia. Report pertinent labs results to physician. Resident have impaired cognitive function/dementia or impaired thought processes, displays deficits in judgement related to Changes in cognitive abilities, Difficulty making decisions, Impaired decision making. Interventions include-Family members will exhibit an understanding of required care and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106021 If continuation sheet Page 3 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130 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 demonstrate appropriate. Coping skills and utilize community resources. I will have appropriate maintenance of mental and psychological function as long as possible and reversal of behaviors when possible. 1:1 visits for support and promotion of venting feelings. Administer medications as ordered. Monitor/document for side effects and effectiveness. Ask yes/no questions to determine the resident's needs. Assist with word finding as needed, do not allow frustrations to build. Communicate with the resident/family/caregivers regarding residents' capabilities and needs. Resident is at risk for depression related to anxiety disorder. Interventions include-Administer medications as ordered. Monitor/document for side effects and effectiveness. Arrange for psych consult, follow up as indicated. Monitor/document/report as needed any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note, intentionally harmed, or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. 2. During Observation on 12/18/23 at 09:22 AM, Resident #49 in wheel chair in hallway being taken to therapy, clean and well groomed, no distress noted, stated everything is good here. On 12/19/23 at 10:18 AM, Resident #49 observed in bed asleep, no distress noted. On 12/20/23 at 09:17 AM, Resident #49 observed in room in wheelchair eating breakfast, stated he is doing great today. Record Review of Resident #49 of Level I PASARR (Preadmission Screening and Resident Review) revealed Section I: PASARR Screen Decision Making: A: MI or suspected MI (check all that apply) - only anxiety disorder checked off. The Findings based on documented history were Section II Other indicators for PASARR screening Decision-Making: All checked no. Does individual have validating documentation to support dementia or related neurocognitive disorder - no. Section III Not a provisional admission. Section IV No diagnosis or suspicion of SMI or ID indicated. Level II PASRR evaluation not required. PASARR Level I was completed by a Registered Nurse at the facility on 7/29/2019. Record Review of Resident #49's psychological consultation dated 9/28/23 revealed, on evaluation the patient was Alert and oriented times two, disoriented to time. He was calm and cooperative, adequately dressed and fair hygiene. Patient presented able and pleasant. He was found socializing in the activity room with other patients. He was engaged in an interview, reported feeling good. His affect flat and congruent to mood. denied symptoms of depression and anxiety during the day. Patient confirmed compliance to medication, tolerating well with no side effects. He reports adequate sleeping patterns, with current medication and a good appetite. Patient denied perceptual disturbances such as visual or auditory hallucinations. Patient denied suicidal or homicidal ideation, intention, or plan. Patient has remained stable, with reported intermittent back and joint pain, generalized weakness, continues smoking. Plan-No changes, continue taking medication as prescribed, monitor for changes and side effects, and Follow up with psychiatry accordingly. Review of the medical records for Resident #49 revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but were not limited to: Dementia, Psychosis, Insomnia and Depression. Review of the Physician's Orders Sheet for May 2022 revealed, Resident #49 had orders that included but not limited to: Trazodone tablet 50 mg-give 1 tablet by mouth at bedtime related to insomnia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106021 If continuation sheet Page 4 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130 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 Temazepam capsule 15 mg-give 1 capsule by mouth at bedtime for insomnia related to insomnia. Zoloft tablet 50 mg (sertraline)-give 50 mg by mouth one time a day for depression. Record review of Resident #49 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section A 1500 resident is currently considered by the state level II PASRR process to have a SMI or ID or a related condition-Not available. Section C for Cognitive Patterns documented Brief interview for mental status score (BIMS), 12 on a 0-15 scale indicating the resident is moderately impaired cognitively. Section I for Active diagnosis documented Depression, dementia, insomnia and Psychotic Disorder. Section N for medications documented resident is taking antidepressant, hypnotic and hypoglycemic medications. Section O for Special Treatments and Procedures documented none received while a resident. Record review of Resident #49 's Care Plans revealed: Resident has impaired cognitive function/dementia or impaired thought processes, displays deficits in judgement related to (r/t) Changes in cognitive abilities, Impaired decision making. Interventions Include-1:1 visit for support and promotion of venting feelings. Administer medications as ordered. Monitor/document for side effects and effectiveness. Assist with word finding as needed, do not allow frustrations to build. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. Resident has Potential for discomfort and side effects related to the use of psychotropic medications: Resident is on antidepressant, and hypnotic therapy related to major depressive disorder, Insomnia and Psychosis. Interventions include-Assess resident's ability to safely self-administer medications specified on admission/re-admission, quarterly, with change in medication orders and with significant changes in condition. Discuss medications with each supervised administration. Demonstrate correct. administration as required. Review each med as necessary with the client. Monitor resident's self-administration (FREQ). Review usage patterns by looking at inventory and reordering patterns to assure compliance. Monitor for changes in condition related to inappropriate medication use. Provide written documentation on each medication for the resident to keep as reference at the bedside. During observation on 12/18/23 at 09:24 AM Resident #81 in bed awake, talking to himself, air mattress running correctly, call light on bed. On 12/19/23 at 10:14 AM Resident #81 in bed asleep, call light on bed, clean and well groomed, positioning devices present in bed, resident ate approximately 50% of breakfast. On 12/20/23 at 08:21 AM Resident in bed asleep, curtains closed, resident expired at 3:58 AM Review of Resident # 81's Level I PASRR (Preadmission Screening and Resident Review) revealed Section I: PASRR Screen Decision Making: A: MI or suspected MI (check all that apply) - only Anxiety Disorder checked off. The Findings based on documented history were Section II Other indicators for PASRR screening Decision-Making: All checked no. Does individual have validating documentation to support dementia or related neurocognitive disorder - no. Section III Not a provisional admission. Section IV No diagnosis or suspicion of SMI or ID indicated. Level II PASRR evaluation not required. PASRR Level I completed by a registered Nurse at the hospital 11/22/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106021 If continuation sheet Page 5 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130 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 Resident #81's Psychological consultation dated 11/14/23 documented Patient was seen for an initial psychiatric evaluation. On evaluation, the patient was awake and alert and oriented to person, place, time. The patient appears as stated age, adequately dressed, and had a fair hygiene. Patient was adequately, engaged to interview, reported symptoms of depression and anxiety increasing over time since hospital admission. The anxiety symptoms are accompanied by edginess, restlessness, describing desire to go home. Impaired concentration. Patient denied significant past psychiatric history or prescribed psychotropic medication. Patient's effect was constricted and congruent to mood. Patient confirmed, adequate sleeping patterns and appetite. Patient confirms good support system consistent of family members with whom they maintain frequent contact with. Patient denied perceptual disturbances, such as visual or auditory hallucinations. Patient denies suicidal or homicidal ideation, intention, or plan. Plan-start Lexapro 5 milligram (mg) by mouth (po) daily every morning. Reviewed and discussed risks and benefits of medication, patient consented to medications, monitor patient for side effects or changes, and follow up accordingly. Review of the medical records for Resident #81 revealed resident was admitted to the facility on [DATE], readmitted on [DATE]. Clinical diagnoses included but not limited to: Major Depressive Disorder, Anxiety Disorder, Psychosis, and Insomnia. Resident #81 expired on 12/20/23. Review of the Physician's Orders Sheet for December 2023 revealed Resident #49 had orders that included but not limited to: Trazodone tablet 50 mg-give 1 tablet by mouth at bedtime related to insomnia, unspecified. Escitalopram oxalate oral tablet 5 mg (escitalopram oxalate)-give 1 tablet by mouth in the afternoon related to major depressive disorder, single episode, unspecified. Seroquel oral tablet 50 mg (quetiapine fumarate)-give 1 tablet by mouth at bedtime related to unspecified psychosis not due to a substance or known physiological condition. Record review of Resident # 49's Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section A 1500 resident is currently considered by the state level II PASRR process to have a SMI or ID or a related condition. Not available. Section C for Cognitive Patterns documented Brief interview for mental status score (BIMS) unable to determined. Section I for Active diagnosis documented Anxiety disorder, Depressive Disorder and Psychotic Disorder. Section N for medications documented resident is taking antipsychotic, antidepressant, anticoagulant, and hypoglycemic medications. Section O for Special Procedures and Treatments documented resident received hospice care while a resident. Record review of Resident #81 's Discharge Return anticipated Care Plans Reference Date 11/14/23 revealed: Resident has the potential for discomfort and side effects related to (R/T) the use of psychotropic medications. Diagnosis: Major depressive disorder and insomnia. Interventions include-Administer medication as ordered. Ask physician to review medication for possible dose reduction every three months. Assess for fall risk. Monitor behavior every shift and document. Observe for possible side effects every shift and report to MD needed: high fever, muscle rigidity, orthostatic hypotension, sedation, dry mouth, balance problem, unsteady gait, restlessness, tremors, Parkinsonism, akinesia, dystonia, akathisia, tardive dyskinesia. Report pertinent labs results to physician. Resident has History of behavior issues as evidenced by: Screaming, yelling causing distress to self and others related to: Others: adjustment issues. Interventions include-Approach in calm, gentle manner, introducing yourself. Assess, review and document behavior per protocol. Be aware of sensory deficits and approach accordingly (hearing aide, eyeglasses). Explain all procedures and reasons (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106021 If continuation sheet Page 6 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130 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 before performing care. If he/she becomes combative or resistive, stop the task and/or leave the room, allowing time to call. Monitor resident closely during acute episode of behavior to keep resident and others safe. Notify MD if behavior escalates. Provide diversional activities i.e. food, 1:1 conversation, books, Television Psychiatric consult as needed. Resident is at risk for mood problems due to diagnosis of anxiety disorder and major depressive Disorder. Interventions include-Follow up psychiatric consult. Give medications as ordered and monitor for adverse symptoms. Give resident a space when agitated/restless. Inquire reason why resident is having episodes of problem mood and attempt to resolve it. Monitor mood problem/issues and document if any. Provide opportunities for resident to discuss problems. Reorient/redirect calmly. Staff will continue to allow verbalization of feeling and provide emotional support. Staff will continue to approach in a calm reassured manner. Maintain a pleasant mood, tone of voice at all times. 3. Record review of Resident #81's nurses notes on 12/20/2023 timestamped 03:58 documented, Resident noted very pale. Skin warm, non-responsive to verbal nor to tactile stimulation. Attempt to take vital sign was unable. Call placed to Hospice, hospice nurse pronounced the patient expired. Interview on 12/19/23 at 01:11 PM Director of Nursing (DON) stated when asked about the PASARR process at the facility stated, on admission I review the PASARR to make sure the residents are a candidate for our facility, if the level one is not completed correctly, prior to being admitted I will redo the PASARR and resubmit the PASARR to (K .) to see if the resident can be admitted to the facility. Surveyor discussed with the DON the three (3) residents noted on record review whose PASARR's were not completed. DON stated Resident #81 is a long-term resident and I know with his previous PASARR he was able to be admitted here in the facility, but I can see based on our records that all of his mental diagnoses are not checked off on his most recent PASARR dated 11/22/23. Resident #49's PASARR was completed in 2019 and there is no diagnosis checked off on the PASARR. Resident #13's PASARR dated 8/4/22 has no diagnosis checked off for this resident. DON stated when Resident # 13 was admitted to the facility he believes she did not have any psychological diagnosis. Surveyor explained to DON that diagnosis were added in May 2022 and the PASARR was completed on 8/2022. DON stated my plan moving forward would be to conduct an audit to confirm that all residents' mental diagnosis in the medical records are on the PASARR. I will be updating the three (3) residents PASARR mentioned immediately. Review of the facility's Policy and Procedure titled PASARR (Pre-admission Screening and Resident Review) revision date 10/2023 states: Pre-admission Screening and Resident Review (PASARR) is a federal requirement mandated by Social Security Act. It Is intended to ensure that Medicaid Certified nursing facility applicants and residents with a diagnosis of or a suspicion of serious mental illness or intellectual disabilities, or related conditions are identified and admitted or allowed to remain in the facility only if there is a verified need for such services. Procedure: Prior to admission, the admission department including nurse navigator must ensure that the hospital or another nursing home facility has completed PASARR Level I for new residents prior to admittance to the facility. If a resident is coming from home or an Assisted Living Facility (ALF), a registered nurse, Master Social Work ( MSW), Licensed Social Worker (LCSW), Advanced Registered Nurse Practitioner (ARNP), Doctor of Osteopathic Medicine (DO), or Medical Doctor (MD) who works in a nursing facility must complete PASARR Level I prior to admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106021 If continuation sheet Page 7 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the safety of vulnerable residents for one out of two sampled residents (Resident #88) for smoking. As evidenced, Resident #88 was smoking out in the smoking area with no staff supervision. This deficient practice has the tendency to affect all 7 residents who smoke at the facility at the time of the survey. The findings included: On 12/19/2023 at 11:14 AM, during an interview with Staff B, a Certified Nurse Assistant, she stated that she was the one who watches the residents when they go to smoke. She stated most residents come 2 or 3 times a day, and a staff is always present at the smoking area to supervise them. Observation on 12/20/2023 at 08:10 AM showed Resident #88 was at the smoking area by himself with a cigarette in his hand smoking, no staff was around. Observed Resident #88 finished smoking at 08:14 AM and still no staff was present. Further observation showed Resident #88 was very hard to hear. Review of Resident #88's quarterly minimum data set (MDS) dated [DATE] revealed Section B showed the resident had hearing impairment and Section C BIMS summary score 10 out of 15, indicating moderate cognitive impairment. Review of Resident #88's Care Plan started on 09/24/2023 and completed 10/24/2023 revealed, Resident #88 likes to smoke, potential for injury to impaired mobility. The resident does not wear smoking apron at times. The facility's Interventions included, Close monitoring while smoking in the smoking area Ascertain resident's wishes about smoking and respect resident's decision Explain Facility's smoking Policy Monitor for compliance with smoking policy Ensure that there is no lighter/cigarettes at bedside; Staff will provide such during smoking time in the smoking area. During an interview with the Activity Director on 12/20/2023 at 10:29 AM, she stated that her and [Staff B] are supposed to watch the residents when the residents are in the smoking area smoking. She stated that she doesn't do the care plan for the residents, but reviews the care plan all the time. She stated that she holds the cigarettes for the residents, and the residents come to get the cigarettes from her each time they need to smoke, but for the lighters, either her or [Staff B] can hold it. She stated that no residents have the cigarettes or lighter in their possession in this facility. She stated that there should not be any resident outside smoking alone, her or [Staff B] will be with the resident. Review of the facility's smoking policy revised in July 2017 revealed: Policy Statement: This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation: 8. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106021 If continuation sheet Page 8 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130 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 Residents Affected - Few 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 observation, record review, and interviews, the facility failed to ensure an accurate count on the narcotic sheet (Resident #71) on one cart and failed to ensure medications were securely stored as evidenced by four loose medication pills found on two carts out of three carts checked. The findings included: On [DATE] at 01:09 PM, in an observation of the third-floor medication cart two with Staff C, RN (Registered Nurse). It was revealed that Resident #71's narcotic count sheet for Tramadol 50 milligrams stated there were 16 remaining, but 15 were remaining in the bingo card. When checking the medication cart, two white loose pills (337 & ET/59) were found. In an interview with Staff C, R.N., when shown that the narcotic count sheet was incorrect. Staff C R.N. stated, I charted the medication that it was given in the electronic medication record. I needed to put the time, which is 8:18 AM that it was given on the narcotic sheet. At that time, a resident called 911 due to shortness of breath. I had to assist Staff D, R.N. with the rescue alert. On [DATE] at 02:36 PM, in an interview with Staff C, R.N. When asked, What is the procedure for documentation when removing a narcotic from the bingo card? What happened earlier that you were unable to update the narcotic count sheet? Staff C R.N. stated, The resident (#71) is alert and wants their medication on time. At 8:18 am, I gave the medication. I was at the nursing station, I picked up the phone, learned that there was a resident that called 911 and I was interviewed on why there was a resident calling 911. I had no time for writing. My coworker called me for assistance. When I left the room. I went to the dining room where nursing is assigned to watch residents. When the resident is full code, nurses are to help. When I remove a narcotic medication, I perform my five checks, ask the resident's pain level, click if the medication was given, and chart the time on the narcotic sheet. In nursing, there is much multitasking, someone is always calling on the nurse. I know it is very important to chart the narcotic administration in the chart and the narcotic count sheet. When asked, What is the facility policy for cleaning medication carts? Staff C, R.N. stated, I work the 7-3 shift, I clean my cart every shift and before my shift. The supervisor says every nurse is to clean their carts. When a loose pill is found. I place it in the drug buster. Record review for Resident #71 revealed, that medical diagnoses of polyneuropathy and osteoarthritis. Record review of physician orders for [DATE] revealed, an order for Tramadol 50 milligrams one time a day for non-acute pain. On [DATE] at 02:02 PM, in an observation with Staff E, R.N. on the second-floor medication cart one, it was revealed that a white pill (KP02 / 10) and an orange pill (2 ½ - 893) were found. On [DATE] at 02:53 PM, in an interview with Staff E, R.N., When asked, What is the facility policy for cleaning medication carts? Staff E, R.N. stated, When a medication is found. I dispose of them in the drug buster bottle. On all shifts, nurses are to clean their carts, reorganize, and check that everything is in place. Sometimes the bingo blister is broken. Our supervisors check the carts (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106021 If continuation sheet Page 9 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130 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 Residents Affected - Few frequently to see that they are clean and organized, medications are available and correct and, everything is dated and not expired. On [DATE] at 09:27 AM, in an interview with the Director of Nursing. It was discussed the finding of an incorrect narcotic count and loose pills. When asked, What is the facility procedure when a nurse removes a narcotic medication and how do your nursing staff maintain a clean medication cart? The Director of Nursing stated, The nurses are supposed to sign out the medication as soon as it's removed. It's documented if the resident received or refused the medication. This was a case that we hadn't dealt with before. If Staff C, R.N. didn't catch it during her shift. Before the shift is over, the nurse and the incoming nurse will review the narcotic count sheets. Every Sunday, nurses will vacuum the medications, and look at the state of the bingo cards. We have had cases where they were broken already. The bingo cards can break at any moment. Any moment a pill can come out. When we find them, we put them in a drug buster. On [DATE] at 11:25 AM, in an interview with the Director of Nursing. The Director of Nursing stated, The narcotic administration record is not a part of the resident's permanent records this is tossed out. Staff C, R.N. had good judgment to attend to the resident's rescue alert. In the electronic medication record. It was given at the right time. Staff C, R.N. corrected it. The permanent record weighs more than the temporary narcotic count record. The nurses did a review with the Pharmacist this past week. We check the medication carts clean them weekly and hose them down. These bingo cards are thin in the back. Last week, we had no loose pills found on the cart. We worked so hard. Review of policies and procedures titled controlled substances. Date initiated 2006. The policy statement stated medications included in the Drug Enforcement Administration (D.E.A) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. In section Procedures, part E, Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication enters the following information on the accountability record and the medication administration record (MAR). 1) Date and time of administration (MAR, Accountability Record). 2) Amount administered (Accountability Record). 3) Remaining quantity (Accountability Record). 4) Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record).' Review of policies and procedures titled, Storage of Medications. Date initiated 2001. Date Revised [DATE]. The policy statement stated, the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. In section, Policies Interpretation and Implementation, section 2, The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106021 If continuation sheet Page 10 of 10